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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 3  |  Page : 665

A rare case of multicentric carcinoma left breast synchronous with carcinoma right lung: Therapeutic challenge in radiotherapy


Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication9-Oct-2015

Correspondence Address:
Jai Prakash Agarwal
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra - 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.140807

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 > Abstract 

Multiple primary malignancies (MPMs) are a known phenomenon. We present a rare case of multicentric carcinoma of left breast synchronous with carcinoma of right lung. There was a diagnostic dilemma about the nature of the lung lesion, which otherwise would have been labeled as a metastasis from the breast primary; however, the immunohistochemistry markers distinguished between the two. The challenges in delivering radiotherapy in such not-so-conventional situations have been discussed. In spite of snag situation, patient can be treated safely with modern techniques and acceptable morbidities.

Keywords: Carcinoma breast, carcinoma lung, multiple primary malignancies, radiotherapy


How to cite this article:
Tanawade P, Misra S, Yathiraj P, Agarwal JP. A rare case of multicentric carcinoma left breast synchronous with carcinoma right lung: Therapeutic challenge in radiotherapy. J Can Res Ther 2015;11:665

How to cite this URL:
Tanawade P, Misra S, Yathiraj P, Agarwal JP. A rare case of multicentric carcinoma left breast synchronous with carcinoma right lung: Therapeutic challenge in radiotherapy. J Can Res Ther [serial online] 2015 [cited 2019 Nov 22];11:665. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/665/140807


 > Introduction Top


Multiple primary malignancies (MPMs) may occur synchronously (within 6 months of the diagnosis of a previous cancer, as seen with exposure to carcinogens, e.g. tobacco) or metachronously (more than 6 months apart and may be an effect of past treatments). [1],[2] Even the same organ can have multiple origin of tumor labeled as multicentric and multifocal as in breast cancer. When two tumors are diagnosed simultaneously, the tumor diagnosed first is designated the index tumor. It remains challenging to discern metastasis from second primary. Here we report a rare case of multicentric carcinoma left breast synchronous with carcinoma right lung.


 > Case report Top


A 60-year post-menopausal lady, with family history of carcinoma tongue in second-degree relative, no comorbidities and no habits, presented with two mobile lumps in her left breast in the upper outer quadrant (UOQ) and upper inner quadrant (UIQ) of three months duration along with dry cough of 15 days. On clinical examination, two non-tender firm lumps were palpable in her left breast with no other significant findings. On bilateral mammography, two spiculated mass lesions of 2 × 1 cm and 1 × 1 cm were identified in UOQ and UIQ of left breast, respectively, confirming physical findings, and the other breast was unremarkable [Figure 1]. On metastatic workup the chest X-ray showed ill defined radio-opacity in the right mid-zone silhouetting a part of right heart border [Figure 2]. It was the only other abnormal metabolically active structure on an 18F-PET-CT study measuring 3.2 × 3.3 × 2.9 cm, and spiculated border with a standardized uptake value of 11.4 [Figure 3]. Core biopsy and immunohistochemistry (IHC) from the breast lump was infiltrating ductal carcinoma grade II with ER, PR positive and Cerb2 score 0 while that from the lung lesion was reported as an adenocarcinoma, TTF-1 positive and ER and PR negative on IHC. She was diagnosed as synchronous malignancy with multicentric carcinoma of left breast cT1 (2) cN0M0 and right lung cT2cN0M0. She underwent left modified radical mastectomy and right lobectomy with mediastinal nodal dissection with a video-assisted thoracoscopic technique. Post-operative recovery was uneventful.
Figure 1: Mammography of left breast showing two irregular masses (in favor of multicentric disease)

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Figure 2: X-ray chest showing ill defined radio opacity in the right mid zone silhouetting a part of right heart border

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Figure 3: FDG avid lesion in the middle lobe of right lung adjacent to the fissure. (3.2 x 3.3 x 2.9 cm, max SUV 11.4)

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The mastectomy specimen showed two primaries, pT 1.9 × 1.4 × 1.2 cm (UIQ) and 1 × 0.4 × 0.9 (UOQ), both infiltrating ductal carcinoma grade III, with presence of lympho-vascular emboli and 17 negative axillary lymph nodes. The specimen of right lobectomy showed a tumor of 3.7 × 2.2 × 2.0 cm, adenocarcinoma histology with invasion of mediastinal pleura and positive bronchial margin. Mediastianal lymph node stations on dissection and pathological examination were negative for malignancy.

