case_images: PMC9884431_01
case_images: Computed tomography scans showing clinical response to treatments. (A-D) Computed tomography scan of lesions and pleural effusion at baseline. (E-H) The patient achieved partial remission after crizotinib treatment. (I-L) PD with mass enlargement and increased pleural effusion. (M-P) Three months after half-dose crizotinib treatment, the patient achieved SD, (Q-T) which was maintained for more than 9 months. Blue arrows indicate lesions, and red arrows indicate pleural effusion.
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case_images: D), invading the right pulmonary artery, with metastasis in the right hilar lymph nodes and the right pleura, accompanied by right pleural effusion (Figure 1B and D). Double ALK- tyrosine kinase inhibitor (TKI), crizotinib, twice daily (250 mg). After 9 weeks of treatment, the lesions and pleural effusion decreased, and partial response was achieved (Figure 1E-H). The symptoms improved within a month, and for the next 9 months the patient showed stable disease without hypohepatia (Figure 1Q-T).
case_images: Timeline and trends of liver function. The selected liver function tests (LFTs) were normal at baseline and increased after nine weeks of treatment with crizotinib. Liver function recovered after treatment interruption and initiation of a liver protection treatment for 40 days. Crizotinib was administered again at a half-dose without liver injury. Normal values for LFTs at our institution are as follows: ALT, 5-40 U/L; AST, 5-40 U/L; ALP, 50-136 U/L; and Tbil, 5.1-22 mumol/L.
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case_images: However, treatment with crizotinib had to be interrupted as the patient complained of fatigue, anorexia, nausea, and vomiting and showed acute liver failure, grade 4 according to the CSH (Chinese Society of Hepatology) guidelines for the diagnosis and treatment of drug-induced liver injury, accompanied by abnormal levels of aminotransferases (alanine aminotransferase, 3700 U/L; aspartate aminotransferase, 1049 U/L), alkaline phosphatase (187 U/L), and total bilirubin (179.9 umol/L); prothrombin time activity (25.2%); and international standardized ratio (2.3) and a moderate amount of ascites (Figure 2).