PMC4191680_01
CT scans of patient 1. A and B: CT scan of the thorax at start of pazopanib, showing a pleural metastasis of the left lung with central hypodensities suggesting necrosis (A, arrow) and showing a pulmonary metastasis in the right lung (B, arrow). C and D: CT scan, when presenting with a left-sided pneumothorax (D), showing progressive hypodensity of the pleural metastasis on the left side (C, arrow) and central cavitation in the metastasis in the right lung (D, arrow).
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F1
A CT scan at the start of pazopanib showed a necrotizing metastasis in the left lung (Figure  1A, B). The CT scan detecting the pneumothorax on the left side, also showed cystic degeneration of metastases in the right lower lobe (Figure  1C, D).
CT scans and X-thorax of patient 2. A: CT scan at start of pazopanib showing metastases in both lungs with a large necrotizing metastasis on the left side. The pleural metastasis indicated by the arrow is also visible in B, which is a CT scan after 3 months of pazopanib treatment, now showing cavitations. C is also an image from the CT scan after 3 months of pazopanib treatment showing a metastasis (arrow) with cavitation next to the pleura. D: The X-thorax shows the right sided pneumothorax. The visceral pleural line is indicated by the arrow.
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F2
Some of the pulmonary metastases already showing cavitation at start of pazopanib (Figure  2A) were increasing in number, size and cavitation during treatment (Figure  2B, C). One week after the start of pazopanib a right sided pneumothorax occurred (Figure  2D), which was treated with drainage, but without pleurodesis, however it recurred one week later and again drained.
CT scans of patient 3. Routine follow-up CT scan showing the pneumothorax on the right side. A shows one of the pulmonary metastasis, B shows a pleural metastasis.
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F3
He was treated for a remarkable 15 months when progression occurred and a hydropneumothorax was diagnosed on a routine follow-up CT scan (Figure  3A, B), treated with drainage and talc pleurodesis.
CT scan of patient 4. The CT scan shows the massive pulmonary metastases and a left-sided pneumothorax.
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F4
After seven months treatment with pazopanib she developed a left-sided pneumothorax (Figure  4), successfully treated with drainage.
CT scans of patient 5. A: CT scan before the start of pazopanib showing multiple metastases in the right lung, one is indicated by the arrow. B: Routine follow-up CT scan during pazopanib treatment showing the left-sided pneumothorax and the earlier mentioned metastasis in the right lung is now showing cavitation.
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F5
Five months after the start of doxorubicin progressive disease was diagnosed and pazopanib was prescribed (Figure  5A). After two months of treatment she developed a left-sided pneumothorax, treated with drainage and pleural rubbing (Figure  5B).
CT scan of patient 6. A: CT scan at start of pazopanib showing a metastasis in the right lower lobe with a diameter of 49.6 mm. B: CT scan after 12 weeks of pazopanib (6 weeks of treatment and 6 weeks on hold due to liver toxicity), showing a decrease in diameter of the metastasis to 33.1 mm. C: CT scan showing the bilateral pneumothorax.
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F6
Due to liver toxicity the pazopanib dose was tapered to a minimum dose of 200 mg with short pauses in treatment, however treatment was successful (Figure  6A, B). Treatment was permanently stopped after 33 months because of a bilateral pneumothorax and disease progression (Figure  6C).