AbstractIntroductionCases of synchronous triple cancers of the esophagus and other organs curatively resected are rare.Presentation of caseA 73-year-old man was admitted to our hospital with bloody feces. He was diagnosed with synchronous triple cancers of the esophagus, colon, and liver. We selected a two-stage operation to safely achieve curative resection for all three cancers. The first stage of the operation comprised a laparoscopy-assisted sigmoidectomy and partial liver resection via open surgery. The patient was discharged without complications. Thirty days later, he was readmitted and thoracoscopic esophagectomy was performed. Although pneumonia-induced pulmonary aspiration occurred as a postoperative complication, it was treated conservatively. The patient was discharged on postoperative day 24.DiscussionEsophagectomy is a highly invasive procedure; thus, simultaneous surgery for plural organs, including the esophagus, may induce life-threatening, severe complications. Two-stage surgery is useful in reducing surgical stress in high-risk patients. For synchronous multiple cancers, the planning of two-stage surgery should be considered for each cancer to maintain organ function and reduce the stress and difficulty of each stage.ConclusionWe successfully treated synchronous triple cancers, including esophageal cancer, by a two-stage operation

Akiyama, Yuji

Endo, Fumitaka

Iwaya, Takeshi

Kashiwaba, Masahiro

Katagiri, Hirokatsu

Kimura, Toshimoto

Kimura, Yusuke

Koeda, Keisuke

Konosu, Masafumi

Mizuno, Masaru

Nitta, Hiroyuki

Otsuka, Koki

Sasaki, Akira

Shioi, Yoshihiro

International Journal of Surgery Case Reports

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Elsevier - Publisher Connector 

