Two-stage minimally invasive pulmonary resections with intraoperative localization technique for bilateral multiple primary lung cancers: A case report.

Multiple primary lung cancers (MPLCs) are becoming more and more common and these patients can benefit from minimally invasive surgery. Here, we report a case of a patient diagnosed with synchronous MPLCs who underwent bilateral thoracoscopic pulmonary resections in a two-stage strategy, and achieved a good surgical outcome and high quality of life. A 66-year-old female was found to have one major ground-glass nodule (GGN) in the right upper lobe and eight minor GGNs in the left upper and lower lobes. The patient underwent right upper lobe resection and systematic mediastinal lymph node dissection via single-utility port thoracoscopic surgery in September 2018. Pathology was lepidic predominant adenocarcinoma pT1bN0M0, IA2. Regular high-resolution computed tomography examination during 36 months after right upper lobectomy showed gradually increasing diameter and solid component of multiple GGNs in left lung. The patient underwent thoracoscopic multiple pulmonary resections using an intraoperative localization technique in a hybrid operating room in October 2021 and all eight nodules in the left lung were resected. Two segmentectomies and four wedge resections were performed, and the pathological results of the eight nodules included four adenocarcinomas, three adenocarcinomas in situ, and one alveolar epithelial hyperplasia. The two operations were successful with no intra- or postoperative 90-day complications. During more than 20 months of follow-up after the second operation, the patient had well recovered pulmonary function and physical status with a Karnofsky performance status score of 90 and no local recurrence or metastasis. A two-stage surgical strategy for synchronous MPLCs is therefore feasible. The surgical strategy, timing of intervention, and extent of pulmonary resection should be individually designed according to the location and characteristics of each nodule. Intraoperative localization of small GGNs is very important to ensure that all nodules are completely and accurately resected during the operation.

Contemporary Incidence of Synchronous Multiple Primary Lung Cancers and Survival in the Era of Lung Cancer Screening.

OBJECTIVE: Up to 15% of lung cancer patients have multiple suspicious nodules. While some of these nodules may represent metastatic lung cancer, others represent synchronous multiple primary lung cancer (SMPLC). The incidence of SMPLC ranges from 0.8% to 8.4% and appears to be increasing. Inconsistent identification of SMPLC can be detrimental for patients who are misdiagnosed as having intrapulmonary metastasis and not offered stage-based treatment. We sought to identify the contemporary incidence of SMPLC at a tertiary institution. METHODS: From January 2018 to September 2019, patients who underwent lung cancer resection were retrospectively reviewed. Patients with SMPLC were identified using the modified Martini-Melamed criteria. RESULTS: During the 21-month period, 227 patients underwent lung cancer resection. There were 47 patients (20.7%) who had 119 pathologically confirmed SMPLC. Most patients had ipsilateral tumors (n = 24, 51.1%) with at least 1 adenocarcinoma (n = 40, 85.1%). Considering histologic subtyping, 38 (80.9%) had histologically distinct tumors. Overall and cancer-specific survival at 4 years was 86% and 90%, respectively. Only patients with 3 or more SMPLC had poor 4-year overall (P = 0.002) and cancer-specific survival (P = 0.043) compared with those with 2 SMPLC. Patient demographics, histology, tumor location, and highest pathologic staging did not affect survival outcomes. CONCLUSIONS: Using a strict inclusion criterion, the incidence of SMPLC is higher than previously reported. SMPLC patients have favorable survival outcomes, suggesting that they behave like primary lung cancer, not intrapulmonary metastasis. Awareness of SMPLC by thoracic surgeons is critical in optimizing outcomes in this patient population.

The correlation between the main and minor lesions of synchronous multiple gastric neoplasms assessed gastroscopically and microscopically.

