PMC9423048_01
Response assessment during the treatment course in CT scan images. (A): the cancer mass at pancreatic body. (B-J) No recurrence at pancreas during the whole treatment course. (K) No retroperitoneal lymph node metastasis at diagnosis. (L) Retroperitoneal lymph nodes metastasis appeared after operation. (M) The metastatic retroperitoneal lymph nodes shrunk after GS chemotherapy and radiotherapy. (N) The metastatic retroperitoneal lymph nodes enlarged. (O and P) The metastatic retroperitoneal lymph nodes grew larger after 5 cycles of Anlontinib. (Q-T) The metastatic retroperitoneal lymph nodes were eliminated during the FOLFIRINOX+Toripalimab).
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On January 03, 2018, the abdominal computerised tomography (CT) revealed a solid tumor (34*29mm) at pancreatic body without retroperitoneal lymph node metastasis of a 57-year-old male who suffered from nausea and vomiting for 2 months (Figure 1A and K). On February 23, 2018, CT scan revealed that the patients had retroperitoneal lymph nodes metastasis (Figure 1L). The follow-up examinations indicated no recurrence in pancreas with shrunken retroperitoneal lymph nodes (Figure 1M) and normal boundaries of tumor markers (Figure 2). CT scan showed that the patient had PDAC-originated lung metastases on the upper lobe of the left lung (12*11mm) and the middle lobe of the right lung (15*13mm) (Figure 4A and B), as well as the enlarged retroperitoneal lymph nodes metastasis (Figure 1N). Following 2 courses of Anlotinib, both lung lesions showed a partial regression with decreased tumor markers but retroperitoneal lymph nodes were enlarged (Figures 4C, D, 2 and 1O). Anlotinib, whereby the left lung lesion and retroperitoneal lymph nodes increased in size (Figures 4E, F and 1P). At this point, genetic testing for BRCA1/2 mutation (blood sample) was conducted, but it was found to be a wild-type. FOLFIRINOX and 3 cycles of Toripalimab, effective responses were observed, indicating the regressed bilateral pulmonary lesions and retroperitoneal lymph nodes and normal tumor markers (Figures 4G, H, 1Q and 2). Following another 4 cycles of FOLFIRINOX and 5 cycles of Toripalimab, the regressed bilateral pulmonary lesions remained stable and retroperitoneal lymph nodes further shrunk (Figures 4I, J and 1R). During the regular follow-up of maintenance therapy, no pancreatic recurrence was observed, and the retroperitoneal lymph nodes were eliminated (Figure 1B-J, S and T).
The serum monitoring of tumor markers.
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The serum level of carcinoembryonic antigen (CEA) was 10.4ng/mL(normal<5ng/mL) and that of cancer antigen 19-9(CA19-9) was 73.7U/mL (normal<37U/mL) (Figure 2). The follow-up examinations indicated no recurrence in pancreas with shrunken retroperitoneal lymph nodes (Figure 1M) and normal boundaries of tumor markers (Figure 2). In addition, CEA was abnormally elevated to 12.6ng/mL (Figure 2). Following 2 courses of Anlotinib, both lung lesions showed a partial regression with decreased tumor markers but retroperitoneal lymph nodes were enlarged (Figures 4C, D, 2 and 1O). FOLFIRINOX and 3 cycles of Toripalimab, effective responses were observed, indicating the regressed bilateral pulmonary lesions and retroperitoneal lymph nodes and normal tumor markers (Figures 4G, H, 1Q and 2). Following another 4 cycles of FOLFIRINOX and 5 cycles of Toripalimab, the regressed bilateral pulmonary lesions remained stable and retroperitoneal lymph nodes further shrunk (Figures 4I, J and 1R). Both lung lesions and tumor makers remained stable within the normal range (Figures 4K-N and 2).
The histopathology and IHC of the PDAC tissues of this patient (200x).
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Immunohistochemical findings showed the presence of CK(7) and Villin, and 22C3 antibody showed PD-L1(20%+), MLH1(+), MSH2(+), MSH6(+), PMS2(+), indicating proficient mismatch repair (pMMR) (Figure 3).
Dynamic changes in lung metastatic lesions. (A and B) The lung metastatic lesions first appeared. (C and D) Both lung lesions regressed after 2 cycles of Anlotinib. (E and F) The left lung lesion grew larger with the shrunken right lung lesion after another 3 cycles of Anlotinib. (G and H) Both lung lesions shrunk obviously after 4 cycles of FOLFIRINOX and 3 cycles of Toripalimab. (I and J) Both lung lesions remained stable after another 4 cycles of FOLFIRINOX and 5 cycles of Toripalimab. (K-N) Both lung lesions remained stable after another 27 cycles of Toripalimab.).
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CT scan showed that the patient had PDAC-originated lung metastases on the upper lobe of the left lung (12*11mm) and the middle lobe of the right lung (15*13mm) (Figure 4A and B), as well as the enlarged retroperitoneal lymph nodes metastasis (Figure 1N). Following 2 courses of Anlotinib, both lung lesions showed a partial regression with decreased tumor markers but retroperitoneal lymph nodes were enlarged (Figures 4C, D, 2 and 1O). Anlotinib, whereby the left lung lesion and retroperitoneal lymph nodes increased in size (Figures 4E, F and 1P). At this point, genetic testing for BRCA1/2 mutation (blood sample) was conducted, but it was found to be a wild-type. FOLFIRINOX and 3 cycles of Toripalimab, effective responses were observed, indicating the regressed bilateral pulmonary lesions and retroperitoneal lymph nodes and normal tumor markers (Figures 4G, H, 1Q and 2). Following another 4 cycles of FOLFIRINOX and 5 cycles of Toripalimab, the regressed bilateral pulmonary lesions remained stable and retroperitoneal lymph nodes further shrunk (Figures 4I, J and 1R). Both lung lesions and tumor makers remained stable within the normal range (Figures 4K-N and 2).
The entire treatment timeline of this patient.
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The patient's entire treatment timeline was displayed in Figure 5.