© 1991 S. K arger A G , Basel 0025-7931/91/0584-0226 $ 2.75/0
Respiration 1991;58:226-228
Adenocarcinoma and Squamous Cell Carcinoma in the Same Lobe of the Lung A Case Report Kaoru Kitamura, Tetsuya Mitsudomi, Teruyoshi Ishida, Satoshi Kaneko, Keizo Sugimachi Department of Surgery II. Kyushu University, Faculty of Medicine, Fukuoka, Japan
Key Words. Synchronous double cancer ■Lung cancer • Same lobe • Adenocarcinoma ■ Squamous cell carcinoma Abstract. Multiple primary lung cancers, either synchronous or metachronous, are unusual. We treated a 70year-old man with double synchronous lung cancers in the right upper lobe, an adenocarcinoma and a squa mous cell carcinoma. As multiple malignant lesions in an early stage may be curable, those patients in whom a lung cancer has already been detected, and who have an increased risk, such as long history of heavy smoking or of exposure to some carcinogens, an aggressive check-up should be performed and should be closely watched.
In routine chest X-rays done on a 70-year-old man, two lesions were definitely noted in the upper lobe of the right lung: one. in the apical segment with spicular formation, was 1.7 x 1.7 cm and the other, in the anterior segment, was 1.8 x 1.7 cm (fig. 1). He de nied any exposure to carcinogens such as asbestos during his working activity, but he had smoked 60 cigarettes a day for 50 years. There was no lymphadenopathy in the mediastinal or hilar areas. Bronchoscopic examination revealed a tumor, which had originated in the right anterior segmental bronchus. Brushing cy tology revealed a poorly differentiated squamous cell carcinoma. TB cultures were negative, and all other laboratory data and the physical examination were within normal limits. There was neither evidence of distant metastases nor of other primary malignancies. Right upper lobectomy with lymph node dissection was done: the resected specimen contained two hard masses (fig. 2). The histopathology of the tumor in the anterior segment was a poorly dif ferentiated squamous cell carcinoma while that in the apical seg ment was a well-differentiated adenocarcinoma (fig. 3a, b). The postoperative course was uneventful.
Discussion The first case of multiple primary lung carcinoma seems to have been reported by Billroth in 1879 [1-3], who was the first to establish the criteria for this rare disease but his descripton was revised by Warren and Gates [2] in 1932 as follows: (1) each tumor must be malignant, (2) each tumor must be anatomically dis tinct and separate, (3) the probability of metastatic disease must be excluded. These criterias are still ac cepted today [2-4]. From 1955 to 1974, the reported incidence has been less than 1%, but the real frequency is higher, varying from 0.5 to 7.0% of all lung cancers [2-5]. Radical sur gery may indeed reveal more of such cases [6, 71. The occurrence of synchronous lesions is less than that of metachronous cases, the ratio being about 1:2 or 1:3 [6-9]. The majority of these lesions are of the
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Case Report
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Double Synchronous Ipsilateral Lung Cancer
Fig. 1. Tomogram of the right lung closely revealed two coin sized lesions in the apical and anterior segments of the upper lobe (arrows). The former had a typical spicular shape.
a
Fig. 2. Macroscopic specimen. Spicular formation and central fibrosis were clearly recognized in the upper mass (framed arrow). The lower mass obstructed the anterior segmental bronchus (ar row).
b
Fig. 3. a Microscopic findings of the apical segmental tumor showed well-differentiated adenocarcinoma. HE. x 114. b The specimen of the anterior segment tumor showed poorly diffentiatcd squamous cell carcinoma. HE. x 114.
types within one tumor, is about 14-16.6% [7-9] and 1% [10], respectively. A different histological synchro nous double cancer in the same lobe is a most unusual combination [7-9], the frequency being about 3.6% [7]. In light of all this evidence, it seems reasonable to assume that more such cases may become evident if we perform not only detailed physical check-ups, but also thorough investigations of the respiratory tract, especially in heavy smokers and those exposed to car cinogens and/or those who have been surgically treat ed for a lung cancer. It is important to underline the fact that two cancer lesions in one lobe do not exclude resectability.
squamous cell type [3, 5], and the same cell type is ob served in about 60% of all cases [7-9], while the com bination of a synchronous occurrence of the tumors with different histological types, or mixture of cell
1 Strove CE: Diagnosis and treatment of bilateral primary bronchogenic carcinoma. J Thorac Cardiovasc Surg 61:501513. 2 Warren S, Gates O: Multiple primary malignant tumors. A sur vey of the literature and a statistical study. Am J Cancer 1932; 16:1358-1414.
