28272214 Visualization

A 52 Age - year Age - old Age man Sex with a 30 History - year History history History of History smoking History presented Clinical_event with an abnormal Detailed_description nodule Sign_symptom measuring 0.8 Area   × Area   1.5 Area   cm Area in the left Biological_structure upper Biological_structure lung Biological_structure lobe Biological_structure imaged through chest Biological_structure computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) scanning in March Date 2012 Date in a community Nonbiological_location hospital Nonbiological_location .
He had previously History been History well History without History any History additional History relevant History or History abnormal History symptoms History .
Physical Diagnostic_procedure examination Diagnostic_procedure suggested no significant abnormalities Sign_symptom .
Laboratory Diagnostic_procedure findings Diagnostic_procedure were within Lab_value normal Lab_value range Lab_value , except for a carcinoembryonic Diagnostic_procedure antigen Diagnostic_procedure ( CEA Diagnostic_procedure ) level of 30.25 Lab_value   ng/mL Lab_value (normal range, 0–5 ng/mL) found in the serum Biological_structure .
Subsequently, a positron Diagnostic_procedure emission Diagnostic_procedure tomography Diagnostic_procedure (PET)/CT scan showed a lung Biological_structure lesion Sign_symptom with a standardized Diagnostic_procedure uptake Diagnostic_procedure value Diagnostic_procedure of 7.94 Lab_value , which was highly suspected to be a malignant Disease_disorder tumor Disease_disorder (Fig.1).
Subsequently, he underwent left Biological_structure upper Biological_structure lung Biological_structure lobectomy Therapeutic_procedure and lymph Therapeutic_procedure node Therapeutic_procedure dissection Therapeutic_procedure .
Postoperative pathological Diagnostic_procedure examination Diagnostic_procedure revealed an adenocarcinoma Disease_disorder ( ADC Disease_disorder ) (Fig.2A).
Immunohistochemistry Diagnostic_procedure ( IHC Diagnostic_procedure ) staining results were positive Lab_value for CK7 Diagnostic_procedure , TTF-1, p63 Diagnostic_procedure , and NapsinA Diagnostic_procedure and negative Lab_value for CK Diagnostic_procedure 5/6 Diagnostic_procedure , Syn Diagnostic_procedure , cgA Diagnostic_procedure , and Ki-67 (20%–30%).
The clinical Diagnostic_procedure stage Diagnostic_procedure was classified as IA2 Lab_value ( pT1bN0M0 Lab_value ).
Because the tumor Coreference was still in an early Detailed_description stage Detailed_description , the patient did not receive adjuvant Medication treatment Medication but continued to be monitored Therapeutic_procedure through regular hospital Nonbiological_location visits Clinical_event every Frequency 3 Frequency months Frequency .
The patient's condition Diagnostic_procedure had been stable Lab_value until the onset of left Biological_structure chest Biological_structure pain Sign_symptom in April Date 2015 Date .
The patient was transferred Clinical_event to our hospital Nonbiological_location (a tertiary Nonbiological_location care Nonbiological_location hospital Nonbiological_location ) for further treatment.
Physical Diagnostic_procedure examination Diagnostic_procedure suggested a significant Severity tender Sign_symptom point Sign_symptom in the left Biological_structure chest Biological_structure wall Biological_structure .
Laboratory Diagnostic_procedure findings Diagnostic_procedure showed only a single parameter outside the normal range: the cytokeratin19 Diagnostic_procedure fragment Diagnostic_procedure antigen Diagnostic_procedure 21–1 (CYFRA21–1) level was 17.45 Lab_value   ng/mL Lab_value in the serum Biological_structure (normal range = 0–3.3 ng/mL).
CT Diagnostic_procedure and PET Diagnostic_procedure / CT Diagnostic_procedure scans highlighted the serious Severity involvement Sign_symptom of left Biological_structure pleura Biological_structure , showing bilateral Detailed_description lung Biological_structure lesions Sign_symptom (Fig.3A and E).
At that point, the clinical Diagnostic_procedure stage Diagnostic_procedure was upgraded Lab_value to IVB Lab_value .
After the CT Detailed_description - guided Detailed_description left Biological_structure pleura Biological_structure puncture Therapeutic_procedure , pathological IHC Diagnostic_procedure analysis Diagnostic_procedure showed positive Lab_value staining for p63 Diagnostic_procedure , p40 Diagnostic_procedure , CK Diagnostic_procedure 7 Diagnostic_procedure , and CK Diagnostic_procedure 5/6 Diagnostic_procedure , while TTF-1 and NapsinA Diagnostic_procedure staining were absent Lab_value , supporting a diagnosis of squamous Disease_disorder cell Disease_disorder carcinoma Disease_disorder ( SCC Disease_disorder ) (Fig.2B).
