What happened, in summary

A 78-year-old man was diagnosed with Stage IV lung adenocarcinoma in January 2014, with metastases to the liver and bone. His earlier history also included treated Stage II prostate cancer, but the treatment pathway here is specific to his lung cancer.

He first received pemetrexed with carboplatin, followed by carboplatin, paclitaxel and bevacizumab. Later treatment lines included docetaxel, then gemcitabine with vinorelbine. When the lung cancer progressed in September 2015, he started nivolumab at 3 mg/kg every 2 weeks.

He completed 38 nivolumab cycles without major complications. After cycle 39, his hemoglobin fell to 8.6 g/dL from a baseline of 11–13 g/dL, with laboratory findings supporting hemolysis. Nivolumab was held. A lower-dose prednisone course did not correct the anemia, so treatment was intensified to prednisone 1 mg/kg/day plus rituximab weekly for 4 doses.

His hemoglobin improved to 11.1 g/dL by completion of rituximab and later reached 14.6 g/dL about 4 months after high-dose treatment began. Nivolumab remained on hold, while CT imaging and clinical assessment showed stable lung cancer. Re-challenge with nivolumab was being considered.