Stage 3C lung cancer: complete remission on immunotherapy and chemotherapy

What happened, in summary

A 44-year-old man with no previous medical history sought care for trouble with esophageal transit. Endobronchial ultrasound-guided transbronchial needle aspiration of a station 7 lesion confirmed non-small-cell lung cancer in the right lower lobe with intrathoracic adenopathy. The tumor involved the mediastinum, compressed the right bronchus, and was partially exposed to the esophagus. Imaging confirmed Stage IIIC NSCLC. Testing showed no driver mutations such as EGFR or ALK, and PD-L1 tumor proportion score was less than 1%. Treatment began with durvalumab, tremelimumab, carboplatin, and nab-paclitaxel. On day 8, he developed grade 2 liver dysfunction and fever, which resolved. On day 34, grade 3 colitis was treated with methylprednisolone. COVID-19 was then detected and treated with remdesivir. Diarrhea worsened, requiring methylprednisolone 1 g for 3 days. On day 43, blood culture grew Candida albicans, and CT showed marked tumor shrinkage but also an esophagomediastinal fistula. That night, he went into shock with cytokine release syndrome and myocarditis. He required antifungal drugs, methylprednisolone pulse therapy, tocilizumab, immunoglobulin, vasopressors, intensive-care support, and hemodialysis. His vital signs stabilized within about 1 week, and dialysis ended after 2 months. Later Candida endophthalmitis and cytomegalovirus infection resolved with treatment. An esophageal stent was placed 2 months after CRS and removed 5 months later after fistula closure. Steroid therapy was tapered over 4 months. Feeding was temporarily maintained through a tube and central vein while the fistula was managed. More than 6 months after treatment began, CT showed tumor remission with no recurrence. Candida endophthalmitis resolved without sequelae, and oral intake restarted after esophageal stent placement.