PMC6489643_01
Three biopsy pathological diagnosis results of the patient.
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Bronchoscopy examination revealed that the mass of basal segment of the right lower lobe occluded the trachea, and the pathology suggested inflammatory myofibroblastic tumor (IMT) (Figure 1A). Immunohistochemistry (IHC) staining revealed the following: TTF-1(+), P43(+), ALK(D5F3) (+) (Figure 1B). Biopsy was performed and pathology showed a malignant spindle cell tumor, which could be considered as pulmonary sarcoma-like carcinoma (PSC) (Figure 1C). Tumor mutation burden was 11.6 Mbs/MB and PD-L1 detection was negative (Figure 1D). CD8+ T cells accounted for 9.07% of the total number of nuclear cells (Figure 1E). Considering the poor effect of prednisone treatment, we switched to oral crizotinib at 250 mg twice a day. The pathology confirmed lung adenocarcinoma (Figure 1F).
Chest CT scan evolution of the tumors.
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Chest CT scan showed there were multiple metastatic nodules of the lungs and right lower lobe obstructive pneumonia with atelectasis (Figure 2A-C). We assessed the condition as partial response (Figure 2D-F). After taking crizotinib for 4 months, a re-examination of chest CT suggested that mediastinal and hilar lymph nodes were larger than before, and right lung obstructive pneumonia increased more than before, showing partial atelectasis (Figure 2G-I). CT showed an increase and fusion of mediastinal lymph nodes (Figure 2J-L), but the patient reported significant improvement in physical strength. Considering the pseudo-progression of the lung lesions, the use of pembrolizumab was continued. With an ECOG of 0 points, the chest CT showed the mediastinal lymph nodes were significantly reduced (Figure 2M-O), which were assessed as a partial response.
IGV screenshots (EML4-ALK) of the fusion sample.
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A second-generation gene sequencing revealed EML4-ALK fusion (Figure 3A and B). The tumor tissue second-generation gene sequencing revealed EML4-ALK fusion and ALK-L1196M mutation (Figure 3C). Tumor mutation burden was 10.4 Mbs/MB.