Long-term survival in SMARCA4-deficient undifferentiated lung carcinoma: a case report

Introduction

Lung cancer remains a leading cause of death from cancers globally (1). Non-small cell lung cancer (NSCLC) represents about 85% of cases (2), within which SMARCA4-deficient carcinoma is a rare (5–10%) yet aggressive subtype (3). Although its proportion is low, its unique biological characteristics pose numerous challenges to clinical diagnosis and treatments.

SMARCA4-deficient undifferentiated lung carcinoma features inactivating mutations of the SMARCA4 gene encoding the BRM/SWI2-related gene 1 (BRG1) protein (4). It is formally recognized in the 2021 WHO Classification (5), which is associated with smoking, predominantly affecting middle-aged males (6,7). This tumor portends a dismal prognosis due to its rapid progression (8), limited response to conventional chemotherapy, and median overall survival often reported to be less than 6 months (9).

The molecular profile of SMARCA4-deficient tumors, frequently linked to a high tumor mutational burden (TMB), provides a theoretical basis for potential sensitivity to immune checkpoint inhibitors (10). However, translating this theoretical susceptibility into tangible, long-term survival benefits remains a significant clinical challenge. According to the current reports, immunotherapy combined with chemotherapy demonstrates a limited objective response rate (ORR) in SMARCA4-deficient tumors, and the associated 12-month survival rate remains suboptimal (11,12). More than 61.5% of patients fail to achieve sustained remission, and the median overall survival is generally less than 6 months (13). There is a critical gap in evidence regarding effective treatment strategies, particularly for patients with unresectable locally advanced disease, which can durably control this aggressive malignancy.

This case report details the exceptional clinical course of a patient with unresectable stage IIIA (T3N1M0) SMARCA4-deficient undifferentiated lung carcinoma. It aims to describe the diagnostic process and the personalized, sequential multimodal therapeutic strategy employed. The purpose is to share an instance of achieving prolonged progression-free survival exceeding 41 months, thereby contributing a potentially informative experience in management, to the limited literature on this challenging disease entity. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-342/rc).

Case presentation

A 51-year-old male farmer presented to the hospital on June 22, 2022, with “acute shortness of breath accompanied by blood-streaked sputum for over one week”. He had a significant smoking history for over 20 years, consuming approximately 20 cigarettes per day. His family history was notable for his father who died of hepatocellular carcinoma. Physical examination on admission revealed dullness to percussion over the left upper lung field, with slightly diminished breath sounds in the same area. A few moist rales were audible in the right lower lung field.

Upon admission, a chest computed tomography (CT) scan (June 22, 2022) was immediately performed, revealing: (I) a mass in the apical-posterior segment of left upper lung lobe 3.7 cm × 4.5 cm × 3.3 cm, with adjacent pleural thickening and adhesion; (II) a soft tissue mass in left hilum 4.2 cm × 4.5 cm, surrounding the blood vessels and bronchi in the left hilum area, resulting in narrowing of left main bronchus; (III) the mediastinum was centrally located, with visible and increased mediastinal lymph nodes, but no obvious enlargement. A positron emission tomography-computed tomography (PET-CT) scan (June 27, 2022, Image No. 80801220628002) showed: a paracardiac mass in the apical-posterior segment of the upper lung lobe (locally adherent to the adjacent mediastinal pleura and with unclear boundary with the aortic arch), and multiple enlarged lymph nodes in left hilum area, both with abnormally increased fluorodeoxyglucose (FDG) metabolism (Figure 1). All imaging assessments were reviewed and agreed upon by two senior thoracic radiologists at Mianyang Third People’s Hospital. Combined with the medical history, this was consistent with peripheral lung cancer accompanied by mediastinal pleural invasion and left hilar lymph node metastasis. On June 24, 2022, “endoscopic ultrasound-guided fine-needle aspiration (FNA) of mediastinal lymph nodes + diagnostic bronchoalveolar lavage (BAL) under bronchoscope” was performed. Endoscopic ultrasound showed: significantly enlarged 10L and 11L lymph nodes with heterogeneous echo and abundant blood supply; 2R and 4R lymph nodes were visible with high density (Figure 2). The pathological examination results of this hospital showed: carcinoma detected, with high malignancy. Immunohistochemistry revealed: tumor cells positive for PCK (+), negative for CD56 (−), negative for SyN (−), focally positive for CgA (focal +), negative for TTF-1 (−), negative for P40 (−), negative for LCA (−), negative for SSTR-2 (−), negative for CD20 (−), and Ki67 index approximately 85% (+) (Figure 3).

