Letters to Editor
Synchronous primary double malignancy involving stomach and hepatic flexure of colon: A case report
Sir, Synchronous or simultaneous cancers of the gastrointestinal tract were noted initially in the 19th century as isolated case reports of specific segments, such as the stomach and colon. [1] Synchronous cancers of the alimentary tract are defined as the presence of two or more lesions noted during the preoperative or intraoperative clinical evaluations or in resected surgical specimens. Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past 100 years. The lesions can be limited to a single organ or may involve multiple organ systems. These lesions generally fall into two categories: Synchronous, in which the cancers occur at the same time or within 2 months, and metachronous, in which the cancers follow in sequence (more than 2 months apart). Metachronous primary malignancies are becoming increasingly frequent because of an increase in the number of elderly patients and improvements in diagnostic techniques. However, synchronous primary malignancies are still unusual.[2,3] A 65‑year‑old man presented to our out‑patient department with anorexia, generalized aches and pains, occasional mild abdominal discomfort, and on and off loose stools with some blood in it. These symptoms were present for last 3-4 months. On examination, the patient was grossly anemic, and some vague mass was palpable in right upper abdomen. Patient was advised gastroduodenoscopy and colonoscopy that showed ulcero‑infiltrative lesion in the gastric antrum and another polypoid lesion in hepatic flexure of colon. Biopsy was taken from both lesions and sent for histopathologic examination. Both the specimens from stomach and colon revealed adenocarcinoma that was well differentiated. A computed tomography (CT) scan of the abdomen was advised, which showed gastric growth and another growth in hepatic flexure of colon, well separated from each other [Figures 1 and 2]. The tissue planes were well preserved and there were no apparent metastatic deposits anywhere in the abdomen and elsewhere. When the patient was specifically asked for, there had been no familial history of gastrointestinal malignancies. Patient was planned for surgery and distal partial gastrectomy with right extended hemicolectomy was done [Figure 3]. The postoperative period was uneventful and patient was discharged after 2 weeks of surgery and is regularly on follow‑up with no significant problems, for last 18 months. Although synchronous cancers of the gastrointestinal tract are not common, health professionals should be aware of the possibility and provide adequate preoperative, intraoperative, and postoperative care that includes continuous follow‑up. The synchronous double malignancy can be treated successfully and both sites should be treated 388
Figure 1: CT picture showing malignancy of stomach and hepatic flexure of colon
Figure 2: Colonoscopic picture showing polypoid lesion in hepatic flexure of colon
Figure 3: Gastrectomy specimen showing ulcero‑infiltrative lesion in stomach
fully as if they were occurring separately considering toxicities. Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Letters to Editor
Majid Mushtaque, Parwez Sajad Khan Department of Surgery, Sher‑i‑Kashmir Institute of Medical Sciences, Medical College Hospital, Bemina Srinagar, Kashmir, India
3.
Germline p53 mutation in a patient with multiple primary cancers. Jpn J Clin Oncol 2001;31:349‑51. Oya M, Takahashi S, Okuyama T, Yamaguchi M, Ueda Y. Synchronous colorectal carcinoma: Clinico‑pathological features and prognosis. Jpn J Clin Oncol 2003;33:38‑43. Access this article online
Correspondence to:
Dr. Parwez Sajad Khan, E-mail: [email protected]
Quick Response Code:
References 1. 2.
DOI: 10.4103/0019-509X.146767
Mitchell ME, Johnson JA, Wilton PB. Five primary synchronous neoplasms of the gastrointestinal tract. J Clin Gastroenterol 1996;23:284‑8. Kimura K, Shinmura K, Hasegawa T, Beppu Y, Yokoyama R, Yokota J.
