Oesophageal cancer associated with other primary cancers: a study of 31 patients

Lifestyle, clinical and histological indices-based prediction models for survival in cancer patients: a city-wide prospective cohort study in China

PURPOSE

We developed a nomogram to predict 3-year, 5-year and 7-year cancer survival rates of cancer patients.

METHODS

This prospective cohort study included 20,491 surviving patients first diagnosed with cancer in Guangzhou from 2010 to 2019. They were divided into a training and a validation group. Lifestyle, clinical and histological parameters (LCH) were included in multivariable Cox regression. Akaike information criterion was used to select prediction factors for the nomogram. The discrimination and calibration of models were assessed by concordance index (C-index), area under time-dependent receiver operating characteristic curve (time-dependent AUC), and calibration plots. We used net reclassification index (NRI) and integrated discrimination improvement (IDI) to compare the clinical utility of LCH prediction model with the prediction model based on lifestyle factors (LF).

RESULTS

13 prediction factors including age, sex, BMI, smoking status, physical activity, sleep duration, regular diet, tumor grading, TNM stage, multiple primary cancer and anatomical site were included in the LCH model. The LCH model showed satisfactory discrimination and calibration (C-index = 0.81 (95% CI 0.80-0.82) for training group and 0.80 (0.79-0.81) for validation group, both time-dependent AUC > 0.70). The LF model including smoking status, physical activity, sleep duration, regular diet, and BMI showed less satisfactory discrimination (C-index = 0.60 (95% CI 0.59-0.61) for training and 0.60 (0.58-0.62) for validation group). The LCH model had better accuracy and discriminative ability than the LF model, as indicated by positive NRI and IDI values.

CONCLUSIONS

The LCH model shows good accuracy, clinical utility and precise prognosis prediction, and may serve as a tool to predict cancer survival of cancer patients.

Co-Occurrence of Hotspot Point Mutation and Novel Deletion Mutation of TERT Promoter in Solid Variant Papillary Thyroid Carcinoma in a Patient with Synchronous Esophageal Cancer

(1) Introduction: Telomerase reverse transcriptase (TERT) promoter mutations are associated with unfavorable clinical outcomes in papillary thyroid carcinomas (PTCs). Two substitution mutations, C228T (c.1-124C>T) and C250T (c.1-146C>T), make up most of the mutations and occur in a mutually exclusive manner. (2) Case presentation: A 72-year-old man was initially referred to a tertiary hospital for treatment of esophageal cancer. Preoperative imaging revealed a 3.2 cm thyroid nodule pathologically diagnosed as PTC on needle biopsy. The patient underwent thyroid lobectomy with esophagectomy and was finally diagnosed with synchronous solid variant PTC (SVPTC) and esophageal squamous cell carcinoma. Sanger sequencing using DNA from the thyroid tumor showed an indel mutation, c.1-132_1-124delinsT, composed of a deletion (c.1-132_1-125del) as well as a hotspot mutation (c.1-124C>T(C228T)) in the TERT promoter. (3) Conclusions: This is the first report of PTC harboring a novel deletion along with a hotspot mutation in the TERT promoter in a patient with synchronous esophageal squamous cell carcinoma.

Definitive radiotherapy in patients of synchronous esophageal and head and neck cancer-treatment outcome and toxicity

AIM

The aim is to retrospectively evaluate the clinical outcomes and treatment related toxicities in patients of synchronous esophageal and head & neck cancer when treated with definitive radiotherapy with or without concurrent chemotherapy.

BACKGROUND

Patients of esophageal cancer with a synchronous second primary in head and neck region can be treated with definitive radiotherapy but the clinical outcome has been reported to be poor.

METHOD AND DESIGN

This is a single institutional retrospective study. Twenty-five patients fulfilling inclusion and exclusion criteria were evaluated. The survival was analysed using Kaplan-Meir method and their relations with various clinicopathologic parameters were compared.