BACKGROUND: Patients with early gastric cancer (EGC) are at high risk of developing synchronous multiple gastric neoplasms (SMGNs) after undergoing endoscopic submucosal dissection (ESD). However, most previous studies have had small sample sizes, and few have focused on association studies. AIMS: This study aimed to analyze the associations between SMGN lesion data from patients with EGC treated with ESD and their correlation coefficients. METHODS: The clinical ESD data from two hospitals from January 2008 to January 2021 were retrospectively analyzed. The main lesions were defined as those with a significant depth of infiltration. The larger tumor diameter was considered the main lesion if the lesions had the same infiltration depth. RESULTS: Of the 1013 post-ESD cases examined, 95 cases (223 lesions) had SMGN, and 25 patients had more than three lesions. For the correlation analysis, 190 lesions were included. The study revealed a similarity in pathological type between main and minor lesions (rs = 0.37) and a positive correlation in infiltration depth (rs = 0.58). The mean diameter sizes of the main and minor lesions were 20.7 ± 8.3 mm and 13.1 ± 6.4 mm, respectively, with statistically significant differences (P < 0.001). A linear correlation was observed between the diameter size and a linear regression model was constructed, producing r = 0.38 [95% confidence interval (CI) 0.19-0.54], b = 0.29 (95% CI 0.14-0.44), t = 3.94, P < 0.001]. A correlation was identified between the vertical distribution of the main and minor lesions, the horizontal distribution, and the gross endoscopic morphology (ϕc = 0.25, P = 0.02; ϕc = 0.32, P < 0.001; ϕc = 0.60, P < 0.001). CONCLUSIONS: The correlation coefficients for microscopic characteristics were higher than those for gastroscopy. There is a significant positive correlation between the main and minor lesions regarding pathological stage and depth of infiltration, respectively. The spatial distribution of the lesions and the gastroscopic morphology were similar.

[Etiological analysis of a patient with multiple primary malignant neoplasms].

To investigate the etiology of multiple primary malignant neoplasms occurred in one patient. Retrospective analysis was performed on a 52-year-old female patient who was admitted to the Department of Endocrinology, the First Affiliated Hospital of Sun Yat-Sen University on October 7, 2021, due to "thyroid occupying lesion for one week". A complete systemic positron emission tomography examination of the patient indicated that the metabolic characteristics of the left thyroid nodules were consistent with medullary thyroid carcinoma, those of the right thyroid nodules were consistent with papillary thyroid carcinoma, and the metabolic characteristics of the T6-7 level were consistent with meningioma, and teratoma was found in the right ovarian region. Intradural subdural mass resection was performed on October 20, 2021, and bilateral total thyroidectomy, isthmus thyroidectomy, bilateral central lymph node dissection and left cervical lymph node dissection were performed on November 2, 2021. The postoperative pathologic diagnosises were meningioma (WHO Grade 1), medullary thyroid carcinoma (left side), and papillary thyroid carcinoma (right side).Whole exon gene sequencing revealed the presence of mutations in the ACAN and FLNB genes, which are associated with dysplasia, as well as mutations in the DDX41 and JAK2 genes, which are linked to active pro-proliferation signaling and tumor susceptibility. In this study, a gene mutation pattern which could lead to multiple primary malignant neoplasms was found.

Synchronous and metachronous neoplasms of different histogenesis with gastrointestinal stromal tumor (GIST): 10 years experience of a single institution.

