Open Access

A novel combination of multiple primary carcinomas: Urinary bladder transitional cell carcinoma, prostate adenocarcinoma and small cell lung carcinoma- report of a case and review of the literature

  • Anastassios V Koutsopoulos1Email author,
  • Konstantina I Dambaki1,
  • George Datseris1,
  • Elpida Giannikaki1,
  • Marios Froudarakis2 and
  • Efstathios Stathopoulos1
World Journal of Surgical Oncology20053:51

https://doi.org/10.1186/1477-7819-3-51

Received: 19 March 2005

Accepted: 26 July 2005

Published: 26 July 2005

Abstract

Background

The incidence of multiple primary malignant neoplasms increases with age and they are encountered more frequently nowadays than before, the phenomenon is still considered to be rare.

Case presentation

We report a case of a man in whom urinary bladder transitional cell carcinoma, metachronous prostate adenocarcinoma and small cell lung carcinoma were diagnosed within an eighteen-month period. The only known predisposing factor was that he was heavy smoker (90–100 packets per year). The literature on the phenomenon of multiple primary malignancies in a single patient is reviewed and the data is summarized.

Conclusion

It is important for the clinicians to keep in mind the possibility of a metachronous (successive) or a synchronous (simultaneous) malignancy in a cancer patient. It is worthy mentioning this case because clustering of three primary malignancies (synchronous and metachronous) is of rare occurrence in a single patient, and, to our knowledge, this is the first report this combination of three carcinomas appearing in the same patient.

Background

The phenomenon of multiple primary malignant neoplasms in the same individual was described firstly by Billroth at the end of the 19th century [1]. Since then, several cases of double or even triple primary malignant neoplasms have been reported. It is believed that multiple primary malignant neoplasms now occur more frequently than before. Although, not uncommon, they occur more often in elderly patients, as the incidence of malignancies increases with age. The diagnosis of second primary neoplasms is rising as a result of prolonged survival of patients treated for previous malignancy with alkylating agents, topoisomerase II inhibitors, and/or radiotherapy[2]. A review of the recent literature indicates clearly that they appear more frequently in the upper digestive tract, respiratory system, head and neck region, or urogenital system; the reported incidence ranges from 2% to 10% [3].

In this report we present a patient who developed primary bladder carcinoma and metachronous prostate and small cell lung carcinoma (SCLC) within an eighteen-month period. This combination of multiple primary carcinomas, to our knowledge, has never been reported in the literature.

Case presentation

A 75-year old ex-smoker (90–100 packet per year) underwent a transurethral resection of urinary bladder papilloma in February 2002. The histology of resected specimen was papillary transitional cell carcinoma grade II (Figure 1A). The tumor cells were positive for cytokeratin 7 (Figure 1B) and negative for cytokeratin 20. There were no muscle fibers in the examined tissue. The ultrasound examination of the urogenital system revealed nodular hyperplasia of the prostate. The tumor clinical stage according to the American Cancer Committee U.I.C.C. (1992) was Ta. Patient's cancer relapsed at the end of the same year and he underwent a programmed transurethral resection of the tumor, which proved to be papillary transitional cell carcinoma grade I-II. No lamina propria or muscle invasion was detected. The patient was also treated with intracystic infusion of bacille Calmette-Guerin (BCG). Ten days later, because of urine retention, he underwent transurethral resection of the prostate. Multiple tissue fragments of total dimensions 4.5 × 3.5 × 2.2 cm were examined histologically. Seven out of the 10 examined slides revealed foci of partially mucinous (Figure 2A) adenocarcinoma of the prostate (the greatest measured focus was 8.5 mm in maximum diameter), Gleason grade II-III and Gleason score 5 (Figure 2A, B). Immunohistochemical study was performed and showed strong positivity for Prostate Specific antigen (PSA) (Figure 2C) whereas; no expression of carcinoembryonic antigen (CEA) was detected in tumor cells. These findings confirmed the diagnosis of primary prostate adenocarcinoma. The tumor's stage according to the 1997 TNM staging system of prostatic adenocarcinoma was T1b. Serum prostate specific antigen (PSA) levels were elevated (9 ng/mL) before surgery. No additional surgical treatment was given and at follow-up visits prostate specific antigen (PSA) levels measurement and intracystic injection of BCG was performed. In September of the same year, due to progressively worsening dyspnea a computed tomography was performed that revealed a mediastinal mass in conjunction to the right lung hilum and to the right main bronchus with maximum diameter of 9 cm. Bronchoscopy showed a large mass which invaded the right main bronchus mucosa and extended to the carina. Histology of the bronchial mucosal sample showed infiltration of lamina propria by malignant cells (Figure 3A). Their immunophenotype was: CD56 (+) (Figure 3B), Pan-Cytokeratin (paranuclear dot stain positivity) (Figure 3C) and Leukocyte Common Antigen negative. Combining the morphological and the immunohistochemical results, we concluded that the patient was suffering from small cell lung carcinoma (SCLC). The patient's stage was IIIB. Ten days after the diagnosis was confirmed, the patient underwent the first cycle of chemotherapy (Cisplatin and Vepesid), during which he died from cardiac arrest due to chemotherapy toxicity.
Figure 1

