YO23 - Neo-adjuvant immunotherapy in operable non-small cell lung carcinoma

Case summary

Title: Neo-adjuvant immunotherapy in operable non-small cell lung carcinoma (NSCLC)

Background: Neoadjuvant immunotherapy in operable NSCLC is a novel approach based on phase II Nadim and Checkmate 816 trial data, that showed promising results with improvement in pathological complete response and disease free survival.

Methods: We describe a case of operable NSCLC treated with neoadjuvant immunotherapy with chemotherapy, followed by surgery.

Results: A 66 years Indian man presented in October 2020 with cough. PET-CT scan showed left lung mass measuring 2.6 x 2.3 x 2.6cm extending to left pleura and FDG avid left hilar and subcarinal lymph nodes, with no distant metastasis. Brain MRI was normal. Biopsy of lung mass revealed squamous cell carcinoma with PDL1 5% positive (SP263). His clinical staging was cT2N2M0, Stage IIIA. After multidisciplinary team (MDT) meeting he was planned for neoadjuvant immunotherapy and chemotherapy combination regimen . He received 2 cycles of neoadjuvant nabpaclitaxel plus carboplatin on day 1,8,15 every 28 days with 4 doses of 2 weekly Nivolumab. PET scan in December 2020 showed significant reduction in size and metabolic activity of previously noted left lung mass and lymph nodes. He then underwent robotic left upper lung lobectomy with mediastinal lymph node dissection in December 2020. Histopathology showed complete pathological response. After a MDT meeting, he received adjuvant therapy with 1 cycle nabpaclitaxel plus carboplatin and 5 doses of nivolumab. He developed grade 2 skin toxicity requiring tropical steroids. A PET-CT scan in May 21 showed no evidence of active disease. He was then observed with no further immunotherapy. He is doing well on follow up without adverse events. PET scans on December 21 and May22 showed no evidence of active disease, and he continues to be in remission.

Conclusion: This case emphasizes on the neoadjuvant immunotherapy plus chemotherapy approach in operable NSCLC that can improve response rates and better outcomes. Immune related adverse effects are known with immunotherapy; early diagnosis and treatment is effective. However, more information is needed to understand the difference in outcome of neoadjuvant immunotherapy versus adjuvant immunotherapy in operable NSCLC.

Clinical trial identification

Editorial acknowledgement