Multiple primary tumours: challenges and approaches, a review

Survival for endometrial cancer as a second primary malignancy

BACKGROUND

Endometrial cancer (EC) often occurs subsequently to a primary cancer arising from a different site. However, little is known regarding the survival experience of EC as a second primary (ECSP) malignancy, specifically in relation to the original primary site and prior treatment.

METHODS

Using Florida's cancer registry, all EC cases (first, second, or higher-order) diagnosed from 2005-2016 were analyzed. Kaplan-Meier methods and Cox Regression were used in a cause-specific survival analysis.

RESULTS

A total of 2879 clinically independent ECSPs and 42,714 first primary ECs were analyzed. The most common first primary sites for ECSPs were breast cancer (BC) (n = 1422) and colorectal cancer (CRC) (n = 359). Five-year cause-specific survival was 84.0% (95% CI: 83.6-84.3) for first primary ECs and 81.8% (95% CI: 80.0-83.4) for ECSPs. After adjusting for age, race/ethnicity, histology, and stage at diagnosis, ECSPs had a lower risk of EC mortality than first primary ECs (hazard ratios [HR] 0.88, 95% CI: 0.79-0.97). ECSPs with a first primary CRC had a higher risk of EC-specific death (HR 1.47, 95% CI: 1.04-2.06) compared to ECSPs that followed BC in multivariable analysis. Finally, women who had chemotherapy for ECSP and preceding BC did not have a higher risk of death (HR 0.80, 95% CI: 0.49-1.31) compared to those who only received chemotherapy for first primary EC.

CONCLUSIONS

ECSPs present a complex clinical profile. ECSP survival is superior to that of first primary EC. However, ECSPs following CRC may constitute a population of interest for their worse prognosis. Chemotherapy for a previous BC does not seem to impact the effectiveness of chemotherapy for ECs.

Risk of Second Malignant Neoplasm in Familial Non-Medullary Thyroid Cancer Patients

INTRODUCTION

Survival rates in patients with non-medullary thyroid carcinoma (NMTC) are high, increasing the possibility to develop a second malignant neoplasm (SMN). Many studies investigated the relationship between increased risk of SMN in NMTC patients treated with radioiodine, but few data are available about the impact of family history (FH) of thyroid cancer on SMN risk.

PURPOSE

To assess the risk of SMN in a large cohort of sporadic and familial NMTC using the standardized incidence ratio (SIR).

PATIENTS AND METHODS

We studied 918 NMTC patients (73.9% female patients) followed for a median follow-up of 9 years. In 798/918 (86.9%) patients, NMTC was sporadic, while the remaining 120 (13.1%) were familial NMTC (FNMTC).

RESULTS

We identified 119/918 (13%) patients with SMN in association with NMTC. NMTCs had an increased risk of SMN when compared to the general population (SIR 2.1, 95% CI 1.7-2.5). The rate of SMN for all sites was significantly higher in familial compared to sporadic NMTC (20% versus 11.9%, p = 0.01), primarily driven by families with more than two affected members. The risk of SMN was remarkably higher for breast cancer, especially in familial cases (SIR 22.03, 95% CI 14.4-41.2) compared to sporadic cases (SIR:17, 95% CI 11.9-24.6).

CONCLUSIONS

NMTC patients have a higher risk of SMN compared to the general population and this risk is much higher in patients with FNMTC. This observation raises the hypothesis that genetic risk factors for a first cancer may predispose to SMN, especially among individuals with familial clustering of the same or other tumors.

Multiple Primary Malignancies in Patients with Gynecologic Cancer

Objective: To investigate the prevalence and oncologic outcomes of patients with multiple primary malignant tumors (MPMT) with gynecologic cancer. Methods: This retrospective study included 1929 patients diagnosed with gynecologic cancer at a tertiary medical center between August 2005 and April 2021. The clinical data included cancer location, age at primary malignancy diagnosis, interval between primary and secondary cancer, stage of cancer, family history of cancer, genetic testing, dates of last follow-up, recurrence, and death. Results: The prevalence of MPMT with gynecologic cancer in patients was 8.6% and the mean diagnostic period between primary and secondary cancer was 60 months. Furthermore, 20 of the 165 patients with MPMT had multiple primary gynecologic cancers (MPGC), whereas 145 had gynecologic cancer coexisting with non-gynecologic cancer (GNC). Endometrial-ovarian cancer (60%) was the most common coexisting cancer in the MPGC group, whereas the most common non-gynecologic cancer in the GNC group was breast cancer (34.5%). There were 48 patients with synchronous cancer and 117 patients with metachronous cancer. The incidence of synchronous cancer was higher in the MPGC group than in the GNC group (p = 0.037). Significantly more patients had early-stage ovarian cancer in the MPGC group than in the GNC group (p = 0.031). The overall recurrence and mortality rates were 15.8% and 8.5%, respectively, in patients with MPMT. Conclusion: Synchronous cancer incidence was significantly higher in the MPGC than in the GNC group. Early-stage ovarian cancer was more highly diagnosed in patients with MPGC than in those with GNC. A systematic examination after primary cancer diagnosis could facilitate the early diagnosis of secondary primary malignancy, thereby improving patient prognosis.

Metachronous breast cancer in a male with previous history of liposarcoma: A case report from Syria

Introduction

Multiple primary cancers (MPC) are defined as the occurrence of two or more non-related cancers. The acquiring of male breast cancer (MBC) as secondary cancer in a sequence of MPC is extremely rare. Only one case of breast cancer following liposarcoma (LP) was previously reported in a female patient. We report the first case of MBC following LP.

Case presentation

A non-smoker male patient with a history of a well-differentiated liposarcoma was treated surgically and with radiotherapy 14 years ago with no signs of recurrence. The patient presented with a left breast mass; The excisional biopsy showed poorly differentiated grade III invasive ductal carcinoma. The patient underwent a mastectomy with axillary node resection and the final diagnosis was invasive ductal carcinoma stage IIA [T:2, N:0, M:0]. The tumor markers reported; Positive Estrogen Receptor (ER+), negative Progesterone Receptor (PR-), and negative Human Epidermal Receptor (HER-). He received eight sessions of chemotherapy with Docetaxel and 16 fractions of radiotherapy. The follow-up showed no signs of recurrence.

Discussion

Despite the rarity of diagnosis MBC as a second primary. Studies have found a relation between different types of breast cancer in male patients, and further, a relation was also found between MBC and lymphoma. While no studies that link MBC and LP were previously reported.

Conclusion

We found that acquiring a treated LP would not affect the MBC prognosis or its response to treatment, yet further studies are needed to confirm this outcome.

•

Multiple primary cancers occur in 2.4–17% of all people.

•

The diagnosis of male breast cancer as a second primary is rare.

•

Having male breast cancer following liposarcoma is even rarer.

•

Well treated liposarcoma would not affect male breast cancer prognosis.

Prevalence and spectrum of pathogenic variants among patients with multiple primary cancers evaluated by clinical characteristics

BACKGROUND

Multiple primary cancers (MPCs) are a hallmark of cancer predisposition syndromes. Here the frequency of germline pathogenic variants (PVs) among patients with MPCs is reported.

METHODS

Patients with MPCs who underwent multigene panel testing from March 2012 to December 2016 were studied. Eligible patients had an analysis of 21 genes: ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, NF1, PALB2, PMS2, PTEN, RAD51C, RAD51D, STK11, and TP53. The frequencies of PVs by sex, number of cancers, and age at diagnosis were compared with 2-sided χ² tests or Fisher exact tests when the number was <10.

RESULTS

Among the 9714 patients analyzed, most were female (91.1%) and White (71.0%); the median age at testing was 63 years, and the median ages at first and second cancer diagnoses were 49 and 58 years, respectively. Overall, 1320 (13.6%) had PVs. The prevalence of PVs increased with the number of primary cancers (PCs): 13.1% with 2 PCs, 15.9% with 3 PCs, and 18.0% with ≥4 PCs (P = .00056). Differences in the prevalence of PVs by age at diagnosis were significant: 14.7% with 2 PCs at an age < 50 years, 15.8% with 1 PC at an age < 50 years, and 12.0% with all PCs at an age ≥ 50 years (P = 2.07E-05). PVs by the age at second cancer diagnosis were also significant: 14.7% at an age < 50 years, 13.9% at an age of 50 to 69 years, and 11.4% at an age ≥ 70 years (P for trend = .005).

