Defining the current role of immune checkpoint inhibitors in the treatment of mismatch repair-deficient/microsatellite stability-high colorectal cancer and shedding light on future approaches.

Introduction: Mismatch repair deficient (MMR-D)/microsatellite instability-high (MSI-H) colorectal cancer (CRC) carries unique biologic features including high tumor mutation burden, increased amount of mutation-associated neoantigen generation, and the presence of marked tumor-infiltrating lymphocytes. Immune checkpoint inhibitor (ICI) therapy has rapidly changed the treatment algorithm of MMR-D/MSI-H CRC.Areas covered: In this review article, we discuss the recent data regarding the use of ICIs in metastatic MMR-D/MSI-H CRC patients. We also elaborated on potential biomarkers of ICI response and innovative therapeutic approaches that may prevail resistance mechanisms for the treatment of MMR-D/MSI-H colorectal cancer.Expert opinion: Pembrolizumab was recently granted approval by the FDA as first-line therapy for metastatic MMR-D/MSI-H CRC based on the results of the Keynote 177 study. The combination of nivolumab and ipilimumab will also likely be a choice for the initial therapy of MMR-D/MSI-H CRC in the near future. More therapeutic modalities with novel immunomodulatory agents as well as targeted therapy directed to immune resistance pathways are needed. The novel approaches discussed in this review article will define potential treatment options for the management of MMR-D/MSI-H CRC patients who progress on first-line ICI therapy.