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References
3 Sindy P, Benjamin B: Three synchronous bilateral lung tumors: A case report. J Surg Oncol 1987;34:253-257. 4 Wu SC, Lin ZQ, Xu CW, Koo KS, Huang OL, Xie DO: Mul tiple primary lung cancers. Chest 1987;92:892-896. 5 Shield TW: Multiple primary bronchial carcinomas. Ann Thorac Surg 1979;27:1-2. 6 Sugimura H, Watanabc S, Tsugane S, Morinaga S, Yoneyama T: Case-control study on histologically determined multiple primary lung cancer. J Clin Invest 1987;79:435-441. 7 Ferguson MK, DeMeester TR. DesLauriers J, Little AG. Pi laux M, Golomb H: Diagnosis and management of synchro nous lung cancers. J Thorac Cardiovasc Surg 1985;89:378-385. 8 Martini N, Melamed MR: Multiple primary lung cancers. J Thorac Cardiovasc Surg 1975;70:606-611. 9 Gerald M. Roberta M. Nestor M. Bill N. Kenneth E. David O: Multicentricity of adenocarcinomas of the lung. Chest 1989; 95:151-154.
Kitamura/Mitsudomi/Ishida/Kaneko/Sugimachi
10 Ishida T. Yano T, Maeda K. Kaneko S, Tateishi M. Sugimachi K: Strategy for lymphadenectomy in lung cancer three centi meters or less in diameter. Ann Thorac Surg 1990;50:708-713.
Received: October 25, 1990 Accepted after revision: May 2, 1991 Kaoru Kitamura, MD Department of Surgery II Faculty of Medicine Kyushu University 3-1-1 Maidashi, Higashi-ku Fukuoka 812 (Japan)
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228
Respiration 1991;58:226-228
Adenocarcinoma and Squamous Cell Carcinoma in the Same Lobe of the Lung A Case Report Kaoru Kitamura, Tetsuya Mitsudomi, Teruyoshi Ishida, Satoshi Kaneko, Keizo Sugimachi Department of Surgery II. Kyushu University, Faculty of Medicine, Fukuoka, Japan
Key Words. Synchronous double cancer ■Lung cancer • Same lobe • Adenocarcinoma ■ Squamous cell carcinoma Abstract. Multiple primary lung cancers, either synchronous or metachronous, are unusual. We treated a 70year-old man with double synchronous lung cancers in the right upper lobe, an adenocarcinoma and a squa mous cell carcinoma. As multiple malignant lesions in an early stage may be curable, those patients in whom a lung cancer has already been detected, and who have an increased risk, such as long history of heavy smoking or of exposure to some carcinogens, an aggressive check-up should be performed and should be closely watched.
In routine chest X-rays done on a 70-year-old man, two lesions were definitely noted in the upper lobe of the right lung: one. in the apical segment with spicular formation, was 1.7 x 1.7 cm and the other, in the anterior segment, was 1.8 x 1.7 cm (fig. 1). He de nied any exposure to carcinogens such as asbestos during his working activity, but he had smoked 60 cigarettes a day for 50 years. There was no lymphadenopathy in the mediastinal or hilar areas. Bronchoscopic examination revealed a tumor, which had originated in the right anterior segmental bronchus. Brushing cy tology revealed a poorly differentiated squamous cell carcinoma. TB cultures were negative, and all other laboratory data and the physical examination were within normal limits. There was neither evidence of distant metastases nor of other primary malignancies. Right upper lobectomy with lymph node dissection was done: the resected specimen contained two hard masses (fig. 2). The histopathology of the tumor in the anterior segment was a poorly dif ferentiated squamous cell carcinoma while that in the apical seg ment was a well-differentiated adenocarcinoma (fig. 3a, b). The postoperative course was uneventful.
