Neoadjuvant Therapy with Alectinib for Non-Small Cell Lung Cancer with Pleural Metastasis: A Case Report

Background: The prognosis of stage IV non-small cell lung cancer(NSCLC) with pleural metastasis is poor, with a 5-year survival rate of only 2% to 4% for patients, with the median survival was 9.5-11.5 months. According to the “NCCN Lung Cancer Guidelines,” stage IV NSCLC lung cancer is a contraindication for surgery. It is recommended to adopt a standard treatment plan mainly based on chemotherapy or targeted therapy with EGFR-TKIs. However, Neoadjuvant therapy with alectinib for non-small cell lung cancer with pleural metastasis is rarely reported. Case presentation: A 41-year-old Asian male patient presented with a persistent cough for one month. A chest computed tomography (CT) scan conducted two years prior revealed that a nodular radiative anomalous concentrated shadow was observed in the inferior tongue segment of the upper lobe of the left lung, approximately 2.2 × 1.6 × 1.2 cm in size, with a SUVmax of about 5.5. Two small nodular shadows were seen beside the disease in the inferior lingual segment of the upper lobe of the left lung, with the larger one having a diameter of approximately 0.6 cm. Multiple lymph node metastases in the left hilum and mediastinum; Multiple metastases of the left pleura and a small amount of pleural effusion on the left side. The patient began to receive 2 courses of chemotherapy and targeted therapy (pemetrexed+ carboplatin+crizotinib) and 1 course of chemotherapy and other targeted therapy (pemetrexed+ carboplatin+ alectinib). The result of re-examination of CT demonstrated that peripheral lung cancer in the lower lingual segment of the left upper lung is approximately 0.8 × 0.9 cm in size, slightly smaller than before. A thoracoscopic lobectomy was performed, and the pulmonary bulla was removed concurrently. Pathological examination confirmed non-small cell lung carcinoma (NSCLC) in the mass. Patient discharged on the 7th day after the operation and received 2 courses of chemotherapy (pemetrexed + carboplatin) and had been receiving alectinib targeted drug treatment all along for over 5 years. However, the patient stopped taking the medicine on his own for half a year. Though in the recent CT examination, the result demonstrated no recurrence and metastasis and the patient has been clinically cured. Unfortunately, the results of brain magnetic resonance imaging suggested that multiple brain metastases of lung cancer occurred, and the patient began taking the third-generation ALK-targeted drug lorlatinib. Conclusions: The patient with stage IV non-small cell lung cancer (NSCLC) presenting with pleural metastasis received neoadjuvant alectinib therapy and underwent thoracoscopic lobectomy, which resulted in significant therapeutic effects and fulfilled the criteria for clinical cure. This case highlights the potential for improved preventative strategies and treatment approaches in similar patients.