Multiple primary malignancies (MPM) was
first described by Billroth at the end of the
19th century.
1 MPM is considered when:
each of the tumors represents a definite pattern
of malignant disease; each malignancy is
distinct; and the possibility of one tumor
being a metastasis of the other has been
excluded.
2 Synchronous malignant tumors
are diagnosed simultaneously or within an
interval of six months.
3 We report a case of
a patient with synchronous malignancies of
the transverse colon and the renal pelvis.
Clinical features
A 52 year-old female was admitted in our
hospital with a chief complaint of abdominal
mass. She had episodes of hematochezia for
two years, with no previous consultations nor
medical intervention. Four months prior to
admission, she noticed an approximately 2 x
2 cm supraumbilical mass that gradually
increased in size, associated with epigastric
and periumbilical pain and weight loss, which
prompted her to seek consultation.
The patient had no history of vomiting,
obstipation, dysuria, hematuria, or flank
pains. Her past medical and family history
were unremarkable. She denied any history
of smoking, alcoholic beverage drinking,
drug abuse, or exposure to toxic chemicals.
Physical examination revealed pale palpebral
conjunctivae, and flabby, soft and non-tender
abdomen. We were able to palpate a hard,
mobile, non-tender, irregular 4 x 4 cm mass
in the supraumbilical area.
Diagnostic approaches
We requested for multiple hematologic and
biochemical tests, which only revealed anemia
(hemoglobin 8.4 g/dL). A barium enema
was initially done, revealing a narrowing in
the transverse colon, measuring 5.6 cm in
length, with an apple-core appearance. We
requested an abdominal CT scan, which
showed an enhancing mass measuring 5.9 x
3.1 cm in the transverse colon, with multiple
enhancing nodular densities in the transverse
mesentery. The scan further revealed a well-
defined, lobulated enhancing mass in the
middle and inferior segments of the right
kidney, with internal calcification measuring
4 x 3.9 x 4.4 cm (Figure 1). The patient's
urinalysis results revealed microscopic
hematuria and bacteriuria. The other
diagnostic work-ups that we did, including
chest X-ray, and carcinoembryogenic antigen
(CEA) and alkaline phosphatase levels, were
all within normal limits.
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Figure 1
CT scan of the whole abdomen showing transverse colon mass with luminal narrowing
(A and B: red ring) and multiple mesenteric adenopathies (C: yellow ring).
The scan further shows a mass in the right kidney (D: blue ring).
|
Therapeutic approaches
We corrected the anemia of the patient by
transfusing 600 mL of packed red blood
cells. Hemoglobin post-transfusion was 10.1
g/dL. The patient underwent an extended
right hemicolectomy and right radical nephrectomy.
The biopsy specimen from the hemicolectomy
(Figure 2) was composed of a portion
of the terminal ileum, cecum with the
appendix, ascending colon, and part of the
transverse colon, with pericolic fat and the
mesentery. Grossly, the intestines measured
28 x 12.3 x 7 cm. The mass measured 5 x 5.6
cm, and it occupied more than 50% of the
largest diameter of the intestine. There were
42 lymph nodes isolated, with the largest
measuring 1.3 cm. Based on the intraoperative
findings, we staged the transverse colon
mass as a IIA carcinoma.
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Figure 2
Gross appearance of the terminal ileum, cecum with the appendix, ascending
colon, and part of the transverse colon, with pericolic fat and the mesentery.
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On the other hand, the specimen from
the nephrectomy (Figure 3) was composed
of the right renal tissue measuring 9.6 x 5.0 x
5.5 cm, with intact capsule, perinephric tissue,
and an attached ureter. The specimen's
cut section revealed a tan, soft, cauliflowerlike
mass attached in the pelvis and major
calyces, measuring 6 cm in greatest dimension.
Based on the intraoperative findings,
we diagnosed the renal mass as a Stage II
carcinoma.
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Figure 3
Gross appearance of the right kidney, showing an irregularly shaped mass on cut
section.
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Table 1
Intraoperative and histopathologic staging of the patient's colonic and renal masses
|
| Specimen |
Intraoperative staging |
Histopathologic staging |
| Transverse colon |
Stage IIA carcinoma |
Stage IIA (pT3N0M0) |
| Right kidney |
Stage II carcinoma |
Stage III (T3N0M0) |
Outcomes
The patient was discharged 5 days after the
surgical procedures and had an unremarkable
post-operative course. Histopathologic findings
were released a week after surgery. The
intestinal specimen showed that all lines of
resection were devoid of tumor cells (Figure
4). The 42 isolated lymph nodes were all
negative for tumor cells. However, tumor cell
invasion was noted in the lymphatic and
perineural vessels, except for the blood vessels.
These findings were consistent with colon
adenocarcinoma stage IIA (pT3N0M0).
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Figure 4
High-power field view (x1000) of the colonic mass tissue showing irregular
glandular structures (orange ring) invading the underlying lamina propria.
These glands are lined by atypical columnar cells exhibiting increased
nuclear-to-cytoplasmic ratio, moderate nuclear pleomorphism, nuclear hyperchromatism,
and prominent nucleoli. There are areas showing moderate nuclear stratification
(orange ring) of up to four cell layers, and majority of the atypical nuclei
(yellow ring) have rounded to oval shape. There is a moderate degree of mononuclear
inflammation among the tumor cells.
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Sections from the renal mass revealed
fused, branching, and delicate papillae that
were lined by anaplastic transitional cells
with slightly pleomorphic nuclei (Figure 5).
There was invasion to the lymphatic vessels.