AIM: Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract. Significant advances have been made in its pathogenesis, diagnosis, and treatment over the past few decades. However, little is known about the occurrence of synchronous or methacronous tumors with other histogenesis in addition to GISTs. The aim of this study was to present a series of 15 patients diagnosed with a second primary neoplasm in addition to GIST. MATERIAL AND METHODS: Patients who were diagnosed with both GIST and other primary neoplasm between January 2010 and December 2019 were included in the study. Demographic, clinicopathologic and immunohistochemical parameters of the patients were analyzed along with the follow-up results RESULTS: This study included 12 men and 3 women with a median age of 68 years (range: 57-83 years). Of the GISTs, 93.3% were localized in the stomach and 73.3% were at very low / low risk category. Of the second primary tumors, 66.6% were in the gastrointestinal tract. Detection of the GIST was synchronous in 9 cases, metachronous in 2 cases and preceded the GIST diagnosis in 4 cases. GIST was incidentally found intra-operatively in 3 of the cases. The mean size of the synchronous GISTs was 20 mm while the most common GIST-associated malignancy was gastric adenocarcinoma. The median follow-up times was 62 months (range: 13-129 months). CONCLUSIONS: The prevalence of secondary malignancies in GIST patients is significantly higher than the healthy population. The high occurrence rate of additional primary tumors in GIST patients has focused the attention of surgeons on this problem. While it is not yet clear if there is a causal association or a common genetic mechanism for the concomitant occurrence of GIST with other malignancies, a closer surveillance of GIST patients is needed due to their proved increased prevalence of a second primary tumor especially during the first year after diagnosis. KEY WORDS: Gastrointestinal stromal tumor, Coexistence, Synchronous malignancy, Second neoplasm, Gastric adenocarcinoma.

Clinicopathological features and prognosis of synchronous and metachronous colorectal cancer: a retrospective cohort study.

BACKGROUND: To investigate the clinicopathological features and prognosis of synchronous and metachronous multiple primary colorectal cancer. MATERIALS AND METHODS: Patients who underwent operation for synchronous and metachronous colorectal cancer at the colorectal surgery department of Shanghai Changhai Hospital between January 2000 and December 2021 were included. Perioperative indicators were comprehensively compared and included in the survival analyses. RESULTS: In total, 563 patients with synchronous ( n =372) and metachronous ( n =191) colorectal cancer were included. Patients with synchronous colorectal cancer were more likely to have a long onset time, positive carcinoembryonic antigen, advanced TNM stage, large tumor, perineural invasion, p53 high expression, and mismatch repair proficient. Compared with metachronous colorectal cancer, patients with synchronous colorectal cancer showed worse 5-year overall survival (68.6±3.0% vs 81.9±3.5%, P =0.018) and 5-year disease-free survival (61.2±3.1% vs 71.0±3.9%, P =0.022). In the subgroup analysis, segmental resection was an independent risk factor for the long-term outcomes of bilateral synchronous colorectal cancer. CONCLUSIONS: Clinicopathological and molecular features were different between synchronous and metachronous colorectal cancer. Patients with synchronous colorectal cancer showed a worse prognosis than those with metachronous colorectal cancer. Bilateral synchronous colorectal cancer requires extended resection to achieve improved long-term outcomes.

Case reports of collision and composite carcinomas of the thyroid: an insight into their origin and clinical significance.

BACKGROUND: Collision and composite carcinomas of the thyroid are extremely rare, and their clinical and biological characteristics are poorly understood. CASE PRESENTATION: The first case was a 41-year-old female patient with a right thyroid nodule. Pathological diagnosis was papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma composite carcinoma. Surgical treatment was right thyroid lobectomy + left partial thyroidectomy + right central neck lymph node dissection. The second case was a 60-year-old female with bilateral thyroid nodules. Total thyroidectomy was performed, and the pathological diagnosis was thyroid collision carcinoma involving follicular thyroid carcinoma on the left side and PTC on the right side. The clinical, histological and gene changes of collision and composite carcinomas of the thyroid are poorly described. With different biological invasion characteristics, the ideal treatment and the prognosis is currently unknown and individualized treatment is necessary. CONCLUSIONS: It is recommended that in composite carcinoma, each cancer is evaluated and treated according to the most severe tumor. Collision carcinoma should be treated as two separate synchronous primary tumors. For both collision and composite carcinomas of the thyroid, the follow-up after treatment should be extensive.

Synchronous Tumour: A Rare Case Report.

