Synchronous neoplasms: Duodenal villous adenoma, hepatocellular carcinoma, and colon carcinoma

Steven E. Brooks, MD

Surgical Resident

Reza F. Saidi, MD

Chief Surgical Resident

Alasdair McKendrick, MD

Consultant Colorectal

Surgeon

Michael J. Jacobs, MD

Consultant Surgeon

Department of Surgery

Providence Hospital

and Medical Centers

Southfield, MI

Clinical Associate

Professor

Wayne State University

School of Medicine

Detroit, MI

ABSTRACT

Introduction: Multiple primary neoplasms identified within 6 months of one another are termed synchronous neoplasms. Synchronous neoplasms are uncommon and present unique considerations for treatment and prognosis.

Results and discussion: This paper reports the case of a patient who was found to have simultaneous duodenal villous adenoma, hepatocellular carcinoma, and colon cancer. It also discusses the importance of considering associations between these cancers.

Conclusion: When diagnosing any of the three cancers identified in this patient, it is important to screen for additional primary tumors. Patients have a good prognosis when colorectal cancers are diagnosed and treated in their early stages.

The term synchronous neoplasms describes multiple primary neoplasms discovered within 6 months of one another. This uncommon condition raises prognostic and treatment dilemmas. We report the case of a patient who presented with three distinct synchronous primary neoplasms, consisting of duodenal villous adenoma, hepatocellular carcinoma, and colonic adenocarcinoma. We also review the literature regarding synchronous neoplasms.

Case report

An 83-year-old white man with a medical history of hypertension and diabetes presented to our institution reporting fatigue and a 3-month history of intermittently passing dark-colored stools. He said that his stools were not tarry and he had noticed no bright red rectal bleeding. He also reported experiencing no nausea, vomiting, jaundice, shortness of breath, dark urine, fevers, chills, or sweats. Routine laboratory evaluations revealed microcytic anemia and a hemoglobin level of 4.2 g/dL.

Colonoscopy confirmed the presence of colorectal carcinoma, and an upper endoscopy study revealed an ampullar villous adenoma in the duodenum. Preoperative computed tomography (CT) scans showed a lesion in liver segments V and VI (Figure). Based on these findings, the patient was taken to the operating room for an exploratory laparotomy.

Partial colectomy with ileocolonic anastomosis was performed, and a mobile spongiform lesion was resected from the distal second portion of the duodenum. A hard, 5-cm mass was palpated within hepatic segment V. Because there was no evidence of portal adenopathy or any other finding that would preclude resection, hepatic segmentectomy was undertaken, which achieved negative section margins. Intraoperative ultrasonography confirmed the absence of additional hepatic lesions.

Subsequent pathological examination of the specimens revealed three distinct primary cancers: a 4 x 5 x 1-cm moderately differentiated adenocarcinoma of the transverse colon; a 4 x 3 x 1-cm villous adenoma from the distal second portion of the duodenum; and a 4.0 x 3.5-cm hepatic lesion that was determined to be a well-differentiated hepatocellular carcinoma. The patient did not receive adjuvant therapy. At 2-year follow-up, he had no evidence of recurrence or any metastatic disease.

Discussion

In addition to presenting a rare example of three synchronous primary cancers, our case report inspires clinicians to consider the associations between these cancers. Although numerous reports discuss the incidence of synchronous colonic neoplasms, few studies evaluate the relationship between colon cancer and synchronous, extracolonic primary neoplasms. One such study found that patients with colorectal cancer have extraintestinal primary cancers 1.4 times more often than expected.¹ Mainwaring and colleagues concluded that the incidence of a synchronous, extracolonic primary neoplasm is at least equal to that of a second colonic lesion (between 4% and 5%).² These reports emphasize the importance of evaluating patients with known colonic primary neoplasms for synchronous colonic and extracolonic tumors according to the recommendations set by the American Cancer Society. Investigations should include using diagnostic modalities such as mammography, colonoscopy, and prostate-specific antigen testing.

Our patient underwent colonoscopy and upper endoscopy to ascertain the cause of his acute blood-loss anemia. Because his duodenal and colonic neoplasms were discovered at the same time, it was necessary to consider the relationship between duodenal adenomas and synchronous colorectal neoplasia. Neoplasia of the small intestine is rare compared with that of the colon.³

Practice

Points

• It is important to evaluate patients with known colonic primary neoplasms for synchronous colonic and extracolonic tumors according to the recommendations set by the American Cancer Society.
• Patients who have duodenal adenomas should undergo colonoscopy to determine whether a synchronous colonic neoplasm is present.
• Surgical resection is adequate for node-negative colorectal tumors; however, metastatic or node-positive tumors require adjuvant therapy.

Murray and colleagues conducted a retrospective case control study evaluating the records of patients who visited their institution from 1992 to 2002.⁴ The authors observed that patients with duodenal adenomas were more likely to have associated colorectal neoplasia than the age- and sex-matched control group.⁴ Apel and associates examined the records of duodenal adenoma patients from 1990 to 2003 and concluded that their risk of concomitant colonic adenoma was 20 times higher than that of the general population (these patients did not have familial adenomatous polyposis).⁵ This suggests that patients who have duodenal adenomas should undergo colonoscopy to determine whether a synchronous colonic neoplasm is present.

Is there any association between hepatocellular carcinoma and synchronous primary neoplasia? Nzeako and colleagues retrospectively reviewed a series of 1,349 hepatocellular carcinoma cases over a 14-year period and found that 5.5% of patients with these carcinomas had at least one other synchronous primary malignancy; the presence of extrahepatic primary malignancies had no effect on survival.⁶ It is also noteworthy that, in this North American series, the most common extrahepatic primary malignancies occurred in the gastrointestinal system, and colonic adenocarcinoma was the most common gastrointestinal tumor.

Due to widespread screening programs, most colorectal cancers are diagnosed at an early stage, and patients have a good prognosis. Surgical resection is adequate for node-negative tumors; however, metastatic or node-positive tumors require adjuvant therapy.²

Conclusion

Our case presents an uncommon example of three synchronous primary malignancies and underscores the importance of evaluating patients for additional primary tumors when confronted with a colonic adenocarcinoma, duodenal adenoma, or hepatocellular carcinoma. Awareness of the associations between different cancers would enable earlier detection of additional synchronous tumors. Future studies of these associations may provide insight into carcinogenetic pathways and lead to new treatments and preventive stratagems.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

References

1. Schottenfeld D, Berg JW, Vitsky B. Incidence of multiple primary cancers. II. Index cancers arising in the stomach and lower digestive system. J Natl Cancer Inst. 1969;43(1):77-86.
2. Mainwaring RD, Rivera J, Wilson W. Synchronous hepatocellular carcinoma and adenocarcinoma of the colon. Am Surg. 1989; 55(8):528-532.
3. Arber N, Neugut AI, Weinstein IB, et al. Molecular genetics of small bowel cancer. Cancer Epidemiol Biomarkers Prev. 1997;6(9):745-748.
4. Murray MA, Zimmerman MJ, Ee HC. Sporadic duodenal adenoma is associated with colorectal neoplasia. Gut. 2004;53(2):261-265.
5. Apel D, Jakobs R, Weickert U, et al. High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis. Gastrointest Endosc. 2004;60(3):397-399.
6. Nzeako UC, Goodman ZD, Ishak KG. Association of hepatocellular carcinoma in North American patients with extrahepatic primary malignancies. Cancer. 1994;74(10):2765-2771.

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