In July 2004, a 77-year-old white male nonsmoker was admitted to the Thoracic Surgery Unit of San Camillo-Forlanini Hospital with a round, irregularly shaped lesion in the left upper lobe (LUL) that measured 1.5 cm×1 cm and a synchronous ground-glass opacity lesion in the right upper lobe (RUL) that measured 2 cm×1 cm. An 8-fluorodeoxyglucose PET-CT scan showed a high maximum standardized uptake value (SUVmax 5.6) of the LUL lesion (Fig 1A) and low maximum standardized uptake value (SUVmax 1.3) of the RUL lesion (Fig 1B). No mediastinal or distant uptake was detected. Fiber-optic bronchoscopy was negative. According to PET evaluation, the multidisciplinary team decision favored resection of the LUL and follow-up of the RUL lesion. After informed consent, an uneventful left upper lobectomy plus radical mediastinal lymphadenectomy was performed, and a moderately differentiated adenocarcinoma pT1, pN0 (UICC-2002 TNM classification) mixed (acinar and papillary) subtype with evidence of angioinvasiveness was diagnosed (Fig 1C). Three months later, a CT scan showed a moderate enlargement of the RUL lesion. Fine needle aspiration demonstrated a well-differentiated adenocarcinoma. The occurrence of synchronous adenocarcinomas in different lobes implied the need to discriminate between metastatic and primary independent lung tumors, but the Martini-Melamed criteria are not applicable to fine needle aspiration.1 Metastatic disease would require a chemotherapeutic approach, whereas synchronous primary tumors might benefit from surgical procedures.2 Different therapeutic options were discussed with the patient, who refused chemotherapy. Because of respiratory function impairment (FEV1 51%), an RUL apical segmentectomy was the selected surgical procedure. A well-differentiated, minimally invasive adenocarcinoma (Fig 1D) with predominant lepidic growth without evidence of lymphatic invasion was detected. On the seventh postoperative day, the patient was discharged without a conclusive staging assessment. To date, 70 months after the second surgical procedure, the patient is still alive and free of disease.