In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?

I would offer cytotoxic platinum doublet chemotherapy and omit immunotherapy based on emerging data that TKI adverse events are often worse after prior immunotherapy exposure (Calles et al., PMID 32421452). The choice and dose of cytotoxic doublet will depend on the individual circumstances of each case (e.g., renal failure, baseline neuropathy, hepatic failure, etc). For adenocarcinoma, I generally favor 2-4 cycles of carboplatin with pemetrexed. For squamous cell carcinoma, I generally favor carboplatin with paclitaxel. For more aggressive phenotypes (large cell neuroendocrine, sarcomatoid, or high Ki-67 index), an argument could be made for cisplatin with etoposide, though I still tend to treat these as non-squamous NSCLC as above.