Stage IIIA squamous lung cancer: surgery after nivolumab-related complications

What happened, in summary

This 74-year-old woman was being evaluated for impaired consciousness when doctors diagnosed type A acute aortic dissection. A chest CT performed before surgery for that condition incidentally found a nodule in the right upper lobe of the lung. Three months later, follow-up CT showed the nodule measured 23 mm and that there was another 5 mm nodule in the same lobe, suggesting intrapulmonary spread. PET/CT showed uptake in the right upper lobe nodules and right hilar lymph node. Bronchoscopy confirmed squamous cell carcinoma, and PD-L1 TPS was 99%. The lung cancer was staged cT3N1M0, Stage IIIA. She had a history of Graves’ disease treated 20 years earlier, but thyroid testing before cancer treatment was within the normal range. Neoadjuvant treatment began with nivolumab, carboplatin, and paclitaxel, but after the first cycle she developed drug-induced kidney injury, and the lung team stopped chemotherapy and planned surgery. Just before surgery, blood tests showed hyperthyroidism. Additional testing showed normal TPOAb and TgAb levels, and ultrasound showed thyroid enlargement without hypervascularity, supporting immune-checkpoint-inhibitor-induced destructive thyroiditis rather than Graves’ disease flare. Surgery was postponed to avoid thyroid crisis. She received oral dexamethasone 6 mg daily for 1 week, and thyroid hormone levels began improving. She then underwent thoracoscopic right upper lobectomy with lymph node dissection. Pathology showed no malignant cells in the primary tumor or adjacent lung tissue, but hilar lymph nodes still contained squamous cell carcinoma with PD-L1 TPS 70%, giving ypT0N1M0 Stage IIB disease. As of January 2025, thyroid function had normalized, and she had no recurrence 7 months after neoadjuvant treatment and 5 months after surgery.