Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 3, Num. 3, 2007, pp. 153-156

Journal of Cancer Research and Therapeutics, Vol. 3, No. 3, July-September, 2007, pp. 153-156

Case Report

Synchronous dual malignancy: Successfully treated cases

Agrawal Rashi

Dept. of Radiotherapy, J. K. Cancer Institute, Kanpur, U.P
Correspondence Address: Rashi Agrawal, 117/139, ‘O’ Block, Geeta Nagar, Kanpur, UP - 208 025, India. E-mail: roopsi_roopal@rediffmail.com

Code Number: cr07040

Abstract

Keywords: Double malignancy, synchronous, treatment

Introduction

The occurrence of a second malignancy in a patient with a known malignant tumor is not uncommon. It has been observed that a person with a malignant tumor may be more prone to develop another malignancy than would be expected by mere chance alone. Metachronous primary malignancies are becoming increasingly frequent because of an increase in the number of elderly patients and improvements in diagnostic techniques. However, synchronous primary malignancies are still unusual. Data regarding treatment and its outcome in such cases is sparse. We present two cases treated successfully at our center.

Case Reports

Case 1

A 70-year-old female presented to us with a lump in her right breast for two years and bleeding per vaginum for two years. On examination, the right breast had a 4 x 4 cm lump in the upper outer quadrant. The axillae and neck regions were free of any adenopathy. The clinical stage was T2N0M0. On pelvic examination, there was an ulceroproliferative growth arising from the cervix, involving all the fornices and extending to the lower third of the vaginal walls. It had involved the parametrium bilaterally up to the lateral pelvic wall-stage IIIB. A modified radical mastectomy (MRM) was done on 08.09.2004 for the right breast lump. She was thoroughly investigated. Complete blood count, liver function tests, renal function tests, X-ray chest PA view, and ultrasound (whole abdomen) were within normal limits. Histopathological examination (HPE) of the mastectomy specimen (09.10.2004) showed that the breast tumor was an infiltrating duct carcinoma and was 5 x 4 x 4 cm in size. Pathological staging was pT2N0M0. Lymph node showed chronic lymphadenitis [Figure - 1],[Figure - 2].

We decided to administer external beam radiation therapy with cobalt-60 for both cervix and breast malignancy at the same time. The chest wall and the supraclavicular fossa were treated with a radiation dose of 45 Gy in 22 fractions. The duration was 4½ weeks with five fields from 19.10.04 to 17.11.04. For the pelvis, 45 Gy was given in 22 fractions. For this also the duration was 4½ weeks with two fields, AP-PA, from 19.10.04 to 17.11.04. On 27.11.04, a pelvic examination showed an ulceroproliferative lesion reaching up to the upper 2/3 ^rd of the vagina; the parametrium was bilaterally free. CT scan of the lower abdomen revealed a heterogeneously enhancing cervical mass measuring 4.13 x 2.32 cm, with hematopyometra and bilateral parametrial lymphadenopathy; there was no hydroureteronephrosis. Phase II radiation to the pelvis was planned. A radiation dose of 26 Gy in 13 fractions was given in 2½ weeks by four fields between 07.12.04 and 23.12.04. After completion of radiotherapy, the patient reported on 02.02.05 with complaints of continuing discharge per vaginum. On examination, the chest wall, axillae, neck, and opposite breast were within normal limits but the pelvic examination showed a proliferative lesion involving the cervix and the vaginal walls; the parametrium was bilaterally free. In view of the residual disease in the cervix and pending adjuvant chemotherapy for carcinoma of the breast, 6 cycles of cisplatin 70 mg day-1, doxorubicin 70 mg day-1, and cyclophosphamide 700 mg day-1, repeated 3-weekly, were delivered between 03.02.05 and 04.08.05. On 03.09.05, the patient again reported with complaints of continuing discharge per vaginum. On examination, her chest wall, axillae, neck, and opposite breast were within normal limits but the pelvic examination showed a proliferative lesion involving the cervix and vaginal walls; the parametrium was bilaterally free.

She was advised surgery for the local lesion; on 08.11.05, she had a total abdominal hysterectomy with bilateral salpingo-oophorectomy done at the government hospital. Histopathological examination of the specimen showed myometrium lined by nonsecretory endometrium, with benign cystic hyperplasia and endometrial polyps.

Patient is on regular follow up and clinically there is no evidence of disease.

