|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 268-269
Successful treatment of a dual malignancy
MSH Zafar1, R Kaur2, P Pankaj3, M Bhargava1, S Aggarwal4
1 Department of Hematology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
3 Department of Nuclear Medicine, Sir Ganga Ram Hospital, New Delhi, India
4 Department of 3Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
|Date of Web Publication||18-Feb-2016|
Department of Hematology, Sir Ganga Ram Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Zafar M, Kaur R, Pankaj P, Bhargava M, Aggarwal S. Successful treatment of a dual malignancy. Indian J Cancer 2015;52:268-9
A patient with two malignancies is not an uncommon finding in the current medical practice. The aim of presenting this case is to highlight the value of high index of suspicion needed for second malignancy in patients of multiple myeloma with bony lesions, ultimately leading to proper management decisions.
A 62-years-old male, non-smoker and non-alcoholic, was on regular treatment for diabetes and hypertension. During a routine investigation, a very high ESR (130 mm first hr) was noted on complete blood count (CBC). History and physical examination was unremarkable. After a detailed evaluation including skeletal survey with magnetic resonance (MRI) of spine, he was diagnosed as asymptomatic multiple myeloma (lytic lesions in skull, serum albumin 3.0 g/dl, serum β2 microglobulin 1.87 mg/L, serum monoclonal spike 2.68 g/dl, monoclonal band in IgG-κ region and bone marrow plasmacytosis of 10%). Patient was being monitored by 3 monthly CBC, blood chemistry, and serum protein electrophoresis (SPE). Eighteen months later, the patient developed sudden excruciating low backache. MRI of spine now showed L2 and L5 vertebral compression [Figure 1]. At this time, investigations revealed mild anemia Hb-10.1 g/dl, serum albumin 3.0 g/dl, M-protein 2.3 g/dl, serum β2-microglobulin 3.2 mg/L, and bone marrow plasmacytosis of 14%. FISH was positive for deletion 13 q14.3. In view of stable myeloma panel, a positron emission tomography/computed tomography (PET/CT) scan was done to look for any other pathology leading to the vertebral fractures. PET/CT revealed FDG avid intraluminal mass lesion in sigmoid colon measuring 2.3 × 2.4 cm [Figure 2]. A polypoidal mass was seen on colonoscopy and snare resected. Histopathologic examination (HPE) of the mass showed moderate to poorly differentiated adenocarcinoma [Figure 3]. Serum levels of CEA (0.26 ng/ml), CA19-9 (26 U/ml) and prostate specific antigen (3.1 ng/ml) were normal. Sigmoid resection with colorectal anastomosis was subsequently performed. HPE of the resected bowel segment showed no tumor in any of the sections examined [Figure 4]. Lymph nodes were negative for the malignancy. As the cause of vertebral compression was not clear in this case, a direct bone biopsy from the fracture site was taken at the time of L2 and L5 kyphoplasty, which on HPE revealed sheets of plasma cells and no evidence of a metastatic deposit, confirming the diagnosis of multiple myeloma stage II with adenocarcinoma sigmoid colon. Patient received 4 cycles of Inj. bortezomib 1.3 mg/m 2 intravenous and oral dexamethasone 40 mg and attained complete response. No further treatment was required for colon cancer. The patient is on our close follow-up on maintenance lenalidomide and is doing well.
|Figure 1: Magnetic resonance imaging of spine showing L2 and L5 vertebral compression|
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|Figure 2: Whole body PET scan showing FDG avid intra-luminal sigmoid lesion|
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|Figure 3: Microscopic examination of sigmoid lesion showing high-grade adenocarcinoma|
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|Figure 4: Microscopic examination of colon showing no residual tumor post-sigmoid resection|
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Multiple myeloma may precede/follow both the hematological or solid malignancies or diagnosed simultaneously although their correlation is still unclear.,, Bhandari et al. reported 6 cases of renal cell carcinoma (RCC) out of 600 cases of plasma cell dyscrasias over a period of 10 years. Todoli Parra et al. retrospectively analyzed 210 cases of multiple myeloma and found 13 cases with second malignancy. In conclusion, an early detection and timely initiation of treatment is the key favorable prognostic factor in the outcome of dual malignancies.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]