Management of Multiple Primary Cancers: What is the Priority?

Abstract

Multiple primary cancers are known entity due to the propensity of cancer survivors to develop additional malignancies both from genetic predisposition and exogenous influences. However, the development of triple or quadruple primary cancers, especially presenting simultaneously, presents challenging diagnostic and treatment dilemmas. We report here a patient who presented initially with neurological symptoms. Extensive evaluation and pathologic workup revealed that the patient actually has an intra-medullary vascular neoplasm at the level of upper thoracic spine, mucinous adenocarcinoma of the right lower lobe, poorly differentiated adenocarcinoma of the stomach near the gastro-esophageal (GE) junction, and conventional type adenocarcinoma of the hepatic flexure of the colon.  The patient underwent neoadjuvant chemo-radiation for the GE junction carcinoma followed by surgical resection of the three different adenocarcinomas simultaneously as definitive management. This case illustrates the utility of immuno-histochemistry in delineating the site of origin for primary tumors, and the challenges posed when dealing with multiple primary neoplasms concurrently.