Multi-organs perioperative immune-related adverse events and postoperative bronchial anastomotic fistula in a patient receiving neoadjuvant immunotherapy with NSCLC

Perioperative immunotherapy for stage II-III non-small cell lung cancer: a meta-analysis base on randomized controlled trials

Background

In recent years, we have observed the pivotal role of immunotherapy in improving survival for patients with non-small cell lung cancer (NSCLC). However, the effectiveness of immunotherapy in the perioperative (neoadjuvant + adjuvant) treatment of resectable NSCLC remains uncertain. We conducted a comprehensive analysis of its antitumor efficacy and adverse effects (AEs) by pooling data from the KEYNOTE-671, NADIM II, and AEGEAN clinical trials.

Methods

For eligible studies, we searched seven databases. The randomized controlled trials (RCTs) pertaining to the comparative analysis of combination neoadjuvant platinum-based chemotherapy plus perioperative immunotherapy (PIO) versus perioperative placebo (PP) were included. Primary endpoints were overall survival (OS) and event-free survival (EFS). Secondary endpoints encompassed drug responses, AEs, and surgical outcomes.

Results

Three RCTs (KEYNOTE-671, NADIM II, and AEGEAN) were included in the final analysis. PIO group (neoadjuvant platinum-based chemotherapy plus perioperative immunotherapy) exhibited superior efficacy in OS (hazard ratio [HR]: 0.63 [0.49-0.81]), EFS (HR: 0.61 [0.52, 0.72]), objective response rate (risk ratio [RR]: 2.21 [1.91, 2.54]), pathological complete response (RR: 4.36 [3.04, 6.25]), major pathological response (RR: 2.79 [2.25, 3.46]), R0 resection rate (RR: 1.13 [1.00, 1.26]) and rate of adjuvant treatment (RR: 1.08 [1.01, 1.15]) compared with PP group (neoadjuvant platinum-based chemotherapy plus perioperative placebo). In the subgroup analysis, EFS tended to favor the PIO group in almost all subgroups. BMI (>25), T stage (IV), N stage (N1-N2) and pathological response (with pathological complete response) were favorable factors in the PIO group. In the safety assessment, the PIO group exhibited higher rates of serious AEs (28.96% vs. 23.51%) and AEs leading to treatment discontinuation (12.84% vs. 5.81%). Meanwhile, although total adverse events, grade 3-5 adverse events, and fatal adverse events tended to favor the PP group, the differences were not statistically significant.

Conclusion

PIO appears to be superior to PP for resectable stage II-III NSCLC, demonstrating enhanced survival and pathological responses. However, its elevated adverse event (AE) rate warrants careful consideration.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42023487475.

Is response evaluation criteria in solid tumors (RECIST) effective in patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC?

BACKGROUND

Neoadjuvant immunotherapy combined with chemotherapy has been used to treat locally advanced non-small cell lung cancer (NSCLC). Several systems have been developed for response evaluation. The aim of this study was to evaluate the predictive value of response evaluation criteria in solid tumors (RECIST) and propose modified RECIST (mRECIST).

METHODS

Eligible patients received chemotherapy combined with personalized neoadjuvant immunotherapy. Radical resection was subsequently performed for potentially resectable tumors evaluated by RECIST. The resected specimens were evaluated to determine the response to neoadjuvant therapy.

RESULTS

A total of 59 patients received radical resection following neoadjuvant immunotherapy combined with chemotherapy. According to RECIST, four patients had complete remission, 41 had partial remission, and 14 had progressive disease. Postoperative pathological examination showed 31 patients achieved complete pathological remission, and 13 achieved major pathological remission. The final pathological results were uncorrelated with RECIST assessment (p = 0.086). The ycN stage and pN stage were irrelevant (p < 0.001). When the cutoff of sum of diameters (SoD) is 17%, the Youden's index reached its highest value. A correlation was found between mRECIST and final pathological results. Patients with squamous cell lung cancer showed higher proportions in objective response (OR) (p < 0.001) and complete pathological remission (CPR) (p = 0.001). A shorter time to surgery (TTS) was correlated with a better OR (p = 0.014) and CPR (p = 0.010). The decrease in SoD was correlated with better OR (p = 0.008) and CPR (p = 0.002).

CONCLUSIONS

mRECIST was effective for patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC. Two modifications were suggested for RECIST: (1) the cutoff value was adjusted to 17% for partial remission. (2) Changes in lymph nodes on computed tomography were eliminated. A shorter TTS, a larger decrease in SoD and squamous cell lung cancer (vs. adenocarcinoma) were correlated with better pathological responses.

Remitting Seronegative Symmetrical Synovitis with Pitting Edema: A Case Report of an Immune-Related Adverse Event following Surgery

Immune checkpoint inhibitors (ICIs) have emerged as a novel class of anti-neoplastic agent in oncology. Their integration into practice has been accompanied by "immune-related adverse events" (irAEs) wherein off-target immune responses damage healthy tissues. Severe irAEs can cause irreversible organ dysfunction and death. Despite this, little is known about factors which predispose certain patients to develop irAEs or which precipitate their onset. Here, we report a case of a patient with melanoma who completed adjuvant immunotherapy, underwent elective hip replacement, and developed a rare rheumatologic irAE (remitting seronegative symmetrical synovitis with pitting edema) post-operatively. Mechanistically, we hypothesize that surgery contributed to irAE pathogenesis as a sensitizing event in which self-antigens were presented to an immune system with diminished peripheral tolerance in the context of recent ICI administration. This case highlights a need for future correlative analyses, investigating whether iatrogenic interventions such as surgery might be associated with irAE development.