Search

Copyright of Pediatrie pro Praxi is the property of SOLEN sro and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aim: to present a rare case report of the accidental urinary bladder carcinoma finding on 18F-FDG positron emission tomography/computed tomography (PET/CT) in a 62-year-old man with non-small cells lung cancer before treatment. Method: The whole body PET/CT scan from base of skull to mid femur was obtained 60 minutes after intravenous injection of 18F-FDG (491 MBq - 5.4 MBq/kg). The PET scan acquisition time was 2.5 minutes per bed position and seven bed positions were necessary. Contrastenhanced CT (venous phase) provided both full CT evaluation (including intravenous and oral contrast) and PET attenuation correction. Results: The examination detected 18F-FDG PET/CT positive tumor in the left lung and left hilar and mediastinal metastatic lymphadenopathy and 18 F-FDG positive, accidental tumor in the urinary bladder and left inguinal metastatic lymphadenopathy. The subsequent cystoscopy resection was performed and urinary bladder carcinoma was proven by histopathology. Conclusion: 18F-FDG PET/CT imaging led to accidental detection of the urinary bladder carcinoma in the early stage and made subsequent successful cystoscopy resection treatment possible. The report gives notice for the accidental detection of the duplicate tumor during PET/CT imaging. [ABSTRACT FROM AUTHOR]

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition characterized by the development of a peri-aortic and peri-iliac tissue showing chronic inflammatory infiltrates and pronounced fibrosis. Ureteral entrapment with consequent obstructive uropathy is one of the most common complications, which can lead to acute renal failure and, in the long term, to varying degrees of chronic kidney disease. Common symptoms at onset include lower back, abdominal or flank pain, and constitutional symptoms such as malaise, fever, and anorexia and weight loss. Pain is frequently referred to the hip, to the groin and to the lateral regions of the leg, with nocturnal exacerbations, and typically does not modify with position. We report a case of 56 year-old male with recurrent lower back pain and lower abdominal pain. Contrast-enhanced computed tomography and was suggestive of retroperitoneal fibrosis and unilateral ureteral occlusion. Histologic examination with immunohistochemical staining for IgG4 demonstrate IgG4-related retroperitoneal fibrosis. Therapy was started with prednison 1 mg/kg, but the tolerance of this dose was poor. Therefore the therapy was switched to combination of rituximab 375 mg/ m2 on day 1, cyclophosphamide 300 mg/m2 mg infusion and dexamethasone 20 mg total dose infusion on day 1 and 15 in 28 days cycle. FDG-PET/CT control in fourth month showed residual accumulation of FDG in retroperitoneal fibrotic mass, and therefore the therapy was prolonged to 8 month. The subjective symptoms of this diseases disappeared in the 8th month. Then the maintenance therapy, administration of rituximab in 6 month interval, was started. The activity of this disease be further evaluated by FDG-PET/CT imagination. Glucocorticoids are considered the cornerstone of therapy. The use of other immunosuppressive agents, including cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil and biological agents such as rituximab, tocilizumab and infliximab and sirolimus have been reported as a valuable option mostly in case reports, cases series and small studies. This agents allowed to reduce cumulative dose of glucocorticoids and its adverse effects. Therefore in our patients we preferred combination of rituximab cyclophosphamide s dexamethasone with lover dose of prednisonem. This combination is preferable for patients who cannot tolerate glucocorticoids or who are likely to suffer from significant glucocorticoids -related toxicity.

Giant Cell Arteritis (GCA) is an autoimmune mediated systemic vasculitis affecting large arteries - the aorta and its branches. It has the highest incidence of all systemic vasculitides and manifests nearly exclusively in patients aged 50 or older. Amongst its non-specific and specific symptoms are headaches, mastication claudication or signs of rheumatic polymyalgia, a relatively common and immediate treatment requiring condition being acute vision loss due to optic ischemia. A GCA diagnosis is based on clinical and paraclinical findings and imaging techniques including PET/CT; with an important role still being played by histological verification from temporal artery biopsy. Treatment is based on immunosuppressive agents - systemic glucocorticoids, with adjunct therapy options being methotrexate and tocilizumab. Currently, there are also several clinical trials examining the efficacy of other modern biological agents in GCA.

