T he presence of bilateral pulmonary nodules in lung cancer usually means distant metastases (M1a). 1 We present an extraordinary example that challenged us to look beyond this classification, illustrating the potential benefits of a multidisciplinary re-evaluation in such a case. CASE REPORT A 70-year-old male, former smoker, and current marathon runner was diagnosed in September 2005 with a probable squamous cell carcinoma of the right upper lobe (RUL) with (possible) small satellite lesions,

more »

... a nodule in the right middle lobe (RML), and a nodular structure in the left upper lobe (LUL) on computed tomography (CT) scan, and 18-fluorodeoxyglucose positron emission tomography (FDG-PET) scan. This was considered to be a primary lung cancer with intrapulmonary metastases (stage IV, histology confirmed). The patient received six cycles of chemotherapy doublet (cisplatinum 150 mg on day 1 and gemcitabine 2000 mg on days 1 and 8), which resulted in a slight reduction in size of the lesion in the RUL, and a clear reduction of the lesion in the LUL, although the RML remained unchanged (Fig. 1) . Eleven months later, the lesion in the RUL increased in size. A second opinion was arranged. After reviewing all data and images with repeated PET and CT, the possibility of multiple primary tumors was considered. A video-assisted thoracoscopy, diagnostic wedge excision of the LUL, and a transthoracic biopsy of the RUL were performed, revealing two papillary adenocarcinomas. A wedge excision of the RML, a lobectomy of the RUL, and mediastinal lymph-node dissection showed a 1.8-cm diameter papillary adenocarcinoma of the LUL, a 3.3-cm diameter mixed papillary adenocarcinoma/adenocarcinoma in situ of the RUL, and a 1.1-cm diameter adenocarcinoma in situ of the RML, all radically resected. All nodes were negative. Arraycomparative genomic hybridization analysis revealed that all these lesions showed different patterns of gains and losses, consistent with three primary tumors (Fig. 2) . 2 In December 2007, a recurrence in the operation scar of the LUL, and a new abnormality in the left lower lobe (LLL) were observed on CT scan, both 18-FDG-PET positive. Diagnostic wedge excisions of the LUL and LLL and a mediastinal lymph-node dissection were performed. Pathological examination showed two invasive papillary adenocarcinomas (LUL and LLL of 1.5 cm and 0.6 cm diameter, respectively), with free resection margins, without lymph-node metastases. The postoperative course was