54-Year-Old Patient With ALK-Positive Non-Small Cell Lung Cancer
Patient Case:
The patient is 54 years old with no tobacco history, presenting with shortness of breath and a recent diagnosis of bilateral lower extremity deep vein thrombosis. CT showed a right lower lobe pulmonary embolism and a 3.8 cm x 3.2 cm mass in the medial left lower lobe with multiple, small surrounding nodules, a separate 10 mm nodule in the right upper lobe, and extensive mediastinal and hilar adenopathy. Abdominal and pelvic CT disclosed metastases to the liver and both adrenals. PET confirmed FDG-avid disease in the left lung, right lung nodules, supraclavicular, mediastinal and hilar lymph nodes, as well as bilateral adrenal lesions and multiple osseous metastases. Molecular testing, including ALK FISH, was initially negative for actionable mutation.
The patient started treatment with pembrolizumab, carboplatin, and bevacizumab with an initial partial response. Six months later, patient developed progression in liver and adrenals and underwent radiofrequency ablation. Tissue was retested and analysis showed an “obscure” ALK rearrangement. The patient was started on crizotinib with initial partial response but developed progression in liver and adrenals. Alectinib was started with continuous chemoradiotherapy for adrenals which became large and necrotic.
