PMC9160189_01
Abdominal CT scans and gastroscopy findings at baseline. (A) Abdominal CT scans suggested thickened gastric wall in the antrum (red arrow for tumor). (B) Abdominal CT scans showed liver metastasis (red arrows for tumors). (C) Gastroscopy examinations revealed gastric ulcer. (D) Histological finding with hematoxylin and eosin-stained biopsy specimen from gastroscopy (400x).
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Abdominal CT showed thickened gastric wall in the antrum and surrounded by enlarged lymph nodes ( Figure 1A ), along with multiple lesions in liver, suggesting metastasis ( Figure 1B ). Subsequently, the patient received gastroscopy examination, the results of which revealed a large ulcer (3.5 cm x 3.5 cm), with dirty surface and scattered bleeding spots ( Figure 1C ). Based on the biopsy findings by gastroscopy, the patient was diagnosed as having gastric adenocarcinoma, with metastasis on interstitial lymph nodes of the liver and stomach, and liver ( Figure 1D ).
Abdominal CT presentations after recurrence (from July 11, 2020 to August 4, 2021, red arrows for tumors). (A1/B1) July 11, 2020. (A2/B2) October 22, 2020. (A3/B3) January 25, 2021. (A4/B4) April 6, 2021. (A5/B5) August 4, 2021.
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On July 11, 2020, his regular abdomen CT showed re-enlargement and fused interstitial lymph nodes of the liver and stomach ( Figure 2A1 ), suggesting progressive disease (PD). Metastatic lymph nodes invaded the portal and splenic veins ( Figure 2B1 ). Efficacy assessment for radiation was conducted by abdomen CT scan in October 2020 ( Figures 2A2,B2 ), which suggested a stable disease (SD, by 16% regression for target lymph nodes). ALT observed during the treatment of nivolumab, monotherapy of sintilimab, another PD-1 inhibitor, was prescribed as maintenance treatment from November 20, 2020. After 2 months treatment of sintilimab, repeat abdomen CT scan revealed a partial response (PR, by 64% regression for target lymph nodes;  Figures 2A3, B3 ). The latest CT scan was performed on August 4, 2021, the results of which still suggested a continuous PR, with complete regression on portal vein and splenic vein (by 67% regression for target lymph nodes;  Figures 2A5, B5 ).
(A) The variations in ratios for LMR (lymphocyte to macrophages ratio), NLR (neutrophils to lymphocyte ratio), and mPLR (modified platelet to lymphocyte ratio, platelet to lymphocyte ratio/50) from July 3, 2020 (No. 1 at x-axis) to August 31, 2021 (No. 31 at x-axis). (B) The means of LMR, NLR, and mPLR before radiotherapy (2 months before radiotherapy) and after radiotherapy (2 months from the beginning of radiotherapy). *p = 0.016, **p = 0.037, ***p = 0.002.
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During the radiotherapy, we surprisingly detected a dynamic change in elevated level of LMR, accompanied with lowered level of NLR and PLR ( Figure 3A ), which suggested a potential response to systematic therapy with immune checkpoint inhibitor. In addition, we also observed a significant variation in the means of LMR, NLR, and mPLR (PLR/50) before radiotherapy (2 months before radiotherapy) and after radiotherapy (2 months from the beginning of radiotherapy), the results of which are presented in  Figure 3B . ALT observed during the treatment of nivolumab, monotherapy of sintilimab, another PD-1 inhibitor, was prescribed as maintenance treatment from November 20, 2020. After 2 months treatment of sintilimab, repeat abdomen CT scan revealed a partial response (PR, by 64% regression for target lymph nodes;  Figures 2A3, B3 ).