Single case of multiple right pulmonary nodules : advanced cancer or resectable early stage tumor?

Abstract: we report the uncommon case of a patient with 3 right pulmonary nodules suspected for metastatic carcinoma. The aim of the paper is to focus the attention of surgeons on complicated cases that need to be managed outside the commonly accepted guides lines. Methods: a 52 years old man underwent in 2007 a laryngectomy for squamous carcinoma T2N2 and adjuvant chemo and radiotherapy . In September 2008 a CT scan showed a 1.2 cm sized nodule at the right upper pulmonary lobe. In December a control CT scan found the nodule slightly increased to 1.4 cm and detected two new smaller nodules of the middle and inferior lobes. A PET scan showed ipermetabolic activity of all nodules. A needle aspiration of the upper nodule was performed and malignant cells were found. Oncologists started a chemotherapy treatment based on the diagnosis of metastatic laryngeal carcinoma. After 3 cycles, CT/PET scan revealed a significant reduction in volume and activity of the inferior nodules but the upper was unchanged. That different behavior suggested a different histology of the upper an inferior nodules. Diagnostic thoracoscopy was planned. Intra-operative histology showed that the upper nodule was and adenocarcinoma and the lower nodules were inflammatory; therefore we performed an upper lobectomy and mediastinal limphoadenectomy. Results: at definitive histology upper nodule was confirmed pulmonary adenocarcinoma T1N0G2 and the inferiors diffuse pulmonary sarcoidosis. Conclusions: despite ipermetabolic activity of the lesions and previous history of advanced laryngeal carcinoma, only one nodule was really neoplastic and not laryngeal metastatic, but pulmonary. Prognosis improved and chemotherapy was not necessary. This report suggests that in case of complicate oncologic history, PET scan positivity could not be enough to diagnose relapse of the disease, and in dubious cases surgery is mandatory.