case_images: PMC11790433_01
case_images: The histological examination of the specimen was depicted, with images (A, B) showing the H&E stained sections. Images (C, D) displayed the enlarged cervical lymph nodes, in 2019 this patient restarted the pemetrexed based chemotherapy in combination with bevacizumab, followed by radiotherapy for cervical lymph nodes and immunotherapy and achieved a relatively stable therapeutic effect. Images (E-L) illustrated the progression of grass ground nodules in the lung from 2013 to 2024. Specifically, images (E, G, J) indicated an increase in size of nodule A, while images (F, H, K) demonstrated the growth of nodule B, a lung puncture was done in 2024 due to the increasing solid component, thus EGFR19ins mutation was found and the afatinib was given. Images (I, L) depicted the presence of nodule C. Over the course of the extended treatment, minor nodules began to appear and gradually increased in size at a slow rate which reflected the complexity of the tumor background.
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case_images: f1
case_images: In February 2012, a 54-year-old Chinese woman was unintentionally found to have enlarged left cervical lymph nodes and diagnosed with metastatic poorly differentiated adenocarcinoma after cervical lymph node dissection biopsy ( Figures 1A, B ). PAX-8 (-), ALK -V (-), and ROS-1 (-)] ( Figures 1C, D ). Peripheral blood 1021 next-generation sequencing (NGS) test (Guangzhou Huayin Healthcare Group Co.) revealed KRASp.G13D mutation (abundance: 0.8%); The patient was treated for 16 months with pemetrexed (750 mg d1) + cisplatin (40 mg d1-d3) + bevacizumab (400 mg d1) q3w, pemetrexed+ bevacizumab, and single bevacizumab regimen, during which the efficacy was evaluated as SD. Then, due to the gradual enlargement of the lung lesions ( Figures 1E-L ), the patient underwent 2 cycles of pemetrexed + cisplatin + pembrolizumab (200 mg d1) q3w in November 2021.
case_images: Timeline diagram of the patient's treatment history. (A, Pemetrexed; AP, Pemetrexed+ Cisplatin; AC, Pemetrexed+ Carboplatin; RT, radiothenapy; Bev, Bevacizumab; TP, Albumin-paclitaxel micelles+ Carboplatin; T, Albumin-pacitaxel micelles + Carboplatin).
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case_images: f2
case_images: T790M, 20-Ins, G719X, S768I, and L816Q revealed negative results ( Figure 2  illustrates the patient's treatment history). The patient completed a baseline examination of 18F-PET-CT revealing a 9-mm solid nodule in the lower lingual segment of the left upper lung, multimal mediastinal, hilum, and bilateral supraclavicular lymph node combined with the right 5th rib, and bilateral ilium metastases.
case_images: Trends in tumor markers from 2012 to 2024 (dotted line represents upper limit of normal) and diameters of the three largest lung nodules in CT scans from 2012 to 2024 (shading represents the period of receiving chemotherapy); Nodule A: located in the posterior segment of the right upper lobe of the lung; Nodule B: located in the anterior segment of the upper lobe of the left lung; Nodule C: located in the posterior basal segment of the left lower lobe of the lung.
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case_images: f3
case_images: However, some small nodules emerged, during which the efficacy was evaluated as SD.  Figure 3  illustrates the changes in blood tumor markers and the three most prominent lung nodules observed in CT scans; it may be a reflection of the prognosis. 18F-PET-CT was done again in 2014, showing nodules in both the upper right and the left lung which increased in size.
case_images: (A-C) showed the PET/CT (2024-04-12): In the anterior segment of the left upper lobe of the lung and the posterior segment of the right upper lobe, there are mixed ground-glass nodules, with the largest measuring approximately 22x20mm and 18x13mm, respectively (B). The lesions mentioned above exhibit abnormally increased uptake with a maximum SUV of 7.36. There are scattered small nodules in both lungs with a long diameter ranging from approximately 3-11mm, showing no abnormal increase in F-FDG uptake. No abnormal increase in 18F-FDG uptake is observed in the bilateral breasts, mediastinal lymph nodes, bilateral pleura, or esophagus. The maximum SUV of the mediastinal blood pool is 2.05, with an average SUV of 1.84. CT scan reveals no enlargement of the mediastinal lymph nodes, no thickening of the bilateral pleura, and no pleural effusion in the chest cavity. Increased bone density was observed in the right iliac bone, with a maximum SUV of 8.51 (C).
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case_images: f4
case_images: Another 18F-PET/CT ( Figure 4 ) was done, and needle biopsy of the left upper lung nodule showed lung adenocarcinoma.