Poster Presentation 29th Lorne Cancer Conference 2017

Dyspnea in the Patient with Pulmonary Metastases from Renal Cell Cancer during the Treatment with Nivolumab (#185)

Petra Jurcic 1
  1. University Hospital Center Sestre Milosrdnice, Zagreb, GRAD ZAGREB, Croatia

Croatia is one of the few EU member states where immunotherapy cannot be obtained at the expense of public health insurance system. Nivolumab is only available through the expanded access and for the following indications: Classical Hodgkin Lymphoma, locally advanced or metastatic non-small cell lung cancer (NSCLC), unresectable or metastatic BRAF V600 wild-type melanoma, and advanced or metastatic renal cell cancer (RCC). In this concrete case, a 70-year-old male patient with a history of long-term arterial hypertension, hyperlipidaemia, type 2 diabetes mellitus and residual muscle weakness secondary to late effect of cerebrovascular accident, to whom an open right radical nephrectomy and ipsilateral adrenalectomy for RCC with adrenal metastasis was performed in October 2014. Histopathological examination showed clear cell carcinoma, nuclear grade 3, R0 resection, 2 mitoses per 50 HPF. Two months after diagnosis, axial CT of the abdomen and pelvis demonstrated osteolytic bone metastases. Therefore, a biopsy of the left superior pubic ramus was performed and mRCC was diagnosed histologically. External beam radiotherapy was performed. Bisphosphonate were introduced. Pazopanib was prescribed from November 2014 to March 2016. Initial dosage was reduced due to persistent hypertension despite antihypertensive therapy (amlodipine, perindopril, nebivolol, moxonidin, torasemid). In April 2016, pulmonary metastases (15mm diameter) were found. Nivolumab was introduced (3 mg/kg = 216 mg). On the 15th day after the first administration of nivolumab, patient was observed at the Emergency Department for dyspnea. CT pulmonary angiography was used to exclude acute pulmonary embolism. Despite the therapy (02 on non-rebreather mask, nitrolingual pump spray, diuretics, rapid-acting insulin, IPP, antihypertensive therapy, ceftriaxone, LMWH – Fragmin) the patient showed improvement only after methylprednisolone (Solu Medrol ®) therapy was applied. The conclusion can be drawn that it is very important to duly recognize side-effects of immunotherapy. Therefore, better ways of following these side-effects will be necessary.