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Introduction
Carcinomas of the stomach are the most common malignant tumors in China. Due to the recent developments in diagnostic techniques and instrumentation, the early detection of gastric carcinoma (GC) has increased. Yet synchronous multiple primary gastric carcinomas, defined as 2 or more primary gastric carcinomas occurring in 1 patient simultaneously, are not frequently seen. The etiology of synchronous tumors is still unclear, and their coexistence can be problematic for surgeons, oncologists and pathologists in regards to diagnosis, treatment, and follow-up. Research has focused mainly on such issues as the frequency of occurrence of primary multiple carcinomas, identification of high-risk groups, early diagnosis, treatment methods, and prognostic factors. The purpose of this article is to present a rare case of synchronous tumors and to review the literature addressing the surgical treatment for patients with multiple cancers.
In conclusion, we consider that in patients with synchronous multiple primaries, systemic preoperative and postoperative examination for the detection of the associated primary carcinoma is essential and we recommend that it be performed.
Case Report
In January 2009, a 58-year-old female was admitted to our hospital for surgery with a 9-month history of vague upper abdominal pain, heartburn, and loss of body weight without hematemesis or dark stools. Her family medical history was unremarkable. Physical examination showed stable vital signs and no abdominal tenderness. Laboratory data showed no anemia, and the level of carcinoembryonic antigen was normal while carbohydrate antigen 19-9 was 43.6 U/mL. Abdominal contrast enhancement computed tomography scan showed that the gastric wall of the pyloric antrum had an area that was irregularly thickened, but no lymphadenopathy was found (Fig. 1).
Abdominal contrast enhancement CT showed the gastric wall in the pyloric antrum irregularly thickened (up to 2.5 cm thick). Signs of advanced disease-multiple liver metastases, extensive peritoneal carcinomatosis, enlarged perigastric lymph nodes and pancreatic involvement were not found.
Endoscopic examination revealed a 5.0 cm × 5.0 cm ulceration (Fig. 2a) at the lesser curvature, as well as an additional 3.0 cm × 3.0 cm ulceration (Fig. 2b) close to the posterior wall of the pyloric antrum at the greater curvature. The duodenobulbar mucous membrane was normal. Light microscopic examination of the specimens taken on endoscopic biopsy showed adenocarcinoma.
The patient subsequently underwent subtotal gastrectomy with a Roux-en-Y esophagojejunostomy and lymphadenectomy on January 31, 2009. During surgery, neither ascites nor peritoneal dissemination was seen. The serosal surface of the greater curvature had an area of red-pink discoloration. No signs of lymphovascular penetration or perigastric lymph node metastasis were found. The TNM stage of gastric cancer in the patient was T3N0M0 upon assessment.
Postoperative microscopic examination showed that the histologic type of the ulcer in the pyloric antrum of the lesser curvature was mucinous adenocarcinoma with invasion beyond the serosa (Fig. 3a). The other ulceration was poorly differentiated adenocarcinoma with invasion within the submucosa (Fig. 3b). There were no micrometastases in the perigastric lymph nodes. No signs of Helicobacter pylori infection were found.
Light microscopic examination of the postoperative specimens (H&E stain, × 100). The histologic type of the ulcer in the pyloric antrum of the lesser curvature was mucinous adenocarcinoma which invaded beyond the serosa (Fig. 3a). The other was poorly differentiated adenocarcinoma which invaded within the superficial portion of the submucosa (Fig. 3b).
The patient had an uneventful postoperative course and was discharged about 20 days after surgery. She received 6 cycles of the CapeOx chemotherapy. The CapeOx regimen was given as follows: 130 mg/m2 of oxaliplatin (L-OHP) added in 500 ml of 5% glucose, administered intravenously within 2 h on the first day of each cycle; 1000 mg/m2 xeloda (capecitabine) given twice orally per day on day 1 to day 14. The regimen was repeated every 21 days. At present, no signs of recurrence or metastasis have been found, and the patient remains disease-free.
Discussion
Although malignant tumors are currently detected more often than in the past because of continued and vast improvements in medical technologies, the incidence of synchronous multiple primary carcinomas, defined as 2 or more primary gastric carcinomas occurring in 1 patient simultaneously, is low[1]. There have been infrequent recent reports multiple primary gastric carcinomas. Until now, little is known about the causes of multiple primary carcinomas. Although the exact mechanism responsible for the coexistence of these tumors is not clear, special carcinogens, H. pylori infection and genetic mutations have been considered agents capable of inducing the transformation of different cell lines from the gastrointestinal tract[2-4]. Family history, genetic factors, immunologic mechanisms, chemotherapy, and radiation therapy all likely contribute to the development of multiple carcinomas[5,6]. Further, a relationship between the carcinogenesis of multiple primary malignancies of the digestive tract and microsatellite instability has been shown[7,8].
Because multiple primary carcinomas have been detected increasingly with the development of new diagnostic techniques, we have learned that it is essential to thoroughly examine the patient both preoperative and postoperative and in the early stages of disease to ensure that incidental concomitant carcinomas are not overlooked. Therefore, gastric carcinoma patients should be carefully examined by endoscopy before surgery, and biopsies must be taken from any suspicious areas to see if other carcinomas coexist. Likewise, we recommend that careful preoperative examination, such as endoscopicultrasonography, colonoscopy, abdominopelvic contrast enhancement CT, and PET-CT be performed. In addition, better survival can be achieved by the early detection of associated primary carcinomas. Intraoperatively, surgical plans may need to be altered due to the incidental discovery of an unexpected concomitant tumor. After surgery, careful postoperative examination, at least in the first year after the diagnosis of gastric carcinoma, is essential[9-11].
As cancer therapy advances, it brings about a progressively larger percentage of long-term survivors, and the number of the patients with multiple primary carcinomas will increase over time. Early diagnosis of the multiple primary carcinomas, based on an awareness of the possibility of second and third cancers, and multidisciplinary treatment strategies will substantially increase patient survival[12].
Conflict of interest statement
No potential conflicts of interest were disclosed.
- Received December 4, 2009.
- Accepted January 25, 2010.
- Copyright © 2010 by Tianjin Medical University Cancer Institute & Hospital and Springer
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