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Singla R, Jajodia A, Agrawal RK, Rao A, Pasricha S, Batra U. Comparison of RECIST and iRECIST criteria in patients with advanced lung cancer treated with nivolumab. J Cancer Res Ther 2023; 19:1212-1218. [PMID: 37787285 DOI: 10.4103/jcrt.jcrt_1456_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Background Systemic therapy in lung cancer is mainstay of treatment as most patients present in advanced stages, with rising importance of new immunotherapy agents. Purpose To compare the RECIST 1.1 and the immunotherapy Response Evaluation Criteria in Solid Tumors (iRECISTs) criteria for response assessment in lung cancer patients on immunotherapy. To find the incidence of pseudoprogression and associated imaging patterns. Material and Methods Retrospective study in 28 patients treated with immunotherapy for advanced metastatic NSCLC. End points were progression-free survival (PFS) and overall survival (OS). Response assessments were separately tabulated according to RECIST 1.1 and iRECIST and classified into dichotomous groups of responders and nonresponders. Agreement in assessments between RECIST 1.0 and iRECIST examined using Cohen kappa (κ) coefficient with 95% confidence intervals. Kaplan-Meier survival analysis was done for PFS and OS. Differences between RECIST 1.1 and iRECIST for both responder and nonresponder were evaluated by the log rank test, Breslow (Generalized Wilcoxon) test, and Tarone-Ware test. Results Incidence of pseudoprogression was 7% (2/28). The RECIST1.1 and iRECIST were in disagreement in two patients. The agreement between RECIST and iRECIST was almost perfect. The PFS and the OS are significantly longer in duration for responders in comparison to nonresponders for both RECIST and iRECIST and the difference between two assessment criteria is not significant. Conclusion Although iRECIST aims to monitor treatment more precisely than conventional response criteria, this must be weighed against how infrequent pseudoprogression is and the cost of this therapy, both financially and in the potential delay in changing to a more effective treatment.
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Affiliation(s)
- Rishu Singla
- Department of Radiology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Ankush Jajodia
- Department of Radiology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - R K Agrawal
- School of Engineering and Computer Sciences, Jawaharlal Nehru University, Delhi, India
| | - Avinash Rao
- Department of Radiology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Sunil Pasricha
- Department of Histopathology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
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2
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Kang DH, Chung C, Sun P, Lee DH, Lee SI, Park D, Koh JS, Kim Y, Yi HS, Lee JE. Circulating regulatory T cells predict efficacy and atypical responses in lung cancer patients treated with PD-1/PD-L1 inhibitors. Cancer Immunol Immunother 2021; 71:579-588. [PMID: 34278517 PMCID: PMC8854239 DOI: 10.1007/s00262-021-03018-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/11/2021] [Indexed: 11/06/2022]
Abstract
Background Immune checkpoint inhibitors (ICIs) have become the standard of care for a variety of cancers, including non-small cell lung cancer (NSCLC). In this study, we investigated the frequency of pseudoprogression and hyperprogression in lung cancer patients treated with ICIs in the real world and aimed to discover a novel candidate marker to distinguish pseudoprogression from hyperprogression soon after ICI treatment. Methods This study included 74 patients with advanced NSCLC who were treated with PD-1/PD-L1 inhibitors at Chungnam National University Hospital (CNUH) between January 2018 and August 2020. Chest X-rays were examined on day 7 after the first ICI dose to identify changes in the primary mass, and the response was assessed by computed tomography (CT). We evaluated circulating regulatory T (Treg) cells using flow cytometry and correlated the findings with clinical outcomes. Results The incidence of pseudoprogression was 13.5%, and that of hyperprogression was 8.1%. On day 7 after initiation of treatment, the frequency of CD4+CD25+CD127loFoxP3+ Treg cells was significantly decreased compared with baseline (P = 0.038) in patients who experienced pseudoprogression and significantly increased compared with baseline (P = 0.024) in patients who experienced hyperprogression. In the responder group, the frequencies of CD4+CD25+CD127loFoxP3+ Treg cells and PD-1+CD4+CD25+CD127loFoxP3+ Treg cells were significantly decreased 7 days after commencement of treatment compared with baseline (P = 0.034 and P < 0.001, respectively). Conclusion Circulating Treg cells represent a promising potential dynamic biomarker to predict efficacy and differentiate atypical responses, including pseudoprogression and hyperprogression, after immunotherapy in patients with NSCLC. Supplementary Information The online version contains supplementary material available at 10.1007/s00262-021-03018-y.
