A case report and literature review of a pathologic complete response to alectinib in ALK-positive stage IV non-small cell lung cancer.

Background: Stage IV non-small cell lung cancer is not a curative stage. However, a novel approach to local treatment of the primary tumor may improve progression-free survival. The choice between radiotherapy or surgery, as well as the optimal timing for these treatments remains to be determined. We report here the first case, to our knowledge, of a multi-metastatic patient treated with consolidative surgery after neoadjuvant alectinib, resulting in a complete pathological response.

Case description: The patient was, as is typically observed in populations with oncogenic alterations such as anaplastic lymphoma kinase (ALK) rearrangements, a young and non-smoker; however, he was male. Bronchial endoscopy confirmed the diagnosis of bronchopulmonary adenocarcinoma with strong ALK expression demonstrated by immunohistochemistry. We initiated alectinib as first-line treatment for metastatic disease; however, due to the induced oligo-metastatic disease, a local treatment of the primary tumor was discussed during multidisciplinary board. Lobectomy was performed and histological examination confirmed the complete pathological response. Adjuvant alectinib was continued for unspecified duration due to the lack of available data.

Conclusions: This case suggests that local treatment, even in patients with stage IV disease, performed at the time of the best response to systemic therapy, may offer an improvement in progression free survival and perhaps a glimpse of a cure.