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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 30-32

Synchronous dual malignancies: Carcinoma larynx and hepatocellular carcinoma


Department of Radiation Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Date of Submission01-Dec-2020
Date of Acceptance03-Dec-2020
Date of Web Publication27-Jan-2021

Correspondence Address:
Dr. Aastha Shah
Department of Radiation Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_68_20

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  Abstract 


Synchronous cancers are defined as two or more primary cancers diagnosed in the same patient at the same time or within 6 months of diagnosis of each other. The diagnosis of multiple primary malignancies is not uncommon. A 70-year-old male reported to our hospital with chief complaints of change in voice and difficulty in swallowing solid food for 2 months accompanied anorexia since 20 days. The patient revealed occasional consumption of alcohol for 3 years and bidi smoking for 50 years (10 bidis per day). The patient was conscious, cooperative, and well oriented to time, place and person with an Eastern Cooperative Oncology Group of 0. On physical examination, the oral cavity and oropharynx were unremarkable. Direct laryngoscopy revealed ulceroproliferative growth in right-sided vallecula, right-sided aryepiglottic fold, right side arytenoid and pyriform sinus, and right vocal cord. Biopsy from this growth turned out to be poorly differentiated squamous cell carcinoma. Computed tomography (CT) scan of the neck and thorax revealed 1.5 cm × 2.6 cm heterogeneously contrast enhancing lesion involving right aryepiglottic fold, pyriform fossa, posterior hypopharyngeal wall, and posterior aspect of both false vocal cords. Few subcentimeter lymph nodes were noted in right side Level II. The CT scan also showed some mass lesion abnormality in the upper section of liver images which could not be properly made out. Hence, triple-phase CT scan of the liver was done which to a great surprise showed 7.7 cm × 6.5 cm × 5.5 cm lesion in segment V and VIII, it showed enhancement on arterial phase, became prominent on portovenous phase and a delayed phase washout. Similar lesion measuring 4.4 cm × 4.1 cm was seen in segment VIII of liver; which was diagnosed radiologically as a multicentric hepatocellular carcinoma. Serum alpha fetoprotein was markedly elevated to a value of 28,600 ng/mL. A multidisciplinary tumor board discussion was done, and an intense literature review was done, and a decision was taken keeping in mind the overall performance score of the patient to commence with a high palliative radiotherapy for laryngeal cancer to a dose of 45 Gray in 15 fractions at a dose of 3 Gray per fraction and tablet tamoxifen at a dose of 60 mg/day till the end of radiation followed by switching over to tablet sorafenib. The patient ultimately developed uremia due to liver failure and died. The patient survived for a period of 3 months from the time of diagnosis of malignancy. Such cases need a meticulous approach for the diagnosis as well as treatment approaches. Keeping in mind the general condition of the patient and available therapeutic options, a patient-based specific approach could be developed.

Keywords: Dual malignancies, hepatocellular cancer, larynx cancer, liver, synchronous


How to cite this article:
Shah A, Shivhare V, Rath S, Anand D, Shah I, Shah R, Suryanarayan U. Synchronous dual malignancies: Carcinoma larynx and hepatocellular carcinoma. J Radiat Cancer Res 2021;12:30-2

How to cite this URL:
Shah A, Shivhare V, Rath S, Anand D, Shah I, Shah R, Suryanarayan U. Synchronous dual malignancies: Carcinoma larynx and hepatocellular carcinoma. J Radiat Cancer Res [serial online] 2021 [cited 2021 Nov 30];12:30-2. Available from: https://www.journalrcr.org/text.asp?2021/12/1/30/308109




  Introduction Top


Synchronous cancers are defined as two or more primary cancers diagnosed in the same patient at the same time or within a span of 6 months of diagnosis of each other. The diagnosis of multiple primary malignancies is not uncommon.[1] However, the presentation of laryngeal carcinoma occurring with hepatocellular carcinoma is unusual. Herein, we therefore report one such rare case.


