British Journal of Radiology (2007) 80, 769-770
© 2007 British Institute of Radiology
doi: 10.1259/bjr/28492491
A case of bilateral upper zone masses on the chest radiograph
A M S Melville, MBBS, MRCP, MD
1
N C Munro, MB, ChB, FRCP
1 and
R M McMenemin, MB, ChB, MSc, FRCPI, FRCR
2
1 University Hospital of North Durham, North Road, Durham DH1 5TW, 2 Northern Centre for Cancer Treatment, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
Correspondence: Dr Alice Melville, Department of Respiratory Medicine, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK. E-mail: alice.melville{at}nhct.nhs.uk
 |
Introduction
|
|---|
A 48-year-old Spanish male smoker with a performance status of 0 was referred to our department with 6 months of lethargy and weight loss. A chest radiograph demonstrated bilateral upper zone masses (Figure 1
). At bronchoscopy a polypoid tumour was seen in the right upper lobe bronchus. No abnormality was detected on the left side. Bronchial brushings from both upper lobes demonstrated markedly atypical cells suggestive of malignancy. Similarities existed between the atypical cells from each side suggesting a common cell type. A staging CT scan confirmed bilateral upper lobe masses with small (less than 1 cm) paratracheal and mediastinal lymph nodes and no extrapulmonary metastases. A CT-guided biopsy revealed non-small cell lung cancer (NSCLC) from the left upper lobe. Following a cycle of vinorelbine (Navelbine) and cisplatin chemotherapy another chest radiograph was taken (Figure 2). What changes have occurred? How should the patient now be managed?
View larger version (128K):
[in this window]
[in a new window]
|
Figure 2. Posteroanterior chest radiograph following one cycle of vinorelbine(Navelbine) and cisplatin chemotherapy.
|
|
Following initial chemotherapy a significant radiological response was observed, particularly by the right-sided mass (Figure 2
). However, the asymmetrical response raised suspicion of the two tumours being of differing cell types. A CT-guided biopsy of the right-sided mass subsequently revealed small cell lung cancer (SCLC). The chemotherapy regime was subsequently altered and four cycles of cisplatin and etoposide were given. A partial bilateral response was observed. Thoracic radiotherapy was subsequently delivered to both cancers followed by prophylactic cranial irradiation. Staged upper lobectomies were then considered but were ultimately not possible because of tumour progression. The patient died 24 months after presentation.
|
Discussion
|
|---|
When two or more cancers are detected contemporaneously they are termed "synchronous". Synchronous primary lung cancers (SPLCs) are rare, accounting for 0.26–1.33% of all lung cancers [1]. When compared with single primary NSCLCs, the presence of SPLCs does not appear to be related to gender, a positive family history of lung cancer or the median number of pack years smoked [2].
Criteria exist for the diagnosis of SPLCs. These state that the cancers should be present or diagnosed at the same time, be physically distinct and separate, and have differing or similar histology [1]. If they have a similar histology they should be in different segments, lobes or lungs, with no evidence of carcinoma seen in the lymphatics and no extrapulmonary metastases present at diagnosis. Squamous–squamous combinations have been the most commonly observed (42.7% of SPLCs), with both adenocarcinoma–adenocarcinoma and squamous–adenocarcinoma combinations being the second most commonly observed (15.5% each) [3]. SCLC–NSCLC combinations (10.9% of SPLCs) represent 0.1% of all lung cancers [3].
When cancers share a common histological type, difficulties in differentiating between multiple primary tumours and metastatic or recurrent disease can occur. In this situation immunohistochemical staining may help. Nonami et al [4] used clinical criteria and antibodies to CK-19, p53, carcinoembryonic antigen (CEA), Hup-1, PE-IO and Ki67 to distinguish SPLCs from metastatic deposits. One out of four cases clinically diagnosed as SPLC was found to be a metastatic lung cancer as immunohistochemical staining to at least two antibodies differed.
Given the scarcity of SPLCs and the lack of relevant literature, the roles and timing of surgery, chemotherapy and radiotherapy in their treatment are uncertain. This was highlighted by the case reports of Hiraki et al [3] and Kubota et al [5], which describe the treatment of synchronous NSCLC and limited-stage SCLC. Hiraki et al advocated initial treatment with chemoradiation followed by surgery to the NSCLC whereas Kubota et al advocated chemoradiation followed by photodynamic therapy to the NSCLC [5].
Survival from diagnosis in SPLC appears to be shorter than with single cancers [1]. van Rens et al [1] observed that survival in cases in which the most advanced tumours were stage 1 or stage 2 was equivalent to that in cases of single NSCLCs of stages 2 and 3A [1]. This may be because of different tumour behaviour or because of misdiagnosis, when the second cancer is in fact a metastatic deposit [1].
Because no consensus exists regarding optimal treatment strategies for SLPC, our case posed challenging management issues. Although SPLCs are rare, the presence of two distinct tumour masses on a chest radiograph should have alerted the clinician to the possible existence of SPLC and this case therefore highlights the need for accurate histological diagnosis of both masses from the outset. Confirmation of SCLC clearly altered the management, with a change in chemotherapy regime. If the visible right lung tumour had been biopsied at the time of bronchoscopy and SCLC detected, a CT biopsy of the left (NSCLC) side would still have been necessary, but chemotherapy targeting the SCLC would have been undertaken at an earlier stage. The initial assumption of metastatic NSCLC clearly led to a delay in surgery, possibly worsening the outcome.
Historically, treatment for SPLCs has followed regimes similar to those used for single tumours, but the optimal approach has yet to be ascertained. A database recording details of cases of SPLCs may potentially assist the management of future cases, which may improve survival in this small group.
Received for publication December 3, 2005.
Revision received February 10, 2006.
Accepted for publication March 6, 2006.
|
References
|
|---|
- Ferguson MK. Synchronous primary lung cancers. Chest 1993;103:398S–400S.[Medline]
- Wang X, Christiani DC, Mark EJ, Nelson H, Wiencke JK, Gunn L, et al. Carcinogen exposure, p53 alteration, and K-ras mutation in synchronous multiple primary lung carcinoma. Cancer 1999;85:1734–9.[CrossRef][Medline]
- Hiraki A, Ueoka H, Yoshino T, Chikamori K-I, Onishi K, Kiura K, et al. Synchronous primary lung cancer presenting with small cell carcinoma and non-small cell carcinoma: diagnosis and treatment. Oncol Rep 1999;6:75–80.[Medline]
- Nonami Y, Ohtuki Y, Sasaguri S. Study of the diagnostic difference between the clinical diagnostic criteria and results of immunohistochemical staining of multiple primary lung cancers. J Cardiovasc Surg 2003;44:661–5.[Medline]
- Kubota K, Furuse K, Kawaguchi T, Kawahara M, Ogawara M, Yamamoto S. A case of long-term survival with stage IV small cell lung cancer and early-stage central-type squamous cell lung cancer treated by photodynamic therapy. Jap J Clin Oncol 1999;29:45–8.[Abstract/Free Full Text]
Top
Introduction
Discussion
