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Xiang Y, Tang W, Wang J, Wang Z, Bi N. Pseudoprogression of thoracic tumor after radiotherapy in the era of immunotherapy: a case series. Front Oncol 2023; 13:1021253. [PMID: 37576884 PMCID: PMC10419187 DOI: 10.3389/fonc.2023.1021253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Pseudoprogression is rarely mentioned after radiotherapy except for central nervous system tumors. With the widespread of immunotherapy, the incidence of pseudoprogression of thoracic tumor after radiotherapy is increasing. This study summarized the clinical features of pseudoprogression in 4 patients who had underwent thoracic radiotherapy after and/or followed by immunotherapy. All of them had received chemotherapy and immunotherapy before thoracic radiotherapy. After radiotherapy, pseudoprogression occurred within 3 months after initiation of immune consolidation/rechallenge therapy. At least a 20% increase in the sum of the longest diameter of target lesions were measured on their chest image. During this period, patients' ECOG PS scores remained stable, specific serum tumor markers did not increase significantly. Treatment strategies did not change after pseudoprogression. The causes of radiographic pseudoprogression in this case series may be attributed to disturbances such as pneumonitis, atelectasis, mucus blockages and infection. In the era of immunotherapy, pseudoprogression of thoracic tumors after chest radiotherapy might become a common phenomenon. It is important for us to identify pseudoprogression based on patient's general status, radiological changes, and laboratory tests.
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Affiliation(s)
- Yongbo Xiang
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Tang
- Center for National Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianyang Wang
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhijie Wang
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nan Bi
- Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Da Y, Shen G, Zhou M, Wang T, Dong D, Bu L, Shao Y, Sun Q, Yu R. Rapid subcutaneous progression after immunotherapy in pretreated patients with metastatic carcinoma: two case reports. J Int Med Res 2022; 50:3000605221094274. [PMID: 35469479 PMCID: PMC9087252 DOI: 10.1177/03000605221094274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
There is heterogeneity in cancer patients' responses to immune checkpoint inhibitors (ICIs), including hyperprogression, which is very rapid tumor progression following immunotherapy, and pseudoprogression, which is an initial increase followed by a decrease in tumor burden or in the number of tumor lesions. This heterogeneity complicates clinical decisions because either premature withdrawal of the treatment or prolonged ineffective treatment harms patients. We presented two patients treated with ICIs with heterogeneous responses. One patient had Merkel cell carcinoma in the right thigh, and the other had nasopharyngeal squamous carcinoma. The first patient was treated with sintilimab and the second with sintilimab combined with abraxane. In the first patient, subcutaneous lesions grew substantially after the first cycle of treatment with sintilimab. In the second patient, subcutaneous lesions grew gradually after the second cycle of treatment with sintilimab combined with abraxane. In both cases, biopsy examination confirmed that newly emerged lesions were metastases of the primary tumor. These two cases remind clinicians that when subcutaneous nodules appear after treatment with ICIs, pathological biopsy is needed to determine the nature-pseudoprogression or rapid progression-of the disease course.
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Affiliation(s)
- Yong Da
- Department of Medical Oncology, Beijing Fengtai You’anmen
Hospital, Beijing, China
- Department of Medical Oncology, Beijing Hui’an TCM-Integrated
Hospital, Beijing, China
| | - Ge Shen
- Department of Medical Oncology, Beijing Fengtai You’anmen
Hospital, Beijing, China
- Department of Medical Oncology, Beijing Hui’an TCM-Integrated
Hospital, Beijing, China
| | - Ming Zhou
- Department of Medical Oncology, Beijing Fengtai You’anmen
Hospital, Beijing, China
| | - Tao Wang
- Department of Medical Oncology, Beijing Hui’an TCM-Integrated
Hospital, Beijing, China
| | - Dapeng Dong
- Department of Medical Oncology, Beijing Hui’an TCM-Integrated
Hospital, Beijing, China
| | - Lina Bu
- Department of Medical Oncology, Beijing Hui’an TCM-Integrated
Hospital, Beijing, China
| | - Yun Shao
- Department of Medical Oncology, Beijing Fengtai You’anmen
Hospital, Beijing, China
- South Campus of the Fifth Medical Center of PLA General
Hospital, Beijing, China
| | - Qiyun Sun
- Department of Medical Oncology, Beijing Fengtai You’anmen
Hospital, Beijing, China
| | - Ruoying Yu
- Nanjing Geneseeq Technology Inc., Nanjing, Jiangsu, China
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3
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Chen MY, Zeng YC. Pseudoprogression in lung cancer patients treated with immunotherapy. Crit Rev Oncol Hematol 2021; 169:103531. [PMID: 34800651 DOI: 10.1016/j.critrevonc.2021.103531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 12/11/2022] Open
Abstract
Lung cancer has attracted much attention because of its high morbidity and mortality worldwide. The advent of immunotherapy approaches, especially the application of immune checkpoint inhibitors (ICIs) has dramatically changed the treatment of lung cancer, but a novel and unexpected pattern of treatment response-- pseudoprogression, has been observed simultaneously which complicates the routine clinical evaluation and management. However, manifestations of pseudoprogression vary and there are many disputes on immune-related response assessment and corresponding treatments for lung cancer. Therefore, we summarized the possible mechanisms, clinical manifestations and corresponding treatment measures of pseudoprogression in lung cancer, as well as potential methods to differentiate pseudoprogression from true tumor progression.
