Excess risk of subsequent primary cancers among colorectal carcinoma survivors, 1975-2001

Incidence and risk outcomes of second primary malignancy of patients with post-operative colorectal cancer

BACKGROUND AND AIMS

This study aimed to investigate the incidence and the risk factors of incidence for second primary malignancies (SPMs) onset among survivors diagnosed with colorectal cancer (CRC).

METHODS

A large population-based cohort study was performed. Data of patients diagnosed with CRC was identified and extracted from 8 cancer registries of Surveillance, Epidemiology, and End Results database from January 1990 to December 2017. The outcome of interest was percentage and common sites of SPM onset after primary CRC diagnosis. The cumulative incidence and standardize incidence rates (SIRs) were also reported. Afterwards, we estimated sub-distribution hazards ratios (SHRs) and relative risks (RRs) for SPM occurrence using multivariable competing-risk and Poisson regression models, respectively.

RESULTS

A total of 152,402 patients with CRC were included to analyze. Overall, 23,816 patients of all CRC survivors (15.6%) were reported SPM occurrence. The highest proportion of SPMs development after primary CRC diagnosis was second CRC, followed by lung and bronchus cancer among all survivors. Also, CRC survivors were more susceptible to develop second gastrointestinal cancers (GICs). Besides, pelvic cancers were analyzed with a relative high proportion among patients who received RT in comparison to those without RT. The cumulative incidence of all SPMs onset was 22.16% (95% CI: 21.82-22.49%) after near 30-year follow-up. Several factors including older age, male, married status, and localized stage of CRC were related to the high risk of SPMs onset. In treatment-specific analyses, RT was related to a higher cumulative incidence of SPMs occurrence (all SPMs: 14.08% vs. 8.72%; GICs: 2.67% vs. 2.04%; CRC: 1.01% vs. 1.57%; all p < 0.01). Furthermore, the increased risk of SPMs onset was found among patients who received RT than patients within the NRT group (SHR: 1.50, 95% CI: 1.32-1.71), p < 0.01; RR: 1.61, 95% CI: 1.45-1.79, p < 0.01).

CONCLUSION

The present study described the incidence pattern of SPM among CRC survivors and identified the risk factors of the SPM onset. RT treatment for patients diagnosed with CRC may increase the risk of SPMs occurrence. The findings suggest the need for long-term follow-up surveillance for these patients.

Primary ovarian cancer after colorectal cancer: a Dutch nationwide population-based study

BACKGROUND AND PURPOSE

Women with colorectal cancer (CRC) are at risk not only of developing ovarian metastases, but also of developing a primary ovarian malignancy. Several earlier studies have in fact shown a link between the development of primary ovarian cancer and CRC. The purpose of this study was therefore to determine the risk of developing a primary ovarian cancer in women with prior CRC compared to the general population.

METHODS

Data from the Netherlands Cancer Registry were used. All women diagnosed with invasive CRC between 1989 and 2017 were included. Standardized incidence ratios (SIRs) and absolute excess risks (AERs) per 10,000 person-years were calculated.

RESULTS

During the study period, 410 (0.3%) CRC patients were diagnosed with primary ovarian cancer. Women with CRC had a 20% increased risk of developing ovarian cancer compared to the general population (SIR = 1.2, 95% CI: 1.1-1.3). The AER of ovarian cancer was 0.9 per 10,000 person-years. The risk was especially increased within the first year of a CRC diagnosis (SIR = 3.3, 95% CI: 2.8-3.8) and in women aged ≤ 55 years (SIR = 2.0, 95% CI: 1.6-2.6).

CONCLUSION

This study found a slightly increased risk of primary ovarian cancer in women diagnosed with CRC compared to the general population. However, this may be partly attributable to surveillance or detection bias. Nevertheless, our findings could be helpful for patient counseling, as CRC patients do not currently receive information concerning the increased risk of ovarian cancer.

Risk of extracolonic second primary cancers following a primary colorectal cancer: a systematic review and meta-analysis

PURPOSE

The purpose of the study is to assess the global risk of extracolonic secondary primary cancers (SPCs) in patients with colorectal cancer (CRC).

METHODS

Studies of SPC in patients with CRC were included if they reported the standardised incidence ratio (SIR) for extracolonic SPCs in patients with CRC compared with the general population. Pooled summary estimates were calculated using a random-effects model.

RESULTS

A total of 7,716,750 patients with CRC from 13 retrospective cohort studies that reported extracolonic SPC incidence were included. The overall risk of several SPCs was significantly higher in patients with CRC compared with the general population, including cancers of the urinary bladder (pooled SIR 1.19, 95% confidence interval (CI) 1.06-1.33; p = 0.003), female genital tract (1.88, 1.07-3.31; p = 0.03), kidney (1.50, 1.19-1.89; p = 0.0007), thorax (lung, bronchus and mediastinum) (1.16, 1.01-1.32; p = 0.03), small intestine (4.26, 2.58-7.01; p < 0.0001), stomach (1.22, 1.07-1.39; p = 0.003), and thyroid (1.40, 1.28-1.53; p < 0.0001), as well as melanoma (1.28, 1.01-1.62; p = 0.04). There was also a decreased risk of developing cancer of the gall bladder (0.75, 0.60-0.94; p = 0.01).