RESULTS

After a median follow-up time of 14 months, the 1 year and 2 year survival was 60% and 17% respectively. Significant improvement in overall survival was observed in patients with early staged esophageal cancer then locally advanced disease (P = 0.03). Patients with locally advanced head and neck cancer had poor survival than with early stage disease (P = 0.06). Those who received concurrent chemotherapy had better survival than those with radiotherapy alone. 40% patients developed grade III & IV dermatitis and 48% patients developed grade III oral mucositis.

CONCLUSION

Chemoradiotherapy can safely be offered to patients with synchronous esophageal and head and neck cancer.

Clinical and Prognostic Features of Patients With Esophageal Cancer and Multiple Primary Cancers: A Retrospective Single-institution Study

OBJECTIVE

To investigate the clinical and prognostic characteristics of patients with esophageal cancer and multiple primary cancers.

SUMMARY BACKGROUND DATA

Patients with esophageal cancer frequently have multiple primary cancers, the presence of which may complicate physicians' decision-making because the clinical and prognostic features of such patients remain unknown.

METHODS

This retrospective single-institution study included 538 consecutive patients who had undergone resection of esophageal cancer. The Cox proportional hazard model was used to compute the hazard ratio (HR) for mortality.

RESULTS

At the time of surgery, 163 patients (30%) had multiple primary cancers (77, metachronous; 86, synchronous). Multiple primary cancers were significantly associated with alcohol use and tobacco smoking (Brinkman index). Patients with synchronous cancers had significantly shorter overall survival than those without multiple primary cancers (log-rank P = 0.032; univariate HR = 1.53, 95% confidence interval 1.02-2.17, P = 0.040; multivariate HR: 1.61; 95% confidence interval: 1.08-2.36; P = 0.020). Patients with metachronous cancers had similar prognoses to those without multiple primary cancers. The prognostic effect of synchronous cancers on overall survival was particularly prominent in patients with Stage I esophageal cancer (log-rank P = 0.0002).

CONCLUSIONS

Multiple primary cancers are associated with a history of tobacco and alcohol use, supporting the concept of field cancerization. Synchronous multiple primary cancers may be an independent predictor of poorer long-term survival in patients undergoing resection of esophageal cancers.

Chemoradiotherapy for Synchronous Multiple Primary Cancers with Esophageal Squamous Cell Carcinoma: a Case-control Study

Objective: To evaluate the efficacy and toxicity of concurrent chemoradiotherapy (CRT) in multiple primary cancers (MPC) of the upper digestive tract in esophageal squamous cell carcinoma (ESCC).

Methods: In a screening of 1193 consecutive patients diagnosed with ESCC and received radiotherapy, 53 patients presenting synchronous MPC in the upper digestive tract were retrospectively investigated. 53 consecutive patients with esophageal non-multiple primary cancer (NPC), matched by stage, age and sex, served as control. All of the patients received concurrent CRT. The median radiation dose was 60 Gy. Chemotherapy regimens were based on platinum and/or 5-fluorouracil. Clinical outcomes and treatment toxicities were compared.

Results: Clinic-pathologic characteristics were well balanced between groups. MPC mostly located in esophagus (43, 81.8%), followed by hypopharynx (8, 15.1%) and stomach (2, 3.8%). In MPC and NPC patients, 94.3% and 96.2% completed the intended treatment. The immediate response rate was 73.6% vs 75.5%, with complete response rate of 11.3% vs 24.5% and partial response rate of 62.3% vs 51.0%. Two-year overall survival (OS), progression-free survival (PFS), locoregional progression-free survival (LRPFS) and distant progression-free survival (DPFS) were 52.2% vs 68.9% (p=0.026), 32.9% vs 54.0% (p=0.032), 60.8% vs 87.8% (p=0.002) and 64.0% vs 70.8% (p=0.22), respectively. Acute grade 3-4 toxicities were observed in 64.2% vs 54.7%, significantly higher in radiation esophagitis (49.1% vs 28.3%, p<0.001), and mucositis (11.3% vs 00p=0.027).

