PMC9484492_01
Dynamic changes on chest CT. (A) The initial CT scan on January 23, 2019, showed an irregular soft tissue mass measuring 5.7 cm x 4.5 cm in the middle and lower lobes of the right lung. (B) A CT scan on December 9, 2019, showed that the right lung lesion was reduced to 2.5 cm x 1.5 cm. (C) A CT scan on May 5, 2020, showed progression of the right lung lesion, which had grown to 4.5 cm x 3.5 cm.
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The right hilar lymph nodes were enlarged, and the mediastinal lymph nodes were slightly enlarged ( Figure 1 ).
PET/CT showed nodules in the right middle and lower lobes near the hilar area (A) the right psoas muscle area (B) and the gastrosplenic space and multiple nodules in the left renal parenchyma (C) uneven density of the left iliac bone (D) multiple round nodules in the right lung (E) and increased FDG metabolism, suggesting malignant lesions.
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FDG metabolism; uneven bone density in the left iliac bone with increased FDG metabolism; and multiple nodules in the left renal parenchyma with increased FDG metabolism, all suggesting malignant tumor lesions; and 2. slightly larger bilateral hilar and mediastinal lymph nodes, increased FDG metabolism, and the possibility of metastasis. Follow-up examination was recommended ( Figure 2 ). Fiberoptic bronchoscopy examination showed that in the right bronchus, the right middle bronchial mucosa was swollen and bulged, cauliflower-like masses grew in the right middle lobe and the lower lobe segment of the bronchial lumen, the lumen was completely occluded, and the lesion was greater than 2 cm from the protuberance ( Figure 3 ).
Bronchoscopic images. (A) Middle bronchial tubes. (B) Right main stem bronchi. (C) Right middle lobe bronchial. (D) Right lower lobe bronchial tube.
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FDG metabolism; uneven bone density in the left iliac bone with increased FDG metabolism; and multiple nodules in the left renal parenchyma with increased FDG metabolism, all suggesting malignant tumor lesions; and 2. slightly larger bilateral hilar and mediastinal lymph nodes, increased FDG metabolism, and the possibility of metastasis. Follow-up examination was recommended ( Figure 2 ). Fiberoptic bronchoscopy examination showed that in the right bronchus, the right middle bronchial mucosa was swollen and bulged, cauliflower-like masses grew in the right middle lobe and the lower lobe segment of the bronchial lumen, the lumen was completely occluded, and the lesion was greater than 2 cm from the protuberance ( Figure 3 ).
Pathological results of lung lesion biopsy. (A) (Hematoxylin and eosin (HE) x 100) Atypical tumor cells were arranged in a sheet-like manner, with vascular proliferation and necrosis. (B) (HE x 400) Atypical tumor cells showed large nuclei, hyperchromatic nuclei, prominent nucleoli, two or more nucleoli, eosinophilic or translucent cytoplasm, and pathological mitosis. (C) (IHC x 100) Vimentin was diffusely expressed, suggesting tumors derived from mesenchymal tissues.
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ALK (-), CK7 (-), myogenin (-), SMA (-), CD34 (-), CD56 (-), Bcl-2 (-), CD99 (partial +), Ki-67>60%, CK (-), TFF-1 (-), napsin A (-), P63 (-), P40 (-), CK7 (-), and CK20 (-). See  Figure 4  for details. After a multidisciplinary discussion, the patient was considered to have MFH with multiple systemic metastases, without surgical indications and with poor chemotherapy efficacy.
Genomic map derived from the biopsied tissue samples of four lung lesions.
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The results of genetic testing showed that the ALK gene had the EML4-ALK (E6:A20) gene rearrangement (fusion) with an abundance of 8.93% ( Figure 5 ).
Dynamic changes on cranial MR. (A) The initial cranial MR on January 28, 2019, showed a nodular lesion in the left parietal lobe with a diameter of approximately 0.6 cm and a clear margin. (B) On December 6, 2019, cranial MR showed that the left parietal lobe nodule was enlarged to 2.1 cm x 2.3 cm, with blurred edges and patchy surrounding edema. (C) On March 23, 2020, cranial MR showed that the left parietal lobe nodule had grown to 3.0 cm x 2.3 cm and had blurred edges and visible patchy edematous lesions around it. (D) Cranial MR showed that the left parietal nodular lesion had grown to 4.5 cmx2.5 cm, with blurred edges and patchy edematous lesions.
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The tumor was considered to be metastatic ( Figure 6 ).