CONCLUSIONS

Among patients with MPCs, there is a high frequency of germline PVs, with a higher frequency found among patients with a higher number of PCs. These findings suggest that genetic testing should be considered even among patients who are older at the diagnosis of an additional primary malignancy.

A Case of Metastatic Non-small Cell Lung Adenocarcinoma and Metachronous Primary Hepatocellular Carcinoma

Multiple primary malignant neoplasms (MPMNs) are generally defined as the co-occurrence of primary neoplasms of distinct histology in the same individual. Second and higher-order primary malignancies now comprise about 18% of all cancer incidence in the United States. Specifically in female cancer survivors, the incidence ratio of developing multiple primary cancers (MPCs) is 1.2 to 1.6. Patients with lung cancer are at higher risk to develop a second malignancy compared to the general population. However, the coexistence of non-small cell lung adenocarcinoma and primary hepatocellular carcinoma (HCC) is not described in the literature. Here we describe a rare case of a 69-year-old female with non-small cell lung adenocarcinoma with vertebral metastasis that developed primary HCC.

Incidence and relative risk of metachronous second primary cancers for 16 cancer sites, Osaka, Japan, 2000-2015: Population-based analysis

Background

An increasing number of cancer survivors have developed multiple primaries. This study aims to describe the incidence and risk patterns of metachronous second primary cancers (SPCs) in Osaka, Japan.

Methods

Data were obtained from the Osaka Cancer Registry, a population‐based database of all cancers diagnosed in Osaka. The study subjects were individuals who were first diagnosed with invasive cancers in 16 major cancer sites during 2000–2014, aged 15–79 years, survived at least 3 months, and were followed up for 10 years. We measured incidence rates, cumulative risks, and standardized incidence ratios (SIRs: with the Osaka general population as the referent) of developing SPCs during 3 months to 10 years after the first diagnosis.

Results

During 2000–2015, among 418,791 cancer survivors, 24,368 (5.8%) developed SPCs within 10 years of first diagnosis. Males had higher incidence rates than females except among young‐onset survivors (aged 15–39 years). 10‐year cumulative risks among survivors aged 70–79 years (the most dominant age group) were 24.0% (male) and 11.8% (female). 10‐year SIRs were 1.38 (95% CI, 1.36–1.40; male) and 1.44 (95% CI, 1.41–1.48; female) with higher estimates among younger survivors in both sexes. Strong bidirectional associations were observed between oral/pharyngeal, esophageal, and laryngeal cancers. Survivors of any smoking‐related cancers had elevated SIRs of developing smoking‐related SPCs. Similar results were observed for alcohol‐related cancers.

Conclusions

Cancer survivors are at excess risk of developing SPCs compared to the general population. Continued surveillance is warranted to inform survivorship care through risk‐based long‐term care planning and lifestyle‐changing efforts to prevent new cancers.

Dysplastic nevus syndrome and pancreatic cancer: A case report

Multiple primary cancers may occur in the same patient, with a prevalence that follows an ascendant trend. Their development is dictated by a complex interplay between a variety of factors, both patient-dependent and external. The case of a 38-year-old female patient diagnosed and treated for pancreatic cancer (PC) is presented in whom the digital dermoscopic monitoring of melanocytic nevi revealed a marked change of two nevi that acquired rapidly highly atypical features. They were surgically excised and the histopathological examination revealed two completely excised dysplastic compound nevi. Clinicians should be aware of the strong association between dysplastic nevus syndrome and PC, a malignancy associated with an extremely poor prognosis. Familial atypical multiple mole melanoma syndrome (FAMMM) predisposes to the development of melanoma, pancreatic cancer and other neoplasms. The common genetic background of PC and hereditary melanoma is discussed and the importance of regular skin checkup and screening for PC in these patients is underlined.

Multiple Primary Cancers in Patients Undergoing Tumor-Normal Sequencing Define Novel Associations

BACKGROUND

Cancer survivors are developing more subsequent tumors. We sought to characterize patients with multiple (≥2) primary cancers (MPC) to assess associations and genetic mechanisms.

METHODS

Patients were prospectively consented (01/2013-02/2019) to tumor-normal sequencing via a custom targeted panel (MSK-IMPACT). A subset consented to return of results of ≥76 cancer predisposition genes. International Agency for Research on Cancer (IARC) 2004 rules for defining MPC were applied. Tumor pairs were created to assess relationships between cancers. Age-adjusted, sex-specific, standardized incidence ratios (SIR) for first to second cancer event combinations were calculated using SEER rates, adjusting for confounders and time of ascertainment. Associations were made with germline and somatic variants.

RESULTS

Of 24,241 patients, 4,340 had MPC (18%); 20% were synchronous. Most (80%) had two primaries; however, 4% had ≥4 cancers. SIR analysis found lymphoma-lung, lymphoma-uterine, breast-brain, and melanoma-lung pairs in women and prostate-mesothelioma, prostate-sarcoma, melanoma-stomach, and prostate-brain pairs in men in excess of expected after accounting for synchronous tumors, known inherited cancer syndromes, and environmental exposures. Of 1,580 (36%) patients who received germline results, 324 (21%) had 361 pathogenic/likely pathogenic variants (PV), 159 (44%) in high penetrance genes. Of tumor samples analyzed, 55% exhibited loss of heterozygosity at the germline variant. In those with negative germline findings, melanoma, prostate, and breast cancers were common.

CONCLUSIONS

We identified tumor pairs without known predisposing mutations that merit confirmation and will require novel strategies to elucidate genetic mechanisms of shared susceptibilities.

IMPACT

If verified, patients with MPC with novel phenotypes may benefit from targeted cancer surveillance.

Synchronous multiple primary malignancies of the esophagus, stomach, and jejunum: A case report

BACKGROUND

Treatment of synchronous multiple primary malignancies is quite often very challenging. Herein, we report on a rare case of synchronous multiple primary malignancies in the esophagus, stomach, and jejunum.

CASE SUMMARY

A 50-year-old man who was a heavy drinker and smoker with a poor diet, and had a family history of cancer sought treatment due to dysphagia lasting for 4 mo. He was finally diagnosed with lower esophageal squamous cell carcinoma (pT3N2M0, G2, stage IIIB), gastric angular adenocarcinoma (pT3N2M0, G2-G3, stage IIIA) with greater omental lymph node metastasis, and jejunal stromal tumor (high risk). The high-risk jejunal stromal tumor was found during surgery. In spite of radical resection and adjuvant chemotherapy, lymph node metastasis occurred 21 mo later. The patient responded poorly to additional chemotherapy and refused further examination and therapy. He died of widespread metastases 33 mo after surgery.

CONCLUSION

This case indicates a poor prognosis of synchronous multiple advanced primary malignancies and the importance of comprehensive assessment in the population at high risk for cancer.

Germ Line BAP1 Mutation in Patients with Uveal Melanoma and Renal Cell Carcinoma

Uveal melanoma (UM) and renal cell carcinoma (RCC) can occur sporadically and as a manifestation of BAP1 tumor predisposition syndrome. We aimed to understand the prevalence of germ line BAP1 pathogenic variants in patients with UM and RCC. We reviewed patients managed at Cleveland Clinic between November 2003 and November 2019 who were diagnosed with UM and RCC. Charts were reviewed for demographic and cancer-related characteristics. RCC samples were tested for BAP1 protein expression using immunohistochemical (IHC) staining, and testing for germ line BAP1 pathogenic variants was performed as part of routine clinical care. Thirteen patients were included in the study. The average age at diagnosis of UM was 61.3 years. Seven patients underwent fine-needle aspiration biopsy for prognostic testing of UM (low risk =5, high risk =2). Twelve patients were treated with plaque radiation therapy, and 3 patients developed metastatic disease requiring systemic therapy. The median time to diagnosis of RCC from time of diagnosis of UM was 0 months. RCC samples were available for 7 patients for BAP1 IHC staining (intact =6, loss =1). All patients underwent nephrectomy (total = 3, partial = 8, unknown =2), and 1 received systemic therapy for metastatic RCC. Six patients underwent germ line BAP1 genetic testing. Of these, 1 patient was heterozygous for a pathogenic variant of BAP1 gene: c.1781-1782delGG, p.Gly594Valfs*48. The overall prevalence of germ line BAP1 pathogenic variants in our study was high (1/6; 17%; 95% CI 0-46%). Patients with UM and RCC should be referred for genetic counseling to discuss genetic testing.