Figure 1 PET/CT image. Initial staging PET/CT. A mass in left upper lobe (white arrow) and left hilar lymph nodes (gray arrow) demonstrate intensely increased FDG uptake, confirming locally advanced disease with high metabolic activity, which guided the aggressive treatment approach. FDG, fluorodeoxyglucose; PET/CT, positron emission tomography/computed tomography.

Figure 2 Ultrasound lymph nodes. Endoscopic ultrasound showed significantly enlarged 10L and 11L lymph nodes with heterogeneous echo and abundant blood supply; 2R and 4R lymph nodes were visible with low density.

Figure 3 Lymph node pathological biopsy. Lesion location: left upper lung lobe orifice, 10L + 11L; specimen type: small biopsy tissue; pathological diagnosis: malignant tumor: immunohistochemistry: tumor cells PCK (+), CD56 (−), SyN (−), CgA (focal +), TTF-1 (−), P40 (−), LCA (−), SSTR-2 (−), CD20 (−), Ki67 index approximately 85% (+). Neuroendocrine carcinoma was suspected, but the current immunohistochemical results did not support this diagnosis, so clinical association was recommended. Original magnification: ×200.

Neuroendocrine carcinoma was suspected based on the focal expression of neuroendocrine markers [chromogranin A (CgA)], however, the overall immunophenotype was atypical and non-diagnostic, presenting a significant diagnostic challenge. Given the undifferentiated morphology and complex immunoprofile, a broad differential diagnosis was considered, including high-grade neuroendocrine carcinoma, other poorly differentiated non-small cell lung carcinomas (e.g., sarcomatoid carcinoma), lymphoma, and metastatic sarcoma. The initial immunohistochemical results were insufficient to definitively classify the tumor. To resolve this diagnostic dilemma, a pathological consultation was conducted at West China Hospital of Sichuan University, and the report showed: Immunohistochemistry: BRG1 (− , loss), PCK (−), partially positive for CgA (partial +), occasionally positive for CD56 (occasional +), partial loss of RB (partial loss), negative for desmin (−), occasionally positive for P53 (occasional +), Ki67 index approximately 80–90%. Combined with the histological morphology, the pathological diagnosis was: malignant tumor, with immunophenotype showing BRG1 protein loss, considered as SMARCA4-deficient undifferentiated tumor. Therefore, the patient was diagnosed with undifferentiated carcinoma of left upper lung lobe, stage IIIA (T3N1M0) (SMARCA4-deficient). Notably, due to limited biopsy tissue and the patient’s preference, TMB and programmed death-ligand 1 (PD-L1) expression were not assessed, which limits the mechanistic interpretation of the immunotherapy response.

Due to the malignant tumor being indistinctly bounded with aortic arch, accompanied by pleural and left hilar lymph node metastasis, there was no indication for surgical resection then. Combined with the teleconsultation opinions from Peking University Cancer Hospital and West China Hospital, a sequential treatment regimen of “systemic chemotherapy-immunotherapy-definitive radiotherapy-immune maintenance” was developed for the patient.

