PMC10152545_01
(A) CT scan shows primary mass in posterior wall of uterus (in 2017). (B) HE staining indicated that tumor cells showed invasive growth (5x). (C) Tumor cells are epithelioid cells with clear or eosinophilic cytoplasm (20x). (D) Tumor cells are densely distributed around blood vessels(20x). (E) Immunohistochemical stain positive for HMB-45 (20x). (F) Immunohistochemical stain negative for Melan-A (20x). (G) Immunohistochemical stain weakly positive for Desmin(20x). (H) Immunohistochemical stain negative for SMA (20x).
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A CT scan showed a cystic and solid mass in the posterior wall of the uterus ( Figure 1A ), suggesting the possibility of malignancy. Histological sections showed aggressive tumour growth ( Figure 1B ). Tumour cells were epithelioid cells with clear or eosinophilic cytoplasm ( Figure 1C ), and they tended to aggregate around blood vessels ( Figure 1D ). Immunohistochemical staining showed that the melanocyte marker HMB45 was positive, and Melan-A was negative ( Figures 1E, F ); the smooth muscle marker desmin was weakly positive, and SMA was negative ( Figures 1G, H ).
(A) CT scan showed a pelvic space-occupying lesion (in 2020). (B) TPS of tumor PD-L1 expression: Number of PD-L1 stained tumor cells/total tumor cells (PD-L1 stained and non-stained) x100%. (C) CPS of tumor PD-L1 expression: Number of PD-L1 stained cells (tumor cells, lymphocytes, macrophages)/total tumor cells (PD-L1 stained and non-stained) x100. (D) CT scan revealed another large mass in the pelvis (in 2022).
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CT, a tumour of approximately 8 cm x 4 cm was found in the pelvis ( Figure 2A ). Considering the high possibility of recurrence, the patient underwent pelvic tumour resection and left ureteral double J-tube placement again. The detection of PD-L1 in the tumour showed a tumour proportion score (TPS) of 2% and combined positive score (CPS) of 5 ( Figures 2B, C ). After a repeat CT scan, a large mass in the pelvis was found again ( Figure 2D ).
(A) The patient's treatment schedule for 4 cycles. Subcutaneous injection of GM-CSF 200 mg was used on days 1-7. Immunotherapy with tislelizumab 200 mg on day 8. For the first and fourth time, SBRT was performed simultaneously with GM-CSF. (B) Radiotherapy treatment plan (isodose lines: 30 Gy, 24 Gy, 20 Gy in red, green, light blue respectively). (C) Radiotherapy treatment plan (isodose lines: 22.8 Gy, 20 Gy, 11.4 Gy in orange, light blue, dark blue respectively).
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After discussion with a multidisciplinary committee, we formulated a triple therapy regimen of anti-PD-1, GM-CSF, and SBRT for the patient ( Figure 3A ). Considering the large mass in the patient's pelvis, to protect the surrounding organs as much as possible, the SBRT target volume was made slightly smaller than the actual tumour ( Figure 3B ). We treated this tumour on June 6 with a triple therapy that included SBRT ( Figure 3A ). The target area of SBRT included paraspinal tumour and tumour invading into the spinal cavity ( Figure 3C ).
CT scans before and after treatment. (A, D) CT scans show changes in the size of irradiated lesions. (B, C, E) Unirradiated lung lesions developed cavities after treatment. (F) The unirradiated lesions in the lungs gradually decreased after treatment.
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The patient's systemic tumour was evaluated in June, and we found that the mass in the pelvis was significantly smaller than it had been in March ( Figure 4A ), and the two nonirradiated metastases in the lungs had transformed into thin-walled cavities ( Figures 4B, C ). At the most recent imaging evaluation (July 22), the patient's lumbar paravertebral tumour had not shrunk significantly ( Figure 4D ). However, we were pleasantly surprised to find a cavity in one of the larger metastases in the left lung ( Figure 4E ). Another pulmonary metastasis had shrunk by 30% in its largest diameter since treatment in March ( Figure 4F ).