Conclusions: Compared with matched NPC, ESCC accompanied with synchronous MPC was related to significantly impaired survival, elevated risk of locoregional disease progression and higher incidence of severe esophagitis and mucositis, following concurrent chemoradiotherapy. Future study on reasons for decreased efficacy of chemoradiotherapy will help to optimize treatment. Advanced radiation techniques may play a role in protecting normal tissues and reduce acute toxicities.

Synchronous second primary cancers in patients with squamous esophageal cancer: clinical features and survival outcome

BACKGROUND/AIMS

Unexpected diagnosis of synchronous second primary cancers (SPC) complicates physicians' decision-making because clinical details of squamous esophageal cancer (EC) patients with SPC have been limited. We evaluated clinical features and treatment outcomes of patients with synchronous SPC detected during the initial staging of squamous EC.

METHODS

We identified a total of 317 consecutive patients diagnosed with squamous EC. Relevant clinical and cancer-specific information were reviewed retrospectively.

RESULTS

EC patients with synchronous SPC were identified in 21 patients (6.6%). There were significant differences in median age (70 years vs. 63 years, p = 0.01), serum albumin level (3.3 g/dL vs. 3.9 g/dL, p < 0.01) and body mass index (20.4 kg/m(2) vs. 22.8 kg/m(2), p = 0.01) between EC patients with and without SPC. Head and neck, lung and gastric cancers accounted for 18.2%, 22.7%, and 18.2% of SPC, respectively. Positron emission tomography-computed tomography (PET-CT) detected four cases (18.2%) of SPC that were missed on CT. Management plans were altered in 13 of 21 patients (61.9%) with detected SPC. Curative esophagectomy was attempted in 28.6% of EC patients with SPC (vs. 59.1% of patients without SPC; p = 0.006). EC patients with SPC had significantly lower 5-year survival than patients without SPC (10.6% vs. 36.7%, p = 0.008).

CONCLUSIONS

Synchronous SPC were found in 6.6% of squamous EC patients, and PET-CT contributed substantially to the detection of synchronous SPC. EC patients with SPC had poor survival due to challenges of providing stage-appropriate treatment.

Curative two-stage resection for synchronous triple cancers of the esophagus, colon, and liver: Report of a case

INTRODUCTION

Cases of synchronous triple cancers of the esophagus and other organs curatively resected are rare.

PRESENTATION OF CASE

A 73-year-old man was admitted to our hospital with bloody feces. He was diagnosed with synchronous triple cancers of the esophagus, colon, and liver. We selected a two-stage operation to safely achieve curative resection for all three cancers. The first stage of the operation comprised a laparoscopy-assisted sigmoidectomy and partial liver resection via open surgery. The patient was discharged without complications. Thirty days later, he was readmitted and thoracoscopic esophagectomy was performed. Although pneumonia-induced pulmonary aspiration occurred as a postoperative complication, it was treated conservatively. The patient was discharged on postoperative day 24.

DISCUSSION

Esophagectomy is a highly invasive procedure; thus, simultaneous surgery for plural organs, including the esophagus, may induce life-threatening, severe complications. Two-stage surgery is useful in reducing surgical stress in high-risk patients. For synchronous multiple cancers, the planning of two-stage surgery should be considered for each cancer to maintain organ function and reduce the stress and difficulty of each stage.

CONCLUSION

We successfully treated synchronous triple cancers, including esophageal cancer, by a two-stage operation.

A Case of Synchronous Squamous Cell Carcinoma in the Esophagus and Stomach: A Rare Duo

Synchronous squamous cell esophageal and squamous cell gastric cancer is a rare duo. A 48-year-old male visited our hospital with a history of dysphagia and melena and was diagnosed with synchronous esophageal and gastric cancer by endoscopy and histopathology. We report a case of a synchronous cancer that was successfully treated by chemotherapy followed by surgery. We also discuss the hypothesis regarding the origin and presentation of the synchronous cancer in the GIT.

Resection of distal gastric tube cancer with sentinel node biopsy: a case report and review of the literature

Background

The frequency of gastric tube cancershas increased with advances in surgical techniques and improvement of survival rates in patients with esophageal cancer. However, a standard surgical treatment has not yet been established. Total resection of the gastric tube with lymphadenectomy has been considered a radical treatment, while repeat surgery with both laparotomy and thoracotomy has been associated with severe complications, including anastomotic leakage, recurrent nerve paralysis, bronchotracheal injury, and damage to other organs.