The patient received six cycles of induction therapy with the etoposide + cisplatin (EP) regimen (etoposide 160 mg on Days 1–3 + carboplatin 500 mg on Day 1) combined with 200 mg of sintilimab on Day 1 from July 14, 2022, to December 19, 2022. The EP regimen based on the initial diagnostic challenge and the focal expression of neuroendocrine markers (CgA) was selected, raising suspicion for a high-grade neuroendocrine carcinoma component, for which EP is an established systemic therapy option. After the 2nd cycle (September 1, 2022), the evaluation showed partial response (PR), indicating significant tumor shrinkage. Given the locally advanced nature of the disease [stage IIIA (T3N1M0)] and the potential for residual microscopic disease despite systemic response, a multidisciplinary tumor board recommended consolidative radiotherapy to enhance local control and reduce the risk of locoregional recurrence. Radiotherapy was initiated with eradicating residual tumor cells in the primary site and involved lymph nodes, while leveraging potential synergistic effects with immunotherapy through immunogenic modulation of tumor microenvironment. Therefore, intensity-modulated radiation therapy (IMRT) was initiated on September 16, 2022 [planned gross tumor volume (pGTV) 60 Gy/30 fractions, pCTV 50 Gy/25 fractions].

During radiotherapy, the 4th cycle of treatment was administered concurrently, and a total of 24 radiotherapy sessions were completed (pGTV 48 Gy, pCTV 48 Gy). The radiotherapy course was shortened from the planned 30 fractions (60 Gy) to 24 fractions (48 Gy) following multidisciplinary re-evaluation after significant tumor shrinkage post-induction therapy. This adjustment aims to minimize potential toxicity while maintaining disease control, given the favorable response already achieved. After the induction therapy combined with radiotherapy, the evaluation showed stable disease (SD) (the lesion in the apical-posterior segment of left upper lung lobe was 1.5 cm × 1.4 cm × 2.2 cm) with the treatment was generally well-tolerated. During the chemotherapy cycles, the patient experienced occasional adverse events including vomiting, dizziness, and anorexia, managed with supportive care. Radiotherapy was associated with grade 1–2 radiation esophagitis (presenting as a throat obstruction sensation) and radiation dermatitis (characterized by itching and burning sensation over the chest skin), both of which were manageable, not leading to treatment interruption. The patient adhered to the planned treatment schedule without any delays or discontinuations. From April 8 to July 11, 2024, based on sustained SD, 3 sessions of sintilimab monotherapy maintenance treatment were initiated (200 mg per session). The decision to resume immunotherapy after an interval was based on a shared decision-making process with the patient, considering the long-term disease stability, the goal of consolidating response, and managing treatment-related costs and patient preferences. The re-initiation was preceded by a thorough reassessment confirming continued SD. During this period, evaluation showed disappearance of the primary lesion and stable hilar nodules. Subsequent long-term follow-ups were conducted. As of the latest reexamination (May 26, 2025), the reexamination revealed no definite, measurable mass according to Response Evaluation Criteria in Solid Tumors, Version 1.1 (RECIST 1.1) criteria in the apical-posterior segment of left upper lung lobe (where the primary lesion had regressed), and the maximum cross-section of residual hilar nodule was 1.1 cm × 1.4 cm, consistent with maintained stable disease. The progression-free survival (PFS) reached 3 years and 5 months, and the overall survival (OS) has not been reached yet, with ongoing follow-up (Figure 4).

Figure 4 Graphical representation of the sequential multimodal treatment logic. The timeline illustrates the conceptual framework of management strategy: Initial induction to achieve systemic cytoreduction and immune activation, followed by consolidative radiotherapy to eradicate residual local disease and potentially synergize with immunotherapy, and finally extended maintenance immunotherapy to sustain immune surveillance, highlighting the strategic sequencing that contributed to long-term disease control. CT, computed tomography; EP, etoposide + cisplatin; IMRT, intensity-modulated radiation therapy; pCTV, planning clinical tumor volume; pGTV, planned gross tumor volume; PR, partial response; SD, stable disease.

