Maulana Azad Medical College Pittsburgh, PA, United States
Rahul Karna, MD, Nabeeha Mohy-Ud-Din, MD, Feifan Chen, MD, Olukemi Esan, MD, Abhijit Kulkarni, MD Allegheny Health Network, Pittsburgh, PA
Introduction: Multiple primary neoplasms (MPNs), especially three or more are rare. Triple primary neoplasms account for 0.5% of all MPNs. MPNs are classified into synchronous and metachronous lesions when other neoplasms are diagnosed within and after six months of first neoplasm respectively. We present a case of triple synchronous primary neoplasm of colon, prostate and urinary bladder diagnosed within a month.
Case Description/Methods: A 68-year-old African American male without any significant medical history presented with worsening abdominal pain, loss of appetite and lower urinary tract symptoms for a week. CT scan of abdomen-pelvis with IV contrast showed a heterogeneous hypodense mass in the liver measuring 2.3 x 3.3 cm, ill-defined density near splenic flexure and heterogeneously enlarged prostate with a nodule projecting into the bladder. His prostate specific antigen was elevated at 11.6 ng/ml. PET CT showed multifocal FDG avid foci adjacent to splenic flexure, liver and left side of prostate.Biopsy of liver mass showed moderately differentiated adenocarcinoma with extensive necrosis, with IHC positive for CK20, CDX-2 and negative for CK7, confirming metastatic disease from colorectal cancer and negative for GATA-3, thus, ruling out urothelial origin. Colonoscopy revealed an obstructing descending colon mass which turned out to be moderately differentiated colonic adenocarcinoma on biopsy, which was microsatellite stable on IHC. Mutation analysis was positive for KRAS, but negative for NRAS and BRAF. A cystoscopy revealed a polypoid tumor inside the bladder neck with transurethral resection confirming low grade papillary urothelial carcinoma without invasion. He also underwent prostate biopsy which confirmed adenocarcinoma, NKX3.1-positive and CDX-2-negative, consistent with prostatic origin and ruling out metastatic disease from colon. He was subsequently started on FOLFOX and Bevacizumab for metastatic colon cancer as prognosis for MPNs depend on the most aggressive neoplasm, in this case, colon cancer.
Discussion: The incidence of MPN is expected to increase with improving outcomes and life expectancy for primary neoplasms. Our patient was diagnosed with MPN based upon criteria put forward by Warren and Gates: each tumor 1) occurs in different parts or organs, 2) malignant with its own pathological features, 3) and metastases is excluded. There are no specific guidelines for management of MPNs. It should be managed by a multidisciplinary team and the treatment is individualized.
Figure: CT abdomen pelvis with contrast showing a (A) mass in the liver and splenic flexure thickening (B) enlarged prostate with nodule projecting into bladder base. (C) PET scan shows FDG avid lesion in liver and adjacent to splenic flexure corresponding to lesions seen in figure A. (D) H&E stain of colon mass biopsy shows dysplastic glands invading into the submucosa, consistent with moderately differentiated invasive adenocarcinoma. (E) H&E stain of bladder biopsy shows papillary structures with fibrovascular core and thick urothelial lining, consistent with low grade papillary urothelial carcinoma without invasion (F) H&E stain of prostate biopsy shows atypical glands which are predominantly discrete well-formed glands with some back-to-back/fused glands, consistent with adenocarcinoma.
Rahul Karna indicated no relevant financial relationships.
Nabeeha Mohy-Ud-Din indicated no relevant financial relationships.
Feifan Chen indicated no relevant financial relationships.
Olukemi Esan indicated no relevant financial relationships.
Abhijit Kulkarni indicated no relevant financial relationships.
Rahul Karna, MD, Nabeeha Mohy-Ud-Din, MD, Feifan Chen, MD, Olukemi Esan, MD, Abhijit Kulkarni, MD. P0196 - Triple Synchronous Primary Neoplasm of Colon, Urinary Bladder and Prostate: A Rare Entity, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.