Clinical and pathological characteristics of multiple primary malignant neoplasms cases

OBJECTIVES

To investigate the clinical and pathological features of multiple primary malignant neoplasms (MPMNs) cases.

METHODS

The clinical data of 24 105 tumour patients admitted to Jiangsu Cancer Hospital in 2018 were retrospectively reviewed, and 270 patients with MPMNs were selected as the research subjects. Among them, 101 cases of synchronous carcinoma (SC) and 92 cases of metachronous carcinoma (MC) were divided into groups for statistical analysis. Univariate and multivariate cox regression analyses were conducted using SPSS 22.0 software.

RESULTS

Among 24 105 cases, there was a male-to-female ratio of 1.45:1. Compared with MC cases, SC patients have a higher proportion of male cases. Primary neoplasms in gastric cancer, head and neck cancer, oesophageal cancer and colon cancer occupied most cases in male MPMNs, while primary breast cancer ranked first in female MPMNs. In addition, the leading secondary neoplasms were duodenal carcinoma, lung cancer and male MPMNs and lung cancer in female MPMNs. As for SC MPMNs, primary neoplasms were occupied by lung cancer, gastric cancer and oesophageal cancer, while the secondary neoplasms were mostly consisted of oesophageal cancer and lung cancer. Finally, the MC MPMNs were mostly consisted of breast cancer and gastric cancer as primary neoplasms, while lung cancer and oesophageal cancer as secondary neoplasms.

CONCLUSIONS

Screening for primary cancer should be strengthened over the age of 50 years for male patients with gastric cancer or female patients with breast cancer to reduce or monitor the occurrence of MPMNs.

LAPOROSCOPIC PELVIC EXENTERATION FOR TREATMENT OF PRIMARY MULTIPLE CANCER. CASE REPORT

This clinical case represents the experience of surgical treatment of a patient with multiple primary metachronous cancer: 1. Sigmoid cancer рТ4NxM0. Resection of sigmoid colon (16.12.2013). Three courses of adjuvant chemotherapy (XELOX). Recurrence (2015). Laparotomy, Colproctectomy with D3 paraaortic lymph dissection. Ileostomy (2015). One course of chemotherapy (XELOX). 2. Upper tract urothelial carcinoma (right ureter) pT2N0M0R0. Right nephroureterectomy with the resection of the bladder and right testicular cord, cystostomy (19.02.2015). Recurrence. Nephrostomy drainage of the left kidney. Adhesive disease. Rectovesical fistula. Taking into account the history and comorbid status of the patient, it was decided to perform laparoscopic supralevator pelvic exenteration, ureterectomy on the left. The duration of the operation was 280 minutes, intraoperative blood loss was 200 ml. The period of stay in intensive care is 24 hours, the patient was discharged on the 7th day after the operation, the resection margin was negative (R0). After 12 months, there is no data for the disease progressed.

The Pattern of Second Primary Tumours in Postmenopausal Women with Prior Breast Cancer in Western Romania: A Retrospective, Single-Institution Study

With improved survival, more patients with prior breast cancer are at risk of having a second primary cancer diagnosed. The pattern and impact of second primary cancers following breast cancer is important for overall breast cancer therapeutic management. Our study is a first analysis of the trend of second primary tumours over time in terms of incidence, sites with significantly elevated risks and correlation with stage, molecular subtype and therapeutic strategies conducted in Eastern Europe in postmenopausal women with breast cancer. Patients and methods: Our study population included 28 patients with prior breast cancer (BC) and second primary tumours, which were diagnosed and treated in our Institution between 2004 and 2017. The criteria for selection were based on the completeness of the documentation of the first treatment for breast cancer, stage of disease, molecular subtype, the site of origin of the second tumours and the survival data. Results: An increased risk of second primary cancer was associated with the 51–60 years age group (53.6%), with the greater prevalence in patients living in urban environments (82.1%). The use of chemotherapy increased the risk of the occurrence of gynecological second malignancies (75%). Our study is a first analysis of the trend of second primary tumours over time in terms of identifying sites with significantly elevated risks and correlation with therapeutic strategies conducted in Eastern Europe in postmenopausal women with breast cancer. Conclusions: Our study is a first analysis of the trend of second primary tumours over time in terms of correlation with luminal subtype and stage at diagnosis of primary cancer sites with significantly elevated risks and correlation with therapeutic strategies in postmenopausal women with breast cancer conducted in Eastern Europe. The reported time from primary to second primary malignancy onset, with a significantly higher rate for postmenopausal breast cancer patients, was less than one year (50%). With the advances and wider availability of genetic testing (e.g., gene panels), patients diagnosed with multiple primaries should be increasingly investigated for an underlying cancer predisposition. Postmenopausal women with breast cancer may benefit from increased surveillance and advice to avoid second malignancies.

Clinicopathologic Characteristics and Survival of Patients With Double Primary Malignancies: Breast and Colorectal Cancer

Purpose

This study aimed to investigate the clinicopathologic features and survival in patients with both breast cancer (BrC) and colorectal cancer (CRC).

Methods

Between 1996 and 2019, patients who were diagnosed with both BrC and CRC were evaluated retrospectively. Patients with distant metastasis, palliative resection, and previous cancer histories except for BrCs or CRCs were excluded. Altogether, 105 patients were divided into the B=C group (n=21), B-first group (n=40), and C-first group (n=44) according to the definition of synchronous and metachronous cancers. The clinicopathologic features and overall survival were evaluated.

Results

TNM stages and histologic types were comparable among the 3 groups (P=0.434). The interval of diagnosis was 67.1±40.4 and 59.3±47.2 months in the B- and C-first groups, respectively. The incidence of adjuvant chemotherapy in the B-first group was 57.5%, which was higher than the B=C and C-first groups (P<0.001). The estrogen receptor, progesterone receptor, Ki-67, and HER-2 molecular markers were not significantly different among the groups. The overall survival of the B-first group showed lower survival rates than the C-first group (P=0.039). In the logistic regression, HER-2 status (hazard ratio [HR], 11.9; P=0.032) and lymph node metastasis of CRC (HR, 5.8; P=0.036) were prognostic factors affecting overall survival.

Conclusion

B-first group had poorer survival outcomes than the C-first group in patients with the metachronous BrC and CRC. HER2 positivity and CRC lymph node metastasis may be prognostic factors that affect overall survival in these patients. The findings support that a colorectal cancer screening program should be included during BrC surveillance.

Impact of Relative Dose Intensity of FOLFOX Adjuvant Chemotherapy on Risk of Death Among Stage III Colon Cancer Patients

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines have recommended tailored chemotherapy for stage III high-risk (T4 and/or N2) and low-risk (T1-T3 and N1) colon cancer since 2018. Studies have investigated the effect of relative dose intensity (RDI) of FOLFOX on stage III colon cancer survival, however, none has performed a stratified analysis by risk profiles. This study aims to identify the FOLFOX optimal RDI for high-risk and low-risk stage III colon cancer patients.

METHODS

Data on 407 eligible patients, diagnosed with stage III colon cancer in 2011 who received FOLFOX, were collected by 8 population-based cancer registries. Multivariable Cox model and Fine-Gray competing risks model were employed to explore Optimal RDI defined as the lowest RDI administered without significant differences in either overall or cause-specific death.

RESULTS

Among the 168 high-risk patients, the optimal RDI cut-off was 70% (HR = 1.59 with 95% CI: 0.69-3.66 in overall mortality; HR = 1.24 with 95% CI: 0.42-3.64 in cause-specific mortality when RDI < 70% vs. RDI ≥ 70%). Among the 239 low-risk patients, none of the evaluated cut-offs were associated with significant differences in risk of death between comparison groups. The lowest assessed RDI was 45%, HR = 0.80; 95% CI: 0.24 to 2.73 for overall mortality and HR = 0.53; 95% CI: 0.06 to 4.95 for cause-specific mortality, when RDI <45% versus RDI ≥45%.

CONCLUSIONS

There is no significant harm on the risk of death when reducing RDI by <30% for high-risk patients. For the low-risk patients, we found that RDI as low as 45% did not significantly affect the risk of death.