After the standardized treatment, the patient’s lesions were significantly reduced, and the quality of life was significantly improved. As shown in Figure 5: at the initial diagnosis (June 22, 2022), the primary lesion in left upper lung lobe 3.7 cm × 4.5 cm × 3.3 cm, and the hilar nodule 4.2 cm × 4.5 cm, increased mediastinal lymph nodes, with moderate heterogeneous enhancement. After the complete treatment cycle of “chemotherapy + immunotherapy combined with radiotherapy + immune maintenance therapy”, the patient’s first systematic chest CT reexamination on November 7, 2024 showed: no mass was detected in the primary lesion, the hilar nodule was reduced to 1.1 cm × 1.4 cm, no definite enhanced mass and mediastinal lymph node enlargement was observed. Compared with this reexamination, no significant changes were found in the latest follow-ups, and the SD status was maintained for a long time. However, morphological imaging alone may fail to fully capture minimal residual disease or early signs of progression. For similar cases in the future, integrating circulating tumor DNA (ctDNA) monitoring or functional imaging assessments could enhance the sensitivity and standardization of follow-up.

Figure 5 Serial chest CT findings throughout the treatment course. CT, computed tomography; RECIST, Response Evaluation Criteria in Solid Tumors.

Through the analysis on this series of comparative imaging images (Figure 6), the patient’s disease changes throughout the treatment could be intuitively observed from tumor invasion and metastasis before treatment to tumor reduction, disappearance, and stable disease after treatment which totally demonstrates the efficacy and safety of sequential treatment regimen on “chemotherapy-immunotherapy-radiotherapy-immune maintenance”, providing an important reference for the treatment of similar patients.

Figure 6 Serial chest CT imaging throughout the treatment course. (A) At initial diagnosis (June 22, 2022): a mass in the left upper lobe (white arrow) and left hilar lymphadenopathy with moderate heterogeneous enhancement. (B) After 2 cycles of induction chemo-immunotherapy (September 1, 2022): significant reduction of the primary lesion and hilar nodule, with patchy weak enhancement. (C) After consolidative radiotherapy (November 14, 2022): further shrinkage of the primary lesion, residual hilar nodule, and stable disease. (D) Prior to the 6th cycle of chemotherapy (December 7, 2022): continued tumor regression, primary lesion size reduced to 1.5 cm × 1.4 cm × 2.2 cm. (E) After completion of 6 cycles of chemo-immunotherapy (July 6, 2023): stable disease, no obvious mass in the left upper lobe, residual hilar nodule with mild heterogeneous enhancement. (F) Before maintenance immunotherapy (February 5, 2024): primary lesion no longer detectable, hilar nodule reduced to 1.6 cm × 1.2 cm, no lymphadenopathy. (G) During maintenance therapy (June 13, 2024): stable disease, residual hilar nodule with no significant change. (H) After maintenance therapy (November 7, 2024): sustained stable disease, primary site remained undetectable, hilar nodule further reduced to 1.1 cm × 1.4 cm. (I) Latest follow-up (May 26, 2025): no definite measurable mass according to RECIST 1.1 criteria, stable residual hilar nodule, sustained deep remission. White arrows indicate the primary lesion in the left upper lobe. CT, computed tomography; RECIST, Response Evaluation Criteria in Solid Tumors.

Patient perspective

The patient, a 51-year-old male farmer, provided a firsthand account of his journey. He described being “terrified and breathless” at diagnosis, with a routine farm work becoming impossible due to severe dyspnea and intermittent hemoptysis. Following the initiation of therapy, he observed a gradual but definitive improvement: “The coughing up of blood stopped within the first few cycles, and I could finally take a deep breath again without struggle.” He successfully returned to light agricultural work approximately 8 months during the treatment. Regarding treatment tolerance, he stated, “Side effects were tough at times, especially the fatigue and throat discomfort during radiotherapy, but the medical team managed them well, and it was bearable knowing it was working.” At the latest follow-up, he expressed profound gratitude for the extended period of stable health, saying, “Being able to live a normal life with my family members for these extra years has been a gift. I followed my check-ups regularly and hope this stability continues.” This narrative highlights not only the clinical efficacy but also the profound personal restoration achieved through this intensive treatment course.