Case presentation

We present a successful case of a gastric tube cancer that was treated with surgical resection in combination with sentinel node biopsy. The tumor was diagnosed as a type 0-IIc lesion with ulceration, and was located proximal to the pyloric ring. Endoscopic submucosal dissection was not indicated because the primary lesion was submucosally invasive, and undifferentiated. By the dye-guided method, sentinel nodes were detected along the right gastroepiploic artery and vein. Intraoperative pathological examination revealed no metastasis of the sentinel nodes. Resection of the distal gastric tube was safely performed with a Roux-en-Y reconstruction, preserving the right gastroepiploic artery and vein and the perfusion of the proximal gastric tube.

Conclusion

We suggest distal resection of the gastric tube with sentinel node biopsy as a novel surgical method for a cT1N0 gastric tube cancer located in the abdomen.

Primary Adenocarcinoma in an Oesophageal Gastric Graft – Case Report

Primary adenocarcinoma in the esophageal gastric graft is a rare complication diagnosed in patients with long-term survival. Most data concerning the diagnosis and treatment of patients with metachronic cancer in esophageal grafts is derived from Japan and South Korea. The diagnosis of cancer in esophageal gastric grafts in the European countries is rare.

The study presented a case of a 66-year old male patient who, 30 months after an esophageal squamous cell cancer resection, was diagnosed with adenocarcinoma of the esophageal gastric graft. Despite control follow-up after the esophagectomy, cancer in the esophageal graft was detected during the stage that prevented performing radical surgery. The study presented the recommended diagnostic procedures and treatment options for esophageal gastric graft cancer, as well as review of available literature data

Triple synchronous malignant tumors of colon, appendix and liver: A case report with literature review

Synchronous cancers are defined as malignant tumors that occur simultaneously. Each tumor must be primary which eliminate the possibility of being metastatic lesion of the other. If three separate organs are involved, that is so-called triple synchronous malignancy with very low morbidity. We report a case of a 33 year old male patient with triple synchronous malignancies at the colon, appendix and liver.

Clinicopathologic characteristics of synchronous primary thyroid cancer detected by initial staging 18F-FDG PET-CT examination in patients with underlying malignancy

BACKGROUND

The objective of this study was to define clinicopathologic characteristics in concurrent primary thyroid cancer detected by initial (18)fluorine-fluorodeoxyglucose positron emission tomography-computed tomography ((18)F-FDG PET-CT) scanning in patients with underlying malignancy.

PATIENTS AND METHODS

Among 155 patients with known underlying malignancy and with focal FDG uptake in the thyroid, 25 patients (22 females; mean age ± SD 54.4 ± 11.2 years; age range 27-70 years) who were confirmed as having papillary thyroid cancer (PTC; synchronous thyroid cancer) by cytological examination were included. Another 25 patients (24 females; mean age ± SD, 48.8 ± 12.7 years) with focal uptake in preoperative (18)F-FDG PET-CT due to PTC and no history of other malignancy (primary thyroid cancer) were also included. Immunohistochemical studies were performed for glucose transporter-1 (GLUT-1) and vascular endothelial growth factor (VEGF).

RESULTS

GLUT-1 expression was significantly lower in synchronous thyroid cancer (7 of 25 patients, 28%) compared with primary thyroid carcinoma (15 of 25 patients, 60%; p = 0.045). However, age and tumor size of synchronous thyroid cancer were not significantly different from the patients with primary thyroid carcinomas. There was no significant difference in VEGF expression, maximal standardized uptake values, extrathyroidal extension, lymph node metastasis, advanced stage, and multifocality between both thyroid cancer groups.

CONCLUSION

Clinicopathologic characteristics of synchronous thyroid cancer in patients with underlying malignancy were not different from those of patients with primary thyroid cancers except for GLUT-1 expression.

