PMC9293051_01
Imagines of computed tomography (CT) and Magnetic resonance (MR) before treatment. (A) Chest CT scan with lung window; (B) Chest CT scan with mediastinal window; (C) Abdominal-enhanced CT scan; (D) Head magnetic resonance (MR) image. Imagines of CT after the first cycle of pemetrexed and cisplatin. (E) Chest CT scan with lung window; (F) Abdominal CT scan; Imagines of CT after three cycles of Sintilimab combined with pemetrexed and cisplatin. (G) Chest CT scan with lung window; (H) Abdominal CT scan; Imagines of computed tomography (CT) and Magnetic resonance (MR) after two cycles of Endostar combined with docetaxel and lobaplatin. (I) Chest CT scan with lung window; (J) Chest CT scan with mediastinal window; (K) Abdominal-enhanced CT scan; (L) Head magnetic resonance (MR) image. These imagines were showed the timeline of different treatments for the patient's entire treatment progression.
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A chest computed tomography (CT) scan revealed numerous uniform pulmonary nodules in the bilateral lungs in addition to a 38x45 mm mass at the dorsal segment of the lower lobe of the left lung, with bilateral hilar and mediastinal lymphadenopathy ( Figures 1A, B ), and multiple bone metastases (including thoracic spine, sternum, ribs and left scapula). The enhanced CT scans showed multiple liver (the largest nodule about 21x21mm) and adrenal metastases ( Figure 1C ). Magnetic resonance examination of the head revealed no obvious metastases ( Figure 1D ). She was given a cycle of pemetrexed (day 1: 500mg/m2) and cisplatin (day 1-3: 25mg/m2 every day), but reexamination of her chest CT and abdominal CT showed no signs of a reduction in her pulmonary nodules ( Figures 1E, F ). Although there were no other immune-related adverse events, the treatment was terminated because of persistent disease progression ( Figures 1G, H ). Fortunately, chest and abdomen CT scans revealed almost complete disappearance of all pulmonary nodules, as well as an accentuated decrease in the primary lung mass (32x32mm) and liver metastasis volume (the largest one about 16x15mm) after this two cycle's treatment ( Figures 1I-L ). The diagram of her specific treatment progress see  Figure 1 .
The line charts of tumor biomarkers during the treatment period. (A) CEA; (B) NSE; (C) CYFRA21-1.
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Her laboratory results (complete blood cell count: WBC (white blood cell) 8.6x109/L, RBC (red blood cell) 4.08x109/L, PLT (platelet) 433x109/L, liver panel: ALT (alanine aminotransferase) 19U/L, AST (aspartate aminotransferase) 34U/L, kidney panel: creatinine 47mumol/L) were within normal limits, her respiratory etiology test results (including tuberculosis) were negative, but her tumor markers were elevated ( Figure 2 ).
Lesion biopsy specimen of the left supraclavicular lymph node. (A) HE x 100; (B) TTF-1x 100; (C) Ki-67 x 100; (D) Syn x 100; (E) P40 x 100; (F) PD-L1 x 100.
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Immunohistochemical staining was positive for PCK, CK7, TTF-1, and Ki-67 at 70%; negative for P40, Napsin A, Syn, and CDX-2; PD-L1(=1%, Clone: 22C3, Dako, Agilent Technologies, Inc.); which is consistent with lung adenocarcinoma ( Figure 3 ).