Figure 1. Case 1, Chronological summary of therapies, imaging studies, and available pathology from diagnosis of adenocarcinoma to transformation to small cell carcinoma.
(A) The patient received four cycles of carboplatin and paclitaxel (C/P) followed by a 17 month therapy holiday. She then received 36 cycles of nivolumab every two weeks with an initial response, and two weeks after her 36th dose of nivolumab she had widespread disease progression with biopsy revealing transformation to small cell carcinoma. She went on to receive six cycles of carboplatin and etoposide (C/E) and had a partial response. Two months after completion of C/E she had disease progression and received eight cycles of paclitaxel (P) with a response in her thoracic disease, but she had progression in the central nervous system prior to her death 11 months after small cell transformation.
(B) Treatment responses were observed in the primary right upper lobe nodule (red arrow) to both carboplatin and paclitaxel and nivolumab, followed by widespread progression, including in the right upper lobe nodule (red arrow), at the time of transformation to small cell carcinoma.
(C) Pathology from a level 4R lymph node at the time of diagnosis demonstrated poorly differentiated adenocarcinoma. Cytology from pericardial fluid at the time of transformation demonstrated small cell carcinoma, confirmed by synaptophysin immunohistochemistry.