The occurrence of synchronous tumors is rare and there have been only a few reported cases. In this particular report, a 30-year-old female presented with abnormal heaviness and anorexia for one month. The case involved the presence of two simultaneous tumors: an immature teratoma in the ovary and a carcinoid tumor in the appendix. This case was complex and presented challenges for diagnosis and treatment. Although synchronous tumors are uncommon, they should be considered as a possibility in the differential diagnosis. Physicians may encounter difficulties in both clinical and histopathological diagnosis when dealing with such cases.

The current evidence on surgical management for synchronous bilateral renal tumors: results from a scoping review.

PURPOSE: Synchronous bilateral renal masses (SBRM) account for a low percentage of kidney tumors, and there is no current recommendation for their management. The objective was to review evidence regarding the best surgical approach for SBRM in terms of type and timing of surgery. METHODS: A broad literature search was performed on 28th January 2023 using Scopus, PubMed, and EMBASE. Only English papers dealing with adults were included. Meeting abstracts were excluded. RESULTS: Twenty-four papers were accepted and included. SBRM behave less aggressively than metachronous tumors, and partial nephrectomy (PN) is the preferred therapeutic option to preserve renal function. Open, laparoscopic, and robot-assisted approaches were found to be similar in oncological outcomes, though robot-assisted surgery resulted in lower comorbidities. Same-sitting PN was demonstrated to be a safe approach, particularly in the robotic-assisted one. Finally, the same-siting and staged NSS were similar in preserving renal function. CONCLUSIONS: PN should be the desirable treatment for SBRM whenever feasible and if patients are fit, but surgeon expertise should also be taken into the account.

A Case of Synchronous Primary Tumors of the Left Ovary and Uterus.

BACKGROUND Synchronous tumors occur when 2 separate primary tumors are diagnosed within 6 months. They can originate from the same site or different locations. For example, synchronous primary tumors of uterine and ovarian origin are a common type. Diagnosis can be challenging, however is critical to determine whether a patient has multiple primary tumors or a single tumor with metastasis to guide effective treatment. Compared with endometrial cancer that has spread to the ovary, synchronous primary tumors of the uterus and ovaries typically require less aggressive treatment. CASE REPORT A 45-year-old woman with nonspecific symptoms of headache and confusion had imaging studies that revealed a neoplasm in her brain, which was likely causing her symptoms. The masses were metastatic lesions, and the primary cancer was determined to be synchronous endometrial ovarian cancer (SEOC). She underwent bilateral frontal craniotomy for tumor resection and diagnostic tests. She had an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. She was stable during hospitalization but lost to follow-up after discharge. CONCLUSIONS Regular gynecologic examinations, including bimanual palpation of the ovaries during cervical cancer screenings, are essential for detecting cancer early and improving chances of recovery. This case also highlights the indolent growth and high risk of metastasis associated with SEOC. Although this type of cancer is rare, patients with it can be at increased risk of developing metastatic lesions in other parts of their bodies. To manage synchronous tumors effectively, a multidisciplinary approach and close collaboration between medical professionals are necessary to ensure best patient outcomes.

Real-world comprehensive diagnosis and "Surgery + X" treatment strategy of early-stage synchronous multiple primary lung cancer.