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Affiliation(s)
- Da Hyun Kang
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Chaeuk Chung
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Pureum Sun
- College of Medicine, Research Institute for Medical Sciences, Chungnam National University, Daejeon, Korea
| | - Da Hye Lee
- College of Medicine, Research Institute for Medical Sciences, Chungnam National University, Daejeon, Korea
| | - Song-I Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Dongil Park
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Jeong Suk Koh
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Yoonjoo Kim
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Hyon-Seung Yi
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea
| | - Jeong Eun Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea.
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Response Prediction and Evaluation Using PET in Patients with Solid Tumors Treated with Immunotherapy. Cancers (Basel) 2021; 13:cancers13123083. [PMID: 34205572 PMCID: PMC8234914 DOI: 10.3390/cancers13123083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary In cancer treatment, immunotherapy is increasingly becoming important as a component of first-line treatment and has improved the prognosis of patients since its introduction. A large group of patients, however, do not respond to immunotherapy, and predicting a treatment response remains challenging. Furthermore, evaluating a response using conventional computed tomography (CT) scans is not straightforward due to the different mechanism of action of immunotherapy compared to chemotherapy. This review provides an overview of positron emission tomography (PET) in predicting and evaluating treatment response to immunotherapy. Abstract In multiple malignancies, checkpoint inhibitor therapy has an established role in the first-line treatment setting. However, only a subset of patients benefit from checkpoint inhibition, and as a result, the field of biomarker research is active. Molecular imaging with the use of positron emission tomography (PET) is one of the biomarkers that is being studied. PET tracers such as conventional 18F-FDG but also PD-(L)1 directed tracers are being evaluated for their predictive power. Furthermore, the use of artificial intelligence is under evaluation for the purpose of response prediction. Response evaluation during checkpoint inhibitor therapy can be challenging due to the different response patterns that can be observed compared to traditional chemotherapy. The additional information provided by PET can potentially be of value to evaluate a response early after the start of treatment and provide the clinician with important information about the efficacy of immunotherapy. Furthermore, the use of PET to stratify between patients with a complete response and those with a residual disease can potentially guide clinicians to identify patients for which immunotherapy can be discontinued and patients for whom the treatment needs to be escalated. This review provides an overview of the use of positron emission tomography (PET) to predict and evaluate treatment response to immunotherapy.
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Immune Checkpoint Inhibitors with or without Radiotherapy in Non-Small Cell Lung Cancer Patients with Brain Metastases: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:diagnostics10121098. [PMID: 33339421 PMCID: PMC7767255 DOI: 10.3390/diagnostics10121098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022] Open
Abstract
This study aimed to evaluate the radiologic response and adverse event rates of immune checkpoint inhibitor (ICI) therapy with or without radiotherapy for the treatment of non-small cell lung cancer (NSCLC) brain metastases. A systematic literature search was performed up to January 3, 2020. Studies evaluating the intracranial objective response rates (ORR) and/or disease control rates (DCR) of ICI with or without radiotherapy for treating NSCLC brain metastases were included. Consequently, twelve studies satisfied inclusion criteria. ICI combined with radiotherapy (pooled ORR, 95%; DCR, 97%) showed better local efficacy compared to ICI monotherapy (pooled ORR, 24%; DCR, 44%; p < 0.01 for both ORR and DCR). Grade 3 or 4 central nervous system (CNS)-related adverse event rates were not different (5% vs. 4%; p = 0.93). In conclusion, ICI combined with radiotherapy showed better intracranial efficacy than ICI monotherapy for treating NSCLC brain metastases. CNS-related grade 3 or 4 adverse event rate was not statistically different between the two groups. Several prospective trials are needed to compare the efficacy of ICI combined with radiotherapy and ICI monotherapy.
