Detailed Treatment Process
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Female, 61 years old
* Pathology report (2 years ago) Age: 59 years Date received: September 22 (2 years ago) Pathological diagnosis: Gross examination: 1. Right middle lobe resection specimen, measuring 13 × 6 × 4 cm, with pleural thickening in some areas. Mass measuring 2.6 × 2 × 1.5 cm, of medium consistency, gray-white in color, with ill-defined borders, adherent to the pleura. 2. Mediastinal mass: cystic lesion measuring 1.5 × 1 × 1 cm, with wall thickness of 0.1–0.2 cm. D. Lymph nodes: one from the right middle lobe bronchial orifice (Φ0.6 cm), one from station 2 (paratracheal, Φ2.5 cm), one from station 4 (tracheobronchial, Φ2.8 cm), one from station 7 (subcarinal, Φ1.9 cm), one from station 8 (paraesophageal, Φ3 cm), three from station 10 (hilar, Φ0.8–0.9 cm), and two from station 11 (interlobar, Φ0.6–1.2 cm). Microscopic examination: 1. Right middle lobe resection specimen. Adenosquamous carcinoma (keratinizing squamous cell carcinoma 60%, with poorly differentiated adenocarcinoma component 40%), measuring 2.6 × 2 × 1.5 cm, with lymphovascular invasion, perineural invasion, and necrosis. Tumor invades the elastic layer of the visceral pleura (PL1) on elastic staining. Bronchial resection margin free of tumor. 2. Mediastinal mass: foregut cyst, cyst wall lined with pseudostratified ciliated columnar epithelium, with focal fibrous hyperplasia and mild inflammatory cell infiltration in the wall, and adjacent atrophic thymic tissue. No tumor metastasis in 0/7 lymph node groups. Lymph nodes: station 2 (0/1), station 4 (0/1), station 7 (0/1), station 8 (0/1), station 10 (0/3), station 11 (0/2), right middle lobe bronchial orifice (0/1). Special studies: Immunohistochemistry: CK(+), P40 (partial +), TTF-1 (partial +), Napsin A (partial +), GATA-3 (partial +), CK7(+), PAX-8(−), Ki-67 (15%+). Date: October 13 Primary reviewer: Second reviewer:
Laboratory Report Sampling time: August 15 08:57:56 Report time: August 16 14:34:19 Hepatitis B virus DNA 458000 (0—50 IU/ml)
Ultrasound Report Report time: September 12 09:20:04 Examination site: Digestive system (abdomen + portal vein) Findings: Liver normal in size and shape. A 32×25 mm isoechoic mass with irregular shape, ill-defined borders, and heterogeneous internal echo is seen in the right posterior lobe; CDFI shows penetrating vessel-like blood flow signals inside. A 6×5 mm hyperechoic mass with regular shape, clear borders, and dense internal echoes is seen near the second hepatic hilum; no obvious blood flow signals inside on CDFI. Remaining liver parenchyma shows slightly coarsened and heterogeneous echoes. Gallbladder normal in size and shape, with rough wall and no obvious abnormal intraluminal echoes; common bile duct not dilated. Spleen normal in size and shape, with smooth capsule and homogeneous echoes; splenic vein at the hilum not dilated. Pancreas normal in morphology with clear outline and homogeneous echoes; main pancreatic duct not dilated. Impression: Solid hepatic mass, suggestive of malignancy; please correlate with clinical findings and other imaging. Examination method: Color Doppler ultrasound ×××××××××× Laboratory Report Details Report time: September 12 12:02:33 Sampling time: September 12 09:26:59 Carcinoembryonic antigen (CEA) 184.54 (0—5 ng/mL) Alpha-fetoprotein (AFP) 3.99 (0—9 ng/ml) ×××××××××× Department: Respiratory Medicine Specialist Clinic October 17, 08:35 Additional history: Cough for 8 months, white frothy sputum without diurnal variation, mainly dry cough, no acid reflux, occasional belching. Pathology from two years ago: lung adenosquamous carcinoma, postoperative molecular testing ALK positive, no adjuvant therapy received. Recent outside hospital imaging suggests liver metastasis. CEA elevated. FeNO 19 ppb. Pulmonary function (August 15): FEV1 87%, FEV1/FVC 72.95%, FEF75 55.7%, FEF50 50.3%, FEF25 54.4%. Tumor markers (September 12): CEA 184.54 ng/mL ↑ Total IgE (September 12): 236.00 IU/mL ↑ Complete blood count + CRP (October 17): normal Abdominal ultrasound (October 17): intrahepatic mass, suggestive of metastasis; gallbladder wall roughened. Chest ultrasound (October 17): no obvious pleural effusion bilaterally. Diagnosis: 1. Postoperative recurrence of lung malignancy, stage IV; 2. Secondary hepatic malignancy; 3. Cough-variant asthma Plan: Laboratory tests – renal function + glucose (outpatient) once, total IgE once, complete blood count + CRP once, liver