Surgical treatment for synchronous multiple primary cancer involving the lung was evaluated on the basis of clinical experience with the treatment of three patients. It is emphasized that careful clinical examination to prevent overlook of secon

Ayabe Hiroyoshi

Kawahara Katsunobu

Tagawa Yutaka

Tomita Masao

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Acta Med. Nagasaki 36:21-23Surgery for Multiple Primary Cancer Involving the Lung     Masao TOMITA, Hiroyoshi AYABE Katsunobu KAWAHARA and Yutaka TAGAWAThe First Department of Surgery, Nagasaki University School of Medicine                        Nagasaki, JapanReceived for publication, December 20, 1990ABSTRACT : Surgical treatment for synchronous multiple primary cancer involving the lung was evaluated on the basis of clinical experience with the treatment of three patients. It is emphasized that careful clinical examination to prevent overlook of second tumor is needed for promising favorable outcome of multiple primary cancer.       INTRODUCTION  Occurrence of metachronous double cancers is now increasing in accordance with prolonged survival time following treatment for carcino-mas. On the other hand, synchronous double cancers are frequently detected with advances in diagnostic techniaues, High incidence of double cancers enables us to pay more careful attention to precise diagnosis and meticulous treatment for patients with carcinoma. Needless to say, definition of double cancers is that two dif-ferent cancer lesions are metachronously or synchronously present in the same host, not only occur accidentally but associate with the states of a host. A few clinical experiences with the treatment for synchronous double cancer provide a good chance to consider the surgical significance for double cancer. The purpose of this study is to clarify the values of surgical treatment for synchronous double cancer on the basis of our clinical experience.         PATIENTS  During the past ten years from January 1980 to December 1989, three patients who had concomitantly existing double cancer involv-ing the lung were surgically treated for both cancers at the First Department of Sugery, Nagasaki University Hospital. The ages ranged from the fifth to the seventh decades as shown in Table 1. Lung cancers were detected in two on the left side and one on the right side. The histologic patterns of lung cancer were adenocarcinoma, adenosquamous carcinoma and squamous cell carcinoma in each one case respectively. These were Stage 111(N2) in Case                 Table 1. 3 Cases of double cancer (operated at the same time) No lung cancer other cancer ope. . Case Age Sex Prognosis                      ope. Histology site ope. Histology date 1. N.K. 58 M S6 Seg. sq. Rectum Miles' ope. adeno. '83.8.24 5M death 2. T.M. 64 M LUL adeno. Lt. kidney nephrectomy renal cell ca. '88.2.23 1Y6M alive 3. C.K. 73 M LS1+2+3Seg. adenosq. Stomach gastrectomy adeno. '89.4.24 3.5M alive1 and 3 and Stage I in Case 2. The second tumors were seen in the rectum (Stage I), kidney (Stage I, not extending the capsula) and stomach (Stage III involving the serosa and regional nodes). These histologic patterns were adenocarcinoma, renal cell carcinoma and adenocarcinoma respectively. The chances of detecting these diseases were offered from the onset of symptoms related to the second tumor. The lung cancer in Case 1 was detected as a primary tumor, the other two cancers were detcted under the suspicion of metastatic lung tumor. Rectal cancer in case 1 was accidentally found out by preoperative examination.  The general conditions in these three cases were satisfactory to achieve a combined resec-tion of double cancers. Aseptic operation of pulmonary resection was first selected, fol-lowed by abdominal and/or retroperitoneal ap-proaches.  In this series, curative and relatively curative operations including distant node dissection were performed on all patients.  The surgical outcomes were not satisfactory. Early death within one year following surgery included one case of case 1, and the other two patients were now going on follow-up study. However, it seemed that the grades of disease stage seems to relate to the prognosis.         