Synchronous and metachronous colorectal carcinoma

Rare synchronous colorectal carcinoma with three pathological subtypes: A case report and review of the literature

BACKGROUND

Synchronous colorectal carcinomas (SCRC) are two or more primary colorectal carcinomas identified simultaneously or within 6 mo of the initial presentation in a single patient. Their incidence is low and the number of pathological types of SCRC is usually no more than two. It is very unusual that the pathological findings of a patient with SCRC show more than two different pathological subtypes. Here, we report a rare case of SCRC with three pathological subtypes.

CASE SUMMARY

A 75-year-old woman who had no previous medical history or family history was admitted to the hospital because of intermittent hematochezia for more than a month. Colonoscopy displayed an irregularly shaped neoplasm of the rectum, a tumor-like lesion causing intestinal stenosis in the descending colon, and a polypoidal neoplasm in the ileocecum. Subsequently, she underwent total colectomy, abdominoperineal resection for rectal cancer, and ileostomy. After operation, the pathological report showed three pathological subtypes including well-differentiated adenocarcinoma of the ascending colon, moderately differentiated adenocarcinoma of the descending colon, and mucinous adenocarcinoma of the rectum. She is now recovering well and continues to be closely monitored during follow-up.

CONCLUSION

Preoperative colonoscopy examination, imaging examination, and extensive intraoperative exploration play important roles in reducing the number of missed lesions.

Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp - The cross-sectional clinical study

The aim of this study was to evaluate the efficacy of endoscopic polypectomy as a therapeutic treatment for malignant alteration of colorectal polyps. In a 5-year research, 89 patients were included, who were tested and treated at the University Clinical Center Kragujevac, Kragujevac, Serbia, with the confirmed presence of malignant alteration polyps of the colon by colonoscopy, which were removed using the method of endoscopic polypectomy and confirmed by the histopathological examination of the entire polyp. After that, the same group of patients was monitored endoscopically within a certain period, controlling polypectomy locations and the occurrence of a possible remnant of the polyp, in the period of up to 2 years of polypectomy. We observed that, with an increasing size of polyps, there is also an increase in the percentage of the complexity of endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer. The highest percentage of incomplete endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer were shown at malignant altered polyps in the field of tubulovillous adenoma. Eighteen patients in total underwent the surgical intervention. In conclusion, our data support the high efficacy of endoscopic polypectomy for the removal of the altered malignant polyp.

Surgical outcomes of left hemicolon sparing resection versus extensive resection in treating synchronous colorectal cancer involving the right-sided colon and sigmoid colon or rectum

BACKGROUND

There are different surgical strategies that can treat synchronous colorectal cancer (SCRC) involving separate segments, namely extensive resection (EXT) and left hemicolon-sparing resection (LHS). We aim to comparatively analyze short-term surgical results, bowel function, and long-term oncological outcomes between SCRC patients treated with the two different surgical strategies.

METHODS

One hundred thirty-eight patients with SCRC lesions located in the right hemicolon and rectum or sigmoid colon were collected at the Cancer Hospital, Chinese Academy of Medical Sciences, and the Peking University First Hospital from January 2010 to August 2021 and divided into EXT group (n = 35) and LHS group (n = 103), depending on their surgical strategies. These two groups of patients were compared for postoperative complications, bowel function, the incidence of metachronous cancers, and prognosis.

RESULTS

The operative time for the LHS group was markedly shorter compared with the EXT group (268.6 vs. 316.9 min, P = 0.015). The post-surgery incidences of total Clavien-Dindo grade ≥ II complications and anastomotic leakage (AL) were 8.7 vs. 11.4% (P = 0.892) and 4.9 vs. 5.7% (P = 1.000) for the LHS and EXT groups, respectively. The mean number of daily bowel movements was significantly lower for the LHS group than for the EXT group (1.3 vs. 3.8, P < 0.001). The proportions of no low anterior resection syndrome (LARS), minor LARS, and major LARS for the LHS and EXT groups were 86.5 vs. 80.0%, 9.6 vs. 0%, and 3.8 vs. 20.0%, respectively (P = 0.037). No metachronous cancer was found in the residual left colon during the 51-month (median duration) follow-up period. The overall and disease-free survival rates at 5 years were 78.8% and 77.5% for the LHS group and 81.7% and 78.6% for the EXT group (P = 0.565, P = 0.712), respectively. Multivariate analysis further confirmed N stage, but not surgical strategy, as the risk factor that independently affected the patients' survival.

CONCLUSIONS

LHS appears to be a more appropriate surgical strategy for SCRC involving separate segments because it exhibited shorter operative time, no increase in the risk of AL and metachronous cancer, and no adverse long-term survival outcomes. More importantly, it could better retain bowel function and tended to reduce the severity of LARS and therefore improve the post-surgery life quality of SCRC patients.

Surgery for synchronous and metachronous colorectal cancer: segmental or extensive colectomy?

PURPOSE

To assess the impact of surgical approach on morbidity, mortality, and the oncological outcomes of synchronous (SC) and metachronous (MC) colorectal cancer (CRC).

METHODS

All patients undergoing resection for double location CRC (SC or MC) between 2006 and 2020 were included. The exclusion criteria were polyposis or SC located on the same side.

