Multiple primary carcinomas of the colon and associated extracolonic primary malignant tumors

Double versus Single Primary Malignant Neoplasm of Breast and Colorectal Cancer: A Case-Control Study

PURPOSE

Breast cancer (BC) and colorectal cancer (CRC) are common in female. This study compared survival time between women affected with both cancers with ones with single BC or single CRC.

METHOD

Medical records of subjects with both BC & CRC (June 1, 2010, to June 30, 2021) were reviewed. Age-matched subjects who had BC or CRC alone were used as control. Survival analysis using Kaplan-Meier method was performed.

RESULT

There were 63 double cancers [40 BC first (DBC): 23 CRC first (DCRC), mean age±SD 60.5±9.9 and 60.9±12.2 years] and 76 subjects in single cancer group [53 SBC: 23 SCRC, mean age 57.4±11.3 and 61.1±12.5 years]. The 5-year survival rate of the double cancer group was 74.6% and the single cancer group was 63.2%. D-group had slightly longer survival time than S-group (116.5±4.0 vs. 101.3±5.5, p=0.055). In D-group, the occurrence of addition of other primary cancers were more common (p=0.015). The second cancer occurred 61.7±45.3 months later in DBC group, and 39.1±26.6 months later in DCRC group (p=0.016). SCRC had shorter survival time vs. DCRC group (p=0.031). SBC and DBC had no different in mean survival time.

CONCLUSION

BC and CRC could occur as a part of multiple primary cancers. Detection of more than one cancer did not lead to decrease survival if the second cancer was early detected and treated. The occurrence of the second cancer might be beyond 5 years after the diagnosis of the first cancer. Thus, longer surveillance may be warranted. Awareness and provision of early screening should be offered to individuals diagnosed with either primary cancer. Detection of more than one cancer did not lead to shorter survival.

Second primary colorectal cancer in adults: a SEER analysis of incidence and outcomes

BACKGROUND

At present, there was no large epidemiological study exploring the actual incidence and survival of second primary colorectal cancer (spCRC). The different characteristics and survival of patients with spCRC and initial primary colorectal cancer (ipCRC) still need to be elucidated. In addition, the factors leading to different survival status of spCRC and ipCRC were still unclear. Our study plan to explore the annual incidence trend of spCRC as well as the factors influencing the occurrence and survival outcome of spCRC.

METHODS

This cohort study analyzed the data of 4680 spCRC patients and 330,937 initial primary colorectal cancer (ipCRC) patients. Whether patients had spCRC and whether spCRC patients survived or died were regarded as outcomes. The annual incidence of spCRC from 2004 to 2016 was analyzed by Jointpoint regression analysis. The truncation points were found, and the annual percentage change (APC) of each segment was calculated to explore the trend of spCRC change in the United States. Univariate and multivariable cox regression analyses were conducted to identify factors associated with the occurrence and prognosis of spCRC patients.

RESULTS

The total incidence of spCRC was decreased during 2000-2016 on the whole. The overall incidence of spCRC was lowered in both males and females despite 2013-2014, in the left colon, right colon, rectum and others. The incidence of spCRC was decreased in both 18-49 years' people and ≥ 50 years' people during 2000-2016, and the incidence of spCRC in the ≥ 50 years' people group was higher than those of 18-49 years. Insured (OR = 0.867 (0.778-0.966), initial primary site of other digestive (OR = 0.46, 95%CI: 0.42-0.50), rectum (OR = 0.74, 95%CI: 0.66-0.82), or right colon (OR = 0.73, 95%CI: 0.68-0.79), N 1 stage (OR = 0.87, 95%CI: 0.76-0.99), M 1 stage (OR = 0.49, 95%CI: 0.30-0.80), AJCC II stage (OR = 0.70, 95%CI: 0.60-0.82), AJCC III stage (OR = 0.69, 95%CI: 0.56-0.84), and radiation (OR = 0.69, 95%CI: 0.57-0.83) were associated with the risk of spCRC. At the end of follow-up, 2,246 spCRC patients were survived and 2,434 spCRC patients were dead. Patients with spCRC had poor survival probability than patients with ipCRC. Older age (HR = 1.02, 95%CI: 1.02-1.03), male (HR = 1.13, 95%CI: 1.04-1.23), Black (HR = 1.20, 95%CI: 1.06-1.35), uninsured (HR = 1.36, 95%CI: 1.16-1.59), Signet ring cell carcinoma (HR = 1.64, 95%CI: 1.19-2.25), T4 stage (HR = 1.63, 95%CI: 1.32-2.01), N2 stage (HR = 1.36, 95%CI: 1.08-1.72), M1 stage (HR = 4.51, 95%CI: 2.00-10.18), AJCC III (HR = 1.47, 95%CI: 1.08-1.98), and radiation (HR = 1.82, 95%CI: 1.43-2.33) were associated with increased risk of mortality in spCRC patients.

