case_images: PMC10185815_01
case_images: CT images (A) and 3D reconstruction (B) of this patient with early-stage MPLC. Nodule 1, nodule 3, nodule 5, nodule 6 and nodule 9 were identified as MIA. Nodule 4, nodule 12, and nodule 11 were identified as AIS. No cancer cells were found in nodule 2, nodule 7, nodule 8, and nodule 10. MPLC, multiple primary lung cancer; AIS, adenocarcinoma in situ; MIA, minimally invasive adenocarcinoma.
case_images: fonc-13-1064475-g001.jpg
case_images: PMC10185815_01_fonc-13-1064475-g001.jpg
case_images: f1
case_images: On the contrary, in July 2019, his CT images revealed multiple enlarged nodules in the upper lobe of the left lung and he was admitted to our hospital for further treatment ( Figure 1A ). Then, the patient was diagnosed with more than 10 nodules and we used a three-dimensional (3D) reconstruction model to evaluate the accurate location of these nodules and their relevant anatomical structures ( Figure 1B ).
case_images: Whole-exome sequencing (A), mIHC analysis (B), biomarker correlations (C), and subtype differences (D) of each nodule in this patient with early-stage MPLC. Whole-exome sequencing showed that there were almost no collective mutations among all nodules. mIHC analysis showed similarly low positive levels of CD4 + T cells (yellow color), CD8 + T cells (green color), CD163+ macrophages (purple color), and PD-L1 expression (red color) in tumor microenvironments of each nodule. Fisher's exact test and Wilcox test were used to analyze the correlation or differences between different groups. *p<0.05 was considered as statistically significant. MPLC, multiple primary lung cancer; AIS, adenocarcinoma in situ; MIA, minimally invasive adenocarcinoma. ns, not statistically significant.
case_images: fonc-13-1064475-g002.jpg
case_images: PMC10185815_01_fonc-13-1064475-g002.jpg
case_images: f2
case_images: In this current case, whole-exome sequencing (WES) ( Figure 2A ) and multiple immunohistochemistry (mIHC) ( Figure 2B ) were performed to reveal the genomic profiling and tumor microenvironments of multiple nodules, including nodule1, nodule 4, nodule 5, nodule 6, nodule 9, and A subsegment (nodule 11). As shown in  Figure 2A , KRAS mutations were observed at nodule 5, mutations at those genes, including MAP2K1, SEZ6L, PAX5 and CACNB2, were observed at nodule 6, no mutations were observed at nodule 9, and mutations at those genes, including SIX3, KRTAP5-11, KEAP1, KRAS, GAS7, FLT4, FAT1, FAM57B, COL9A2, CD99L2, were observed at A subsegment (nodule 11). As seen in  Figure 2B , mIHC analysis showed similarly low positive levels of CD4 + T cells (less than 17%), CD8 + T cells (less than 5%), CD163+ macrophages (less than 15%), and PD-L1 expression (less than 15%) in tumor microenvironments of each nodule. As shown in  Figure 2C , maximum diameter and TMB levels were found to be significantly associated with CD8+ T cell proportion (p<0.05). CD4+ T cells proportion, and CD163+ macrophage proportion. Comparing the relevant results of MIA and AIS nodules in  Figure 2D , CD163+ macrophages and CD4+ T cell proportions were higher in MIA nodules than in the AIS nodules (p<0.05).