- 50 year old female from Africa
- never smoker
- worsening productive cough and exertional shortness of breath for the past 2 months
- past medical history of
- essential hypertension, obesity, GERD,
- COVID-19 infection 3 months prior
- Clinical
- not febrile, respiratory rate 36, saturating 94% normal.
- Labs
-
- WBC 6.9, hemoglobin 10.5
- alkaline phosphatase 148.
- HIV negative.
- CTPA showed no PE, diffuse patchy opacities with lower lobe predominance concerning for multifocal pneumonia versus miliary tuberculosis,
- Right adrenal mass,
- hypodense lesions are seen throughout the
- thoracic spine and sternum
- concerning for malignancy/metastatic disease.
- spine MRI showed
- numerous vertebral metastatic lesions in the cervical, thoracic, and lumbar spine as well as the pelvis. N
- No extension of these lesions into the spinal canal or neural foramina.
- No cord compression.
- ? metastases in the cerebellum.
- adenocarcinoma likely has a targetable mutation that would change her prognosis with targeted therapy.
- Stage IVB, cT4, cN2, cM1c, PD-L1; 0%,
- NGS: RET fusion (KIF5B).
- RX with Selpercatinib and Zometa
- given presence of RET fusion
- 4 months later
- had to change immunotherapy to Xgeva,(DENOSUMAB) (severe arthralgias to prior immunotherapy)
- status post Whole Brain XRT
- Immunotherapy Selpercatinib
- 7 months later
- PET CT
- Complete metabolic response to treatment in this patient with history of
stage IV lung adenocarcinoma.
- No hypermetabolic activity in a residual left lower lobe shrinking
- ill-defined 16 x 17 mm pulmonary nodule or rounded atelectasis ,
- improvement of previously hypermetabolic lytic
lesions
- MRI Brain
- interval increase in enhancement and edema
- likely secondary to postradiation changes.
