Case report: multiple lesions during navigation bronchoscopy; seen one, seen them all?

Background: Peripheral pulmonary nodules are often detected as multiple nodules in one patient. Computed tomography (CT) guided transthoracic biopsy (TTNB) is the most widely implemented method for minimal invasive biopsy of pulmonary nodules, but generally only one nodule is sampled per procedure. Navigation bronchoscopy is an endobronchial procedure with very low complication rates, and uses high-end image guidance which allows for the sampling of multiple nodules in one session, while also allowing inspection of the central airways and endobronchial ultrasound (EBUS) guided staging in one session. This report presents a unique case with three different synchronous primary tumors treated with three different treatment modalities that highlights the added value of cone-beam CT guided navigation bronchoscopy (CBCT-NB) in the diagnostic work-up of suspected early-stage lung cancer. Case Description: This case describes an asymptomatic patient with no history of prior lung cancer referred because of a shadow seen on a screening X-ray. CT and positron emission tomography (PET) showed two nodules for which a navigation procedure was performed. Both nodules were sampled, and on inspection, a third occult endobronchial lesion was also found. Pathology revealed three separate primary tumors, which were treated with three different treatment modalities: surgery, radiotherapy and endobronchial cryoablation. Current follow-up at 12 months shows no signs of recurrence. Conclusions: This case highlights that synchronous primary malignancies do occur and require a patient tailored approach to minimize treatment related morbidity and optimize survival. To this goal, image guided navigation bronchoscopy allows for a full and complete diagnostic evaluation and can be combined with a staging EBUS in one single session.