CASE REPORT
A 54-year-old male patient had 30 pack-years of cigarette smoking and intermittent dry cough that persisted for one month, especially when changing body positions, without any significant weight loss, less sputum without blood, and fluctuating body temperature between 37.3°C to 38.0°C (axillary temperature). There’s no effect after being treated with the Suhuang Zhike capsule (a traditional Chinese medicine used to relieve cough and resolve phlegm). Therefore, he went to Xishan People’s Hospital of Wuxi City for further diagnosis and treatment on 2nd May 2022. The patient’s information was disclosed with consent following a discussion by the hospital ethics committee (No. xs2022ky012).
The physical examination and initial vital signs were as follows: On admission, body temperature, 36.7°C (axillary temperature), pulse rate, 99 beats/min; respiratory rate, 17 breaths/min; and blood pressure, 115/86 mmHg. His height and body weights were 178 cm and 67.5 kg. His familial history was unremarkable. Laboratory examinations showed blood cell analysis, liver function, coagulation function, and serum tumor biomarkers within the normal range (Table 1 ). Other Laboratory examinations showed a negative result (Table 2 ).
Unfortunately, CT revealed a clear pulmonary mass that almost filled the right interlobar fissure area (Figure 1, A-B ), which was also confirmed by PET-CT (Figure 3, A-B ). Reviewing the medical history, a small subpleural pulmonary nodule, the diameter of which was approximately 5 mm, was detected by the chest CT in the patient’s right lower lobe oblique fissure in our hospital on 3rd July 2020 (Figure S1, A-B ), but not attracted attention at that moment. After performing a pathological puncture on the right lung mass, bloody pleural effusion and tumor heteromorphic cells were discovered. Pathologically, Hematoxylin & eosin (H&E) (Figure 2, A ) and immunohistochemistry (IHC) staining (Figure 2, B-D ) (Figure S2, A-G ) suggested PSC. Simultaneously, extensive panel-based genetic testing, and next-generation sequencing (NGS), showed that ROS1 was overexpressed in this PSC patient. While, immune-checkpoint and programmed death ligand-1 (PD-L1) were performed TPS (tumor proportion score) and CPS (combined positive score) were 50% and 55%, respectively. Collectively, all these results indicated and diagnosed as PSC (right lobe), subtyped as spindle cell carcinoma, non-squamous, TNM Classification was T4NxM1a, stage IVa. Consequently, following a multidisciplinary consultation, chemotherapy, antiangiogenesis, and immunochemotherapy were planned for the patient, including Apealea (paclitaxel micellar) (480mg, intravenous injection, day1) + Cisplatin (40mg, intravenous injection, per day, days 1-3 of a 21-day cycle) +Anlotinib (12mg, oral, per day, days 1-14 of a 21-day cycle) + Crizotinib (250mg, oral, twice a day).
A re-examination of PET-CT revealed that after three cycles of the treatment, the lesion’s glucose metabolism was significantly lower than before (Figure 3, C-D ). Based on this situation, the patient underwent the treatment of thoracoscopic right middle and lower lobectomy plus mediastinal lymph node dissection after discussion, which was completed as R0 resection, classification was T4N1M1a, stage IVa. However, a severe pulmonary infection happened in the patient two weeks post-operation (Figure 1, C-D ). A second procedure, called thoracoscopic empyema fibrous plate stripping plus thoracic irrigation and drainage, was then carried out. Shocking discovery, extensive pleural metastases were found intraoperatively, sizes ranging from 5 mm to 15 mm, and additionally, pathological biopsy was also performed which was in line with previous results but even worse (Figure S3, A-L ). No more soon, the patient developed a rapid, extensive tumor metastasis (Figure S1, C-D ), and in a poor general nutritional status. Although antiangiogenetic- and immunochemical- therapy (Anlotinib + Crizotinib) which was stopped during this two-operation period, was carried out again, it did not play a good job and not limited the progress of the tumor (Figure S1, E-F) , leading to widespread metastasis followed by multiple organ failures, eventually causing death.
In this case, this patient’s condition appears to be better before operation, which may be linked to the performance of chemo-, antiangiogenetic-, and immunochemical therapy. However, the deterioration of this PSC was very rapid, especially after surgical treatments which seem to accelerate the death of the patient. Nevertheless, the diagnosis and treatment of this patient is still controversial.