case_images: PMC9304872_01
case_images: Chest computed tomography (CT) scan of the primary lung cancer at diagnosis (A), 3 months after treatment (B), and 6 months after treatment (C). An irregular mass (3.5 cm x 2.7 cm) was detected in the right upper lobe (A), which shrunk (2.6 cm x 2.2 cm) after 3 months of treatment (B) but enlarged (5.2 cm x 2.6 cm) after 6 months of treatment (C).
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case_images: PMC9304872_01_fonc-12-922016-g001.jpg
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case_images: On admission, a computed tomography (CT) scan of the chest revealed an irregular mass measuring 3.5 cm x 2.7 cm in the right upper lobe (RUL), with mediastinal mildly enlarged lymph nodes ( Figure 1A ). After 3 months of treatment (August 2021), a follow-up chest CT scan revealed a reduction in the RUL mass (with the maximum cross section measuring 2.6 cm x 2.2 cm,  Figure 1B ). Unfortunately, 6 months after the initial diagnosis, the patient showed further disease progression with the enlargement of the primary lung mass ( Figure 1C ) and multiple metastatic lesions involving the bilateral adrenal glands and abdominal cavity ( Figures 4B, C ).
case_images: Abdominal CT scan and endoscopic view of the gastric tumor at diagnosis (A, C) and 3 months after treatment (B, D). A mass (2.0 cm x 2.0 cm) located in the gastric fundus was detected by CT (A) and gastroscopy (C), which disappeared 3 months after treatment (B, D).
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case_images: Additional workup using abdominal CT detected a gastric fundal mass that measured 1.9 cm ( Figure 2A ). Further gastroscopy demonstrated an ulcerated tumor 2.0 cm x 2.0 cm in size located in the gastric fundus ( Figure 2C ). The gastric mass in the fundus exhibited complete regression in the CT scan ( Figure 2B ) and gastroscopy examination ( Figure 2D ).
case_images: Hematoxylin and eosin (H&E) and immunohistochemical staining of the primary lung cancer and gastric tumor biopsy. H&E staining showed poorly differentiated adenocarcinoma in the primary lung cancer tissue (A) and gastric tumor tissue (C). Immunohistochemical staining showed a positive reaction for thyroid transcription factor-1 (TTF-1) in the primary lung cancer tissue (B) and gastric tumor tissue (D) (magnification, x200).
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case_images: A CT-guided lung mass biopsy and pathological examination revealed poorly differentiated tumor cells ( Figure 3A ). The immunohistochemical stains showed that the tumor was thyroid transcription factor-1 (TTF-1) (+), CK7 (+), p63 (+-), Napsin A (focally+), Ki67 (25%+), CK20 (-), CD56 (-), CK5/6 (-), and p40 (-), which is most consistent with lung adenocarcinoma ( Figure 3B ). Meantime, a gastric mass biopsy revealed poorly differentiated carcinoma with a similar morphological feature to the tumor from the pulmonary biopsy ( Figure 3C ). Figure 3D ). Furthermore, genetic studies demonstrated the same EGFR L858R+T790M mutation in both the gastric and pulmonary lesions, while the pulmonary sample also harbored a programmed cell death ligand 1 (PD-L1) Tumor Proportion Score (TPS) of 90%.
case_images: Abdominal CT scan of other metastatic lesions 3 months after treatment (A) and 6 months after treatment (B, C). A nodule (2.9 cm x 2.0 cm) in the right adrenal gland (arrow) was detected after 3 months of treatment (A). Multiple metastatic lesions were shown in bilateral adrenal glands (arrow, B) and left lower abdominal cavity (arrow, C) after 6 months of treatment.
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case_images: PMC9304872_01_fonc-12-922016-g004.jpg
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case_images: Meanwhile, an abdominal CT detected a nodule measuring 2.9 cm x 2.0 cm in the right adrenal gland, considered as a new metastatic lesion ( Figure 4A ). Unfortunately, 6 months after the initial diagnosis, the patient showed further disease progression with the enlargement of the primary lung mass ( Figure 1C ) and multiple metastatic lesions involving the bilateral adrenal glands and abdominal cavity ( Figures 4B, C ).