CASE REPORT – OPEN ACCESS
International Journal of Surgery Case Reports 13 (2015) 1–4
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journa l homepage: www.caserepor ts .com
Curative two-stage resection for synchronous triple cancers of the
esophagus, colon, and liver: Report of a case
Yuji Akiyama ∗, Takeshi Iwaya, Masafumi Konosu, Yoshihiro Shioi, Fumitaka Endo,
Hirokatsu Katagiri, Hiroyuki Nitta, Toshimoto Kimura, Koki Otsuka, Keisuke Koeda,
Masahiro Kashiwaba, Masaru Mizuno, Yusuke Kimura, Akira Sasaki
Department of Surgery, Department of Palliative Care Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505,
Japan
a r t i c l e i n f o
Article history:
Received 9 April 2015
Received in revised form 27 April 2015
Accepted 25 May 2015
Available online 30 May 2015
Keywords:
Esophageal cancer
Synchronous triple cancers
Two-stage operation
a b s t r a c t
INTRODUCTION:Casesof synchronous triple cancersof theesophagusandotherorgans curatively resected
are rare.
PRESENTATION OF CASE: A 73-year-old man was admitted to our hospital with bloody feces. He was
diagnosed with synchronous triple cancers of the esophagus, colon, and liver. We selected a two-stage
operation to safely achieve curative resection for all three cancers. The ﬁrst stage of the operation com-
prised a laparoscopy-assisted sigmoidectomyandpartial liver resection via open surgery. Thepatientwas
discharged without complications. Thirty days later, he was readmitted and thoracoscopic esophagec-
tomy was performed. Although pneumonia-induced pulmonary aspiration occurred as a postoperative
complication, it was treated conservatively. The patient was discharged on postoperative day 24.
DISCUSSION: Esophagectomy is a highly invasive procedure; thus, simultaneous surgery for plural organs,
including the esophagus, may induce life-threatening, severe complications. Two-stage surgery is useful
in reducing surgical stress in high-risk patients. For synchronous multiple cancers, the planning of two-
stage surgery should be considered for each cancer to maintain organ function and reduce the stress and
difﬁculty of each stage.
CONCLUSION:We successfully treated synchronous triple cancers, including esophageal cancer, by a two-
stage operation.
© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Reports of synchronous multiple cancers have been increasing
due to prolonged lifespan and improvements in diagnostic tech-
niques [1,2]. The incidence of multiple cancers of the esophagus
and other organs is reported to range from 9.5% to 20.7% [3–6].
Head and neck squamous cell carcinoma and gastric adenocarci-
noma are most frequently observed as multiple primary cancers of
other organs in esophageal cancer patients [7,8]. In Japan, the sur-
gical procedure for thoracic esophageal cancer generally comprises
subtotal esophagectomy with three-ﬁeld lymphadenectomy; dis-
section of the mediastinal, abdominal, and cervical lymph nodes;
and gastric tube reconstruction [9]. However, this is an extremely
invasive procedure with a high mortality rate. Surgery for multiple
cancers of other organs with esophagectomy is a highly com-
plicated procedure. In addition to esophageal cancer surgery, for
example, simultaneous total gastrectomy for synchronous gastric
∗ Corresponding author. Tel.: +81 19 651 5111; fax: +81 19 651 7166.
E-mail address: yakiyama@iwate-med.ac.jp (Y. Akiyama).
cancer requires reconstruction of the colon with the addition of
total pharyngolaryngoesophagectomy for synchronous head and
neck cancer. It has been reported that two-stage surgery was both
useful and safe for high-risk patients with esophageal cancer [10].
Therefore, a two-stage procedure may be suitable for complicated
surgery for synchronous cancers of the esophagus andother organs.
Cases of synchronous triple cancers of the esophagus and other
organs are rare [1,7]. Here, we describe a case of synchronous triple
cancers of the thoracic esophagus, sigmoid colon, and liver success-
fully treated with a two-stage operation.
2. Case report
A 73-year-oldmanwas admitted to a local hospital with bloody
feces. A barium enema revealed two tumors in the sigmoid colon
(Fig. 1A). Endoscopic biopsy of both tumors revealed moderately
differentiated adenocarcinoma. A screening esophagogastroscopy
to search for other gastrointestinal lesions showed a superﬁcial ele-
vated lesion with a surrounding Lugol-voiding lesion from 27cm
to 30 cm below the incisor (Fig. 2A). A diagnosis of poorly differ-
entiated squamous cell carcinoma was histologically conﬁrmed.
http://dx.doi.org/10.1016/j.ijscr.2015.05.032
2210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS
2 Y. Akiyama et al. / International Journal of Surgery Case Reports 13 (2015) 1–4
Fig. 1. (a) Barium enema showed two tumors as defects in the sigmoid colon (arrows). (b) Surgical specimen of the sigmoid colon (arrows). (c) Pathological specimen from
the sigmoid colon showed a moderately differentiated adenocarcinoma.
Computed tomography (CT) showed no evidence of lymph node
involvement for the esophageal cancer, but revealed lymph node
metastasis from the sigmoid colon cancer. A CT scan during hep-
atic arteriography showed a high-density area of 7 cm in diameter
on subsegments 4 (S4) and 8 (S8), which was diagnosed as hep-
atocellular carcinoma (HCC) (Fig. 3A). The laboratory data were
as follows: WBC count, 6890/mm3; RBC count, 442×104/mm3;
hemoglobin, 13.9 g/dL; platelet count, 204×103/mm3; prothrom-
bin time, 97%; albumin, 4.2 g/dL; total bilirubin, 0.3mg/dL; and
indocyanine green retention rate at 15min, 12%. The hepatitis
markers were negative. The prothrombin induced by vitamin K
absence or antagonist II levelwas 2016mAU/mL, alpha-fetoprotein
Fig. 2. (a) Esophagogastroscopy revealed a superﬁcial elevated lesion with a surrounding Lugol-voiding lesion from 27cm to 30 cm below the incisor. (b) Surgical specimen
of the esophagus. (c) Pathological examination of a specimen from the esophagus showed poorly differentiated squamous cell carcinoma.
CASE REPORT – OPEN ACCESS
Y. Akiyama et al. / International Journal of Surgery Case Reports 13 (2015) 1–4 3
Fig. 3. (a) A CT scan during hepatic arteriography showed a 7 cm, high-density area on S4 and S8. (b) Surgical specimen of the liver. (c) Pathological examination of a specimen
from the liver showed moderately differentiated HCC.
was 13.1ng/mL, and carcinoembryonic antigen was 4.5ng/mL. The
levels of the other tumor markers, including carbohydrate antigen
19–9 and squamous cell cancer antigen were within normal lim-
its. The patient was diagnosed with synchronous triple cancers of
