Case Presentation and Overview

Mrs. GG is a 76-year-old woman who presented in March 2020 with a 4-month history of middle back pain radiating to the right chest wall. A magnetic resonance image of the thoracic spine on March 11, 2020, revealed the presence of 4.4-cm right posterior mediastinal lung mass in close contact with the T8 and T9 vertebral bodies. A computed tomography (CT) scan of the chest on April 3, 2020, revealed a 4.3-cm × 4.7-cm mass with central necrosis in the posterior segment of the right lower lobe with close proximity to the descending thoracic aorta and esophagus. CT-guided biopsy of the mass confirmed the presence of a poorly differentiated squamous cell cancer with PD-L1 expression in 50% of cells. A positron emission tomography/CT scan showed significant (18)F-fluorodeoxyglucose uptake in the right lower lobe with a standardized uptake value of 13.6 and a small focus of uptake in the right lung hilum with a standardized uptake value of 3.5 (Fig. 1). A magnetic resonance image of the brain was negative for metastasis, and endobronchial ultrasound and sampling of the mediastinal lymph nodes revealed no mediastinal node involvement. The patient was very functional, with an Eastern Cooperative Oncology Group performance status of 1.

The patient's case was discussed in our thoracic tumor board in April 2020, and it was debated whether surgery was an option in this case. It was decided to give the patient neoadjuvant therapy and assess her response after that. It was appreciated that a good response was needed in this patient if we were to consider surgical excision at all. Given the consistently higher response rates with a combination of chemotherapy and immunotherapy compared with chemotherapy alone and the strong PD-L1 expression of this patient's tumor, we gave the patient 3 cycles of carboplatin/gemcitabine and pembrolizumab.

Repeat imaging in June 2020 showed a minor response in the tumor (Fig. 2). However, the patient's initial complaints of severe back pain completely resolved after the first cycle of therapy. The patient's case was discussed again in the thoracic tumor board, and it was decided to proceed with surgical excision given the significant necrosis seen on imaging and the resolution of the patient's back pain.

The patient underwent right lower lobe lobectomy and osteotomy of the T8 and T9 vertebral bodies on June 25, 2020. A complete resection with negative margins (R0 resection) was achieved. Microscopic evaluation revealed 98% necrosis in the tumor specimen with only a small focus of residual squamous cell cancer, negative surgical margins, and negative hilar and mediastinal lymph nodes (Fig. 3). There was no evidence of therapy effect in the hilar lymph node that had mild activity on the baseline positron emission tomography scan. Postoperatively, the patient received intensity-modulated radiation therapy (IMRT) to the tumor bed (50.4 grays in 28 fractions) and was maintained on pembrolizumab.

A follow-up CT scan in October 2020 revealed postoperative changes with no evidence of disease recurrence. Unfortunately, the patient caught COVID-19 infection in December 2020 complicated by bacterial pneumonia, necessitating a prolonged hospital stay and interruption of her therapy with pembrolizumab. The patient had 2 small metastatic brain lesions in February 2021 that were treated with stereotactic radiation therapy (RT). After her COVID-19 infection, the patient never recovered adequately and had multiple hospital admissions for respiratory failure. She is currently at home receiving supportive care, including continuous oxygen supplementation.

中文翻译：

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局部晚期肺癌

案例介绍和概述

GG 夫人是一名 76 岁女性，她于 2020 年 3 月就诊，有 4 个月的中背痛病史，放射至右胸壁。2020 年 3 月 11 日的胸椎磁共振图像显示存在与 T8 和 T9 椎体紧密接触的 4.4 厘米右后纵隔肺肿块。2020 年 4 月 3 日的胸部计算机断层扫描 (CT) 扫描显示，右下叶后段有一个 4.3 厘米 × 4.7 厘米的肿块，中央坏死，靠近胸降主动脉和食道。CT 引导下的肿块活检证实存在低分化鳞状细胞癌，50% 的细胞表达 PD-L1。正电子发射断层扫描/CT 扫描显示右下叶有显着的 (18)F-氟脱氧葡萄糖摄取，标准化摄取值为 13。6 和右肺门的一个小焦点摄取，标准化摄取值为 3.5（图 1）。脑部磁共振成像显示转移阴性，支气管内超声和纵隔淋巴结取样显示没有纵隔淋巴结受累。患者的功能非常好，东部肿瘤合作小组的体能状态为 1。

该患者的病例于 2020 年 4 月在我们的胸腔肿瘤委员会进行了讨论，并就该病例是否可以选择手术进行了辩论。决定给予患者新辅助治疗并在此之后评估她的反应。值得赞赏的是，如果我们要考虑手术切除，则该患者需要良好的反应。鉴于与单独化疗相比，化疗和免疫治疗相结合的反应率始终较高，并且该患者肿瘤的 PD-L1 表达很强，我们给予患者 3 个周期的卡铂/吉西他滨和派姆单抗。

2020 年 6 月的重复成像显示肿瘤有轻微反应（图 2）。然而，患者最初的严重背痛主诉在第一个治疗周期后完全解决。胸部肿瘤委员会再次讨论了患者的情况，考虑到影像学上看到的明显坏死和患者背痛的消退，决定进行手术切除。

2020 年 6 月 25 日，患者接受了右下肺叶切除和 T8 和 T9 椎体截骨术，实现了切缘阴性的完整切除（R0 切除）。显微镜评估显示，肿瘤标本中 98% 坏死，只有小灶残留鳞状细胞癌，手术切缘阴性，肺门和纵隔淋巴结阴性（图 3）。在基线正电子发射断层扫描扫描中没有轻度活动的肺门淋巴结中没有治疗效果的证据。术后，患者接受了肿瘤床调强放射治疗 (IMRT)（50.4 灰分，28 次），并继续使用 pembrolizumab。

2020 年 10 月的后续 CT 扫描显示术后变化，没有疾病复发的证据。不幸的是，该患者于 2020 年 12 月感染了 COVID-19，并发细菌性肺炎，需要延长住院时间并中断派姆单抗治疗。该患者在 2021 年 2 月有 2 个小的转移性脑损伤，接受了立体定向放射治疗 (RT)。感染 COVID-19 后，患者从未完全康复，多次因呼吸衰竭入院。她目前在家接受支持性护理，包括持续吸氧。