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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 40-42

A metachronous malignancy: An interesting case report

Department of Respiratory Medicine, PSG institute of Medical Research and Science, Coimbatore, Tamil Nadu, India

Date of Submission05-Apr-2021
Date of Acceptance03-May-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
S Muthulakshmi
Department of Respiratory Medicine, PSG Institute of Medical Research and Science, Coimbatore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_19_21

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Guillian-Barré syndrome (GBS) is an acute immune-mediated polyradiculoneuropathy that is often related to a previous infectious exposure. GBS emerged as a potentially serious complication of covid 19 infection. Here we present a case of 64 years old female who presented to us with worsening respiratory failure and progressive flaccid symmetrical sensorimotor neuropathy following covid infection. She was diagnosed to have GBS as post covid complication . Hence started on Intravenous Immunoglobulin infusion following which she had improvement in respiratory failure and prevented from intubation and mechanical ventilation.

Keywords: Metachronous malignancy, multiple primary malignancy, synchronous malignancy

How to cite this article:
Muthulakshmi S, Murthy K A. A metachronous malignancy: An interesting case report. J Assoc Pulmonologist Tamilnadu 2021;4:40-2

How to cite this URL:
Muthulakshmi S, Murthy K A. A metachronous malignancy: An interesting case report. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 Jan 28];4:40-2. Available from: http://www.japt.com/text.asp?2021/4/1/40/326407

[TAG:2]Background [/TAG:2]

Multiple primary malignancies (MPM) are slowly increasing in trend due to prolonged survival of cancer patients and advancement in diagnostic and therapeutic modalities. MPM first was cited in 1869 by Billroth.[1] Risk factors are being genetic predisposition, environmental modifications, or therapy induced. Multiple primary cancers are all independent in origin and can be classified as metachronous or synchronous. Malignancies that occur within 6 months of the first primary tumor are defined as synchronous, while those that develop after the first 6-month interval are defined as metachronous.[2]

  Case Report Top

A 62-year-old male, farmer, presented with complaints of cough, breathlessness, and decreased appetite for 10-day duration. He is a known case of NHL thyroid-S/P chemoradiotherapy (7 years back) and S/P cystostomy for bladder carcinoma (10 years back). Personal history: Ex-smoker (quit 10 years back) with pack-years of more than 30 years. Family history: Carcinoma of stomach in father (expired). General examination revealed pallor and clubbing with no cyanosis, icterus, lymphadenopathy, pedal edema, or fever. Vitals were stable. Respiratory system examination showed stony dull and absent breath sound in right hemithorax. Other system examination was normal. Baseline investigations showed anemia and deranged thyroid function test. Renal Function test(RFT) Liver Function test (LFT) were within normal limits. Chest X-ray showed homogenous opacity in right hemithorax with mediastinum shift to contralateral side [Figure 1]. Pleural fluid analysis showed low adenosine deaminase, lymphocytic predominant exudative effusion. Cytology showed positive for malignancy-adenocarcinoma, immunohistochemistry (IHC) marker-CK7 positive. Serum tumor markers CA19-9, CEA and PSA were negative for Malignancy. Positron emission tomography-computed tomography showed large lobulated mass in anterior portion of right pleural space and lung parenchyma causing compression with collapse of right upper and middle lobe, multiple pleural deposits in right hemithorax with gross right pleural effusion-metachronous right lung primary with metastasis [Figure 2]. Low Fluorodeoxyglucose uptake was noted in visualized thyroid gland, ipsilateral medistinal and subcarinal lymph nodes. No abnormal metabolic activity was noted elsewhere in whole body survey. Thoracoscopy showed multiple nodular lesions over visceral and parietal pleura [Figure 3]. Thoracoscopy was preferred over bronchoscopy in this case, because it serves both diagnostic purpose and relieves patient's symptoms. Histopathology showed metastatic carcinomatous deposits, IHC markers showed CK7 and CK19 positive, whereas TTF 1, CDX2, P63, calretinin, and WT1 were negative and suggestive of metastatic adenocarcinoma from primary in hepatobiliary tract/pancreas/lung to be considered [Figure 4].
Figure 1: Chest X-ray showing implantable cardioverter defibrillator in situ following thoracoscopy and right upper zone and hilar mass

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Figure 2: Positron emission tomography-computed tomography showing fluorodeoxyglucose-avid large lobulated mass in the right pleural space and involving adjacent lung parenchyma causing compression and collapse of right middle lobe and anterior segment of upper lobe

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Figure 3: Medical thoracoscopy showing multiple nodular lesions noted over parietal and visceral pleura. Multiple biopsies were taken from parietal pleural lesions

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Figure 4: Histopathological examination showed fibrocollagenous tissue with infiltrating neoplasm composed of eosinophilic cells, vacuolated cytoplasm, and pleomorphic vesicular nuclei – suggestive of metastatic adenocarcinomatous deposits

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  Discussion Top

Most of the studies have shown that individual with one primary cancer is more likely to develop a subsequent primary cancer compared to the normal population. Although the reason is unknown, incidences of multiple primary cancers are increasing in recent trends.[3] This is due to earlier detection and increased survival rates due to improved therapeutic measures.[4],[5] The intrinsic risk factors are being radiotherapy, hormonal therapy, medical imaging, environmental factors, and genetic disposition.