BACKGROUND: Diagnosing and treating synchronous multiple primary lung cancers (sMPLC) are complex and challenging. This study aimed to report real-world data on the comprehensive diagnosis and treatment of patients with early-stage sMPLC. MATERIALS AND METHODS: A single-center cohort study was carried out and a large number of patients with early-stage sMPLC were included. A single- or two-stage surgery was performed to remove the primary and co-existing lesions. The "X" strategies, including ablation, SBRT, and EGFR-TKIs treatment, were applied to treat the high-risk residual lesions. Wide panel-genomic sequencing was performed to assess the genetic heterogeneity of the co-existing lesions. RESULTS: A total of 465 early-stage sMPLC patients with 1198 resected lesions were included. Despite most patients being histologically different or harboring different genetic alternations, about 7.5% of the patients had the same histological type and driver gene mutation changes, comprehensive re-evaluation is thus needed. The "Surgery + X" strategy showed remarkable efficacy and safety in treating multiple lesions. Follow-up data revealed that the T2 stage (p = 0.014) and the solid presence of a primary lesion (p < 0.001) were significantly related to tumor recurrence. And a T2-stage primary tumor had a significantly higher rate of developing new lesions after the initial surgery (p < 0.001). CONCLUSIONS: In real-world practice, histopathological and radiological evaluation combined with genetic analyses could be a robust diagnostic approach for sMPLC. The "Surgery + X" treatment strategy showed remarkable efficacy, superiority, and safety in the clinical treatment of early-stage sMPLC.

Sublobar resection versus lobectomy in the treatment of synchronous multiple primary lung cancer.

OBJECTIVE: Although synchronous multiple primary lung cancers (sMPLCs) are common in clinical practice, the choice of surgical modalities for the main lesion is still at the stage of exploration. This study is designed to analyze the prognosis of sMPLCs and single primary lung cancers with similar tumor stages and to explore whether sublobar resection has a similar prognosis as lobectomy for sMPLCs. METHODS: One-hundred forty-one cases of sMPLCs were selected, including the following: 65 cases underwent lobectomy for main lesions, and 76 cases underwent sublobar resection for main lesions. One thousand one hundred forty-four cases of single primary lung cancer were matched at 1:1 by propensity score matching. Then, the patients with sMPLCs were divided into a lobectomy group and a sublobar group according to the first tumor stage. Ninety-eight cases of patients with sMPLCs were matched. The short-term perioperative effect, 5-year disease-free survival (DFS) rate, and 5-year overall survival (OS) rate between the two groups were compared. RESULTS: There was no significant difference in OS between sMPLCs and single primary lung cancer after lobectomy (77.1% vs. 77.2%, P = 0.157) and sublobar resection (98.7% vs. 90.7%, P = 0.309). There was no significant difference in OS (86.7% vs. 83.9%, P = 0.482) or DFS (67.6 vs. 87.7%, P = 0.324) between the lobectomy group and sublobar group with sMPLCs. The sublobar resection group obtained a lower incidence of postoperative complications (40.8% vs. 16.3%, P = 0.007) and shorter postoperative hospital stay (11.22 vs. 9.27, P = 0.049). CONCLUSION: The prognosis of patients with sMPLCs generally depends on the main tumor state, which has no statistical difference regardless of sublobar resection or lobectomy, and the perioperative period of sublobar resection is safer than that of lobectomy.

Clinical Analysis of 80 Patients of Multiple Primary Lung Cancers Undergoing Simultaneous Video-Assisted Thoracoscopic Surgery.

