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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 139-141

Dual malignancy: Carcinoma of different cells in different organs


1 Department of Respiratory Medicine, Sundaram Medical Foundation, Chennai, Tamil Nadu, India
2 Department of Respiratory Medicine, Main Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission04-Mar-2021
Date of Decision13-Mar-2021
Date of Acceptance15-Mar-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
R Sridhar
Sundaram Medical Foundation, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_5_21

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  Abstract 


Incidence of multiple primary cancers, though uncommon, is being frequently reported nowadays, owing to better diagnostic techniques, the prolonged life span, and the increased incidence of long-term survival of cancer patients. In our case, lung mass in a patient with prior history of transitional cell carcinoma (TCC) of the urinary bladder on evaluation turned to be small cell carcinoma. Dual malignancy of different cells in different organs is rare, and very few case reports are reported. We report a rare case of novel combination of multiple primary carcinomas reported as TCC of the bladder and small cell carcinoma of the lung.

Keywords: Dual malignancy, lung mass, metastasis


How to cite this article:
Sridhar R, Narasimhan R. Dual malignancy: Carcinoma of different cells in different organs. J Assoc Pulmonologist Tamilnadu 2020;3:139-41

How to cite this URL:
Sridhar R, Narasimhan R. Dual malignancy: Carcinoma of different cells in different organs. J Assoc Pulmonologist Tamilnadu [serial online] 2020 [cited 2021 Sep 20];3:139-41. Available from: http://www.japt.com/text.asp?2020/3/3/139/314969




  Introduction Top


Multiple primary malignancies in a single patient were first described in 1879 by Billroth.[1] Incidence of multiple primary cancers, though uncommon, is being frequently reported nowadays, owing to better diagnostic techniques, the prolonged life span, and the increased incidence of long-term survival of cancer patients. Patients, who were diagnosed with a cancer, have a life time risk of developing another de novo malignancy depending on various inherited, environmental, and iatrogenic risk factors.[2] Lung masses in a patient with prior history of malignancy not always due to metastasis, rarely it may be primary. Transitional cell carcinoma (TCC) is an unusual metachronous tumor with lung cancer.

We report a rare case of novel combination of multiple primary carcinoma – TCC of the bladder and small cell carcinoma of the lung.


  Case Report Top


A 51-year-old male from Bangladesh, police constable by occupation, came with complaints of breathlessness Grade 2 Modified Medical Research Council, dry cough, central chest pain, history of hoarseness of voice, and dysphagia for 4 months with a history of left nephroureterectomy for TCC followed by six cycles of chemotherapy in July 2017. Respiratory system auscultation revealed reduced breath sounds over the left hemi-thorax and D'Espine sign positive. He was a heavy smoker with a smoking index of 800.

Basic blood investigations were normal. Chest X-ray [Figure 1] showed mediastinal widening with left-sided pleural effusion; further evaluation with whole-body positron emission tomography-computed tomography (PET-CT) [Figure 2] showed a hypermetabolic infiltrative mass involving the left mediastinal region with compression of the left main bronchus and complete collapse of the left lung with left-sided pleural effusion and hypermetabolic enlarged mediastinal lymph nodes.
Figure 1: Chest X-ray

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Figure 2: Positron emission tomography scan

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Figure 3: Whole-body scan

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CT-guided biopsy of the mediastinal mass was suggestive of small cell carcinoma.


  Discussion Top


Lung mass in the patient with prior history of cancer is a challenge to pulmonologist whether new lesion in the lung metastasis of old tumor or separate primary lung carcinoma. To confirm the exact nature of new mass lesion, the ideal method is to biopsy the lesion but before we decide whether to go ahead with biopsy or not is based on the risk factors for carcinoma and nature of prior tumor and its stage at the time of treatment, time interval between the old tumor and new mass and treatment, chance of metastasis to lung, and character of lung lesion.

Diagnosis may be confidently made without the need for a biopsy when a patient with a history of prior cancer known to metastasize to the lungs presents with nodules with highly typical characteristics: multiple, new, or growing lower lobe pulmonary nodules with smooth borders. A diagnosis may also be possible without the need for a biopsy when, less commonly, there are measurable diagnostic serum markers (CA19-9, CA125, carcinoembryonic antigen, alpha-fetoprotein, β human chorionic gonadotropin, CYFRA21-1). However, for most tumors other than those of germ cell origin, these epithelial markers are not sufficiently specific, and a biopsy is warranted to guide therapy.[3]

The most common site of metastasis of TCC was the regional lymph nodes (78%). Other common sites included the liver (38%), lung (36%), bone (27%), adrenal gland (21%), and intestine (13%).[4]

Although the chance of metastasis to the lung is 36%, the character of mass is not typical of metastasis as described above. In our case, it was a large mass hypermetabolic infiltrative mass involving the left mediastinal region with compression of the left main bronchus and complete collapse of the left lung with left-sided pleural effusion and hypermetabolic enlarged mediastinal lymph nodes and no other hypermetabolic lesion anywhere in the whole-body PET CT scan.