Spleen angiosarcoma: a world review

Introduction: Spleen angiosarcoma (SA) is a rare malignant neoplasm that arises from the splenic vascular endothelium, with only around 300 cases reported to date. Due to a limited number of reported cases, there is a paucity of data and a lack of understanding of its presentation, diagnosis, and management. In this study, we aim to provide a comprehensive review of SA.Areas covered: On 27 February 2021, a literature search was done in PubMed and Embase database. The search yielded 122 articles involving 205 patients. The focus was on patient demographics, risk factors, clinical presentations, investigation results, preliminary diagnoses, therapies provided, and patient outcomes. These factors were analyzed to identify possible risk factors, diagnostic modalities, and therapeutic principles that were not mentioned before.Expert opinion: The clinical presentation or investigation results of patients with SA are often nonspecific. Hence, they may not be sufficient to clinch the diagnosis of SA if used alone. The authors recommend a triple assessment of clinical examination, imaging findings, and pathology to diagnose SA with high accuracy. Splenectomy should be the mainstay of management, with chemotherapy and radiotherapy considered as adjuncts, especially in the presence of metastases.

Excess risk of subsequent malignant neoplasms in adolescent and young adult cancer survivors: Results from the first Italian population-based cohort

BACKGROUND

Evidence about late effects in adolescent and young adult (AYA) cancer survivors is scarce. This study assessed the risk of subsequent malignant neoplasms (SMNs) to identify the most common SMNs to be considered in follow-up care.

METHODS

Population-based cancer registries retrospectively identified first primary tumors (between 1976 and 2013) and SMNs in AYAs (15-39 years old at their cancer diagnosis). AYA cancer survivors were those alive at least 5 years after their first cancer diagnosis. The excess risk of SMNs was measured as standardized incidence ratios (SIRs) and absolute excess risk together with the cumulative incidence of SMNs.

RESULTS

The cohort included 67,692 AYA cancer survivors. The excess risk of developing any SMN (SIR, 1.6; 95% confidence interval, 1.5-1.7) was 60%. The excess risk of SMNs was significantly high for survivors of lymphomas; cancers of the breast, thyroid, female genital tract, digestive organs, gonads, and urinary tract; and melanomas. The cumulative incidence of all SMNs in AYA cancer survivors within 25 years of their first cancer diagnosis was approximately 10%. Subsequent tumors contributing to approximately 60% of all SMNs were breast cancer, colorectal cancer, corpus uteri cancer, and ovarian cancer in females and colorectal cancer, bladder cancer, prostate cancer, lung cancer, and lymphomas in males.

CONCLUSIONS

These results highlight the need to personalize follow-up strategies for AYA cancer survivors.

Risks and cancer associations of metachronous and synchronous multiple primary cancers: a 25-year retrospective study

Background

The situation of patients developing multiple primary cancers is becoming more frequent and graver. This study investigated the risks of developing second primary cancers that are related to first primary cancers, and the interval times of synchronous and metachronous multiple primary cancers.

Patients and methods

Retrospective data were retrieved from 109,054 patients aged ≥18 who were diagnosed with a first solid cancer and registered at Siriraj Cancer Center between 1991 and 2015. A two-month period between first- and second- primary cancers was used to differentiate metachronous and synchronous multiple primary cancers. The combinations of subsequent cancers and relative risks (RRs) of having multiple primary cancers versus having single primary cancer for the top-ten first and second primary cancers were examined. The RR was adjusted for age of the first primary cancer. A survival analysis of the time to second-primary-cancer development was performed.

Results

Multiple primary cancers were found in 1785 (1.63%) patients. Most (70.87%) second primary cancers occurred after 2 months of first breast, skin, colorectal, lung, head and neck, liver, male genital cancer–prostate, thyroid, and female genital cancer–non-uterine cancers, resulting in those cancers being classified as metachronous multiple primary cancer. After adjustment for age at first diagnosis, head and neck cancers had the highest metachronous association with second esophageal cancers (RR, 25.06; 95% CI, 13.41–50.77). Prostate cancer and second colorectal cancer also demonstrated a high metachronous association (RR, 2.00; 95% CI, 1.25–3.05). A strong synchronous association was found between uterine and ovarian cancers (RR, 27.77; 95% CI, 17.97–43.63). The median time from the first uterine cancer to second-cancer development was 55 days.

Conclusions

The top-ten most frequent multiple primary cancers were the following: breast; liver; head and neck; colorectal; male genital cancer–prostate; skin; female genital cancer–uterine; thyroid; lung; and female genital cancer–non-uterine. Second primary cancers showed specific associations that depended on the first primary cancer. Physicians should be cognizant of the most common combinations and the interval times of metachronous and synchronous multiple primary cancers.

Diagnosis and Individualized Treatment of Three Primary Malignant Tumors: A Case Report

Continuous optimization of diagnosis and treatment of malignant tumors has led to significantly prolonged survival in cancer patients. Despite the recent increase in the incidence of multiple primary malignant tumors (MPMT), it remains rare in clinical practice; therefore, normative guidance on its etiology, diagnosis, and treatment is insufficient. Here we describe the case of a patient with three primary malignant tumors, namely breast cancer, diffuse astrocytoma, and hepatic malignant perivascular epithelioid cell tumors (PEComa) and discuss relevant literature.

Multiple Primary Tumors Originating From the Prostate and Colorectum A Clinical-Pathological and Therapeutic Challenge

Considering that the incidence of colorectal (CRC) and prostatic cancer (PC) increases with age, metachronous and synchronous tumors can often affect the same patient. Despite the importance of this subject for the diagnosis and management of oncologic patients, in medical literature the data are scarce. The aim of the study was to evaluate the incidence and the characteristics of double/multiple primary malignant tumors (D/MPMTs) with colorectal and prostatic origin, in patients admitted to a reference hospital in West Romania. A 4-year retrospective observational study (2016–2019) was conducted by analyzing the medical records of all patients admitted in the hospital. Demographic and clinical data, as well as tumor-related parameters, were extracted. We identified 413 consecutive hospitalized patients with PC, and 21 (5%) of them also had a primary CRC. At the time of diagnosis, the mean age of the patients with PC was 71.2 ± 6 years, and 71.8 ± 10 years for patients with CRC. Synchronous PC and CRC tumors were identified in 3/21 cases and metachronous tumors in 18/21 cases. Prostate cancer was the first tumor to be diagnosed in 13/18 cases and CRC in 5/18 cases. The most frequent subtype of PC was acinar adenocarcinoma (90%) and for CRC cases, conventional adenocarcinoma (90%). Prostate and colorectal cancers tend to co-occur in a single patient. The diagnosis of one of these two types of tumors should imply the screening for the other one, because these patients require a multidisciplinary and personalized approach.

Secondary peripheral T-cell lymphoma and acute myeloid leukemia after Burkitt lymphoma treatment: A case report

BACKGROUND

Multiple primary cancer refers to more than one synchronous or sequential cancer in the same individual. Multiple primary cancer always presents as solid cancer or acute myeloid leukemia (AML) secondary to lymphoma. Here, we report a rare case of secondary peripheral T-cell lymphoma and AML after Burkitt lymphoma treatment.

CASE SUMMARY

A 54-year-old female patient was admitted to our hospital complaining of edema on her left lower limb. Physical examination revealed multiple superficial lymphadenectasis on her neck and pelvis. Color ultrasonography examination showed multiple uterine fibroids and a solid mass at the lower left side of the abdomen. Pathological biopsy revealed Burkitt lymphoma. After three hyper-CVAD (A + B) regimens, she achieved complete remission. Two years later, lymphadenectasis reoccurred. A relevant biopsy confirmed the diagnosis of peripheral T-cell lymphoma, which was accompanied by gastrointestinal invasion and hemocytopenia. Meanwhile, bone marrow examination revealed AML. On the second day of scheduled treatment, she developed gastrointestinal bleeding, peptic ulcers, and hemorrhagic shock and was critically ill. She was then discharged from the hospital due to financial concerns.

CONCLUSION

This is the first report of secondary peripheral T-cell lymphoma and AML after Burkitt lymphoma treatment with heterochronous and synchronal multiple primary cancers.

Standardized Incidence Rate, Risk and Survival Outcomes of Second Primary Malignancy Among Renal Cell Carcinoma Survivors: A Nested Case-Control Study

Purpose

Second primary malignancy (SPM) is challenging for treatment and long-term survival. We sought to investigate the standardized incidence rate (SIR), risk factors, and survival outcomes for SPM after renal cell carcinoma (RCC) treatment.