CONCLUSION

The incidence of spCRC was decreased except in people with initial primary tumor grade IV and those aged 15-39 years. The overall survival of spCRC patients was lower than ipCRC patients. Cancer patients with older age, high tumor grade, TNM stage, and AJCC stage should be caution to the occurrence of spCRC and timely interventions should be provided for spCRC patients to improve their outcomes.

Radiotherapeutic Management of Synchronous Prostate and Rectal Cancers Using Proton Beam Therapy

Treatment of synchronous prostate and rectal cancers is a rare yet challenging problem with compounded toxicities. We report a case of a 65-year-old man who underwent proton beam therapy (PBT) with concurrent capecitabine and hormonal therapy for his synchronously found prostate (intermediate-risk) and rectal (cT2, N2b, stage IIIB) cancers; he also received low anterior resection. Before PBT, the patient experienced hematochezia. His baseline American Urological Association symptom score was a total of 0, and he was not sexually active. He completed PBT with grade 1 acute toxicities including fatigue, nausea, and increased urinary and bowel frequencies. He also developed mild anemia (10.7), which was resolved. Subsequent surgical pathology showed a pathologic complete response in his rectum. At follow-up of 2.5 years, he remained disease-free on surveillance imaging for both malignancies and reported increased bowel urgency and frequency, minimal urinary leakage when having urgency, and peripheral neuropathy. This case, along with a succinct literature review, demonstrates that PBT can be successful in the definitive treatment of synchronous prostate and rectal cancers with minimal toxicities. Further research is required to evaluate the efficacy and side effect profiles of PBT.

A Rare Occurrence of Three Primary Malignancies of the Rectum, Breast, and Kidney in the Same Patient: A Case Report and Review of the Literature

An increasing number of patients with multiple primary cancers are encountered due to improved cancer detection, widespread cancer screening, and better cancer treatment. Here, we report such a patient without a family history of malignancies or a known genetic predisposition developing three primary malignancies of the rectum, breast, and kidney. A 63-year-old female who underwent an anterior resection for rectal cancer was detected to have an elevated carcinoembryonic antigen (CEA) level during a routine follow-up, 8 years after the initial surgery. Clinical examination revealed a left breast lump which was confirmed as invasive ductal carcinoma (pT3 pN0 cM0). Imaging and colonoscopy excluded a local recurrence. However, a right renal lesion suggestive of a renal cell carcinoma was detected (pT1a). She underwent left mastectomy with a sentinel lymph node biopsy and a right partial nephrectomy with a curative intent. Postoperatively, CEA levels declined to normal limits. Management of multiple primary malignancies poses a major challenge. A multidisciplinary approach and tailored decision-making for the individual patient help with the optimum outcome.

Analysis of Overall Survival in Patients With Multiple Primary Malignancies: A Single-center Experience

Introduction Multiple primary malignancies (MPMs) are seen in ~5% of all tumors. The aim of this study was to determine the quantitative impact on overall survival (OS) and treatment choices in patients with MPMs. Methods A retrospective analysis to determine patients with MPMs was conducted over a six-year period. Patients were defined as simultaneous MPMs if the second malignancy was discovered within 60 days of the first, and as sequential MPMs if discovered after 60 days of the first. Results Fifty-six patients with MPMs as defined above were identified, 38 (68%) simultaneous and 18 (32%) sequential. Development of second malignancy did not affect treatment in 47 (84%) of patients. Median OS after diagnosis of first malignancy was 13.0 months (95% confidence interval (CI) 10.3-15.8 months), compared to 10.6 months (95% CI 7.1-13.9 months) after the diagnosis of second malignancy. Median OS for the simultaneous MPM group was 13.5 months (95% CI 7.1-19.9 months), compared to 3.2 months (95% CI 0.0-9.8 months) for the sequential MPM group. Conclusions The development of a second malignancy impacts OS and treatment decisions. Patients who developed sequential MPM performed poorer than those who developed simultaneous MPM. This was likely in part due to effects of existing treatment on performance status as well as treatment preferences when second MPM is diagnosed (as many patients opted for supportive care after second MPM). Further analysis with larger patient cohorts is necessary to ascertain the aforementioned effects of OS and treatment options with respect to tumor pathology, stage, and performance status.

Do Patients with Second Primary Colorectal Cancer Hold the Similar Prognosis and Therapeutic Benefits as Those with Initial Primary Colorectal Cancer?

Aim

The objective is to compare the differences on prognosis and the therapeutic benefits between initial and second primary colorectal cancer (pCRC).

