1) Condition after 3 courses of the second line of polychemotherapy (4 courses of EP, pemetrexed in monoregime for 3 courses). Progression. Condition after 6 courses of immune therapy (with atezolizumab) from November 11, 2019 to March 2020. Condition after 3 courses of chemotargeted therapy (docetaxel + nintedanib).
2) Post-radical mastectomy condition from 1999. Condition during therapy with bisphosphonates (zoledronic acid). Condition during the follow-up course of therapy: (nintedanib) + Photodynamic therapy + Bioelectrotherapy of lungs. Second clinic group. ICD-10 C34.1
Histology: No. 2449 dated February 23, 2019 – moderately differentiated lung adenocarcinoma, glandular version of structure.
Immunohistochemistry dated February 24, 2020 – TTF-1: reaction in tumour cells is not found. GATA-3: diffuse nuclear reaction with varying degrees of severity in most tumour cells.
Allred receptor status: estrogen receptors (clone EP1): 5 (PS)+3(ls)=8(TS). Progesterone receptors (clone 1E2):5(PS)+2(IS)=7(TS). Value of ASCO/CAR’13 Her2-status: Her2-status: 0 – immunophenotype of the tumour most of all corresponds to the immunophenotype of breast cancer.
Immunohistochemistry dated October 3, 2019 – ALK tumour – negative, ROS1 – negative. The patient had 4 courses of polychemotherapy according to the scheme (EP) – during CT of chest organs dated June 15, 2019.
Conclusion: CT scan of a large formation at the root of the left lung (central cr) with invasion of organs in the mediastinum, focal formation in S7 to the right. Multiple small focal changes in both lungs. Quantitative lymphadenopathy. Inhomogeneous structure of the Th6 vertebral body, posterior segment of the 6th rib on the right. Fluid in the pericardial cavity. The patient was consulted in SBHOMR "Moscow Regional Oncology Hospital" in Balashikha. Recommended: three courses of the second line of polychemotherapy (pemetrexed 1000 mg once every 3 weeks) + therapy with bisphosphonates (zoledronic acid 4 mg once every 28 days) at the place of residence.
At Onco.Rehab the patient underwent a course with no features.
On follow-up examination — progression. Chest CT scan with IV contrast dated November 13, 2019
Conclusion: CT-image of the central C-r left lung with partial atelectasis S3, invasion of the mediastinum, the left pulmonary artery, the pericardium, traces of liquid in the pericardial cavity involving the interlobular pleura. Multiple focal shadows in the lung parenchyma and at the pleura, small increase of one of foci in S3 to the right, possibility of mts. Osreoblastic changes in the body Th6 vertebra and in the sixth and eighth ribs to the right, the breast being removed, possibility of mts. Visualization of lymph nodes of the mediastinum and the retroperitoneal space – without dynamics. Concrement in the gallbladder. Formation of the right adrenal gland – possibility of adenoma. Additional lobule of the spleen. The patient was consulted in SBHOMR “Moscow Regional Oncology Hospital” in Balashikha, immunotherapy (atezolizumab 6 courses), undergone from November 11, 2019 to March 3, 2020. Negative trend on CT scan of the chest organs with IV contrast dated March 24, 20.
Conclusion: CT signs of formation of the upper part of the left lung, surrounded by plastic atelectasis and infiltrative changes (possibility of small-cell c-r). Diffuse hematogenic nodular dissemination in all segments of the right and S ½, 3, 4, 5, 6, 8 left lungs. Mediastinal and bilateral bronchopulmonary lymphadenopathy. Left axillary lymphadenopathy. Atherosclerosis of the descending thoracic aorta and coronary heart vessels, enlargement of the pulmonary artery. Cardiomegaly. Changes are in the body of Th6 vertebra and in 6, 8, 7 ribs to the right (possibility of osteoblastic mts).Compared with the screening dated November 13, 2019: negative dynamics in the form of the nidus's size growth, the number of metastases in the lungs, enlargement of the left axillary lymph nodes. CT of abdominal organs with IV contrast, dated March 24, 2020.
Conclusion: CT – signs of pyeloсaliecoureteroectasia from two sides (possibility of chronic pyelonephritis). Atherosclerosis of the abdominal aorta. Thickening of Gerota’s fascia to the left. Retroperitoneal hepatic lymphadenopathy. Choledochoectasia. Mesenteric panniculitis. Osteoblastic metastasis in L5 and S1 vertebrae. Additional lobule of the spleen. Hepato- and splenomegaly. Calculous cholecystitis. Formation of the left adrenal gland. Compared to the March 21, 2018 screening: negative dynamics in the form of increased number of enlarged lymph nodes: hepato- and splenomegaly. Chemotargeted therapy (docetaxel 75 mg/m2 i/v 1 time every 21 days + nintedanib (vargatef) 200 mg x 2 times a day per os 2-21 days No.3). The patient does not get medications under the Supplementary Medicines Provision (DLO and RLO).