Method

A nested case-control study was designed, we identified all T1-4N0-1M0 RCC patients diagnosed between 2004 and 2015 in the Surveillance, Epidemiology, and End Results database and followed them for SPM diagnosis for up to 13 years. Patients with SPM diagnosis ≥6 months after treatment of primary T1-4N0-1M0 RCC were identified as the case cohort and SPM-free patients were the control cohort. SIRs and the excess risk were calculated. A competing risks and Cox model were used to evaluate the risk factors of SPM and overall survival (OS).

Results

A cohort of 6,204 RCC patients with SPM were matched with a control group of 31,020 RCC patients without SPM. The median time-to-SPM interval was 54.5 months in RCC patients with SPM diagnosis. Besides, an SPM of T3/4 or/and M1 stage diagnosis was positively associated with a longer time-to-SPM interval. SIR of SPM increased by follow-up time and decreased with age at diagnosis (P_{for all <}0.001). SPM in the kidney had the highest SIR (54.6, P <0.001) among all SPMs. Prostate cancer (29.8%) in males and breast cancer (23.5%) in females were the most common SPM. Older age, black ethnicity, male sex, higher family income, papillary RCC, and lower TNM stage were significant risk factors for SPM diagnosis. The proportion of deaths from SPM exceeds that of deaths from RCC 3 years after the first RCC treatment. Patients with SPM and early time-to-SPM interval shortens the OS compared with SPM-free patients. The 5-year OS was 85.9% and 58.9% from the first RCC and the SPM diagnosis, respectively. Besides, patients with low-grade/early-stage SPM could benefit from aggressive surgical treatment for solid tumors.

Conclusions

Collectively, our study described the epidemiological characteristics of SPM among RCC survivors and identified the independent predictors of the SPM diagnosis and its survival outcomes. This study highlights the importance of patient education and follow-up after the surgery for RCC.

Preliminary results of targeted sequencing of BRCA1 and BRCA2 in a cohort of breast cancer families: New insight into pathogenic variants in patients and at‑risk relatives

Breast cancer (BC) is the most commonly diagnosed cancer worldwide and a major health concern in Egypt. There is a known association between pathogenic variants identified in breast cancer susceptibility gene (BRCA)1 and 2 and the risk of developing BC. However, the number of studies investigating mutations in BRCA1 and BRCA2 in Egypt remains limited. Thus, the aim of the present study was to investigate the frequency of BRCA1 and BRCA2 variants in patients with BC and their relatives. For this purpose, 11 families (11 patients and 16 relatives) were included in the present study. BRCA1 and BRCA2 variants were investigated using the Ion S5 next‑generation sequencer. It was found that pathogenic variants were more frequent in patients with familial BC (FBC) than in those with sporadic BC, with 71% of variants in BRCA2, including the first reported identification of c.9089del, c.5583_5584dup, c.8243G>A and c.7976G>A pathogenic variants in Egyptian patients with BC. Pathogenic variants in relatives were confined to FBC c.1278delA, c.1960_1961del, and c.1224delT, with a higher incidence of variants of uncertain significance (VUS), such as BRCA2 intron 2 c.68‑16delT. Of note, two cold spot benign variants, c.3113A>G and c.4837A>G, were repeatedly found (67%) in patients and relatives. In conclusion, to the best of our knowledge, novel pathogenic variants and VUS in Egyptian patients with BC and their high‑risk relatives were identified for the first time in the present study. These findings should be integrated with other genomic data concerning Egyptian families and carefully interpreted during genetic counseling.

Cell membrane-camouflaged liposomes for tumor cell-selective glycans engineering and imaging in vivo

The dynamic change of cell-surface glycans is involved in diverse biological and pathological events such as oncogenesis and metastasis. Despite tremendous efforts, it remains a great challenge to selectively distinguish and label glycans of different cancer cells or cancer subtypes. Inspired by biomimetic cell membrane-coating technology, herein, we construct pH-responsive azidosugar liposomes camouflaged with natural cancer-cell membrane for tumor cell-selective glycan engineering. With cancer cell-membrane camouflage, the biomimetic liposomes can prevent protein corona formation and evade phagocytosis of macrophages, facilitating metabolic glycans labeling in vivo. More importantly, due to multiple membrane receptors, the biomimetic liposomes have prominent cell selectivity to homotypic cancer cells, showing higher glycan-labeling efficacy than a single-ligand targeting strategy. Further in vitro and in vivo experiments indicate that cancer cell membrane-camouflaged azidosugar liposomes not only realize cell-selective glycan imaging of different cancer cells and triple-negative breast cancer subtypes but also do well in labeling metastatic tumors. Meanwhile, the strategy is also applicable to the use of tumor tissue-derived cell membranes, which shows the prospect for individual diagnosis and treatment. This work may pave a way for efficient cancer cell-selective engineering and visualization of glycans in vivo.

Prevalence of cancer susceptibility variants in patients with multiple Lynch syndrome related cancers

Along with early-onset cancers, multiple primary cancers (MPCs) are likely resulting from increased genetic susceptibility; however, the associated predisposition genes or prevalence of the pathogenic variants genes in MPC patients are often unknown. We screened 71 patients with MPC of the stomach, colorectal, and endometrium, sequencing 65 cancer predisposition genes. A subset of 19 patients with early-onset MPC of stomach and colorectum were further evaluated for variants in cancer related genes using both normal and tumor whole exome sequencing. Among 71 patients with MPCs, variants classified to be pathogenic were observed in 15 (21.1%) patients and affected Lynch Syndrome (LS) genes: MLH1 (n = 10), MSH6 (n = 2), PMS2 (n = 2), and MSH2 (n = 1). All carriers had tumors with high microsatellite instability and 13 of them (86.7%) were early-onset, consistent with LS. In 19 patients with early-onset MPCs, loss of function (LoF) variants in RECQL5 were more prevalent in non-LS MPC than in matched sporadic cancer patients (OR = 31.6, 2.73–1700.6, p = 0.001). Additionally, there were high-confidence LoF variants at FANCG and CASP8 in two patients accompanied by somatic loss of heterozygosity in tumor, respectively. The results suggest that genetic screening should be considered for synchronous cancers and metachronous MPCs of the LS tumor spectrum, particularly in early-onset. Susceptibility variants in non-LS genes for MPC patients may exist, but evidence for their role is more elusive than for LS patients.

Case Report: Triple Primary Malignant Tumors of the Esophagus, Stomach, and Colon in a Patient With Genetic Analysis

The incidence of multiple primary malignant tumors (MPMTs) has increased greatly with the progress of tumor diagnosis and therapy technology. However, triple primary cancer is still very rare, and its genetic change is not clear yet. This case report described a 70-year-old Chinese male patient with triple primary cancers of the esophagus, stomach and right-sided colon. Pathological examination confirmed that each malignant tumor developed independently. Next-generation sequencing (NGS) using a 599-gene panel revealed five TP53 mutations in three tumor tissues. These variations might contribute to development of the triple primary malignant tumors in the patient. The patient underwent laparoscopic feeding jejunostomy and postoperative radiotherapy for synchronous esophageal and gastric carcinomas. Then, he underwent laparoscopic-assisted resection of right-sided colonic cancer and lysis of abdominal adhesions. By the time of submitting this manuscript, the patient had been well and no sign of recurrence or metastasis had been observed. To the best of our knowledge, this case is the first one to clarify the genetic abnormalities of triple primary cancers of esophagus, stomach and colon in a Chinese patient. It may contribute to understanding the molecular pathogenesis of multiple primary digestive malignancies and providing valuable treatment strategies for the similar patients in the future.

Sonapatha (Oroxylum indicum) mediates cytotoxicity in cultured HeLa cells by inducing apoptosis and suppressing NF-κB, COX-2, RASSF7 and NRF2

Oroxylum indicum (Sonapatha) is traditionally used to cure several human ailments. Therefore, the cell killing effect of chloroform, ethanol, and water extracts of Sonapatha was studied in cultured HeLa cells treated with 0-100 µg/mL of these extracts/doxorubicin by MTT assay. Since ethanol extract was most cytotoxic its effect was further investigated by clonogenic, apoptosis, necrosis, and lactate dehydrogenase assays. The mechanism of cytotoxicity of Sonapatha was determined at the molecular level by estimation of caspase 8 and 3 activities and Western blot analysis of NF-κB, COX-2, Nrf2, and RASSF7 which are overexpressed in neoplastic cells. HeLa cells treated with Sonapatha extract exhibited a concentration and time-dependent rise in the cytotoxicity as indicated by the MTT assay. Ethanol extract of Sonapatha (0, 20, 40, and 80 μg/mL) reduced clonogenicity, increased DNA fragmentation, apoptotic and necrotic indices, lactate dehydrogenase release, caspase 8 and 3 activities and inhibited the overexpression of NF-κB, COX-2, Nrf2, and RASSF7 in HeLa cells concentration-dependently.

