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case_images: Evaluation after first-line endocrine therapy (A) CT evaluation of the bons lesion after first-line endocrine therapy in September 2020. (B) CT evaluation of right scapula the ninth rib and SPECT evaluation after first-line endocrine therapy in September 2020.
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case_images: To be more accurate and for comprehensive staging, the patient underwent [ 18F]FDG PET/CT examination on 31 March 2020, which showed multiple lymph nodes metastases (in the right axilla) and bone metastases (in the anterior coracoid process of the right scapula, 1st thoracic vertebra, first, second and fourth lumbar vertebrae, and right ilium) ( Supplementary Figure 1 ). WBS showed that the bone metabolism of the lumbar vertebra, right sacroiliac joint, and first thoracic vertebra decreased or even disappeared with increased bone density on CT ( Figure 1A ). The bone metabolism of the right scapula was similar, but its bone density on a CT scan showed an increase first and then a decline, suggesting that bone metastasis was progressing ( Figure 1B , left). In addition, new nuclide-concentrated foci appeared in the right ninth rib, as shown by WBS, and the bone density of the lesion increased after endocrine therapy, so this was identified as a new lesion ( Figure 1B , center and right).
case_images: Evaluation after second-line chemotherapy. (A) CT evaluation of the right sacroiliac joint before chemotherapy and after cycles in December 2020. (B) CT evaluation of the right scapula before chemotherapy and after chemotherapy in May 2021 (C) CT evaluation of the bone lesion after second-line therapy in July 2021, (D) CT evaluation of the right scapula and SPECT evaluation after second-line therapy in July 2021.
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case_images: After four cycles of combined therapy, the CT scan showed that, despite most of the bone metastases being similar to before, the edge of the right iliac lesion had begun to blur ( Figure 2A ). On 6 May 2021, the CT examination after the first two cycles of capecitabine alone showed different degrees of osteolytic changes in the right scapula ( Figure 2B ). The new osteolytic lesions were also found in the thoracic vertebra, the first and third lumbar vertebrae, and the right sacroiliac joint ( Figure 2C ), and the original osteolytic lesion in the coracoid process of the right scapula was enlarged ( Figure 2D , left). Combined with the decreased density of bone lesions, increased tumor markers, and the exacerbation of bone pain symptoms, after efficacy evaluation the disease was categorized as PD again ( Figure 2D , right); the advanced second-line chemotherapy was declared a failure. The levels of both enzymes fluctuated within the normal range during endocrine therapy, both increased to varying degrees during the advanced second-line chemotherapy, and both decreased to within the normal range after the original endocrine therapy was applied ( Supplementary Figures 2 ,  3 ).
case_images: Imaging examinations during the third-line endocrine therapy (A) CT evaluation of the bone lesion after 3 months of third-line endocrme therapy in October 2021. (B) PET/CT evaluation of each bone lesion after 3 months of third-line endocrine therapy in October 2021.
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case_images: During 3 months of the re-administration, the patient's clinical manifestations and other indicators generally improved, the CT scan revealed that the scope of osteogenic lesions expanded, and the density increased ( Figure 3A ). In October 2021, approximately three cycles after endocrine therapy administration, the patient received radiotherapy as a synergistic treatment. [ 18F]FDG PET/CT in the same month demonstrated that the FDG uptake in multiple original bone lesions (thoracic vertebrae, lumbar vertebrae, and right sacroiliac joints) decreased significantly or disappeared, and lesion density changed from osteolysis into osteogenesis ( Figure 3B ). The levels of both enzymes fluctuated within the normal range during endocrine therapy, both increased to varying degrees during the advanced second-line chemotherapy, and both decreased to within the normal range after the original endocrine therapy was applied ( Supplementary Figures 2 ,  3 ).
case_images: Changes in bone lesions during the treatment. (A) CT evaluation of the lumbar lesion 1 during the treatment. (B) CT evaluation of lumbar the lesion 2 during the treatment. (C) CT evalution of the right sacroiliac joint during the treatment. (D) CT evaluation of the coracoid process of the right scapula during the treatment. (E) SPECT/CT evaluation during the treatment. T: Albumin paclitaxel; X: Albumin paclitaxel.
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case_images: After 10 cycles, the osteoblastic range of each bone metastasis lesion continued to increase, and osteolytic lesions of the right scapular acoid began to show osteogenic changes ( Figures 4A-D ). SPECT/CT scan indicated increased bone density and a decrease in the number of bone-concentrated foci and the degree of nuclide concentration ( Figure 4E ).