PMC10409480_01
Computed tomography (CT) of the thorax with contrast and positron emission tomography/computed tomography (PET/CT) at the time of diagnosis. (A) Thoracic CT revealed multiple masses (the superior lobe of the right lung, supraclavicular region, right hilar and mediastinal lymph nodes). (B) PET/CT revealed suspicious primary lung cancer and metastasis.
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Computed tomography (CT) of the chest showed multiple masses in the superior lobe of the right lung, supraclavicular region, and right hilar and mediastinal lymph nodes ( Figure 1A ). CT and suggested additional metastases involving right axillary lymph nodes, bilateral adrenal glands and multiple bones (cervical vertebras, lumbar vertebras, left iliac crest, left side 4th rib) ( Figure 1B ). Core biopsy of the right supraclavicular mass confirmed the diagnosis of poorly differentiated adenocarcinoma. The patient responded to chemotherapy well (partial remission) and reached stable disease during the following two cycles of chemotherapy plus immunotherapy ( Supplemental Figure 1 ). Chest CT with intravenous contrast before the third cycle showed the shrinkage of the lung nodules ( Supplemental Figure 1A ). Chest CT with intravenous contrast before the fourth cycle (4thC) showed slight further shrinkage of the lung nodules (stable disease) ( Supplemental Figure 1B ). Chest CT suggested stable disease ( Supplemental Figure 1C ).
Computed tomography (CT) of the brain at the time of diagnosis of the cerebral infarction. CT of the brain revealed a large area of low density in the left occipital and temporal lobes.
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ANC and platelet count increased to 660/muL (3 days after the initiation of methylprednisolone) and 31,000/muL (9 days after the initiation of methylprednisolone), respectively. A peripheral blood smear was then performed 5 days after the initiation of methylprednisolone for abnormalities and showed a decrease of nucleated cells that consisted of predominantly neutrophils (81%), however, negative for malignant cells and parasites ( Supplemental Figures 2A, B ). Emergency CT of the brain revealed a large area of low density in the left occipital and temporal lobes suggestive of a cerebral infarction ( Figure 2 ).
Supraclavicular mass before and after savolitinib treatment. A bulging mass was shown on the right supraclavicular area before treatment with savolitinib (left). The supraclavicular mass shrank dramatically after two weeks of treatment with savolitinib (400 mg/day) (right).
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Considering the progression of the lesions ( Supplemental Figure 3A ), he finally agreed to have a core rebiopsy of the right supraclavicular mass 4 months after the 4thC, and next-generation sequencing (NGS) was performed to screen for gene mutations, which revealed a mesenchymal epithelial transition (MET) exon 14 skipping mutation (METDeltaex14). Two weeks after the initiation of savolitinib, the right supraclavicular lesion became flat and invisible from the outside ( Figure 3 ). Chest CT showed remarkable remission of all the lesions, and this remission continued, as revealed by chest CT ( Supplemental Figure 3B ) with intravenous contrast 66 days after the initiation of savolitinib.