PMC10495838_01
Serial CT and MRI of the case. (A,B) Baseline CT at diagnosis of the lung. (C) Baseline CT at diagnosis of the brain metastases. (D,E) CT after 3 months of osimertinib therapy with progressive disease of the lung. (F) MRI after 3 months of osimertinib therapy with progressive disease of the brain metastases with encephaledema. (G,H) CT after 3 months of alectinib therapy with a partial response of the lung. (I) MRI after 3 months of alectinib therapy and radiotherapy with a partial response of the brain metastases.
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F1
A chest computed tomography (CT) scan revealed a mass measuring 4.2 cm x 3.3 cm in the middle and lower lobe of the right lung (Figures 1A, B). Further brain magnetic resonance imaging (MRI) and positron emission computed tomography (PET) scans indicated the presence of multiple metastases in the brain and ribs (Figure 1C). Multiple lymph node metastases had also grown larger, measuring up to 3 cm x 2 cm (Figure 1D-e). A subsequent brain MRI revealed multiple scattered nodules in both brain hemispheres, which had increased in both size and quantity since the last examination (Figure 1F). After 2 weeks of treatment, follow-up chest CT and brain MRI scans showed a noticeable reduction in the size of the mass in the right lung, enlarged lymph nodes, and brain metastasis (Figure 1H-j).
Immunohistochemical staining features. (A) Immunohistochemistry of the lung. (B) Expression patterns of PD-L1. (C) Expression patterns of TTF-1. Immunohistochemistry of ALK rearrangement.
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F2
A transthoracic needle biopsy of the right lung mass revealed non-small cell carcinoma-favor adenocarcinoma (Figure 2). Aide, and the detection instrument used was Agilent MX3000P. Additionally, EML4-ALK was retested using immunohistochemistry, which showed strong positive expression of PD-L1 (>90%) (Figure 2).
EGFR and ALK testing was performed by real-time polymerase chain reaction (PCR).
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F3
Further molecular screening using real-time polymerase chain reaction (PCR) revealed the presence of EGFR 19 exon deletion and echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion (Figure 3).