Importance of under graduate oncology training
Sir, The development of cancer control services in INDIA cannot be dissociated from training in oncology, at both under graduate and post‑graduate levels. Countries develop their cancer control services in different ways according to their socio‑economic conditions and the availability of staff. This, in turn, has influenced the system and content of undergraduate program in oncology. In India, the arrangement for oncology training is done within established disciplines like gynecology, surgery, internal medicine, and pediatrics. Cancer is a major health problem, but medical undergraduate education about cancer leaves most practitioners ill‑prepared. All practitioners need some knowledge of cancer. Patients with cancer expect their family practitioners to be knowledgeable enough to act as their advocate and to be able to interpret for them, the complex array of tests and treatments that they could face. The goals of undergraduate medical education should be to provide a core of basic knowledge and a framework to permit further development of that knowledge. The structure of teaching and experience in cancer medicine should reflect the increasing importance of cancer in the community. Undergraduate teaching of oncology and its scientific basis is currently fragmented, and in some cases, may be deficient. Undergraduate cancer education in Indian medical schools is not integrated, and there is very little evidence of change in content or structure, in recent years, in spite of major changes in knowledge about cancer epidemiology, cancer biology, and in cancer management. Further, whatever is taught in regards to cancer education is being taught by a generalist within the established disciplines and not by a specialist trained in oncology. The readers of the Indian Journal of Cancer may be interested to know of the Ideal Oncology Curriculum, developed in 1999, by an Oncology Education Committee of the Cancer Council of Australia, [1] wherein, cancer teaching is fragmented across disciplines with resulting risk
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Website: www.indianjcancer.com
PMID: *****
of duplication or omission of cancer knowledge and skills. The Ideal Oncology Curriculum provides a comprehensive checklist for course design that allows adaptation to local conditions, as well as a checklist against which outcomes can be monitored. Undergraduate course should be structured such that students learn about various modalities for diagnosing cancer and once diagnosed, what prognostic and predictive factors impact on treatment decisions. Basics of radiation therapy and drug therapy (hormones, chemotherapy, biologics) are covered, as well as discussions related to the principles of therapy (curative versus palliative) and toxicities and side‑effects that might be anticipated should also be covered. Interwoven with the clinical oncology teaching, patient‑centered care activities should also be taught and discussed, such as how to break bad news, dealing with changes in body image, psychosocial impact on the family during cancer treatment, grief, and mourning. Palliative care topics, including pain management, delirium, dyspnea, and bowel complications etc., can also be some topics that can be roofed. It is further reiterated that oncology should be taught by oncologist to make oncology teaching more sententious, irrefutable, and more exemplary. Jain S, Bhowmik KT Department of Radiotherapy,VMMC and Safdarjang Hospital, New Delhi, India Correspondence to: Dr. Sunny Jain, E‑mail: [email protected]
Reference 1.
Gaffan J, Dacre J, Jones A. Educating undergraduate medical students about oncology. J Clin Oncol 2006;24:1932‑9.
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146769 PMID: *****
389
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Synchronous primary double malignancy involving stomach and hepatic flexure of colon: A case report
Sir, Synchronous or simultaneous cancers of the gastrointestinal tract were noted initially in the 19th century as isolated case reports of specific segments, such as the stomach and colon. [1] Synchronous cancers of the alimentary tract are defined as the presence of two or more lesions noted during the preoperative or intraoperative clinical evaluations or in resected surgical specimens. Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past 100 years. The lesions can be limited to a single organ or may involve multiple organ systems. These lesions generally fall into two categories: Synchronous, in which the cancers occur at the same time or within 2 months, and metachronous, in which the cancers follow in sequence (more than 2 months apart). Metachronous primary malignancies are becoming increasingly frequent because of an increase in the number of elderly patients and improvements in diagnostic techniques. However, synchronous primary malignancies are still unusual.[2,3] A 65‑year‑old man presented to our out‑patient department with anorexia, generalized aches and pains, occasional mild abdominal discomfort, and on and off loose stools with some blood in it. These symptoms were present for last 3-4 months. On examination, the patient was grossly anemic, and some vague mass was palpable in right upper abdomen. Patient was advised gastroduodenoscopy and colonoscopy that showed ulcero‑infiltrative lesion in the gastric antrum and another polypoid lesion in hepatic flexure of colon. Biopsy was taken from both lesions and sent for histopathologic examination. Both the specimens from stomach and colon revealed adenocarcinoma that was well differentiated. A computed tomography (CT) scan of the abdomen was advised, which showed gastric growth and another growth in hepatic flexure of colon, well separated from each other [Figures 1 and 2]. The tissue planes were well preserved and there were no apparent metastatic deposits anywhere in the abdomen and elsewhere. When the patient was specifically asked for, there had been no familial history of gastrointestinal malignancies. Patient was planned for surgery and distal partial gastrectomy with right extended hemicolectomy was done [Figure 3]. The postoperative period was uneventful and patient was discharged after 2 weeks of surgery and is regularly on follow‑up with no significant problems, for last 18 months. Although synchronous cancers of the gastrointestinal tract are not common, health professionals should be aware of the possibility and provide adequate preoperative, intraoperative, and postoperative care that includes continuous follow‑up. The synchronous double malignancy can be treated successfully and both sites should be treated 388
Figure 1: CT picture showing malignancy of stomach and hepatic flexure of colon
Figure 2: Colonoscopic picture showing polypoid lesion in hepatic flexure of colon
Figure 3: Gastrectomy specimen showing ulcero‑infiltrative lesion in stomach
fully as if they were occurring separately considering toxicities. Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Letters to Editor
Majid Mushtaque, Parwez Sajad Khan Department of Surgery, Sher‑i‑Kashmir Institute of Medical Sciences, Medical College Hospital, Bemina Srinagar, Kashmir, India
3.
