PMC9619101_01
Representative 18F/FDG PET-CT images of the patient: (A) enlarged bilateral supraclavicular and (B) mediastinal lymph nodes; (C) a 3.4*2.4 cm soft tissue density mass in the right lower lobe; and (D) increased metabolism in right ilium.
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Tongji Medical College of Huazhong University of Science and Technology in October 2020 for chest tightness and chest pain. The 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) revealed a soft tissue density shadow in the right lower lobe with a size of 3.4*2.4 cm; enlarged bilateral supraclavicular and mediastinal lymph nodes, thickened bilateral pleura and increased pericardial effusion were metabolism increased; the metabolism in thoracic vertebrae T4, lumbar vertebrae L1, L5, and right ilium were also increased ( Figure 1 ).
Representative CT or MRI images of the patient: (A) CT image of October 2020 before the treatment. (B) CT image of January 2021 after treatment with crizotinib. The therapeutic effect of the patients was evaluated as partial response. (C) CT image of September 2021 after pituitary metastases; the lung lesion was stable. (D) CT image of February 2022 after treatment with ceritinib; the lung lesions shrank further. (E) CT image of August 2022 after treatment with ceritinib; the lung lesion is still shrinking. (F) MRI image obtained in October 2020 before treatment; brain MRI showed no abnormalities. (G) MRI image of September 2021 after finding pituitary metastases. (H) MRI image after 1 month of supplemental hormone therapy. The pituitary gland was enlarged. (I) MRI image after sphenoid sinus exploration and nasal endoscopic saddle area tumor excision, and the brain MRI showed no mass. (J) Follow-up MRI images 9 months after tumor resection and 9 months after ceritinib administration.
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Baseline lung enhanced CT images are shown in  Figure 2A . Brain MRI showed no abnormalities ( Figure 2F ). In January 2021, the patient's lung CT showed that the lesion in the lower lobe of the right lung was 2.2*1.7 cm, and the pericardial effusion was significantly reduced ( Figure 2B . The patient started to have headache and dizziness in September 2021, and brain MRI showed that the pituitary gland was full in shape on September 7, 2021, approximately 1.4*1.4*1.3 cm in size, and the lung lesion was stable ( Figures 2C, G ). On November 15, 2021 ( Figure 2H ), the patient underwent sphenoid sinus exploration and nasal endoscopic saddle area tumor excision in our neurosurgery department. On February 7, 2022, the patient's lung CT showed that the lesion in the lower lobe of the right lung had shrunk further with a size of 1.8*1.4 cm, and the brain MRI re-examination showed no abnormalities ( Figures 2D, I ). The latest reexamination was on August 7, 2022, and no progression was observed ( Figures 2E, J ).
Histopathological findings of pericardial effusion by paraffin embedding of cell sediment. IHC yielded the following: PCK (+), Claudin-4(+), TTF-1(+), NapsinA(+), Calretinin (-), CK5/6 (-), P40 (-), EGFR (-), C-met (-), Ros-1 (-), ALK(+).
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Upon pathological examination of the pericardial effusion, cancer cells were detected, which was consistent with lung adenocarcinoma ( Figure 3 ).
Histopathological findings of pituitary metastases. IHC yielded the following: PCK (+), TTF-1 (+), NapsinA (+), EMA (+), Syn (partial +), CgA (focal +), GFAP (-), S1001 (-), CD68 (-), CD34 (-), ACTH (-), GH (-), PRL (-), FSH (-), LH (-), TSH (-), Ki67 (Li:5%).
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TTF-1 (+), Napsin A (+), ACTH (-), GH (-), PRL (-), FSH (-), LH (-), TSH (-), Ki67 (Li: 5%) ( Figure 4 ). The next-generation sequencing (whole-exome sequencing by company of gloriousmed) conducted on the pituitary metastasis suggested EML4 -ALK fusion with VAF of 2.63%.