Synchronous primary squamous lung cancers: long disease control after multimodal therapy, then Stage IVA lung recurrence

What happened, in summary

This 66-year-old man first presented with intermittent hemoptysis, about 4 mL of fresh blood each time. CT showed a right hilar mass with hilar and mediastinal lymphadenopathy, and biopsy confirmed squamous cell carcinoma. At re-evaluation 3 months later, the right upper-lung cancer was staged cT4N2M0, Stage IIIB. He received 2 cycles of carboplatin plus albumin-bound paclitaxel, but CT showed stable disease. Bronchoscopy then found an obstructing right bronchial tumor and a separate smooth left bronchial lesion. Both were squamous cell carcinoma, p40-positive and p63-positive. PD-L1 expression was 20%, and no other driver mutations were detected. After multidisciplinary review, the disease was treated as synchronous multiple primary lung cancers: Stage IIIB right upper-lung SCC and Stage IA left upper-lung SCC. He initially declined further recommended treatment and used traditional Chinese medicine at home. After later progression, surgery and concurrent chemoradiotherapy were considered too risky because of lung function, age, COPD, and tumor burden. He received induction carboplatin, albumin-bound paclitaxel, and toripalimab, but developed grade III myelosuppression with neutropenia and thrombocytopenia. He then received radiotherapy to the residual right lung lesion and high-risk lymphatic regions, 60 Gy in 30 fractions. Endostar was given during radiation, followed by 19 cycles of maintenance pembrolizumab plus Endostar. He remained stable for years, with PET-CT stable at 24 months. At 72 months, PET-CT and biopsy confirmed recurrent squamous cell carcinoma with bilateral lung metastases, Stage IVA. As of November 2025, he remained alive at 75 months with KPS 80 and had restarted systemic therapy with tislelizumab, paclitaxel, carboplatin, and Endostar.