Necrobiotic xanthogranuloma (NXG) is a rare chronic condition, belonging to the group non-Langerhans cell histiocytoses, which is relevant due to the possibility of extracutaneous involvement and association with systemic diseases, particularly monoclonal gammopathy, MGUS and multiple myeloma. The case reported here NXG was diagnosed after 1 years of evolution in patient with asymptomatic multiple myeloma. After treatment with bortezomib, lenalidomid and dexamethasone, there was evident abrupt decrease of monoclonal immunoglobulin to not measurable level (complete remission of multiple myeloma) and in the same time was evident disappearance of cutaneous and hepatic lesions of NXG on FDG-PET/CT. The etiopathogenetic association of monoclonal immunoglobulin with NXG is documented in this case report with disappearance of NXG in the time of disappearance of monoclonal immunoglobulin.

Transformation of IgM-MGUS into Waldenström´s macroglobulinemia in two of six patients treated for Schnitzler´s syndrome Schnitzler´s syndrome is a very rare, adult-onset, apparently acquired autoinflammatory disease. Chronic urticarial rash and symptoms of systemic inflammation including fever, arthralgia and bone pain with the presence of monoclonal immunoglobulin M (IgM), rarely IgG, are among hallmarks of the disease. We performed a retrospective study of 6 patients (5 men, 1 woman) diagnosed with Schnitzler´s syndrome fulfilling the Strasbourg criteria who had been treated at our centre in the University Hospital Brno from 2007 to 2021. Median age at diagnosis was 54 (45-67) years, median follow up was 8 (3-14) years. All 6 patients had IgM κ monoclonal gammopathy, increased CRP and/or erythrocyte sedimentation rate and arthralgia or bone pain, 4 patients suffered from fever, three had leucocytosis 10 × 109/L and lymphadenopathy was found in one patient. 18FDG-PET/CT scan with low-dose total body CT became a part of the initial baseline assessment in 5 patients with suspected Schnitzler´s syndrome, while Na18F-PET/CT was used in one patient to confirm the presence of osteosclerotic leasions as a criterion of the disease. All patients had osteosclerotic or hyperostotic bone lesions detected by low-dose CT examination, with increased 18FDG uptake in illiac and femoral bone marrow. The patient with Na18F-PET/CT scan revealed intensive abnormal tracer uptake with Na18F-PET/CT being more sensitive for detection of osteosclerotic lesions in Schnitzler´s syndrome than 18FDG-PET/CT. All patients were treated with daily subcutaneous anakinra without any adverse events, with excellent clinical results. We observed complete disappearance of urticaria and other symptoms persisting during years of anakinra administration. IgM-MGUS transformed into Waldenström´s macroglobulinemia in two of six patients, but only one patient developed symptoms requiring RBD (Rituximab, Bendamustin, and Dexamethasone) treatment, which induced almost complete remission of the disease. Successful RBD therapy enabled to prolong intervals of maintenance anakinra from 24 to 48 hours with almost complete control of urticarial rash and other symptoms. We suggest close monitoring of patients with Schnitzler´s syndrome to early capture potential transformation into Waldenström´s macroglobulinemia with succesful treatment of both conditions.

Cardiac abnormalities associated with hypereosinophilia represent rare diseases and occurs most commonly due to hypersensitivity or allergic reactions, other possible etiologies cover infections, malignancy, vasculitis or hypereosinophilic syndromes. Three stages of cardiac involvement are usually described. Initially, myocardial inflammation occurs, that can continue with a thrombotic stage and eventually progress to the last irreversible stage called endomyocardial fibrosis, which represents one of the acquired forms of restrictive cardiomyopathy. In most patients, increased levels of eosinophils in the blood differential test; however, it may not be present in the initial stages of the disease. Of the imaging methods, magnetic resonance imaging and positron emission tomography combined with CT PET-CT are used in addition to echocardiography. Endomyocardial biopsy may be indicated for definitive evidence of eosinophilic myocarditis. The clarification of the cause of hypereosinophilia is necessary for specific treatment of this disorder.

