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case_images: Preoperative magnetic resonance imaging brain with and without intravenous gadolinium contrast shows brain lesions from non-small-cell lung cancer. There is a partially cystic enhancing lesion measuring 4 cm in the left occipital lobe seen on T1c on axial slice (a). There is a moderate amount of surrounding edema seen on T2/FLAIR, also on axial slice (b). Sagittal (c) and coronal (d) sections are also shown in T1c. Not shown are scattered supratentorial small enhancing lesions consistent with brain metastases measuring 1 cm or less.. T1c: T1 post-contrast; T2/FLAIR: T2 with fluid-attenuated inversion recovery.
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case_images: Magnetic resonance imaging (MRI) of the brain revealed at least 25 enhancing brain lesions, the largest of which was a partially cystic lesion in the left occipital lobe measuring up to 4 cm (Figure 1).
case_images: Treatment planning and dosimetric evaluation for fractionated SRS. Computed tomography scans from the simulation are shown with dose color wash overlay in the axial (a), coronal (b), and sagittal (c) views. DVH shows dose metrics for target structures and critical OARs. CTV (red) and PTV (salmon) are target structures of the left occipital lobe postoperative cavity. The prescription dose is 27 Gy in three fractions delivered every other day to the PTV. Crosshair on the DVH highlights that the volume of PTV receiving 100% of the prescription dose is 97%. OARs shown include brain (brown), left optic nerve (ON; blue), optic chiasm (purple), brainstem (orange), and right ON (yellow). In panels a and c, there are other smaller brain lesions seen, and there were a total of 12 areas treated in this SRS plan all treated to 27 Gy in three fractions every other day.. CTV: clinical target volume; DVH: dose-volume histogram; OAR: organs at risk; PTV: planning target volume; SRS: stereotactic radiosurgery.
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case_images: Figure 2 shows the radiation treatment fields and corresponding dose volume histogram.
case_images: Postoperative brain MRI with and without intravenous contrast following left occipital craniotomy. There is interval resection of a left occipital lobe lesion with residual blood products, post-surgical changes, and residual enhancement suggestive of possible residual disease on T1c in the axial plane (a). There is evidence of residual moderate edema without any midline shift on T2/FLAIR (b). Sagittal (c) and coronal (d) slices are shown as well using T1c. Again, not shown is a redemonstration of numerous scattered enhancing bilateral parenchymal brain lesions consistent with metastases, overall stable in size and number.. T1c: T1 post-contrast; T2/FLAIR: T2 with fluid-attenuated inversion recovery.
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case_images: Follow-up MRI of the brain, performed 5 months postoperatively, showed partial response in his brain metastases and expected post-surgical changes (Figure 3).
case_images: (a) Initial PET/CT showing FDG avidity in the hilum and L5 and (b) post-treatment PET/CT showing interval resolution of FDG avidity.. FDG: fluorodeoxyglucose-18; PET/CT: positron emission tomography-computed tomography.
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case_images: Five months after initiating larotrectinib, PET/CT showed resolution of FDG avidity in the lung and bone metastases (Figure 4).
case_images: Follow-up brain magnetic resonance imaging scans in T1 sequence with intravenous contrast. At 3 months after stereotactic radiosurgery (a), there was complete resolution of contrast enhancement. There were some residual cystic and inflammatory changes consistent with the post-treatment effect. His additional 11 lesions showed interval resolution as well. This was consistently demonstrated as his follow-up scans did not show any evidence of disease at 6 months (b), 16 months (c), and 20 months (d).
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case_images: His most recent MRI showed no evidence of disease (Figure 5).
case_images: Timeline of pertinent events, procedures, and diagnostic tests from the patient presentation to the most recent follow-up.
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case_images: See Figure 6 for a graphical depiction of the events from diagnosis to follow-up.