A Retrospective 5-Year Single Center Study Highlighting the Risk of Cancer Predisposition in Adolescents and Young Adults

The knowledge of inherited cancer susceptibility opens a new field of cancer medicine. We conducted a retrospective single-center cohort study. Data of AYA cancer patients registered between January 2014 and December 2018 were analyzed. The median age at cancer diagnosis of 704 patients (343 males, 361 females) was 32 years (range, 15-39 years), median follow-up was 181 days (range, 1-1975 days). Solid tumors were diagnosed in 575 (81.7%) patients, hematologic malignancies in 129 (18.3%) patients. Multiple primary cancers were reported in 36 (5.1%) patients. Malignancies that may be indicators of inherited cancer susceptibility were diagnosed in 2.6% of patients with cancers of the endocrine system, in 73% of cancers of the gastrointestinal system, in 88% of tumors of the central nervous system, in 92% of cancers of the urinary tract, and in 59% of head and neck tumors. In addition, all patients with breast cancer, sarcoma, and peripheral nerve sheath tumor were in need of genetic counselling. In sum, at least 181 of 704 (25.7%) AYA cancer patients presented with malignancies suspicious of harboring pathogenic germline variants. Evaluation of AYA cancer patients for hereditary cancer predisposition needs to be integrated into daily practice.

A clinical case of multiple primary cancers in a carrier of rare SDK2 and NOTCH2 gene mutations

Background

Genetic predisposition is one of the risk factors for the development of multiple primary cancers (MPCs), the frequency of which increases and ranges from 2 to 17%. This study describes a combination of rare mutations, rs746551843 in the NOTCH2 gene and rs144933006 in the SDK2 gene, in a woman with breast cancer and leiomyosarcoma without a clearly burdened family history.

Case presentation

A 55-year-old Caucasian woman received complex treatment on the basis of the National Medical Research Centre for Oncology for left breast cancer and leiomyosarcoma of soft tissues of the left thigh. The patient was referred for consultation with a geneticist. Among direct relatives, a maternal aunt with a history of kidney cancer was not a carrier of the studied single nucleotide polymorphisms (SNPs). The healthy son of the patient inherited both mutations.

Conclusion

Thus, perhaps in the described case, there is a synergistic effect of two alleles of moderate and low penetrance, which led to the phenotype of multiple primary cancers.

The Common Thread: A Case of Synchronous Lung Cancers and a Germline CHEK2 Mutation

Patients with one form of cancer are at increased risk for another, and this is true for lung cancer, where synchronous primary lung cancers are an increasing multifaceted challenge.^1,2 Here, we present the case of a middle age woman who was found to have bilateral lung masses. Biopsy and subsequent testing revealed unique synchronous lung adenocarcinomas, each with unique genetic signatures. Despite having two unique tumors, she was found to have CHEK2 mutations in both tumors and in germline testing. Because of this extensive testing that showed unique tumors, she was ultimately diagnosed with stage IIIb and IA2 lung cancers, and this changed her treatment options. Consideration of unique primary tumors leads to thorough diagnostics, which changed this patient's diagnosis, prognosis, and treatment. We hope this case raises awareness for multiple primary tumors, as well as CHEK2 as an important oncogene.

A Case Series of Multiple Primary Malignancies Among Patients With Advanced Melanoma

Multiple primary malignancies (MPM) are described as two or more primary tumors within the same individual. The impact of MPM on the tumor microenvironment among patients with melanoma is poorly understood. Here, we describe this unique group of patients who have both advanced melanoma and at least one other primary malignancy and report their survival outcomes. In this study, patients with advanced melanoma and a second primary malignancy were identified. Medical records were reviewed for cancer treatment history. Kaplan-Meier methods were used to derive survival curves and estimate overall survival (OS), and log-rank tests were used to compare OS. Among 11 MPM patients, the most common non-melanoma cancers were breast (n = 3) and thyroid (n = 3). Median OS was 153.5 months for all patients. Median OS for synchronous MPM (sMPM) and metachronous MPM (mMPM) were 83.1 and 196.7 months, respectively (p= 0.10). Median OS was not reached when melanoma was diagnosed first, and 153.5 months when diagnosed second (p= 0.45). For six patients receiving immunotherapy for melanoma, there was a 100% complete response rate. In conclusion, patients with melanoma are at risk of secondary malignancies, including breast and thyroid cancer. The timing of secondary malignancies may impact prognosis. Further study of the impact of immunotherapy on MPM is warranted.

Metachronous prostate and colon adenocarcinomas

Multiple primaries in patients with prostate cancer are uncommon. We report a case of prostate adenocarcinoma who did not receive any form of treatment, diagnosed 7 months later with colon adenocarcinoma. The patient underwent right extended hemicolectomy and recovered well. He is planned to receive adjuvant chemotherapy and hormonal therapy. Management of such cases can present a dilemma and multiple factors must be taken into consideration, particularly when the first primary tumour is still active.

Comparison of radiomic feature aggregation methods for patients with multiple tumors

Radiomic feature analysis has been shown to be effective at analyzing diagnostic images to model cancer outcomes. It has not yet been established how to best combine radiomic features in cancer patients with multifocal tumors. As the number of patients with multifocal metastatic cancer continues to rise, there is a need for improving personalized patient-level prognosis to better inform treatment. We compared six mathematical methods of combining radiomic features of 3,596 tumors in 831 patients with multiple brain metastases and evaluated the performance of these aggregation methods using three survival models: a standard Cox proportional hazards model, a Cox proportional hazards model with LASSO regression, and a random survival forest. Across all three survival models, the weighted average of the largest three metastases had the highest concordance index (95% confidence interval) of 0.627 (0.595–0.661) for the Cox proportional hazards model, 0.628 (0.591–0.666) for the Cox proportional hazards model with LASSO regression, and 0.652 (0.565–0.727) for the random survival forest model. This finding was consistent when evaluating patients with different numbers of brain metastases and different tumor volumes. Radiomic features can be effectively combined to estimate patient-level outcomes in patients with multifocal brain metastases. Future studies are needed to confirm that the volume-weighted average of the largest three tumors is an effective method for combining radiomic features across other imaging modalities and tumor types.

Increased risk of breast cancer-specific mortality among cancer survivors who developed breast cancer as a second malignancy

Background

Cancer survivors who develop breast cancer as a second malignancy (BCa-2) are common. Yet, little is known about the prognosis of BCa-2 compared to first primary breast cancer (BCa-1).

Methods

Using the Surveillance, Epidemiology, and End Results database, we conducted a population-based cohort study including 883,881 patients with BCa-1 and 36,313 patients with BCa-2 during 1990–2015. Compared with patients with BCa-1, we calculated hazard ratios (HRs) of breast cancer-specific mortality among patients with BCa-2, using multivariable Cox regression.

Results

During the follow-up (median 5.5 years), 114,964 and 3829 breast cancer-specific deaths were identified among BCa-1 and BCa-2 patients, respectively. Patients with BCa-2 had more favorable tumor characteristics and received less intensive treatment e.g., surgery and chemo−/radio-therapy, compared to patients with BCa-1. When adjusting for demographic factors, patients with BCa-2 were at similar risk of breast cancer-specific mortality (HR 1.00, 95% CI 0.97–1.03) compared to patients with BCa-1. However, when additionally controlling for tumor characteristics and treatment modes, BCa-2 patients were at an increased risk of breast cancer-specific mortality (HR 1.11, 95% CI 1.08–1.15). The risk elevation was particularly greater when the first malignancy was lung, bladder, ovarian or blood malignancy (HRs 1.16–1.85), or when the first malignancy was treated with chemotherapy and radiotherapy (HR 1.44, 95% CI 1.28–1.63).