Methods

A dataset containing 377,271 initial pCRC cases and 18,617 second pCRC cases from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 1988-2015 was evaluated. Survival comparisons were made using the log-rank test. Cox proportional hazards models were used to assess the survival benefits.

Results

The cancer-specific survival rate of patients with initial pCRC was significantly higher than that of patients with second pCRC (5-years survival rate: 64.85% vs. 60.22%, P<0.001). The Chi-square of stratified log rank for age at diagnosis was lower than that for primary site, pTNM stage, sex, race, histology, and grade (Chi-square=86.73). There were almost no differences on therapeutic benefits between patients with initial and second pCRC except that treatments with chemotherapy were significantly associated with longer survival rate compared with treatments without chemotherapy among stage III surgical initial and second primary left-sided colon cancers patients (HR=0.764 vs. 0.581; P for interaction =0.008).

Conclusion

Patients with second pCRC have worse prognosis than those with initial pCRC primarily because of older age in the former group. The results evidenced that the therapeutic benefits on the prognosis for colorectal cancer were generally similar between patients with initial and second pCRC.

Colorectal cancer in cases of multiple primary cancers: Clinical features of 59 cases and point mutation analyses

The present study aimed to investigate the occurrence and clinical features of cases of multiple primary cancers including colorectal cancer (MPCC). The medical records of patients with colorectal cancer (CRC) who underwent surgery at the Third Xiangya Hospital of Central South University (Changsha, China) between August 2007 and August 2014 were retrospectively analyzed. Patients with MPCCs were identified and mutation analyses were performed on colon specimens. The results revealed that among 1,311 patients with CRC, 59 had MPCC (including 35 cases of ≥1 CRC with ≥1 other cancer type, and 24 cases with multiple CRCs and no other primary cancers). Foci occurred on the right side of the colon (n=32), in the rectum (n=28), and on the left side of the colon (n=24). MPCCs were synchronous in 24 patients, metachronous in 32 patients, and both in 3 patients. Age of onset and presence of polyps were identified as significantly different between MPCC and CRC overall (P<0.05); however, sex or adenoma incidence were not observed to differ significantly between groups. Mutation incidence rates in 26 specimens were 11.54% for KRAS proto-oncogene GTPase (KRAS) G13D, 3.85% for KRAS Q61R and 3.85% B-Raf proto-oncogene serine/threonine kinase V600E. Mutations of exon 21 of the epithelial growth factor receptor gene, including L858R and L861Q, and of KRAS G12V were not detected. In conclusion, the likelihood of occurrence of MPCC is closely associated with the age of onset and the presence of polyp(s). Routine examination of multiple systems is necessary for patients with CRC to avoid missed diagnosis and misdiagnosis. Further study is required to demonstrate the molecular mechanism of CRC in cases of multiple primary cancers.

Synchronous triple carcinoma of the colon and rectum

Synchronous multiple colorectal cancers are defined as multiple malignant colorectal tumors that occur simultaneously. All tumors are distant from each other, and none are the result of metastasis from other tumors. Here, we present a case of a 79-year-old man who was admitted to our hospital because of a 3-month history of abdominal pain associated with anemia, loss of appetite, and body weight loss. The patient did not have a family history of cancer. Computed tomography revealed bowel wall thickness and mesentery inflammation at the hepatic flexure of the colon and cecum. Colonoscopy revealed a tumor located 10 cm from the anal verge. Colonoscopic examination of the large bowel was not possible because of bowel obstruction due to the rectal tumor. Synchronous triple adenocarcinoma of the colon and rectum was confirmed by pathologic examination. The tumor was surgically resected by two-segment resection of the colon, low anterior resection, and right hemicolectomy. We used intraoperative colonoscopy to confirm that there were no other lesions after the resection of the three tumors. To the best of our knowledge, this is the first case of synchronous triple carcinoma of the colon and rectum in Taiwan. We consider that comprehensive preoperative study, extensive intraoperative exploration, and radical resection can increase the survival rate of patients with synchronous multiple colorectal cancers.

Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer

PURPOSE

To describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers.

METHODS AND MATERIALS

An Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination.

RESULTS

At 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal.

CONCLUSIONS

Chemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.

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.

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.

