What happened, in summary

A 23-year-old man presented with chest and abdominal pain in March 2022. Imaging showed extensive thoracic disease with pleural and pericardial effusions and enlarged mediastinal lymph nodes, and testing confirmed ALK-positive lung adenocarcinoma. He was diagnosed with Stage IV disease and started alectinib in April 2022. The lymph nodes shrank and the pleural and pericardial effusions improved. Eight months later, however, he developed headaches and vomiting, and MRI showed multiple brain metastases. He switched to lorlatinib in January 2023. Within just 12 days, the brain lesions had broadly decreased, and by 3 months they had completely disappeared on MRI with major symptom improvement. The intracranial response lasted for about 6 months. In July 2023, new brain metastases were detected, marking renewed progression despite the striking early response to lorlatinib.