Incidence of second primary malignancies in patients with esophageal cancer: a comprehensive review

BACKGROUND

Development of a second primary malignancy (SPM) after an index esophageal cancer is fairly rare, primarily due to decreased survival in patients with esophageal cancer. However, with advances in early detection and therapy, the number of long-term survivors is increasing, as is the incidence of SPMs in this population.

SCOPE

We review herein the published literature on the incidence of SPMs after an index esophageal cancer as well as its associated risk factors, prognosis and surveillance. We discuss predisposing factors that may contribute to the development of SPMs, epidemiology and attempts at chemoprevention.

FINDINGS

Data from population-based studies, retrospective reviews and case reports indicate an increased risk of SPMs in patients with esophageal cancer with reported incidence rates between 8.3 and 27.1%. Index esophageal squamous cell carcinomas have a higher association with other tobacco-related cancers such as those of the head and neck and lung. They have also shown an association with second primary cancers of the breast, stomach, thyroid, and kidney. Individuals with esophageal adenocarcinomas are at a higher risk of developing second cancers of the stomach, oropharynx and lung/bronchus. Other primary cancer sites involved include the kidney, colorectum and pancreas. Common risk factors including lifestyle and genetic alterations may explain the increased incidence of second primary cancers in this patient population.

CONCLUSIONS

Risk of developing a second malignancy should be anticipated after curative treatment of esophageal cancer, and raises concerns for optimal surveillance and therapy of these patients. Recent literature suggests similar survival rates in esophageal cancer patients with and without SPMs. With the increasing incidence of SPMs in subjects with esophageal cancer, there may be benefit to close screening for and aggressive therapy of SPMs. However, further studies are needed to elucidate optimal management strategies.

Metachronous adenocarcinoma in a gastric tube after radical surgery for oesophageal cancer

In recent years the prognosis for oesophageal squamous cell carcinoma patients has improved. Together with this improvement, the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after oesophagectomy must be taken into account. We report a case of a patient who had this clinical presentation, which was revealed not in the normal follow-up, but in a consecutive operation carried out because of an anastomotic problem.

Surveillance and treatment for second primary cancer in the gastric tube after radical esophagectomy

BACKGROUND

Recent improvement in the survival of patients after esophagectomy for esophageal cancer has led to increasing occurrence of second primary cancer in the pulled-up stomach as gastric tube cancer (GTC). However, a treatment strategy for GTC including surveillance has not been established. The aims of this study are to clarify the incidence and clinicopathological characteristics of GTC and to assess the treatment results of endoscopic resection.

METHODS

Twenty-five patients with 29 GTC lesions treated between 1989 and 2007 were analyzed retrospectively.

RESULTS

The median interval between esophagectomy and GTC detection was 86 months, and the 10-year cumulative incidence rate of GTC was 8.6%. Of 18 asymptomatic GTCs, 17 lesions (94.4%) were detected by periodic endoscopy and 15 (88.2%) of them were treated endoscopically. Of all 29 GTCs, endoscopic submucosal dissection (ESD) was performed in 10 GTCs with a completely curative resection rate of 90%, which was significantly higher than that of 7 GTCs treated with endoscopic mucosal resection (EMR) (14.3%, P = 0.004). In these 17 GTCs, no cancer recurrence developed during a median follow-up period of 24 months, and the 3-year survival rate was 80.8%.

CONCLUSIONS

For patients after esophagectomy with gastric pull-up, long-term follow-up including periodic endoscopy is necessary to detect a potentially curable GTC. ESD is a feasible and safe procedure for GTC, with oncologically favorable features.

