ALK-Positive Metastatic Lung Cancer Responding to Lorlatinib During Hemodialysis

What happened, in summary

A 76-year-old woman who had never smoked and was receiving regular hemodialysis developed headaches in January 2023. Brain imaging found two masses, and surgery on one of them showed metastatic mucinous adenocarcinoma consistent with a lung primary. Imaging also found a left hilar lung mass, mediastinal lymph nodes, and lesions in both adrenal glands, making this Stage IV lung cancer.

Testing showed an ALK rearrangement in 80% of analyzed cells. EGFR, BRAF, and ROS1 testing was negative, and PD-L1 was also negative. After removal of the brain metastasis, she received stereotactic radiation to the brain. She then started the ALK-targeted drug lorlatinib in February 2023 while continuing hemodialysis 3 days each week.

Within the first month, her cholesterol and triglycerides rose. A statin was added, allowing lorlatinib to continue without a dose reduction. At 3 months, imaging showed marked tumor regression and no active brain metastases. By January 2024, PET-CT findings were almost compatible with a complete response, brain MRI remained clear, and her performance status had improved.

At the latest follow-up, she had taken lorlatinib for about 1 year with no major reported toxicity other than manageable high cholesterol, while continuing regular dialysis.