Stage 3 squamous cell lung cancer: major response to chemo-immunotherapy

What happened, in summary

An 81-year-old man was evaluated for cough and found to have squamous cell lung cancer in the right lower lobe. Imaging showed a 51 mm mass extending toward the central side of the right upper lobe and involving the #11 hilar lymph node. PET/CT showed no distant metastasis, and bronchoscopy showed B6 obstruction and erythematous bronchial mucosa. The preoperative stage was cT3N1M0, Stage IIIA. PD-L1 testing showed tumor expression of 30%-40%. A right pneumonectomy would normally have been needed to remove all cancer, but his age, chronic kidney disease, and reduced lung function made that approach high risk. To shrink the tumor and preserve more lung, he received 3 courses of neoadjuvant paclitaxel 200 mg/m², carboplatin AUC 5, and nivolumab 360 mg. After treatment, the tumor decreased from 51 mm to 18 mm, PET uptake fell, and there was still no distant metastasis. The post-treatment stage was ycT1bN0M0, Stage IA2, allowing a sleeve right lower lobectomy rather than pneumonectomy. Surgery removed the right lower lobe with bronchial reconstruction between the intermediate and middle lobar bronchi. The postoperative course was uneventful, and he was discharged without home oxygen. Pathology showed a 4 mm residual squamous cell carcinoma, negative bronchial margins, no lymph-node metastasis, and a major pathological response with 7.8% residual viable tumor. At 6 months after surgery, no metastasis or recurrence was observed. Bronchoscopy 1 month after surgery showed no stenosis or poor blood flow at the reconstructed airway, supporting safe preservation of the middle lobe despite the complex sleeve procedure.