Ying-Tang Fang*, Kuo-Tung Huang*, Chin-Chou Wang*,**,***

A 63-year-old male who had been diagnosed as having esophageal squamous cell carcinoma (T1N0Mx post- endoscopic submucosal dissection) in 2011 presented with a left soft palate mass in 2012. Biopsy of the oral mucosa was performed and the pathology showed well-differentiated squamous cell carcinoma. This patient presented to Chang Gung Memorial Hospital in 2014 with blood-tinged sputum and progressive dyspnea. Initial chest x-ray showed right upper lobe consolidation. Chest CT examination revealed right upper lobe consolidation with a suspicious 6cm infiltrative mass invading the right hilum

and mediastinum. Multiple liver nodules and masses in both lobes of the liver were also noted. Bronchoscopy examination with tissue biopsy for pathologic study revealed small cell carcinoma of the bronchus. Echo-guided fine needle aspiration for the right liver lobe tumor was performed and the pathology study showed small cell carcinoma, metastatic. The initial approach to patients with suspected lung cancer is based on the study results of patients with non-small cell lung cancer. In general a few things need to be considered, including selecting a biopsy site and obtaining an adequate sample for microscopic examination. Immunohistochemical and genetic analyses are necessary for confirmation of the diagnosis. Aggressive tissue biopsy for pathology study may increase the rate of diagnosis for double, or even triple primary malignancies. More precise diagnosis will provide more treatment choices.