Lung scale cancer heart encapsulation fluid, where to go from? Look at immunotherapy and fight and go.

On June 23, at the third MDT of "Jinling Lung Cancer Network Forum", Professor Ji Lei from the Affiliated Hospital of Xuzhou Medical University shared a wonderful case of immunotherapy for lung squamous cell carcinoma.the basic information of the case was Zhang, a 51 year old male.chief complaint: 3 years after left lung cancer surgery.current history: the patient underwent left total lung cancer radical operation in the thoracic surgery of XX Hospital 3 years ago. The postoperative pathology was squamous cell carcinoma of lung; gene detection: no mutation target; postoperative pathological stage: p-t2n0m0ib stage.the patients were treated with docetaxel 120mg D1 + cisplatin 30mg D1-3 chemotherapy for four times and local chest radiotherapy for one cycle.follow up of oncology department after conventional treatment.chest CT Reexamination on April 17, 2019 showed: "after left lung cancer surgery", multiple nodules were added in the right lung, except for metastasis, pericardial effusion, enlarged lymph node shadow in left hilar and mediastinum.admitted to our department.auxiliary examination: blood routine, urine routine, liver and kidney function, electrolyte, myocardial enzyme, brain natriuretic peptide, thyroid function and coagulation function were not abnormal; ECG, digestive system, cranial magnetic resonance imaging, bone scan were not abnormal.chest CT (see the following figure): "after left lung cancer surgery", multiple nodules were added in the right lung, except for metastasis, pericardial effusion, enlarged lymph node shadow in left hilar and mediastinum, and a small amount of pleural effusion.chest CT diagnosis and treatment plan: according to the clinical diagnosis and treatment guidelines, the first cycle of treatment was performed on May 11, 2019 according to the clinical diagnosis and treatment guidelines. The regimen: paclitaxel liposome 240mg D1 + nedaplatin 50mg D1-3 + sindilimab 200mg.what is the effect of immunotherapy? Efficacy evaluation after the end of the first cycle: blood routine, urine routine, liver and kidney function, electrolyte, myocardial enzyme, brain natriuretic peptide, thyroid function, electrocardiogram, etc. were not abnormal; chest CT on May 30, 2019 showed that: after surgery for left lung cancer, pericardial effusion slightly increased compared with that on May 9, 2019, and node nodes of right upper lobe increased.the efficacy evaluation was stable, and the current regimen was continued. After that, the second and third cycles of treatment were performed on May 31, 2019 and 6-25, respectively.how to break the side effects of immunotherapy? Evaluation of curative effect: chest CT examination on June 25, 2019: after left lung cancer surgery, compared with 2019-5-0-30, some nodules in right lower lobe of lung slightly reduced, pericardial effusion.effective after treatment.however, the patient complained of lethargy, fatigue, loss of appetite, and edema of both lower limbs. Considering the side effects of immunotherapy, the patient found hypothyroidism [thyroid function: free triiodothyronine (FT3): 0.81 pmol / L; free thyroxine (FT4): 0.91 pmol / L; thyroid stimulating hormone (TSH) & gt; 100 mIU / l]. The incidence of hypothyroidism was 6.6%.according to the "general principle of recommended treatment of adverse reactions of different grades", the endocrinology experts were invited for consultation, and the current diagnosis and treatment plan was suspended, and thyroid hormone was supplemented to promote the recovery of thyroid function. the changes of TSH, FT3 and FT4 in the patients, the progress of the disease, the aggravation of symptoms, and the course of treatment? On July 29, 2019, the patient went to our department for asthma and dyspnea. Chest CT Reexamination showed that after left lung cancer surgery, the number of right pulmonary nodules decreased and the right pleural effusion increased. Color Doppler ultrasound: moderate to large amount of pericardial effusion. physical examination showed edema of both lower limbs. pericardiocentesis: exudative, mainly monocytes, and suspected cancer cells were found. according to the pathology of pericardial effusion, cisplatin and tumor necrosis factor were given local treatment; patients continued to take oral thyroid hormone, followed up. chest CT and pericardiocentesis pathological examination results of the patient at that time. Initial follow-up of 2019-8: the assessment was effective after local treatment. After 3 cycles of treatment, the pericardial effusion increased. Was pericardial effusion caused by metastasis? Combined with the patient's condition, and the patient's thyroid function gradually recovered, the