Page 15 - Delaware Medical Journal - January 2017
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CASE REPORT
imaging showed progression of the pulmonary nodules. Sunitinib was discontinued and the patient was started on everolimus (an oral m-TOR inhibitor) in March 2013.
The patient’s pulmonary nodules increased in size and number on subsequent imaging; She also developed lower back and bilateral groin pain. MRI revealed new metastatic lesions throughout her lumbar and sacral spine, as well as a lesion in her left iliac crest. Imaging also revealed a 9 cm lytic lesion in her left proximal femoral shaft with impending pathologic fracture. This was treated with embolization and intramedullary rod placement. The patient also received post-operative radiotherapy to the left femur and L4-S3 spine.
The patient was started on third line systemic treatment with pazopanib (another oral TKI) in November 2013, but was abdominal pain, nausea, vomiting, and diarrhea). Treatment was discontinued. Over the next ten months, the patient received additional radiotherapy for lytic bone lesions. A repeat CT scan in October 2014 showed continued progression of pulmonary nodules and a new 2.2 cm hepatic lesion.
The patient was initiated on sorafenib (another oral TKI) as fourth
The drug was promptly discontinued. Over the next year, the patient received multiple cycles of bevacizumab (a monoclonal anti-VEGF antibody) and then upon progression, temsirolimus (another IV m-TOR inhibitor), which she tolerated well. However, she again experienced disease progression.
Over the course of these three years and six treatment regimens, the patient’s functional status steadily declined.
She developed an oxygen requirement as well as wheelchair dependence due to severe joint pain and ambulatory dysfunction. Worsening anorexia led to a greater than 100-pound weight loss. In the fall of 2015, discussion was initiated with the patient about exploring the option of hospice care. In December, 2015, the patient was found to have a 7 mm lesion in the left frontal gyrus on a routine MRI of the brain; that was subsequently treated with Cyberknife radiation.
The PD-1 inhibitor nivolumab was approved for the treatment of advanced renal cell carcinoma in November 2015. It had already been in use as an approved treatment of melanoma and non-small
CT Chest 03/24/16
CT Chest 11/02/15
FIGURE 1
Reduction in pulmonary nodule following three months of nivolumab therapy.
Del Med J | January 2017 | Vol. 89 | No. 1
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