PMC10387523_01
Variations of the primary and metastatic lesions in lung detected by chest CT scans during the treatment (red arrowheads). (A,B) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 20 November 2021. (C,D) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 5 January 2022. (E,F) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 15 March 2022. (G,H) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 12 April 2022. (I,J) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 29 June 2022. (K,L) Chest CT scans showed the primary and metastatic lesions (red arrowheads) in the lungs on 25 July 2022. Abbreviations: CT, computerized tomography.
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F1
A chest computed tomography (CT) was performed on 20 November 2021, and multiple space-occupying lesions in the right lung were revealed (Figures 1A, B), accompanied by enlargement of the lymph nodes in the right hilum and mediastinum. In addition, she also acknowledged that repeated chest CT on 5 January 2022 revealed substantial regression (partial response, 85%) of the primary tumor as well as metastatic tumors in the lung (Figures 1C, D). ALT and AST levels decreased to the normal range (Figure 2C). A chest CT was conducted again after liver function recovery on 15 March 2022, and the results revealed enlargement of the tumors again (Figures 1E, F). ALK-TKI, was administered at a dose of 225 mg once per day after sufficient discussion with the patient. After a month of ensartinib administration, efficacy assessment with repeated chest CT revealed partial response (PR) (Figures 1G, H), and it continues (Figures 1I, J). Ensartinib treatment was terminated due to progressive disease on 25 July 2022 (Figures 1K, L).
Histological findings with hematoxylin and eosin stain, NGS, and variation of ALT and AST. (A) Histological findings with biopsy from percutaneous puncture of the lesion in the right lung; (B) NGS results showing missense mutations of ALK D1225N (column in yellow color for the specific missense mutation as 'G'); and (C) variation of ALT and AST during the treatment. Abbreviations: NGS, next-generation sequencing; ALT, alanine transaminase; AST, aspartate transaminase; and ALK, anaplastic lymphoma kinase.
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Subsequently, a percutaneous puncture biopsy was performed, the results of which revealed invasive lung adenocarcinoma (Figure 2A) based on the following immunohistochemistry findings: TTF-1 (positive), NapsinA (positive), P40 (negative), P63 (negative), CK7 (positive), CDX-2 (negative), Syn (negative), CgA (negative), Ki-67 10% (positive), and programmed cell death ligand-1 (PD-L1) (negative). DNA (sample from tumor tissue, tumor cellularity 20%, detection depth in target area 970.75, and target area coverage 99.33%) was subjected to tumor driver gene profile testing via next-generation sequencing (NGS, Biomed Diagnostics, Shanghai), which revealed an anaplastic lymphoma kinase (ALK) p. D1225N alteration caused by an exon 24 c.G3673A missense mutation (Figure 2B). A liver function test with the serum sample showed extremely elevated alanine transaminase (ALT, 2246.8 U/L, normal range 4.0-48.0 U/L, Figure 2C) as well as elevated aspartate transaminase (AST, 710.3 U/L, normal range 4.0-42.0 U/L, Figure 2C). ALT and AST levels decreased to the normal range (Figure 2C). A chest CT was conducted again after liver function recovery on 15 March 2022, and the results revealed enlargement of the tumors again (Figures 1E, F).