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case_images: Patient's tumor response to corresponding chemo and hormonal therapy. (A) Hematoxylin and eosin stain of the primary tumor and right inguinal metastasis. (B) Patient's CA-125 level as a function of time. Mar. 2016 when the patient received cytoreductive surgery, was marked as zero time point. The duration of chemo and hormonal therapies this patient received were indicated as colored boxes at the top of the graph. (C) The CT/MRI images of hepatic hilar metastasis (top) and right inguinal metastasis (bottom) pointed by the red arrows at each time point, along with evaluated tumor response to therapy were shown. The time of next generation sequencing of tumor samples was indicated by a green arrow.
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case_images: Postoperative pathology of tumor samples from the ovary revealed high-grade serous adenocarcinoma (Figure 1A). Cancer antigen 125 (CA-125) decreased from 441.82 U/mL to 71.01 U/mL after cytoreductive surgery (Figure 1B). The information of systematic therapies is summarized in Table 1, and as shown in Figure 1B, the level of CA-125 remained at a relatively low level within nine months after surgery. Tumors (RECIST) version 1.1 criteria (Figure 1C). Side effects of grade 2 white blood cell decrease and grade 1 platelet decrease were reported. Then, she received two cycles of gemcitabine, which only resulted in a temporary decrease in CA-125 level.  The hematoxylin and eosin stains of the biopsy sample confirmed high-grade serous adenocarcinoma (Figure 1A). After three months of tamoxifen treatment, both the right groin and the hepatic hilar tumor nodules significantly shrank (Figure 1C), which reached a partial response (PR) according to RECIST 1.1, and the level of CA-125 decreased to 186.38 U/mL. However, the size of hepatic hilar lymph nodes significantly increased (Figure 1C) after another two months of tamoxifen treatment, suggesting a progressive disease (PD). Aromatase inhibitor letrozole (2.5 mg oral daily) was subsequently given, which led to the shrinkage of metastatic hepatic hilar and right-groin nodules as well as the decrease in CA-125 (Figure 1C).
case_images: Amplification and overexpression of ESR1 in tumor samples from hepatic hilum and right groin. (A) The amplification of the ESR1 gene in tumor tissue samples at the indicated time. A decrease of ESR1 amplification in tumor tissue was observed after chemotherapy and hormonal therapy. Primary tumor and two right inguinal metastasis samples for next-generation sequencing were collected on Feb. 2016, Aug. 2018 and Aug. 2019 respectively. (B) Immunohistochemical staining of ESR1 in samples from the primary tumor (Mar. 2016) and right inguinal metastasis (Aug. 2018). (C) Change of allele frequency of TP53 in ctDNA of the patient. Patient's ctDNA was sequenced at indicated time points, which were calculated as months since surgery on Mar. 2016. The allele frequency of TP53 gene was normalized to the sample at 27 months and compared with each other. PD represents the progressive disease.
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case_images: The information of systematic therapies is summarized in Table 1, and as shown in Figure 1B, the level of CA-125 remained at a relatively low level within nine months after surgery. Both primary and metastatic tumor specimens underwent capture-based hybrid next-generation sequencing (NGS) by targeting 425 cancer-related genes, which revealed 8.7- and 5.3-fold ESR1 gene amplification in the primary tumor and metastatic lesion, respectively (Figure 2A). Immunohistochemical (IHC) staining (VENTANA anti-ER (SP1) Rabbit Monoclonal Primary Antibody, Roche) results showed a positive expression of ER in both primary tumor (>80%) and metastatic inguinal lymph node (>90%) (Figure 2B). A re-biopsy of the right inguinal lymph node metastasis was performed for NGS testing, and a 3.2-fold amplification of ESR1 was detected (Figure 2A).