RESULTS

Sixty-seven patients (age, 64.8 years; male, 78%) with SC (n = 41; 61%) or MC (n = 26; 39%) were included. SC was treated with segmental colectomy (right and left colectomy/proctectomy; n = 19) or extensive colectomy (subtotal/total colectomy or restorative proctocolectomy with pouch; n = 22). Segmental colectomy was associated with a higher incidence of anastomotic leakage (47.4 vs. 13.6%; p = 0.04) and a higher rate of medical morbidity (47.4 vs. 16.6%; p = 0.04). The mean number of lymph nodes harvested was similar. For MC, the second cancer was treated by iterative colectomy (n = 12) or extensive colectomy (n = 14) and there was no significant difference in postoperative outcomes between the two surgical approaches. The median follow-up period was 42.4 ± 29.1 months. The 5-year overall and disease-free survival of the SC and MC groups did not differ to a statistically significant extent.

CONCLUSIONS

Extensive colectomy should be preferred for SC to reduce morbidity and improve the prognosis. In contrast, iterative colectomy can be performed safely for patients with MC.

Clinicopathologic characteristics and prognosis of synchronous colorectal cancer: a retrospective study

Background

The clinical characteristics of synchronous colorectal cancer (SCRC) reported in previous studies differ significantly. Furthermore, little is known about the characteristics of early-onset synchronous colorectal cancer (EO-SCRC). The aim of this retrospective study was to identify the clinicopathological characteristics of SCRC and EO-SCRC and define their relevant prognostic factors.

Methods

Patients who underwent surgery for SCRC and primary unifocal colorectal cancer (PCRC) between January 2007 and December 2020 were included in this study. The clinical, histological, and molecular characteristics of the patient’s tumours were analysed. The primary endpoint was overall survival (OS). Univariate and multivariate Cox regression analyses were used to assess the association between clinicopathological factors and patient survival.

Results

A total of 1554 patients were included in the analysis. Of these, 1132 (72.84%) had PCRC and 422 (27.16%) had SCRC. SCRC occurred more frequently in the elderly (P < 0.001) and in male patients (P = 0.002). The 5-year OS rate was 73.7% ± 2.0% for PCRC and 61.9% ± 3.9% for SCRC (P < 0.05). However, the Cox regression analysis showed that SCRC was not an independent prognostic factor for the prediction of OS. A total of 64 patients (15.17%) in the SCRC group had early-onset colorectal cancer (EOCRC), whereas 257 (22.70%) in the PCRC group had EOCRC (P = 0.001). The proportion of patients with deficient mismatch repair proteins (dMMR) in EO-SCRC subgroup was significantly higher than that in late-onset synchronous colorectal cancer (LO-SCRC) subgroup (23.44% vs. 10.34%, P = 0.006). Patients with EO-SCRC had more TNM stage IV (P < 0.001) and fewer opportunities for radical surgery (79.69% vs. 92.22%, P = 0.007) than those with early-onset primary unifocal colorectal cancer (EO-PCRC). There was no significant difference in 5-year OS between the EO-SCRC and LO-SCRC subgroups (P = 0.091) and between the EO-SCRC and EO-PCRC subgroups (P = 0.094). Multivariate analysis revealed that EOCRC was an independent good prognostic parameter for colorectal cancer (CRC) and SCRC.

Conclusion

For patients with operative treatment, EO-SCRC is different from LO-SCRC and EO-PCRC. Patients with SCRC show a poorer survival rate than those with PCRC. However, SCRC is not an independent prognostic factor for CRC, whereas EOCRC is a good prognostic factor for CRC and SCRC.

Synchronous colorectal and renal cancers: Case report and literature review

Introduction

Even though colorectal cancer is one of the most frequent in the world, its simultaneous presence with other neoplasms, such as renal, is still rare in incidence. This article aims to report and expose a literature review of the synchrony of colorectal cancer and renal carcinoma.

Presentation of case

A 57-year-old female patient complaining of diffuse abdominal pain that worsened with food and improved with evacuation, especially in the periumbilical region and right iliac fossa, from moderate to strong intensity, starting 1 year ago, worsening in the last 3 months. An abdominal CT scan was performed, showing a lesion in the right kidney and a narrowing of the ascending colon lumen. Due to the possibility of cure, we opted for right colectomy and right nephrectomy at the same surgery.

Discussion

Synchronous tumors are neoplasms in which the diagnostic interval is up to 6 months, and must be differentiated from metachronic neoplasms and even metastases between tumors. The incidence of synchronous colorectal and renal cancer is rare but appears to be divergent.

Conclusion

The presence of synchronous tumors can be evidenced in imaging tests, such as CT scan, but appropriate diagnostic tests for each neoplasm, such as colonoscopy, should not be ruled out. The treatment of choice must be surgery, when possible, with the options of conventional access, videolaparoscopic and robotic surgery.

•

Synchronous colorectal and renal cancers are rare in clinical practice.

•

Simultaneous findings tend to increase due to imaging exams.

•

Single-procedure surgical treatment is the gold standard when there is possibility.

