Neoadjuvant chemo-immunotherapy in a kidney transplant recipient with locally advanced non-small cell lung cancer: a case report of a therapeutic dilemma

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Background: Immune checkpoint inhibitors (ICIs) have significantly improved outcomes in locally advanced non-small cell lung cancer (NSCLC), establishing chemo-ICI as the current standard of care. However, solid organ transplant recipients were systematically excluded from clinical trials because of the high risk of immune-mediated allograft rejection. In kidney transplant recipients, reported rejection rates range from 25% to 45% with frequent irreversible graft loss. Balancing antitumor efficacy and graft tolerance, therefore, represents a major therapeutic dilemma. We present a rare case illustrating the challenges and potential strategies for managing locally advanced NSCLC in a kidney transplant recipient. Case Description: A 69-year-old male kidney transplant recipient (grafted in 2012) treated by tacrolimus and mycophenolate mofetil presented with an incidental left lower lobe opacity on chest radiography. Further imaging revealed two pulmonary masses in the upper and lower lobes, both hypermetabolic on positron emission tomography-computed tomography (PET-CT). Pathological analyses from bronchial biopsies revealed a squamous NSCLC (stage IIIA-cT4N0M0). A neoadjuvant regimen combining carboplatin, paclitaxel and nivolumab was initiated after multidisciplinary discussion involving oncological and nephrological teams. Treatment was well tolerated without renal impairment. Post-treatment CT showed significant tumor shrinkage, and the patient underwent a left pneumonectomy. Pathologic analysis revealed a dissociated response with major regression in the lower lobe and residual viable tumor in the upper lobe. At 3 months, follow-up imaging showed no recurrence and no evidence of graft rejection, but a fatal pneumocystis infection at 5 months. Conclusions: This case highlights the feasibility of a neoadjuvant chemo-ICI approach in a renal transplant recipient with locally advanced NSCLC. The limited exposure to ICI may represent a safer compromise, reducing the risk of rejection while maintaining a meaningful antitumor response. Close multidisciplinary coordination between oncologists and transplant specialists remains essential to tailor immunosuppression and monitor graft function. This case suggests that selected transplant recipients might benefit from carefully controlled, short-course ICI-based regimens.

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