From metabolic to pathologic complete response: case report of Neoadjuvant Lorlatinib in Stage IIIB ALK-positive NSCLC combined with uniportal VATS

While stage IIIB non-small cell lung cancer (NSCLC) is generally considered unresectable, a subset of patients may benefit from neoadjuvant therapy following comprehensive evaluation. We report a 35-year-old non-smoking female diagnosed with stage IIIB (cT1bN2bM0) adenocarcinoma of the left lower lobe with multiple-station mediastinal lymph node metastasis. Based on multidisciplinary evaluation of multimodality imaging and ALK-positive status, the patient with high tumor burden yet no significant comorbidities received neoadjuvant lorlatinib. The patient achieved a complete metabolic response (CMR) on restaging PET-CT after 10 weeks of lorlatinib, which led to a multidisciplinary decision to undergo uniportal VATS lobectomy. Pathological examination confirmed a pathological complete response (pCR). After an uneventful 5-day hospitalization without complications, the patient remains disease-free at the 12-month follow-up. This is the first report of neoadjuvant lorlatinib followed by uniportal VATS achieving pCR predicted by CMR in stage IIIB ALK-positive NSCLC, given the limitations of short-term follow-up and a single-case design.