Surgical outcomes of one-stage resection for synchronous multiple primary lung adenocarcinomas with no less than three lesions

Case Report: Cracking the case: unique presentation of pulmonary sarcomatoid carcinoma with spherical lung metastases

Background

Pulmonary sarcomatoid carcinoma (PSC) is rare among lung malignancies, but it has a high degree of malignancy, and the average survival time for clinically diagnosed patients with PSC is less than 1 year. There are few reports of multiple solid spherical metastases in the lungs of patients with PSC.

Case presentation

This case presents an 80-year-old male with a history of Alzheimer's disease who was hospitalized due to a frequent dry cough. A 16-slice computed tomography examination of the chest revealed multiple solid, egg-sized lesions with smooth borders in both lungs. Because this type of medical imaging data is very rare in clinical practice, the patient's diagnosis was initially confusing. Given that the patient had no history of fever and no special abnormalities in the results of laboratory tests, the multidisciplinary team (MDT) suggested that lung metastases or lung malignancies with intrapulmonary metastasis should be considered. A magnetic resonance imaging (MRI) examination of the head was performed and revealed brain metastatic lesion. Finally, a puncture biopsy of the lung lesion was performed under ultrasound guidance. The case results confirmed PSC.

Conclusion

This case presents a very rare medical imaging dataset of solid lesions with multiple egg-sized having smooth borders in both lungs. This special medical imaging data highlights the variability of PSC imaging and the complexity of accurate diagnosis, aiming to improve the understanding of PSC.

Indocyanine green localization for preoperative CT-guided localization of multiple pulmonary nodules

OBJECTIVES

This study assesses the safety and efficacy of using indocyanine green (ICG) for preoperative CT-guided localization of multiple pulmonary nodules.

METHODS

We included patients who underwent CT-guided preoperative ICG localization followed by video-assisted thoracoscopic surgery (VATS). Four primary outcomes were evaluated: technical success, pneumothorax, pulmonary hemorrhage, and postoperative hospital stay (PHS). Patients were classified into single nodule and multiple nodules groups, with further subgroups based on the side of localization including unilateral and bilateral subgroups. Univariate and multivariate analyses were used to evaluate risk factors for PHS and pneumothorax.

RESULTS

A total of 374 patients (54.8 ± 11.4 years, 99 with multiple nodules). The success rate in the multiple nodules group was 98.3%, similar to single nodules. Apart from PHS, no significant differences were observed in outcomes between patients with single and multiple nodules. Longer PHS was observed for patients with multiple nodules (3 [2-4] days vs. 3 [3-4] days, p = 0.022). Multivariable analysis indicated longer stays were associated with pulmonary hemorrhage during localization, surgical blood loss, postoperative complications, and non-segmentectomy procedures. Advanced age emerged as the sole independent risk factor for pneumothorax. The success rate in the unilateral subgroup and the bilateral subgroup was 97.8% and 99%, respectively, with higher pneumothorax rates in the unilateral subgroup (38.3% vs. 20%).

CONCLUSION

CT-guided preoperative ICG localization of multiple pulmonary nodules is safe and effective. It can be applied to both unilateral and bilateral nodules, supporting simultaneous VATS resection.

Super multiple primary lung cancers harbor high-frequency BRAF and low-frequency EGFR mutations in the MAPK pathway

The incidence of multiple primary lung cancer (MPLC) is increasing, with some of our surgical patients exhibiting numerous lesions. We defined lung cancer with five or more primary lesions as super MPLCs. Elucidating the genomic characteristics of this special MPLC subtype can help reduce disease burden and understand tumor evolution. In our cohort of synchronous super early-stage MPLCs (PUMCH-ssesMPLC), whole-exome sequencing on 130 resected malignant specimens from 18 patients provided comprehensive super-MPLC genomic landscapes. Mutations are enriched in PI3k-Akt and MAPK pathways. Their BRAF mutation frequency (31.5%) is significantly higher than MPLC with fewer lesions and early-stage single-lesion cancer, while EGFR mutations are significantly fewer (13.8%). As lesion counts increase, BRAF mutations gradually become dominant. Also, invasive lesions more tend to have classic super-MPLC mutation patterns. High-frequency BRAF mutations, especially Class II, and low-frequency EGFR mutations could be a reason for the limited effectiveness of targeted therapy in super-MPLC patients.

Expert consensus on the multidisciplinary diagnosis and treatment of multiple ground glass nodule-like lung cancer (2024 Edition)

ABSTRACT

This expert consensus reviews current literature and provides clinical practice guidelines for the diagnosis and treatment of multiple ground glass nodule-like lung cancer. The main contents of this review include the following: ① follow-up strategies, ② differential diagnosis, ③ diagnosis and staging, ④ treatment methods, and ⑤ post-treatment follow-up.

Primary squamous cell carcinoma and adenocarcinoma simultaneously occurring in the same lung lobe: a case report and literature review

The co-occurrence of distinct lung cancer types within the same lobe is an exceedingly rare phenomenon. Here, we present a unique case wherein primary invasive squamous cell carcinoma and invasive adenocarcinoma concurrently manifested in the identical lung lobe. Additionally, we provide a comprehensive overview of the diagnosis and treatment approaches for multiple primary lung cancers, along with highlighting existing challenges based on the most recent guidelines. Our case underscores the importance of sampling each lesion individually, conducting separate diagnostic procedures, and determining the histological subtype for effective treatment planning irrespective of their location or size.

