Sequential anlotinib and camrelizumab combination therapy achieves exceptional survival in multi-driver mutated, TMB-low/PD-L1-low/MSS pulmonary sarcomatoid carcinoma: case report and literature review

Pulmonary sarcomatoid carcinoma (PSC) is a rare and aggressive subtype of non-small cell lung cancer (NSCLC) whose molecular characteristics and therapeutic strategies remain poorly defined. This case report documents an exceptional 72-month overall survival in a 40-year-old male patient with stage IVa pulmonary sarcomatoid carcinoma (PSC). The patient harbored seven coexisting driver mutations [<i>ROS1</i>, <i>RET(exon16,exon19)</i>, <i>TSC2</i>, <i>ALK</i>, <i>STK11</i>, <i>PTEN</i>] and exhibited triple-negative immunosuppressive biomarkers: low PD-L1 expression (TPS 3%), low tumor mutational burden (TMB, 11mut/Mb), and microsatellite stable (MSS) status. Sequential anlotinib (anti-angiogenic drug) and camrelizumab (PD-1 inhibitor) combination therapy overcame three biological barriers: (1) angiogenesis inhibition reversed PD-L1 primary resistance by remodeling the tumor microenvironment; (2) treatment induced neoantigens bypassed TMB-L/MSS limitations; (3) multi-target synergy against seven driver mutations. This approach resulted in unprecedented survival outcomes: the 72-month overall survival dramatically exceeds the median OS of less than 12 months reported for advanced PSC, and the patient maintained a progression-free survival of over 37 months on combination therapy, surpassing historical PFS benchmarks. This case provides a clinically actionable framework for managing multi-driver mutated, immunoresistant PSC.