Ann Thorac Surg 2001;72:270-272
© 2001 The Society of Thoracic Surgeons
Case report
Synchronous primary lung carcinoma and lung metastasis from extrathoracic carcinoma
Shinji Kanemitsu, MDa,
Motoshi Takao, MD, PhDa,
Akira Shimamoto, MD, PhDa,
Hideto Shimpo, MD, PhDa,
Isao Yada, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, Mie, Japan
Accepted for publication June 8, 2000.
Address reprint requests to Dr Kanemitsu, Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
e-mail: kanemi{at}clin.medic.mie-u.ac.jp
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Abstract
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We present the cases of 2 patients in whom primary lung cancer was found unexpectedly when pulmonary resection was performed for metastatic lung cancer. The possibility of combined primary and metastatic carcinoma should be considered in patients with a diagnosis of multiple pulmonary metastases from extrathoracic tumor.
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Introduction
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Cases of primary lung cancer encountered in association with metastatic lung disease from extrathoracic sites have been rare. However, improvements in diagnostic techniques may show that the frequency of such cases is greater than was previously thought [1, 2]. When multiple lung nodules develop in patients recovering from surgical intervention for malignant disease, accurate differential diagnostic assessment of the lung lesions is difficult but important.
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Case reports
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Patient 1
An 84-year-old man underwent a Hartmann operation for rectal cancer (well to moderately differentiated adenocarcinoma, stage II) on September 19, 1996. In November 1997, a chest radiograph revealed a nodule 2 cm in diameter in the left lung. In computed tomographic images, the nodule was located in the left superior lingular segment and showed clear, regular margins without scalloping (Fig 1A). In addition, an area of consolidation 1 cm in diameter in the left upper lobe had the pattern of an air bronchogram, a ground-glass appearance, and pleural indentation (Fig 1B). Computed tomography–guided needle biopsy of the larger nodule was done, and histological study indicated it was a metastasis from the rectal cancer.
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Fig 1. (Patient 1.) Computed tomographic images of (A) nodule (arrow) 2 cm in diameter in left superior lingular segment, and (B) small nodule (arrow) 1 cm in diameter with ground-glass opacity in periphery of anterior portion of left upper lobe. (C) The 2-cm nodule was a metastasis from the rectal adenocarcinoma, and (D) the 1-cm nodule was the primary lung adenocarcinoma. (Hematoxylin and eosin; x400 before 67% reduction.)
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Segmental resections of the lingula and partial resection of another portion of the left upper lobe were performed on March 2, 1998. Histological examination disclosed that whereas the larger nodule was a metastasis from the rectal cancer (Fig 1C), the smaller nodule had a different pattern indicating a well-differentiated adenocarcinoma of the lung (Fig 1D). The patient is alive without evidence of recurrence of lung or rectal cancer 25 months after lung resection.
Patient 2
A 55-year-old woman underwent a hysterectomy for cancer involving the corpus (endometrial carcinoma, histologic grade 3, stage Ib) on April 1, 1996. A chest radiograph in December 1997 indicated a mass in each lung. Chest computed tomography defined a mass 5 cm in diameter with irregular margins in the right lower lobe and a nodule 1.5 cm in diameter in the left upper lobe (Fig 2A).
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Fig 2. (Patient 2.) Computed tomography shows mass (arrow) 5 cm in diameter in superior segment of right lower lobe and mass (arrow) 1.5 cm in diameter in superior segment of left upper lobe. (B) Larger mass was a metastasis from the endometrial cancer and (C) smaller mass, the primary lung adenocarcinoma. (Hematoxylin and eosin; x400 before 53% reduction.)
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Right lower lobectomy and partial resection of the left upper lobe were performed on April 6, 1998. Postoperative histologic examination showed the mass in the right lower lobe to be metastatic endometrial cancer (Fig 2B). The left upper lobe nodule showed a different pattern diagnostic of primary adenocarcinoma (Fig 2C). The patient is alive without evidence of recurrence of lung or endometrial carcinoma 24 months after lung resection.
Both patients 1 and 2 had the same immunophenotype on surfactant apoprotein A (DAKO, Glostrup, Denmark): the primary lung carcinoma was positive, and the metastatic carcinoma was negative.
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Comment
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Between 1963 and 1998, we performed 267 resections in 207 patients for pulmonary metastases, including 48 resections in 38 patients with rectal cancer and 17 resections in 15 patients with uterine cancer. The 2 patients presented here are the only ones in whom primary lung cancer was unexpectedly found to coexist with a metastasis to the lung, although we had 149 resections (56%) involving multiple pulmonary lesions.
Usually we do partial resections of lobes with metastases provided that margins sufficiently distant from the tumor can be obtained and preoperative imaging and intraoperative examination do not detect lymph node enlargement [3]. Although commonly lobectomy or pneumonectomy with radical lymph node dissection is completed for primary lung cancer, limited resection might be chosen in compromised cases [4]. When primary lung cancer is found incidentally with synchronous metastases to the lung from malignant extrathoracic lesions previously resected, it is important to plan the treatment of the primary lung cancer. Prognostic characteristics of both the metastatic lung tumor or tumors and the coexisting primary lung cancer should be considered. In many instances, partial resection or segmentectomy of both lesions can be reasonable because lung metastases are likely to be a major prognostic factor; in particular, the disease-free interval from operation is short [3]. We must be aware of the possibility of primary lung cancer with synchronous metastases and choose the best operative procedure for patients in whom multiple lung nodules are found after surgical intervention for malignant disease.
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Acknowledgments
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We thank Taizo Shiraishi, MD, PhD, Second Department of Pathology, School of Medicine, Mie University, for help with the histopathological study.
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References
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Abstract
Introduction