Microscopically, the extracted urinary bladder tissue particles proved to be pieces of papillary transitional cell carcinoma grade II [A) hematoxylin and eosin × 40] and immunohistochemically they expressed cytokeratin 7 [B) cytokeratin 7 × 100].

Figure 2

Histologically, in most of the prostate tissue fragments were recognized areas of, partially mucinous, adenocarcinoma of the prostate, grade II-III (A. hematoxylin and eosin × 40, B: hematoxylin and eosin × 100). The tumor cells were strongly positive for PSA (C: PSA × 40).

Figure 3

The bronchial mucosa showed extensive invasion from small blue round cells (A: hematoxylin and eosin × 100) that were positive for the neuroendocrine marker CD56 (B: × 200) and pan-cytokeratin (C: × 200).

Discussion

We report a patient who developed three histologically distinct malignancies, i.e. primary bladder carcinoma and metachronous prostate and SCLC within an eighteen-month period. There are several predisposing or causal factors for each malignancy. For our patient there was only one common causal factor, the fact that he was a heavy smoker (90–100 packets per year). No other predisposing factor or a family history was found that might have contributed to the development of these three malignancies. The presence of bladder and prostate carcinomas in the same patient is not a rare event. Chun [3] reported that the rate of bladder carcinoma in patients with prostate carcinoma is eighteen times higher (p < 0,01) and the rate of prostate carcinoma in those with bladder carcinoma is nineteen times higher (p < 0,01) than expected. Although bladder and prostate carcinoma can coexist in the same individual frequently enough, the rare event is the appearance of a third malignancy. There is a case report by Rovinescu et al [4] referring to a patient with three primary malignancies. The first tumor was a clear cell carcinoma of the kidney, which was followed by a transitional cell carcinoma of the bladder and then by a distinct adenocarcinoma of the prostate. More recently, in 2003, Satoh et al [5] also reported the same combination of multiple primary malignancies in a patient. Our case is the first one of an individual having these two primary malignancies of the urogenital system and another tumor of the lower respiratory tract.

Table 1 summarizes the cases with three or more primary malignancies. As can be easily seen, although the appearance of three primary malignancies in one patient is not very common, should not be considered such a rare event.
Table 1

There are summarized the cases of triple or more malignancies, the first author, journal, year of publication and combination of neoplasms.

