case_images: PMC10832448_01
case_images: A-B: Computed tomography (CT) angiogram of the chest reveals two masses in the right lung apex measuring 2.3 x 2.1 cm and 3.6 x 1.7 cm (A), and a CT of the abdomen and pelvis demonstrates a destructive lytic lesion of the left acetabulum measuring 3.9 x 3.4 cm (B).
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case_images: A follow-up computed tomography (CT) angiogram of the chest was remarkable for two masses in the right lung apex measuring 2.3 x 2.1 cm and 3.6 x 1.7 cm respectively (Fig. 1A). In addition, a CT of the abdomen and pelvis demonstrated a destructive lytic lesion of the left acetabulum measuring 3.9 x 3.4 cm (Fig. 1B) and a 1.3 cm cystic lesion in the uncinate process of the pancreas without a solid component.
case_images: A-B: Histologic sections of the needle core biopsy of the right lung mass reveals two morphologically distinct areas including a well-differentiated adenocarcinoma in the left half of the image and a moderately-differentiated adenocarcinoma on the right half of the image (A). Immunohistochemistry for TTF1 shows positivity in the well-differentiated adenocarcinoma component of the needle biopsy (B).
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case_images: Oro Valley, AZ, USA), PAX8 (Abcam, Cambridge, MA, USA), GATA3 (Ventana Medical Systems, Oro Valley, AZ, USA) and Napsin A (Lecia Novocastra, Deer Park, IL USA). In addition, immunohistochemical stains for mismatch repair proteins (MMRPs) including PMS2, MSH2, MSH6, and MLH1 (Ventana Medical Systems, Oro Valley, AZ, USA/BD Pharmingen, San Diego, CA, USA) showed intact and preserved MMRPs. One week later, the lung mass was biopsied and revealed adenocarcinoma with two distinct histologic patterns including a well-differentiated and a moderately-differentiated component (Fig. 2A). TTF1 and Napsin A were strongly positive in the well-differentiated component and negative in the moderately-differentiated component (Fig. 2B).
case_images: A-B: Higher power image of lung needle core biopsy showing well-differentiated adenocarcinoma (A) with the corresponding targeted NGS revealing two sensitizing EGFR mutations including S768I (B) & G719C (not shown).
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case_images: The repeat NGS results identified the two sensitizing EGFR mutations including G719C and S768I in the well-differentiated, TTF1-positive portion of tumor (Fig. 3A and B), and the KRAS G12A in the less differentiated component of tumor (Fig. 4A-B).