J Cancer Clin | Volume 1, Issue 1 | Case Report | Open Access

Immunotherapy and Mixed Radiographic Response in Non-Small Cell Lung Cancer

Roya Tabatabai and Ronald Natale*

Department of Cancer, Cedars-sinai Medical Center, USA

*Correspondance to: Ronald Natale 

Fulltext PDF


Since ipilumumab was first approved for the treatment of metastatic melanoma in 2010, an increasing number of immunotherapeutic agents have been developed and approved for a multitude of tumor types. The era of immunotherapy has ushered new challenges of assessing disease response. Traditionally, radiographic response as determined by Response Evaluation Criteria in Solid Tumors (RECIST) has guided cancer treatment based on the assumption that an early increase in tumor size or appearance of new lesions signaled progressive disease that warrants discontinuation of treatment [1]. However, in early trials of melanoma patients treated with ipilumumab, distinct immune related radiographic patterns were observed. A portion of patients with radiographic progression preceding response, or with expanding or new lesions in the presence of other responsive lesions derived a meaningful clinical benefit. These findings could be explained by anticancer immune activation leading to an inflammatory response apparent on imaging [2]. Clearly these patients would have been deemed to have disease progression based on RECIST criteria, and with strict implementation of RECIST, would be denied an efficacious therapeutic option. On the other hand, many patients with initial radiographic progression or a mixed response were found to have true disease progression and would not benefit from continued treatment with an ineffective drug.
Since these initial observations were made, investigators have worked towards identifying an effective way to capture and measure disease response with immune therapy. Several criteria have been proposed, including Immune-Related Response Criteria (irRC), Immune-Related RECIST (irRECIST), modified RECIST 1.1 of Immune-based Therapeutics (iRECIST), and ImmuneModified RECIST (imRECIST). Studies are ongoing to determine the validity of these tools. Based on the observation that tumor pseudo-progression was seen more frequently in melanoma as compared with non-small cell lung cancer [3,4] in clinical trials, it is unlikely that one set of criteria will be applicable to all immune therapies and all tumor types for which immune therapy has been approved.
In our institution we noted radiographic mixed response, which we define as reduction in some lesions concomitant with expansion in others or appearance of new lesions, among the early lung cancer patients treated with immunotherapy. We present five cases of patients treated with immunotherapy for advanced non-small cell lung cancer with mixed radiographic responses per RECIST criteria and divergent clinical outcomes. We anticipate that approach to management of such patients will continue to be a challenge until a standardized tool to assess true disease response is available.


Tabatabai R, Natale R. Immunotherapy and Mixed Radiographic Response in Non-Small Cell Lung Cancer. J Cancer Clin. 2018; 1(1): 1005.

Subscribe to Our Newsletter