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Affiliation(s)
- Meng-Yu Chen
- Department of Radiation Oncology, Cancer Center, The Second Affiliated Hospital of Hainan Medical University, 368 Yehai Road, Haikou, 570311, China; Department of Clinical Oncology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yue-Can Zeng
- Department of Radiation Oncology, Cancer Center, The Second Affiliated Hospital of Hainan Medical University, 368 Yehai Road, Haikou, 570311, China.
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Abstract
Fluorodeoxyglucose (FDG) PET/CT is sensitive to metabolic, immune-related, and structural changes that can occur in tumors in cancer immunotherapy. Unique mechanisms of immune checkpoint inhibitors (ICIs) occasionally make response evaluation challenging, because tumors and inflammatory changes are both FDG avid. These response patterns and sequelae of ICI immunotherapy, such as immune-related adverse events, are discussed. Immune-specific PET imaging probes at preclinical stage or in early clinical trials, which may help guide clinical management of cancer patients treated with immunotherapy and likely have applications outside of oncology for other diseases in which the immune system plays a role, are reviewed.
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Affiliation(s)
- Osigbemhe Iyalomhe
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael D. Farwell
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Oliveira LJC, Gongora ABL, Barbosa FG, Dos Anjos CH, Munhoz RR. Atypical response with bone pseudoprogression in a patient receiving nivolumab for advanced cutaneous squamous cell carcinoma. J Immunother Cancer 2018; 6:130. [PMID: 30482243 PMCID: PMC6258146 DOI: 10.1186/s40425-018-0444-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/05/2018] [Indexed: 12/25/2022] Open
Abstract
Currently, there is no established standard of care for patients with metastatic CSCC. Based on the mechanisms of CSCC carcinogenesis has been postulated that these tumors may be amenable to PD-1/PD-L1 blockade.This case illustrates a patient with CSCC with nodal involvement and pulmonary metastases, refractory to two lines of platinum-based regimens and salvage surgery, for whom treatment with nivolumab was recommended. His clinical course was marked by an atypical pattern of response, with initial reduction of soft tissue/visceral lesions, yet development of new bone findings, followed by overall improvement in subsequent scans and sustained disease control upon treatment continuation.The case of patient with metastatic CSCC, refractory, received immunotherapy and evolved with atypical pattern of response.
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Affiliation(s)
- Leandro J C Oliveira
- Oncology Center - Hospital Sírio Libanês, Rua Dona Adma Jafet, 91. 2nd floor. Building A, São Paulo, 01308-050, Brazil
| | - Aline B L Gongora
- Oncology Center - Hospital Sírio Libanês, Rua Dona Adma Jafet, 91. 2nd floor. Building A, São Paulo, 01308-050, Brazil
| | - Felipe G Barbosa
- Radiology and Nuclear Medicine Service - Hospital Sírio Libanês, São Paulo, Brazil
| | | | - Rodrigo R Munhoz
- Oncology Center - Hospital Sírio Libanês, Rua Dona Adma Jafet, 91. 2nd floor. Building A, São Paulo, 01308-050, Brazil. .,Oncology Service, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil.
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Vrankar M, Unk M. Immune RECIST criteria and symptomatic pseudoprogression in non-small cell lung cancer patients treated with immunotherapy. Radiol Oncol 2018; 52:365-9. [PMID: 30367809 DOI: 10.2478/raon-2018-0037] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Liu G, Chen T, Li R, Zhu L, Liu D, Ding Z. Well-controlled pleural effusion indicated pseudoprogression after immunotherapy in lung cancer: A case report. Thorac Cancer 2018; 9:1190-1193. [PMID: 29978949 PMCID: PMC6119617 DOI: 10.1111/1759-7714.12799] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/06/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
Squamous cancer (SqCC) of the lung has a poor prognosis. With the advent of immunotherapy, prognosis has tended to improve; however, pseudoprogression poses a challenge to the management of immunotherapy. Herein, we discuss the case of a 47‐year‐old heavy smoker with advanced SqCC. The patient had recurrent disease after initial successful control of the tumor by concurrent radiochemotherapy, together with ample pleural effusion. Pleural effusion was well controlled with systematic nivolumab and intra‐thoracic recombinant endostatin; however with simultaneous deterioration of performance and tumor progression. Nivolumab was maintained with the addition of nab‐paclitaxel. The combination soon led to a partial response and rapid improvement of the patient's performance. During treatment of this case, we advocated the early control of pleural effusion as an indicator for pseudoprogression. Our experience might be helpful to identify pseudoprogression for the clinical management of immunotherapy.
