case_images: PMC10876774_01
case_images: Images from pre-targeted therapy (December 2019). (A1) Soft tissue mass near the heart margin of the lower lingual segment of the left upper lobe (x) and a small effusion of the left thoracic cavity (*) on the CT scan. (B1) Lymph node metastases ( ), pleural metastases (#), and a small effusion of the left thoracic cavity (*) on the CT scan. (C1) Spinal metastasis on the MRI scan ( ). (D1) A CT scan of liver. (E1) A CT scan of the brain. Images from post-immunotherapy (November 2023). (A2) No mass at the left superior lobe lingual segment on the CT scan. (B2) No nodules of mediastinum and hilum on the CT scan. (C2) Inactive of the spinal metastasis on the MRI scan. (D2) A change after ablation of the liver S7 segment on the MRI scan. (E2) Radionecrotic inflammatory response of the left frontal lobe on the MRI scan. Changes in the left lung mass and the left supraclavicular fossa lymph nodes on the CT scans during immunotherapy (F-I). (F) The left supraclavicular fossa mass (52x69mm) and the left lung mass before immunotherapy; (G) The left supraclavicular fossa mass (19x20mm) and on the left lung mass after 2 months of immunotherapy. (H) Without any masses after 13 months of immunotherapy. (I) Without any masses after 29 months of immunotherapy.
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case_images: Figures 1A1, B1 ). Further evaluation through a magnetic resonance imaging (MRI) scan indicated the presence of vertebral metastases ( Figure 1C1 ). No metastatic lesion was observed in the liver ( Figure 1D1 ) or brain ( Figure 1E1 ). A follow-up CT scan in June 2021 ( Figure 1F ) revealed an increase in the size of both the bilateral hilar and left supraclavicular fossa lymph nodes, measuring 52x69mm, indicating a progression of the metastatic disease. An August 2021 CT scan revealed a notable reduction in the size of the pulmonary nodules, which had nearly disappeared, and a decrease in the size of the left supraclavicular fossa nodule to 19x20mm, as shown in  Figure 1G . August 2021 to March 2022 classified the patient's condition as stable disease (SD). A CT scan in July 2022 ( Figure 1H ) found no pulmonary or supraclavicular nodules. August 2023, the patient had a PS of 0 and elected to switch to sintilimab (PD-1 monoclonal antibody, 200 mg), citing economic reasons after two years of pembrolizumab treatment without medicinal donations. As of November 2023, chest CT scans showed no detectable lesions ( Figures 1I ,  A2, B2 ), and MRI scans revealed no active lesions in the spine, liver, and brain ( Figures 1C2, D2, E2 ).
case_images: The ARMS-PCR result of the ALK gene in December 2019 and the immunohistochemistry results before and after resistance to ALK-TKIs. (A) The ARMS-PCR shows ALK fusion in December 2019. (B) PD-L1 (IHC)-TPS of 90% (200x)after resistance to ALK-TKIs. (C) CK5/6(100x), P63(100x), and CK7(100x)-positive in December 2019; CD8(100x)-scattered in a few positive in December 2019, about 10% of lymphocytes; CD4(100x), CD20(100x), and TTF-1(100x)-negative in December 2019; CK7(200x), TTF-1(100x), CK5/6(200x), and CD8(200x)-positive in April 2021; P63(200x), CD4(200x), and CD20(200x)-negative in April 2021.
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case_images: Immunohistochemical analysis revealed positive staining for CK, CK7, CKHMW, CK5/6, P63, and CK7, with a Ki-67 proliferation index of 40% (staining for CK5/6, P63 and CK7 in  Figure 2C ). TTF-1 in  Figure 2C ). An EML4-ALK fusion was detected using ARMS-PCR (Amplification Refractory Mutation System-Polymerase Chain Reaction) analysis( Figure 2A ). Immunohistochemical analysis demonstrated that the tumor cells were positive for cytokeratin (CK), CK7, TTF-1, CK5/6, CD8 and Ki-67 (60%) (staining for CK7, TTF-1, CK5/6 and CD8 in  Figure 2C ), while negative for NapsinA, P40, P63, PAX-8, CD10, CgA, CD4, CD20, CD56, Hepatocyte, TG, and BEER(staining for P63, CD4, and CD20 in  Figure 2C ). The NGS findings indicated a negative status for ALK fusion, while programmed death-ligand 1 (PD-L1) expression was significantly positive (90%) (PD-L1 expression in  Figure 2B ). August 2023, the patient had a PS of 0 and elected to switch to sintilimab (PD-1 monoclonal antibody, 200 mg), citing economic reasons after two years of pembrolizumab treatment without medicinal donations. As of November 2023, chest CT scans showed no detectable lesions ( Figures 1I ,  A2, B2 ), and MRI scans revealed no active lesions in the spine, liver, and brain ( Figures 1C2, D2, E2 ).
case_images: The timeline treatment and some progressive images. (A) Liver S7 nodule (11mmx10mm) on an MRI scan in March 2020. (B) A mass (32x47mm) fused by lymph nodes in the left supraclavicular fossa on the CT scan in April 2021. (C) The treatment timeline. LSCC, lung squamous cell carcinoma; PD, progressive disease; PR, partial response; SD, stable disease; CR, complete response; SRS, Stereotactic radiosurgery.
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case_images: CT scan in March 2020 revealed a reduction in the size of the left mass (22x13mm), mediastinal and left hilar lymph nodes, and pleural tubercle. Concurrently, an MRI scan detected a hepatic S7 nodule, suspected to be a metastasis (11mmx10mm), as shown in  Figure 3A . April 2021, the patient noted a mass on the left side of his neck with PS 2, accompanied by symptoms, such as severe hoarseness and moderate dizziness. A CT scan at this time revealed no significant change in the left lung mass size, but there was an apparent fusion of lymph nodes in the left supraclavicular fossa into a larger mass measuring 32x47mm, as depicted in  Figure 3B . The timeline of the treatment process is depicted in  Figure 3C .  Figure 4  illustrates the dynamic changes in lesions located in the left lung, liver, brain, and left supraclavicular fossa throughout the course of treatment.
case_images: Imaging changes of the left lung, liver, brain, and left supraclavicular fossa mass during treatment in our case(the black and red lines on the horizontal coordinate indicate that inactivity of the metastases on the MRI scans).
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case_images: The timeline of the treatment process is depicted in  Figure 3C .  Figure 4  illustrates the dynamic changes in lesions located in the left lung, liver, brain, and left supraclavicular fossa throughout the course of treatment.