CONCLUSION

Patients with CRC had a significantly increased risk of extracolonic SPCs compared with the general population. These findings highlight the need to develop research strategies for the management of second primary cancer in patients with CRC.

Metachronous small bowel adenocarcinoma after rectal adenocarcinoma: A case report

RATIONALE

Small bowel adenocarcinoma (SBA), an uncommon gastrointestinal malignant tumor, is difficult to diagnose at an early stage because of its non-specific disease presentation. Metachronous SBA is a special type of SBA that is rarely reported. We herein report a case of metachronous primary SBA following resection of rectal adenocarcinoma.

PATIENT CONCERNS

A 65-year-old man presented to our hospital after having experienced recurrent bowel obstruction for 6 months. He had undergone a Dixon operation 30 months previously followed by adjuvant chemotherapy with capecitabine plus oxaliplatin.

DIAGNOSIS

Abdominal computed tomography showed thickened bowel walls in the right lower abdomen, and the patient was initially misdiagnosed with intestinal adhesion. After the operation, he was diagnosed with primary SBA (T3N0M0, stage IIA).

INTERVENTIONS

Treatment with a transnasal ileus tube was ineffective. Therefore, we performed small intestinal segmental resection and side-to-side anastomosis through open surgery.

OUTCOMES

The patient completed all postoperative adjuvant chemotherapy, and posttreatment surveillance revealed no further abnormalities.

LESSONS

This case suggests that patients with colorectal adenocarcinoma may have an increased risk of metachronous SBA. Corresponding symptoms in high-risk patients should raise clinicians' suspicion for SBA, and further detailed examinations are imperative. Early screening for SBA may help to improve the patients' prognosis.

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.

Risk of Second Primary Malignancies Based on the Histological Subtypes of Colorectal Cancer

Background: Previous studies have revealed an increased risk of second primary malignancies (SPMs) after colorectal cancer (CRC); however, no previous investigation has quantified differences in the risk of SPMs based on the histological subtypes of first primary CRC.

Methods: Patients diagnosed with first primary CRC between 2000 and 2011 were identified from the Surveillance, Epidemiology, and End Results cancer registries. The patients were divided into three cohorts: classical adenocarcinoma (CA), mucinous adenocarcinoma (MA), and signet-ring cell carcinoma (SRCC). Standardized incidence ratios were calculated to assess the risk of SPMs among the patients.

Results: Overall risk of SPMs was significantly higher among patients with three histological subtypes of CRC than in the general population. The risk of esophagus cancer was significantly increased in SRCC. The risk of small intestine, colon and rectum, and corpus uteri cancers was high in three histological subtypes, with the highest risk observed in SRCC, followed by MA. Increased risks of second stomach, uterus, urinary bladder, kidney, and thyroid cancers were only observed in CA patients, while increased risk of second renal pelvis cancer was limited to MA patients. Furthermore, the high overall risk of SPMs in CA patients persisted regardless of clinicopathological factors. After surgery combined with chemotherapy treatment, CA patients were more prone to developing second small intestine, colon and rectum cancers than those treated with surgery only. A lower second prostate cancer risk was observed in rectal CA patients treated with surgery combined with radiotherapy than in patients treated with surgery only.

Conclusion: The present study revealed that the risk of developing SPMs after CRC varied based on the histological subtypes of the first primary CRC. Although the mechanisms underlying the observed patterns of SPM risk remain unknown, the study provided insights into future cancer surveillance based on the histological subtypes of CRC.

Incidence of second malignancies in patients with chronic myeloid leukemia in the era of tyrosine kinase inhibitors

Patients with chronic myeloid leukemia (CML) treated with tyrosine kinase inhibitors (TKIs) have near-normal life expectancies. With this comes the possibility of developing second cancers; we aimed to evaluate the incidence of second malignancies in patients with CML using Surveillance, Epidemiology, and End Results Program data. We identified 13,276 patients with CML newly diagnosed in 2001-2014. Patients who had prior history of cancer, a concurrent diagnosis of other malignancies in the same diagnostic year, or a second leukemia after CML diagnosis were excluded. Second malignancies were observed in 597 patients (4%) with a median follow-up of 69 months. The 5- and 10-year cumulative incidences of death for all patients were 30.5% and 41.8%. The 5- and 10-year cumulative incidences of second malignancies were 4.4% and 7.2%, respectively. The overall standardized incidence ratio (SIR) was 1.204. Increased SIRs compared to the general population were observed for the male genital system, 1.593; digestive system, 1.291; skin, 1.588; and urinary system, 1.366. Overall excess absolute risk was 1.714 per 1000 person-years at risk. Our results suggest that relative incidence of overall second malignancies in CML is slightly higher than that of the general population, with minimal increase in the excess absolute risk.