Synchronous Recto-Sigmoid Colorectal Carcinomas With Microsatellite Instability and an Activating PIK3CA Mutation

Synchronous colorectal cancer is a rare subtype of colorectal carcinoma defined by the presence of 2 or more primary tumors simultaneously or within 6 months of initial detection. The overall impact of a synchronous presentation on prognosis is not yet clear. Surgical resection is the primary treatment. However, higher rates of local recurrence and metastasis in synchronous colorectal cancer demand greater exploration of the role of adjuvant therapy. The increased frequency of microsatellite instability observed in synchronous colorectal cancer also affects therapy selection. Similarly, activating PIK3CA mutations are regularly noted in colorectal cancer, but their role in a synchronous presentation has not yet been described. We report a case of a young patient with a synchronous recto-sigmoid colorectal carcinoma complicated by microsatellite instability and an activating PIK3CA mutation—a presentation as of yet unreported in literature. We also review the impact of these molecular events on the efficacy of several chemotherapies and targeted therapies.

Three colonic cancers, two sites of complete occlusion, one patient: A case report

BACKGROUND

Synchronous colonic cancer incidence is uncommon, and awareness about this rare condition is improved recently. However, in the presence of acute colonic obstruction, investigation and management of synchronous colonic cancer can be difficult and challenging.

CASE SUMMARY

A patient presented with acute colonic obstruction with impending rupture and complete examination of this patient revealed the presence of three colonic cancers, of which two were completely occluding.

CONCLUSION

The presence of multiple colonic cancers must be ruled out in order to plan the best management. We present the case with a review of literature and discuss the management of the case.

Clinicopathologic features and prognosis of synchronous and metachronous multiple primary colorectal cancer

PURPOSE

Multiple primary colorectal cancers (MPCCs) are different from solitary colorectal cancers in many aspects, which are not well studied. The aim of this study was to clarify the clinicopathological features and prognosis of MPCCs.

METHODS

The data of 64 patients with MPCCs out of 2300 patients with colorectal cancers (CRCs) from January 2009 to December 2017 were retrospectively analyzed. Stratified analysis was conducted based on subtypes and microsatellite status.

RESULTS

The overall incidence of MPCC was 2.8% and the median follow-up duration was 51.5 (range 1-120) months. Metachronous CRCs (MCRCs) are more likely to appear in the right colon (p < 0.05). However, no significant differences regarding age, sex, BMI, tumor size, smoking/drinking history, TNM stage, family history of cancer, and 5-year survival rate were observed between synchronous CRC (SCRC) and MCRC. Advanced TNM stage (III) and the presence of polyps were found to be independent poor prognostic factors for MPCCs. The prevalence of mismatch repair deficiency (dMMR) in MPCCs was 28.1%. Deficient MMR is more likely to appear in younger, lighter MPCC patients with polyps (p < 0.05). Of four mismatch repair proteins, MLH-1, MSH-2, MSH-6, and PMS-2 were negative in nine, nine, five, and nine patients, respectively. The 5-year survival rate did not differ significantly between MMR-proficient (pMMR) and dMMR groups (p = 0.752).

CONCLUSIONS

Synchronous CRC (SCRC) and MCRC might represent similar disease entities with different courses. Deficient MMR is more likely to appear in younger, lighter MPCC patients with polyps and it is an essential indicator for screening Lynch syndrome.

Synchronous colorectal cancer using CT colonography vs. other means: a systematic review and meta-analysis

OBJECTIVES

The objective of our study was to systematically review the evidence about synchronous colorectal cancer diagnosed with or without computed tomography colonography (CTC).

MATERIALS AND METHODS

Two systematic searches were performed (PubMed and EMBASE) for studies reporting the prevalence of synchronous colorectal cancer (CRC): one considering patients who underwent CTC and the another one considering patients who did not undergo CTC. A three-level analysis was performed to determine the prevalence of patients with synchronous CRC in both groups of studies. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% confidence interval (CI) were calculated. A quality assessment (STROBE) was done for the studies.

RESULTS

For CTC studies, among 2645 articles initially found, 21 including 1673 patients, published from 1997 to 2018, met the inclusion criteria. For non-CTC studies, among 6192 articles initially found, 27 including 111,873 patients published from 1974 to 2015 met the inclusion criteria. The pooled synchronous CRC prevalence was 5.7% (95% CI 4.7%-7.1%) for CTC studies, and 3.9% (95% CI 3.3%-4.4%) for non-CTC studies, with a significant difference (p = 0.004). A low heterogeneity was found for the CTC group (I² = 10.3%), whereas a high heterogeneity was found in the non-CTC group of studies (I² = 93.5%), and no significant explanatory variables were found. Of the 22 STROBE items, a mean of 18 (82%) was fulfilled by CTC studies, and a mean of 16 (73%) by non-CTC studies.

CONCLUSIONS

The prevalence of synchronous CRC was about 4-6%. The introduction of CTC is associated with a significant increase of the prevalence of synchronous CRCs.

Various clinicopathological features of patients with metachronous colorectal cancer in relation to different diagnostic intervals

BACKGROUNDS

Clinicopathologic factors relating to developing metachronous colorectal cancer (CRC) have been reported. However, the effects of different diagnostic intervals on these risk factors required further analysis.