Conclusions

Overall, patients with BCa-2 have worse breast cancer-specific survival, compared with their BCa-1 counterparts, although the risk elevation is mild. High-risk subgroups based on first malignancy’s characteristics may be considered for active clinical management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08132-9.

Unexplained anemia: A case report of metachronous adenocarcinoma arising in the transverse colon following right hemicolectomy for a primary cecal carcinoma

Metachronous colonic carcinomas arise from months to years after the resection of the first or index primary colorectal cancer. They are not a result of tumor recurrence or metastasis and likely arise as a result of the field cancerization effect. This report presents the case of a 63-year-old male patient without family history of a colorectal cancer but had an index primary adenocarcinoma of the cecum (stage IIIC) five years ago that was treated with surgical resection and adjuvant radiotherapy and chemotherapy. He presented with fatigue and anemia of 6-month duration secondary to recurrent melena, and the specific cause of which remained obscure despite intensive diagnostic workup. Recurrence of a malignancy at the previous anastomosis site was ruled out. The patient continued to have recurrent and intermittent gastrointestinal bleeding until a nuclear red blood cell scan detected a bleeding spot in the epigastric region, which actually turned out to be a second primary carcinoma (stage I) arising from an adenoma in the transverse colon. The patient underwent a left colectomy with ileosigmoid anastomosis formation. During a two-month postoperative follow-up, the patient did not experience any episode of melena or anemia. Even though metachronous colon cancers rarely present with a recurrent and intermittent gastrointestinal bleeding with melena, an aggressive workup must be aimed at ruling out a second independent malignancy in patients who are in remission after an index primary colorectal cancer resection through hemicolectomy. Any neoteric lesion found on colonoscopy in such cases should be dealt with a higher degree of suspicion. Therefore, the need for surveillance colonoscopy as recommended by the National Comprehensive Cancer Network guidelines is imperative and should be practiced in resource-limited countries.

Synchronous primary malignancy of colon cancer and mantle cell lymphoma: A case report

Multiple primary malignancies in a single patient are relatively rare; however, the frequency of this has increased significantly in recent decades. Here, we retrospectively reported an unusual case of a 70-year-old man who was admitted to the hospital with mantle cell lymphoma (MCL) and colon cancer and aimed to explore measures to reduce missed diagnosis. Based on the data, the investigation of the related literatures, colonoscopy examination, and abdominal computed tomography (CT) scan were conducted for the detection of colon cancer. Following this, a precise diagnosis of MCL was confirmed by immunohistochemistry and bone marrow biopsy, which were performed to analyze the clinical characteristics and essentials for the diagnosis and differential of the disease. The results of colonoscopy showed that the patient had colon cancer, while the abdominal CT scan demonstrated colon cancer accompanied by multiple lymphadenopathy throughout the entire body. Besides, the results of immunohistochemistry confirmed that the patient suffered from MCL. The bone marrow biopsy revealed the active hematopoietic tissue hyperplasia but no tumor issue involvement in the bone marrow. In conclusion, our study combined the analysis and summary of the diagnosis and treatment of the colon cancer with MCL to provide clinical guidance for the rare multiple primary malignancy.

[Multiple primary synchronous colon cancers in patients with advance gastric cancer]

Two patients with locally advanced gastric cancer are reported. Both patients underwent colonoscopy in preoperative period. Preoperative examination revealed synchronous colorectal cancer. Preoperative colonoscopy in patients with gastric cancer ensured timely diagnosis of synchronous colorectal cancer and adequate minimally invasive treatment with favorable results.

Significant current epidemiological trend: Haematological malignancies as subsequent primary tumours in cancer patients

BACKGROUND

Numbers of patients who develop subsequent primary tumours have markedly increased recently. This study aimed to carry out a comprehensive analysis documenting the risk of incidence of subsequent haematological malignancies.

METHODS

The Czech National Cancer Registry was the main data source, containing records of 126,822 haematological malignancies diagnosed in the period 1977-2016. Subsequent haematological malignancies were identified according to IACR rules. Joinpoint regression was employed to assess the time trends. The risk of development of subsequent haematological malignancy was evaluated by the standardised incidence ratio. The Kaplan-Meier curves were used to assess the differences in survival.

RESULTS

Age-standardised incidence of subsequent haematological malignancies increased from 0.5 in 1977 to 9.1 in 2016. In 1992, there was a significant change in the trend: a sharp increase by 7.7 % annually was revealed thereafter. The risk of development of a haematological malignancy was approximately 1.5 times higher in persons with history of any cancer than in the general Czech population. Patients with haematological malignancies - mainly myelodysplastic syndromes, polycythaemia vera and non-Hodgkin lymphoma - were shown to be at the highest risk of developing a subsequent haematological malignancy. While the median survival following a first haematological malignancy was 2.3 years, it was only 1.1 years for subsequent haematological malignancies (p < 0.001).

CONCLUSIONS

Our study identified the highest-risk diagnoses in terms of development of subsequent haematological malignancy. The results might be useful to set up correctly follow-up procedures from which cancer patients could benefit.

A Patient with an Ileocecal MiNEN and a Synchronous Squamous Non-Small-Cell Lung Cancer: Case Report and Review of the Literature

Mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs) are rare tumors composed of two different histological components, one of which is of a neuroendocrine origin. Given its suggested underdiagnosis and consequent low prevalence, no clear diagnostic and treatment guidelines are available, and treatment usually follows regimens similar to that of the most aggressive component. On the other hand, multiple primary tumors (MPTs) are also rare neoplastic entities that usually confer a challenge regarding treatment options, for a regimen that comprises both the primary and the synchronous/metachronous malignancy should be used. Here, we discuss the challenging diagnostic and therapeutic management of a patient with an ileocecal MiNEN that presented along with a synchronous squamous non-small-cell lung cancer (SQ-NSCLC). The patient presented with intestinal obstruction symptoms for which he underwent an emergency resection of the ileocecal MiNEN. An initial CT scan showed an additional lung mass later identified as an SQ-NSCLC after bronchoscopy biopsy analysis. Given the rapid hepatic metastatic progression, palliative platinum-based chemotherapy was initiated, with an adequate response of the local and metastatic lesions of the MiNEN, but suggested platinum resistance and progression of the pulmonary neoplasm. Second-line treatment with pembrolizumab directed for the SQ-NSCLC was initiated; however, it was stopped after immune-mediated toxicities developed. A third-line chemotherapy scheme with carboplatin/gemcitabine was initiated, but central nervous system (CNS) progression developed, with the patient dying 11 months after initial diagnosis.

Lung Cancer Characteristics in the World Trade Center Environmental Health Center

The destruction of the World Trade Center (WTC) towers on 11 September 2001 resulted in acute and chronic dust and fume exposures to community members, including local workers and residents, with well-described aerodigestive adverse health effects. This study aimed to characterize lung cancer in the WTC Environmental Health Center (WTC EHC) focusing on gender and smoking history. WTC EHC patients undergo an initial evaluation that includes WTC exposure information, demographics, and tobacco use. Detailed cancer characteristics are recorded from pathology reports. As of 31 December 2019, 248 WTC EHC patients had a diagnosis of lung cancer. More patients with lung cancer were women (57%) compared to men (43%). Many cases (47% women, 51% men) reported acute dust cloud exposure. Thirty-seven percent of lung cancer cases with available smoking history were never-smokers (≤1 pack-years) and 42% had a ≤5 pack-year history. The median age of cancer diagnosis in never-smoking women was 61 years compared to 66 years in men. Adenocarcinoma was more common in never-smokers compared to ever-smokers (72% vs. 65%) and in women compared to men (70% vs. 65%). We provide an initial description of lung cancers in local community members with documented exposure to the WTC dust and fumes.

Screening is associated with lower mastectomy rates in eastern Switzerland beyond stage effects

Background

A recent study found an influence of organized mammography screening programmes (MSPs) on geographical and temporal variation of mastectomy rates. We aimed to quantify the effect on the example of one of the cantonal programmes in Switzerland.

Methods

We used incidence data for the years 2010–2017 from the cancer registry of Eastern Switzerland. We included women with invasive-non-metastatic breast cancer (BC) in the screening age group 50–69-year-olds in the canton of St.Gallen. We compared mastectomy rates among cancer patients detected through the organised screening programme (MSP) vs. otherwise detected by stage.