Clinical characteristics of patients with sporadic colorectal cancer and primary cancers of other organs

Most cancer patients often neglect the possibility of secondary cancer. Colorectal cancer (CRC) is the third leading cause of cancer death in Taiwan. It is important to be aware of the clinical characteristics of double cancer in CRC patients for early diagnosis and treatment. We retrospectively analyzed 1,031 CRC patients who underwent surgical treatment at the Department of Surgery of Kaohsiung Medical University Hospital between January 1998 and December 2004. Among these patients, CRC was accompanied by cancer of other organs in 17 patients (1.65%), either synchronously or metachronously. Therefore, we describe our experience regarding the location of CRC, the clinical symptoms and signs of these patients, the TNM stage, histology, phase, association with other malignancies, interval between cancers and clinical outcomes. Of the 17 patients in whom CRC was accompanied by primary cancer of other organs, there were four synchronous and 13 metachronous multiple cancer patients. Our patient group comprised six men and 11 women with ages ranging from 47 to 88 years (median age, 66 years). The most common location of CRC was the sigmoid colon. Six gastric cancers (35.2%) and six breast cancers (35.2%) were associated with primary CRC. The remaining six second primary cancers were one lung cancer, one thyroid cancer, one cervical cancer, one ovarian cancer, one skin cancer, and one urinary bladder cancer. Of the 13 metachronous multiple cancer patients, eight patients developed subsequent CRC after primary cancers of other organs, whereas two patients developed a subsequent second primary cancer after CRC. The intervals between the development of metachronous multiple cancers ranged from 2 to 19 years. In this retrospective analysis, breast and gastric cancer patients were at increased risk of developing subsequent secondary CRC. Careful attention should always be paid to the possibility of secondary CRC in treating these cancer patients. Cancer patients with hematochezia or gastrointestinal symptoms/signs should be evaluated for the possibility of second primary CRC during their regular follow-up.

Synchronous early primary adenocarcinoma of both rectum and gallbladder. Report of a case

Background

Synchronous early primary cancers are rare and in addition synchronous adenocarcinoma of both rectum and gallbladder is extremely rare.

Case report

We report an unusual case of synchronous early primary adenocarcinoma of rectum and gallbladder. The patient was a 72-year-old woman with complaints of bloody stools and constipation. An endoscopy revealed adenocarcinoma of the lower rectum. A through preoperative investigation showed also cholelithiasis. The patient underwent abdominoperineal resection and cholecystectomy. The histopathological diagnosis was well to middle differentiate adenocarcinoma of the gallbladder (T2, N0, M0; stage II) and middle differentiate adenocarcinoma of the rectum (T2, N0, M0; stage II).

Conclusion

For the cases of extracolonic primary cancer associated with colorectal primary carcinoma, Warren and Gates' diagnostic criteria are used. All patients with colorectal carcinoma, should undergo a throughout preoperative examination to exclude the possibility of synchronous early primary cancers.

Multiple primary malignancies involving lung cancer-clinical characteristics and prognosis

The incidence of multiple primary malignancies has increased in recent decades. The present study attempts to determine the clinical characteristics, the smoking factor, prognosis and temporal relationship of lung cancer to other cancers in patients with multiple primary malignancies. A total of 193 patients with multiple primary cancers involving lung cancer were found among 22,405 cancer cases diagnosed in Taipei Veterans General Hospital, between 1993 and 1997. Patients' clinical characteristics, smoking habit, tumor location, lung cancer histology, staging and survival were recorded and analyzed. The results showed that smoking is a significant risk factor for the development of multiple primary malignancies involving lung cancer (P<0.001). Of the 193 patients in this study, 51 had lung cancer diagnosed before the occurrence of other primary cancers (lung cancer first group, LCF group) and the remaining 142 patients had another cancer site develop ahead of the lung cancer (other cancer first group, OCF group). There was a significant difference between the time of the diagnosis of the first primary cancer to that of the second primary cancer in the LCF group and in the OCF group (median 10 vs. 46 months, P<0.001). For lung cancer staging, 53.3% of LCF patients suffered from stage I-II lung cancer, while 24.5% of OCF patients suffered from stage I-II lung cancer. Upper aerodigestive tract tumors were the most frequent tumors accompanying lung cancer, followed by colorectal and cervical cancer. Patients with cervical cancer were at a higher risk of developing lung cancer. Median survival was 65 months in the LCF patients and 81 months in the OCF patients, when calculated from the diagnosis of the first cancer (P=0.558). Median survival was 36 and 14 months, respectively, when calculated from the diagnosis of the second cancer (P=0.081). Median survival (37 vs. 14 months, P=0.085) and 3-year survival (62.5 vs. 25.4%, P=0.002), calculated from the diagnosis of the second primary lung cancer, was better in those LCF patients who developed another primary lung cancer than in the OCF patients who developed a second primary lung cancer. In conclusion, smoking is a risk factor for the development of multiple primary cancers. Upper aerodigestive tract cancer, colorectal cancer and cervical cancer were the tumors most frequently accompanying lung cancer. The staging status and median survival of patients who had a second primary lung cancer were better than in the general lung cancer population. Careful follow-up and intensive treatment is suggested for these patients.

Results of a screening program for prostate cancer in patients scheduled for abdominoperineal resection for colorectal pathologic findings

OBJECTIVES

Because of the difficulty of accessing the prostate for tissue sampling after surgical removal of the rectum and obliteration of the anus, we started an early detection program for prostate cancer in all men scheduled for abdominoperineal resection.

