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Synchronous Primary Lung Cancer With Adenocarcinoma and Squamous Cell Carcinoma in the Right Upper Lobe
IMAGES IN THE MEDICAL SCIENCES
Synchronous Primary Lung Cancer With Adenocarcinoma and Squamous Cell Carcinoma in the Right Upper Lobe Matias Migliaro, MD, David H. Ballard, MD*, Amol Takalkar, MD, Jaiyeola O. Thomas-Ogunniyi, MD, Carlos H. Previgliano, MD and Eduardo Gonzalez-Toledo, MD, PhD Department of Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
55-year-old female presented to clinic with a 6month history of malaise, dyspnea on exertion and with an approximate 30-pound weight loss. She had a 20-pack-year smoking history and reported quitting 4 years prior. A chest radiograph demonstrated a nodular lesion in the right lung apex and an additional nodule in the right suprahilar region. A subsequent contrast-enhanced computed tomography (CT) of the chest confirmed the presence of both nodules in the right upper lobe. Flurodeoxyglucose positron emission tomography/CT (FDG PET/CT) showed increased FDG uptake in both right upper lung nodules without signs of FDG-avid extrathoracic lesions (Figure A, arrows). A right upper lobectomy was suggested for treatment and the patient was amenable to this course of action. At surgery, an initial wedge resection of the more superior right upper lobe mass was sent for intraoperative surgical pathology. This revealed an area of firm consolidation, measuring 3.2 2 1 cm, which was confirmed as adenocarcinoma with lepidic pattern (Figure B) and foci of adenocarcinoma in situ on frozen section. A completion lobectomy was subsequently performed and surgical pathology revealed a centrally located firm spiculated area measuring 1.5 1 0.5 cm at the hilum associated with a segmental bronchus. The histologic sections of this area confirmed invasive welldifferentiated squamous cell carcinoma (Figure C). Following postoperative recovery and discharge, at 1-year follow-up, the patient has no dyspnea, fatigue, or new lung masses on serial imaging. Synchronous primary lung cancer (SPLC) is an uncommon entity that poses the challenge to differentiate between true
SPLC and lung cancer with intrapulmonary metastasis. On FDG PET/CT imaging, different histologic types may have different intensities of FDG uptake. If 2 synchronous lung lesions have significantly different intensities of FDG uptake, they are unlikely to be related or of similar histology. However, standardized uptake value or the intensity of FDG uptake on FDG PET/CT scans can be affected by several other factors, and subcentimeter lesions may show low intensity of FDG uptake in spite of being high grade due to relatively lower cellular volume.1 Therefore, these criteria have no power to differentiate between metastasis and a second primary lung cancer. It is important to differentiate whether these cancers have developed from independent primaries or represent metastatic foci, as treatment and prognosis for these circumstances are different. When there are different primary tumors, surgery may be helpful; however, when there is lung cancer with metastasis, surgery may not adequately address the underlying systemic disease.2 The optimal management of SPLC remains controversial but long-term survival after resection has been reported to be better than that of patients with stage IIIB or IV lung cancer. Surgical resection generally offers the best chance of treatment with improved survival rates.3 Although uncommon, SPLC is a diagnosis that should be considered in the presence of more than 1 pulmonary nodule.
REFERENCES 1. Veselle H, Salskov A, Turcotte E, et al. Relationship between non–small cell lung cancer FDG uptake at PET, tumor histology, and Ki-67 proliferation index. J Thorac Oncol 2008;3:971–8. 2. Tanvetyanon T, Finley DJ, Fabian T, et al. Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data. Ann Oncol 2013;24: 889–94. 3. Sepehripour AH, Nasir A, Shah R. Multiple synchronous primary tumours in a single lobe. Interact Cardiovasc Thorac Surg 2012;14:340–1.
Copyright © 2015 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
1
Synchronous Primary Lung Cancer With Adenocarcinoma and Squamous Cell Carcinoma in the Right Upper Lobe Matias Migliaro, MD, David H. Ballard, MD*, Amol Takalkar, MD, Jaiyeola O. Thomas-Ogunniyi, MD, Carlos H. Previgliano, MD and Eduardo Gonzalez-Toledo, MD, PhD Department of Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
55-year-old female presented to clinic with a 6month history of malaise, dyspnea on exertion and with an approximate 30-pound weight loss. She had a 20-pack-year smoking history and reported quitting 4 years prior. A chest radiograph demonstrated a nodular lesion in the right lung apex and an additional nodule in the right suprahilar region. A subsequent contrast-enhanced computed tomography (CT) of the chest confirmed the presence of both nodules in the right upper lobe. Flurodeoxyglucose positron emission tomography/CT (FDG PET/CT) showed increased FDG uptake in both right upper lung nodules without signs of FDG-avid extrathoracic lesions (Figure A, arrows). A right upper lobectomy was suggested for treatment and the patient was amenable to this course of action. At surgery, an initial wedge resection of the more superior right upper lobe mass was sent for intraoperative surgical pathology. This revealed an area of firm consolidation, measuring 3.2 2 1 cm, which was confirmed as adenocarcinoma with lepidic pattern (Figure B) and foci of adenocarcinoma in situ on frozen section. A completion lobectomy was subsequently performed and surgical pathology revealed a centrally located firm spiculated area measuring 1.5 1 0.5 cm at the hilum associated with a segmental bronchus. The histologic sections of this area confirmed invasive welldifferentiated squamous cell carcinoma (Figure C). Following postoperative recovery and discharge, at 1-year follow-up, the patient has no dyspnea, fatigue, or new lung masses on serial imaging. Synchronous primary lung cancer (SPLC) is an uncommon entity that poses the challenge to differentiate between true
SPLC and lung cancer with intrapulmonary metastasis. On FDG PET/CT imaging, different histologic types may have different intensities of FDG uptake. If 2 synchronous lung lesions have significantly different intensities of FDG uptake, they are unlikely to be related or of similar histology. However, standardized uptake value or the intensity of FDG uptake on FDG PET/CT scans can be affected by several other factors, and subcentimeter lesions may show low intensity of FDG uptake in spite of being high grade due to relatively lower cellular volume.1 Therefore, these criteria have no power to differentiate between metastasis and a second primary lung cancer. It is important to differentiate whether these cancers have developed from independent primaries or represent metastatic foci, as treatment and prognosis for these circumstances are different. When there are different primary tumors, surgery may be helpful; however, when there is lung cancer with metastasis, surgery may not adequately address the underlying systemic disease.2 The optimal management of SPLC remains controversial but long-term survival after resection has been reported to be better than that of patients with stage IIIB or IV lung cancer. Surgical resection generally offers the best chance of treatment with improved survival rates.3 Although uncommon, SPLC is a diagnosis that should be considered in the presence of more than 1 pulmonary nodule.
REFERENCES 1. Veselle H, Salskov A, Turcotte E, et al. Relationship between non–small cell lung cancer FDG uptake at PET, tumor histology, and Ki-67 proliferation index. J Thorac Oncol 2008;3:971–8. 2. Tanvetyanon T, Finley DJ, Fabian T, et al. Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data. Ann Oncol 2013;24: 889–94. 3. Sepehripour AH, Nasir A, Shah R. Multiple synchronous primary tumours in a single lobe. Interact Cardiovasc Thorac Surg 2012;14:340–1.
Copyright © 2015 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
1