case_images: PMC8523915_01
case_images: Imaging scans, pathological findings, and timeline with relevant data from the episode of care. HE staining of the postoperative pathological specimen indicated adenocarcinoma (scale bars represent 100 microm). Before first-line treatment, representative PET-CT images were shown. Regular revision computed tomography (CT) was used to assess treatment efficacy during first-line treatment. After five cycles of gemcitabine and cisplatin chemotherapy followed by three cycles of nab-paclitaxel in combination with gemcitabine and cisplatin chemotherapy, representative PET-CT images were shown. No lesions were detected by PET-CT, when an elevated CA199 was tested. When the patient began to experience progressively worsening abdominal pain and an abnormal increase in CA199, PET-CT was performed and representative images were shown. CT scan was performed after two cycles of nab-paclitaxel plus gemcitabine and cisplatin chemotherapy, and showed a PR of all tumor lesions. Rx, treatment; PET-CT, positron emission tomography-computed tomography; CT computed tomography; CA199, cancer antigen 199; PR partial response; CR, complete response; G, gemcitabine; A, nab-paclitaxel; P, cisplatin.
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case_images: His postoperative pathology confirmed the diagnosis of GBC, and suggested a stage of pT3N1M0, stage IIIB according to the National Comprehensive Cancer Network staging criteria ( Figure 1 ). December 2018, a fluorodeoxyglucose (FDG)-positron emission tomography computed tomography (PET-CT) at our hospital revealed multiple masses in the liver, extensive lymph nodes enlargement involving the anterior abdominal aorta, lesser omentum, and anterior supra-diaphragmatic, all with high FDG accumulation; and multiple nodules in the lung were considered inflammatory nodules ( Figure 1 ). Detection of tumor markers showed that CA199 was >1,000.00 U/ml and carcinoembryonic antigen (CEA) was 21.63 ng/ml ( Figure 2 ). After three cycles of the triple-drug chemotherapy, a CT scan showed disappearance of the tumor lesions, and PET-CT demonstrated no lesions in the liver and upper abdominal lymph nodes; the anterior group of lymph nodes in the diaphragm was smaller than before, and no increase in glucose metabolism was observed ( Figure 1 ). In June 2020, his CA199 was abnormally elevated to 115 U/ml, while no other hematological abnormalities were observed, and no lesions were detected by PET-CT ( Figure 1 ). S-1 in July 2020, and he began to experience progressively worse epigastric pain and signs of epigastric tenderness after 4 months, with an increase in CA199 and CEA to 733.40 U/ml and 7.52 ng/ml, respectively. Subsequently, PET-CT, conducted in December 2020, showed multi-metastatic lesions in both lungs and liver, along with tumor metastases in the right parasternal, parietal trunk, and para-aortic lymph nodes ( Figure 1 ). After two cycles of chemotherapy, an enhanced CT revealed significant downsizing of the tumor lesion with an evaluation of a PR efficacy ( Figure 1 ).
case_images: Changes in CA199 levels during the treatment and follow-up. The CA199 tumor marker was measured in patients' blood at periodic intervals throughout the clinical course and annotated with date, therapeutic approach, and treatment efficacy. CA199, cancer antigen 199; CR complete response; PR partial response.
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case_images: After surgery, the serum CA199 level decreased to 80 U/ml ( Figure 2 ). December 2018, a fluorodeoxyglucose (FDG)-positron emission tomography computed tomography (PET-CT) at our hospital revealed multiple masses in the liver, extensive lymph nodes enlargement involving the anterior abdominal aorta, lesser omentum, and anterior supra-diaphragmatic, all with high FDG accumulation; and multiple nodules in the lung were considered inflammatory nodules ( Figure 1 ). Detection of tumor markers showed that CA199 was >1,000.00 U/ml and carcinoembryonic antigen (CEA) was 21.63 ng/ml ( Figure 2 ). Moreover, CA199 dropped to the normal range of 8.65 U/ml and CEA was 2.74 ng/ml ( Figure 2 ). CA199 and CEA levels also gradually decreased ( Figure 2 ). Currently, the patient is still receiving regular triple-drug chemotherapy and his disease is well controlled.
case_images: Immunohistochemical results from post-operative pathological tissues of the patient. The results showed higher number of CD4+ and CD8+ T cells and the lower number of FOXP3+ Tregs and PD-(L)1 expression in tumor microenvironment. Scale bars represent 100 microm (20 microm in the inset images). FOXP3, Forkhead box P3; PD-L1, programmed cell death-ligand 1.
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case_images: In addition, compared to Forkhead box P3 (FoxP3)+ regulatory T cells (Tregs), the number of CD8+ cytotoxic T lymphocytes and CD4+ T helper lymphocytes was higher in the tumor microenvironment ( Figure 3 ).