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case_images: Abdominal CT showing multiple liver metastases. (a) Before the administration of brigatinib: detection of multiple liver lesions. (b) After 13 days of treatment with brigatinib. (c) After 25 days of treatment with lorlatinib and before the administration of ABCP: progression of multiple liver lesions. (d) After four cycles of ABCP: partial response of multiple liver lesions.
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case_images: In August 2021, CT analysis showed multiple metastases in the liver (Figure 1a) and lymph nodes (ie, cervical, supraclavicular fossa, axillary, mediastinal, and abdominal lymph nodes). The results showed the progression of the liver metastases and occurrence of new lesions (Figure 1b), and his treatment was switched from brigatinib to lorlatinib (sixth-line treatment). A CT scan showed a continued increase in the size of multiple liver metastases (Figure 1c), but shrinkage of multiple lymph node metastases.  Following four cycles, a CT scan showed a reduction of the liver metastases (Figure 1d), and the serum levels of biliary enzymes, bilirubin, and CEA continued to improve.
case_images: Results of liver biopsy. The scale bars below each image are equivalent to 100mum. (a) Hematoxylin and eosin staining showing atypical cell hyperplasia and formation of glandular luminal structures. (b-d) Immunohistochemical staining of TTF-1, ALK, and Napsin A showing diffuse staining of tumor cells.
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case_images: Pathological tissue analysis revealed lung adenocarcinoma (Figure 2a). The examination yielded positive results for thyroid transcription factor-1 (TTF-1) (Figure 2b), ALK (Figure 2c), and Napsin A (Figure 2d).
case_images: Clinical course of the patient and transition of hematologic examination. Timeline after the administration of brigatinib, Day 1 was defined as the day brigatinib was administered. Serum levels of gamma-GPT, ALT, T-bil, and CEA, the transition of the hematologic examination, and treatment regimen.
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case_images: However, the serum levels of hepatobiliary enzymes continued to increase (Figure 3). However, biliary enzymes and total bilirubin (T-bil) levels continued to rise (Figure 3). After administrating the first cycle of ABCP, these levels improved to 360 U/L, 2.15 mg/dL, and 204 ng/mL, respectively (Figure 3).