Results

MSP-detected patients in St.Gallen presented with lower stages. 95% of MSP-detected had stages I-II vs 76% of Non-MSP-detected. Within all non-metastatic stage, tumour size and nodal status groups, MSP-detected patients had lower mastectomy rates, overall 10% vs 24% in 50–69-year-old non-participants. Their odds of receiving a mastectomy are about half of the Non-MSP-detected (OR = 0.48, p = 0.002).

Conclusions

Our study showed that MSPs have a positive effect on lowering mastectomy rates. Screening participants are significantly less likely to receive a mastectomy compared to non-participants, which must be attributed to additional factors than just lower stages. Lower mastectomy rates lead to a higher quality of life for many patients.

Geospatial analysis of multiple cancers in individuals in the US, 2004-2014

BACKGROUND

There is a projected rapid increase in cancer survivors in the US population, from 15.5 million in 2016 to 26.1 million by 2040. Improvements in treatment and detection have led to increased survival, however, there is now a risk of developing new cancers as a result of environment toxins, behavioral risk factors, genetic predisposition, and late-term effects of radiation and chemotherapeutic treatments. This study takes a geospatial approach to examining the place of occurrence of multiple cancers originating in the population of four screenable cancers-female breast, colorectal, prostate, and cervical cancers-among the US population.

METHODS

During 2004-2014, 6,523,532 primary cancer patients with one of these four screenable cancers were examined, and subsequent primary cancers (multiple cancers of any type) were noted. Individual level analyses estimated the odds of diagnosis with multiple cancers controlling for age, sex, and race-ethnicity. Change in effects on odds of multiple cancer diagnoses with age, sex, and race-ethnicity were evaluated controlling separately for late-stage diagnosis of the primary cancer or each primary cancer diagnosis type. County-level spatial cluster analysis was employed to identify and visualize higher than average multiple cancer rates.

RESULTS

Over half of the study population were female and almost 30% of the study population were diagnosed at late-stage for their first cancer. Multiple occurrences of all cancers increased during the time period for patients with initial breast or colorectal cancers. Among BC primary cancer cases, subsequent multiple cancers were mostly new breast cancers. By contrast, for CRC primary cancer cases, subsequent multiple cancers were about equally likely to be new CRC cases or other cancer types. Sex, age and race-ethnicity were all significantly associated with multiple cancers. In the model controlling for CRC as the primary type, the age and race-ethnicity effects were somewhat different than for all the other models. Thus, there was something distinctly different about the multiple cancer incidence among patients with CRC as their primary cancer as compared to patients with BC, CVC, or PC primaries. In subsequent analyses by county, there were distinct geospatial patterns in multiple cancer rates with most high-rate clusters occurring in the north- and mid-west US.

CONCLUSIONS

There were distinct individual level and geospatial disparities in multiple cancer diagnoses for the study population of all primary breast, colorectal, cervical, or prostate cancer patients during the decade studied. It is importance to emphasize continued screening for cancer survivors and research on personal and environmental drivers of multiple primary cancers.

Second primary neoplasms in patients with lung and gastroenteropancreatic neuroendocrine neoplasms: Data from a retrospective multi-centric study

BACKGROUND

Patients with sporadic neuroendocrine neoplasms may exhibit a higher risk of a second primary tumor than the general population.

AIM

This study aimed to analyze the occurrence of second primary malignancies.

METHODS

A retrospective cohort of 2757 patients with sporadic lung and gastro-entero-pancreatic neuroendocrine neoplasms, managed at eight Italian tertiary referral Centers, was included.

RESULTS

Between 2000 and 2019, a second primary malignancy was observed in 271 (9.8%) neuroendocrine neoplasms patients with 32 developing a third tumor. There were 135 (49.8%) females and the median age was 64 years. The most frequent locations of the second tumors were breast (18.8%), prostate (12.5%), colon (9.6%), blood tumors (8.5%), and lung (7.7%). The second primary tumor was synchronous in 19.2% of cases, metachronous in 43.2%, and previous in 37.6%. As concerned the neuroendocrine neoplasms, the 5- and 10-year survival rates were 87.8% and 74.4%, respectively. PFS for patients with a second primary malignancy was shorter than for patients without a second primary malignancy. Death was mainly related to neuroendocrine neoplasms.

CONCLUSION

In NEN patients the prevalence of second primary malignancies was not negligible, suggesting a possible neoplastic susceptibility. Overall survival was not affected by the occurrence of a second primary malignancy.

Hydronephrosis in patients with cervical cancer is an indicator of poor outcome: A nationwide population-based retrospective cohort study

Cervical cancer is a common malignancy in women. The presence of hydronephrosis in patients with cervical cancer can be a challenging clinical problem. The appropriate management of these patients and the prediction of their outcomes are concerns among gynecologists, urologists, medical oncologists, radiation oncologists, and nephrologists. We enrolled a total of 2225 patients with cervical cancer over a 12-year period from the nationwide database of Taiwan's National Health Insurance Bureau. Among them, 445 patients had concomitant hydronephrosis. The remaining 1780 patients without hydronephrosis were randomly enrolled as a control group for the analysis of associated factors. The results indicated that the proportions of patients with hypertension, chronic kidney disease, and diabetes were significantly higher in the hydronephrosis group. The hydronephrosis group showed a higher all-cause mortality than the non-hydronephrosis group (adjusted hazard ratio 3.05, 95% confidence interval 2.24-4.15, P < .001). The rates of nephrectomy and stone disease were also significantly higher in the hydronephrosis group. A higher percentage of other cancers was also observed in the hydronephrosis group than in the non-hydronephrosis group (12.36% vs 8.99%, respectively). This study shows that cervical cancer with hydronephrosis may have a higher morbidity and mortality than cervical cancer without hydronephrosis. Other factors such as human papilloma virus vaccination, smoking, and cancer staging need to be further studied.

Full robotic multivisceral resections: the Modena experience and literature review

The robotic platform is becoming a multidisciplinary tool, versatile, and suitable for multiple procedures. Combined multivisceral resections may represent an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy. We herein present our initial experience with full robotic multivisceral resections, and a review of the literature available. Between January 2018 and April 2020, 11 patients underwent multivisceral full robotic abdominal surgery: 4 patients presented with two synchronous tumors, 4 with primary cancer associated with a benign condition and 3 cases involved deep infiltrating endometriosis. Surgical teams enrolled were: General Surgery, Urology and Gynecology. A systematic bibliographic research up to April 2020 was conducted in PubMed. 4 colorectal resections combined with partial or radical nephrectomy were performed, as well as 2 right colectomies in combination with right adrenalectomy and gastric banding removal, 2 radical prostatectomies with Nissen Fundoplication and abdominal wall hernia repair, and 3 resections of deep pelvic endometriosis with colorectal involvement. Mean total operative time was 367 min. No intraoperative complication or conversion to open was registered. Overall postoperative complication rate was 18.2%. 26 papers were included in the review (10 case series and 16 case reports) with a total of 156 combined multivisceral robotic procedures recorded. Robotic combined multivisceral resections proved to be safe and feasible when performed in high volume centers by expert surgeons. The heterogeneity of reports does not allow for a standardization of the procedure. Further studies and accumulation of experience are needed.

Second primary malignancies in colorectal cancer patients

The prevalence of second primary malignancies (SPMs) in the western world is continually increasing with the risk of a new primary cancer in patients with previously diagnosed carcinoma at about 20%. The aim of this retrospective analysis is to identify SPMs in colorectal cancer patients in a single-institution cohort, describe the most frequent SPMs in colorectal cancer patients, and discover the time period to occurrence of second primary tumors. We identified 1174 patients diagnosed with colorectal cancer in the period 2003–2013, with follow-up till 31.12.2018, and median follow-up of 10.1 years, (median age 63 years, 724 men). A second primary neoplasm was diagnosed in 234 patients (19.9%). Older age patients, those with early-stage disease and those with no relapse have a higher risk of secondary cancer development. The median time from cancer diagnosis to development of CRC was 8.9 years for breast cancer and 3.4 years for prostate cancer. For the most common cancer diagnosis after primary CRC, the median time to development was 0–5.2 years, depending on the type of malignancy. Patients with a diagnosis of breast, prostate, or kidney cancer, or melanoma should be regularly screened for CRC. CRC patients should also be screened for additional CRC as well as cancers of the breast, prostate, kidney, and bladder. The screening of cancer patients for the most frequent malignancies along with systematic patient education in this field should be the standard of surveillance for colorectal cancer patients.