DISCUSSION  The occurrence of double cancer involving the lung have been reported as being 17%1' to 4.5%2.3'. With repect to the age, Nishiki4' reported that the average age of multiple primary cancers involving the lung was 67 years old, although that of single cancer was 60. We must take it into consideration that our subjects of double canser were the operated cases, but the autopsied cases were cases of single cancer.  It is accepted that the stomach and the colon are more often involved in association with double cancers involving the lung. It also is believed that squamous cell carcinoma is predominant in multiple primary cancers involving the lung.  In general, multiple primary cancer is called in accordance with the appearing time of double cancer, synchronous or metachronous. In thisseries, the surgical treatment and prognosis of synchronous multiple primary cancer involving the lung was evaluated on the basis of our clinical experience. It is not easy to determine the indication of one stage or two stage operative procedures, which depends on the patient's condition, disease extension of double cancer, and the degree of surgical stress including surgical curability.   Ferguson", Mathisen6' and Struve-Christensen`' recommended aggressive surgical treatment for a better outcome of multiple primary cancer. Temeck8' emphaseized that physicians pay at-tention to more frequent occurrence of second primary cancer in continued and careful follow-up survey following the treatment for the first primary tumor.  Chaudhuri9' believes it is necessary for the two tumors of double cancer which have dissimilar histopathologic characteristics to be considered as independent primaries. Others cite the certain time interval of 30 to 36 months is required for multiple primary cancer so as to neglect a metastatic tumor. However, it is only in recent years that the occurrence of second and third lung primaries have been reported11, 12) and it is argued that aggressive surgical approach for these tumors is not precluded.  The poor outlook of synchronous primaries was reported by Mathisen6' as well as our series. This is in contrast to a 28% five-year survival of patients with synchronous multile primary lung cancer in the Memorial Sloan-Kettering seriesl3'  We believe that better outcome for synchro-nous primaries is in association with early detection in the early disease stage. Early detection and early treatmne promise physicians to get better results of the surgical treatment of multile primary cancer.         REFERENCES 1) Mitchel RI : Multiple primary cancers involving    the lung. The Canadian Journal of Surgery 22:   54-68, 1979. 2) Naruge H : Double cancer involving the lung.    Lung Cancer 13: 60, 1973. 3) Rohwedder J. J., Weatherbee L : Multiple    primary bronchogenic carcinoma with a review   of the literaure. Am. Rev. Respir. Dis. 109:435-  445, 1974. 4) Nishiki, M, Kataoka T : A study of multiple    primary malignant neoplasma associated with    lung cancer. Hiroshima Jhournal of Medical    Sciennce. 33:447-453, 1984. 5) Ferguson MK, De Meester TR, Des Lauriers J,    et al : Diagnosis and management of synchro-   nous lung cancers. J. Thrac. Cardiovasc. Surg.   89:378-385, 1985. 6) Mathisen DJ, Jensik RJ, Faber LP, et al: Survival    following resection for second and third prima-   ry lung cancers. J. Thorac. Cardiovasc. Surg. 88:   502-510, 1984. 7) Strure-Christensen E : Diagnosis and treatment    of bilateral primary bronchogenic carcinoma. J.    Thorac. Cardiovasc. Surg. 6:501-513, 1971.8) Temeck BK, Flehinger BJ, Martin N : A    retrospective analysis of 10 year survivors from   carcinoma of the lung. Cancer 53:1405, 1984. 9) Chaudhuri MR: Independent bilateral primary    bronchial carcinomas. Thorax 26: 476-480, 1981. 10) Legal Y, Bauer WC: Second primary brom-   nchogenic carcinoma. A complication of    successful lung cancer surgery. T. Thorac.   Carciovasc. Surg. 41 :114-124, 1961. 11) Martine N, Melamed MR : Multiple primary lung    cancers. J. Thorac. Cardiovasc. Surg. 70: 606-612,   1975. 12) Smith RA, Nigam BK, Thompson JM : Second    primary lung carcinoma Thorax 31 : 507-516, 1976. 13) Struve-christensen E : Diagnosis and treatment    of bilateral primary bronchogenic carcinoma J.    Thorac Cardiovasc. Surg. 62:501-513, 1971.

Surgery for Multiple Primary Cancer Involving the Lung

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Surgery for Multiple Primary Cancer Involving the Lung

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