e54 Journal of Thoracic Oncology •  Volume 8, Number 6, June 2013 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 multidis- ciplinary re-evaluation in such a case. CASE REPORT A 70-year-old male, former smoker, and current mara- thon runner was diagnosed in September 2005 with a prob- able squamous cell carcinoma of the right upper lobe (RUL) with (possible) small satellite lesions, 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-fluo- rodeoxyglucose 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 (cis- platinum 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 con- sidered. 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 diam- eter 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. Array- comparative 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, with- out lymph-node metastases. The postoperative course was Copyright © 2013 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/13/0806-0e54 Beneit of a Second Opinion Intrapulmonary Metastases or Multiple Primary Tumors? Marleen J. ter Avest, BSc,* Romane M. Schook, MD,* Pieter E. Postmus, MD, PhD,* Katrien Grünberg, MD, PhD,† Bauke Ylstra, PhD,‡ and Marinus A. Paul, MD, PhD§ Departments of *Pulmonary Diseases, and †Pathology, VU University Medical Center, Amsterdam, The Netherlands; ‡Micro Array Facility, VU University Medical Center-Cancer Center, Amsterdam, The Netherlands; and §Department of Thoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands. Disclosure: The authors declare no conflict of interest. Address for correspondence: Romane M. Schook, MD, Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands. E-mail: r.schook@vumc.nl FIGURE 1. Computed tomography scan at time of irst  presentation and after six cycles of chemotherapy. A, Shows  a reduction of the lesion in the right upper lobe. B, Shows an  unchanged right middle lobe lesion. C, Shows a clear reduc- tion of the left upper lobe lesion. CASE REPORT