PATIENTS AND METHODS

This retrospective study comprised 14,481 patients diagnosed from January 1995 to December 2012. Metachronous CRC was defined as the occurrence of a second colorectal cancer at least 1 year post-operatively.

RESULTS

A total of 153 (1.06%) patients developed metachronous CRCs during the follow-up. Significantly higher rates of developing metachronous cancer occurred in male patients (1.2 vs 0.9%), patients with synchronous CRC (2.0 vs 1.0%), and patients with a positive family history of CRC (1.4 vs 0.9%). Pertaining to diagnostic intervals related to clinicopathological features, more severe staging was significant in the diagnostic interval between 2 and 3 years (35 vs 7.7%, 20.6%, 17.5%, P = .01) compared with other intervals. Male patients were more frequently detected to have CRC within 3 years compared with females (53.1 vs 29.1%, P = .005). For a diagnostic interval ≧ 5 years, a significantly higher rate of metachronous CRC located at the right colon was observed than that located at the left colon (36.6 vs 19.7%, p = 0.03).

CONCLUSIONS

We evinced that a diagnostic interval between 2 and 3 years was a key time for metachronous CRC diagnosis with worse staging distribution. Based on current findings, we recommend the stratification of metachronous CRCs into diagnostic intervals of 1-2, 2-3, and ≧ 3 years, as they exhibit significantly different characteristics.

Clinical outcomes of laparoscopic-assisted synchronous bowel anastomoses for synchronous colorectal cancer: initial clinical experience

The primary aim of this study was to explore the safety and feasibility of laparoscopic-assisted synchronous bowel anastomoses (LSBA) for synchronous colorectal cancer (SCRC). All patients who underwent LSBA for SCRC were retrospectively reviewed and analyzed for clinical and pathological features, technical feasibility and short-term as well as long-term oncological outcomes. Between July 2008 and January 2012, a series of 11 consecutive SCRC patients underwent LSBA. Six patients underwent laparoscopic-assisted right hemicolectomy and anterior resection. Five patients had laparoscopic-assisted right hemicolectomy and sigmoidectomy. There were no intraoperative complications that required open conversions. Mean operation time was 233 (range, 195–285) minutes, and mean estimated blood loss was 224 (range, 100–300) mL. The postoperative course of the patients was uneventful with the mean return to oral intake was 6.9 (range 5–12) days, and mean length of hospital stay was 12.6 (range 9–17) days. All surgical wounds showed good cosmetic outcome, and the mean incision length was 4.1 (range 3.5-5.0) cm. During a median follow-up period of 76 months, no local tumor recurrences were found. LSBA is a potentially feasible and safe procedure for SCRC when performed by an experienced surgeon. Further large clinical controlled trials are warranted to confirm the findings.

Treatment and Outcome of Synchronous Colorectal Carcinomas: A Nationwide Study

BACKGROUND

Synchronous colorectal carcinomas (CRC) occur in 1-8% of patients diagnosed with CRC. This study evaluated treatment patterns and patient outcomes in synchronous CRCs compared with solitary CRC patients.

METHODS

All patients diagnosed with primary CRC between 2008 and 2013, who underwent elective surgery, were selected from the Netherlands Cancer Registry. Using multivariable regressions, the effects of synchronous CRC were assessed for both short-term outcomes (prolonged postoperative hospital admission, anastomotic leakage, postoperative 30-day mortality, administration of neoadjuvant or adjuvant treatment), and 5-year relative survival (RS).

RESULTS

Of 41,060 CRC patients, 1969 patients (5%) had synchronous CRC. Patients with synchronous CRC were older (mean age 71 ± 10.6 vs. 69 ± 11.4 years), more often male (61 vs. 54%), and diagnosed with more advanced tumour stage (stage III-IV 54 vs. 49%) compared with solitary CRC (all p < 0.0001). In 50% of the synchronous CRCs, an extended surgery was conducted (n = 934). Synchronous CRCs with at least one stage II-III rectal tumour less likely received neoadjuvant (chemo)radiation [78 vs. 86%; adjusted OR 0.6 (0.48-0.84)], and synchronous CRCs with at least one stage III colon tumour less likely received adjuvant chemotherapy [49 vs. 63%; adjusted OR 0.7 (0.55-0.89)]. Synchronous CRCs were independently associated with decreased survival [RS 77 vs. 71%; adjusted RER 1.1 (1.01-1.23)].

CONCLUSIONS

The incidence of synchronous CRCs in the Dutch population is 5%. Synchronous CRCs were associated with decreased survival compared with solitary CRC. The results emphasize the importance of identifying synchronous tumours, preferably before surgery to provide optimal treatment.

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.

Clinical characteristics of synchronous colorectal cancers in Japan

BACKGROUND

Incidence and clinical characteristics of synchronous colorectal cancer (sCRC) patients significantly vary among studies, likely due to differences in surveillance methodology. If remain undetected, sCRC can progress to more advanced stages seriously aggravating patient prognosis. We studied the incidence and clinicopathological characteristics of Japanese patients with sCRCs who underwent surgery for primary CRC and received exhaustive perioperative surveillance.

