Multisystem Radiology

Immune Checkpoint Inhibitor Cancer Therapy: Spectrum of Imaging Findings

Author Affiliations

Published Online:Nov 13 2017https://doi.org/10.1148/rg.2017170085

Abstract

Immune checkpoint inhibitor cancer therapy is a targeted approach that has demonstrated dramatic successes in the treatment of advanced cancer and is rapidly expanding in clinical use; radiologists must be knowledgeable of its atypical treatment response pattern and commonly associated adverse events.

Immune checkpoint inhibitors are a new class of cancer therapeutics that have demonstrated striking successes in a rapid series of clinical trials. Consequently, these drugs have dramatically increased in clinical use since being first approved for advanced melanoma in 2011. Current indications in addition to melanoma are non–small cell lung cancer, head and neck squamous cell carcinoma, renal cell carcinoma, urothelial carcinoma, and classical Hodgkin lymphoma. A small subset of patients treated with immune checkpoint inhibitors undergoes an atypical treatment response pattern termed pseudoprogression: New or enlarging lesions appear after initiation of therapy, thereby mimicking tumor progression, followed by an eventual decrease in total tumor burden. Traditional response standards applied at the time of initial increase in tumor burden can falsely designate this as treatment failure and could lead to inappropriate termination of therapy. Currently, when new or enlarging lesions are observed with immune checkpoint inhibitors, only follow-up imaging can help distinguish patients with pseudoprogression from the large majority in whom this observation represents true treatment failure. Furthermore, the unique mechanism of immune checkpoint inhibitors can cause a distinct set of adverse events related to autoimmunity, which can be severe or life threatening. Given the central role of imaging in cancer care, radiologists must be knowledgeable about immune checkpoint inhibitors to correctly assess treatment response and expeditiously diagnose treatment-related complications. The authors review the molecular mechanisms and clinical applications of immune checkpoint inhibitors, the current strategy to distinguish pseudoprogression from progression, and the imaging appearances of common immune-related adverse events.

^©RSNA, 2017

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Article History

Received: Apr 10 2017
Revision requested: June 30 2017
Revision received: July 17 2017
Accepted: July 27 2017
Published online: Nov 13 2017
Published in print: Nov 2017

Vol. 37, No. 7

Abbreviations

Abbreviations:
CTLA-4	cytotoxic T-lymphocyte antigen-4
FDA	Food and Drug Administration
irAE	immune-related adverse event
irRC	Immune-related Response Criteria
NSCLC	non–small cell lung cancer
PD-1	programmed cell death protein 1
PD-L1	programmed cell death 1 ligand 1
RECIST	Response Evaluation Criteria in Solid Tumors

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