Ethical consideration

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. All patient-identifying information has been anonymized to strictly protect privacy.

Discussion

This case details a patient with stage IIIA (T3N1M0) SMARCA4-deficient undifferentiated lung carcinoma achieving a progression-free survival exceeding 41 months following a multimodal sequential treatment strategy. It must be emphasized that the overall prognosis of SMARCA4-deficient undifferentiated lung carcinoma remains extremely poor, with a median survival typically less than 6 months (11,14). Given the historically poor outcomes associated with this aggressive subtype, this favorable result warrants the discussion in the context of specific management decisions applied.

The primary strength of this report is the detailed longitudinal documentation of a novel therapeutic sequence achieving long-term disease control in a malignancy where the median overall survival is typically measured in months, providing a real-world, hypothesis-generating example. Several limitations must be acknowledged: first, the absence of TMB and PD-L1 expression data due to patient preference limits the mechanistic interpretation of immunotherapy response, rendering the immunological rationale speculative. Second, while the response was assessed per RECIST 1.1, the lack of independent central radiology review introduces potential subjectivity. Finally, as a single-case report, the findings are not generalizable and require validation.

The diagnostic process in this case underscores the challenges in recognizing SMARCA4-deficient tumors. The undifferentiated morphology and heterogeneous immunophenotype-such as the focal expression of neuroendocrine markers observed here-easily lead to confusion with entities such as high-grade neuroendocrine carcinoma or sarcomatoid carcinoma (15). Initial immunohistochemical findings were insufficient for definitive classification, and diagnosis was only confirmed upon detection of BRG1 protein loss highlighting the necessity of routinely incorporating SMARCA4 (BRG1) immunohistochemistry into the diagnostic workup of undifferentiated thoracic tumors, as a prerequisite for accurate diagnosis and enabling subsequent personalized treatment planning.

Existing literature reports limited objective response rates and rare sustained long-term remission with immunotherapy combinations in SMARCA4-deficient carcinoma (16). The observed outcomes of this case may be explained by multifaceted interactions between treatment components: early integration of sintilimab, informed by the frequent association of SMARCA4-deficient tumors with high TMB (17); Consolidative intensity-modulated radiotherapy after significant systemic response, potentially enhancing local control through direct eradication of residual clones, reduced target volume, and immunomodulatory effects (18-20); And maintenance immunotherapy possibly sustaining “immune surveillance” (21).

This case highlights key management considerations: advocating a “molecular-first” diagnostic approach with routine SMARCA4 (BRG1) testing; adopting an integrated, longitudinal treatment perspective encompassing induction, consolidation, and maintenance phases. For future prospective, biomarker-driven studies are needed to validate this sequential strategy and define optimal treatment components.

Conclusions

In conclusion, this case report describes a patient with unresectable stage IIIA(T3N1M0) SMARCA4-deficient undifferentiated lung carcinoma achieving prolonged progression-free survival exceeding 41 months following a personalized, sequential multimodal strategy on induction chemo-immunotherapy, consolidative radiotherapy, and maintenance immunotherapy. While limited to a single observation, this outcome demonstrates that long-term disease control is attainable in this aggressive malignancy which underscores the potential importance of accurate molecular diagnosis, the early integration of immunotherapy based on molecular profiling, and the strategic sequencing of local and systemic modalities. This case contributes a hypothesis-generating management example to the limited literature, highlighting the need for prospective, biomarker-driven studies to validate and optimize such integrated therapeutic approaches for this challenging disease.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-342/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-342/prf

Funding: This study was supported by the Key Research Project of Sichuan Province (No. 20PJ267).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-342/coif). All authors declared that this study was supported by the Key Research Project of Sichuan Province (No. 20PJ267). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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