Primary jejunal adenocarcinoma as part of multiple primary cancers of the digestive tract

Multiple primary cancers including small intestinal tumors are rare. We describe the first curative resection case of metachronous triple early cancers involving the jejunum as well as the stomach and esophagus. The patient had undergone total gastrectomy for a gastric adenocarcinoma and subsequent esophagectomy for an esophageal squamous cell carcinoma. A jejunal adenocarcinoma, the third primary, occurred at the blind stump of the jejunal limb of a Roux-en-Y esophagojejunostomy reconstructed previously. This tumor was removed by partial resection of the limb with the preservation of the esophagojejunostomy. The patient died from complications of acute pancreatitis 3 years after the last operation, without overt clinical signs of cancer recurrence. Immunohistochemistry of the specimen showed the increased expression of p53 and cyclin D1 proteins in all three cancers, suggesting their involvement in metachronous carcinogenesis in this case. Early diagnosis of each cancer was made possible by regular endoscopic follow-up and favorable anatomical location of each tumor, which were considered to allow less invasive surgery as well as to contribute to the favorable outcome. This case suggests the importance of regular surveillance for metachronous carcinogenesis, especially when the preceding cancers carry genetic abnormalities that may potentially increase the risk for subsequent carcinogenesis.

Multiple primary carcinomas with esophageal squamous cell cancer: clinicopathologic outcome

The incidence of multiple primary carcinomas (MPCs) associated with esophageal cancer has increased. The purpose of this study was to analyze clinicopathologic findings for MPC and for only esophageal cancer (OEC). Of 157 patients with MPCs, 60 had synchronous cancer and 97 metachronous cancer. Another 42 patients had antecedent esophageal cancer (AEC), and 55 patients had subsequent esophageal cancer (SEC). We retrospectively analyzed the clincopathologic findings for patients in these categories. The incidence of early-stage carcinoma was higher in patients with MPCs than in those with an OEC. Of patients with MPCs, those with metachronous cancer had a higher rate of early-stage carcinoma than those with synchronous cancer. The 5-year survival rates were not significantly different for MPC and OEC patients. Patients with metachronous cancer had a significantly better prognosis than those with synchronous cancer (p = 0.017); and in the metachronous cancer group the prognosis was significantly better for patients with AEC than for those with SEC (p = 0.0005). Meticulous follow-up after treatment of a first cancer should be required to detect other early-stage carcinomas.

Frequent microsatellite instability in primary esophageal carcinoma associated with extraesophageal primary carcinoma

Patients with esophageal squamous cell carcinoma (ESCC) frequently develop other primary cancers, such as gastric cancer and head and neck cancer. Details of carcinogenesis in patients with multiple primaries that include esophageal carcinoma with other primary carcinoma (ECOPC) remain uncertain. We examined microsatellite instability (MSI) status, frameshift mutation in target genes of MSI, mismatch repair protein expression and hypermethylation of the hMLH1 promoter region in ECOPC patients to better understand the underlying carcinogenic processes. High frequency MSI (MSI-H) was found in 15 (44.1%) of 34 patients with ECOPC, but in only 6 (14.3%) of 42 patients with esophageal cancer alone (p < 0.01). Frameshift mutations in TGFbetaRII, BAX, MSH3 and MSH6 genes respectively were present in 4, 1, 2 and 2 of 34 ECOPC patients. Immunohistochemical study showed that 12 (80.0%) of 15 MSI-H tumors showed loss of expression of either hMLH1 or hMSH2. In addition, 6 of 9 tumors (66.7%) that showed reduced hMLH1 expression also had hypermethylation of the hMLH1 promoter region. Our findings suggested that carcinogenesis in ECOPC was closely associated with the MSI pathway because of mismatch repair protein deficiency.

Laparoscopic intragastric surgery for gastric tube cancer following esophagectomy

As a result of the recent improvement of the prognosis of esophageal cancer, the reporting frequency of gastric tube cancer following esophageal cancer has increased. Gastric tube total resection following median sternotomy, a highly invasive surgical procedure, is applied to the cases of advanced gastric tube cancer, whereas endoscopic mucosal resection is selected for the cases of early gastric tube cancer. If endoscopic mucosal resection is not applicable for some reason, partial or total resection of the gastric tube following median sternotomy has been selected. We applied laparoscopic intragastric surgery to such a case: The patient, a 59-year-old man with esophageal cancer, had undergone subtotal esophagectomy followed by gastric tube reconstruction through the retrosternal route 6 years before. Since endoscopy revealed early gastric cancer in the body of the stomach, we tried to perform mucosal resection but failed because of anastomotic stenosis. However, we successfully performed intragastric surgery, in which a camera and forceps were inserted directly into the gastric tube. Thus, laparoscopic intragastric surgery is a useful technique in cases to which endoscopic mucosal resection is not applicable.

