74 year old male, a chronic smoker, with a past medical history of Chronic Obstructive Pulmonary Disease presented with complaints of cough, wheezing episodes, worsening shortness of breath and episodes of streaky hemoptysis of 2 weeks duration .Chest X ray done revealed bilateral chronic interstitial changes with elevation of right hemidiaphragm and presence of a left upper lobe nodule. Computerized Tomography (CT) of Chest done revealed Right Lower lobe collapse and a 2.4 cm x 1.3 cm x 2.7 cm left upper lobe mass. Flexible bronchoscopy showed a fleshy mass obstructing the right lower lobe bronchus just distal to the right middle lobe bronchus, the biopsy of which revealed a well differentiated neuroendocrine tumor suggestive of carcinoid. A CT guided biopsy of the left upper lobe lesion revealed an invasive poorly differentiated non-small cell carcinoma. Immunohistochemistry done on the specimen was positive for TTF-1 and negative for Chromogranin A, NAPSIN-A, P63 and CK5/6 which favored the diagnosis of adenocarcinoma. The patient was referred to a tertiary care facility for possible endobronchial resection of carcinoid tumor and cyber knife treatment of the left upper lobe lesion.
The development of synchronous lung tumors is very rare. Within the range of neuroendocrine tumors of the lung, various combination of squamous, adeno-, large cell and pleomorphic carcinoma can be found with small cell carcinoma and large cell neuroendocrine carcinoma, but is exceptional with typical carcinoids. There are only few reports about simultaneous occurrence of tumors of the lung, one which is a typical well differentiated carcinoid and other non-small cell carcinoma with pathological and immunohistochemistry favoring adenocarcinoma. Although cases of synchronous adenocarcinomas and carcinoids are frequently described in other tissues, e.g. the digestive system, the synchronous occurrence of these two entities in the lungs is very rare.
There is limited survival data concerning patients with synchronous non-small cell lung cancers. The prognosis may not be dismal if both tumors are resectable and the tumor stage is I or II. However it is very important to know about the possibility of existence of synchronous tumors to achieve the best outcome for the patient.