PMC7274020_01
PET-CT scan (November 2016) and histopathological results after postoperative recurrence. (A) Solitary right pulmonary nodule and (B) enlarged right hilar lymph node were found and identified as metabolically active lesions (SUVmax = 8.32) (C). (D,E) Subcarinal lymph node enlarged with intense FDG uptake (SUVmax = 13.19). (F) Holistic view of PET-CT: metabolic lesions in the lung, hilum, and subcarina. (G) Histopathological features of CT-guided biopsy tissue of the nodule in the right upper lobe: alveolus tissue with some naked nuclear-like lymphocytes. (x20 hematoxylin/eosin). (H) Histopathological features of EBUS biopsy tissue of the subcarinal lymph node: cancer cells arranged in disperse or the nest bulk in mucoid tissue (x20 hematoxylin/eosin).
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Further positron emission tomography CT (PET-CT) showed a lobulated nodule with diameter 0.8 x0.9 cm in the upper lobe of the right lung with intense fluorodeoxyglucose (FDG) uptake (SUVmax = 8.32) (Figures 1A-C). The enlarged right hilar and subcarinal lymph nodes were also identified as metabolically active lesions (SUVmax = 13.19) (Figures 1D,E). There were no signs of other distant metastasis (Figure 1F). Pathologic assessment of the biopsy tissue revealed alveolus tissue (Figure 1G), with positive expression for LCA but negative expression for CK, CD56, Syn, and TTF-1. Further histopathological diagnosis was suspected adenocarcinoma after endobronchial ultrasound (EBUS) biopsy of the subcarinal lymph node (Figure 1H). An EGFR E19 del was discovered by the ADx-ARMS method (Supplementary Figure 1).
PET-CT scan (November 2017) and histopathological and molecular results after gefitinib therapy resistance. (A,B) Original mass in the upper lobe of the right lung enlarged (1.4 x1.1 cm) with more intense FDG uptake (SUVmax = 11.24). (C,D) Right hilar and subcarinal lymph node enlarged with more intense FDG uptake. (E-G) New mediastinal, right subclavian, and bilateral cervical lymph nodes were found with FDG uptake. (H) Holistic view of PET-CT: metabolic lesions in multiple metastases. Histopathological features of ultrasound-guided biopsy tissue. (I) Cancer cells arranged in streaks and nest bulk and invasive growth manner in left cervical lymph nodes (x20 hematoxylin/eosin). (J) HER-2 amplification was detected by FISH in left cervical lymph nodes tissue. HER-2 signal (red) was found in clusters distributed. (K) Irregular adenoid and cord-like cancer cells were found in the biopsy tissue from the nodule in the upper lobe of the right lung (x20 hematoxylin/eosin). (L) Cancer cells scattered or arranged in groups observed in right hilar and subcarinal lymph nodes tissues acquired by EBUS-guided biopsy (x20 hematoxylin/eosin).
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Further PET-CT in November 2017 revealed more intense FDG uptake in the right lung nodule (1.4 x1.1 cm, SUVmax = 11.24) and hilar and subcarinal lymph nodes (Figures 2A-E). Enlargement in bilateral cervical and right subclavian lymph nodes was found (Figures 2F-H). HE staining (Figure 2I) combined with IHC (positive expression for ER [80%], PR [20%], HER-2 [2-3+], Gata-3, GCDFP-15 and mammaglobin, but negative expression for TTF-1 and Napsin A), and FISH (HER-2 amplification, Figure 2J) suggested that metastatic cervical lymph nodes derived from breast cancer. Irregular adenoid and cord-like cancer cells were found in the biopsy tissue from the nodule in the upper lobe of the right lung (Figure 2K) with IHC results of positive expression for ER (80%), PR (20%), HER-2 (2-3+), Ki-67 (10%), and Gata-3, but negative expression for TTF-1, Napsin A, and P40 (Supplementary Figure 2). Cancer cells scattered or arranged in groups were observed in biopsy tissues of right hilar and subcarinal lymph nodes (Figure 2L) with IHC results of positive expression for ER (80%), PR (20%). HE staining (Figures 2K,L) combined with IHC (positive expression for ER [80%], PR [20%], and HER-2 [3+], but negative expression for TTF-1) confirmed all the biopsy sites metastasized from breast cancer.
PET-CT (May 2018) scan after 6 cycles of combination treatment with trastuzumab, vinorelbine, and capecitabine. (A-F) All metastases shrank with almost no FDG uptake.
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Repeated PET-CT in May 2018 indicated that all metastatic lesions significantly shrank (Figure 3).
Treatment process and effect evaluation of the patient. (A) New metastatic lymph node in left neck confirmed by MR in September 2018. (B) New metastatic lymph node of right neck confirmed by MR in July 2019. (C) Review of treatment process (from February 2014 to November 2019).
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After 9.7 months of treatment with trastuzumab, the patient was pathologically confirmed as having a new metastatic lymph node in the left neck and received capecitabine combined with lapatinib from September 2018 (Figure 4A). The patient had stable disease for over 9 months until a new progressive disease was found in the right cervical lymph node in July 2019 (Figure 4B). The patient survived for 36 months after lung metastasis and 69 months after diagnosis of breast cancer (Figure 4C).