PMC8117145_01
(A) The 2014 pathological examination indicated a pleomorphic liposarcoma (hematoxylin and eosin staining, 400 x magnification) and MDM2 amplification in tumor tissues as revealed by fluorescence in situ hybridization (red fluorescence: MDM2, green fluorescence: CEP12; mean MDM2 signal: 35.1, mean CEP12 signal: 1.7, MDM2/CEP12 ratio = 20.65). (B) The 2017 pathological examination indicated a de-differentiated liposarcoma (hematoxylin and eosin staining, 400 x magnification) and MDM2 amplification in tumor tissues as revealed by fluorescence in situ hybridization (red fluorescence: MDM2, green fluorescence: CEP12; mean MDM2 signal: 27.4, mean CEP12 signal: 1.8, MDM2/CEP12 ratio = 15.22).
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A pleomorphic liposarcoma with positive surgical margins was again confirmed by surgical pathology ( Figure 1A ). A de-differentiated liposarcoma with a negative surgical margin was confirmed by surgical pathology ( Figure 1B ).
(A) A PET/CT scan obtained before combined oncotherapy on April 9 2019 (white arrows, the tumor mass with high FDG metabolism). (B) A PET/CT scan obtained before surgery on September 30 2019 (white arrows, the tumor mass was smaller than before and its FDG metabolism was less than before).
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The FDG metabolism of the left sixth anterior rib was elevated, with an SUVmax of 3.2 ( Figure 2A ). Apitherapy focused principally on the chest wall area corresponding to the tumor mass indicated by PET/CT ( Figure 2A ). Ten days later, he underwent repeat PET/CT ( Figure 2B ) and then a complex surgery featuring enlarged resection of the chest wall tumor, thoracoplasty, and surgical repair of the chest wall, pulmonary, and diaphragm defects.
(A) During the first apitherapy session, the patient was stung by only one bee and observed in a ward for 2 h (black arrow). (B) After 9 weeks, the dose had gradually increased to 50 bee stings each time (black arrow). (C) A finger ulcer (white arrow) and (D) a heel ulcer were side effects of apatinib (white arrow).
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We initially used only one bee to sting ( Figure 3A ). We discontinued it on the weekends because the patient developed painful ulcers of the fingertips, heels, and throat after 4 weeks on the drug ( Figures 3C, D ). We increased the apitherapy dose from 18 to 50 bee stings each time, and discontinued apatinib because the sore throat and consequent dysphagia did not resolve within 3 weeks ( Figure 3B ).
(A) In the section with most residual tumor tissue, the tissue area was about 0.3 x 0.2 cm and the boundary (black arrows) between that tissue and the hyaline degeneration was distinct (hematoxylin and eosin staining, 100 x magnification). (B) Many tumor cells were observed near remnant tumor tissue, but these gradually decreased in number in the distal areas (the direction shown by the black arrow, hematoxylin and eosin staining, 200 x magnification). (C) The closer the transition zone of hyaline degeneration, the thinner the density of tumor cells (black arrows, residual tumor cells), and the greater the extent of necrotic degeneration (white arrow, hematoxylin and eosin staining, 200 x magnification). (D) Complete hyaline degeneration (without residual tumor cells) was observed in all other sections (hematoxylin and eosin staining, 200 x magnification).
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In the section with most such tissue, the tumor area was about 0.3 x 0.2 cm ( Figures 4A-D ).
A flowchart/timeline of the therapy.
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The patient receives a medical re-examination every 4 months, and no evidence of tumor recurrence was apparent to his fourth follow-up (thus to 16 months after surgery) ( Figure 5 ).