What happened, in summary

A 49-year-old man sought care for breathlessness, palpitations, and fever. Imaging showed a right upper-lobe lung tumor and a rapidly enlarging right adrenal mass. The adrenal lesion was surgically removed, and pathology showed pleomorphic carcinoma. Further evaluation confirmed pleomorphic carcinoma of the lung, classified cT3N0M1b, stage IVA.

Although his performance status was good, the lung tumor grew quickly and a new metastasis appeared in the left adrenal gland. He received four cycles of carboplatin and nab-paclitaxel. The primary tumor progressed, and bone metastases then developed. Radiation to 30 Gy in 10 fractions was delivered to the bone lesions.

Testing found no EGFR, ALK, ROS1, or BRAF driver alteration. PD-L1 expression was high at 60% to 70%. Next-generation sequencing identified BRCA2, RBM10, and TP53 mutations but no actionable mutation, while tumor mutation burden was high at 42 mutations per megabase.

Pembrolizumab monotherapy was started at 200 mg. Assessment 11 months later showed a reduction in tumor diameter, and treatment was still continuing at 12 months. His disease had progressed on cytotoxic chemotherapy but then achieved sustained control with immune-checkpoint therapy.