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.