the esophagus (T1N0N0 stage I), colon (T3N1M0 stage IIIA), and
HCC (T3N0M0 stage IIA) (Union for International Cancer Control
ver. 7). A two-stage operation was performed with the intent of
curative resection of all three cancers to reduce invasiveness of
simultaneous complicated surgery. The ﬁrst-stage of the proce-
dure comprised sigmoidectomy for thecolorectal cancer andpartial
resection of the liver for HCC. Laparoscopy-assisted sigmoidec-
tomy was ﬁrst performed, followed by upper midline laparotomy
for partial hepatectomy of S4 and S8. A few sheets of Sepraﬁlm
(Genzyme, Cambridge, MA, USA) were placed directly around the
stomach and under the abdominal wound before abdominal clo-
sure. The surgical durationwas 472minwith a blood loss of 211mL.
The postoperative course of the ﬁrst stage of the operation was
uneventful and the patient was discharged on postoperative day
13. The pathological diagnosis of the colorectal cancer was moder-
ately differentiated adenocarcinoma and pathologically staged as
T3N1M0 (stage IIIA). The liver tumor was diagnosed as HCC and
staged as T3N0M0 (stage IIA) (Fig. 3C). The patient was placed
on a modiﬁed diet and underwent preoperative inspiratory mus-
cle training until the second-stage of the surgery. Forty-nine days
after the ﬁrst stage of the surgery, esophagectomy with three-ﬁeld
lymph node dissection and gastric tube reconstruction was per-
formed as the second stage using a thoracoscopic approach in the
prone position, laparotomy, and bilateral cervical approaches. In
the abdominal space, there were no adhesions around the liver or
stomach. Posterior mediastinal route reconstruction was achieved
using the gastric tube. The surgical duration was 572min and
blood loss was 516mL. Pneumonia occurred as a postoperative
complication and was treated conservatively. The patient was dis-
charged on postoperative day 24. The pathological diagnosis of the
esophageal tumor was poorly differentiated squamous cell carci-
noma and pathologically staged as T1N0M0 (stage I) (Fig. 1C). The
patient is alive and has remained cancer-free for 7months after the
second stage of the surgery.
3. Discussion
Radical esophagectomy with simultaneous resection of other
organs can be safely performed in most patients with syn-
chronous double cancers [11]. However, as esophagectomy is a
highly invasive procedure by itself, it is possible that simultane-
ous surgery for plural organs, including the esophagus, may induce
life-threatening, severe complications. For esophageal cancer in
high-risk patients, two-stage surgery is sometimes performed to
reduce surgical stress. Therefore, it is also expected that a two-stage
operation can reduce the invasivenessof surgical treatment for syn-
chronous cancers of the esophagus and other organs. Fukaya et al.
[7] reported a case of surgical resection for synchronous triple can-
cers of the esophagus, stomach, and ampulla of Vater. In thepresent
case, the preoperative diagnosis was esophageal cancer (T2N0M0,
stage IB) with gastric cancer (T1N0M0, stage IA) and cancer of
the ampulla of Vater (T2N1M0, stage IIB) (Union for International
Cancer Control ver. 7). The ﬁrst stage of the operation comprised
right-side transthoracic subtotal esophagectomy with external
esophagostomy in the neck and gastrostomy. Thirty-ﬁve days after
the ﬁrst surgery, total gastrectomy and pancreatoduodenectomy
were performed as the second stage. Esophageal reconstruction
was performed using the ileocolon via the percutaneous route [7].
In this case of triple cancer, intrathoracic and abdominal surgeries
were divided into separate stages. For synchronous multiple can-
cers, the planning of two-stage surgery should be considered for
each cancer to maintain organ function and reduce the stress and
difﬁculty of each stage. In the present case, cancers of the colon
and liver were more advanced than the esophageal cancer, and
CASE REPORT – OPEN ACCESS
4 Y. Akiyama et al. / International Journal of Surgery Case Reports 13 (2015) 1–4
esophagectomywith lymphadnectomy and reconstructionwas the
most invasive procedure. Therefore, laparoscopic sigmoidectomy
and partial hepatectomy were preferentially performed with radi-
cal eshophagectomy a month later as the second stage.
The period between the ﬁrst and second stages is needed for
recovery from stress from the ﬁrst stage and to prepare for the sec-
ond. Patients undergoing esophageal surgery are at a high risk for
post-operative pulmonary complications. It has been reported that
pre-operative inspiratory muscle training reduces the risk of post-
operative pulmonary complications [12]. Our patient underwent
preoperative inspiratory muscle training under the supervision of
a physiotherapist for 1month prior to the second stage esophagec-
tomy. Furthermore, it is well-known that a high body mass index
(BMI) increases the risk of post-operative complications [13]. Our
patientwas obesewith a BMI of 25.7 kg/m2 at time of the ﬁrst oper-
ation [14]. Therefore, hewas placed on a restricted calorie diet for 1
month until the second operation, which resulted in a weight loss
of 7.8 kg and a reduced BMI of 22.7 kg/m2. It seemed that this pre-
operative management regimen reduced the risk of postoperative
complications because only mild pneumonia-induced pulmonary
aspiration occurred after the second surgery.
The disadvantage of a two-stage operation is the possibility of
rapid progression of the cancer until the second operation as a
result of immune suppression following highly invasive surgery.
Therefore, an accurate diagnosis and staging of the cancer of each
organ is quite important.
Natsugoe et al. [1] reported that patientswith synchronous can-
cers, including esophageal cancer, had poorer prognoses than those
with metachronous cancer and that esophageal cancer was the
most frequent cause of death. Treatment with higher curability for
esophageal cancer and safety may be warranted.
4. Conclusions
Here, we reported the successful treatment of synchronous
triple cancers of the thoracic esophagus, sigmoid colon, and liver
by a two-stage operation. Two-stage surgery for curative resection
is a useful treatment option formultiple primary cancers, including
esophageal cancer.
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Curative two-stage resection for synchronous triple cancers of the esophagus, colon, and liver: Report of a case 

Curative two-stage resection for synchronous triple cancers of the esophagus, colon, and liver: Report of a case

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