A man aged 60 years was examined for intense inflammatory response, night sweats, subfebrile and later febrile temperatures and a weight loss of 18 kg in 7 months. CRP was 270 mg / l, i.e. more than 20 times the upper limit of the physiological range. Reactive leukocytosis (10 × 109/l), thrombocytosis (530 × 109/l), increased fibrinogen (greater than 7 g/l), and anemia with hemoglobin of 80 g/l were present. No infection or systemic autoimmune disease has been proven. The patient had normal renal function and had no osteolytic deposits detectable by FDG-PET/CT. The procalcitonin level was not elevated. The bone marrow examination revealed a 30-40% infiltration of proplasmacyte type with admixture of plasmablasts, expressing light chains λ. Monoclonal immunoglobulin IgA λ was at a low concentration of about 8 g/l and the ratio of free light chains κ/λ was 0.13. The extent of bone marrow infiltration and anemia met the criteria for the diagnosis of symptomatic multiple myeloma. Following initiation of the combination therapy using thalidomide, bortezomib and dexamethasone, the maximum decrease in the concentrations of monoclonal immunoglobulin, free light chains and CRP was observed already after the first 2 cycles of treatment. Later, during the following two 2 cycles, the disease began to progress again. The patient underwent successful stem cell collection after the application of cyclophosphamide 2.5 g/m 2 and leukocyte growth factor (G-CSF), and high-dose chemotherapy (melphalan 200 mg/m 2) with the support of stem cell transplantation. At 2 months following high-dose chemotherapy, CRP levels of the physiological range decreased, the blood count was normalized, and monoclonal immunoglobulin was not detectable. Conclusion: The chronic inflammatory response may be due to plasmocytary bone marrow infiltration even if there are no other symptoms of multiple myel-oma present, except for anemia which, however, also involves the inflammatory reaction. In this case, the systemic inflammatory reaction with high CRP levels signalled aggressive behaviour of the disease. Key words: CRP - multiple myeloma - procalcitonin - systemic inflammatory response.

Sarcoidosis is a systemic granulomatous disease of unknown etiology that can affect any organ including the heart. Clinical manifestations of heart disease are seen in about 5 % of patients, but histology shows a higher rate of heart involvement by sarcoidosis. Therefore, heart sarcoidosis is underdiagnosed because of clinically non-symptomatic course in some patients or physicians simply do not think about this heart involvement. Echocardiography, Holter monitoring, magnetic resonance imaging, positron emission tomography/computed tomography, thallium scintigraphy, and endomyocardial biopsy are methods of investigation when suspected of heart involvement by sarcoidosis. In particular, magnetic resonance has gained importance recently in the diagnosis of cardiac sarcoidosis. Key words: cardiac sarcoidosis - diagnostics - therapy.

A disease associated with immunoglobulin IgG4 is a rare unit with very variable symptoms. We describe the course and treatment of the disease in a patient who presented with multiple lymphadenopathy and infiltrates in the area of the retroperitoneum and pelvis and signs of chronic sclerosing pancreatitis. The disease was clinically manifested by a significant loss of weight, but also by a loss of perception of taste and smell. The diagnosis was made based on a high amount of IgG4 expressing plasma cells in the sampled tissue and an increased concentration of immunoglobulins of type IgG and mainly subclass IG4. Rituximab in 475 mg/m2 dose was used in the treatment, the initial four doses of rituximab were administered at 14-day intervals, always with a one-off administration of a 40 mg dose of dexamethasone. According to FDG-PET/CT, only partial remission of the disease was reached after 4 applications of rituximab and dexamethasone. The patient recovered its sense of smell and taste. In another 4 cycles ritu-ximab was administered on day 1 of a 28-day cycle. On days 1 and 15 of the cycle dexamethasone at 40 mg and cyclophosphamide at 600 mg were administered by intravenous infusion. After the completion of 8 cycles of treatment based on rituximab and dexamethasone and with cyclophosphamide added in the second half of the treatment, the control FDG-PET/CT examination proved the complete remission. Before the treatment commencement the concentration of the subclass of immunoglobulin IgG4 was equal to 51.0 g/l, after the completion of the aforementioned treatment it dropped to 3.5 g/l. The patient tolerated the treatment without any adverse effects. Ritu-ximab, dexamethasone and cyclophosphamide induced the complete remission of this disease.Key words: IgG4-associated/releated disease - rituximab.