Excessive risk of second primary cancers in young-onset colorectal cancer survivors

With an increasing trend of patients with young-onset colorectal cancer (CRC), risks of second primary cancers (SPCs) among them become a concerning issue. We aimed to define the detailed risk and site-distributed patterns of SPCs in young CRC individuals (age ≤50). A population-based cohort were identified from the Surveillance, Epidemiology, and End Results database between 1973 and 2013. Standardized incidence ratios (SIRs) and absolute excess risk (AER) were calculated to assess the risk for SPCs compared with the general population. A total of 44,106 patients, including 3245 (7.4%) the young and 40,861 (92.6%) the old, developed 50,679 secondary malignancies subsequently. With increased age, the risk of secondary cancers gradually decreased. A significant 44% excess risk of SPCs was observed in the young (SIR = 1.44, AER = 34.23), while a slightly increased risk was noted in the old (SIR = 1.02, AER = 4.29). For young survivors, the small intestine (SIR = 8.49), bile ducts (SIR = 3.77), corpus, and uterus (SIR = 2.45) were the most common sites of SPCs. Significantly, excess SIRs in the young were persisted regardless of other factors. For the young, secondary cancer-related deaths were responsible for 51.2% of overall deaths and secondary stomach, liver and bile, pancreas cancers were top three causes. An excessive risk of SPCs existed in young CRC survivors, and this trend was consistent among different subgroups. We hope our findings may inform future targeted screening strategies among young-onset CRC survivors.

Secondary Primary Prostate Cancer after Colorectal Cancer: A Nationwide Population-based Cohort Study in Korea

Background

Colorectal cancer (CRC) and prostate cancer frequently occur in developed countries. There are several reports on the association between CRC and prostate cancer; however, the conclusions are inconsistent to investigate the association of the development of secondary primary prostate cancer among patients with prior primary CRC using a nationwide population-based dataset.

Methods

Patients registered in the Republic of Korea National Health Insurance System database who were diagnosed with CRC between 2007 and 2012 were followed-up until the end of 2015, and we investigated the new diagnosis secondary primary prostate cancer. We compared the incidence of prostate cancer in age-matched controls using the Cox proportional hazards models.

Results

We analyzed a total of 85,455 first primary CRC survivors. During the follow-up period of 494,222 person-years, 2,005 patients (2.30%) developed secondary primary prostate cancer (incidence rate 4.06/1,000 person-years). The median duration of follow-up was 5.78 years. Compared with the general population, CRC patients had a significantly increased risk of secondary primary prostate cancer (HR = 2.30, 95% CI = 2.18–2.43; P < 0.001). Multivariate analysis (including age, sex, body mass index, hypertension, diabetes mellitus, dyslipidemia, and income) showed that age < 55 years (HR = 20.74, 95% CI = 11.81–36.41; P < 0.001) is a significant independent predictor of secondary primary prostate cancer development.

Conclusions

Men diagnosed with colorectal cancer are at an increased risk of secondary primary prostate cancer, particularly those aged < 55 years. The data suggests that colorectal cancer patients aged < 55 years require regular screening for prostate cancer.

The Incidence Characteristics of Second Primary Malignancy after Diagnosis of Primary Colon and Rectal Cancer: A Population Based Study

Background

With the expanding population of colorectal cancer (CRC) survivors in the United States, one concerning issue is the risk of developing second primary malignancies (SPMs) for these CRC survivors. The present study attempts to identify the incidence characteristics of SPMs after diagnosis of first primary colon cancer (CC) and rectal cancer (RC).

Methods

189,890 CC and 83,802 RC cases were identified from Surveillance, Epidemiology and End Results Program (SEER) database. We performed rate analysis on incidence trend of SPMs in both CC and RC. Expected incidence rates were stratified by age, race and stage, calendar year of first CRC diagnosis and latency period since first CRC diagnosis. The standardized incidence ratios (SIRs), measure for estimating risk of SPMs, were calculated for CC and RC respectively.

Results

The trends of incidence of SPMs in both CC and RC were decreasing from 1992 to 2012. Both CC and RC survivors had higher risk of developing SPMs (SIRCC = 1.13; SIRRC = 1.05). For CC patients, the highest risks of SPM were cancers of small intestine (SIR = 4.03), colon (SIR = 1.87) and rectum (SIR = 1.80). For RC patients, the highest risks of SPMs were cancers of rectum (SIR = 2.88), small intestine (SIR = 2.16) and thyroid (SIR = 1.46). According to stratified analyses, we also identified incidence characteristics which were contributed to higher risk of developing SPMs, including the age between 20 and 40, American Indian/Alaska Native, localized stage, diagnosed at calendar year from 2002 to 2012 and the latency between 12 and 59 months.

Conclusions

Both CC and RC survivors remain at higher risk of developing SPMs. The identification of incidence characteristics of SPMs is extremely essential for continuous cancer surveillance among CRC survivors.

Young patients with colorectal cancer have increased risk of second primary cancers

OBJECTIVE

Because the number of long-term survivors of colorectal cancer has increased, second primary cancer has become an important issue. However, previous studies were heterogeneous in design, and few data for Asia-Pacific area were available.

METHODS

This was a retrospective population-based study conducted using the national database of the Taiwan Cancer Registry. Patients who have histology-proven primary colon cancer and rectal cancer from 1995 to 2005 were enrolled in this study. All second primary cancer events had to be histology proven. The standardized incidence ratio of second primary cancer was used as an indicator. Standardized incidence ratio was counted as the number of observed second primary cancer divided by the expected number of cancer cases in the general population.