METHODS

Twenty consecutive men were screened for prostatic adenocarcinoma before planned abdominoperineal resection for colorectal pathologic findings. Patients were 48 to 77 years old (mean 66.9). Screening included serum prostate-specific antigen determination and digital rectal examination. Those patients with suspicious findings underwent transrectal ultrasound-guided sextant biopsies of the prostate.

RESULTS

One patient was excluded because of a prior history of prostate cancer. Six (31.6%) of the remaining 19 patients demonstrated elevated prostate-specific antigen levels (greater than 4.0 ng/mL); two of these patients also had an abnormal digital rectal examination. Transrectal ultrasound and prostate biopsies in these 6 patients revealed prostatic adenocarcinoma in 3 patients (50% of those undergoing biopsies or 15.8% of those screened). The 13 patients who did not undergo prostate biopsies had prostate-specific antigen levels from 0.4 to 2.4 ng/mL (mean 0.9) and normal prostate glands according to the digital rectal examinations.

CONCLUSIONS

Screening for prostate cancer in men 50 years old or older with 10 years or longer life expectancy before they undergo abdominoperineal resection detects a significant number of prostatic malignancies and should be encouraged.

External beam radiotherapy for synchronous rectal and prostatic tumors

Two patients were diagnosed with large rectal tumors and localized prostate cancer. The prostate-specific antigen level at diagnosis was 7.9 ng/mL and 9.0 ng/mL in the 2 patients. Knowledge of the presence of both tumors and their close proximity allowed creation of a modified three-dimensional conformal radiotherapy plan to treat both tumors. The patients had no evidence of rectal tumor recurrence and their prostate-specific antigen level was 0.5 ng/mL and 0.7 ng/mL at 1 and 2 years after therapy, respectively. We conclude that efficient, effective pelvic irradiation can be designed for synchronous rectal and prostate malignancies.

Predictive factors for detecting colorectal carcinomas in surveillance colonoscopy after colorectal cancer surgery

PURPOSE

The aim of this study was to identify the high-risk groups for metachronous colorectal carcinoma among patients who undergo colorectal cancer surgery.

METHODS

Three hundred forty-one patients undergoing colorectal cancer surgery who had undergone surveillance colonoscopy at least twice during a period of more than three years were analyzed. A metachronous colorectal carcinoma was defined as a new colorectal carcinoma detected by surveillance colonoscopy after surgery.

RESULTS

Surveillance colonoscopy was performed 4.6 times per patient during an average of 6.2 years. Twenty-two metachronous colorectal carcinomas in 19 patients were detected, and 14 (64 percent) of 22 were detected within five years of surgery. The cumulative incidence of developing colorectal carcinomas during a five-year period was 5.3 percent. Seventeen (77 percent) of 22 carcinomas were 10 mm or less in size. Ten (71 percent) of the 14 carcinomas in early stages showed a flat appearance. Univariate analysis showed that extracolonic malignancy, coexistence of adenoma, and synchronous multiple colorectal carcinoma were significant predictive factors for detecting colorectal carcinomas in surveillance colonoscopy and that family history of colorectal carcinoma was a possible predictive factor. Multivariate analysis performed with Cox proportional hazards regression model showed that extracolonic malignancy and the coexistence of adenoma were significant predictive factors.

CONCLUSION

We recommend that patients with the above predictive factors receive surveillance colonoscopy meticulously and regularly.

Five primary synchronous neoplasms of the gastrointestinal tract

Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past hundred years. The lesions can be limited to a single organ or involve multiple organ systems. It is relatively common for patients with colorectal carcinoma or carcinoid tumors to have more than one primary neoplasm. Colonic lesions can be synchronous or metachronous in presentation and colonic or extracolonic in location. We present a patient with five primary synchronous neoplasms of the gastrointestinal tract, involving the stomach, small bowel, and colon. The patient had no evidence of metastatic disease and underwent resection of all the lesions. This case illustrates the need for a thorough search for additional neoplasms in the treatment of patients with cancer.

Surveillance of colorectal cancer: effectiveness of early detection of intraluminal recurrences on prognosis and survival of patients treated for cure

PURPOSE

The authors evaluate the effectiveness of routine colonoscopy and marker evaluation in diagnosis of intraluminal recurrent cancer.

METHODS

Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Clinical visits were scheduled and carcinoembryonic antigen evaluation was performed every three months, and colonoscopy was performed preoperatively, 12 to 15 months after surgical treatment, and then with intervals of 12 to 24 months or when symptoms appeared.