Contemporary Incidence of Synchronous Multiple Primary Lung Cancers and Survival in the Era of Lung Cancer Screening

OBJECTIVE

Up to 15% of lung cancer patients have multiple suspicious nodules. While some of these nodules may represent metastatic lung cancer, others represent synchronous multiple primary lung cancer (SMPLC). The incidence of SMPLC ranges from 0.8% to 8.4% and appears to be increasing. Inconsistent identification of SMPLC can be detrimental for patients who are misdiagnosed as having intrapulmonary metastasis and not offered stage-based treatment. We sought to identify the contemporary incidence of SMPLC at a tertiary institution.

METHODS

From January 2018 to September 2019, patients who underwent lung cancer resection were retrospectively reviewed. Patients with SMPLC were identified using the modified Martini-Melamed criteria.

RESULTS

During the 21-month period, 227 patients underwent lung cancer resection. There were 47 patients (20.7%) who had 119 pathologically confirmed SMPLC. Most patients had ipsilateral tumors (n = 24, 51.1%) with at least 1 adenocarcinoma (n = 40, 85.1%). Considering histologic subtyping, 38 (80.9%) had histologically distinct tumors. Overall and cancer-specific survival at 4 years was 86% and 90%, respectively. Only patients with 3 or more SMPLC had poor 4-year overall (P = 0.002) and cancer-specific survival (P = 0.043) compared with those with 2 SMPLC. Patient demographics, histology, tumor location, and highest pathologic staging did not affect survival outcomes.

CONCLUSIONS

Using a strict inclusion criterion, the incidence of SMPLC is higher than previously reported. SMPLC patients have favorable survival outcomes, suggesting that they behave like primary lung cancer, not intrapulmonary metastasis. Awareness of SMPLC by thoracic surgeons is critical in optimizing outcomes in this patient population.

CT imaging features regarding ground-glass nodules and solid lesions reflect prognostication of synchronous multiple lung adenocarcinoma

The prognosis of synchronous multiple lung adenocarcinoma (SMLA) dramatically differs due to its nature of multiple primaries or intrapulmonary metastases. This study aimed to assess computed tomography (CT)-reflected SMLA features regarding ground-glass nodules (GGNs) and solid lesions and their correlation with prognostication. One seventy eight SMLA patients who underwent surgical resection were reviewed. According to preoperative CT features, patients were categorized as: multiple GGN (MG) group: MGs without solid lesions; solid plus GGN (SPG) group: one solid lesion and at least one GGN; multiple solid (MS) group: MS lesions, with or without GGNs. Clinical characteristics, disease-free survival (DFS), and overall survival (OS) were retrieved. Largest tumor size (P < .001) and lymph-node metastasis prevalence (P < .001) were different among three groups, which were highest in the MS group, followed by the SPG group, and lowest in the MG group. Besides, the dominant tumor subtype also varied among the three groups (P < .001), while no difference in other clinical characteristics was discovered. DFS was more deteriorative in the MS group compared to the SPG group (P = .017) and MG group (P < .001), while of no difference between the SPG group and MG group (P = .128). Meanwhile, OS exhibited similar treads among the three groups. Besides, after multivariate Cox analyses adjustment, MS versus MG independently correlated with DFS (P = .030) and OS (P = .027), but SPG versus MG did not. In conclusion, preoperative CT-imaging MS lesions reflect advanced disease features and poor prognosis compared to MG and solid lesion plus GGN in SMLA patients who underwent surgical resection.

Clinical Features and Surgical Treatment of Synchronous Multiple Primary Lung Adenocarcinomas With Different EGFR Mutations

Background

With the popularity of lung cancer screening and advances in imaging technology, more and more synchronous multiple primary lung adenocarcinomas (SMPLA) are being diagnosed clinically, however, the clinical characteristics and prognosis of SMPLA with different EGFR mutations remains unclear. We aimed to explore clinical features and surgical outcomes of these patients to aid in the diagnosis and treatment of SMPLA.

Methods

Medical records of patients with different EGFR mutations who have been diagnosed as SMPLA and underwent surgical resection from March 2015 to December 2019 were retrospectively analyzed. Clinical characteristics, surgical outcomes, recurrence-free survival (RFS) and overall survival (OS) were investigated.

Results

A total of 70 patients (68.6% female and 77.1% non-somkers) were included. Total of 161 lesions in all patients, 84.4% were ground-glass opacity (GGO) lesions. EGFR mutations were detected in 108 lesions, most of which were L858R (35.4%) and 19Del (20.5%). The mutation rate of mixed GGO is significantly higher than that of pure GGO and solid nodules (SN); the mutation rate of invasive adenocarcinoma is significantly higher than that of other histology subtypes; the mutation rate of lesions >20 mm was significantly higher than that of ≤20 mm. However, there is no significant difference in the mutation rate of specific driver gene between different radiological features, pathological characteristics and sizes. After a median follow-up time of 29 months, the 3-year OS and RFS were 94.4% and 86.0%, respectively.

Conclusions

A high discordance of EGFR mutations were identified between tumors in patients with SMPLA. Synchronous multiple lung adenocarcinomas with predominantly multiple GGO should be considered as SMPLA, and surgery may be aggressively performed for these patients due to a good prognosis.