BACKGROUND A patient diagnosed with synchronous DPM of the colon and the breast is rare and presents with poor prognosis. This combination, to the best of our knowledge, has never been reported in the Philippines.

 CASE PRESENTATION

A 45-year-old pre-menopausal woman was referred to the Adult Cancer Institute, Outpatient Clinic of the Southern Philippines Medical Center (SPMC), due to hematochezia and a left breast mass. A detailed past medical, family, personal, and social history were unremarkable. Pertinent physical exam revealed a left breast mass of 3 cm x 2.5 cm and an unremarkable abdominal and rectal findings. Mammogram revealed a 4.5 cm x 3.0 cm left breast mass, BIRADS 4. CNB revealed fibrocystic disease of the breast. Colonoscopy revealed sigmoid mass 18 cm from anal verge, with biopsy of well- differentiated adenocarcinoma. The patient was advised to have a repeat biopsy of the breast mass but did not consent. CT scan was performed which revealed a breast mass and a sigmoid colon mass with no evidence of other sites of metastasis. CEA was elevated. Patient was presented in a multidisciplinary conference; the consensus was to have surgical resection of the DPM.  

LEARNING POINTS

The patient underwent successful double set up procedure without any complication post-operatively. IHC revealed these two lesions were of different primaries. The patient underwent adjuvant treatment.  

 

Genetic testing and counseling may be considered in patients presenting with DPM. Since, there is no appropriate guidelines in the management of DPM, treatment should be planned in a multidisciplinary setting for each patient.  

CONCLUSION DPM is a consideration in patients presenting with synchronous masses. Genetic testing is considered in this subset of patients. Multidisciplinary team approach is highly recommended in the management of these rare conditions.  

CT scan of the Breast, Left CT scan of the colon,

Figure 1B. Circumferential wall thickening with luminal narrowing spanning a length of about 5.5 cm is seen in the sigmoid colon.

 

Figure 1A. A well defined, lobulated, enhancing mass is seen in the left upper outer region of the breast measuring 4.2 cm x 2.3 cm x 3.9 cm (LWT).

 

Cytokeratin 7/20 of the Breast, Left

Cytokeratin 7/20 of the Colon

3B. Cytokeratin 7 Control-shows distinct cytoplasmic staining reaction. Patient-Tumor cells also show positive staining reaction (cytoplasmic staining pattern) to Cytokeratin 7.

3B. Cytokeratin 20. Control- The columnar epithelial cells show a distinct cytoplasmic staining reaction Patient- The tumor cells however do not show staining reaction , hence are negative for the Cytokeratin 20 .

 

3A. Cytokeratin 7. Control-shows positive cytoplasmic reaction. Patient-Tumor cells are negative for Cytokeratin 7 since they do not show any cytoplasmic staining reaction. Cytokeratin 20. Control- The columnar epithelial cells show a distinct cytoplasmic staining reaction (pointed by the red arrows). Patient- The tumor cells as well show distinct cytoplasmic staining reaction, hence are positive for the Cytokeratin 20 .

 

DISCUSSION The incidence of DPM has been documented to be as low as 1% to as high as 16% (4). Incidence of breast and colon cancer in women at the same time is 3.85% (10).

The diagnoses of multiple primary malignancies are becoming more frequent, although synchronous DPM is still rare, due to higher incidence of metachronous tumors over synchronous tumors. Our patient presented with two primary cancers. She was symptomatic at the outset hence surgical resection was decided as the initial treatment. This patient received adjuvant therapy with a regimen using Docetaxel plus Capecitabine to possible cover for both malignancies. The multidisciplinary team agreed that the patient will benefit from adjuvant treatment. One limitation of the manuscript is the lack of genetic testing performed.  

SYNCHRONOUS DOUBLE PRIMARY MALIGNANCY (DPM) OF THE COLON AND THE BREAST: A CASE REPORT

 FATIMA AMINA H. IBRAHIM, MD, FPCP1, ARTHUR GREGORY A. LUI, MD, FPCP, FPSMO1  

1Section of Medical Oncology, Department of Internal Medicine,Southern Philippines Medical Center, Davao City, Philippines