RESULTS

About 10 percent of patients developed intraluminal recurrences. More than one-half of metachronous lesions arose within the first 24 months, and median time to diagnosis was 25 months. Patients with left-sited tumors in the advanced stage had a higher risk of developing recurrent intraluminal disease. Twenty-nine patients underwent a second surgical operation, of which 17 cases were radical. In this group, the five-year survival was 70.6 percent, although no nonradically treated or nonresected patients survived longer than 31 months. Twenty-two patients were asymptomatic at time of diagnosis of recurrence, and of these, 12 patients underwent radical operation; on the other hand, of the 24 symptomatic patients, only 5 were treated radically. Carcinoembryonic antigen was the first sign of recurrence in eight cases. Colonoscopy must be performed within the first 12 to 15 months after operation, whereas an interval of 24 months between examinations seems sufficient to guarantee early detection of metachronous lesions.

CONCLUSION

Serial tumor marker evaluation is of help in earlier diagnosis of local recurrences. Asymptomatic patients more frequently undergo another operation for cure and thus have a better survival rate.

Survival in colorectal carcinoma associated with previous extracolonic cancer

Between 1971 and 1990, 1198 patients presented with a primary colorectal cancer, of whom 70 patients (5.8%) had survived previous extracolonic primary malignancies. Complete data were available on 63 cases (metachronous group) of the 70 patients, who had a total of 67 previous extracolonic cancers. Clinical and pathological characteristics of these cases were identical to the remaining patients with primary colorectal cancer (primary group, n = 1128), except that the former group was significantly older, P < 0.05. In the metachronous group there was a preponderance of breast, female genital, gastric, urological, lung and skin cancers, and the median time to develop a colorectal primary tumour was 7 years. The 5-year overall actuarial survival was better in the metachronous group, log rank test: chi 2 = 4.07, P = 0.04. In the metachronous group, 44 patients who had undergone curative resection were matched with patients with primary colorectal cancer (control group, n = 88) in the ratio of 1:2 based on age, sex, tumour site, Dukes' stage, tumour differentiation, grade of surgeon and date of operation. Comparison between these groups showed a significantly better survival in the former group, log rank test: chi 2 = 5.99, P = 0.01. These results suggest that patients with colorectal cancer and a history of previous extracolonic tumours have similar clinicopathological features as the general colorectal cancer population but have a better survival.

Colorectal carcinoma: importance of clinical and pathological factors in survival

A series of clinicopathological variables was assessed on 312 patients undergoing surgical resection for primary colorectal cancer. Although the presence of venous invasion was related to mortality (P = 0.02), classifying invasion into involvement of thick-walled or thin-walled veins did not produce a variable of prognostic value. Intestinal obstruction (P = 0.04) and the macroscopic appearance of the tumour (P = 0.04) were related to mortality from colorectal cancer, but not from all causes of death. Duke's stage, increasing patient age and poorly differentiated tumours were the variables which were individually most significantly related to poor prognosis (P < 0.001 for each analysis). Cox's regression analysis identified these three variables as independent predictors of outcome in colorectal cancer. This study confirms that Duke's stage, patient age and tumour differentiation are still the most important clinicopathological variables in colorectal cancer.

Sacral chordoma developing two years after low anterior resection for rectal cancer

A 43-year-old male with sacral chordoma associated with rectal cancer is herein reported. A presacral tumor with extensive destruction of S4 and S5 was found 2.5 years after a low anterior resection for advanced rectal mucinous carcinoma. Under the preoperative diagnosis of a solitary sacral metastasis of rectal cancer, the lower sacral segments together with the tumor were removed by amputation at S3. Histologically, the tumor was a chordoma composed of polyhedral cells with an abundant eosinophilic cytoplasm mixed with typical vacuolated physaliferous cells within a myxoid matrix. Colorectal cancer associated with an extracolic primary malignant neoplasm is not uncommon; however, this is only the second case of colorectal cancer associated with chordoma to the best of our knowledge.

Multiple colorectal carcinomas and colorectal carcinoma associated with extracolonic malignancies

In this study, we analyzed 149 surgical cases of colorectal cancer between January 1983 and August 1989. Thirteen cases (8.7 percent) of colorectal primary cancer associated with extracolonic primary malignancy of 14 lesions and 10 cases (6.7 percent) of multiple primary colorectal cancers were included. Among the 14 lesions of extracolonic primary malignancy, there were 6 gastric carcinomas, 2 endometrial carcinomas, 2 urinary bladder carcinomas, and one each in the esophagus, liver, bile duct and jejunum. The second tumor was not detected preoperatively in 3 of 4 cases of synchronous multiple primary colorectal carcinoma. A curative resection was done in 10 (77 percent) out of 13 cases of colorectal cancer associated with extracolonic malignancy, while 7 (88 percent) out of 8 cases of multiple colorectal cancers had a curative resection. Nine patients (69 percent) with colorectal cancer associated with extracolonic malignancy were disease-free for 2 months to 14 years. Seven patients (88 percent) with multiple colorectal cancers were disease-free for one to 22 years. We recommend, therefore, that in any patient with colorectal cancer, the entire large bowel should be thoroughly searched for any other primary tumors, by taking the existence of extracolonic tumors into account. A curative resection should be performed, and the follow-up period should be life-long.