In view of positive bronchial cut margin the patient underwent an unsuccessful re-exploration for bilobectomy due to dense adhesions. She received postoperative radiotherapy (RT) to the bronchial margin with 3D conformal technique (3D-CRT) to a dose of 56 Gy in 28 fractions in 5.5 weeks. She tolerated treatment well with acute grade I dermatitis. She was started on adjuvant Tab Letrozole.


 > Discussion Top


MPMs are not very infrequent occurrence with incidence rates of approximately 16%, with upper aero-digestive track being more frequent to have MPMs. [3] However, metastatic disease is more common than a second primary and should be thought as a first differential in dealing with MPMs. The breast is known to have MPMs in ipsilateral as well as contralateral side, but simultaneous presentation of breast primary especially multicentric breast lesions with a lung lesion was first thought of a lung metastasis from the breast primaries. However, the radiological findings of ill-defined spiculated radio opacity in the right mid zone with silhouetting of the right heart border on PET-CT and no other site of abnormal metabolic uptake elsewhere and the presentation of the breast lesion without associated nodal spread was unusual for a metastatic disease which gave us a strong suspicion about the nature of lung lesion and hence a lung biopsy was performed. The differential IHC expressions of the two lesions with ER and PR positivity in breast lesion and TTF positivity with ER and PR negativity in lung lesion helped to confirm the diagnosis of MPMs in this case.

The treatment of MPMs depends on the individual primaries as per their respective stages. The sequence of the treatment is often guided by aggressiveness of the individual primary, the one with more aggressive antecedes over the other although these can be treated simultaneously. Nevertheless, the MPMs should be treated with a multidisciplinary team on individual case to case basis. The indication for adjuvant RT to right lung in this case was the involved cut margin. RT to the post-mastectomy left chest wall was not indicated. Had there been any indication of RT to the left chest wall in addition to right lung, it would have been a challenge to plan and we decided to simulate such a situation and wish to share its nuances. These patients can be treated with modern techniques like Arc IMRT/VMAT or with Helical Tomotherapy. We did this exercise using Helical Tomotherapy® Hi Art treatment planning system. The target delineation was done independent of the other tumor. The 3D-CRT plan (delivered to the lung tumor alone) was compared with the inverse intensity modulated radiotherapy (IMRT) plan (simulated for the right lung and left chest wall targets) with a view to highlight the normal tissue doses received with these strategies. The incidental dose received by the organs at risk (OARs) in treating the right lung and left chest wall were higher than treating the right lung alone and were very obviously attributable to the large and spatially apart volumes of the PTVs in the two case scenarios and critical location of OARs in relation to target [Figure 4] and [Figure 5]. Achievable dose constraints to OARs were minimally higher than usually recommended for single site primary cancers but clinically acceptable [Table 1]. [4],[5],[6],[7]
Figure 4: CTV for right lung treated case (left panel) and CTV including right lung with left chest wall for the hypothetical case (right panel)

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Figure 5: 95% dose color wash for treated case (left panel) and for simulated case (right panel)

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Table 1: Dosimetric comparison of the two plans


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There exists a challenge in the diagnosis and management of MPMs. The recommended RT dose constraints to OARs may not be achievable every time; nevertheless patient can be treated safely with modern techniques and acceptable morbidities.


 > Acknowledgement Top


Department of Medical Physics, Tata Memorial Hospital, Mumbai.

 
 > References Top

1.
Warren S, Gates O. Multiple primary malignant tumors: Survey of the literature and statistical study. Am J Cancer 1932;16:1358-414.  Back to cited text no. 1
    
2.
Travis LB. Therapy associated solid tumors. Acta Oncol 2002;41:323-33.  Back to cited text no. 2
    
3.
Travis LB. The epidemiology of second primary cancers. Cancer Epidemiol Biomarkers Prev 2006;15:2020-6.  Back to cited text no. 3
    
4.
Kirkpatrick JP, van der Kogel AJ, Schultheiss TE. Radiation dose-volume effects in the spinal cord. Int J Radiat Oncol Biol Phys 2010;76:S42-9.  Back to cited text no. 4
    
5.
Marks LB, Bentzen SM, Deasy JO, Kong FM, Bradley JD, Vogelius IS, et al. Radiation dose-volume effects in the lung. Int J Radiat Oncol Biol Phys 2010;76:S70-6.  Back to cited text no. 5
    
6.
Gagliardi G, Constine LS, Moiseenko V, Correa C, Pierce LJ, Allen AM, et al. Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys 2010;76:S77-85.  Back to cited text no. 6
    
7.
Werner-Wasik M, Yorke E, Deasy J, Nam J, Marks LB. Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys 2010;76:S86-93.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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