PMC9748473_01
First-line treatment: (A1/A2) Baseline CT before first-line treatment; (B1/B2) CT after 2 cycles showed left lung nodules similar to before, pelvic metastases were significantly reduced; (C1/C2) follow-up CT on May 29, 2019 showed slightly enlarged left lung nodules, no pelvic metastases were observed.
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Re-examination of chest CT during postoperative adjuvant chemotherapy (30 August 2018) ( Figure 1A1 ) revealed a small nodule shadow in the left lower lung; the nodule had a cavity. On 3 September 2018, abdominal CT re-examination( Figure 1A2 ) due to abdominal pain revealed the following: 1. abdominal postoperative changes; 2. lower abdominal mass (metastasis was considered); and 3. a small amount of pelvic effusion. On 26 September 2018, first-line treatment (cetuximab + capecitabine and oxaliplatin (XELOX)) for mCRC was initiated, and the efficacy was evaluated as PR after 2 cycles ( Figure 1B1/B2 ). In May 2019, abdominal CT re-examination ( Figure 1C2 ) showed no clear pelvic swelling, and chest CT ( Figure 1C1 ) revealed small nodules in the left lower lung; the nodules were slightly larger than the nodules on previous imaging.
The period from the progression of lung metastasis to before the application of anlotinib + TAS-102 treatment: (A1/A2) Follow-up CT (2020.06.12): multiple nodules in bilateral lung; (B1/B2) CT (2020.08.12) after 1 cycle of second-line treatment; (C1/C2) initial application of cetuximab + TAS-102 in the third line, and discontinuation due to adverse reactions after only 2 cycles of cetuximab. On November 24, 2020, reexamination of CT showed that pulmonary nodules were increased and enlarged than before.
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In June 2020, chest CT ( Figures 2A1/A2 )showed multiple nodules in both lungs, and metastasis was considered. After the first cycle, the patient refused to continue chemotherapy because of severe diarrhoea, and chest CT ( Figures 2B1/B2 ) showed a reduction in the number of bilateral lung nodules. CT (24 November 2020) ( Figure 2C1/C2 ) revealed that the number and size of pulmonary nodules increased. Considering that anlotinib is administered orally and some previous studies have shown that the adverse reactions caused by anlotinib in the treatment of mCRC are controllable, after informed consent of the patients, in December 2020, the third-line treatment regimen was adjusted to anlotinib + TAS-102 (TAS-102 40 mg d1-5, d8-12 bid po; q28d + anlotinib 10 mg d1-14 qd po; q21d).
Anlotinib + TAS-102 treatment:(A1/A2) CT after 2 cycles (2021.03.15): the pulmonary nodules were larger than before (the right pulmonary nodules was 7.3 mm), and some cavities were formed; (B1/B2) reexamination CT (2021.05.31) showed that the right pulmonary nodules were smaller than before (6.4 mm); (C1/C2) last reexamination CT (2022.08.23): the right pulmonary nodules was 7.3 mm; multiple nodules in the left lung, and some cavities were formed.
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On lung CT (15 March 2021) ( Figures 3A1/A2 ), the bilateral lung nodules were larger than the nodule on previous imaging, and some cavities had formed. CT showed no pelvic mass. Chest CT ( Figures 3B1/B2 ) indicated that the pulmonary nodules were smaller than they were before and that some cavities had formed. The last re-examination ( Figures 3C1/C2 ) was 23 August 2022.
Diagnosis and treatment timeline.
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Efficacy was stable, and the PFS for Anlotinib + TAS-102 treatment was more than 20 months ( Figure 4 ).