# Case report: complete response and long-term survival on third-line immunotherapy in patient with pleural mesothelioma

## TL;DR

A patient with pleural mesothelioma survived seven years after receiving third-line immunotherapy, highlighting the potential of immunotherapy in this aggressive cancer.

## Contribution

This case report demonstrates long-term survival with third-line immunotherapy in pleural mesothelioma, suggesting a potential for late-line immunotherapy benefit.

## Key findings

- The patient achieved a complete and prolonged response to third-line pembrolizumab immunotherapy.
- The tumor microenvironment showed an immune-inflamed profile, possibly explaining the excellent response to immunotherapy.
- The case suggests that predictive biomarkers could help identify patients who benefit from late-line immunotherapy.

## Abstract

Pleural mesothelioma (PM) is a rare neoplasm with median survival time range from 8 to 14 months from diagnosis, and the 5-year survival rate less than 10%, indicating a poor prognosis. The standard treatment for unresectable PM for a long time has been polychemotherapy with pemetrexed and cisplatin for fit patients. Currently, the combination of the anti PD-1 inhibitor nivolumab and the anti-CTLA4 inhibitor ipilimumab has been recognized as the best possible frontline therapy (especially in the sarcomatoid or biphasic type) due to improved outcomes compared to the standard chemotherapy combination. There are still no established predictive biomarkers for any type of systemic therapy in this disease.

Patient who presented with cough and dyspnea has been diagnosed with advanced epithelioid type PM in May 2016. He was treated with three lines of therapy, including an antiangiogenic agent and immunotherapy with pembrolizumab in the third line. Immunotherapy with the PD-1 inhibitor pembrolizumab achieved a complete and prolonged response that transferred to long- term survival. Seven years from diagnosis, the patient is still alive. Histological findings showed an unusually immune-inflamed tumor microenvironment possibly leading to excellent response on immunotherapy.

The course of the disease in our patient points out that we need better predictive biomarkers to direct the treatment algorithm, as some of the patients, although chemorefractory to the best chemotherapy option, can sustain great benefit of second-line chemotherapy in combination with antiangiogenic agent, and especially immunotherapy, even in late lines of therapy.