Introduction: Radiation-induced angiosarcoma is a rare but very aggressive tumour. The highest risk of sarcoma development is in patients after breast-conserving surgery.Case 1: The 66 years old patient underwent radical mastectomy with axillary dissection because of ductal carcinoma with consequent radiotherapy, chemotherapy and hormonal therapy. After 6 years, high-grade angiosarcoma was diagnosed and resected with negative resection margins. Within subsequent 24 months, additional three radical re-excisions were performed because of repeated sarcoma recurrence. 29 months from the diagnosis of the first sarcoma, another radical re-excision was performed, this time with positive resection margins and with consequent disease progression. The patient died three years after the first angiosarcoma diagnosis.Case 2: The 68 years old patient underwent breast-conserving surgery with axillary dissection because of ductal carcinoma and radiotherapy. Breast colour changes were observed 6 years later; radical mastectomy was performed after additional 16 months due to locally advanced angiosarcoma. Given positive resection margin, radical re-excision with musculocutaneous musculus latissimus dorsi flap was done. 24 months later, a small sarcoma recurrence was detected near the upper resection margin, which was managed by radical re-excision. 52 months after radical operation, a metastasis was diagnosed by means of PET/CT in the contralateral axilla. Radical axillary dissection was performed (two metastases were found in axillary lymph nodes). According to follow-up, the patient has been free of any recurrence for 66 months from the radical surgery., Conclusion: Recommendations regarding the management of radiotherapy induced breast angiosarcoma are very vague due to limited evidence. Radical surgical excision with negative resection margins (potentially with complementary flap reconstruction) presents the fundamental approach to breast angiosarcoma.Key words: radiation-induced angiosarcoma - breast cancer - surgery.

Introduction: Solid pseudopapillary neoplasm (SPN) is a very rare neoplasm that occurs in girls and young women in 90% of cases; the range is 779 years of age, and the median is 28 years of age. This tumour was first described by Virginia Frantz in 1959 as a papillary cystic tumour of the pancreas., Methods: The aim of this retrospective study was to analyse the incidence of SPN in all patients with a pancreatic tumour operated at the 1st Dept. of Surgery, University Hospital Olomouc between years 2006 and 2015. Clinical symptoms, imaging methods used, tumour marker positivity, histological findings, postoperative complications and disease-free interval were all evaluated., Results: Of the 454 patients operated on between 20062015, the diagnosis of SPN was made in five female patients. The following imaging methods were used in the preoperative diagnostic process: CT, MRI, PET/CT and endosonography. In four patients the tumour was localised in the tail of the pancreas; these women underwent left-sided pancreatectomy. In one patient, the tumour was located in the pancreatic head and a pylorus-preserving pancreaticoduodenectomy was performed. Complications were seen only in one patient who underwent revision on the first postoperative day for bleeding from the pancreatic cut surface. Pancreatic fistula was not observed in any of the patients. The procedures were considered as sufficient from the oncological viewpoint due to the radical resection procedure and negative resection margin, and therefore no adjuvant oncological treatment was indicated in any of the patients. During the follow-up period, recurrence was not observed in any one of the patients., Conclusion: Solid pseudopapillary neoplasm of the pancreas is a rare disorder with a low malignant potential occurring primarily in young women. Generally, SPN has a good prognosis; however, advanced stages of the disease with distant metastases may be encountered in rare cases. The only curative treatment is radical surgical resection.Key words: solid pseudopapillary neoplasm Frantzs tumour pancreas.

Aortic graft infection is one of the most serious complications of aortovascular surgery. Diagnosis is based on clini-cal and radiologic findings. The emphasis is put on early diagnosis and its impact on prognosis of patients. The management should be individualized. The gold standard is surgical treatment with complete excision of the infected foreign material with debridement of the surrounding tissue and repair of vascular continuity by extra-anatomic bypass or in situ bypass with autologous femoral vein or cryopreserved arterial allografts. In stable patients with high risk perioperative mortality a conservative strategy may be an alternative approach. We report the case of a 54-year-old man with complicated history of aortic repair surgery. Diagnosis made on clinical findings and radiologic images (CT angiography of aorta and positron emission tomography/computed tomography). After multidisciplinary conference conclusion the conservative strategy was recommended.Key words: antibiotic therapy - aortic graft infection - conservative treatment.

