Multiple consecutive cancers involving different organs in a female individual are presented. Here in, we present a rare case of primary left renal cell carcinoma (RCC), in which two different malignancies of left cervical lymph node and left breast were occurred consecutively. We present the case of a 84-year-old female with three primary malignant neoplasms detected synchronously. She was admitted to our clinic with left neck upper mass.The result of the left cervical lymph node biopsy revealed diffuse B large cell lymphoma, the result of the left breast biopsy revealed well differantiated invasive ductal carcinoma and the result of the kidney’s noduler biopsy was clear cell carcinoma respectively. Rituximab chemotherapy was started as the lymphoma treatment because of the patients age and low performance status. Pathological assessment of newly detected lesions in multiple primary cancer cases is important for the treatment approach.
Multiple primary cancers are defined as occurrence of two or more malignancies, synchronous or metachronous, in different organs without any relation to each other. Cancer survivors are a growing group owing to improvements in scanning and treatment. In this group the most serious event is the diagnosis of a new second cancer. Also older people population increases. Because of these two reasons multiple primary cancers are likely to increase. Cancer patients have a 20% higher risk of new primary cancer, in the same organ or in another organ, compared with the general population. Also, second cancers have become a leading cause of death among long-term cancer survivors.
The first report of multiple primary malignant neoplasms in an individual patient was published at the end of the 19th century. Since then, several papers worldwide have addressed this issue and the prevalence of multiple primary malignant neoplasms reported varies from 0.734% to 11.7% [3-5]. The etiopathogenesis of multiple neoplasms includes hereditary aspects, the influence of environmental agents,previous therapies and tumor-producing hormones [5-8].Multiple neoplasms could be defined when they occur as synchronous or metachronous. The development of second cancer in cancer survivor is expected but third, or higher order malignancies are rare. The letter is applied for the neoplasms appearing in a single patient [5,9]. Herein, we report a case of a patient diagnosed with cervical nodal DLBCL in a private hospital where staging workup also revealed synchronous left breast carcinoma and left renal cell carcinoma . A review of the relevant literature is also discussed.
A 84-year-old female was admitted to our clinic with left neck upper masse. On physical examination, left neck upper masse about 2-3 cm was found and Eastern Cooperative Oncology Group=ECOG” was 2. Fever, night sweats or weight loss was not noted.
A neck ultrasound demonstrated left middle posterior cervical,bilateral submandibular-cervical lymph nodes. She underwent excisional biopsy of the left cervical node which demonstrated DLBCL (Figure 1). Her bone marrow biopsy was negative for malignancy. Due to the findings on her staging PET/CT scan and a palpable mass in the left breast, a bilateral mammogram was performed that showed a solid density in the vicinity of the left breast mass. Ultrasound-guided needle core biopsy of the breast lesions demonstrated well differantiated invasive ductal carcinoma in the left breast (Figure 2), also in the PET/CT scan there were bilateral axiller,aortopulmoner,prevascular,bilateral hiler,subcarinal,hepatic hilus,paraaortic,left iliac series ,right external iliac and bilateral inguinal lymph nodes and left renal anterolateral 4.5x4.7 cm large nodullary mass (Figure 4). Kidney’s biopsy was clear cell carcinoma (Figure 3).
Figure 1. Left neck node biopsy demonstrating diffuse large Bcell lymphoma
Figure 2. Left breast infiltrating ductal carcinoma.
Figure 3. Left renal clear cell carsinoma.
Figure 4. PET/CT scan images before treatment
Figure 5. PET/CT scan images after treatment.
She was treated with Rituximab 375 mg/m2 D1 + Metilprednizolone 40 mg/m2 D1-5 every 21 day. After 4 cycles response was evaluated as partial response and very good partial response after 8 cycles of chemotherapy. Her clinical status, 6 months after the diagnosis was good.
As the use of PET/CT scans for the staging of malignancies has become more common, the detection of second occult malignancies has also increased. A recent prospective study of non-Hodgkin lymphoma patients staged by PET/CT demonstrated that 2.9% of them had a second, occult, nonlymphoma malignancy [11,12]. Although there are wellestablished guidelines for the workup, staging, and treatment of individual malignancies, optimal treatment in the setting of multiple simultaneous malignancies is difficult.
The literature contains several small case series and individual case reports of patients with primary breast malignancies with synchronous lymphoproliferative disorders including follicular lymphoma [11,13-15], small lymphocytic lymphoma/chronic lymphocytic leukemia [11,14,16]. Hodgkin lymphoma , mantle cell lymphoma [11,15], MALT lymphoma [17,18]. Two individual case reports document primary breast carcinoma with simultaneous DLBCL; these both occurred in the breast rather than in the axilla [19,20].
The increased risk of subsequent malignancies among cancer survivors is well-established and initially diagnosed with cancer ages 30 to 49. Second primary cancers can be examined into three categories; therapy releated, syndromic and those resulting from shared etiologic influences by Travis et al . Warren and Gates established three criteria:
1. each of the tumors must have a definite features of malignancy,
2. each must be distinct, and
3. the probability of one being a metastasis of the other must be excluded .
By this definition, our patient had three different primary malignant neoplasms. Watanabe et al. analyzed multiple primary malignancies in 285 (5.2%) double primary cancers, 58 (1.1%) triple or more in 5,456 consecutive autopsy cases . In Antal et al.’s study with 719 cancer patients, multiple malignancies were found in 53 cases (7.4%). 49 of these being second malignancy and 4 were third malignancy. Colorectal and gynecological malignancies appeared with breast cancer in 5 cases  Ng et al. Reported 181 patients second malignancies in 1,319 Hodgkin lymphoma patients.
In conclusion, the appropriate use of sensitive staging studies makes the discovery of occult simultaneous malignancies a distinct possibilityal also we need an improvement for our knowledge of the risks and patterns of high-order malignancies. Careful review of these studies with evaluation and discussion in a multidisciplinary setting ensures the most efficacious treatment regimen is planned and executed to maximize the chance of cure of these malignancies.
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