synchronous primary lung cancers are uncommon and the occurrence of synchronous non small cell lung carcinomas ( nsclc ) with different histological morphologies within the same lobe is rare . the aim of this report is to discuss surgical and oncological management of this entity together with a review of the current literature . a 61-year - old female smoker ( 42 pack years ) was found to have left upper zone shadowing on chest x ray following a history of weight loss . her performance status was 1 with a forced expiratory volume in one second ( fev1 ) of 1.94 litres . positron emission tomography in conjunction with computed tomography ( pet - ct ) showed two nodules in the left upper lobe . there was a 2 cm spiculated lesion in the anterior segment with a standardised uptake value ( suv ) max of 5.6 units ( fig 1a ) and a 2.2 cm cavitating lesion in the apico - posterior segment with a suv max of 2.7 units ( fig 1b ) . coronal view pet ct scan of a high uptake nodule in the left upper lobe coronal view of pet ct scan of moderate uptake synchronous nodule in the left upper lobe a left thoracotomy with upper lobectomy was performed and the intra - operative findings were consistent with the radiological appearances seen in the pet - ct scan . there was a 2 cm infiltrating squamous cell carcinoma in the anterior segment with vascular invasion ( pathological ( p ) t2a according to tnm 7th edition ) and a separate 2.4 cm adenocarcinoma with associated broncho - alveolar spread in the apical segment ( pt1b ) . an adjacent peribronchial lymph node was positive for tumour ( pn1 ) , however due to the poorly differentiated morphology of the tumour cells it was unclear as to which tumour it originated . cisplatin and vinorelbine adjuvant chemotherapy was administered with no overt complications ; however recurrence of the disease was discovered radiologically one year post - operatively in the form of a left hilar soft tissue mass with bony metastases . the patient subsequently received radiotherapy without complications but a staging ct chest / abdomen / pelvis performed three months later showed progressive disease with left lung collapse in addition to multiple , palpable subcutaneous nodules . these features were in keeping with the patient s symptoms of worsening breathlessness and wheeze . further investigations including bronchoscopy showed a tumour in left main bronchus which was treated with laser ablation and placement of a tracheo - bronchial stent . histological assessment of this nodule showed a poorly differentiated adenocarcinoma , which was confirmed with immunohistochemical techniques . specialist genetic analysis of the subcutaneous lesion was performed , which showed the presence of an egfr mutation sensitive to anti - egfr tyrosine kinase inhibitors . this enabled the oncologists to use monoclonal antibody therapies ( anti egfr tki ) and the patient was treated for one month with iressa ( gefitinib ) . she responded well with significant decrease in the size of the metastatic subcutaneous nodules . due to her progressive disease the patient deceased with an overall survival ( from the time of the lung resection ) of 20 months synchronous primary lung cancers ( splc ) were first described in 1924 by beyreuther h ( 1 ) . the true incidence of these remains uncertain but evidence has shown figures between 1% to 8% ( 2 ) . the criteria for the diagnosis of splc , which was proposed by martini and melamed in 1975 , are that synchronous tumours are physically distinct and that the histology is different surgical resection of splc was recommended by many of the reviewed authors ( 3 - 5 ) . rostad et al studied the outcome and characteristics of synchronous primary lung cancers . in 15,308 lung cancer resection cases , 94 patients were found to have synchronous non small cell lung cancers , nsclc , 9 patients had synchronous lung cancers with different histological morphologies and only 2 ( 0.01% ) patients had synchronous lung cancers with different histological morphologies within the same lobe . the relative survival rate in patients with different histological morphologies ( n=9 ) was 12.7% . patients with similar morphologies had a better outcome with a relative survival rate of 29.2% , although the difference was not statistically significant ( p=0.24 ) . the authors concluded that surgical resection should be offered to patients with synchronous lung cancers who are operable with respectable tumour . ( 3 ) lymph node metastases were found to be a statistically significant prognostic factor . in a study of 92 patients who had surgical resections for multiple synchronous primary lung cancers , the results showed the 5-year survival were 52.5% and 15.5% for patients without and with lymph node metastasis respectively ( p = 0.001 ) . ( 3 ) skin metastases from lung cancers are not uncommon , and their presence is a poor prognosis factor ( 6 ) . recently anti - egfr tki molecules have been introduced for the treatment of advanced malignancies including lung cancers , however long term treatment resistance remains a therapeutic challenge . our patient had a disease free survival of 12 months post surgery despite a positive lymph node , but she later developed recurrence with distant subcutaneous metastases and an endobronchial mass , which was treated palliatively . she received anti egfr1-tk inhibitors based on genetic analysis from the metastatic adenocarcinoma subcutaneous lesions and her initial response was good . patients with resectable synchronous primary non small cell lung carcinomas within the same lobe should be offered surgical resection after careful pre - operative staging . skin metastases should be biopsied and egfr testing should be requested in order to determine the originating the tumour and to assess the patients suitability for anti egfr - tki treatment .
we report the case of a sixty one year old female diagnosed with two synchronous primary lung cancers located within the same lobe . 
 surgical resection was performed , followed by adjuvant chemotherapy . 
 the patient developed distant bone and skin metastases one year post - surgical resection . in this report 
 we discuss the multimodality therapy used to treat this patient .