RESULTS

A total of 65 648 eligible index patients were enrolled, and 3810 second primary cancer events were identified. The standardized incidence ratio for all of the patients was 1.03 (95% confidence interval: 0.99-1.06), which implied that the risk of second primary cancer was not significantly elevated in the index patients compared with that of the general population. The standardized incidence ratio for the patients aged <50, 50-70 and >70 years was 2.52 (95% confidence interval: 2.28-2.78), 1.18 (95% confidence interval: 1.12-1.23) and 0.80 (95% confidence interval: 0.76-0.84), respectively. In young patients (aged <50 years), the standardized incidence ratio increase was statistically significant and persisted for over 10 years and this significantly increased across all subgroups. The small intestine, the large intestine, the female genital organs and the lungs were the most common sites of second primary cancer in young patients.

CONCLUSIONS

Young patients with colorectal cancer have an increased risk of developing second primary cancer.

Incidence of Second Primary Malignancies Following Colorectal Cancer: A Distinct Pattern of Occurrence Between Colon and Rectal Cancers and Association of Co-Morbidity with Second Primary Malignancies in a Population-Based Cohort of 98,876 Patients in Taiwan

The purpose of this study is to determine the features of second primary malignancies (SPMs) among patients with prior colorectal cancer (CRC) using a nationwide population-based dataset.Patients with CRC newly diagnosed between 1996 and 2011, and >1 year of follow-up were recruited from the Taiwan National Health Insurance database. Standardized incidence ratios (SIRs) of SPMs in patients with CRC were calculated.During the 16-year study period, 4259 SPMs developed among 98,876 CRC patients. The median duration of follow-up was 4.03 years. The SIR for all SPMs was 1.13 (95% confidence interval = 1.10-1.17). Compared with the general population, a higher incidence of thyroid, prostate, ovarian, and hematologic malignancies developed among patients with colon cancer, whereas the risk for bone and soft tissue cancers increased among patients with rectal cancer. The risk for breast, bladder, kidney, lung, and uterine cancers was significantly higher in patients with colon and rectal cancers than the general population. The risk for liver and biliary tract cancers declined in patients with rectal cancer. Based on multivariate analysis among patients with CRC, age ≥70 years, men, chronic obstructive pulmonary disease (COPD), cirrhosis, and dyslipidemia were independent predictors of an SPM.In conclusion, patients with CRC were at increased risk for a second cancer. The pattern of SPMs was distinct between patients with colon and rectal cancer. Age, men, COPD, cirrhosis, and dyslipidemia were independent risk factors for SPMs. Surveillance and education should be provided for survivors with respect to risk for SPMs.

Body mass index and risk of second obesity-associated cancers after colorectal cancer: a pooled analysis of prospective cohort studies

PURPOSE

To determine whether prediagnostic body mass index (BMI) is associated with risk of second obesity-associated cancers in colorectal cancer (CRC) survivors, and whether CRC survivors have increased susceptibility to obesity-associated cancer compared with cancer-free individuals.

PATIENTS AND METHODS

Incident first primary CRC cases (N = 11,598) were identified from five prospective cohort studies. We used Cox proportional hazards regression models to examine associations between baseline (prediagnostic) BMI and risk of second obesity-associated cancers (postmenopausal breast, kidney, pancreas, esophageal adenocarcinoma, endometrium) in CRC survivors, and compared associations to those for first obesity-associated cancers in the full cohort.

RESULTS

Compared with survivors with normal prediagnostic BMI (18.5-24.9 kg/m(2)), those who were overweight (25-29.9 kg/m(2)) or obese (30+ kg/m(2)) had greater risk of a second obesity-associated cancer (n = 224; overweight hazard ratio [HR], 1.39; 95% CI, 1.01 to 1.92; obese HR, 1.47; 95% CI, 1.02 to 2.12; per 5-unit change in BMI HR, 1.12; 95% CI, 0.98 to 1.29). The magnitude of risk for developing a first primary obesity-associated cancer was similar (overweight HR, 1.18; 95% CI, 1.14 to 1.21; obese HR, 1.61; 95% CI, 1.56 to 1.66; per 5-unit change in BMI HR, 1.23; 95% CI, 1.21 to 1.24). Before diagnosis CRC patients were somewhat more likely than the overall cohort to be overweight (44% v 41%) or obese (25% v 21%).

CONCLUSION

CRC survivors who were overweight or obese before diagnosis had increased risk of second obesity-associated cancers compared with survivors with normal weight. The risks were similar in magnitude to those observed for first cancers in this population, suggesting increased prevalence of overweight or obesity, rather than increased susceptibility, may contribute to elevated second cancer risks in colorectal cancer survivors compared with the general population. These results support emphasis of existing weight guidelines for this high-risk group.

[Clinicopathologic features of colorectal cancer combined with synchronous and metachronous gastric cancer]

BACKGROUND/AIMS

The purpose of this study was to investigate the clinicopathologic features of double primary cancers of the stomach and colorectum, compared to colorectal cancer alone.

METHODS

A retrospective analysis was made of 5,288 patients who underwent colorectal cancer surgery between January 2000 and December 2009 at Severance Hospital of Yonsei University. The clinicopathologic features were analyzed between 63 patients of double primary cancers and case-matched 126 patients of colorectal cancer alone. We classified double primary cancers into subgroups as premetachronous, synchronous and postmetachronous gastric cancer to identify differences between the three subgroups also.

