A lengthy discussion ensued regarding treatment for the 3 cancers. The AJCC Cancer Staging Manual, 7th edition, was used as the framework for all staging.1 The patient had a stage IIA (T1bN0MX), grade 3 sarcoma, which could be removed by neck dissection. He had a stage IIIB esophageal carcinoma (T3N2MX), which would require concurrent chemoradiation. His limited stage small cell lung cancer might have been amenable to a lobectomy if a mediastinoscopy was negative. The standard of care for limited stage small cell lung cancer is that if the cancer is precisely staged and the patient is a good surgical candidate, then surgery can be considered. The rationale for considering resection in this case was that if his other cancers could be cured, then surgery would be an excellent option.2 These options were presented to the patient, who opted for chemotherapy. The oncologist treating the patient elected to target the small cell cancer initially, because it was likely the fastest growing cancer. The patient started treatment with etoposide/carboplatin shortly thereafter. Mr. F. was also referred to palliative care.
Discussion
When a patient presents with several tumor masses detected either clinically or radiologically, it is reasonable to assume, at least initially, that all the lesions can be attributed to the same disease (ie, a primary neoplasm and distant metastases). Based on this assumption, it is rational to establish a tissue diagnosis by sampling the most accessible lesion. In the correct clinical context, this may be sufficient to initiate an appropriate therapy. However, health care providers should be aware that unrelated neoplasms can develop simultaneously, and about 8% of patients have > 1 malignancy at presentation.3
This patient presented with 3 different malignant neoplasms: esophageal adenocarcinoma, pulmonary small-cell carcinoma, and high-grade sarcoma. These types of tumors have completely different histogenesis. Esophageal adenocarcinoma develops from glandular cells of Barrett’s esophagus, small-cell carcinoma develops from neuroendocrine Kulchitsky cells, and sarcoma arises from mesenchymal cells. This constellation of neoplasms does not represent any known multicancer syndrome, such as Li-Fraumeni syndrome or Lynch syndrome. Whether these concomitant tumors represent coincidental neoplasms or have common underlying molecular alterations remains unknown.
The treatment for each of this patient’s cancers was very different and required a multidisciplinary, staged approach for management. This could have been arranged for him had he wanted to pursue multiple resections of the neck and lung plus have chemotherapy and radiation for the esophageal cancer. The patient opted for chemotherapy for the most aggressive cancer, but other options would have been possible had he wanted to pursue them.
Conclusion
This complex case demonstrates the role for careful review of all data and the importance of not making assumptions when analyzing images and history despite all the procedures and time to diagnosis.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
