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A3998 - Incidentally Found Synchronous Adenocarcinoma and Primary Pulmonary Lymphoma Within a Single Lobe
Author Block: E. Jones, K. E. Gross, O. Ibrahim; University of Connecticut, Farmington, CT, United States.
Introduction Synchronous presentation of pulmonary adenocarcinoma and primary pulmonary extranodal marginal zone B cell lymphoma is extremely rare, especially within a single lobe. Here we present a case of incidentally found synchronous pulmonary adenocarcinoma and primary pulmonary BALToma in a 56 year-old woman with no risk factors and presenting with renal colic. Case A 56 year-old woman with no known medical history and no tobacco use presented to our emergency department with acute onset right flank pain. An abdominal CT scan showed a stone at the right ureterovesicular junction and a 1.5 x 0.8 cm mass-like density in the base of the right lower lobe. She had no pulmonary symptoms. A follow-up chest CT scan one month later again showed the right lower lobe basilar lesion, as well as a 2.6 x 2.2 cm lobulated nodule in the lateral segment of the right lower lobe. Bronchoscopy with biopsy of the lateral segment mass returned non-small cell lung cancer with squamous and glandular differentiation. Subsequent PET-CT showed two metabolically active lesions in the right lower lobe and was otherwise negative. Surgical resection with right lower lobectomy was recommended and a thorascopic right lower lobectomy was performed. Pathology showed the lateral segment mass to be invasive adenocarcinoma and the basilar mass to be low-grade B cell non-hodgkin lymphoma. Dissected lymph nodes were negative for local lymphatic spread, and a diagnosis of synchronous stage IB pulmonary adenocarcinoma and primary pulmonary extranodal marginal zone B cell lymphoma (MALT) was made. No adjuvant chemotherapy was offered for either primary cancer due to complete resection and negative imaging. Follow-up surveillance imaging was scheduled in six months. Discussion Synchronous multiple primary lung cancers are becoming more common in clinical practice. This case exemplifies the importance of histologic identification of all suspicious pulmonary nodules when feasible. If multiple primary cancers exist, determining optimal treatment requires staging of each individual cancer. In potentially operable patients, failing to make this distinction could deprive the patient of potentially curative surgery. In non-operable patients, assuming metastatic disease would subject the patient to unnecessary chemotherapy which would be indicated in stage II or III disease, versus radiation only in the case of two synchronous stage IA cancers. In both scenarios, by not sampling all suspicious nodules there is a risk of suboptimal or even inappropriate treatment.