PMC9441579_01
Radiologic images at diagnosis. Computed tomography (CT) angiography of the lower extremities showed osteolytic and sclerotic lesions with extraosseous mass formation at the right iliac bone (A). Chest CT scan showed a 6.2x4.3 cm sized mass in the right upper lobe abutting the right brachiocephalic vein (B). Positron emission tomography confirmed the hypermetabolic mass at right upper lobe and multiple bone metastases at right iliac and ischial bone, right sacrum, left iliac bone, and lumbar spines (C).
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In addition, osteolytic and sclerotic lesions with extraosseous mass formation at the right iliac bone and ischium, suggestive of bone metastasis of malignancy, were noted (Figure 1A). Scan results revealed a 6.2x4.3 cm mass in the right upper lobe abutting the right brachiocephalic vein (Figure 1B). Brain magnetic resonance imaging (MRI) was negative for CNS metastasis, while positron emission tomography (PET) revealed a hypermetabolic mass in the right upper lobe with a maximum standard uptake value of 5.1, and multiple metastases at the lumbar spines (L3 and L5), left iliac bone, right sacrum, right iliac, and ischial bone, suggesting that the lung cancer was at stage IVB (Figure 1C).
Chest CT images during clinical course. Increased right upper lobe mass were noted after 4 cycles of pemetrexed maintenance chemotherapy (A). Two cycles of paclitaxel slightly decreased tumor size (B), however, progression was observed after third cycle of the treatment (C). Atezolizumab monotherapy was not effective and resulted in right total atelectasis after two cycles of therapy (D). We started capmatinib 400mg twice daily and markedly decreased mass of right upper lobe and improved right total atelectasis were noted after two months of the treatment (E).
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Follow-up chest CT scan conducted after the fourth cycle of pemetrexed maintenance showed enlargement of the primary lung mass (Figure 2A). Although chest CT after two cycles of paclitaxel revealed partial response (Figure 2B), the follow-up scan showed progressive disease (Figure 2C). Moreover, chest images showed total atelectasis of the right lung due to an increased right lung mass obstructing the right main bronchus (Figure 2D). A follow-up chest CT scan taken 2 months after capmatinib was administered showed a markedly decreased right lung mass and improved atelectasis (Figure 2E).
Brain magnetic resonance imaging. Axial contrast-enhanced 3D black blood imaging before capmatinib treatment revealed numerous, rim and nodular enhancing brain metastases in bilateral cerebral cortex and subcortex, cerebellum, basal ganglia, thalamus, and spinal cord (A). There are linear and nodular enhancements along the right sylvian fissure, optic chiasm, both optic tract, right trigeminal nerve, both seventh/eighth cranial nerves, surface of brainstem and ependymal linings following the hydrocephalus (arrows), which were compatible with leptomeningeal seeding (B). Follow-up axial contrast-enhanced 3D black blood imaging after 2 months of capmatinib treatment showed nearly complete disappearance of aforementioned brain and leptomeningeal metastases (C and D).
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Brain MRI showed interval development of numerous and variable-sized masses and nodules in both the cerebral and cerebellar hemispheres and the spinal cord (Figure 3A), and enhancement along both the optic chiasm-optic tract, right trigeminal nerve, and both the seventh/eighth nerve complex, which were compatible with brain metastasis and LM (Figure 3B). Surprisingly, extensive CNS metastases nearly completely disappeared on brain MRI (Figure 3C and D).