What happened, in summary

A 46-year-old nonsmoking woman was found to have a suspicious chest X-ray while hospitalized with SARS-CoV-2 in February 2021. Chest CT showed a 5.5 cm mass involving the costophrenic angle in the right lower lobe. PET-CT showed high FDG uptake in the right lower-lobe lesion and moderate uptake in ipsilateral mediastinal lymph nodes, with no distant metastasis. Brain MRI also showed no intracranial metastasis. CT-guided biopsy confirmed lung adenocarcinoma, and tissue next-generation sequencing identified an EML4-ALK fusion rearrangement. Her disease was classified as T3N2M0, consistent with Stage III lung cancer. She started neoadjuvant brigatinib, initially at 180 mg, but fever and weakness required a 50% dose reduction to 90 mg, which was maintained for 7 weeks. Follow-up chest CT showed a partial response with about 60% tumor shrinkage. She then underwent right lower lobectomy and mediastinal lymph-node dissection. Pathology showed a pT1cN1 response and negative spread through air spaces. After surgery, she continued adjuvant brigatinib 90 mg once daily for 32 months. Follow-up PET-CT showed no evidence of disease, and brain MRI showed no brain metastases. The important details are the EML4-ALK fusion, toxicity-driven dose reduction, substantial radiologic response before surgery, and prolonged adjuvant brigatinib after resection. Her disease was local-regional at diagnosis, not metastatic, and the later imaging supports a cancer-free/NED outcome. The initial discovery during SARS-CoV-2 hospitalization is also important because the lung cancer was detected through imaging performed for another reason. Her fever and weakness were treatment-limiting but manageable through dose reduction rather than treatment discontinuation, allowing her to reach surgery and continue long-term adjuvant therapy.