What happened, in summary

This 48-year-old woman was first treated as if she had Stage IV lung cancer, but a second opinion later changed the diagnosis and treatment path. She had an FDG-PET-avid, TTF-1-positive adenocarcinoma of the right lower lung invading thoracic vertebra 10, plus an additional PET-negative right kidney lesion. Cytology from the kidney lesion had been interpreted as adenocarcinoma, so it was initially considered a kidney metastasis from lung cancer, giving a presumed cT4NxM1 diagnosis. She received palliative radiotherapy, 30 Gy, to vertebrae Th9-Th12 and 4 cycles of gemcitabine plus carboplatin. Both lesions decreased slightly, and observation was chosen because of the presumed Stage IV status. She then sought a second opinion. Review of pathology and new PET/CT imaging found no metastases except the kidney lesion, so the situation was reconsidered as 2 primary tumors: Stage IIIB lung adenocarcinoma, cT4N0M0, and a right kidney tumor, cT1a. She received 2 cycles of neoadjuvant cisplatin plus pemetrexed before lung surgery. Surprisingly, no tumor was found in the right lower lobe during surgery. Treatment included hemicorporectomy of Th10, resection of the transverse processes of Th10 and Th11, and spinal stabilization. The small kidney lesion was initially observed because it was stable, only 2.3 cm, and located in the mid-pole, then treated 11 months later with cryoablation when she wanted it removed. Pathology confirmed papillary renal cell carcinoma rather than lung cancer spread. As of February 2014, she was doing well more than 6 years after the initial diagnosis, a very different outcome from the expected course of presumed Stage IV lung cancer. Her story underscores how re-reviewing pathology and imaging changed both prognosis and treatment strategy.