case_images: PMC11269150_01
case_images: Computed tomography images before and after treatment with brigatinib. (A-C) Before treatment, a primary mass measuring 4.9 cm can be observed, along with a satellite nodule measuring 1.2 cm in the lower lobe of the right lung, with right interlobar lymph node metastasis. (D-F) A significant response in the primary lung lesions, satellite nodule, and lymph node can be observed after brigatinib therapy.
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case_images: On chest computed tomography, two lobulated enhancing lung lesions, measuring 4.9 and 1.2 cm, were identified in the right lower lobe, along with an enlarged right interlobar lymph node ( Figures 1A-C ). This treatment provided a dramatic radiographic response, with a significant reduction in the primary lung tumor size from 4.9 to 1.7 cm ( Figures 1D-F ).
case_images: Pathological examination of the tissue specimen from endobronchial ultrasound-guided transbronchial needle aspiration and video-assisted thoracoscopic right lower lobectomy with mediastinal lymph node dissection. (A) The biopsy sample shows clusters of atypical epithelial cells with plump cytoplasm (H&E, 200x). (B) Representative immunohistochemistry image showing tumor cells nuclear-positive for TTF1 (200x). (C) Representative image showing strong granular cytoplasmic expression of anaplastic lymphoma kinase (D5F3, Ventana CDx) (H&E, 200x). (D) Representative image showing a break in the ALK locus, indicated by the Vysis ALK Break abnormal signal pattern of isolated red and distinct break-apart signals (Vysis ALK Break Apart FISH probe).
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case_images: Histopathological examination of the biopsy specimen revealed adenocarcinoma with focal mucinous differentiation ( Figures 2A, B ). Break-Apart FISH Probe Kit, Abbott Molecular Inc., Abbott Park, IL, USA) showed an ALK gene rearrangement ( Figures 2C, D ). After a multidisciplinary discussion, the patient decided to proceed with surgery, after neoadjuvant brigatinib therapy. Brigatinib monotherapy was administered at a dose of 90 mg, once daily for the first 7 days.
case_images: (A) The low magnification view shows a nodular area, considered the tumor bed (H&E, 10x). (B) Lymphoid aggregation and fibroblast can be observed in the nodular area of (A) (H&E, 100x). (C) Fibrotic changes can be seen in the peribronchial area, which is compatible with the tumor bed (H&E, 400x). (D) In the high-power view of (C), macrophage and lymphocyte infiltration and a cholesterol cleft can be observed in the fibrotic area. (H&E). Overall, there are no viable tumor cells on tumor bed and the final diagnosis is compatible with pathologic complete response.
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case_images: Histopathological examination of the resected specimen then confirmed a pCR, with no evidence of viable tumor cells ( Figure 3 ).
case_images: The timeline of the entire therapy process.
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case_images: Additionally, the patient did not experience any brigatinib-related adverse events, and there were no notable findings in either the tumor marker or biochemistry laboratory test results.  Figure 4  illustrates the timeline of the entire therapy process.