METHODS

We recruited 1005 patients with surgically resected CRCs between January 2007 and December 2011. The associations of clinical and pathological factors with sCRC development were assessed by univariate and multivariate logistic regression.

RESULTS

Eighty-four patients (8.4 %) developed sCRCs, 16 of them (19.0 %) harboring three or more cancers. Companion sCRCs were smaller and earlier stage than the index lesion (P < 0.0001). In multivariate analysis, advanced age (odds ratio (OR) 1.03 per year; P = 0.009) and left colon tumor location (OR 1.78; P = 0.013) are associated with higher risk of sCRCs, particularly in females. Overall survival did not differ between solitary CRC and sCRC (P = 0.62).

CONCLUSIONS

Our results highlight the importance of perioperative colonoscopy examination to ensure the absence of sCRCs that, being small and early staged, are more difficult to detect. The incidence of sCRC, and notably of triple or more sCRCs, was higher than previously recognized. Because they are also significantly higher than expected by merely stochastic accumulation of individual cancerous lesions, we suggest that the occurrence of many sCRC reflects a hitherto uncharacterized predisposition condition.

Synchronous trifocal colorectal cancer

Synchronous colorectal cancers (SCRCs) have been increasingly diagnosed due to emerging diagnostic modalities. The presence of three or more synchronous colorectal cancers has, however, only rarely been reported. A 76-year-old white man presented for management of two concurrent colorectal adenocarcinomas in the left colon evidenced on total colonoscopy. Preoperative abdominal ultrasonography and thoracoabdominal computed tomography were negative for metastatic disease. The patient underwent an elective left hemicolectomy. The pathology report ultimately showed the presence of three moderately differentiated, distinct colorectal cancers. The patient experienced an uneventful recovery.

Role of colonic stents in the management of colorectal cancers

Colorectal cancer is one of the commonly encountered cancers across the Western World. In United Kingdom, this constitutes third most common ranked cancer and second most common ranked cause of cancer related deaths. Its acute presentation as a malignant colonic obstruction imposes challenges in its management. Colonic stent has been used for many years to alleviate acute obstruction in such cases allowing optimisation of patient’s physiological status and adequate staging of cancer. In this review, current literature evidence regarding use of colonic stent in acute malignant colonic obstruction is critically appraised and recommendations on the use of colonic stent are advocated.

Four tumours including neuroendocrine tumour of the ileum

Gastroenteropancreatic neuroendocrine tumours are associated with development of further primary tumours. Certain conditions give an inherited predisposition to developing neoplasia. To the best of our knowledge, this is the first paper to report a patient with neuroendocrine tumour and three other tumours: a further bowel cancer, a brain tumour and a skin cancer. We report a case of a 42-year-old Caucasian man presenting with clinical features of intestinal obstruction who on histopathology of surgical specimen was found to have two distinct tumours of the bowel: a colonic adenocarcinoma at the splenic flexure and a well-differentiated neuroendocrine tumour of the terminal ileum. His history included a basal cell carcinoma and a benign brain tumour. He had extensive family history of neoplasia suggesting an inherited predisposition. Our case demonstrates the importance of investigating patients with known neuroendocrine tumours for further malignancy and suggests that patients with multiple primary malignancies should be referred for genetic testing.

A rare case of eight multiple primary malignant neoplasms in a female patient: A case report and review of the literature

In recent years, the number of patients exhibiting multiple primary malignant neoplasms has been increasing. The current study reports the rare case of a 61-year-old Chinese female with eight histopathologically confirmed primary malignant neoplasms; to the best of our knowledge, such a high number of malignant neoplasms in one patient has not previously been described in the English literature. The tumors originated from the colon (five separate tumors over 32 years), the endometrium, the breast and the small intestine. It is important to diagnose multiple primary malignant neoplasms as such patients generally exhibit a more favorable prognosis compared with metastatic carcinoma patients. In addition, prolonged follow-up after surgery should be considered.

Synchronous colorectal cancer: Clinical, pathological and molecular implications

Synchronous colorectal carcinoma refers to more than one primary colorectal carcinoma detected in a single patient at initial presentation. A literature review has shown that the prevalence of the disease is approximately 3.5% of all colorectal carcinomas. This disease has a male to female ratio of 1.8:1. The mean age at presentation of patients with synchronous colorectal cancer is in the early half of the seventh decade. Patients with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease), hereditary non-polyposis colorectal cancer, familial adenomatous polyposis and serrated polyps/hyperplastic polyposis are known to have a higher risk of synchronous colorectal carcinoma. These predisposing factors account for slightly more than 10% of synchronous colorectal carcinomas. Synchronous colorectal carcinoma is more common in the right colon when compared to solitary colorectal cancer. On pathological examination, some synchronous colorectal carcinomas are mucinous adenocarcinomas. They are usually associated with adenomas and metachronous colorectal carcinomas. Most of the patients with synchronous colorectal cancer have two carcinomas but up to six have been reported in one patient. Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. Overall, the prognosis of patients with synchronous colorectal carcinoma is not significantly different from that in patients with solitary colorectal carcinoma, although a marginally better prognosis has been reported in patients with synchronous colorectal carcinoma in some series. A different management approach and long-term clinical follow-up are recommended for some patients with synchronous colorectal cancer.

