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Multiple right-sided pulmonary nodules: metastatic cancer or resectable early stage tumor?
© Cioffi et al; licensee BioMed Central Ltd. 2011
Received: 18 May 2011
Accepted: 5 September 2011
Published: 5 September 2011
The aim of this paper is to focus attention on complex cases of lung disease that may benefit from being managed outside formal guidelines. A 52 year-old man who had previously undergone a laryngectomy for squamous cell carcinoma, presented with a 1.2 cm nodule in the right upper pulmonary lobe. Three months later a new CT scan found that the nodule had slightly increased in size and also detected two new smaller nodules in the middle lobe. A PET/CT scan showed metabolic hyperactivity of all nodules. Since needle aspiration of the upper one revealed malignant cells, the patient was considered to be suffering from metastatic cancer and started on chemotherapy. At follow-up both CT and PET scans found a significant reduction in volume and activity of the lower nodules but no change in the upper one. At diagnostic thoracoscopy, histology demonstrated that the upper nodule was an adenocarcinoma while the lower ones were inflammatory. An upper lobectomy and systematic nodal dissection were therefore performed. Histology established a diagnosis of upper pulmonary adenocarcinoma and sarcoidosis. Our report suggests that in complicated oncologic cases in which non-invasive diagnostic tools yield incongruous results surgery should be considered without delay.
We report the case of a patient with three right pulmonary nodules and a previous advanced metastatic carcinoma of the pharynx. Follow-up and treatment were managed by a team of surgeons and oncologists according to the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines . The complexity of the case lies in its being open to different diagnostic interpretations and in the impossibility of obtaining sufficient clarification by means of non-invasive techniques. The non-conventional ultimate decision to perform a surgical biopsy of all nodules led to an unexpected diagnosis which entailed a better prognosis and a change in the therapeutic strategy. The aim of this paper is to focus attention on the role of timely surgery in the diagnosis of complicated oncologic cases that may at some point require a more personalised approach, outside formal guidelines.
The hypothesis of multiple lung metastases of pharyngeal carcinoma seemed the most likely and the patient underwent chemotherapy with cisplatin and vinorelbine. After three chemotherapy cycles a CT scan was repeated. It showed that the right upper lobe nodule was unchanged and that the two middle lobe nodules were significantly reduced. A PET/CT scan confirmed this pattern of evolution, showing that the activity of the upper lobe nodule was stable (SUV = 9 g/ml versus 10.6 g/ml) whereas the activity of the middle lobe nodules was in one case significantly reduced (SUV = 2.6 g/ml versus 5.1 g/ml) and in the other almost completely absent (Figure 1). Even though it had been reasonably presumed that they originated from the same neoplastic disease, the different response to chemotherapy of the upper and lower nodules suggested they had a different histological nature. Before any decision was taken relative to chemotherapy we believed it was mandatory to acquire further information by obtaining a tissue diagnosis of the middle lobe nodules. Consequently, wedge resections of these nodules were performed by a three-port thoracoscopy. An intra-operative frozen section revealed no evidence of carcinoma, but several granulomatous structures with multinucleated giant cells suggestive of sarcoidosis. This unexpected result prompted us to carry out a wedge resection of the upper nodule, as in the case of metastasectomy. An intra-operative frozen section showed it to be an adenocarcinoma. This finding excluded a pharyngeal carcinoma metastasis, and established a diagnosis of primitive lung cancer. In accordance with it we went on to perform an upper lobectomy with systematic nodal dissection. The definitive diagnosis was infiltrating primitive pulmonary adenocarcinoma of the right upper lobe, pT1N0M0G2, and multifocal granulomatous disease of the middle lobe suggestive of sarcoidosis.
Over the last few years a number of international scientific societies like the ACCP have developed evidence-based guidelines for the diagnosis and management of lung cancer. They certainly have a great value in assisting physicians throughout the decision-making process and as such are being increasingly used in clinical practice. Abidance to the guidelines means better outcomes for patients, a standardised approach to a disease of worldwide importance and also legal shielding in the case of alleged malpractice. However, the case we report shows there are unusual and complex situations in which the physician's clinical judgment still plays a key role and that must be addressed in a more flexible manner, even by adopting less conventional approaches.
In our patient the clinical and instrumental data - previous history of neoplasia, metabolic hyperactivity of the three pulmonary nodules and positive cytology of the upper nodule - strongly pointed to metastatic pharyngeal carcinoma but intra-operative diagnostics painted a different picture altogether. In fact only one nodule was truly neoplastic and indeed it was not a metastasis but an early-stage primary lung cancer. This information changed the prognosis and the therapeutic strategy. Thus, correct diagnosis and management were possible only thanks to a surgical approach that is commonly inappropriate in such context but was justified by unexpected findings on post-chemotherapy CT and PET imaging.
In the current era of thoracoscopy, when non-invasive diagnostic tools yield incongruous results surgery can give an important contribution to the diagnosis of lung diseases. The invasiveness of endoscopic surgery is minimal and risks are more than outweighed by benefits, namely saving time and avoiding excessive instrumental exams, misdiagnoses and inappropriate treatments.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
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