Synchronous Esophageal and Colon Adenocarcinomas

Abstract

Synchronous carcinomas in the same patient were first elucidated in the early 1930s. Following this initial recognition, awareness of synchronous carcinomas coupled with advancements in medical technology have made diagnosis of two primary carcinomas from separate sites in the same time interval possible. We present a case of newly diagnosed synchronous primary esophageal and ascending colon adenocarcinomas in a patient presenting with lower gastrointestinal bleed. A 74-year-old female with history of abdominal aortic aneurysm repair on dual-antiplatelet therapy and chronic obstructive pulmonary disease on supplemental oxygen presented with bright red blood per rectum. Initial hemoglobin was 12.5g/dL, down-trending to 9.0g/dL. Esophagogastroduodenoscopy (EGD) revealed a nodule in the proximal esophageal mucosa, a submucosal lesion in the esophageal body 30 centimeters from the entry point, and a hiatal hernia with pathology showing high grade dysplasia in Barrett mucosa (Figure 1). Her hemoglobin stabilized after one transfusion and symptoms resolved. Days later, repeat EGD with endoscopic mucosal resection and colonoscopy showed Barrett’s esophagus, a distal esophageal mass at 30cm (Figure 2), and synchronous colon masses in the ascending colon (Figure 3). Pathology from EGD biopsies revealed Barrett mucosa leading to esophageal adenocarcinoma (Figure 4) with MLH1 and PMS2 mismatch repair (MMR) proteins intact, demonstrating nuclear positivity. Histopathologic analysis of the ascending colon mass revealed BRAF mutation positivity (Figure 5) and loss of MLH1 and PMS2 MMR proteins, confirming a sporadic microsatellite unstable colonic adenocarcinoma. She was staged at T2N0 by endoscopic ultrasound and T2N0 colon adenocarcinoma with recommendations for esophageal resection and hemicolectomy. Given her oxygen requirements and chronic hypercarbia, she was not a candidate for esophagectomy, however underwent hemicolectomy. Colonic neoplasias (up to 20%) are the most common synchronous cancers in patients with primary gastric cancer; the incidence of esophageal and synchronous colon cancers is unknown. Upon discovering multiple primary malignancies, accurate staging along with immunohistochemical analysis is key to distinguish each primary cancer and determine appropriate therapy.