Surgical management of three synchronous, bilateral primary lung tumors: A case report

The Patient: A 66 y.o. female with severe chronic obstructive pulmonary disease (COPD) presents with cough. Chest radiography (CXR) reveals a nodule in the left chest. Computer tomography (C.T.) confirms the presence of a 1 cm nodule in the apex of the left upper lobe, a 2 cm mass in the left lower lobe and a 1 cm nodule in the apex of the right upper lobe. Metastatic screen, bronchoscopy and mediastinoscopy are negative. Pulmonary function studies show FEV1=0.940 L and FVC=2.00 L. Background: When a patient presents with multiple pulmonary nodules the differential diagnosis includes infectious, granulomatous, and metastatic disease. It is unlikely that synchronous primary lung tumours and subsequent surgical management would usually be considered. We present a patient with three synchronous bilateral lung tumors in three separate lobes treated successfully with a staged muscle sparing thoracotomies. Management: The patient underwent a left muscle sparing thoracotomy. An anatomic superior segmentectomy (left lower lobe)(1) and an anatomic posterior segmentectomy (left upper lobe)(2) were completed after intraoperative biopsy. Five weeks later, the patient underwent a right muscle sparing thoracotomy and an anatomic anterior segmentectomy (right upper lobe)(3) for the remaining nodule. All resection margins were clear. Pathology: Three distinct synchronous primary lung tumors were identified: 1) poorly differentiated adenosquamous carcinoma, 2) moderately differentiated adenocareinoma and a 3) bronchioloalveolar carcinoma. Follow-up: Post-op, FEV1=1.05 L, FVC=1.40 L Discussion: The incidence of two synchronous primary lung tumors is estimated at 0.52%, while the incidence of three is vanishingly low. A lobectomy is considered the minimal resection for lung tumors. In our patient (FEV1=0.940 L), such an approach was not feasible. We performed anatomic segmental resections without compromise of her lung function and achieved negative margins. A review of the literature on multiple synchronous lung tumors suggests local control and improved survival are reasonable goals in this patient population. However, in order to provide a survival advantage the diagnosis must be made early.