RESULTS

Double primary cancers group showed 4.3 year-older age, lower BMI, and higher percentage of peritoneal metastasis, compared to colorectal cancer alone group. Overall and colorectal cancer specific survival did not have any significant difference between two groups. In histologic type of gastric cancer, a high percentage of undifferentiated adenocarcinoma (55.6%) and signet ring cell carcinoma (30.2%) were noted.

CONCLUSIONS

Double primary cancers of the stomach and colorectum had older-age onset, lower BMI and higher metastasis to peritoneum than colorectal cancer alone. Combined gastric cancer consisted of high percentage of undifferentiated and signet ring cell carcinomas.

Anatomic subsite of primary colorectal cancer and subsequent risk and distribution of second cancers

BACKGROUND

Individuals with a history of colorectal cancer (CRC) have an increased risk of subsequent cancer. In this study, the authors used cancer registry data to evaluate whether this increased risk of cancer after CRC differed by anatomic subsite of a first CRC.

METHODS

Individuals diagnosed with a first primary CRC between 1992 and 2009 were identified from 12 Surveillance, Epidemiology, and End Results (SEER) cancer registries. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing the incidence of subsequent cancers in these patients who had an index CRC versus the cancer incidence rates in the general population. SIRs were calculated for cancers at anatomic sites within and outside the colorectum in analyses stratified by subsite of the index CRC.

RESULTS

Cancer incidence rates were significantly higher in individuals who had a previous CRC than in the general population (SIR, 1.15; 95% CI, 1.13-1.16). Individuals with an index CRC located between the transverse and descending colon experienced the greatest increased risk both overall (SIR, 1.29-1.33) and particularly with respect to the risk of a second CRC (SIR, 2.53-3.35). The incidence of small intestinal cancer was elevated significantly regardless of the index CRC subsite (SIR, 4.31; 95% CI, 3.70-4.77), and the incidence of endometrial cancer was elevated in those who had an index CRC in the proximal colon (SIR, 1.37-1.79).

CONCLUSIONS

The risk of second cancer after CRC differs by anatomic site of the first tumor and is particularly pronounced for those with prior CRC located in the transverse to descending colon. The mechanisms underlying this pattern of second cancer risk remain unknown.

Emergency caudate lobectomy for ruptured hepatocellular carcinoma with multiple primary cancers

We report a case of metachronous multiple primary malignancies involving both rectum and liver with colonic metastasis from hepatocellular carcinoma (HCC) through hematogenous pathway. A 72-year-old woman was admitted to the emergency department with right upper abdominal pain for 4 h. Considering her surgical history of Mile’s procedure plus liver resection for rectal cancer with liver metastasis three years ago and the finding of urgent computed tomography scan on admission, the preoperative diagnosis was spontaneous rupture of rectal liver metastasis located in caudate lobe and colonic metastasis from rectal cancer. The patient underwent an emergency isolated caudate lobectomy at a hemorrhagic shock status. Pathology reported a primary HCC in the caudate lobe and colonic metastasis of HCC with tumor embolus in the surrounding vessels of the intestine. No regional lymph node involvement was found. It is hypothesized that HCC may disseminate hematogenously to the ascending colon, thus making it a rare case.

Why is there a change in patterns of GE cancer?

Recent decades have seen a worrying trend in incidence rates of distal oesophageal and proximal gastric cancers. Fuelled by radical changes in lifestyle, diet, physical activity and environmental exposures, as well as an ageing population and host genetic predisposition, the incidence of oesophageal adenocarcinoma (OAC) is on the rise in Western populations. While overall incidence of gastric cancers is declining, the ageing of society means that an increase in absolute numbers is expected over coming years. Both cancers tend to present at an advanced stage, hence prognosis remains poor despite increasingly effective screening and treatment strategies. The development of gastric and oesophageal malignancies is influenced by myriad factors, not least geographical, racial and socioeconomic differences in addition to lifestyle choices. The multidimensional nature of these risk factors requires a holistic understanding of their net influence in the development of malignancy. This review explores the evidence base for established and putative risk factors in the development of gastric and oesophageal cancers. It is hoped that with a clear understanding of important risk factors, a multidisciplinary approach including effective primary prevention, regular screening of high-risk groups and continued research into the molecular biology of gastrointestinal carcinogenesis may facilitate a reduction in incidence rates, as well as early detection and optimal management of upper gastrointestinal malignancies.

Patients with colorectal and renal cell carcinoma diagnoses appear to be at risk for additional malignancies

Patients with colorectal cancer (CRC) and renal cell carcinoma (RCC) may be at risk for additional primary malignancies. A review of 101 patients with these concurrent diagnoses was performed. Forty-two percent of patients had 1 or more additional malignancies; none appeared to be associated with Lynch syndrome (LS). This suggests the need for careful follow-up in these patients and further study.

BACKGROUND

Small studies have demonstrated that patients who have both colorectal and renal cell carcinoma may be at increased risk for the development of additional malignancies. A possible genetic basis has been suggested. Our study describes the clinicopathologic features of these patients and clarifies the relationship of this cohort with Lynch syndrome (LS).