 

Year

Author

1st Malignancy

2nd Malignancy

3rd Malignancy

4th Malignancy

5th Malignancy

1

1949

Crail H.W [6]

Thyroid Carcinoma

Rectal Carcinoma

Medulloblastoma

  

2

1974

Hamoudi A.B.[7]

Colon Carcinoma

Thymus Carcinoma

Skin Carcinoma

Astrocytoma G3

 

3

1975

Ohsato K. [8]

Colon Carcinoma

Astrocytoma G3

Duodenal Carcinoma

  

4

1976

Kawanami K. [9]

Ileum Carcinoma

Glioblastoma

Colon Carcinoma

  

5

1976

Rovinescu I.[4]

Clear Cell Carcinoma Of Kidney

Transitional Cell Carcinoma Of Bladder

Prostate Carcinoma

  

6

1979

Itoh H.[10]

Colon Carcinoma

Stomach Carcinoma

Astrocytoma G3

  

7

1979

Mullen J.L.[11]

Hodgkin' Disease

Squamous Cell Carcinoma Of Larynx

Squamous Cell Carcinoma In Esophagus

  

8

1979

Pinel J.[12]

7 Squamous Cell Carcinomas In 9 Years

    

9

1980

Cohen C.[13]

Multiple Cutaneous Squamous Cell Carcinomas

Multiple Cutaneous Basal Cell Carcinomas

Diffuse Poorly Differentiated Lymphocytic Lymphoma

  

10

1982

Friedman C.D. [14].

Breast Carcinoma

Colon Carcinoma

Glioblastoma In Brain

  

11

1983

Li F.P.[15]

Colon Carcinoma

Astrocytoma G3

Leukemia

  

12

1984

Haibach H.[16]

Thyroid Carcinoma

Renal Carcinoma

Duodenal Carcinoma

  

13

1985

Alessi E.[17]

Multiple Sebaceous Tumors

Keratoacanthoma

3 Primary Adenocarcinomas Of Colon

  

14

1985

Kobayashi T. [18]

Uterus Carcinoma

Stomach Carcinoma

Breast Carcinoma

Glioblastoma In Brain

 

15

1985

Megighian D.[19]

Squamous Cell Carcinoma Of Parotid

Squamous Cell Carcinoma Of Tongue

Squamous Cell Carcinoma Of Soft Palate

Squamous Cell Carcinoma Of Larynx

Squamous Cell Carcinoma Of Hypopharynx

16

1985

Staren E.D.[20]

Carcinoma Of Larynx

Carcinoma Of Floor Of Mouth

Dual Primary Bronchogenic Carcinomas

  

17

1986

Craig D.M.[21]

Squamous Cell Carcinoma Of The Floor Of The Mouth

Adenocarcinoma Of Lung

Squamous Cell Carcinoma Of Larynx

Squamous Cell Carcinoma Of The Tongue

 

18

1986

Ogasawara K.[22]

Breast Carcinoma

Breast Carcinoma

Lung Carcinoma

Glioblastoma In Brain

Thyroid Carcinoma

19

1987

Hayashi K.[23]

Colon Carcinoma

Rectal Carcinoma

Glioblastoma In Brain

  

20

1987

Kobayashi T.[24]

Uterus Carcinoma

Stomach Carcinoma

Glioblastoma In Brain

  

21

1988

Ohi H. [25]

Skin Carcinoma

Medulloblastoma

Thyroid Carcinoma

  

22

1991

Baigrie R.J.[26]

7 Primary Carcinomas

    

23

1991

Solan M.J.[27]

Two Breast Carcinomas

Thyroid Carcinoma

Multiple Skin Carcinomas

  

24

1992

Melkert P.W. [28]

Squamous Cell Carcinoma Of Skin

Squamous Cell Carcinoma Of Vulva

Squamous Cell Carcinoma Of Vagina

Squamous Cell Carcinoma Of Anus

Squamous Cell Carcinoma Of Cervix Uteri

25

1992

Marcos Sanchez F. [29]

Colon Carcinoma

Renal Carcinoma

Breast Carcinoma

  

26

1993

Brugieres L. [30]

Soft Tissue Tumor

Brain Tumor

Thyroid Carcinoma

Breast Carcinoma

 