Discussion The first case of multiple primary lung carcinoma seems to have been reported by Billroth in 1879 [1-3], who was the first to establish the criteria for this rare disease but his descripton was revised by Warren and Gates [2] in 1932 as follows: (1) each tumor must be malignant, (2) each tumor must be anatomically dis tinct and separate, (3) the probability of metastatic disease must be excluded. These criterias are still ac cepted today [2-4]. From 1955 to 1974, the reported incidence has been less than 1%, but the real frequency is higher, varying from 0.5 to 7.0% of all lung cancers [2-5]. Radical sur gery may indeed reveal more of such cases [6, 71. The occurrence of synchronous lesions is less than that of metachronous cases, the ratio being about 1:2 or 1:3 [6-9]. The majority of these lesions are of the
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 7/2/2018 4:58:53 AM
Case Report
227
Double Synchronous Ipsilateral Lung Cancer
Fig. 1. Tomogram of the right lung closely revealed two coin sized lesions in the apical and anterior segments of the upper lobe (arrows). The former had a typical spicular shape.
a
Fig. 2. Macroscopic specimen. Spicular formation and central fibrosis were clearly recognized in the upper mass (framed arrow). The lower mass obstructed the anterior segmental bronchus (ar row).
b
Fig. 3. a Microscopic findings of the apical segmental tumor showed well-differentiated adenocarcinoma. HE. x 114. b The specimen of the anterior segment tumor showed poorly diffentiatcd squamous cell carcinoma. HE. x 114.
types within one tumor, is about 14-16.6% [7-9] and 1% [10], respectively. A different histological synchro nous double cancer in the same lobe is a most unusual combination [7-9], the frequency being about 3.6% [7]. In light of all this evidence, it seems reasonable to assume that more such cases may become evident if we perform not only detailed physical check-ups, but also thorough investigations of the respiratory tract, especially in heavy smokers and those exposed to car cinogens and/or those who have been surgically treat ed for a lung cancer. It is important to underline the fact that two cancer lesions in one lobe do not exclude resectability.
squamous cell type [3, 5], and the same cell type is ob served in about 60% of all cases [7-9], while the com bination of a synchronous occurrence of the tumors with different histological types, or mixture of cell
1 Strove CE: Diagnosis and treatment of bilateral primary bronchogenic carcinoma. J Thorac Cardiovasc Surg 61:501513. 2 Warren S, Gates O: Multiple primary malignant tumors. A sur vey of the literature and a statistical study. Am J Cancer 1932; 16:1358-1414.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 7/2/2018 4:58:53 AM
References
3 Sindy P, Benjamin B: Three synchronous bilateral lung tumors: A case report. J Surg Oncol 1987;34:253-257. 4 Wu SC, Lin ZQ, Xu CW, Koo KS, Huang OL, Xie DO: Mul tiple primary lung cancers. Chest 1987;92:892-896. 5 Shield TW: Multiple primary bronchial carcinomas. Ann Thorac Surg 1979;27:1-2. 6 Sugimura H, Watanabc S, Tsugane S, Morinaga S, Yoneyama T: Case-control study on histologically determined multiple primary lung cancer. J Clin Invest 1987;79:435-441. 7 Ferguson MK, DeMeester TR. DesLauriers J, Little AG. Pi laux M, Golomb H: Diagnosis and management of synchro nous lung cancers. J Thorac Cardiovasc Surg 1985;89:378-385. 8 Martini N, Melamed MR: Multiple primary lung cancers. J Thorac Cardiovasc Surg 1975;70:606-611. 9 Gerald M. Roberta M. Nestor M. Bill N. Kenneth E. David O: Multicentricity of adenocarcinomas of the lung. Chest 1989; 95:151-154.
Kitamura/Mitsudomi/Ishida/Kaneko/Sugimachi
10 Ishida T. Yano T, Maeda K. Kaneko S, Tateishi M. Sugimachi K: Strategy for lymphadenectomy in lung cancer three centi meters or less in diameter. Ann Thorac Surg 1990;50:708-713.
Received: October 25, 1990 Accepted after revision: May 2, 1991 Kaoru Kitamura, MD Department of Surgery II Faculty of Medicine Kyushu University 3-1-1 Maidashi, Higashi-ku Fukuoka 812 (Japan)
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