METHODS

Patients with primary CRC and RCC treated at our institution were identified. Medical records were reviewed for demographic and clinical information. Immunohistochemical staining for mismatch repair (MMR) proteins was performed on tumor tissue when possible.

RESULTS

During the study period, 24,642 patients were treated for CRC and 7,366 were treated for RCC at our institution. One hundred seventy-nine patients had both diagnoses, with 101 patients eligible for inclusion in our cohort. Tumors were typically early stage. The 2 cancers presented as synchronous lesions in 42% of patients. Thirty-two patients had 1 additional primary malignancy, 7 patients had 2 additional primary malignancies, and 3 patients had 3 additional primary malignancies. No patient had a family history that met the Amsterdam II criteria (AC) for LS, but 50% had family members with 1 malignancy. One of 10 colorectal tumors analyzed for the absence of MMR protein expression demonstrated the absence of MSH6, but the corresponding RCC demonstrated intact expression of all 4 MMR proteins.

CONCLUSION

It is rare for patients to be diagnosed with both CRC and RCC. The clinicopathologic features of this cohort and the results of immunohistochemical analysis performed on a sample of these patients do not suggest LS. However, the high rate of additional carcinomas suggests a need for careful follow-up. Multicenter longitudinal studies are warranted to further understand the natural history and possible genetic basis for this entity.

Risks of primary extracolonic cancers following colorectal cancer in lynch syndrome

BACKGROUND

Lynch syndrome is a highly penetrant cancer predisposition syndrome caused by germline mutations in DNA mismatch repair (MMR) genes. We estimated the risks of primary cancers other than colorectal cancer following a diagnosis of colorectal cancer in mutation carriers.

METHODS

We obtained data from the Colon Cancer Family Registry for 764 carriers of an MMR gene mutation (316 MLH1, 357 MSH2, 49 MSH6, and 42 PMS2), who had a previous diagnosis of colorectal cancer. The Kaplan-Meier method was used to estimate their cumulative risk of cancers 10 and 20 years after colorectal cancer. We estimated the age-, sex-, country- and calendar period-specific standardized incidence ratios (SIRs) of cancers following colorectal cancer, compared with the general population.

RESULTS

Following colorectal cancer, carriers of MMR gene mutations had the following 10-year risk of cancers in other organs: kidney, renal pelvis, ureter, and bladder (2%, 95% confidence interval [CI] = 1% to 3%); small intestine, stomach, and hepatobiliary tract (1%, 95% CI = 0.2% to 2%); prostate (3%, 95% CI = 1% to 5%); endometrium (12%, 95% CI = 8% to 17%); breast (2%, 95% CI = 1% to 4%); and ovary (1%, 95% CI = 0% to 2%). They were at elevated risk compared with the general population: cancers of the kidney, renal pelvis, and ureter (SIR = 12.54, 95% CI = 7.97 to 17.94), urinary bladder (SIR = 7.22, 95% CI = 4.08 to 10.99), small intestine (SIR = 72.68, 95% CI = 39.95 to 111.29), stomach (SIR = 5.65, 95% CI = 2.32 to 9.69), and hepatobiliary tract (SIR = 5.94, 95% CI = 1.81 to 10.94) for both sexes; cancer of the prostate (SIR = 2.05, 95% CI = 1.23 to 3.01), endometrium (SIR = 40.23, 95% CI = 27.91 to 56.06), breast (SIR = 1.76, 95% CI = 1.07 to 2.59), and ovary (SIR = 4.19, 95% CI = 1.28 to 7.97).

CONCLUSION

Carriers of MMR gene mutations who have already had a colorectal cancer are at increased risk of a greater range of cancers than the recognized spectrum of Lynch syndrome cancers, including breast and prostate cancers.

Multiple primary cancers among colorectal cancer survivors in Queensland, Australia, 1996-2007

PURPOSE

To quantify the demographic and clinical factors associated with an increased risk of multiple primary cancers (MPCs) among colorectal cancer survivors.

METHODS

Standardized incidence ratios for MPCs were calculated for residents of Queensland, Australia, who were diagnosed with a first primary colorectal cancer between 1996 and 2005 and survived for at least 2 months. Relative risk ratios were calculated for all MPCs combined and selected individual sites using multivariate Poisson models.

RESULTS

A total of 1,615 MPCs were observed among 15,755 study patients. The cohort had a significant excess risk of developing subsequent colorectal (SIR = 1.47, 95 % CI 1.30-1.66) or non-colorectal (SIR = 1.24, 95 % CI 1.18-1.31) cancers relative to the incidence of cancer in the general population. Age at initial diagnosis, follow-up time, initial colorectal subsite, and surgical treatment were independently associated (p < 0.01) with the overall risk of developing MPCs after adjustment. The relative risk ratio was 1.23 (95 % CI 1.07-1.41) for those aged 20-59 years compared with the 70-79 age group and 0.82 (95 % CI 0.72-0.92) for 1-5-year follow-up relative to the first year. The likelihood of being diagnosed with a MPC was 33 % higher (95 % CI 1.12-1.56) for surgically treated patients and 45 % higher (95 % CI 1.29-1.64) after proximal colon cancers relative to rectal cancer.

