Five primary synchronous neoplasms of the gastrointestinal tract

Clinical presentation, endoscopic features, treatment and prognosis of synchronous upper gastrointestinal malignancies

OBJECTIVE

To study the clinical presentation, endoscopic features and prognosis of patients with synchronous upper gastrointestinal (GI) cancers.

METHODS

A prospective database review of consecutive patients with synchronous upper GI malignancies was performed in a tertiary university hospital endoscopy unit. Gender, age, symptoms and cancer sites, endoscopic and pathological findings, as well as the long-term survival of these patients were analyzed.

RESULTS

A total of 64 patients with a median age of 56 years were included, in which 81.3% were male, 71.9% presented with notable features, 68.8% had familial history of cancer, 56.3% of gastric cancers were at the gastric body, 92.9% of the duodenal malignancies at the duodenal bulb, all esophageal cancers at the middle and lower part of esophagus and a significant proportion of tumors in the synchronous malignancies group were poorly differentiated. In all patients, 20 underwent curative surgical treatment and the 5-year survival rate was only 20%.

CONCLUSIONS

Patients with synchronous upper GI cancers are mainly male and present with different anatomic distribution and endoscopic features. They carry a poor prognosis as compared with single primary cancer patients. This case series describes the clinical profiles and emphasizes the necessity of a thorough examination for additional cancers before treatment of upper GI cancer.

Triple synchronous primary cancers of rectum, thyroid, and uterine cervix detected during the workup for hematochezia

Multiple primary cancers are defined as multiple occurrences of malignant neoplasm of different histologic origin in the same individual. The synchronous occurrence of triple distinct cancers in the same patient is very rare. Herein, we report an extremely rare case of synchronous triple primary cancers of the rectum, thyroid gland and uterine cervix; all were detected during the work-up for hematochezia. To the best of our knowledge, this is the first such report in the medical literature.

[Gastrointestinal carcinoid tumors: cellular biology, molecular expression and physiopathological consequences of an enigmatic neoplasia]

Gastrointestinal carcinoid tumors arise from cells of the diffuse neuroendocrine system localized in the digestive trace and represent more than 70% of all carcinoid tumors in humans. The present article reviews the following topics: 1) The biological profile of these tumors (histopathology, cytokine markers, metabolic alterations, storage of neuroamines and hormonal proteins, cytodynamic behavior, and biological behavior according to embryological origin). 2) The etiological circumstances (exceptional hereditary factors, association of gastric carcinoid tumors with autoimmune gastritis, little-known exogenous factors). 3) Pathogenic aspects (persistent mitogenesis of endocrine cells associated with hypergastrinemia, inactivation of some putative tumor suppressor genes, the doubtful participation of oncogenes, autocrine action of some cellular growth-stimulating proteins). 4) The repercussions of certain physiopathological events (peritumoral desmoplastic reaction causing the "mass effect" on the digestive tube, the "kidnapping" of dietary tryptophan by tumoral cells toward an abnormal metabolic pathway; the easy metastatic dissemination coexisting with low tumoral aggressivity, and the release into the bloodstream of stored secretory products leading to "carcinoid syndrome" and some endocrine hyperfunction syndromes. Finally, it should be remembered that gastrointestinal carcinoid tumors represent only a proportion of the neoplasms classified as neuroendocrine tumors.

Orbital carcinoid metastases

OBJECTIVE

To describe a series of patients with metastatic orbital carcinoid tumors.

DESIGN

Retrospective case series and literature review.

PARTICIPANTS AND METHODS

Patients were identified from the orbital database and pathology records at Moorfields Eye Hospital. Records were evaluated for age at presentation, race, gender, laterality, visual function and clinical features, site of orbital metastasis, treatment, and outcome. The site of the primary tumor, presence of systemic symptoms, diagnosis and treatment of the primary tumor, and current survival status were also noted.

MAIN OUTCOME MEASURES

Time from tumor to death.