Synchronous colorectal carcinoma: a risk factor in colorectal cancer surgery

BACKGROUND

Synchronous colorectal carcinoma occurs in 1% to 8% of cases. There are little data on the impact of synchronous colorectal cancer on surgical treatment and short-term postoperative outcomes.

OBJECTIVE

The purpose of this work was to evaluate clinical characteristics and treatment patterns of synchronous colorectal carcinoma and their influence on short-term postoperative outcomes in comparison with solitary colorectal carcinoma.

DESIGN

This was a population-based observational study. Patient and tumor characteristics, treatment patterns, and postoperative outcomes are described for patients with a solitary and synchronous colorectal carcinoma separately. Multivariable logistic regression analysis was used to analyze the association between synchronous colorectal carcinoma and postoperative complications in comparison with a solitary colorectal carcinoma.

SETTINGS

The study included in-hospital registration for the Dutch Surgical Colorectal Audit.

PATIENTS

Patients were those with primary colorectal carcinoma from 2009 to 2011.

MAIN OUTCOME MEASURES

Severe postoperative complications, reinterventions, and 30-day mortality were measured.

RESULTS

Of 25,413 patients with colorectal cancer, 884 (3.5%) had synchronous colorectal tumors. Patients with synchronous colorectal carcinoma were older and more often of male sex compared with patients with solitary colorectal carcinoma. In ≥ 35% of cases, an extended surgical procedure was conducted (n = 310). In multivariable logistic regression analysis, synchronous colorectal carcinoma was associated with a higher risk of severe postoperative complications (OR, 1.40; 95% CI, 1.20-1.63) and reinterventions (OR, 1.37; 95% CI, 1.14-1.65) compared with solitary colorectal carcinoma but not with higher 30-day mortality (OR, 1.34; 95% CI, 0.96-1.88).

LIMITATIONS

This study was limited by the data being self-reported. Case-mix adjustment was limited to information available in the data set, and no long-term outcome data were available.

CONCLUSIONS

Synchronous colorectal carcinomas are prevalent in 3.5% of patients and require a different treatment strategy in comparison with solitary colorectal carcinoma. Postoperative outcomes are unfavorable, most likely because of extensive surgery.

Clinical characteristics of colorectal cancer patients with a second primary cancer

PURPOSE

The incidence of colorectal cancer is increasing due to a westernized dietary lifestyle, and improvements in treatment and diagnostic tools have resulted in more patients being confirmed of having multiple primary cancers. However, studies regarding multiple primary cancers are insufficient. In this study, the clinical aspects of patients with primary multiple cancers, including colorectal cancers, were investigated, and the results were compared to those of patients with primary colorectal cancer only.

METHODS

Seven hundred eighteen patients who received surgery for colorectal cancer between March 2003 and September 2012 in CHA Medical Center were enrolled. A retrograde cohort was done for comparison of the two groups: those with and those without multiple primary cancer. The analysis was done according to sex, age, tumor location, tumor size, metastatic regional lymph-node number, vascular/lymphatic microinvasion, staging, tumor markers, microsatellite instability, and C/T subgroup of polymorphism in methylenetetrahydrofolate reductase.

RESULTS

Of the 718 subjects, 33 (4.6%) had multiple primary cancers: 12 (36.4%) synchronous and 21 (63.6%) metachronous. The malignancy most frequently accompanying colorectal cancer was gastric cancer, followed by thyroid, prostate, and esophageal malignancies in that order. In the comparison between groups, mean age, tumor location, and microsatellite instability showed statistically significant differences; others parameters did not.

CONCLUSION

The incidence of multiple primary cancers, including colorectal cancer, is increasing. Therefore, defining the characteristics of patients with multiple primary cancers is crucial, and those characteristics need to be acknowledged in the follow-up of colorectal cancer patients.

Molecular heterogeneity and prognostic implications of synchronous advanced colorectal neoplasia

BACKGROUND

It is uncertain whether synchronous colorectal cancers (S-CRCs) preferentially develop through widespread DNA methylation and whether they have a prognosis worse than solitary CRC. As tumours with microsatellite instability (MSI) may confound the effect of S-CRC methylation on outcome, we addressed this issue in a series of CRC characterised by BRAF and MS status.

METHODS

Demographics, clinicopathological records and disease-specific survival (DSS) were assessed in 881 consecutively resected CRC undergoing complete colonoscopy. All tumours were typed for BRAF(c.1799T>A) mutation and MS status, followed by search of germ-line mutation in patients with MSI CRC.

RESULTS

Synchronous colorectal cancers (50/881, 5.7%) were associated with stage IV microsatellite-stable (MSS) CRC (19/205, 9.3%, P=0.001) and with HNPCC (9/32, 28%, P<0.001). BRAF mutation (60/881, 6.8%) was associated with sporadic MSI CRC (37/62, 60%, P<0.001) but not with S-CRC (3/50, 6.0%, P=0.96). Synchronous colorectal cancer (HR 1.82; 95% CI 1.15-2.87; P=0.01), synchronous advanced adenoma (HR 1.81; 95% CI 1.27-2.58; P=0.001), and BRAF(c.1799T>A) mutation (HR 2.16; 95% CI 1.25-3.73; P=0.01) were stage-independent predictors of death from MSS CRC. Disease-specific survival of MSI CRC patients was not affected by S-CRC (HR 0.74; 95% CI 0.09-5.75; P=0.77).

