Abstract

Two randomized phase III studies provided cumulated long-term results, comparing second line treatment with Nivolumab versus Docetaxel in advanced non-small cell lung cancer (NSCLC). With the advent of modern immunotherapy (IO), the potential for even more immune activation by radiation therapy, inducing tumor specific immunity led to a novel role for radiotherapy in systemic disease.

This case proposes to evaluate the benefit of second line immunotherapy with Nivolumab, a PD-1 checkpoint inhibitor, and hypofractionated radiotherapy, in a patient with advanced oligometastatic adenocarcinoma of the lung, with progressive disease after first line chemotherapy, and the analysis of a possible abscopal effect. A 50-year-old male, heavy smoker with a 30 years-pack index, presented with a history of left posterior thoracic pain. MRI identified an osteolytic lesion on the 10th rib and CT scan showed an additional 25 mm nodule in the left upper lobe (LUL) and a 7 mm nodule in the left lower lobe (LLL). Atypical resections of the nodules and resection of the osteolytic lesion of the rib were performed. The pathological examination revealed a G2 adenocarcinoma of the lung (ALK and EGFR negative) pT4Nx pM1 with metastases in the rib and pleura, with unspecified margins. Chemotherapy was administered, with complete response on imaging after 6 cycles of Gemcitabine/Carboplatin, and hematologic toxicity. After 7 ½ months a regional and distant progression of the disease with metastases on the 7^th and 10^th rib was revealed on PET-CT. Palliative hypofractionated radiotherapy was administered to a dose of 20 Gy/ 5 fr to the painful 7^th rib metastasis and the patient started second line treatment with Nivolumab, 240 mg iv q2wks. Three years later, at his last follow-up in Nov 2021, the patient maintains a (PET)-CT complete response, with no adverse events.

A possible abscopal effect may be suspected in this case.