RESULTS

Thirteen patients (9 male) had an average age at biopsy-proven diagnosis of 65.3 years. The primary tumor was ileal in 7, colonic in 4, and from bronchus and breast (1 each); in 9 patients, the primary tumor was already known. Eleven of the 13 patients had noted a mass, 8 had diplopia, 3 had reduced vision, and only 2 had orbital pain. One patient presented with visual hallucinations. Imaging showed single muscle enlargement in 7 patients, a discrete mass in 5, and diffuse fat infiltration in 1 patient. Six patients underwent a meta-iodobenzyl guanidine/octreotide scan and metastatic disease was found in 4. Four patients underwent exenteration, 5 had radiotherapy after tumor debulking, 2 had radiotherapy alone, and 2 patients had local radiotherapy with receptor-targeted chemotherapy. Seven patients died from metastatic tumor. Kaplan-Meier analysis showed a 5-year survival rate of 72% and a 10-year survival rate of 38%. Comparison of the current series with other published series shows a significant difference (improvement) in survival at 5 years (P = 0.027) but not at 10 years (P = 0.08).

CONCLUSIONS

The largest published series of orbital carcinoid tumors is presented, there being a recent trend towards less aggressive surgical management and probably a greater survival rate.

Four Primary Tumors of Lung, Bladder, Prostate, and Breast in a Male Patient

We present a very rare case of quadruple cancers in a 65-year-old male patient. It is a case of both synchronous and metachronous primary malignant neoplasms occurring in four different organs. Immunohistochemical stains showed tumor cell nuclei to be negative for p53 over-expression. To our knowledge, this is the first documented case with this combination of primary tumors. The tumors included an adenosquamous cell carcinoma of the lung, transitional cell carcinoma of the urinary bladder, and adenocarcinomas of the prostate and the breast. We also review the medical literature for the possible causes of multiple primary malignant neoplasms.

Solitary versus multiple carcinoid tumors of the ileum: a clinical and pathologic review of 68 cases

It is well known that small intestinal carcinoid tumors may occur as solitary or multiple lesions. However, the biologic significance of multiple carcinoid tumors has not been clearly defined. The purpose of this study was to compare the clinical and pathologic features and prognosis of patients with solitary versus multiple carcinoid tumors of the ileum. Sixty-eight patients, including 50 with solitary and 18 with multiple carcinoid tumors, were included in the study. Hematoxylin and eosin-stained slides from routinely processed tumor resection specimens of the ileum were evaluated for a variety of histologic features such as tumor size, depth of invasion, tumor stage, and venous, perineural, and lymphovascular invasion. Follow-up and clinical data, such as patient age, gender, presenting complaints, presence of synchronous or metachronous malignancies, and presence of the carcinoid syndrome, were obtained and the results were compared between the two patient groups. Fifty patients with solitary carcinoid tumors (male/female ratio, 27:23) and 18 patients with multiple tumors (male/female ratio, 7:11) were identified. Patients with multiple carcinoid tumors were significantly younger than patients with solitary tumors at the time of diagnosis (55 years vs 63 years, p = 0.006). There was a high association between multiple carcinoid tumors and the carcinoid syndrome (4 of 18 vs 1 of 50, p = 0.004) as compared with patients with solitary carcinoid tumors. There was also an association between tumor multiplicity and venous invasion, but this relationship was not statistically significant (p = 0.07). The follow-up period was similar for both groups (mean 36 months, median 26 months, range 1-139 months). A significantly higher proportion of patients with multiple carcinoid tumors were either alive with disease or died of disease (56%) compared with those with solitary carcinoid tumors (18%, p = 0.002), and this relationship persisted in multivariate analysis (p = 0.02). Overall, no significant differences were observed between these two patient groups with respect to other clinicopathologic features such as tumor size, depth of invasion, presence of distant metastases, lymphatic or perineural invasion, or presence of an associated malignancy (p >0.05). In conclusion, we found that patients with multiple carcinoid tumors are younger, have a significantly greater risk of developing the carcinoid syndrome, and have a poorer prognosis than patients with solitary tumors.

Carcinoid tumour

Carcinoid tumours are often indolent asymptomatic tumours. However, a small but significant proportion are malignant and difficult to manage. Multiple endocrine neoplasia type 1 (MEN-1) may be associated with carcinoid tumours and should therefore be considered in the investigation of these patients. This review puts into context the use of newer imaging modalities, including octreotide scintigraphy. The therapeutic treatment options are discussed, including the use of octreotide, the role of receptor-targeted therapy, hepatic-artery embolisation, and the arguments against chemotherapy. We review the need for careful patient selection when considering curative and palliative surgery, including liver transplantation. We conclude that there are now better diagnostic tools and therapeutic options available for those patients with malignant carcinoid tumours, and that these patients are best managed by a multidisciplinary approach. Earlier detection and treatment of these tumours should lead to improved quality of life and survival, which, ideally, should be assessed in formal trials.