Erdheim-Chester disease is a histiocytic neoplasm of diseases from the group of non-Langerhans-cell histiocytoses, formed by infiltrates of foamy histiocytes. These pathological histiocytes produce pro-inflammatory cytokines. Therefore Erdheim-Chester disease is called inflammatory histiocytary neoplasm. The disease is accompanied by clinical symptoms of systemic inflammatory response, i.e. B symptoms. Imaging examinations detect typical osteosclerotic changes affecting diaphyses and metaphyses of the lower long bones and fibrotic changes which affect the aorta wall and the vessels leading from it. Also characteristic are perirenal fibrotic changes spreading in the retroperitoneum. They can cause serious complications - hydronephrosis with all its consequences. The therapy for this disease was not satisfactory in the previous years. Conventional chemotherapy or glucocorticoids do not bring any substantial and long-term improvement. Considering cytostatic drugs, only 2-chlorodeoxyadenosine (cladribine) is effective, though not in all patients. We have only reached complete remission through 2-chlorodeoxyadenosine in one of our two patients, which now lasts more than 5 years, while cladribine in the same patient did effect the reduction of infiltrates into the CNS, but it did not achieve abatement of the disease activity in other locations as shown by PET/CT with the application of the radio-pharmaceutical fluorodeoxyglucose (FDG). Another effective medicine for patients with Erdheim-Chester disease is interferon α. However its long-term administration is associated with multiple adverse effects and so we did not test it in the described patient. The introduction of anakinra, the interleukin-1 receptor blocker, to therapy brought a new hope for these patients. We are describing the patient who has been treated with anakinra for more than 5 years. The patient applies 1 ampoule of 100 mg subcutaneously per day. This treatment completely removed systemic B symptoms, relieved bone pains and attained normalization of all findings that signalled systemic inflammatory response. The treatment effect is regularly checked by CT imaging of the abdomen and by FDG-PET/CT examinations. The retroperitoneal fibrotic changes gradually regressed during the 5 years of anakinra treatment, as documented by the pictures in the text. Low-dose CT imaging which was part of the PET/CT examination, identified many osteosclerotic lesions in the skeleton, mainly in the legs, with an increased accumulation of 18F-fluorodeoxyglucose (FDG). Osteosclerotic lesions remain well visible at repeated examinations. Still during the course of the 5-year period the FDG accumulation in them decreased, as shown by the pictures in the text. Anakinra treatment has a character of maintenance therapy. The BRAFV600E mutation was not proven in the described patient, therefore we did not test vemurafenib treatment., Conclusion: anakinra effected regression of fibrotic changes in the retroperitoneum and disappearance of B symptoms as well as decrease in FDG accumulation at FDG-PET/CT examination.Key words: anakinra - Erdheim-Chester disease - cladribine - retroperitoneal fibrosis - vemurafenib.

Unlabelled: Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a very rare disease belonging to a group of histiocytoses (more precisely non-Langerhans cell histiocytoses). Rosai-Dorfman disease is characterised by the presence of atypical histiocytic cells in the sinuses of lymph nodes or in the extranodal lymphoid tissue, absorbing lymphocytes and plasma cells. The structure and function of the absorbed cells is not impaired and they can leave histiocytes as viable cells. This effect is called emperipolesis, whereas ingestion of cells with their destruction is called phagocytosis. In our text we describe a patient with this disease located, characteristically, in supraclavicular lymph nodes, but also in mediastinal lymph nodes. Along with lymphadenopathy skin alterations appeared which were both clinically and histologically described as eczema dermatitis. At the same time as lymphadenopathy also strong headaches started which the patient had never suffered before. Within the first-line treatment prednisone was administered, but no effect was achieved. 2-chlorodeoxyadenosine in 5 mg/m2 s. c. dose was used in the second-line treatment, for 5 successive days in monthly intervals. There were four cycles of this treatment administered overall. Therapy was tolerated without any manifestations of toxicity. Already after the 1st cycle skin alterations as well as headaches entirely disappeared. To assess the effect of treatment the PET/CT examination with 18F-fluorodeoxyglucose (FDG-PET/CT) was made. After 4 cycles of treatment the mediastinal lymph nodes diminished to a physiological size and the accumulation of fluorodeoxyglucose in them was assessed as physiological. Lymphadenopathy in the neck area also significantly diminished by 50-75 % and the accumulation of fluorodeoxyglucose was reduced as well, though it did not reach the norm. Therefore we evaluate the effect of treatment as a partial remission with complete disappearance of skin alterations and headaches. The cause of the eczema and headaches has not been clarified, however considering the same time of their arising and then disappearance after the application of 2-chlorodeoxyadenosine the causal connection with Rosai-Dorfman disease is likely., Key Words: Castlemans disease - lenalidomide - Rosai-Dorfman disease - rituximab - sinus lymphadenopathy with massive lymphadenopathy - thalidomide - 2-chlorodeoxyadenosine.

