In 2009, a 42-year-old non-smoking male presented to our hospital for the evaluation of a right lung nodule detected during physical examination. He underwent radical resection of the right lung, and the postoperative pathological report revealed a mucoid adenocarcinoma of the inferior lobe of the right lung (3.5 × 3.0 cm), but no positive lymph nodes (0 of 29; T2aN0M0 stage I). The patient relapsed in 2015. A computed tomography (CT) scan revealed a mass in the superior lobe of the right lung and mediastinal lymph node enlargement. He underwent resection of the residual right lung. Postoperative pathological evaluation and hematoxylin and eosin staining showed different histomorphologies in the primary lung site (mucinous type) (Fig a) and the fourth group of lymph node metastases (solid type, T2N2M0 stage III) (Fig b). Immunohistochemistry indicated a pulmonary origin of both tumors: TTF-1 and Napsin A were positive, and CK 5/6 and P63 were negative. We simultaneously detected ALK and EGFR gene status by reverse transcription-PCR (Amoy, Xiamen, China) in two tumor tissue specimens. The results indicated a positive EML4-ALK rearrangement in tissues and wild EGFR (Fig ). The patient received adjuvant chemotherapy and achieved stable disease.
A 56-year-old female was admitted to our clinic with a complaint of multiple masses in her left neck region. The past medical history of the patient included a left nephrectomy for renal cell carcinoma (the pathological analysis revealed clear cell + chromophob cell carcinoma) in 2000, otherwise normal. A physical examination of the patient revealed multiple painless cervical masses at different lymphatic levels in the left cervical region [].\nLaboratory findings were as follows, hemoglobin:14 gr/dl, hematocrit: 41,1%, erythrocyte count: 5.180.000/ mm3, leucocyte count: 6.390 / mm3 (66.4% neutrophils, 23.9% lymphocytes, and 7.2% monocytes), and erythrocyte sedimentation rate 31 mm / 1 hour. Urine analysis was normal. The Brucella agglutination test, and the MONO, VDRL, ANA, ANTİ-DNA, ASMA, AMA, ASO, and CRP tests were normal. The thyroid function tests were normal. The scintigraphic bone scan imaging was negative for metastatic lesions. Thyroid ultrasonographic examination and high resolution Pulmonary imaging were also found to be negative for metastasis. An abdominal ultrasonograpic examination showed a nephrectomy scar on the left side, but was otherwise normal. Ultrasonographic examination of the neck detected five lymphadenopathies of different sizes with the greatest dimension of 3 × 3 cm. The magnetic resonance imaging (MRI) scan also confirmed the ultrasonographic findings, and post contrast scanning showed heterogen and noduler contrast. Pathological examination of the fine needle aspiration biopsy (FNAB) of the lymphadenopathy that was greatest in dimension showed renal cell carcinoma (RCC), clear cell type.\nIn December 2006, left functional neck dissection was performed. Totally 23 lymphadenopathies were counted in the surgical specimen. The greatest lymph-node metastasis appeared as a thick, irregularly walled cystic mass, with a minimally enhancing or dense surrounding reaction that effaced the adjacent tissue planes []. In the pathological examination of the dissected lymphadenopathies, it was found that a third of them in the jugulodigastric region were metastatic renal cell carcinoma []. Postoperative radiotherapy to the neck region was performed. In the second and fourth months after the second operation, she has no evidence of recurrence in the neck region.