Stage IV Non-small Cell Lung Adenocarcinoma in Complete Response for 5 Years Post-first-line Nivolumab Immunotherapy: Are We Talking about a Cure?
Background: Metastasis of the Central Nervous System (CNS) is one of the frequently occurring complications of advanced Non-Small Cell Lung Cancer (NSCLC) and has been observed in 24– 44% of patients. Patients suffering from NSCLC along with CNS metastases have a generally poor prognosis. Case Report: A 57-year-old nonalcoholic, non-diabetic, heavy smoker male patient was diagnosed with stage IV NSCLC (non-small cell lung cancer) (Adenocarcinoma), PD-L1 expression 80% with liver, spleen, and brain metastases. In June 2016, the patient was diagnosed with Stage III-A EGFR wild right-sided lung adenocarcinoma (T4N0M0), for which he underwent Curative Concurrent chemo-radiotherapy in Jordan, followed by two cycles of Etoposide plus CDDP (Cisplatin). In February 2017, the patient came to the hospital with the chief complaint of massive hemoptysis. His CT scan showed an appearance in keeping with the right upper-lobe cavitating tumor with possible contralateral lung, splenic, and hepatic metastases. The patient was offered pneumonectomy but refused it. Interventional radiology (IR) tumor embolization of the apical and posterior (A1 and A2) branches of the right superior pulmonary artery with no procedural complication was performed to stop the bleeding. At the end of that same month, on February 28, 2017, he presented to emergency with seizures, for which a contrast CT scan showed two enhancing lesions, one of the left parietal lobe posteriorly 1.8 cm with marked white matter oedema causing a mass effect and the effacement of the posterior horn of the left lateral ventricle. The second is a small ring-enhancing deposit of the right occipital lobe 6 mm with surrounding oedema. The liver biopsy failed to show any malignancy. After the MDT discussion, the largest lesion in the brain was removed and a small lesion was kept. The left occipital metastasis was resected and was found to be a metastatic adenocarcinoma of lung origin. It was positive for TTF-1 and positive for Moc 31. P63 and CK5/6 were negative (no squamous component is seen). No brain radiotherapy was offered. First-line palliative Nivolumab was started on March 20, 2017. Nivolumab first proved to be highly successful against brain metastases. However, it was discontinued as the patient developed myelitis after seven months of continuous treatment. After the discontinuation and improvement of myelitis symptoms, Nivolumab was resumed. The amazing thing about this treatment approach was that his disease was completely cleared up and he had been in complete remission for five years. Additionally, all of his tumor indicators had decreased and normalized. Conclusion: Our case report demonstrated a full response to first-line Nivolumab in a patient with PD-L1-positive NSCLC having visceral and brain metastases. However, our patient suffered from myelitis, which may have been a Nivolumab-related adverse event. The important point is that he has been achieving a durable complete response for nearly 5 years, so are we talking about the certain biology of a tumor that can be cured by immunotherapy?