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Zhou L, Zhang M, Li R, Xue J, Lu Y. Pseudoprogression and hyperprogression in lung cancer: a comprehensive review of literature. J Cancer Res Clin Oncol 2020; 146:3269-3279. [PMID: 32857178 DOI: 10.1007/s00432-020-03360-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Immune checkpoint inhibitors are associated with clinical benefit in lung cancer. However, response patterns to immunotherapy, including pseudoprogression and hyperprogression, are difficult to diagnose, and their mechanisms remain unclear. This review aimed to describe two response patterns observed in lung cancer, namely pseudoprogression and hyperprogression, including their epidemiology, diagnostic characteristics, and plausible mechanisms. METHODS We performed a comprehensive literature search in the PubMed database, using keywords "pseudoprogression", "hyperprogression", and "lung cancer", among others. The literature was examined for pseudoprogression and hyperprogression characteristics and plausible mechanisms. RESULTS Pseudoprogression manifests in multiple forms; however, the immune system-related response criteria and biopsy data are helpful to make accurate diagnosis. Serological biomarkers, such as neutrophil-to-lymphocyte ratio (NLR) and circulating tumor DNA (ctDNA), might help distinguish pseudoprogression from true progression. The incidence of hyperprogression ranges within 5-19.2%, depending on definition. The unique response pattern of rapid progression is observed not only with immunotherapy, but also with other treatment regimens. Molecular mutations and amplifications may result in hyperprogression; however, the exact mechanism remains unclear. CONCLUSION Atypical response patterns, such as pseudoprogression and hyperprogression, are increasingly common in clinical practice. Immune-related response criteria can help diagnose pseudoprogression. Molecular mechanisms of hyperprogression remain unclear. Biomarkers for pseudoprogression and hyperprogression are required.
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Affiliation(s)
- Laiyan Zhou
- Department of Thoracic Cancer, Cancer Center, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, 610041, China
| | - Mai Zhang
- Department of Thoracic Cancer, Cancer Center, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, 610041, China
| | - Rui Li
- Department of Thoracic Cancer, Cancer Center, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, 610041, China
| | - Jianxin Xue
- Department of Thoracic Cancer, Cancer Center, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, 610041, China.
| | - You Lu
- Department of Thoracic Cancer, Cancer Center, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, 610041, China.
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Humbert O, Cadour N, Paquet M, Schiappa R, Poudenx M, Chardin D, Borchiellini D, Benisvy D, Ouvrier MJ, Zwarthoed C, Schiazza A, Ilie M, Ghalloussi H, Koulibaly PM, Darcourt J, Otto J. 18FDG PET/CT in the early assessment of non-small cell lung cancer response to immunotherapy: frequency and clinical significance of atypical evolutive patterns. Eur J Nucl Med Mol Imaging 2019; 47:1158-1167. [PMID: 31760467 DOI: 10.1007/s00259-019-04573-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE This prospective study aimed (1) to assess the non-small cell lung cancer (NSCLC) evolutive patterns to immunotherapy using FDG-PET and (2) to describe their association with clinical outcome. DESIGN Fifty patients with metastatic NSCLC were included before pembrolizumab or nivolumab initiation. FDG-PET scan was performed at baseline and after 7 weeks of treatment (PETinterim1) and different criteria/parameters of tumor response were assessed, including PET response criteria in solid tumors (PERCIST). If a first PERCIST progressive disease (PD) without clinical worsening was observed, treatment was continued and a subsequent FDG-PET (PETinterim2) was performed at 3 months of treatment. Pseudo-progression (PsPD) was defined as a PERCIST response/stability on PETinterim2 after an initial PD. If a second PERCIST PD was assessed on PETinterim2, a homogeneous progression of lesions (termed immune homogeneous progressive-disease: iPDhomogeneous) was distinguished from a heterogeneous evolution (termed immune dissociated-response: iDR). A durable clinical benefit (DCB) of immunotherapy was defined as treatment continuation over a 6-month period. The association between PET evolutive profiles and DCB was assessed. RESULTS Using PERCIST on PETinterim1, 42% (21/50) of patients showed a response or stable disease, most of them (18/21) reached a DCB. In contrast, 58% (29/50) showed a PD, but more than one-third (11/29) were misclassified as they finally reached a DCB. No standard PETinterim1 criteria could accurately distinguished responding from non-responding patients. Treatment was continued in 19/29 of patients with a first PERCIST PD; the subsequent PETinterim2 demonstrated iPDhomogeneous, iDR and PsPD in 42% (8/19), 26% (5/19), and 32% (6/19), respectively. Whereas no patients with iPDhomogeneous experienced a DCB, all patients with iDR and PsPD reached a clinical benefit to immunotherapy. CONCLUSION In patients with a first PD on PERCIST and treatment continuation, a subsequent PET identifies more than half of them with iDR and PsPD, both patterns being strongly associated with a clinical benefit of immunotherapy.
