Triple Synchronous Primary Neoplasms in the Gastrointestinal Tract
Multiple primary malignancies are a rare occurrence in clinical practice, with most cases being metachronous or involving more than one organ system. This report presents a unique case of triple synchronous primary neoplasms confined to the gastrointestinal tract, highlighting the complexities in diagnosis, management, and treatment strategies for such cases.
A 61-year-old male patient with no significant medical history or chronic illnesses presented with vague abdominal complaints. Initial abdominal computerized tomography (CT) scan revealed thickening of the descending colon wall, raising suspicion of colon cancer (clinical stage cT3N+). The patient had no history of smoking or alcohol consumption and no family history of malignancies. Further evaluation with a chest CT scan showed esophageal wall thickening, prompting additional investigations.
Upper gastrointestinal tract (GIT) endoscopy identified a mid-esophageal mass and a gastric mucosal lesion. Biopsy results confirmed the esophageal mass as squamous cell carcinoma and the gastric lesion as adenocarcinoma. Colonoscopy revealed a mass in the descending colon, which was histopathologically confirmed as adenocarcinoma. Endoscopic ultrasound of the upper GIT provided further details, showing an esophageal mass with an enlarged mediastinal lymph node, indicating a clinical stage of cT4N1 for the esophageal cancer. The gastric lesion was staged as cT1aN0.
The treatment plan was tailored to address each malignancy sequentially. Endoscopic mucosal resection (EMR) was performed for the gastric cancer, which was successful and allowed for the reconstruction of GIT continuity. Histopathology of the resected gastric lesion showed well-differentiated adenocarcinoma without lymphovascular or perineural invasion and with negative resection margins.
The patient underwent robotic esophagectomy and cervical esophagogastrostomy as upfront surgery for the esophageal cancer. Histopathology of the resected esophageal tumor confirmed squamous cell carcinoma (pT2N2), necessitating adjuvant chemotherapy with 5-fluorouracil and cisplatin. Subsequently, laparoscopic left hemicolectomy was performed for the colon cancer. Histopathology of the resected colon tumor revealed adenocarcinoma (pT1N0). Genetic studies showed that the KRAS and NRAS genes were wild-type, and the tumor was microsatellite stable.
Interestingly, the pathological stage of the colon cancer (pT1N0) differed significantly from the initial clinical stage (cT3N+), likely due to the response to 5-fluorouracil-based adjuvant chemotherapy administered post-esophageal cancer surgery. One year after surgery, the patient experienced no complications, showed no signs of recurrence, and reported a good quality of life.
The management of multiple primary malignancies presents unique challenges, particularly when they occur synchronously within the same organ system. International guidelines for mid-esophageal cancer (clinical stages II and III) typically recommend neoadjuvant chemoradiotherapy followed by surgery. However, in this case, upfront surgery was chosen to avoid delays in treating the other primary cancers. This decision was supported by studies showing no significant difference in overall five-year survival between neoadjuvant chemotherapy followed by surgery and upfront surgery with pathological stage-based adjuvant chemoradiation.
The successful treatment of the gastric cancer with EMR allowed for its use in reconstructing GIT continuity, demonstrating the importance of a tailored and sequential approach in managing multiple malignancies. The case underscores the need for healthcare professionals to develop special strategies for the management of multiple primary malignancies to achieve the best oncological outcomes.
In conclusion, this case report highlights the complexities and challenges in diagnosing and managing triple synchronous primary neoplasms in the gastrointestinal tract. It emphasizes the importance of a multidisciplinary approach, tailored treatment strategies, and the consideration of patient-specific factors to optimize outcomes. The successful management of this case provides valuable insights into the treatment of similar complex cases in the future.
doi.org/10.1097/CM9.0000000000001389
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