Coexistence of Three Malignancies: Two Different Lung Cancers Synchronous with Lymphoma
Nalan OGAN1,Ayşe BAHA1,Egemen AKINCIOĞLU2,Tevfik KAPLAN3,Handan DOĞAN4,Meral GÜLHAN5
1Department of Chest Diseases, Ufuk University, Faculty of Medicine, Ankara-Turkey
2Department of Pathology, Gülhane Education and Reseach Hospital, Ankara-Turkey
3Department of Chest Surgery, Ufuk University, Faculty of Medicine, Ankara-Turkey
4Department of Pathology, Ufuk University, Ankara-Turkey
5Department of Chest Diseases, Hitit University, Ankara-Turkey
DOI : 10.5505/tjo.2017.1624


Epithelial tumors synchronous with hematologic malignancies are very rare. The hystopathologic type and stage of synchronous tumors are very important for prognosis. A 77-year-old male patient was diagnosed with lymphoma after an excisional biopsy was taken from the retroauricular region. Positron emission tomography, performed for lymphoma staging, revealed a positive solid nodule (SUVmax: 24.3) in the posterobasal segment of the right lower lobe and a negative subsolid nodule in the anterior segment of the upper lobe. Right lower lobectomy and wedge resection for subsolide nodule in the upper lobe were performed. Histopathological examination revealed mildly differentiated squamous cell carcinoma for the solid nodule and mildly differentiated adenocarcinoma with lepidic pattern for the subsolid nodule. The patient was treated for only lymphoma according to the decision of the tumor board, and his condition is stable for 1 year without any evidence of lung cancer recurrence. This case presents the treatment approach and the fact that triple synchronic malignant cases are rare in the literature.


Multiple lung malignancies are cancers that require a harder and specialized approach for diagnosis and treatment. Their incidence has increased with the progress in imaging and other techniques. They can be synchronous or metachronous. Metachronous cases are more frequent because of the increased risk caused by antitumoral treatments.[1] Hematologic malignancies synchronous with epithelial lung malignancies are rare, as case reports in the literature. It is very important to define the type and stage of every single tumor for treatment strategy and prognosis in patients with multiple synchronous tumors. In this case report, a diffuse large B-cell lymphoma synchronous with two different (squamous and adenocarcinoma) tumors of the lung is presented because it is very rarely seen in the literature.


The incidence of synchronous lung cancer is 0.2%-20%. [2] PET-CT, which has become widely used, plays an important role in the diagnosis and grading of such cases. Although rare, false negativity is possible.[3] PET scan was negative for the nodule located on the right lung upper lobe; however, our patient was diagnosed with adenocarcinoma after wedge resection. False negativity for subsolid nodules in PET-CT, like our case, is common.

Hematologic malignancy synchronous with lung cancer is very rare. Its etiology and pathophysiology is still unclear.[4] Coexistence with lung cancers in known cases is usually metachronous or diagnosed by biopsy from intrathoracic residue after lymphoma treatment. The risk of a second primary cancer increases after chemotherapy, radiotherapy, or combination therapy for malignancies with high therapeutic response such as Hodgkin"s lymphoma or testicular cancer.[1] Pulmonary carcinoma synchronous with lymphoma cases are reported in the literature. We described two separate lung malignancies synchronous with lymphoma in this case report.[5,6]

Five-year survival rates of patients with synchronous tumors are lower than those with metachronous tumors. In a study by Marcel et al., patients who underwent resection for synchronous lung cancers were compared to patients with lung cancers, which had a single primary, and it was shown that approximately half of the synchronous tumors were bilateral (51%) and 5-year survival was 23% in the early stages. A study reports that in synchronous tumors, the tumor with the most advanced stage is the best predictor for survival.[7]

Studies state that multiple pulmonary lesions have to be elucidated histopathologically because of the risk of synchronous tumors, and aggressive surgery in the early stages is necessary.[8] The American College of Chest Physicians guidelines for synchronous lung cancers state that following invasive mediastinal staging and extrathoracic imaging, every single tumor should be removed unless there is enough pulmonary reserve and no N2 involvement. Lobectomy, bilobectomy, or pneumonectomy is recommended for synchronous tumors of the same lung, while consecutive surgical resection in 4-6 weeks is recommended for bilateral synchronous tumors.[9] A study states that pneumonectomy should be avoided because of poor postoperative prognosis.[10] Every case should be evaluated according to the patient"s functional status. Lobectomy for the tumor in the lower right lobe and limited (wedge) resection was performed in our case because of the patient"s advanced age and comorbidities. Lesions were evaluated separately postoperatively, and adjuvant therapy for lung cancer was not planned, but lymphoma treatment without delay was performed.


As a result, separate diagnosis, differentiation between a metastasis and a synchronous tumor, in addition to a thorough staging is necessary for patients with multiple tumors. A multidisciplinary approach and an evaluation by a tumor board are important for the prognosis of these patients, and curative treatment for the coexistence of two different solid tumors with lymphoma was thus possible.

Disclosures Statement
The authors declare no conflicts of interest.

Ethics Committee Approval: This study was conducted inaccordance with local ethical rules.

Peer-review: Externally peer-reviewed.

Conflict of Interest: None declared.
Authorship contributions: Concept - N. O, M. G; Design - A. B, T. K; Supervision - M. G; Materials - Egemen Akıncıoğlu; Handan Doğan; T. K; Data collection &/or processing - N. O, A. B; Analysis and/or interpretation - M. G; Literature search - N. O, A. B; Writing - N. O; Critical review - M. G


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