The blood vessels and ureter were free of
tumor cells. The histopathological findings
led to a diagnosis of urothelial cell carcinoma
of the right renal pelvis stage III
(T3N0M0).
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Figure 5
Microscopic views (A: x40, B: x100) of the renal mass tissue (B: upper left quadrant) showing
fused, branching, and delicate papillae (A: red ring).
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The surgical and histopathologic findings
(Table 1) were vital to the definitive diagnosis
for this patient's condition. Given the two
distinct histopathologic results, we considered
the patient as having synchronous
adenocarcinoma of the colon and urothelial
cell carcinoma. The patient was advised by
the colorectal team to start adjuvant chemotherapy
using the Mayo regimen six weeks
after her surgery. Chemotherapy is ongoing
as of this report. On the other hand, the
urology team plans to carry out a complete
oncologic resection of the urothelial cell
carcinoma, hence the patient was also
advised to undergo right ureterectomy with
bladder cuff post-chemotherapy.
Discussion
The association of colorectal carcinoma and
renal tumors has been previously described,
with incidence of 0.3% to 4.85%.
2 4 5 6
Among patients with urologic cancer, MPM
exists in 3.3% to 10.3%.
1 2 This is
the first documented case in our institution.
The exact mechanisms involved in the
occurrence of MPM are not yet fully
elucidated. DNA mismatch repair and overexpression
of tumor suppressor genes have
been proposed as possible mechanisms.
7
Risk factors for the development of this
condition include strong family history of
cancer, Lynch II syndrome, and environmental
factors such as tobacco, pollution,
exposure to asbestos, petroleum products,
heavy metals, ultraviolet light, therapeutic
chemotherapy, and radiotherapy.
8 9 Our
patient did not have any of the risk factors
mentioned.
Management of concomitant colonic and
kidney malignant masses involves simultaneous
radical resection of both malignancies
in one surgical session.
10 The usual
approach is by open laparotomy, but laparoscopic
resections have also been done.
11
For complete oncologic resection of the
tumor, nephroureterectomy is recommended
for urothelial cell carcinoma of the upper
urinary tract in a patient with a normal
functioning contralateral kidney.
12 13 Since
our patient did not present with symptoms
leading to a clinical suspicion of urothelial
cell carcinoma, we initially managed her as
having an incidental renal cell carcinoma, and
we only did a radical nephrectomy. Histopathologic
reports are crucial in establishing
whether one of two concomitant tumors is
metastatic from the other or both tumors are
primary.
9 In our patient, we have ruled out
metastatic neoplasms postoperatively, based
on the different histopathologic characteristics
of the two tumors. Upon confirmation
of the urothelial cell carcinoma
diagnosis, we advised our patient to undergo
ureterectomy with bladder cuff after adjuvant
chemotherapy.
Adjuvant chemotherapy is recommended
for stage IIA colorectal carcinoma to decrease
recurrence rate rather than prolong
survival.
14 Although controversial if used in
stage II colon cancer patients,
15 adjuvant
systemic chemotherapy improves survival for
high risk patients.
16 The recommended
follow-up post-operative diagnostics include:
monitoring of CEA level every three to six
months for two years, then every six months
for a total of five years; chest, abdominal,
and pelvic CT scan annually for up to five
years; and colonoscopy one year after
resection.
14As in our patient's case, a stage II colonic
adenocarcinoma has a 5-year recurrence rate
of 10%
17 and an observed 5-year survival
rate of 66.7%,
18 while stage III urothelial
carcinoma has a lower five-year survival rate
of 16-33%.
8 14 In one study, patients with
localized renal cancer with different coexisting
cancers had poorer overall survival
compared to those with localized renal carcinoma
alone.
3Conclusion
A patient presented to us with a palpable
abdominal mass, CT scan findings of a
colonic mass, and an incidental finding of a
right renal mass, hence we did an extended
right hemicolectomy and a right radical
nephrectomy in one setting. Post-operative
biopsy results revealed a stage IIA colon
adenocarcinoma and a stage III urothelial
carcinoma. A frozen section biopsy, which is
not routinely done for the surgical management
of renal masses, could have helped us
early on in coming up with a more accurate
intraoperative diagnosis. A suspicion of a
urothelial cell carcinoma would have provided
a good reason for considering a right
nephroureterectomy with bladder cuff at the
outset.
In essence
Synchronous malignancies is a rare condition, and the diagnosis
requires ruling out the possibility of a metastatic tumor.
In this case report, a diagnosis of synchronous malignancies
of the transverse colon and the renal pelvis on a patient who
presented with two masses was made post-operatively, after the
histopathologic results of the specimens were released.
A high index of suspicion for the possibility of synchronous
malignancies can facilitate accurate diagnoses and help provide
early definitive treatments.
Acknowledgments
We would like to acknowledge the consultants and fellows from the
Southern Philippines Medical Center (SPMC) Colon and Rectal
Surgery Section (Dr Orlando Basilio, Dr Robert Bandolon, Dr
Alyasher Unnoh, Dr Sharmaine Paragas, and Dr Chris George
Pales), and the consultants and fellows from the SPMC Urology
Section (Dr Victor Espino, Dr Michael Jonathan Latayan, Dr Manuel
Belisario, Dr Luis Antonio Balajadia, and Dr Alwidzrin
Jupli) for their
invaluable contributions to this report. We also gratefully acknowledge Dr Oscar P Grageda, Dr Marlon M Maramion, and Dr Ma Theresa A Fedoc of the SPMC Department of Pathology and Laboratories for their role in the diagnosis of our patient's condition.
Competing interests
None declared
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