Spatial clustering of multiple hyperplastic, adenomatous, and malignant colonic polyps in individual patients

Analysis of relative polyp locations in 426 consecutive patients with multiple colonic polyps found on colonoscopy showed novel findings. First, synchronous and metachronous neoplastic polyps showed spatial clustering in individual patients. For example, patients with their largest neoplasm in the cecum or proximal ascending colon, had 34.3 percent +/- 4.6 percent (standard error) of their other colonic neoplasms in the same location. Second, hyperplastic polyps showed spatial clustering in individuals that was statistically significantly greater than expected from the increased hyperplastic polyp concentration in the rectum and sigmoid. Third, hyperplastic polyps showed spatial clustering with neoplastic polyps; this clustering was similar in magnitude to clustering for exclusively hyperplastic or neoplastic polyps. In contrast, lipomas were not spatially clustered with hyperplastic and neoplastic polyps. The magnitude of clustering between hyperplasia and neoplasia showed a closer association between these histologic types than previously appreciated. Because of clustering, regions with prior polyps appear to merit closer surveillance. These findings suggest clinical study, using a randomized controlled clinical trial, of whether a patient who had only rectal and sigmoid adenomas on initial and follow-up colonoscopy should have surveillance with flexible sigmoidoscopy alternating annually with colonoscopy. A patient with a prior cecal adenoma should have surveillance only with a complete colonoscopy or adequate cecal views on barium enema.

Multiple adenocarcinomas of the colon and rectum. An analysis of incidences and current trends

Three hundred forty-five colorectal cancers were identified in 320 patients over a nine-year period. Twenty-one patients (7 percent) had synchronous cancers. Metachronous cancers were identified in five patients (2 percent). Thirteen of the synchronous cancers were foci of invasive adenocarcinoma in polyps with elements of benign neoplastic tissue. There was a trend for younger patients to have multiple colon cancers. Fifteen percent of the synchronous colon cancer patients were less than 50 years of age. The mean age of patients who presented with metachronous cancer was 54, and 11 years was the average time interval between the diagnosis of the initial and the metachronous tumor. Colonoscopy proved to be more reliable than barium-enema examinations in identifying synchronous cancers. It is concluded from this review that before elective resections, colonoscopy should be used to effectively screen patients for synchronous cancers, and following curative resection, the residual colon should be periodically examined for the remainder of the patient's life.

Multiple primary malignant tumors

Members of colon cancer-prone nonpolyposis families who had multiple primary malignant tumors were analyzed to determine the frequencies, locations, and stages of their cancers, and the duration of their survival. Colon cancers tended to be more proximal, were in a less advanced stage than in the general population, and in a majority of instances were associated with colonic adenomas. The multiple primary malignant tumors were more common in women, and occurred at a younger age than in the general population. Six or more multiple primary malignant tumors occurred in each of 4 patients. All patients survived for more than 10 yr after the diagnosis of the first cancer. Extracolonic cancers were most frequent in the breast and endometrium.

Origin of multiple "primary" colon carcinomas. A retrospective flow cytometric study

Multiple, synchronous, apparently primary carcinomas of the colon are a relatively common occurrence. The DNA ploidy in 23 colon carcinomas from 10 patients was determined to see if this parameter supported common or independent origins for such synchronous lesions. Paraffin blocks of each tumor were prepared for flow cytometry, then analyzed for nuclear DNA content. In 3 of the 10 cases, the tumors within each colon differed with respect to DNA ploidy; in four cases all tumors were diploid; and in three cases both (all) tumors within each colon had identical aneuploid DNA indices. Tumors from the same colon with identical DNA histograms often had dissimilar histology. The replicate aneuploid DNA indices strongly suggest a common origin for the multiple tumors within these colons; tumors in the other groups are compatible with either single or multiple origins. These findings suggest that multiple "primary" colon carcinomas may, in some cases, arise as translumenal metastases from an initial single lesion.

Quintuple synchronous colon carcinoma: a report of two cases

Two patients with five synchronous colon cancers are reported. The diagnostic and surgical approach to synchronous colorectal tumors is discussed.

