Recognizing Synchronous Multiple Primary Lung Cancer: A Case Report

Pulmonary nodules are frequently identified on radiographic evaluation, often due to lung cancer screening with low-dose computed tomography, an increasingly utilized technology in high-risk patients, or incidentally discovered with alternative imaging modalities. Although most nodules are benign, lung cancer remains difficult to treat, particularly in its late stages, which are more prone to metastasis. We present a case of a 71-year-old female, a former smoker, who was evaluated in the emergency department for chronic cough and dyspnea. On evaluation, computed tomography pulmonary angiography incidentally revealed three distinct pulmonary nodules. Following evaluation by our multidisciplinary team, robot-assisted bronchoscopy (RAB) was performed, revealing three distinct primary malignancies: well-differentiated adenocarcinoma with KRAS mutation, poorly differentiated adenocarcinoma with EGFR mutation, and a well-differentiated carcinoid tumor. The patient underwent staged surgical resections for curative intent. This case underscores the limitations of strict adherence to existing pulmonary nodule guidelines, such as those from the Fleischner Society, which, in this instance, could have led to inaccurate staging and palliative systemic therapy. It also highlights the critical value of considering biopsy of multiple nodules, now increasingly feasible with advanced technologies such as RAB. Early and accurate characterization of each lesion allowed for appropriate staging and individualized, potentially curative treatment.