Case Presentation
In December 2020, a male patient presented with symptoms of cough,
sputum and chest tightness for one month and worsened over one week.
Ultrasound showed a large pericardial effusion, hypoechoic nodules
measuring approximately 31*40 mm (Figure1) and a small amount of pleural
effusion, and a diagnosis of NSCLC (adenocarcinoma of the lung) with
tumor stage IVB (T3N3MIC) was considered after puncture biopsy of the
corresponding site. Next-generation sequencing-based genomic testing
showed the result that a mutation in KRAS Q61H was carried out by the
patient (Table 1). Immunohistochemical results: Cytokeratin 7 (CK) 7
(+), Cytokeratin20 (CK20) (-), Carcinoembryonic antigen (CEA) (weak +),
Transcription termination factor (TTF-1) (+), Napsin-A (+), P63 (An
oncogene) (few +), Ki67 (A protein encoded in humans by the MKI67 gene
(an antigen recognized by the monoclonal antibody Ki-67) (about 30% +),
P53 (An oncogene) (part +). The patient was in good health, denied any
history of chronic medical conditions such as hypertension, diabetes and
family history of tumors, and admitted to a history of smoking, 20
cigarettes/day, for over 30 years. In March 2021, when the patient was
scheduled for his fifth chemotherapy treatment, a chest CT revealed an
increase in pleural thickening, an increase in peripheral inflammation
and a significant increase in pleural effusion after 3 months of using
cisplatin (100mg) and pemetrexed (800mg) (AP scheme) in combination with
endothelial inhibitors. The diameter of the tumor was 39mm ×36 mm
(Figure 1). On 20 April 2021, the patient was admitted to the hospital
with dyspnea and was diagnosed with malignant pleural effusion the
treatment regimen was adjusted to the combined treatment of Cisplatin
(100mg) and Docetaxel (120mg) (TP scheme) in combination with
camrelizumab (200mg) and endostatin (210mg) was administered. On 2
September 2021, reconsidering the progression of the disease the
combined treatment of camrelizumab (200mg) and endostatin (210mg) was
administered, during this period the patient underwent proton heavy ion
therapy 6 times at external hospitals (details not available). On 20
March 2022, while continuing treatment with camrelizumab, an
ultrasound-guided biopsy of the thyroid gland and lymph nodes was
performed and papillary thyroid cancer was identified. The patient’s
condition was discussed as multiple primary malignancies (MPMN)[10],
which refers to the simultaneous or sequential occurrence of 2 or more
primary malignancies in the same body organ, the mechanism of which is
currently unknown and perhaps related to the patient’s reduced ability
to monitor immune function to clear the mutated cells. Given the
critical nature of the patient’s primary disease at this time, neither
the patient nor the physician considered temporary management in
relation to papillary thyroid cancer. Serum lung tumour markers were
further controlled with targeted therapy. Changes in lung tumour
serology during respiratory chemotherapy are shown in Table 2 and
imaging reports are shown in Figure 1. The patient’s liver and kidney
function were monitored regularly during the drug administration, and no
significant hepatic or renal adverse effects were observed in this
patient. Since the patient had a fatty liver, the patient’s lipid
profile and liver function were monitored, as shown in Table 3. After 12
cycles of immunotherapy, the patient’s dosing regimen was adjusted from
camrelizumab (200mg) in combination with endonuclease (210mg) to a
combination of camrelizumab (200mg) and bevacizumab (900mg) with a
higher recommendation grade according to the relevant clinical treatment
guidelines[9]. This patient’s dosing regimen was all based on a
21-day dosing cycle, with all antineoplastic drugs administered
intravenously, except for recombinant human vascular endothelial
inhibitors, which were administered intra-pump. Interestingly within 18
months of immunotherapy, we not only found that the patient’s pleural
effusion disappeared but also that the levels of several tumour markers
tested fell from above normal to normal range. In addition, the primary
tumor in the lung did not progress. As of the last follow-up date
(December 2023), the overall survival was 27 months.