Colorectal tumor screening in women with a past history of breast, uterine, or ovarian malignancies

Epidemiologic studies have shown that women who have successfully recovered from breast, uterine, or ovarian cancer have about twice the expected risk of developing colorectal cancer. These high-risk women were entered, therefore, into a large bowel screening program based on fecal occult blood detection, flexible sigmoidoscopy, and colonoscopy, when appropriate. The study group consisted of 183 women and the results were compared with 252 comparison subjects of similar age and ethnic origin. Neoplastic lesions, adenomatous polyps, or cancer were 2.5 times more frequent in the study group. However, for the largest group, women with a past history of breast cancer, the relative risk, adjusted for a family history of gastrointestinal cancer, was 3.0 (P = 0.03). This pilot study confirms the value of continuing to screen these patients, especially those with a positive family history of gastrointestinal malignancies. However, for psychological and administrative reasons, it may be better that their colon screening be integrated into a combined colon, breast, and gynecologic tumor follow-up, and not be part of a separate service.

A comparison of multiple synchronous colorectal cancer in ulcerative colitis, familial polyposis coli, and de novo cancer

Multiple synchronous colorectal cancer (MSCC) among 1537 patients (69 with familial polyposis coli (FPC), 780 with ulcerative colitis (UC), and 685 with de novo colorectal (DNC) cancers) admitted to The Mount Sinai Hospital between 1945 and 1981 was tabulated. MSCC occurred in five of 24 cancer patients with FPC (21%), in 12 of 65 cancer patients with UC (18%), but in only 17 of 685 DNC patients (2.5%). The proportions of MSCC cases with more than two synchronous tumors were also much greater in the former two groups (UC 6/12 = 50%, FPC 3/5 = 60%) than in DNC (0/17 = 0%). Multiplicity of cancers is thus a distinguishing feature of UC and FPC. MSCC differed from solitary cancers by association with older age and more advanced stage at diagnosis in patients with FPC and by a rightward shift in anatomic distribution in all patients, especially those with FPC and UC.

Multiple primary malignant tumors involving the large bowel

We reviewed 5680 autopsy protocols in order to determine the frequency of Multiple Primary Malignant Tumors (MPMT) in different organs. The large bowel was the organ most frequently involved, making up to 32 per cent of all MPMT cases. Of 26 patients with colorectal MPMT, six were multicentric in the large bowel, and 20 were associated with extracolonic malignancies. The tissues harboring primary malignancies were, in order of decreasing frequency, liver, lung, and female and male reproductive organs. We compared the exact location of large bowel cancers in patients with and without a prior cholecystectomy; there was no statistically significant difference between the two groups, especially for right-sided colonic carcinoma in women.

Synchronous and metachronous malignancies of the colon and rectum in Japan with special reference to a coexisting early cancer

The authors reviewed the medical records of 1005 patients with multiple colorectal cancers (763 synchronous and 242 metachronous) to study the number and site of the tumors, their preoperative detectability, and the results of treatment. Concurrent advanced cancers were found in 35.1%, concurrent advanced and early cancers in 59.0%, and concurrent early cancers in 5.9% of patients with synchronous malignancy. In 60.1% of these patients, the existence of multiple lesions was diagnosed preoperatively; coexisting early cancers were often overlooked. In patients with metachronous malignancy, early cancers were less frequent than in patients with synchronous malignancy. The cumulative 5-year survival rate in curatively operated patients was 70.4% for synchronous malignancy and 66.5% for metachronous malignancy, similar to that for colon cancer in general.

The true incidence of synchronous cancer of the large bowel. A prospective study

The reported incidence of synchronous primary cancers and polyps associated with single cancers of the large bowel is varied. In a prospective study over a 5 year period, 166 patients with primary colorectal cancer had either total colonoscopy preoperatively or total colonoscopy within 6 months of surgical resection. One hundred seventy-eight cancers were detected. Synchronous cancers were found in eight patients (5 percent), and benign neoplastic polyps were demonstrated in 46 patients with single cancers (28 percent) and in 112 patients with synchronous primary cancers (38 percent). Of significance is that seven of eight (88 percent) synchronous cancers would not have been included in the standard resection for the index primary cancer. Similarly 31 of 46 neoplastic polyps (67 percent) were not in the same surgical segment as the primary cancer. Total large bowel evaluation, preferably using colonoscopy, is essential in all patients with cancer of the large bowel.

Subtotal colectomy for obstructing carcinoma of the left colon

This retrospective review of seven patients with completely obstructing cancers of the left half of the colon, in addition to other reports in the literature, suggests that subtotal colectomy with primary ileal proctostomy may be the treatment of choice for those lesions that are technically resectable and located high enough to permit an intraperitoneal ileal proctostomy. The morbidity and mortality is less than that seen with the staged approach and the length of hospitalization is shorter. By eliminating a second or third hospitalization and a temporary colostomy, palliation is better in those patients who ultimately die from recurrent cancer. Furthermore, those patients resected for cure may have increased rates of long-term survival.