Ann Thorac Surg 2004;78:2154-2155
© 2004 The Society of Thoracic Surgeons
Case report
Metachronous and Synchronous Lung Tumors: Five Malignant Lung Pathologies in 1 Patient During 7 Years
Michael J. Flynn, FRCSI*,a,b,
Doris Rassl, MRCPatha,b,
Amira El Shahira, MBa,b,
Bernard Higgins, MRCPa,b,
Sion Barnard, FRCSa,b
a Department of Cardiothoracic Surgery, Newcastle-on-Tyne, United Kingdom
b Department of Pathology, and Respiratory Medicine, Freeman Hospital, Newcastle-on-Tyne, United Kingdom
Accepted for publication July 29, 2003.
* Address reprint requests to Dr Flynn, Department of Cardiac Surgery, Freeman Hospital, High Heaton, Newcastle-on-Tyne NE7 7DN, UK
barradrum{at}hotmail.com
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Abstract
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We present the case of a 70-year-old man who previously had a left upper lobectomy for nonsmall cell lung carcinoma that subsequently developed into small cell carcinoma, which was successfully treated, and finally he had a right upper lobectomy that revealed three synchronous lung malignancies. We were unable to find a previous case report with a total of five separate lung malignancies with a combination of metachronous and synchronous tumors. This case demonstrates the importance of screening after the diagnosis and treatment of lung carcinoma.
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Introduction
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Patients treated surgically for lung carcinoma have a 1% to 5% risk per year of having a second primary tumor [1] develop, and such metachronous lung carcinomas account for approximately 1% of all pulmonary resections. Resection options for such lesions are often limited. Survival after resection of a metachronous lung carcinoma is poorer than that of primary lung carcinomas [2]. However, subsequent survival depends on complete resection. The incidence of synchronous lung carcinoma is variably reported between 1% and 16%. With the application of a screening program after diagnosis of lung carcinoma, the incidence of metachronous and synchronous tumors may increase. We present the case of a patient with a combination of metachronous and synchronous lung malignancies.
An asymptomatic 63-year-old man with hemoptysis was found to have a left upper zone mass on chest roentgenogram and proceeded to have a left upper lobectomy for a T2N0 large cell carcinoma. He stopped cigarette smoking at that time. On routine follow-up 4 years later, the patient presented with a small cell carcinoma of the right lower lobe that was treated with chemotherapy, which consisted of five courses of carboplatin and etoposide with mediastinal and brain radiotherapy (40Gy and 30Gy, respectively). Three years later (at the latest admission), a right upper zone mass was demonstrated on a screening chest roentgenogram. Computerized tomography demonstrated the presence of two separate masses in the right upper lobe of the lung (Figs 1, 2). Fine needle aspiration of the larger and more peripheral of these lesions revealed squamous cell carcinoma. At the latest presentation, the forced expiratory volume in one second was 1.7 L (58.8% of predicted), with a vital capacity of 2.9 L (74.3% of predicted). Transfer factor was 68% of predicted. Perfusion scanning (technetium 99 mol/L) revealed the left lung to receive 39% of total lung perfusion, whereas the bone scan (technetium 99 mol/L) and computed tomographic scan of the brain were normal.
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Fig 1. Computerized tomographic image of the thorax demonstrating a lesion in the right upper lobe (postoperatively proven to be adenocarcinoma).
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Fig 2. Computerized tomographic image of the thorax demonstrating a second right upper lobe lesion (preoperatively proven to be squamous cell carcinoma).
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The patient was taken to the operating room and a right posterolateral thoracotomy was performed with the intention of performing wedge excision of both lesions. The peripheral tumor was removed by wedge excision. However, due to the deep central position, the smaller tumor necessitated a right upper lobectomy that was performed in standard fashion. Extubation took place without difficulty in the operating room. Basal atelectasis developed in the remaining right lung, which required rigid bronchoscopy and the insertion of a mini-tracheostomy (SIMS, Portex, UK) for pulmonary toilet on postoperative day 3. Streptococcus pneumonia was grown, which necessitated antibiotics, and the mini-tracheostomy was removed on postoperative day 6. The patient continued to improve clinically, mobilized well, and was discharged on postoperative day 9.
Histology of the right upper lobe revealed: (1) that the lesion was preoperatively biopsied, which confirmed poorly differentiated squamous cell carcinoma; (2) moderately differentiated adenocarcinoma, and (3) the unexpected finding of a small typical carcinoid tumor 3 mm in diameter. Review of the patient at 6 weeks postoperatively reveals no problems and mild dyspnea. The patient remains under regular review.
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Comment
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Although the incidence of metachronous lung carcinoma in patients previously treated for nonsmall cell lung carcinoma may be as high as 10%, the prevalence of synchronous lung cancers has been estimated at approximately 1% of all surgical cases. The incidence of separate nonsmall cell lung carcinoma primaries in surgical series varies from 0.8% to 14.0% [3]. Criteria for the diagnosis of separate primaries in lung specimens have been described on the basis of meeting two of the following histologic characteristics: (1) anatomically distinct tumors, (2) presence of associated pre-malignant lesions, (3) absence of systemic metastasis, and (4) no mediastinal disease and different DNA ploidy [4]. Flow cytometric methods also have been used to differentiate metastatic lesions from synchronous lesions and recurrent disease from metachronous primaries [5]. Martini and Melamed [6] have stated that a second tumor in a patient with a previous lung cancer would be a metachronous primary and not metastatic, first, if the histologies were different, and second, if the interval between the presentations of the two lesions was greater than 24 months with no evidence of distant metastatic disease.
Complete resection is an important determinant of survival after the development of metachronous lung carcinoma [2]. Five-year survival after the development of a subsequent primary varies from 26% to 38% [2, 7]. Surgical strategy in patients with metachronous and synchronous lung carcinomas, although challenging, is determined on the grounds of patient status and tumor resectability. Many authors propose conservative resection of metachronous lung carcinoma, however pneumonectomy after contralateral lobectomy has been described [8]. A small series of pulmonary resection after previous pneumonectomy with excellent results has been described [9]. However, in the setting of previous pneumonectomy, lobectomy has no survival benefit compared with limited resection [9].
Although anatomical resection should be performed where feasible, lung preservation is of paramount importance in this clinical situation as in primary lung carcinoma cases. In the treatment of metachronous nonsmall cell lung carcinoma there is no evidence of any survival difference between limited and more extensive resections. Specific to our case report, although the initial plan had been to perform wedge resections of both lesions demonstrated on computed tomography, it became operatively apparent that a right upper lobectomy was necessary to resect the smaller central lesion. We emphasize the importance of lung preservation in this clinical scenario.
The incidence of synchronous lung cancers may be increasing. In a North American series, the increase in the proportion of adenocarcinoma of total nonsmall cell lung carcinoma may relate to a slight rise in the incidence of synchronous tumors [10, 11]. Combined with increased screening after previous resection, patients presenting with a combination of metachronous and synchronous tumors may increase slightly in frequency. Thus, we present a rare case of a patient with five histologically distinct lung malignancies over a 7-year period, emphasizing the importance of a long-term screening program after lung resection for lung carcinoma.
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References
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Abstract
Introduction
