PMC5896645_01
Histopathological and immunohistological findings of the lymph nodes tissues samples. (A) Hematoxylin and eosin staining showed malignant spindle cells (200x), which displayed immunohistochemical positive staining for CK, SMA, CD34, CD99, and Bcl-2, and negative for Des, S-100, and B-Catenin. (B) IHC of our patient did not reveal supported ALK gene mutation (200x).. Abbreviations: IHC, immunohistochemistry; ALK, anaplastic lymphoma kinase.
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ALK was not supported (Ventana IHC) (Figure 1).
The progression in the lung. (A1 and A2) were taken on October 9, 2015. (B1 and B2) were taken on December 10, 2015, and the green arrows refer to the new lesions.
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The brain imaging showed that the primary tumor was enlarged with edema, and new metastases could be found in the lung (Figure 2).
The dynamic evolution of the patient's primary and metastases tumors during the treatment in the PET-CT images. (A) Images A1-A4 were taken at the first clinic visit on August 10, 2015. The right upper chest mass was 51x41 mm, with a the maximum of standardized uptake value (SUVmax) of 5.6, MTV value of 28.8, and TLG value of 105 (A1). The right subscapularis muscle mass was 27x12 mm, with a SUVmax of 4.9, MTV value of 2.1, and TLG value of 6.4 (A2). The liver mass was 12x11 mm, with a SUVmax of 6.2, MTV value of 2, and TLG value of 8.2 (A3). The larger mass in the occipital lobe of the brain mass was 26x17 mm (A4). (B) Images B1-B4 as baseline were taken after the methylprednisolone on September 10, 2015. The right upper chest mass was 53x52 mm, with a maximum SUV value of 7.2, MTV value of 39.9, and TLG value of 174 (B1). The right subscapularis muscle mass was 27x17 mm, with a SUVmax value of 4.8, MTV value of 5.2, and TLG value of 15.5 (B2). The liver mass was 12x11 mm, with a SUVmax value of 6.7, MTV value of 4, and TLG value of 15.4 (B3). The brain mass was 27x18 (B4). (C) Images C1-C4 were taken after 1 month treatment of oral crizotinib on October 9, 2015. The size of the tumor seemed to be stable. The right upper chest mass was 44x38 mm, with a maximum SUV value of 8, MTV value of 14.2, and TLG value of 24.9 (C1). The right subscapularis muscle mass was 27x17 mm, with a SUVmax value of 2.9, MTV value of 4.8, and TLG value of 11.3 (C2). The liver mass was 18x14 mm, with a SUVmax value of 4, MTV value of 2.2, and TLG value of 6.8 (C3). The brain mass was 27x18 mm (C4). (D) Images D1-D4 were taken on December 10, 2015, after 3 months of oral crizotinib, and there was progressive disease in the brain. The right upper chest mass was 46x43 mm, with a maximum SUV value of 3.6, MTV value of 28.5, and TLG value of 72.5 (D1). The right subscapularis muscle mass was 28x16 mm, with a SUVmax value of 2.9, MTV value of 9, and TLG value of 15.5 (D2). The liver mass was 13x8 mm, with a SUVmax value of 1.7, MTV value of 11, and TLG value of 14.1 (D3). The brain mass was 28x18 mm (D4). (E) Images E1-E4 were taken on February 2, 2016, after two cycles of bevacizumab with oral crizotinib, and all tumors were increased in bulk. The right upper chest mass was 60x56 mm, with a maximum SUV value of 3, MTV value of 88.4, and TLG value of 168.6 (E1). The right subscapularis muscle mass was 42x34 mm, with a SUVmax value of 2.4, MTV value of 49.8, and TLG value of 73.4 (E2). The liver mass was 17x13 mm, with a SUVmax value of 3.5, MTV value of 13.1, and TLG value of 25.2 (E3). The brain mass was 30x19 mm (E4). The change of the tumor of the right chest wall (A1-E1). The change of the right upper arm muscle space (A2-E2). The change of the liver (A3-E3). The change of the brain (A4-E4).. Abbreviations: PET-CT, positron emission tomography coupled with computed tomography; SUVmax, the maximum of standardized uptake value; MTV, metabolic tumor volume; TLG, total lesion glycolysis.
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The KPS score was 50, PET-CT imaging showed right pleural effusion, all body metastases were enlarged, and the MTV and TLG values were significantly increased, indicating progressive disease (Figure 3). The patient was administered nutritional supportive treatment.
The clinical course of the diagnosis and treatment of the patient. On August 11, 2015, the PET-CT scan of the patient suggested right upper chest, brain, bone, liver, and right subscapularis muscle metastases. Methylprednisolone was given at 800 mg/d, d1-5, started on August 20, 2015. On September 10, 2015, PET-CT imaging showed tumor volume enlargement, and crizotinib was given at 250 mg daily. On October 9, 2015 (after one month of crizotinib treatment), PET-CT imaging showed a dramatic reduction in tumor size and metabolism, resulting in SD. (The concentrations in the left elbow and chest wall were radiocontamination.) On December 7, 2015, the brain imaging PET-CT showed that the primary tumor was enlarged, representing progressive disease in the brain, and bevacizumab (500 mg/d, d1, every 21 days), combined with crizotinib at 250 mg daily, was administered. On February 2, 2016 (after two cycles of bevacizumab with crizotinib), PET-CT imaging showed right pleural effusion, all body metastases were enlarged, and pleural cavity and peritoneal effusions could be found. Then, nutritional supportive treatment was given. The patient died in March 2016.. Abbreviations: PET-CT, positron emission tomography coupled with computed tomography; PD, progressive disease; SD, stable disease.
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Unfortunately, the patient died 1 month later in March 2016 (Figure 4).