Synchronous multiple primary non-small cell lung cancer or intrapulmonary metastasis from an index lesion: a dilemma—case report

Lung cancer is considered one of the major causes of cancer-related mortality. Our case report wishes to highlight the confusion one may have when faced with a lesion that could be a synchronous lesion or metastasis from an index lesion, and its management including whether re-do VATS is a good option. We report our case of a 68 years old male who came to our attention in March 2018 with history of weight loss and repeated chest infections. He was smoking until he was reviewed in our clinic, with a 40- pack year history. PET scan revealed an intense uptake of left lower nodule of size 3.5 cm (cT2aN0M0). He underwent uniportal VATS left basal segmentectomy and lymphadenectomy with the histopathology confirming a squamous cell carcinoma (SCC) (pT2aN0M0R0). During his follow-up, a new left upper lobe lesion was noticed in February 2019. PET scan showed increased uptake in the lesion and CT guided biopsy showed poorly differentiated SCC (cT1cN0M0). The patient underwent uniportal VATS left upper trisegmentectomy and lymphadenectomy with histopathology revealing the presence of two different lesions this time around: the larger one being a SCC with a staging of pT1cN0M0R0 and the smaller being a basaloid type of SCC with a staging of pT1aN0M0. In our opinion, the three cancerous nodules the patient developed represented multiple primary tumours arising on a background of field change rather than intrapulmonary metastasis from an index lesion (differentiating this was important from management point of view). Moreover, we managed to safely perform a redo surgery via uniportal VATS for the same sided lung lesion. This is feasible as long as the patient has an adequate cardiorespiratory function. We wish to take this opportunity to add to the literature our experience with this case of multiple primary lung cancer (MPLC).