PMC9647058_01
Contrast-enhanced CT scans of the patient (A) prior to, and (B) 5 months after the initiation of therapy. (C) At 6 months post-diagnosis, the curative effect was evaluated as progressive disease, with no effect of third-line therapy of Tislelizumab combined with Apatinib. (D) The disease returned to partial remission after treatment with the fourth-line treatment. LV, liver; STM, stomach; SP, spleen; K, kidney.
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After hospitalization, an enhanced Computed Tomography (CT) examination was performed to further evaluate the patient's condition, which showed there were multiple nodular lesions in the liver with local gastric wall thickening ( Figure 1A ). The original regimen was continued for two courses, and imaging was performed after the fourth course to assess PR ( Figure 1B ). AFP had increased again to 21,520 ng/ml ( Figure 2A ). At the same time, CT revealed that the liver lesions had increased in size again ( Figure 1C ). CT evaluation showed that the efficacy achieved PR again ( Figure 1D ), blood examination showed a progressive decrease in AFP level to 12,238 ng/ml ( Figure 2A  ). Considering this positive response, another 5 cycles of Atezolizumab in combination with Irinotecan and Surufatinib therapy were conducted with the last treatment on March 23, 2022, and the efficacy was assessed as sustained PR.
Graph depicting the patient's therapeutic course and serum tumor marker of AFP levels (A) and CEA level (B). The patient received the following treatments: a, paclitaxel liposome plus S-1 (tegafur/gimeracil/oteracil potassium); b, Tislelizumab combined with Oxaliplatin; c, Tislelizumab combined with Apatinib; d, Atezolizumab in combination with Irinotecan and Surufatinib capsules. AFP, alpha-fetoprotein; CEA, carcinoembryonic antigen.
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Among the tumor markers, AFP levels were significantly elevated to more than 54,000 ng/ml (normal level: < 12 ng/ml), and the serum carcinoembryonic antigen (CEA) levels were 22.82 ng/ml (normal range: < 5 ng/ml) ( Figures 2A, B  ). Regular reexamination showed a progressive decrease in AFP level to 7169 ng/ml and the CEA level dropped to within the normal range ( Figures 2A, B  ). AFP had increased again to 21,520 ng/ml ( Figure 2A ). At the same time, CT revealed that the liver lesions had increased in size again ( Figure 1C ). CT evaluation showed that the efficacy achieved PR again ( Figure 1D ), blood examination showed a progressive decrease in AFP level to 12,238 ng/ml ( Figure 2A  ). Considering this positive response, another 5 cycles of Atezolizumab in combination with Irinotecan and Surufatinib therapy were conducted with the last treatment on March 23, 2022, and the efficacy was assessed as sustained PR.
Gastroscopy and gastric biopsy pathology results. (A) Image of gastroscopy results, showing a tumor located at the body of the stomach (as indicated by the arrows). (B) Histopathological examination revealed poorly differentiated gastric adenocarcinoma (hematoxylin and eosin staining; magnification, x100). (C) Negative staining for HER2 (magnification, x100). (D) Positive staining for Mut L homolog 1 (MLH1) (magnification, x100).
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Gastroscopy revealed a giant crateriform ulcer within the stomach body ( Figure 3A ), and pathological examination showed a poorly differentiated adenocarcinoma. Immunohistochemical labeling revealed the presence of proficient mismatch repair (pMMR)/microsatellite stability (MSS) as well as deficiencies in Human Epidermal growth factor Receptor 2 (HER2) and EBV-encoded RNA (EBER) hybridization ( Figures 3B-D ).