Objective: To explore the diagnosis, treatment and prognosis of multiple primary lung cancers (MPLCs) through summarizing and analyzing the clinical data of 80 patients with MPLCs. Methods: The clinical and pathological data of 80 patients who were diagnosed with MPLCs according to the Martini-Melamed criteria and who underwent simultaneous video-assisted thoracoscopic surgery in our hospital from January 2017 to June 2018 were retrospectively analyzed. The Kaplan-Meier method was used for survival analysis. Log-rank test was used for univariate analysis and Cox proportional hazards regression model for multivariate analysis to evaluate the independent risk factors affecting the prognosis of MPLCs. Results: Among the 80 patients, there were 22 cases with MPLCs and 58 cases with double primary lung cancers. The surgical approach was mainly pulmonary lobectomy and pulmonary segmental or wedge resection (41.25%, 33/80), and lesions occurred predominantly in the upper lobe of the right lung (39.8%, 82/206). The pathology of lung cancers was mainly adenocarcinoma (89.8%, 185/206), with invasive adenocarcinoma as a dominant pathological type (68.6%, 127/185), in which acinar subtype was found to be predominant (79.5%, 101/127). The proportion of MPLCs with the same histopathological type (96.3%, 77/80) was higher than that with different histopathological types (3.7%, 3/80). Postoperative pathological staging showed stage I in most patients (86.25%, 69/80). Univariate analysis revealed that the maximum tumor diameter, highest pathological stage and lymph node metastasis were correlated with disease-free survival (P < .05). The overall median survival time of patients was 50 months. Cox multivariate regression analysis indicated that lymph node metastasis was an independent risk factor affecting the prognosis of MPLC patients (P < .05). Conclusion: MPLCs occur principally in the upper lobe of the right lung and pulmonary adenocarcinoma is the most dominant pathological type, with acinar type as the predominant pathological subtype. Lymph node metastasis is an independent risk factor affecting the prognosis of MPLC patients. A favorable prognosis can be achieved through early diagnosis and active surgical treatment for individuals who are highly suspected of MPLCs indicated by imaging examination.

Treatments and whole exon sequencing of a case with multiple primary lung cancer.

INTRODUCTION: The number of patients with synchronous multiple primary lung cancer (sMPLC) has increased recently. However, diagnosing and selecting the appropriate therapeutic strategy for this type of disease is not simple. CASE PRESENTATION: This report presented a case of sMPLC with lymph node metastasis. With no smoking and cancer history, this patient had seven nodules in the right lung and underwent single-portal video-assisted thoracoscopic surgery (VATS). In addition, she received four cycles of chemotherapy after the operation. Whole exon sequencing (WES) was performed in five resected tissue samples (four tumors and one lymph node). We conducted genomic profiling and clone evolution analysis of the five samples. Gene detection helped to confirm that the metastasis lymph node was transferred from one nodule. There was apparent heterogeneity of gene mutations among the five samples of the patient, with only one shared "neurofilament heavy polypeptide" (NEFH) mutation. A dominant substitution of C > T/G > A was found in all the samples. Pyclone model was used to calculate all tissues' cellular prevalence (CP) values, and NEFH mutations were thought to be the ancestral clones. During the follow-up period, residual lesions showed no apparent changes and limited response to chemotherapy. CONCLUSIONS: This report showed an essential role in genomic detection and selecting the appropriate treatment of sMPLC. Surgery remains the primary treatment strategy for this type of disease, and the occurrence and development of sMPLC need more in-depth research.

A Novel Prognostic Score Based on Multiple Quantitative Parameters of Chest CT for Patients with Synchronous Multiple Primary Lung Cancer: Is Solid Component Size a Better Prognostic Indicator?

BACKGROUND: There is no simple and definitive way to predict the prognosis of synchronous multiple primary lung cancer (SMPLC). In this study, we developed a clinical prognostic score for predicting the survival of patients with SMPLC. PATIENTS AND METHODS: This study included 206 patients with SMPLC between 2011 and 2020 at three hospitals. Kaplan-Meier analysis was used to determine the optimal cutoff values for the quantitative chest computed tomography (CT) parameters. Multivariable Cox proportional hazards regression was carried out to identify independent prognostic factors for predicting overall survival (OS) and disease-free survival (DFS). The time-dependent receiver operating characteristic curve was analyzed to evaluate the prognostic performance. RESULTS: A CT-based prognostic score (CTPS) comprising six chest CT parameters was developed. Compared with T stage, CTPS had a higher prediction accuracy for OS and DFS. All C-indices of the model reached a satisfactory level in both the development and validation cohorts. Significant differences in the OS and DFS curves were observed when the patients were stratified into different risk groups. The high-risk group (CTPS of 5-6) had poorer survival than the low-risk group (CTPS of 0-4). CONCLUSIONS: The developed CTPS and the corresponding risk stratification system are valid for predicting the survival of patients with SMPLC.