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Affiliation(s)
- Guihong Liu
- Oncology Department, Chengdu No. 7 People's Hospital, Chengdu Tumor Hospital, Chengdu, China.,Division of Thoracic Oncology, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Tao Chen
- Cardiology Department, Chengdu No. 7 People's Hospital, Chengdu Tumor Hospital, Chengdu, China
| | - Ronghui Li
- Oncology Department, Chengdu No. 7 People's Hospital, Chengdu Tumor Hospital, Chengdu, China
| | - Li Zhu
- Oncology Department, Chengdu No. 7 People's Hospital, Chengdu Tumor Hospital, Chengdu, China
| | - Dingyi Liu
- Oncology Department, Chengdu No. 7 People's Hospital, Chengdu Tumor Hospital, Chengdu, China
| | - Zhenyu Ding
- Division of Thoracic Oncology, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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Vander Jagt TA, Davis LE, Thakur MD, Franz C, Pollock JM. Pseudoprogression of CNS metastatic disease of alveolar soft part sarcoma during anti-PDL1 treatment. Radiol Case Rep 2018; 13:882-885. [PMID: 29991973 PMCID: PMC6037874 DOI: 10.1016/j.radcr.2018.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/17/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors are increasingly used in treatment of metastatic renal cell carcinoma, melanoma, and nonsmall cell lung cancer, as well as in clinical trials for novel targets. We present a pediatric patient with metastatic alveolar soft part sarcoma who was treated with MPDL3280 (Atezolizumab), a monoclonal anti-programmed death ligand-1 antibody. Imaging results for the patient suggested disease progression of multiple brain metastases with stable systemic disease. The patient met response evaluation criteria in solid tumors (RECIST) criteria of progression of disease and was removed from treatment with MPDL3280. Subsequent surgical resection of the brain lesions revealed nonviable tumor with extensive lymphocytic infiltrates consistent with pseudoprogression. This case report adds to a growing number of reports that question reliance on RECIST criteria and suggest need for further refinement of RECIST or irRECIST during immune checkpoint inhibitor treatment for central nervous system metastatic lesions.
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Affiliation(s)
| | - Lara E Davis
- Department of Pediatric Hematology and Oncology; Knight Cancer Institute Division of Hematology and Medical Oncology, Oregon Health Science University, Portland, OR, USA.,Division of Oncology Biomarker Development, Genetech, South San Francisco, CA, USA
| | - Meghna Das Thakur
- Division of Oncology Biomarker Development, Genetech, South San Francisco, CA, USA
| | - Carl Franz
- Division of Chemistry and Biology, Lake Tahoe Community College, South Lake Tahoe, CA, USA
| | - Jeffery M Pollock
- Department of Radiology, Oregon Health Science University, Portland, OR, USA
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Abstract
A 61-year-old woman with lung adenocarcinoma failed first-line treatment and was placed on immunotherapy with nivolumab. FDG-PET/CT before immunotherapy showed metastases to thoracic nodes, liver, adrenal gland, and skeleton. Seven weeks after starting nivolumab, FDG-PET/CT showed mild residual activity in thoracic nodes and otherwise complete response. After 15 weeks, enlarged and FDG-avid axillary lymphadenopathy and worsening supraclavicular lymphadenopathy developed. After 20 weeks, FDG-PET/CT demonstrated marked improvement of axillary and supraclavicular lymphadenopathy. This case demonstrates that later progression of disease can still respond to continuing immunotherapy, hypothetically because of dynamic adaptations in the tug-of-war between the immunotherapy-augmented immune system and tumor.
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Wang Q, Gao J, Wu X. Pseudoprogression and hyperprogression after checkpoint blockade. Int Immunopharmacol 2018; 58:125-135. [DOI: 10.1016/j.intimp.2018.03.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/10/2018] [Accepted: 03/19/2018] [Indexed: 12/25/2022]
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Kobari Y, Kondo T, Takagi T, Omae K, Nakazawa H, Tanabe K. Rapid Progressive Disease After Nivolumab Therapy in Three Patients with Metastatic Renal Cell Carcinoma. ACTA ACUST UNITED AC 2018; 31:769-771. [PMID: 28652455 DOI: 10.21873/invivo.11129] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND/AIM Rapid progressive disease (RPD), accelerated tumour growth immediate after the initiation of immune checkpoint inhibitor therapy, has been reported in melanoma and lung cancer. Herein, we describe 3 cases of RPD during the initial phase of nivolumab treatment for metastatic renal cell carcinoma. PATIENTS AND METHODS The first and second patients received nivolumab in the fourth-line setting. The third patient received nivolumab therapy as third-line treatment. RESULTS The first patient developed severe respiratory failure due to carcinomatous lymphangiosis 14 days after initiation of nivolumab therapy. The second patient developed leg paraplegia due to rapid growth of the metastatic tumour at the sixth thoracic vertebrae 5 days later. The third patient developed grade 4 hypercalcemia due to RPD on day 3. CONCLUSION Clinicians should be aware of RPD during the initial phase of nivolumab therapy, especially in patients with critical lesions in the late-line setting.
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Affiliation(s)
- Yuki Kobari
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenji Omae
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hayakazu Nakazawa
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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