CONCLUSIONS

While these population-based results do not incorporate all possible risk factors, they form an important foundation from which to further investigate the etiological causes that result in the development of MPCs among colorectal cancer survivors.

Synchronous breast and rectal cancers in a man

Breast cancer in men is relatively rare and its coexistence with other primary non-breast cancers exceptional. Here, we report the case of a 50-year-old man who presented with symptoms of rectal adenocarcinoma and in whom a synchronous, asymptomatic cancer of the left breast was found incidentally at physical examination.

Synchronous carcinoma of the ampulla of vater and colon cancer

Carcinoma of the papilla of Vater is a relatively rare tumor and its coexistence with other primary sporadic cancers is very exceptional. Here we report the case of a 76-year-old man who presented with painless obstructive jaundice, pathologically elevated liver function tests and increased serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen. Endoscopic retrograde cholangiography revealed a large polypoid mass in the ampulla of Vater. A large tumor in the ascending colon was also incidentally detected by abdominal computed tomography. Endoscopic biopsies from both lesions showed adenocarcinomas. Metastases to the liver and to the hepatoduodenal ligament and hepatic artery lymph nodes were found during surgery. Right colectomy and a biliary bypass were performed. Histological analysis showed an ampullary adenocarcinoma with metastases to regional lymph nodes and the liver and a colonic adenocarcinoma with local invasion into the pericolic fat. Treatment with gemcitabine plus cisplatin was suggested postoperatively. The association of sporadic ampullary and colonic adenocarcinomas and the mutually increased risk of developing either a synchronous or a metachronous tumor following each other should be considered in patients with primary ampullary or colorectal cancer during the preoperative evaluation and postoperative follow-up of these patients.

Clinicopathologic characteristics of colorectal cancer patients with synchronous and metachronous gastric cancer

BACKGROUND

We investigated the characteristics of synchronous and metachronous gastric cancer in patients with colorectal cancer.

METHODS

We reviewed 8,680 patients who underwent operations for primary sporadic colorectal cancer from 1989 to 2008. Synchronous gastric cancer was defined as gastric cancer diagnosed within 6 months of a colorectal cancer diagnosis. Gastric cancer diagnosed more than 6 months before or after colorectal cancer was defined as metachronous.

RESULTS

The incidences of synchronous and metachronous gastric cancer were 0.93 and 1.4%, respectively (combined 2.4%). The standardized incidence ratio was 1.199 (95% confidence interval [CI] = 1.005-1.420) when the patients with premetachronous gastric cancer were excluded. Patients with synchronous and metachronous gastric cancer were 5 years older on average compared to the control population without gastric cancer. In addition, multivariate analysis revealed an odds ratio (OR) of 3.6 for being male, OR = 2 for positive family history of solid tumors, OR = 2.2 for colonic lesion, and OR = 4 for MSH2 expression loss compared to patients without gastric cancer. Patients with postmetachronous gastric cancer (when compared to synchronous and premetachronous gastric cancer), a preoperative CEA level of less than 6 ng/ml, and a relatively early stage of colorectal cancer had significantly higher overall (p = 0.016, 0.007, and 0.004, respectively) and disease-free survival rates (p = 0.046, 0.003, and 0.004, respectively), only on univariate analysis. Lymphovascular invasion of colorectal cancer and an advanced stage of gastric cancer were independent poor prognostic factors for both overall (p = 0.018) and disease-free survival (p = 0.028).

CONCLUSIONS

Gastric cancer surveillance is recommended for patients with colorectal cancer, especially when the patient is old and male, has a positive family history of solid tumors, has a colonic lesion, or lacks MSH2 expression.

Incidence of second cancer within 5 years of diagnosis of a breast, prostate or colorectal cancer: a population-based study

The objective of this study was to evaluate the risk for cancer patients of developing a new primary invasive cancer. Using data from a French Cancer Registry, we included 14,353 cancer patients (breast, colorectal or prostate cancer) diagnosed between 1989 and 1997. Observed second cancers occurring during the first 5 years after the first cancer were compared with the expected number, based on primary cancer incidence rate, by the standardized incidence ratio (SIR). Breast cancer patients had significantly elevated SIR for contralateral breast cancer (SIR=1.7), kidney cancer (SIR=3.5) and myeloid leukaemia (SIR=8.3). Patients diagnosed with colorectal cancer had significantly elevated risk for small intestine (SIR=10.7) and colorectal cancer (SIR=1.6). Young age at diagnosis of breast and colorectal cancers was associated with risk of a second cancer. After prostate cancer, men had no greater risk of cancer, except for kidney cancer. Our results help to direct attention to regions especially vulnerable to secondary cancers after primary breast or colorectal cancer.

Multiple primary malignancies involving colorectal cancer--clinical characteristics and prognosis with reference to surveillance

BACKGROUND/AIM

The purpose of this study was to investigate clinically useful information for effective screening for synchronous and metachronous second primary cancers and to suggest potential surveillance tool.

METHODS

We retrospectively reviewed 1,063 patients who were treated with potentially curative surgery for colorectal cancer at Gachon University, Gil Hospital from 1997 to 2007.

