case_images: PMC9679790_01
case_images: Case report timeline and clinicopathological details. Legend. Representative breast cancer pathology images from the patient's bone biopsy are courtesy of Dr. Esther Sanfeliu (Pathology Department, Hospital Clinic of Barcelona). DIC, ductal invasive carcinoma; SLNB, sentinel lymph-node biopsy; CT, chemotherapy; IV, intravenous; IM, intramuscular; PO, per os; q3w, every 3 weeks; q3/4w, every 3 weeks out of 4; q4w, every 4 weeks; ET, endocrine therapy; RT, radiotherapy; NV, normal value; FISH, fluorescence in situ hybridization; COPD, chronic obstructive pulmonary disease; SUV, standard uptake volume; FNAB, fine needle aspiration biopsy; ER, estrogen receptor; PR, progesterone receptor; H&E, hematoxylin and eosin; CTA, computed tomography angiography; CDKi, CDK4/6 inhibitor; CT, computed tomography; PFI, progression-free interval; SC, subcutaneous and PTC, papillary thyroid carcinoma.
case_images: fonc-12-1009352-g001.jpg
case_images: PMC9679790_01_fonc-12-1009352-g001.jpg
case_images: f1
case_images: After the first 5 years of ET, it was decided to continue letrozole up to 10 years ( Figure 1 ). BC, with estrogen receptor (ER) and progesterone receptor (PR) expression levels of 0% and 20%, respectively, and no HER2 amplification/overexpression ( Figure 1 ). Because of the double tumor diagnosis, the patient was then tested for the presence of genomic mutations in hereditary cancer predisposition genes with the assay Illumina TruSight  Hereditary Cancer Panel. RECIST 1.1 criteria, with resolution of the lymphangitis and reduction in the number, dimension, and FDG uptake of nodal and bone lesions already at the December 2020 PET/CT ( Figures 1 ,  2 ). Ribociclib-based treatment was well tolerated, with only mild mucositis, skin dryness, and alopecia as AEs.
case_images: Representative images from the most relevant radiologic assessments. (A, B) CT Angiography at hospitalization showing signs of lymphangitis carcinomatosis. (C, D)Chest X-ray pre (C) and post (D) hospitalization showing the disappearance of lymphangitis signs and considerable reduction in pleural effusion. (E, F): PET/CT imaging at metastatic relapse diagnosis (E) and at first reassessment (F) after first-line treatment start, showing SUV reduction in metastatic sites. (G, H): CT scan at progression, showing two new hepatic lesions in the IV (G) and VI (H) segments.
case_images: fonc-12-1009352-g002.jpg
case_images: PMC9679790_01_fonc-12-1009352-g002.jpg
case_images: f2
case_images: A PET/CT detected multiple lesions with increased FDG uptake in bones and mediastinal and hilar lymph nodes ( Figure 2 ). A subsequent CT angiography detected a subpleural nodule in the left lung compatible with a malignant pleural implant, along with conspicuous bilateral pleural effusions, peribronchovascular and interlobular septal thickening, centrilobular micronodules, and the already-detected mediastinal and hilar adenopathies, all signs suggestive for lymphangitis carcinomatosis ( Figure 2 ). RECIST 1.1 criteria, with resolution of the lymphangitis and reduction in the number, dimension, and FDG uptake of nodal and bone lesions already at the December 2020 PET/CT ( Figures 1 ,  2 ). Ribociclib-based treatment was well tolerated, with only mild mucositis, skin dryness, and alopecia as AEs.