function (outpatient) once, CEA once, HBV DNA quantification once. Imaging – chest ultrasound once, abdominal ultrasound (abdomen + portal vein) once. Remarks: Lorlatinib 100 mg once daily ×××××××××× Laboratory Report Details Report time: October 17 11:42:01 Sampling time: October 17 08:57:24 Carcinoembryonic antigen (CEA) 422.53 (0—5 ng/mL) ×××××××××× PET/CT Imaging Report Examination date: October 31 Clinical diagnosis: Status post right lung malignancy resection; hepatic space-occupying lesion Brief history: Right lung radical resection performed two years ago; pathology showed lung adenosquamous carcinoma. Chest CT at our hospital on February 12 last year showed postoperative changes in the right lung, tiny nodules in both upper lobes, and sclerotic changes in the left 4th and 5th ribs, plus hepatic cyst. Follow-up CT on February 1 this year showed multiple tiny nodules in both lungs, some unchanged and some new. Outside hospital MRI on October 28 showed multiple intrahepatic lesions, increased in size compared with August 2 imaging. This PET/CT was performed to evaluate systemic disease. Fasting blood glucose 6.0 mmol/L, no history of diabetes, hypertension, cerebrovascular disease, or tumor family history. Normal bowel and bladder habits. History of hepatitis B. No recent fever, no leukocyte-elevating medications, no trauma. Left breast surgery 15 and 4 years ago, details unknown. Postmenopausal. Imaging findings: Patient fasted for more than 6 hours, received intravenous 18F-FDG, rested quietly for 60 minutes, then underwent whole-body PET/CT tomography. Brain parenchyma shows homogeneous radiotracer distribution; bilateral frontal, parietal, temporal, occipital lobes and cerebellum are symmetric without abnormal focal uptake. CT shows small low-density foci in bilateral basal ganglia; no other abnormal density in brain parenchyma. Sulci, fissures, and cisterns normal; midline structures not shifted. Nasal septum midline, turbinates normal, nasal passages patent. Paranasal sinuses normal in size with good aeration, no mucosal thickening or bone abnormality. Nasopharynx and oropharynx normal. No abnormal uptake on PET. Trachea midline. Thyroid symmetric with clear borders; right lobe contains a 6.8 mm low-density lesion with increased uptake, SUVmax 4.2. Left lobe normal. No enlarged cervical lymph nodes. No abnormal uptake on PET. Status post right upper lobe malignancy resection with high-density suture material and linear opacities at the surgical site. Mild increased uptake at right hilum, SUVmax 3.6. Lung markings slightly prominent. Scattered tiny pulmonary nodules, largest 2.3 mm, without increased uptake. Multiple small mediastinal lymph nodes with mildly increased uptake, SUVmax 4.6. Nodular density in left breast; right breast normal. No abnormal uptake on PET. Liver shows heterogeneous density with multiple slightly low-density lesions in left lateral, right anterior, and right posterior segments. Largest in right posterior lobe measures 29.9 × 24.8 mm (new compared with February 1 CT), with mildly increased FDG uptake, SUVmax 3.7, rising to 4.0 on delayed imaging. Small low-density lesion in left medial segment (11.4 × 7.8 mm) without increased uptake. Colonic uptake along bowel wall without corresponding CT abnormality. Gallbladder, spleen, pancreas, adrenals, kidneys, stomach, and uterus normal. No enlarged lymph nodes in abdomen, retroperitoneum, pelvis, or inguinal regions. No abnormal uptake on PET. Mild increased uptake at left temporomandibular joint, SUVmax 4.7, with sclerotic changes on CT. Osteolytic destruction at T9 and L1 with wedge deformity of L1, SUVmax 11.6. Sclerotic nodules in left acetabulum and femoral head. Remaining bones normal. No other abnormal uptake on PET. Imaging impression: 1. Status post right lung malignancy resection; multiple new hepatic low-density lesions with mildly increased FDG uptake, suspicious for malignancy—correlate with pathology; bone metastases at T9 and L1. 2. Small lacunar infarcts in bilateral basal ganglia; low-density lesion in right thyroid with increased FDG uptake—suggest follow-up ultrasound or thyroid function tests. 3. Tiny pulmonary nodules—suggest follow-up; mediastinal lymph nodes likely reactive; calcified nodule in left breast—suggest ultrasound or mammography. 4. Hepatic cyst; colitis. 5. Degenerative changes of the spine; probable left temporomandibular joint arthritis; sclerotic foci in left acetabulum and femoral head. Report date: October 31