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Affiliation(s)
- O Humbert
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France. .,Laboratory Transporter in Imaging and Radiotherapy in Oncology (TIRO), UMR E 4320, CEA, UCA, Nice, France.
| | - N Cadour
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - M Paquet
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - R Schiappa
- Department of Biostatistics, Centre Antoine-Lacassagne, UCA, Nice, France
| | - M Poudenx
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France
| | - D Chardin
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France.,Laboratory Transporter in Imaging and Radiotherapy in Oncology (TIRO), UMR E 4320, CEA, UCA, Nice, France
| | - D Borchiellini
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France.,Clinical Research and Innovation Office, Centre Antoine-Lacassagne, UCA, Nice, France
| | - D Benisvy
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - M J Ouvrier
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - C Zwarthoed
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - A Schiazza
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - M Ilie
- Laboratory of Clinical and Experimental Pathology, Hospital-Integrated Biobank (BB-0033-00025), Nice Hospital University, FHU OncoAge, UCA, Nice, France
| | - H Ghalloussi
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France
| | - P M Koulibaly
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France
| | - J Darcourt
- Department of Nuclear Medicine, Centre Antoine-Lacassagne, Université Côte d'Azur (UCA), 33 Avenue de Valombrose, 06189, Nice, France.,Laboratory Transporter in Imaging and Radiotherapy in Oncology (TIRO), UMR E 4320, CEA, UCA, Nice, France
| | - J Otto
- Department of Medical Oncology, Centre Antoine-Lacassagne, UCA, Nice, France
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Kim EY, Park I, Kim YS, Ahn HK, Lee HY, Kim JH. Unusual radiologic manifestation of pseudoprogression in pulmonary metastases after durvalumab treatment in metastatic bladder urothelial cancer. Thorac Cancer 2019; 10:1016-1018. [PMID: 30734514 PMCID: PMC6449229 DOI: 10.1111/1759-7714.12994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 11/28/2022] Open
Abstract
Durvalumab is an immune checkpoint inhibitor that blocks PD-L1. Unlike cytotoxic chemotherapy or molecularly targeted agents, immune checkpoint inhibitors occasionally present distinct response patterns, including radiologic pseudoprogression (initial tumor enlargement with subsequent tumor regression) and immune-related adverse events in normal tissues. We report a case of unusual computed tomography (CT) findings of pseudoprogression of pulmonary metastases in a patient with metastatic bladder cancer after durvalumab treatment: multiple pulmonary metastases turned into ground-glass opacity on first follow-up CT; on second follow-up CT, and after sustained treatment of the PD-L1 inhibitor, the lesion was resolved.
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Affiliation(s)
- Eun Young Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Inkeun Park
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Young Saing Kim
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Hee Kyung Ahn
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Hee Young Lee
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
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Kim EY, Kim YS, Park I, Ahn HK, Lee HY, Kim JH. Radiologic presentation of non-small cell lung cancer treated with anti-PD-1 therapy. J Thorac Dis 2018; 10:S3930-S3932. [PMID: 30631519 DOI: 10.21037/jtd.2018.09.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eun Young Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Young Saing Kim
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Inkeun Park
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hee Kyung Ahn
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hee Young Lee
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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Immune RECIST criteria and symptomatic pseudoprogression in non-small cell lung cancer patients treated with immunotherapy. Radiol Oncol 2018; 52:365-369. [PMID: 30367809 PMCID: PMC6287173 DOI: 10.2478/raon-2018-0037] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/12/2018] [Indexed: 01/04/2023] Open
Abstract
Background Uncommon response during immunotherapy is a new challenging issue in oncology practice. Recently, new criteria for evaluation of response to immunotherapy immune response evaluation criteria in solid tumors (iRECIST) were accepted. According to iRECIST, worsening of performance status (PS) accompanied to pseudoprogression reflects most probably the true progression of the malignant disease. Methods A systematic review of the literature was made by using several electronic database with the following search criteria: symptomatic pseudoprogression, atypical response, immunotherapy and lung cancer. Results In the literature, we identified five reports of seven patients treated with immunotherapy that met the inclusion criteria. We also report our experience of patient with pseudoprogression and almost complete response after one dose of immunotherapy. Conclusions As seen from our review, iRECIST criteria might be insufficient in distinguishing true progression from pseudoprogression in some patients with advanced NSCLC treated with immunotherapy. More precise assessment methods are urgently needed.
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