Synchronous triple cancers at middle and lower esophagus and stomach with different histological features and genetic alterations

Synchronous multiple primary malignancies are relatively unusual. We describe a case of synchronous triple cancers located at the middle and lower esophagus and the stomach in a 59-year-old Taiwanese man who presented with progressive dysphagia, epigastralgia, and bodyweight loss in 1 month. Endoscopic and histological features, microsatellite instability status of genomic DNA, and immunohistochemical staining of p53, MUC2, Fhit, c-erbB-2 and E-cadherin of all three cancers were demonstrated. We noted that these three cancers arose from different clones and that p53 mutation, instead of microsatellite instability, may play a major role in the development of multiple primary malignancies in this patient.

Second primary carcinoma in the gastric tube constructed as an esophageal substitute after esophagectomy

BACKGROUND

The prognosis of esophageal carcinoma has improved, but along with this improvement, concern has increased about the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after esophagectomy. We describe our experience in the diagnosis and treatment of gastric tube carcinoma.

STUDY DESIGN

We retrospectively examined 31 cases of gastric tube carcinoma; these cases occurred in 26 patients who received esophagectomy between September 1968 and October 2000.

RESULTS

Surgical resection was performed in 10 patients. Gastrectomy with regional lymph node dissection was performed in 7 patients and partial resection of the stomach without lymph node dissection in 3 patients. In 6 patients leakage was encountered after gastrectomy; 3 of these patients died of multiple organ failure. Only one of the gastrectomy patients is alive without disease. Over the past 7 years, 15 patients with 20 lesions have been treated by endoscopic mucosal resection (EMR). Three of these patients required additional operation because of massive submucosal invasion by the tumor. One complication occurred at EMR, but it was successfully treated by conservative therapy. All patients treated by EMR alone were alive with neither local nor distant metastasis during a median followup period of 27.5 months. Of those patients who received surgical resection initially and were diagnosed as inoperable, all 10 had not received periodic checkups and had some symptoms. In contrast, of 15 patients who underwent EMR, all 20 lesions were found by annual followup endoscopic examination in the absence of symptoms.

CONCLUSIONS

EMR for gastric tube carcinoma is safe and has few complications, in contrast to surgical resection of the gastric tube, which places a severe burden on the patient and has high morbidity and mortality. Early detection of the tumor by annual endoscopic examination is recommended for achieving good outcomes in gastric tube carcinoma after esophagectomy.

Quadruple cancer in a single patient: a report of four cases

Multiple primary neoplasia was once considered a rare curiosity but is now a well recognized phenomenon. Only a few papers have been published in the English literature with regard to occurrence of four or more primary malignancies in a single patient. We report four cases of quadruple cancer; a review of the literature about this topic is discussed.

Multiple primary cancers of the esophagus and thyroid gland

The occurrence of multiple primary cancers in the aerodigestive tract is a well known phenomenon that has been explained by the concept of 'field carcinogenesis'. Metachronous or synchronous esophageal cancer has usually been identified in patients with head and neck cancer, gastric cancer or colon cancer. The incidence of multiple primary cancers of the esophagus and thyroid gland is very low. We treated four patients with synchronous cancers of the cervical esophagus and the thyroid gland. Histologically, all of the esophageal cancers were squamous cell carcinomas. Thyroid cancers were evaluated as papillary carcinoma or follicular carcinoma. Both the esophageal cancer and the thyroid cancer frequently metastasized to lymph nodes. All patients had multiple lymph nodes metastasis from the esophageal or the thyroid cancer. In one patient, both the esophageal and the thyroid cancers were detected in the same lymph node. Three of four patients died from recurrence of esophageal cancer. The prognosis of these patients was poor. In the treatment of esophageal carcinoma, cancers of other organs including the thyroid gland should be carefully investigated.