CONCLUSION

Microsatellite-stable CRCs have a worse prognosis if S-CRC or synchronous advanced adenoma are diagnosed. The occurrence and the enhanced aggressiveness of synchronous MSS advanced neoplasia are not associated with BRAF mutation.

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.

Clinicopathologic and molecular characteristics of synchronous colorectal cancers: heterogeneity of clinical outcome depending on microsatellite instability status of individual tumors

BACKGROUND

The contribution of chromosomal instability, microsatellite instability, and epigenetic instability to the development of synchronous colorectal carcinomas is controversial.

OBJECTIVE

This study aimed to investigate the relative roles of microsatellite instability and epigenetic instability in the development of synchronous colorectal cancers.

DESIGN

This was a retrospective study of medical records with histologic, immunohistochemical, and molecular examination of stored tissue samples.

SETTING

The study took place at Seoul National University Hospital, Korea.

PATIENTS

A total of 46 patients with synchronous colorectal cancers and 105 patients with solitary colorectal cancers were included.

MAIN OUTCOME MEASURES

Clinicopathologic and molecular characteristics including microsatellite instability, mismatch repair gene expression, CpG island methylator phenotype, and mutation of KRAS and BRAF were analyzed.

RESULTS

Patients with synchronous tumors were more likely to be men than those with solitary tumors and had a tendency toward colocalization of individual tumors in the left or right colon. MSI-deficient cancers were more frequent in synchronous than in solitary cancers. The frequencies of CpG island methylator phenotype-high and KRAS and BRAF mutations were not different between synchronous and solitary cancers. No differences between synchronous cancers and solitary cancers were observed in overall survival or progression-free survival. Within the synchronous cancer group, patients with individual tumors discordant for microsatellite instability status had the worst clinical outcome, whereas those with individual tumors concordant for microsatellite instability-deficient status had the best clinical outcome.

LIMITATIONS

The study was limited by its retrospective nature. Molecular analysis was performed only on cancerous lesions.

CONCLUSIONS

Our findings suggest that microsatellite instability plays a more important role than does epigenetic instability in the development of synchronous colorectal cancers, and that information regarding concordant or discordant microsatellite instability status between individual tumors might help to predict clinical outcome of synchronous colorectal cancers.

A prospective cohort study shows unique epigenetic, genetic, and prognostic features of synchronous colorectal cancers

BACKGROUND & AIMS

Synchronous colorectal neoplasias (2 or more primary carcinomas identified in the same patient) are caused by common genetic and environmental factors and can be used to study the field effect. Synchronous colon cancers have not been compared with control solitary cancers in a prospective study.

METHODS

We analyzed data collected from 47 patients with synchronous colorectal cancers and 2021 solitary colorectal cancers (controls) in 2 prospective cohort studies. Tumors samples were analyzed for methylation in LINE-1 and 16 CpG islands (CACNA1G, CDKN2A [p16], CRABP1, IGF2, MLH1, NEUROG1, RUNX3, SOCS1, CHFR, HIC1, IGFBP3, MGMT, MINT1, MINT31, p14 [ARF], and WRN); microsatellite instability (MSI); the CpG island methylator phenotype (CIMP); 18q loss of heterozygosity; KRAS, BRAF, and PIK3CA mutations; and expression of beta-catenin, p53, p21, p27, cyclin D1, fatty acid synthase, and cyclooxygenase-2.

RESULTS

Compared with patients with solitary colorectal cancer, synchronous colorectal cancer patients had reduced overall survival time (log-rank, P = .0048; hazard ratio [HR], 1.71; 95% confidence interval [CI]: 1.17-2.50; P = .0053; multivariate HR, 1.47; 95% CI: 1.00-2.17; P = .049). Compared with solitary tumors, synchronous tumors more frequently contained BRAF mutations (P = .0041), CIMP-high (P = .013), and MSI-high (P = .037). Methylation levels of LINE-1 (Spearman r = 0.82; P = .0072) and CpG island methylation (P < .0001) correlated between synchronous cancer pairs from the same individuals.

CONCLUSIONS

Synchronous colorectal cancers had more frequent mutations in BRAF, were more frequently CIMP- and MSI-high, and had a worse prognosis than solitary colorectal cancers. Similar epigenomic and epigenetic events were frequently observed within a synchronous cancer pair, suggesting the presence of a field defect.

Clinicopathologic characteristics of metachronous colorectal cancer: an analysis of 31 cases

AIM: To investigate the clinicopathologic characteristics of metachronous colorectal cancer and to facilitate its diagnosis and treatment.

METHODS: Thirty-one cases diagnosed with metachronous colorectal cancer were treated and closely followed up. Clinical records such as the occurrence, distribution, and stage of index and secondary tumors were retrospectively reviewed. The prognosis after surgery was also analyzed.