Germline p53 mutation in a patient with multiple primary cancers. Jpn J Clin Oncol 2001;31:349‑51. Oya M, Takahashi S, Okuyama T, Yamaguchi M, Ueda Y. Synchronous colorectal carcinoma: Clinico‑pathological features and prognosis. Jpn J Clin Oncol 2003;33:38‑43. Access this article online
Correspondence to:
Dr. Parwez Sajad Khan, E-mail: [email protected]
Quick Response Code:
References 1. 2.
DOI: 10.4103/0019-509X.146767
Mitchell ME, Johnson JA, Wilton PB. Five primary synchronous neoplasms of the gastrointestinal tract. J Clin Gastroenterol 1996;23:284‑8. Kimura K, Shinmura K, Hasegawa T, Beppu Y, Yokoyama R, Yokota J.
Importance of under graduate oncology training
Sir, The development of cancer control services in INDIA cannot be dissociated from training in oncology, at both under graduate and post‑graduate levels. Countries develop their cancer control services in different ways according to their socio‑economic conditions and the availability of staff. This, in turn, has influenced the system and content of undergraduate program in oncology. In India, the arrangement for oncology training is done within established disciplines like gynecology, surgery, internal medicine, and pediatrics. Cancer is a major health problem, but medical undergraduate education about cancer leaves most practitioners ill‑prepared. All practitioners need some knowledge of cancer. Patients with cancer expect their family practitioners to be knowledgeable enough to act as their advocate and to be able to interpret for them, the complex array of tests and treatments that they could face. The goals of undergraduate medical education should be to provide a core of basic knowledge and a framework to permit further development of that knowledge. The structure of teaching and experience in cancer medicine should reflect the increasing importance of cancer in the community. Undergraduate teaching of oncology and its scientific basis is currently fragmented, and in some cases, may be deficient. Undergraduate cancer education in Indian medical schools is not integrated, and there is very little evidence of change in content or structure, in recent years, in spite of major changes in knowledge about cancer epidemiology, cancer biology, and in cancer management. Further, whatever is taught in regards to cancer education is being taught by a generalist within the established disciplines and not by a specialist trained in oncology. The readers of the Indian Journal of Cancer may be interested to know of the Ideal Oncology Curriculum, developed in 1999, by an Oncology Education Committee of the Cancer Council of Australia, [1] wherein, cancer teaching is fragmented across disciplines with resulting risk
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Website: www.indianjcancer.com
PMID: *****
of duplication or omission of cancer knowledge and skills. The Ideal Oncology Curriculum provides a comprehensive checklist for course design that allows adaptation to local conditions, as well as a checklist against which outcomes can be monitored. Undergraduate course should be structured such that students learn about various modalities for diagnosing cancer and once diagnosed, what prognostic and predictive factors impact on treatment decisions. Basics of radiation therapy and drug therapy (hormones, chemotherapy, biologics) are covered, as well as discussions related to the principles of therapy (curative versus palliative) and toxicities and side‑effects that might be anticipated should also be covered. Interwoven with the clinical oncology teaching, patient‑centered care activities should also be taught and discussed, such as how to break bad news, dealing with changes in body image, psychosocial impact on the family during cancer treatment, grief, and mourning. Palliative care topics, including pain management, delirium, dyspnea, and bowel complications etc., can also be some topics that can be roofed. It is further reiterated that oncology should be taught by oncologist to make oncology teaching more sententious, irrefutable, and more exemplary. Jain S, Bhowmik KT Department of Radiotherapy,VMMC and Safdarjang Hospital, New Delhi, India Correspondence to: Dr. Sunny Jain, E‑mail: [email protected]
Reference 1.
Gaffan J, Dacre J, Jones A. Educating undergraduate medical students about oncology. J Clin Oncol 2006;24:1932‑9.
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146769 PMID: *****
389
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