Meanwhile, molecular Diagnostic_procedure evaluation Diagnostic_procedure confirmed an L858R Sign_symptom mutation Sign_symptom in exon Detailed_description 21 Detailed_description and a T790M Sign_symptom mutation Sign_symptom in exon Detailed_description 20 Detailed_description (Fig.4B and C).
Considering Other_entity the Other_entity pathology Other_entity of Other_entity the Other_entity SCC Other_entity was Other_entity quite Other_entity distinct Other_entity compared Other_entity with Other_entity that Other_entity of Other_entity the Other_entity originally Other_entity resected Other_entity NSCLC Other_entity specimen, Other_entity we Other_entity retrospectively Other_entity reassessed Other_entity the Other_entity surgery Other_entity specimen Other_entity to Other_entity verify Other_entity our Other_entity primary Other_entity diagnosis Other_entity .
The Other_entity morphologic Other_entity and Other_entity IHC Other_entity results Other_entity were Other_entity in Other_entity complete Other_entity agreement Other_entity with Other_entity the Other_entity initial Other_entity diagnoses, Other_entity but Other_entity an Other_entity L858R Other_entity mutation Other_entity was Other_entity identified Other_entity using Other_entity the Other_entity newly Other_entity added Other_entity molecular Other_entity evaluation Other_entity (Fig.4A).
To relieve the acute pain in the left pleura as quickly as possible, palliative Detailed_description three Therapeutic_procedure - dimensional Therapeutic_procedure conformal Therapeutic_procedure radiotherapy Therapeutic_procedure ( 3D Therapeutic_procedure - CRT Therapeutic_procedure ) for the chest Biological_structure lesion Sign_symptom was delivered at a total dose of 42 Dosage   Gy/14 Dosage fractions Dosage (f), once Frequency daily Frequency and 5f/week Dosage (Fig.5).
The volume Diagnostic_procedure over Diagnostic_procedure radiation Diagnostic_procedure dose Diagnostic_procedure 5 Diagnostic_procedure   Gy Diagnostic_procedure (V5) values of the left Biological_structure , right Biological_structure , and total Biological_structure lungs Biological_structure were 20% Lab_value , 0% Lab_value , and 7.8% Lab_value , respectively; the volume Diagnostic_procedure over Diagnostic_procedure radiation Diagnostic_procedure dose Diagnostic_procedure 20 Diagnostic_procedure   Gy Diagnostic_procedure (V20) values were 10% Lab_value , 0% Lab_value , and 5% Lab_value , respectively; the mean Diagnostic_procedure lung Diagnostic_procedure dose Diagnostic_procedure ( MLD Diagnostic_procedure ) was 5 Lab_value   Gy Lab_value .
Meanwhile, considering the MST pathology was that of SCC, the patient received GP Medication chemotherapy Medication ( cisplatin Medication 75 Dosage   mg/m2 Dosage d1 Dosage , gemcitabine Medication 1250 Dosage   mg/m2 Dosage d1, Dosage d8 Dosage , for 21 Detailed_description days Detailed_description as Detailed_description a Detailed_description cycle Detailed_description ) for 4 Lab_value cycles Lab_value , and the patient achieved partial Detailed_description remission Sign_symptom (PR) after Date 2 Date cycles Date , followed by stable Disease_disorder disease Disease_disorder ( SD Disease_disorder ) after Date 4 Date cycles Date (Fig.3[B3[B and F] and [C and G]) according to response Diagnostic_procedure evaluation Diagnostic_procedure criteria Diagnostic_procedure in Diagnostic_procedure solid Diagnostic_procedure tumors Diagnostic_procedure ( RECIST Diagnostic_procedure ) 1.1 Detailed_description .
Then, gefitinib Medication ( 150 Dosage   mg Dosage qd Dosage ) was used as maintenance treatment from Date November Date 2015 Date onward.
During the treatment, Ibandronate Medication sodium Medication was given monthly Frequency for skeletal Sign_symptom - related Sign_symptom events Sign_symptom .
The patient is currently under Clinical_event surveillance Clinical_event with SD Diagnostic_procedure (Fig.3D and H) and with PS Diagnostic_procedure scores of 0 Lab_value .