  Case Report Top


This is a rare case of synchronous primary malignancies with both larynx cancer and hepatocellular carcinoma. A 70-year-old male reported to our hospital with chief complaints of change in voice and difficulty in swallowing solid food for 2 months accompanied anorexia for 20 days. On further investigation, the patient revealed a history of cardiac stent placement 2 years back due to myocardial infarction attack and is on antihypertensives and antilipidemic drugs since then. The patient revealed occasional consumption of alcohol for 3 years and bidi smoking for 50 years (10 bidis per day). The patient was conscious, cooperative and well oriented to time, place and person with a Eastern Cooperative Oncology Group of 0. On physical examination, the oral cavity and oropharynx were unremarkable. Direct laryngoscopy revealed ulceroproliferative growth in right-sided vallecula, right-sided aryepiglottic fold, right side arytenoid and pyriform sinus, and right vocal cord. Biopsy from this growth turned out to be poorly differentiated squamous cell carcinoma as shown in [Figure 1]. Computed tomography (CT) scan of the neck and thorax revealed 1.5 cm × 2.6 cm heterogeneously contrast-enhancing lesion involving right aryepiglottic fold, pyriform fossa, posterior hypopharyngeal wall, and posterior aspect of both false vocal cords. Few subcentimeter lymph nodes were noted in right side level II. Rest of the scan showed no abnormal changes; the CT scan showed some mass lesion abnormality in upper section of liver images which could not be properly made out. So triple phase CT scan of liver was done due to concern for metastasis but to a great surprise showed 7.7 cm × 6.5 cm × 5.5 cm lesion in segment V and VIII, it showed enhancement on arterial phase, that became prominent on porto venous phase and a delayed phase washout. Another similar lesion measuring 4.4 cm × 4.1 cm was seen in segment VIII of liveras shown in [Figure 2]. Which was diagnosed radiologically as a multicentric hepatocellular carcinoma. Serum alpha fetoprotein was markedly elevated to a value of 28,600 ng/mL. A multidicsiplinary tumor board discussion was done including medical, surgical and radiation oncologists and an intense literature review was done and a decision was taken keeping in mind the overall performance score of the patient to commence with a high palliative radiotherapy for laryngeal cancer to a dose of 45 Gray in 15 fractions at a dose of 3 Gray/fraction and tablet tamoxifen at a dose of 60 mg/day till the end of radiation followed by switching over to tablet sorafenib. Patient ultimately developed uremia due to liver failure and died. Patient survived for a period of 3 months from the time of diagnosis of malignancy.
Figure 1: Computed tomography scan of the larynx showing contrast-enhancing lesion

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Figure 2: Triple phase of computed tomography of the liver showing multicentric lesions

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  Discussion Top


The most common cause of morbidity in head and neck cancers is the development of metachronous second primary malignancies.[2] Synchronous and metachronous second primary malignancies have been very well defined but whether the second lesion is truly a second primary or a metastatic lesion has been proposed by Warren and Gates.[3]

  1. Each tumor should present a definite picture of malignancy
  2. Each tumor should be histologically distinct
  3. The possibility that one is a metastasis of the other must be excluded.


The most common second primary malignancy associated with a head and neck primary is lung cancer.[4] The occurrence of synchronous dual malignancies have also risen due to advent of modern advanced diagnostic techniques. The incidence of metachronous dual malignancies have also risen due to increase in the lifespan of the cancer patients due to advancement in the treatments offered and subsequently the development of second malignancies as the late manifestations of these treatments itself which include radiation and chemotherapy. Thus, it can be seen as a longer cancer survivorship is been offered at the cost of second malignancy itself. However, the modern approaches have even combat such challenges.[5] The management of synchronous dual malignancies poses a significant challenge concerning both the treatment dilemma and the capacity of the patient in tolerating aggressive treatment regimes. The diagnostic yield can be improved by looking for the genetic clonality between two primary malignancies presenting synchronously to yield a better tumor control rate and achieve a better cancer survivorship.[6] Here, in this case, the laryngeal cancer can be staged according to current American Joint Cancer Committee tumor node metastasis staging as T2N0 which is stage II and the liver tumor could be staged as T3N0 which is Stage IIIA. Keeping in mind, the standard protocols for the treatment for the two malignancies and keeping in mind the co-occurrence of these tumors and the general physical condition of the patient, decision for the consideration of palliative radiation for larynx tumor and the liver tumor could not be resected due to the multicentric nature of the tumor so the decision to start on oral chemotherapy was taken. The comorbidities hinder to offer the radical approach as the tolerance of the patient reduces due to such conditions.


  Conclusion Top


Such cases need a meticulous approach for the diagnosis as well as treatment approaches. Keeping in mind, the general condition of the patient and available therapeutic options, a patient-based specific approach could be developed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kuna J, Das P, Patnayak R, Tyagi A. Synchronous dual primary malignancy of urinary bladder and hypopharynx: An extremely rare phenomenon. J Clin Sci Res 2016;5:136-9.  Back to cited text no. 1
  [Full text]  
2.
Cooper JS, Pajak TF, Rubin P, Tupchong L, Brady LW, Leibel SA, et al. Second malignancies in patients who have head and neck cancer: Incidence, effect on survival and implications based on the RTOG experience. Int J Radiat Oncol Biol Phys 1989;17:449-56.  Back to cited text no. 2
    
3.
Warren S, Gates D. Multiple primary malignant tumor: A survey of the literature and a statistical study. Am J Cancer 1932;51:1358-414.  Back to cited text no. 3
    
4.
Acharya P, Ramakrishna A, Kanchan T, Magazine R. Dual primary malignancy: A rare organ combination. Case Rep Pulmonol 2014;2014:760631.  Back to cited text no. 4
    
5.
Li F, Zhong WZ, Niu FY, Zhao N, Yang JJ, Yan HH, et al. Multiple primary malignancies involving lung cancer. BMC Cancer 2015;15:696.  Back to cited text no. 5
    
6.
Spencer SA, Harris J, Wheeler RH, Machtay M, Schultz C, Spanos W, et al. Final report of RTOG 9610, a multi-institutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the head and neck. Head Neck 2008;30:281-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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