27

1993

Kikuchi T. [31]

Glioblastoma

Colon Carcinoma

Colon Carcinoma

  

28

1993

Shiseki M.[32]

Skin Carcinoma

Colon Carcinoma

Glioblastoma In Brain

  

29

1994

Bumpers H.L.[33]

Squamous Cell Carcinoma Of Larynx

Squamous Carcinoma Of Lung

Adenocarcinoma Of Breast

Adenocarcinoma Of Colon

 

30

1994

Nishihara K. [34]

Papillary Adenocarcinoma Of Papilla Of Vater

Papillary Adenocarcinoma Of Common Bile Duct

Papillary Adenocarcinoma Of Pancreas

  

31

1995

Angeli-Besson C. [35]

Chronic Myeloid Leukemia, Multiple Squamous Cell Carcinomas

    

32

1996

Hayashi T.[36]

Squamous Cell Carcinoma In Soft Palate

Squamous Cell Carcinoma In Larynx

Squamous Cell Carcinoma In Esophagus

  

33

1996

Nagane M.[37]

Tubular Adenocarcinoma Of Stomach

Transitional Cell Carcinoma Of Bladder

Glioblastoma In Brain

  

34

1996

Nagane M. [37]

Papillary Adenocarcinoma Of Lung

Adenocarcinoma Of Rectum

Glioblastoma In Brain

  

35

1997

Potzsch C.[38]

Breast Carcinoma

Small Cell Lung Carcinoma

Renal Cell Carcinoma

Acute Myelomonocytic Leukemia

 

36

1997

Shan L.[39]

14 Foci Of Primary SCC, Esophagus, Oral Floor, Soft Palate, Uvula, Lingual Radix, Piriform Recess, Hypopharynx, Trachea, Lingual Body

    

37

1999

Cribier B. [40]

Eccrine Porocarcinoma

Tricholemmal Carcinoma

Multiple Squamous Cell Carcinomas

  

38

1999

Ramsay H.M.[41]

Acute Myeloid Leukemia

Chronic Lymphocytic Leukemia

Basal Cell Carcinomas

  

39

1999

Schon M.P.[42]

Basal Cell Carcinomas

Hairy Cell Leukemia

Basal Cell Carcinomas

  

40

2000

Beswick S.J.[43]

Basal Cell Carcinomas

Malignant Melanoma In Situ

Basal Cell Carcinomas

  

41

2001

Mukai [44]

Stomach Carcinoma

Duodenal Carcinoma

Esophageal Cancer

Renal Cancer

Colon Carcinoma In Situ

42

2003

Satoh H.[5]

Carcinoma Of Kidney

Transitional Cell Carcinoma Of Bladder

Prostate Carcinoma

  

Additionally, studying the existing bibliography, we noticed that there is a little confusion regarding the terms used, such as synchronous, simultaneous and metachronous or successive neoplasms. All of these words have to do with the time that the neoplasms are discovered and have nothing to do with the time of their genesis. The word synchronous is a Greek one that should refer to neoplasms appearing in the same time. It is synonymous to the word simultaneous and they are interchangeable. Metachronous (meta- means after and -chronous is the time) is also a Greek word referring to a neoplasm that is discovered while there is already a known neoplasm in the same patient. The word successive could be used equally to metachronous.

Conclusion

Summarizing, it is important for the clinicians to keep in mind that the appearance of another tumor in a patient suffering from cancer could be either a metastasis or another malignancy and should always investigate the possibility of a metachronous (successive) or a synchronous (simultaneous) malignancy. Moreover, the combination of the three different neoplasms (bladder, prostate and SCLC) in one patient, to the best of our knowledge, has never been reported before.

Declarations

Acknowledgements

The permission was obtained from the next of kin of patient for publication of this case report.

Authors’ Affiliations

(1)
Department of Pathology, Heraklion University Hospital
(2)
Department of Pneumonology, Heraklion University Hospital

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