PMC9909182_01
The brain MRI images before and after primary surgery. (A) The preoperative image showed a tumor occupied in the posterior fossa, medial to the right mastoid bone. (B) The postoperative 9 days MRI after surgery showed edema in the surgical region, some residual tumor existed for being unable to resect the tumor completely. (C) The MRI image showed that the tumor remained stable 6 months after radiotherapy.
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F1
The preoperative brain MRI showed a tumor in the right cerebellopontine angle (CPA) area (Figure 1).
CT and X-ray images of the left fourth rib and proximal left femur before and after treatment. (a1) the left fourth rib showed expansive low-density changes before treatment; (a2-a4) A gradually expanding speckled high-density foci and sclerotic edges was detected in the left fourth rib before the 3rd
(a2), 4th
(a3), and 5th
(a4) chemotherapy, respectively. (b1) Osteolytic changes and local cortical thinning were found before treatment. (b2) After the 6th chemotherapy, X-ray images showed obvious calcification at the osteolytic destruction of the proximal left femur. (c1) Osteolytic changes at the proximal left femur and local cortical thinning were found in CT images before treatment. (c2-c4) The metastasis at the proximal left femur showed gradually expanding high-density foci and sclerotic edges before the 2nd
(c2), 3rd
(c3), and 4th
(c4) chemotherapy. Three-dimensional CT reconstruction of the left fourth costal metastasis and left proximal femoral metastasis before treatment and the fifth chemotherapy. (d1) the size of the metastasis before treatment was 135.20 cm3, and the average CT value was 29.35 hu. (d2) Before the 5th chemotherapy, the size of the metastasis was 92.28 cm3, and the average CT value was 319.78 hu. (e1) The size of metastases was 89.71 cm3, and the average CT value was 82.30 hu before treatment. (e2) The size of the metastasis was 93.69 cm3, and the average CT value was 374.06 hu before the 5th chemotherapy.
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F2
DIA chemotherapy were completed, during which VAS of patients were regularly assessed, LDH and AKP were tested, X-rays and CT were rechecked (Figure 2). During the treatment, the patient developed myelosuppression, alopecia, nausea, and vomiting, but no other adverse events were found.
PET-CT examination before treatment and after the 6th chemotherapy. (a-d) The lower two rows are images before treatment, and the upper two rows are images after the 6th chemotherapy. After treatment, FDG metabolism in all metastases decreased (bilateral paraacromial side of the clavicle, left 5th and 6th posterior intercostal space, right lower lobe of the lung, lymph nodes in mesentery area, and multiple parts of the whole body: T2-T12, L1-L4 vertebral bodies, T2, T6, T12, and L2 attachments, left 4th rib, right 11th posterior rib and 8th anterior rib, left clavicle, sacrum, femoral head and upper segment of the femur, right acetabulum, and sciatic bone), except that the local FDG metabolism at the proximal left femur was still higher than normal (significantly lower than that before treatment). The multiple bone metastases showed varying extents of high-density calcification. There was little change from the mastoid process to the petrous tip of the right temporal bone, showing irregular morphology and increased bone density, and no significant increase in FDG metabolism.
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F3
The multiple bone metastases showed different extent of high-density calcification, and the volume of the metastases in the fourth left rib was reduced significantly (Figure 3).
(a) Postoperative pathology of primary skull tumor showed that it was consistent with osteosarcoma (he x 200), immunohistochemical staining results: CD3 (scattered+), CD68 (scattered+), CD20 (occasionally+), lysozyme (occasionally+), CD34 (vascular+), PLAP (-), Ki-67 (focal about 20%). (b1-b5) The biopsy of left femur was pathologically consistent with osteosarcoma (he x 200), immunohistochemical staining results: CDK4 (+), CD68 (+), CD99 (+), MDM2 (+), h3k36m (+), SATB-2 (+), p53 (about 5%+), p16 (large cell+), NSE (focal+), H33g34w (-), p63 (-), S-100 (-), syn (-), Ki-67 (about 30-40% +). [(b1) HE, (b2) CDK4, (b3) CD68, (b4) MDM2, (b5) Ki-67]. (c1-c5) After the 6th chemotherapy, the pathology of left femur puncture biopsy was consistent with the pathological changes of skull osteosarcoma metastasis (he x 200), immunohistochemical staining results: SATB-2 (+), CD68 (focal+), CDK4 (partial+), p16 (partial+), p53 (small number of cells+), MDM2 (partial+), S-100 (-), H33g34w (-), h3k36m (-), p63 (-), Ki-67 (about 10%+). [(c1) HE, (c2) CDK4, (c3) CD68, (c4) MDM2, (c5) Ki-67].
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F4
The left femoral puncture biopsy was performed again, and the pathology confirmed osteosarcoma metastasis, while Ki-67 decreased to about 10%+ (Figure 4).