Extensive-stage small cell lung cancer with brain and adrenal progression after prolonged disease control

What happened, in summary

A 58-year-old man with no smoking history presented in November 2020 after 1 month of cough. CT showed a right hilar lung mass with enlarged lymph nodes at the right neck root and mediastinum. Tumor markers were elevated, including CEA 10.09 ng/mL, neuron-specific enolase 74.80 ng/mL, cytokeratin 19 fragment 4.34 ng/mL, and gastrin-releasing peptide precursor 470.00 pg/mL. Brain MRI showed an abnormal signal in the right frontal skull but no clear intracranial abnormality; abdominal CT and bone imaging did not show definite metastases. Bronchoscopic biopsy of the right middle lobe confirmed small cell lung cancer, with immunostaining positive for CD56, CgA, TTF-1, and CK8/18, and Ki-67 around 80%. He was diagnosed with extensive-stage SCLC, T3N3M1. In December 2020, he started etoposide plus cisplatin every 3 weeks for 6 cycles. After 2 cycles, the tumor and lymph nodes had shrunk enough to fit within one radiation field, so concurrent chemoradiotherapy began in January 2021, delivering 60 Gy in 30 fractions to the right lung tumor, mediastinum, and right neck root. He declined immunotherapy because of cost and declined prophylactic cranial irradiation. CT later showed no residual lung tumor. In December 2021, brain and right adrenal metastases appeared. He again declined immunotherapy and chose anlotinib with whole-brain radiation, irinotecan, and carboplatin. Brain lesions partially responded, and the right adrenal lesion was stable, then later partially responded after adrenal radiation. He continued anlotinib, with disease stability for 31 months. In July 2024, new brain metastases and adrenal progression appeared. He declined further chemotherapy, immunotherapy, lurbinectedin, and tarlatamab because of cost and continued anlotinib.