RESULTS: Secondary tumors occurred in all 31 patients in an average of 5.1 years after the diagnosis of their index colorectal cancers. Three cases had a third tumor after an average of 3.8 years, and then two of them had a fourth tumor after an average interval of 3.5 years. Of the 31 cases, 45.2 percent of them had synchronous adenoma. The majority of index tumors (59.5%) were located in the rectum or sigmoid colon. Most of the secondary tumors were similar to or better than their index tumors in the levels of differentiation and pathological grades. An average survival of 8.3 years was achieved after the radical operation of the index tumor. The 5-year survival rate reached 84.8%.

CONCLUSION: In patients with metachronous colorectal cancer, the primary tumor is more commonly located in the rectum or sigmoid colon. With the occurrence of subsequent tumor, interval time was shortened gradually. An intensive periodic checkup after operation is strongly recommended for improvement of prognosis.

Epidemiology and prognosis of synchronous colorectal cancers

BACKGROUND

The aim of this population-based study was to report on the incidence, treatment and prognosis of synchronous colorectal carcinomas.

METHODS

Data were obtained from the population-based cancer registry of Burgundy.

RESULTS

Between 1976 and 2004, 15 562 colorectal cancers were diagnosed. Some 3.8 per cent of patients had synchronous colorectal cancers. The risk of having synchronous cancers was higher in men (odds ratio (OR) 1.41 (95 per cent confidence interval (c.i.) 1.19 to 1.68)), when associated adenomas were present (OR 2.02 (95 per cent c.i. 1.69 to 2.41)), when there were adenomatous remnants on pathological examination (OR 2.10 (95 per cent c.i. 1.73 to 2.55)) and in patients aged over 75 years (OR 1.31 (95 per cent c.i. 1.08 to 1.59)). Synchronous tumours were more often located on the same intestinal segment, although the correlation was weak (kappa = 0.26). Resection for cure was performed in 74.8 per cent of synchronous cancers and 72.0 per cent of single cancers (P = 0.131). Five-year relative survival for synchronous (48.7 per cent) and single (48.3 per cent) cancers was almost identical. Stage, age, associated adenomas and adenomatous remnants were independent prognostic factors.

CONCLUSION

Synchronous colorectal cancers convey a similar prognosis to single tumours. Men and patients aged over 65 years with associated adenomas are more prone to multiple colorectal cancers.

Clinical characteristics of multiple primary colorectal cancers

PURPOSE

Although multiple primary colorectal cancer has been recognized as a significant clinical entity, its clinical and pathological features and its prognosis are still controversial. The purpose of this study was to clarify clinical and pathological features of multiple primary colorectal cancer.

MATERIALS AND METHODS

Among 1669 patients who underwent surgery for primary colorectal cancer from January 1997 to June 2005, 26 patients (1.6%) with multiple primary colorectal cancer were identified. We reviewed clinical characteristics including diagnostic interval, lesions, operating methods, and TNM stage, and we defined the index lesion as the most advanced lesion among the synchronous lesions. For the purposes of the study, the colon and rectum were classified into three segments. The right-side colon included the appendix, cecum, ascending colon, hepatic flexure, and transverse colon, and the left-side colon included the splenic flexure, descending colon, and sigmoid colon.

RESULTS

Of the 26 patients with multiple primary colorectal cancers, nineteen patients were male and seven patients were female, with a mean age of 61.5 years. Nineteen patients had synchronous colorectal cancers and seven patients had metachronous colorectal cancers. In the metachronous cases, the mean diagnostic interval was 36.8 months. The site of the first lesion in metachronous colorectal cancers was the right colon in five cases (71.4%) and the left colon in two cases (28.6%), and the site of the second lesion was the rectum in six cases (55.5%), the right colon in three cases (33.3%), and the left colon in one case. The TNM stage of the second lesions in the metachronous colorectal cancers was stage II in four cases (57.1%), stage III in one case (14.3%), and stage IV in one case (14.3%). For the synchronous colorectal cancers, the operation methods were single-segment resection combined with endoscopic mucosal resection in five cases (26.3%), single-segment resection alone in six cases, two-segment resection in six cases, and total colectomy in two cases.

CONCLUSION

In metachronous colorectal cancers, the secondary lesions were later-stage cancer. Therefore, careful postoperative follow-up is necessary for patients who have undergone surgery for colorectal cancers. Further study of therapeutic modalities is important for synchronous colorectal cancers.

Synchronous appendiceal tumours

Primary appendiceal neoplasms are a rare clinical and pathological entity. We report a case of synchronous appendiceal tumours of different histological types which presented as a symptomatic palpable and radiologically apparent mass in the right iliac fossa. This case demonstrates the importance of pre-operative diagnosis of these neoplasms, as it may alter the surgical approach and obviate the need for additional surgery. Furthermore, some of the controversies associated with the management of an appendix mass in the elderly population are discussed.

Preoperative evaluation of colorectal cancer

Surgery is a primary modality for the treatment of patients with colorectal cancer. Before any surgical therapy, patients diagnosed with colorectal cancer require an evaluation. This preoperative evaluation can be used to assess the patient's risk associated with surgery, plan the surgical resection, and stage the patient's cancer. Staging of the cancer preoperatively is primarily of concern in rectal cancer patients. This article focuses on the elective surgical setting and the recommended preoperative evaluation of patients who have been diagnosed with colorectal cancer.