A medical commission took place. It was decided to carry out the multi-course photodynamic therapy + the treatment described above. According to new recommendations from SBHOMR, the Moscow Regional Oncology Hospital in Balashikha, the patient received the following therapy: docetaxel + vargenetif 200 mg x 2 times a day. Then it was decided to choose polychemotherapy docetaxel 75 mg/m2 – 150 mg i/v 1 time every 21 days + vargatef 200 mg 1 time daily, because of visible toxicity, reducing the dosage up to 50%. The patient received three courses of the previously mentioned docetaxel plus vargef therapy. CT of chest organs with IV contrast dated July 10, 2020.
Conclusion: Central cr of the upper lobe of the left lung, atelectasis of S3 segment of the left lung. Disseminated focal changes in the parenchyma of both lungs. Bifurcational lymphadenopathy. Osteosclerotic mts in the body of Th6 vertebra and in 6, 8 ribs to the right; dated March 24, 20 – positive dynamics in the form of decreased intensity of foci in lungs, reduced size of formation in the root of the lung and of intrathoracic lymph nodes. CT scan of abdominal organs with IV contrast dated July 10, 2020.
Conclusion: Diffuse liver changes, moderate hepatomegaly. Gallstones. Chronic calculous cholecystitis. Additional formation of the posterior segment of the left kidney, dated October 5, 2020, without visible dynamics. Lymphadenopatia of retroperitoneal, mesenteric lymph nodes, the lymph nodes of porta hepatis (dated October 5, 2020 without negative dynamics). Nodular thickening of the left medial adrenal pedicle (without dynamics). Additional lobule of the spleen. Osteosclerotic mts in the body of L5 vertebra, sacrum and iliac bones without visible dynamics at the screening dated October 5, 2020. The patient had a consultation in SBHOMR "Moscow Regional Oncology Hospital" in Balashikha on on February 1, 21, recommended to continue therapy vargatef for 2 months + zoledronic acid once every 3 months.
Medical commission took place in Onco.Rehab clinic.
There was taken a decision to follow the therapy with 50%-reduction because of remarkable toxicity + LPS. Reduction of vargatef by 50% and docetaxel by 25% was caused by their toxic effect. The therapy passed satisfactorily. CT of abdominal organs with IV contrast dated January 5, 2020
Conclusion: Diffuse changes of liver, fatty hepatosis. Gallstones. Chronic calculous cholecystitis. Bilateral moderate pyeloectasia. Additional formation of rear segment of the left kidney, more information for angioma, dated July 10, 2020 – without dynamics. Lymphadenopatia of retroperitoneal, mesenteric lymph nodes, the lymph node of porta hepatis (dated July 10, 2020 – some decrease of sizes of the lymph node of porta hepatis). Nodular thickening of the left medial adrenal pedicle (without dynamics). Additional lobule of the spleen. Osteosclerotic mts in the bodies of I5, S1 vertebrae and right iliac bone without visible dynamics. CT of abdominal organs with i/v contrast dated January 5, 2020.
Conclusion: Central cr of the upper lobe of the left lung, atelectasis of S3 segment of the left lung. Disseminated focal changes in the parenchyma of both lungs. Bifurcational lymphadenopathy. Osteosclerotic mts in the body of Th6 vertebra and in 6, 8 ribs to the right; dated March 24, 20 – positive dynamics in the form of decreased intensity of subsolid focus in S4 right lung, decrease of the bifurcation lymph node. Other - without negative dynamics. The patient had a consultation in SBHOMR "Moscow Regional Oncology Hospital" in Balashikha, recommendation to continue therapy nintedanib 200 mg daily for 3 months. Courses of therapy passed without particularities. Negative dynamics of the process at the control screening. MSCT of chest organs with IV contrast dated January 21, 2020.
Conclusion: Central cr of the upper lobe of the left lung, atelectasis of S3 segment of the left lung. Disseminated focal changes in the parenchyma of both lungs. Lymphadenopathy of bifurcation, subcinarical lymph nodes. Hydropericard. Osteosclerotic mts in the body of Th6 vertebra and in 6, 8 ribs to the right; dated 05.20.2020 – negative dynamics in the form of quantity and size increase and densification of disseminated foci in both lungs, some increase of the sizes of bifurcational, subcarinal lymph nodes. MSCT of chest organs with IV contrast dated January 21, 2020.
Medical commission took place in Onco.Rehab clinic.
There was taken a decision to follow the therapy described above. Scintigraphy of bones of the skeleton dated February 21, 2021. Radiopharmaceutical: Pirfotechum 99mTc, introduced activity: 700 MBq. Total efficient dose: 3.99 MSv.
Protocol: Screening was performed 120 minutes after the introduction of the radiopharmaceutical. The whole-body skeletal bones were imaged in anterior and posterior views, and an SPECT-CT was obtained. The physiologic distribution of the radiopharmaceutical in the kidneys and the bladder is observed. Distribution of the radiopharmaceutical in bones is heterogeneous due to the presence of segments of hyperfixation of the medication in the projection: frontal parietal area on the right. Body of the lower jaw, Th6, the posterior segment of the 6 rib on the right, Th11 on the left. L2-S1,2, the sacroiliac joint on both sides, bodies of the left iliac bone, and diaphyses of femurs on both sides, most likely due to the neoplastic process.
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The manager contacts patients just after the concilium of doctors (every Thursday) where the specialists look through all the documents and make a decision about the necessary treatment.
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