case_images: PMC7604326_01
case_images: Fibrinogen and CEA levels during treatment (g/L). (A) Fibrinogen levels during WBRT. (B) Fibrinogen levels during immunotherapy. (C) CEA levels (ng/mL) during treatment. Fibrinogen normal value, 2.00-4.00 g/L; the critical value, <1 g/L; CEA normal value, <5 ng/mL. CEA, carcinoembryonic antigen.
case_images: fonc-10-526096-g001.jpg
case_images: PMC7604326_01_fonc-10-526096-g001.jpg
case_images: F1
case_images: Infusion of fresh frozen plasma, cryoprecipitate, and fibrinogen concentrate was not effective, and reexaminations of fibrinogen still indicated the critical value, as shown in Figure 1A. CEA continued to rise (Figure 1C). Computed tomography indicated multiple metastatic tumors in the S3 and S8 segments of the liver and 3.3-cm-long metastatic lymph nodes. Before the fourth immunotherapy, fibrinogen rose to 1.98 g/L, a near-normal value (Figure 1B). CEA decreased from 803.9 to 110 ng/mL (Figure 1C).
case_images: Immunohistochemical PD-L1 staining (Magnification: 10 x 40). The patient's expression level of PD-LI was detected using the VENTANA PD-L1 (SP263) Assay. The brown cells in the immunohistochemical staining for PD-L1 are positive cells, including tumor cells (TCs) with membrane staining at any intensity and immune cells (IC) in the tumor area, such as lymphocytes and macrophages. After counting the positive cells, the corresponding proportion was calculated according to the formula. Tumor Proportion Score (TPS), which is the percentage of viable tumor cells showing partial or complete membrane staining at any intensity. Combined positive score (CPS) = (positive TC + positive IC)/total tumor cells x 100.
case_images: fonc-10-526096-g002.jpg
case_images: PMC7604326_01_fonc-10-526096-g002.jpg
case_images: F2
case_images: Considering the previously detected indicators of this patient, such as tumor proportion score (TPS) > 15% and combined positive score (CPS) of 20, the expression of programmed cell death 1 ligand 1 (PD-L1) was considerable (TPS > 1%, CPS > 1) on tumor cells (TCs), immune cells, and mesenchymal cells (Tables 1, 2 and Figure 2).
case_images: Before the fourth immunotherapy by sintilimab, the liver metastases showed no obviously change.
case_images: fonc-10-526096-g003.jpg
case_images: PMC7604326_01_fonc-10-526096-g003.jpg
case_images: F3
case_images: Tumors (RECIST Version 1.1). The liver metastases showed no obvious change (Figure 3), and the left axillary lymph node was smaller than before (25 mm vs. 33 mm).