Stage IIIA lung adenocarcinoma: major pathological response after neoadjuvant immunochemotherapy, complicated by DILI/TEN

What happened, in summary

This 58-year-old man had a 40 pack-year smoking history, daily alcohol intake, type 2 diabetes, and hypertension. In September 2023, he developed a persistent cough lasting 2 months. Imaging showed a mass in the left upper lung, and CT-guided biopsy confirmed lung adenocarcinoma, staged cT2N2M0 / Stage IIIA because mediastinal lymph nodes were involved. He received 2 cycles of neoadjuvant chemotherapy plus immunotherapy with tislelizumab, carboplatin, and docetaxel. The last 200 mg dose of tislelizumab was given on 5 November 2023, 31 days before surgery. Follow-up CT showed a 68% reduction in tumor size and resolution of mediastinal lymph-node metastasis, allowing surgery to proceed. On 6 December 2023, he underwent thoracoscopic left upper lobectomy with systematic lymph-node dissection. Pathology showed less than 10% residual viable tumor cells, consistent with a major pathological response. The postoperative course was complicated by severe pneumonia. Because he had a beta-lactam allergy, moxifloxacin was used, followed by additional antimicrobial treatment. During recovery, he developed mixed-pattern drug-induced liver injury and toxic epidermal necrolysis, with oral erosions, widespread rash, and skin detachment affecting more than 30% of body surface area. Treatment included stopping the suspected drug, hepatoprotective therapy, methylprednisolone, antihistamines, and IVIG for 5 days. Liver enzymes improved by more than 50% within 2 weeks and returned near normal within 4 weeks. At 23 months after surgery, he remained clinically stable with no tumor recurrence. His story combines a favorable cancer outcome with a serious postoperative drug reaction. The cancer response was strong, and the complication required rapid recognition, withdrawal of the suspected trigger, and coordinated supportive care.