Title: Case reports of multiple synchronous tumors after breast chemotherapy

Mehmet VELIDEDEOGLU1, Fahrettin KILIC2, Yasemin KUCUK1, Akif Enes ARIKAN1,

Abdullah TUTEN3, M. Halit YILMAZ2, Varol CELIK1, Ertugrul GAZIOGLU1, Mehmet

FERAHMAN1

1Istanbul University, Cerrahpasa Medical Faculty, Department of General Surgery, Istanbul,

Turkey

2Istanbul University, Cerrahpasa Medical Faculty, Department of Radiology, Istanbul, Turkey

3Istanbul University, Cerrahpasa Medical Faculty, Department of Gynecology and Obstetrics,

Istanbul, Turkey

Introduction

Multiple primary malignant tumors can be defined as more than two different tumors,

located in the same organ or different organs. As well as, three different concurrent primary

malignancies are extremely rare conditions. We present a case with both invasive ductal

carcinoma of the breast, neuroendocrine tumor of the other breast and mucinous adenocarcinoma

of the colon.

Case 1

A 52 year-old woman with history of left modified radical mastectomy and adjuvant

chemotherapy for invasive ductal carcinoma admitted with right mastalgia. No lesion was

detected in physical examination. Ultrasonography (US) showed a 20*15 mm mass in the upper

outer quadrant of the breast .She received invasive ductal carcinoma by an US-guided core

biopsy. Full body positron emission tomography (PET CT) with 10 mCi F-18 fludeoxyglucose

(FDG) showed an increase metabolic activity at same localization in breast site, and transverse

colon. On colonoscopy, ~6*5 cm long mass was found on transvers colon, the lesion was

diagnosed as epithelial high grade neoplasia with punch biopsies.

The patient underwent right partial mastectomy and axillary dissection, as sentinel lymph node

biopsy was positive. Transverse colon resection and omentectomy was planned as another

session. Pathological examination of the mastectomy revealed a 2 cm good differentiated

neuroendocrine tumor with histological grade 2, and 2/14 axillary lymph nodes was positive as

micrometastases. Synaptophysin was positive and chromogranin focal positive. Hormonal

receptors were strongly positive and Cerb-B2 was negative with %30 Ki-67 score. Pathological

examination of transverse colon, mucinous adenocarcinoma was determined as a third different

cancer focus.

Case 2

During follow-ups, of an 80 year-old woman with a history of right breast conserving surgery

and right axillary dissection 9 years ago with adjuvant chemotherapy, mammography and

ultrasonography showed a 10*18 mm mass in in upper outer quadrant of the left breast. US-

guided core biopsy of the lesion revealed invasive lobular carcinoma. FDG PET/CT revealed

lesions with increased uptake in upper quadrant of the left breast and rectal colon segment.

Colonoscopic punch biopsies were revealed invasive adenocarcinoma of the rectum. (Figure)

The patient underwent left mastectomy with negative sentinel lymph node biopsy. At the same

session low anterior resection with total abdominal hysterectomy and bilateral salpingo-

oophorectomy were performed, as the tumor was invaded to vagina and cervix. Partial

ureterectomy and double-j catheterization was also performed, because there was an invasion to

the left ureter. Breast lesion was 1.5 cm pleomorphic variant invasive lobular carcinoma, CK7

and GCDFP 15 was positive. Lesion in the transverse colon diagnosed as low graded

adenocarcinoma as a third different cancer focus.

Conclusion:

Multiple primary tumors can include variable types and localizations of tumors. Adjuvant

treatments after breast surgery may lead to multiple primary tumors in long term follow up

despite of increased survival.

Figure. Legends detected with imaging modalities.

Biography

I was born in 1985 in Konya. I graduated from Istanbul University, Cerrahpasa Medical Faculty

(English Program). Between 2007-2009 I served on the student representative council. I began

my General Surgery residency at the same faculty in 2011. In 2014, I was elected as President of

the Turkish Surgical Society’s Resident Committee. I’m currently listed as an editor in the

journal Medicine. In addition, I’m one of the founding members of the Turkish Young Doctors’

Platform and Association and currently their vice President. My research interests are endocrine

surgery new technologies in medicine in terms of diagnostics and treatment modalities.