Fig. 1

Treatment course. First-line treatment with cisplatin/pemetrexed shrunk the primary lesion and mediastinal lymph nodes (a, b), but PD was noticed 9 months after the beginning of treatment (c). Re-biopsy performed during treatment with cisplatin/pemetrexed indicated that the tumor was ALK-positive. Therefore, second-line treatment with alectinib was subsequently initiated. Although alectinib treatment was successful, the patient developed DILD 4 months after the start of treatment (d). After DILD was relieved upon treatment with steroids, third-line treatment with nab-paclitaxel was initiated, but PD was observed 4 months later (e). Thereafter, fourth-line treatment with lorlatinib was started and has been continued for more than 33 months while maintaining SD (f). PD progressive disease, ALK anaplastic lymphoma kinase, DILD drug-induced interstitial lung disease, SD stable disease, nab-paclitaxel nanoparticle albumin bound paclitaxel