Especially, radiotherapy has been shown to be associated with the development of second primary cancers. Regions that are anatomically near the targeted treatment are at high risk for the development of malignancy. Specifically, an increased incidence of lung cancers has been noted following radiotherapy of the breast region, neck, and mediastinum.[6] Most of the studies have shown that the extensive use of medical imaging can potentiate multiple primary cancers in individual's genetic susceptibility. This patient had multiple cycles of radiotherapy for non-Hodgkin lymphoma of thyroid that might lead to second primary malignancy.

The effects of smoking on cancer are well-documented temporal relationship.[7] Mutations such as K-RAS and p53 genes and other harmful substances found within tobacco smoke can promoting angiogenesis and tumor growth.[8] Tobacco smoke found to associated with at least 17 types of human cancer including lung squamous cell, oral cavity, esophagus, colorectal, and stomach cancers. In our patient, the first cancer being bladder carcinoma that was treated surgically 10 years back may be attributed to smoking. Following a latent period of 3 years, he developed non-Hodgkin lymphoma of thyroid that was treated with multiple cycles of radiotherapy and chemotherapy. Now, the patient is diagnosed to have metastatic adenocarcinoma of lung with unknown primary since all markers for lung malignancy were negative. The main risk factors are tobacco smoke and radiotherapy to thyroid in this patient. One study demonstrated that, among smokers that developed second primary tumors, those who quit had an 11.55-year gap before the second tumor manifested. In smokers who did not quit, the gap before a new tumor was significantly less at 6.10 years.[9]

Importantly, genetic disposition is etiology for multiple primary cancers.[10] One study found that 13.7% of more than 26,000 patients diagnosed with lung cancer had one or more first-degree relatives who had also been diagnosed.[10] Since this patient had a family history of carcinoma stomach, it is reasonable to conclude he was at higher risk for its development.

Given the complex nature of presentation of multiple primary cancers in this patient, it is not possible to identify single risk factor that was responsible. Although inquiry into the epidemiological and clinical perspectives of such cases is rising, definitive statements have remained elusive given the complex interplay of social and medical factors involved.

  Conclusion Top

Whenever a patient with known malignancy complaints of new symptom, we tend to correlate it with recurrence of primary one. However, one should always keep in mind the possibility of subsequent new malignancy. As a clinician should always have a high index of suspicion for MPM for early detection and better outcome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pennell V. Primary carcinoma multiplex; a series of 17 cases with review of the literature. Br J Surg 1958;46:108-13.  Back to cited text no. 1
Moertel CG, Dockerty MB, Baggenstoss AH. Multiple primary malignant neoplasms. I. Introduction and presentation of data. Cancer 1961;14:221-30.  Back to cited text no. 2
Owen LJ. Multiple malignant neoplasms. J Am Med Assoc 1921;76:1329-33.  Back to cited text no. 3
American Cancer Society. Cancer Facts and Figures. Atlanta, GA American Cancer Society; 2016.  Back to cited text no. 4
Supramaniam R New malignancies among cancer survivors: SEER cancer registries, 1973–2000. J Epidemiol Community Health 2008;62:375-6.  Back to cited text no. 5
Lin E. Radiation risk from medical imaging. Mayo Clin Proc 2010;85:1142-6.  Back to cited text no. 6
Alexandrov LB, Ju YS, Haase K, Van Loo P, Martincorena I, Nik-Zainal S, et al. Mutational signatures associated with tobacco smoking in human cancer. Science 2016;354:618-22.  Back to cited text no. 7
Heeschen C, Jang JJ, Weis M, Pathak A, Kaji S, Hu RS, et al. Nicotine stimulates angiogenesis and promotes tumor growth and atherosclerosis. Nat Med 2001;7:833-9.  Back to cited text no. 8
Howren MB, Lamkin DM, Suls J. Associations of depression with C-reactive protein, IL-1, and IL-6: A meta-analysis. Psychosom Med 2009;71:171-86.  Back to cited text no. 9
Bailey-Wilson JE, Amos CI, Pinney SM, Petersen GM, de Andrade M, Wiest JS, et al. A major lung cancer susceptibility locus maps to chromosome 6q23-25. Am J Hum Genet 2004;75:460-74.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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