original scheme was maintained. However, the use of immunomonoclonal antibody (paclitaxel liposome 210 combined with nedaplatin 50mg D1-3 + sindilimab 100mg) reduced the patient's nausea, vomiting and other discomfort after treatment, which could not be relieved. considering that chemotherapy combined with immune side effects is relatively large, and after CT evaluation, some pulmonary nodules are larger than those on August 2, 2019, and some of them are new, and pericardial effusion is slightly increased; after communicating with family members, the patients were treated with xindilimab 100mg monotherapy (maintained for 2 cycles on September 16, 2019 and October 18, 2019, respectively). what is the efficacy of immunomonotherapy? Jump out of the guidelines and seek vitality for patients. Can patients control their condition with single drug maintenance? What is the follow-up plan? At the 29th World Conference on lung cancer (wclc) in 2019, Professor Han Baohui of Shanghai Chest Hospital reported the clinical research results of sindilimab combined with anlotinib: sindilimab combined with anlotinib showed encouraging anti-tumor activity in untreated advanced non-small cell lung cancer, with an objective remission rate of 72.7% and a disease control rate of 100%, and it was shown in all subgroups The combination therapy was safe and tolerable. after being informed of the most timely clinical study, the team immediately communicated with the family members of the patients, and started the combination therapy of sindilimab 100mg + anlotinib 12mg from November 12, 2019, and has maintained the curative effect so far (pulmonary nodules are significantly reduced), and thyroid function has gradually recovered. in the course of treatment, this case is still a successful case of immunotherapy in the treatment of advanced lung squamous cell carcinoma. the following difficulties appeared in the treatment process, and the guests also had a wonderful discussion as follows: 1. How to arrange and arrange the troops for immunization, targeting and chemotherapy: how to combine them? When does the dose change? For this patient, when the pulmonary nodules and pericardial effusion were found for the first time, immunotherapy combined with chemotherapy was applied according to the guidelines, and a certain effect was achieved; however, after the occurrence of side effects, how to choose drug combination? The side effects of chemotherapy are obvious, but the clinical treatment scheme is standard; immunotherapy will have serious adverse reactions, so we should be vigilant, such as fulminant myocarditis, the relevant treatment is relatively difficult, and the heart function needs to be detected in time during the treatment. when choosing the combined treatment scheme in clinical practice, it is necessary to make a specific analysis according to the specific conditions of patients and the guidelines. generally, after 4-6 cycles of combined immunochemotherapy, if there are serious side effects or patients refuse to use, they can be considered to switch to immune plus vascular targeted therapy; whether the dosage of immunotherapy is increased or not depends on the patient's condition and the degree of related adverse reactions. If the patients can tolerate the side effects, the dosage can be considered to increase the curative effect. Br / > at present, it is possible to carry out surgical adjuvant therapy for patients in the early stage. Side effects of immunotherapy: how to treat hypothyroidism? Oral thyroid hormone or glucocorticoid alone? With the wide application of immunotherapy in clinic, the relevant adverse reaction classification and treatment plan have been formulated. during the treatment, hypothyroidism occurred in this patient, and the treatment was in line with the treatment plan; before treatment, suspected cancer cells were found in pericardial effusion of the patient, so it is considered that it is related to the condition of malignant tumor, so the use of glucocorticoid may promote the recovery of thyroid function. 3? This patient had pericardial effusion before treatment, which increased in the course of immunotherapy, and cancer cells were found by puncture. Therefore, there may be the following reasons: it is related to the condition of malignant tumor; it is related to hypothyroidism; it may also be related to immune reconstruction caused by late immunotherapy. in addition, the patient is in the late stage. Is there any effusion caused by malnutrition (such as hypoproteinemia) caused by cachexia? Therefore, for pericardial effusion, the next step is to consider the second generation sequencing of exfoliated cells in the effusion, and make further pathological analysis, which may help to guide clinical treatment.