PMC9389357_01
(A) Radiologic images of tumor metastases after the XEOLX therapy. (B) Radiologic images of tumor metastases after the second-line treatment. (C) Radiologic images of tumor metastases after anti-PD1 immunotherapy. (D) The entire treatment process of this patient.
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CT examination suggested bone destruction of the right iliac crest, which was considered metastasis. Colonoscopy revealed a neoplasm at the top of the anastomosis, and pathology revealed a moderately differentiated adenocarcinoma ( Figure 1A ). However, after two cycles of combined targeted therapy with chemotherapy treatment, she developed disease progression again, presenting with enlarged tissue mass shadow around the right iliac crest and multiple metastases in the thoracolumbosacral vertebral body and appendages ( Figure 1B ). Unfortunately, this patient experienced a rapid progression again with widespread metastases including bone, ovary, and retroperitoneal lymph nodes after three cycles of anti-PD1 therapy ( Figure 1C ). To intuitively express this patient's treatment process and efficacy, we listed the entire treatment process in  Figure 1D .
The characteristics of her family history.
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We presented her family history in  Figure 2 .
(A) The protein expression of CD8 and PDL1 and red arrow represents CD8 positive T cells in the tumor, and the purple arrow represents CD8 positive T cells in the stroma. Quantification results of CD8 and PDL1 expression by IHC with the tumor and tumor stroma. (Microscopic magnificationx200) (B) IHC images of MMR protein expression in this patient (Microscopic magnificationx200); (C) NGS detection showed several gene mutations with high frequency from peripheral blood and tumor tissue in this patient. (D) Results of TMB detection from peripheral blood and tumor tissue in this patient.
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We reviewed her tumor tissue immunohistochemical (IHC) results and found a loss of MSH2 protein ( Figure 3B ). These data showed a small number of CD8+T cells were infiltrated in the tumor, and a large number of CD8+T cells were infiltrated in the stroma ( Figure 3A ). And we found a negative protein expression of PDL1 in this patient ( Figure 3A ). These mutations were showed in  Figure 3C . In addition, the results of tumor mutation burden from peripheral blood and tumor tissue were 100/Mb and 63.5/Mb, respectively ( Figure 3D ).