PMC6027823_01
Immunohistochemical analysis showing (A) CAM5.2 (+) and (B) Ki-67 (50%).
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Referring to immunohistochemical reevaluation, which was CAM5.2 (+), CK7 (+), PAX8 (+), CK20 (+) partly, Ki-67 (50%), vimentin (+) partly, P53 (-), WT1 (-), CD10 (+) partly, P63 (+) partly, beta-catenin (+), ER (-), PR (-), and P16 (+) partly, adenosquamous carcinoma was confirmed ultimately (Figure 1).
Serum CA19-9 and CA125 levels during treatment.
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During the first cycle, the serum CA19-9 increased over the normal range (Figure 2). The patient's serum CA19-9 and CA125 level decreased sharply and returned to within the normal range in 2 months, followed by a slow increase (Figure 2).
Pelvic MRI showing the right side pelvic cavity metastasis.. Notes: (A) After first-line chemotherapy (December 20, 2016). The new metastasis was 2.1x2.8 cm2 in size. (B) Prior to olaparib and pembrolizumab treatment (March 25, 2017). The metastasis was 5.3x7.0 cm2 in size. (C) After olaparib and pembrolizumab treatment (August 1, 2017). The metastasis was 3.3x4.0 cm2 in size.. Abbreviation: MRI, magnetic resonance imaging.
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Tumors 1.0 criteria. The patient's positron emission tomography-computed tomography results revealed metastases in the apex of the left lung, retroperitoneal lymph nodes, left armpit, and right side of the pelvic cavity, which was further clarified by pelvic magnetic resonance imaging (MRI; Figure 3A). However, as with the first-line chemotherapy, after 2 cycles, her serum CA19-9 level was found to be increased to 43.41 U/mL, and pelvic MRI indicated that the mass in the right side of the pelvic cavity had increased in size since the previous report (Figure 3B). After 4 cycles, pelvic MRI showed that the mass in the right side of the pelvic cavity had been reduced approximately 65% (Figure 3C).
Liver MRI showing multiple metastases.. Notes: (A) After 1 cycle of epirubicin, cyclophosphamide, and bevacizumab treatment (March 27, 2017). The metastases were first detected, and the largest was 2.5 cm in diameter. (B) After 4 cycles of olaparib and pembrolizumab treatment (August 2, 2017). The number of metastases increased tremendously, and the largest was 2.5 cm in diameter. (C) After 6 cycles of nivolumab and pazopanib treatment (October 22, 2017). The metastases diminished in volume and the largest was 2.3 cm in diameter.. Abbreviation: MRI, magnetic resonance imaging.
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She received 1 cycle of epirubicin (48 mg/m2), cyclophosphamide (4 mg/kg), and bevacizumab (15 mg/kg), which was discontinued because multiple new metastases were observed by liver MRI just a month later (Figure 4A). Liver MRI indicated an increased number of metastases and enlarged lymph nodes in the retroperitoneum and both the lesser and greater curvature of the stomach on August 2, 2017 (Figure 4B). After 6 cycles, liver MRI revealed that the metastases in the retroperitoneal lymph nodes and both the lesser and greater curvature of the stomach had shrunk (Figure 4C).
Moderate expression of PD-L1 detected by RT-Q-PCR.. Notes: Curve a is the sample and curve b is the reference. Ct a =17.22, Ct b =4.77, DeltaCt =12.45.. Abbreviation: PD-L1, programmed death ligand 1; RT-Q-PCR, real time quantitative polymerase chain reaction.
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The patient underwent whole-exome sequencing by gene capture, high-throughput sequencing, and real time quantitative polymerase chain reaction (RT-Q-PCR) in April 2017, which revealed moderate plasma expression of PD-L1 (Figure 5) and mutations in BRCA1 and BRCA2 at 7% and 5% frequency, respectively.