Multiple right-sided pulmonary nodules: metastatic cancer or resectable early stage tumor?

We report the case of a patient with three right pulmonary nodules and a previous advanced metastatic carcinoma of the pharynx. Follow-up and treatment were managed by a team of surgeons and oncologists according to the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines [1]. The complexity of the case lies in its being open to different diagnostic interpretations and in the impossibility of obtaining sufficient clarification by means of non-invasive techniques. The non-conventional ultimate decision to perform a surgical biopsy of all nodules led to an unexpected diagnosis which entailed a better prognosis and a change in the therapeutic strategy. The aim of this paper is to focus attention on the role of timely surgery in the diagnosis of complicated oncologic cases that may at some point require a more personalised approach, outside formal guidelines.A 52 year-old male who was a heavy smoker presented with a single right upper lobe pulmonary nodule 1.2 cm in diameter. In May 2007 he had developed a tongue carcinoma which had been treated by a supraglottic laryngectomy extended to the tongue base, temporary tracheotomy and elective neck nodal dissection. Histology was pharyngeal squamous cell carcinoma, pT2N2M0G2 with minimal invasion of the deep tongue surgical edge. The advanced tumor stage had required adjuvant radiotherapy (65 Gy) and chemotherapy (two cycles of cisplatin). In September 2008 a CT scan revealed the 1.2 cm irregular nodule in the upper pulmonary lobe. The radiologic report stated it was suggestive of scarring tissue. Bronchoscopy and bronchoalveolar lavage cytology were negative. The fully informed patient chose a non-aggressive management approach. Therefore, according to the ACCP evidence-based clinical practice guidelines, a serial CT scan observation was adopted [2]. In December 2008 a chest CT scan showed a slight increase in size of the right upper lobe nodule (1.4 cm) and the appearance of two nodules i