a 65-year - old woman with a smoking history of about 45 pack - years was referred to our clinic . in 1986 , she had been treated for a cervical cancer stadium t2b with intracavitary brachytherapy and external radiation of the pelvis up to 50 gy . apart from chronic urge incontinence , she had developed no acute or late toxicity after radiotherapy . , she was diagnosed with a stage i , node - negative breast cancer . in preparation of adjuvant radiotherapy after breast - conserving surgery , a chest x - ray showed two pulmonary nodules , one in the right upper lobe and one in the left upper lobe . by that time , she was in good performance status , had no pulmonary symptoms and no weight loss . thoracic ct scan showed a 29  30  25 mm spiculated lesion in the right upper lobe . in the left upper lobe , a conflating lesion of 15  19 none of the lesions were in range for bronchoscopic biopsy , but ct - guided biopsy of the nodule in the right lung was performed . a poorly differentiated squamous cell carcinoma was diagnosed and the limited biopsy material showed positive staining for ck 7 , 5 and 6 , berep4 and ttf1 . the pathologists could not definitely conclude if it was a primary lung carcinoma or a relapse from her cervical cancer . after interdisciplinary discussion , it was decided to start combination chemotherapy with topotecan and cisplatin , as the tumour was considered a cervical cancer metastasis . after 6 cycles with moderate toxicity , ct revealed that the nodule in the left lung was no longer apparent . unfortunately , there was a significant growth of the lesion in the right lung , and a 18fdg - pet / ct showed intense metabolic activity with high uptake of fdg in the tumour with a standardised uptake value ( suv ) of 34 ( fig . 1 ) . surprisingly , pathological uptake in a nodule in the proximal rectum with an suv of 12 was also found . mri of the pelvis was performed and a colonoscopy with biopsy verified a highly differentiated adenocarcinoma in the sigmoideum , staged as duke a. the patient underwent an abdominal rectosigmoid resection and colorectal anastomosis . due to the inconclusive histopathological evaluation of the tumour in the right upper lobe , the limited effect of chemotherapy , and the radiological consistence with primary lung cancer , it was concluded that this tumour most likely was a primary lung carcinoma , and a radical approach was recommended . due to chronic obstructive pulmonary disease , the patient had severe reduction of lung function , excluding her from thoracic surgery and conventional radiotherapy . the only remaining curative alternative was a high - dose stereotactic body radiotherapy ( sbrt ) for her primary t2a lung cancer . in december 2008 , the patient underwent a 4-dimensional ct - gated sbrt against the lesion in the right upper lobe ( fig . sbrt was performed to a total dose of 45 gy , delivered in 3 fractions given every other day . image guidance with on - board ct scan was performed to re - localize the target lesion before every treatment delivery . six weeks after sbrt , the patient presented with intense thoracic pain requiring moderate morphine doses , chest wall oedema and fever . ct scan showed significant tumour reduction from 29  30  25 mm to 20  22  18 mm , consolidating lung parenchyma and atelectasis due to stricture of a segment bronchus and a pronounced thoracic oedema . these early complications after high - dose stereotactic radiotherapy are well documented , but are rare in this intensity . the solid swelling over the right chest wall corresponded to the radiation field . in order to eliminate the possibility of a relapse after treatment with corticosteroids , nonsteroidal anti - inflammatory drugs and morphine for 3 months , the clinical and radiological alterations reversed and medication could be reduced . pet - ct showed a markedly inflammatory response in the chest wall without uptake suspicious of malignancy . the patient was followed up with alternating ct scans and pet - ct every 3 months , and a total regression of the clinical symptoms was registered after 1 year ( fig . one and a half year after sbrt , she was without clinical or metabolic indicators of tumour activity . nevertheless , a minor chest wall oedema and mild lung fibrosis around the high - dose area without clinical impact could be verified . multiple synchronous or metachronous malignancies are not rare . estimates between 0.73 and 11.7% are published . treating a patient with multiple malignancies previous treatment with surgery , chemotherapy and radiation therapy can lead to severe comorbidity that may have an impact on further possibilities of effective cancer treatment . the technological development in radiotherapy has undergone an era of unprecedented transformation , allowing the precise and non - invasive administration of high radiation doses in an aggressive , decisive manner to eradicate a discrete focus of cancer , and has opened a new treatment option for patients who formerly had no curative alternative . high - dose sbrt for early - stage lung cancer is a well - established , well - documented and safe approach . acute pneumonitis or fibrosis is regularly seen radiographically after sbrt , but such findings are usually without clinical relevance even though many patients undergoing sbrt have reduced lung function . in our case , acute pneumonitis and stricture of a segment bronchus with consecutive atelectasis developed already 6 weeks after sbrt and diminished after 1 year . studies measuring pulmonary function before and after treatment with sbrt have not shown permanent declines in function . skin erythema , fractures of the ribs , vertebral body , chest wall inflammation , and acute and chronic chest pain are side effects that may appear in high - dose areas . for chronic chest pain and rib fracture after sbrt , a dose - response correlation and a dose - volume relationship are well documented [ 6 , 7 ] . in our patient , the dose per fraction to 2 cm of the rib was 13.9 gy and the volume of the chest wall receiving > 30 gy was 67 cm . the minimum distance from our patient 's lesion to the chest wall was only 25 mm , which unavoidably gives a high dose contribution to the chest wall . chronic chest pain is also a common problem after thoracic surgery in up to 10% of patients , and the response to treatment is poor . our patient 's soft tissue reaction could be influenced by the radio - sensitizing effect of cisplatin . even if the time interval between chemotherapy and sbrt in our patient was 5 months , one can speculate about a contributing effect of cisplatin on the excessive soft tissue reaction after sbrt . this theory is supported by the fact that our patient had tolerated high doses given to the pelvis in 1986 . a third option is that she is genetically susceptible to cancer and to radiotherapeutic side effects due to her genetic characteristics involved in dna repair . our knowledge about the genetics underlying differences in normal tissue radiosensitivity is still sparse , and there are no obvious candidate genes identified . after diagnosed with cancer for the first time , our patient has survived 4 life - threatening cancer diagnoses . she is in excellent condition and according to her , she has more courage to face life than ever .
patients experiencing several cancers can be a challenge , as optimal treatment options for the different cancers might interfere with each other . in this case report , we present a woman diagnosed with 4 different types of cancer . 
 she was treated with surgery , chemotherapy and radiotherapy . 
 her performance status was generally good , and she tolerated the treatment very well , except some troublesome side effects in the thoracic soft tissue after stereotactic body radiotherapy .