RESULTS

The incidence of synchronous or metachronous cancer in addition to colorectal cancer was 5.3% (57 patients). The most common second primary cancer was stomach (54.3%), followed by cancers in cervix (12.2%). The time interval between the first and second tumor in colorectal cancer associated with metachronous extracolonic malignancy ranged from 1.1 to 10.8 years. The incidence of early-stage tumor was higher in patients with synchronous cancer than in those with a metachronous cancer with statistical significance (p = 0.034). The 5-year survival rate of the colorectal cancer group without second primary cancer was 70.1%, whereas that for the second primary cancer group was 63.8% (p = 0.253). The 5-year survival rate of the colorectal cancer group with stomach cancer was 70.5%, whereas that for the second primary cancer other than stomach cancer group was 56.6% (p = 0.282).

CONCLUSION

The frequent association between colorectal cancer and gastric cancer suggests an inclusion of gastrofiberscope when surveillancing patients with colorectal cancer in Korean population. Second primary cancers may develop even 10 years after the initial operation; thus, a need for lifelong surveillance even more than 5 years may be necessary.

Double primary malignancy in colorectal cancer patients--MSI is the useful marker for predicting double primary tumors

BACKGROUND AND AIMS

The incidence of double primary malignancies (DPM) is known to be higher in colorectal cancer patients than the general population. And, the role of microsatellite instability (MSI) in DPM has been previously studied. We evaluated the clinical features and association between MSI and colorectal cancer patients with DPM.

MATERIALS AND METHODS

From September 1994 to May 2004, we reviewed 2,301 colorectal cancer patients with regard to secondary primary malignancies. A subgroup analysis was performed for MSI after January 2003.

RESULTS

One hundred forty-five patients (6.3%) had a DPM identified. In DPM group, 57 patients had a synchronous DPM (39.3%), and 88 patients had a metachronous malignancy (60.7%). Male gender (p<0.001) and colon cancer (p<0.001) were the factors related with the development of the DPM. Most of the second malignancies occurred within 3 years after the primary operation. The common second malignancies were stomach (58 patients, 40%) and lung (21 patients, 14.5%). In the subgroup analysis, there was a higher frequency of DPM in the MSI group when compared to the microsatellite stable group (p=0.021).

CONCLUSIONS

The careful pre- and postoperative evaluation should be paid for detecting DPM as well as for detecting recurrence in colorectal cancer patients. The results of this study suggest that MSI might be a useful marker for the detection of DPM in colorectal cancer patients.

Multiple primary cancers in extracolonic sites with colorectal cancer

PURPOSE

The present study was undertaken to clarify the clinical and pathological features of multiple primary cancers, especially those at extracolonic sites, in patients with colorectal cancers.

METHODS

We reviewed the records of 2,176 patients who underwent surgery for colorectal cancers in our institute from January 1997 to December 2006. A synchronous multiple primary cancer was defined as extracolonic cancer detected within 6-month interval before and after the detection of colorectal cancer. Any metastasis from colorectal cancers was excluded.

RESULTS

Synchronous multiple primary cancers were identified in 32 patients. The stomach is the most common organ for synchronous multiple primary cancer development in patients with colorectal cancers (0.9%, 20/2,176).

CONCLUSIONS

Gastric cancer is the most common synchronous multiple primary cancers occurring concomitantly with colorectal cancers. Careful preoperative screening is necessary for the detection of multiple primary cancers in extracolonic sites in patients with colorectal cancers.

Potential role of human papillomavirus in the development of subsequent primary in situ and invasive cancers among cervical cancer survivors

BACKGROUND

The recent licensure of human papillomavirus (HPV) vaccines will likely decrease the development of primary in situ and invasive cervical cancers and possibly other HPV-associated cancers such as vaginal, vulvar, and anal cancers. Because the HPV vaccine has the ability to impact the development of >1 HPV-associated cancer in the same individual, the risk of developing subsequent primary cancers among cervical cancer survivors was examined.

METHODS

Using the 1992 through 2004 data from the Surveillance, Epidemiology, and End Results (SEER) program, 23,509 cervical cancer survivors were followed (mean of 4.8 person-years) for the development of subsequent primary cancers. The observed number (O) of subsequent cancers of all sites were compared with those expected (E) based on age-/race-/year-/site-specific rates in the SEER population. Standardized incidence ratios (SIRs = O/E) were considered statistically significant if they differed from 1, with an alpha level of 0.05.

RESULTS

Among cervical cancer index cases, there was a significant elevated risk for subsequent in situ cancers of the vagina and vulva (SIRs of 53.8 and 6.6, respectively); and invasive vaginal, vulvar, and rectal cancers (SIRs of 29.9, 5.7, and 2.2, respectively). Significantly elevated risks were observed across race and ethnic populations for subsequent vaginal in situ (SIR for whites of 49.4; blacks, 52.8; Asian/Pacific Islander [API], 91.4; and Hispanics, 55.7) and invasive cancers (SIR for whites of 25.7; blacks, 34.5; API, 48.5; and Hispanics, 25.2).

CONCLUSIONS

The results of the current study demonstrate a substantially increased risk of the development of subsequent primary in situ and invasive cancers among cervical cancer survivors and have implications for the development of prevention and early detection strategies as the role of HPV infection becomes evident.