Case 2

A 40-year-old female presented with mild headache off and on for one year, projectile vomiting for three months, and right-sided facial swelling for three months.

On examination, the patient had intact higher functions. There was no sensory or motor deficit and no facial nerve involvement. Bladder and bowel functions were within normal limits. The right parotid was enlarged, 3 x 3 cm, firm, mobile, and nontender. Plain and contrast CT scan of the brain revealed a large low-attenuating lesion on the left side, involving the frontoparietal region and crossing the midline frontal horns and the anterior part of the corpus callosum; the mass was ~53 x 48 mm in size [Figure - 3]. USG of the neck revealed a right parotid mass-a well-defined mixed echogenic lesion 3.1 x 3.4 cm in size, with anechoic areas [Figure - 4]. Histopathological examination of the brain tissue showed astrocytoma grade II [Figure - 5],[Figure - 6].

The initial treatment was for the astrocytoma. Decompression of the malignant mass was done by the surgeon on 27.06.05. External beam radiotherapy with cobalt-60 was delivered by two lateral opposed fields to the local area between 01.08.05 and 16.09.05.

The radiation dose was 60 Gy in 30 fractions; the total duration was 6 weeks. After this, surgery for the parotid tumor was planned and a partial parotidectomy was done on 10.12.2005. External beam radiotherapy with cobalt-60 was delivered to the tumor bed from 27.12.05 to 31.01.06. The radiation dose was 50 Gy in 25 fractions delivered over the 5 weeks.

Patient is on regular follow-up; she has no new complaints and clinically there is no neurological dysfunction and no evidence of disease at the right parotid and neck region.

Thus, it was concluded that patients responded well to the treatment [Figure - 7],[Figure - 8].

Discussion

Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past hundred years. The lesions can be limited to a single organ or may involve multiple organ systems. These lesions generally fall into two categories: (1) synchronous-in which the cancers occur at the same time (as was the case in our patients) or within two months and (2) metachronous-in which the cancers follow in sequence (more than two months apart). ^[1]

The prevalent coincidence of microsatellite instability suggests that the genetic defect of mismatch repair deficiency may be responsible for a small subset of double cancers of the colorectum and stomach. Germ-line mutations of P53, tumor suppressor gene, were found in children and young adults with a second malignant neoplasm. Kimura et al . also found germ-line p53 mutation in a patient with multiple primary cancers. ^[2]

Bongers et al . concluded that, in addition to external carcinogens, an intrinsic susceptibility may influence the risk for the development of second primary tumors in patients with head and neck squamous cell carcinoma. ^[3]

It is relatively common for patients with colorectal carcinoma or carcinoid tumors to have more than one primary neoplasm. Mitchell reported a patient with five primary synchronous neoplasms of the gastrointestinal tract, involving the stomach, small bowel, and colon. ^[4]

Synchronous primary cancers of the breast and cervix as reported by us has also been reported by Verstovsek et al . ^[5] An interesting case of double malignancy-carcinoma lung and rhabdomyosarcoma of scapula-has also been reported by Masood et al . ^[6] These cases illustrate the need for a thorough search for additional neoplasms when treating patients with cancer.

Multiple primary carcinomas in patients with head and neck malignancies have been studied intensively. Grosjean et al . retrospectively studied patients who had been treated for head and neck cancer. They concluded that early diagnosis and treatment of second primary tumors results in a survival rate very similar to that of patients with a single head and neck cancer. This provides indirect evidence that in patients with curable initial head and neck cancer intensive screening for second primary tumors may result in an improved overall outcome. ^[7]

Di Martino et al . also retrospectively studied patients treated for head and neck cancer. They concluded that the treatment of a second primary is often less successful than that for the same malignancy occurring primarily. The prognosis of synchronous tumors is significantly lower when compared to malignancies of a metachronous nature, despite some encouraging individual results. Only the early implementation of aggressive treatment methods for second primaries is successful in terms of survival. In one study, an aggressive treatment strategy was employed wherever clinically appropriate and yielded the most favorable results, with a five-year survival rate of 66.8% and 35.9% for index tumors and second primary malignancies, respectively. ^[8]

Thus, treatment strategies in case of synchronous double malignancy depend on treating the malignancy that is more advanced first or sometimes both could be treated simultaneously. In our case, we concluded that a synchronous double malignancy can be treated successfully. Both sites should be treated fully as if they were occurring separately considering toxicities.

References

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