Differential diagnosis of single or multiple pulmonary nodules in patients with prior cancer[4]

  • Malignant


    • Metastasis
    • Primary lung cancer.


  • Benign
  • Infectious


    • Fungal infection
    • Mycobacterial infection
    • Nocardia
    • Septic emboli.


  • Noninfectious


    • Rheumatoid nodules
    • Hamartoma
    • Carcinoid
    • Sarcoidosis
    • Cryptogenic organizing pneumonia
    • Vasculitis (granulomatous angiitis).


The North American Association of Central Cancer Registries (NAACCR) classifies multiple primary tumors into two categories: (1) synchronous, in which cancers occur at the same time (the Surveillance Epidemiology and End Results Program definition is within two months) and (2) metachronous, in which cancers follow in sequence, that is, more than 2 months apart.[2]

Warren and Gates criteria proposed that a diagnosis of multiple primary malignancies requires the following: (1) each tumor should present a definite picture of malignancy; (2) each tumor should be histologically distinct; (3) the possibility that one is a metastasis of the other must be excluded.[1]

The pathophysiology behind the occurrence of multiple primary malignancies has been theorized to be common carcinogen induced multiple cancers in an exposed epithelial surface, called “field cancerization” as seen in head neck tumors, late side effect of treatment used to treat the first tumor or genetic predisposition to neoplasia.[5] Other possible causal factors include persistent carcinogen exposure from environment, progressive ozone depletion and effects of ionizing radiation, increased use of organ transplant, and the increasing use of newer treatment modalities such as hormonal manipulation, target therapies, genetic manipulation, and immunomodulators.

Smoking is a significant risk factor for the development of multiple primary malignancies involving lung cancer. In our case, the patient was a heavy smoker which is a well-known risk factor for lung carcinoma, but smoking is the common risk factor for both lung cancer and TCC.

Liu et al. reported that the most common tumors accompanying lung cancer were in the aerodigestive tract (in the descending order of frequency: larynx, nasopharynx, esophagus, oral cavity, and hypopharynx), followed by colorectal and cervical malignancies.[6]

Kurishima et al. in their study of 98 lung cancer patients who had synchronous and/or metachronous malignancies did not report dual malignancy of lung carcinoma and TCC of the bladder.[7] In our case, the lung biopsy came as small cell carcinoma. Hence, Double primary cancer is a more reasonable diagnosis in this case since the histopathology of the bladder was TCC and that of the lung mass was small cell carcinoma. This assumption is also in agreement with the NAACCR definition that “multiple lesions of different histologic types occurring in different sites are considered as separate primaries whether occurring simultaneously or at different times.”[2]


  Conclusion Top


This case highlights the fact that the presence of a lesion anatomically away from the primary malignancy should be labeled as a metastasis only after detailed evaluation; otherwise, there is a possibility of missing a synchronous or metachronous primary malignancy. Treatment and prognosis will vary much between metastasis and dual primary malignancy. Early dual primary malignancy may have definite treatment and better prognosis than single primary with distant metastasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank to Department of Pathology, Radiology, and Medical Oncology, Apollo Hospitals, Chennai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Warren S. Multiple primary malignant tumors, a survey of the literature and a statistical study. Am J Cancer 1932;16:1358-414.  Back to cited text no. 1
    
2.
Howe HL. A review of the definition for multiple primary cancers in the United States. In: Howe HL, editor. Workshop Proceedings from December 4 6, 2002 in Princeton, New Jersey. Springfield, IL, USA: North American Association of Central Cancer Registries; 2003.  Back to cited text no. 2
    
3.
Broaddus VC, Mason RJ, Ernst JD, King TE Jr., Lazarus SC, Murray JF, et al. Murray & nadel's textbook of respiratory medicine: Elsevier; 2016.  Back to cited text no. 3
    
4.
Babaian RJ, Johnson DE, Llamas L, Ayala AG. Metastases from transitional cell carcinoma of urinary bladder. Urology 1980;16:142-4.  Back to cited text no. 4
    
5.
Hsieh WC, Chen YM, Perng RP. Temporal relationship between cancers of the lung and upper aerodigestive tract. Jpn J Clin Oncol 1997;27:63-6.  Back to cited text no. 5
    
6.
Liu YY, Chen YM, Yen SH, Tsai CM, Perng RP. Multiple primary malignancies involving lung cancer – Clinical characteristics and prognosis. Lung Cancer 2002;35:189-94.  Back to cited text no. 6
    
7.
Kurishima K, Satoh H, Homma S, Kagohashi K, Ishikawa H, Ohtsuka M, Sekizawa K. Multiple primary malignancies in patients with lung cancer. Radiology and Oncology 2005;39(1).  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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