Introduction: The frequency of pancreatic metastases ranges from 2% to 5%. Pancreas is an elective site for metastases from renal carcinoma. Pancreatic metastases from renal cell carcinoma are frequently the only metastatic site and they typically occur in the seventh decade of life., Case Report: We report 1 female patient (aged 58 years) with multifocal and isolated pancreatic metastases of renal cell carcinoma. Total duodenopancreatectomy was performed., Conclusion: In selected cases, pancreatic resection due to renal cell cancer metastases is deemed indicated, improving overall patient survival., Key Words: renal cell carcinoma (RCC) isolated pancreatic metastases total duodenopancreatectomy.

Background: Recent advances in the use of the imaging modalities, especially PET/CT, and their utilization for determining clinical stage (CS) and assessment treatment response (TR) in malignant lymphomas, along with development of prognostic tools and new treatment modalities, formed the basis for the revised criteria for evaluating CS and TR (published as the Lugano classification, 2014)., Materials and Methods: The authors summarize the new Lugano recommendations (published in 2014) and the changes from the criteria published in 2007. Moreover, discussion of the changes places emphasis on practical use. The practicality of the Lugano classification, 2014 was the subject of consensus meeting at the annual meeting of the Cooperative Lymphoma Study Group (CLSG) in March 2015. This study reports the final consensus. The CLSG recommends use of the Lugano classification, 2014, but recommends some modifications., Conclusions: Standardization of the criteria used to determine CS and TR in malignant lymphomas has led to improvements in initial staging and assessment of TR. The criteria are helpful for unifying response assessment in clinical trials and simplify the work of regulatory agencies (e.g., the EMA and the Czech State Institute for Drug Control) when registering new drugs. It also allows evaluation of treatment outcomes outside clinical trials, for example within the CLSG prospective registry of patients with newly diagnosed lymphoma., Key Words: malignant lymphoma - computed tomography - positron emission tomography - staging - treatment responseThis work was supported by the grant Prvouk P27/2012 of the Third Faculty of Medicine, Charles University in Prague and by the grant of the Czech Lymphoma Study Group No. NT12193-5/2011.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 24. 1. 2016Accepted: 16. 2. 2016.

Background: Multiple primary lung cancer is a relatively rare nosological entity. This case report is a reminder and points out the pitfalls of its diagnosis and therapy., Case Report: A 62-year-old patient was indicated for surgical therapy for non-small cell lung cancer of the middle lobe and right lung, which were diagnosed during a screening investigation after the patient had undergone previous mastectomy of the right breast with axillary dissection for invasive ductal adenocarcinoma. Another infiltration in the lower lobe of the same lung was removed at the same time and was classified as a primary lung carcinoma; it was a synchronous lung cancer., Conclusion: Lung cancer presenting with more than one primary lesion in the lung is a rare nosological entity that can be classified into two types; synchronous and metachronous. Whereas synchronous cancers arise in the lung at the same time, metachronous cancers develop after treatment of the initial lesion. The incidence of multiple lung cancer is increasing due to earlier diagnosis and because successful treatment of the initial cancer at an early stage has led to an increase in patient survival, resulting in an increase in the interval between detection of the initial cancer and detection of the second. Smoking is one of the main risk factors. Diagnosis is made difficult because metastatic disease must be excluded. Basic information is obtained from a biopsy of the tumor. The staging of more than one primary lung cancer is complex and needs to be meticulous if curative resection is being contemplated. Magnetic resonance imaging of the brain and fluorodeoxyglucose positron emission tomography should be performed to evaluate for extra-thoracic metastases., Key Words: lung carcinoma - multiple cancer disease - synchronous - metachronous - diagnosis - therapyThe authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 22. 2. 2016Accepted: 20. 4. 2016.