Synchronous Triple Malignancy of Upper Aero Digestive Tract

We managed a case of synchronous triple primary in a 60year male, presenting to us with a complaint of dysphasia for 4 months and bilateral neck nodes for 2 months. On examination, patient had bilateral large fixed nodes. On Fiber optic laryngoscopy patient was found to have growth right lateral wall of nasopharynx and an ulcerated fungating growth at soft palate and uvula. On upper gastrointestinal endoscopy, patient was found to have circumferential growth obstructing the lumen at 30cm. The lesion at all Detection of a second primary at the time of initial work-up of patients with head and neck cancers is rare and it has an important bearing on management planning. All three sites were biopsied and which were proved to be squamous cell carcinoma on histopathology. As all the malignancies, could not be included in radiotherapy portal, the treatment plan changed from curative to palliative intent with informed consent by patient.


Background
We managed a case of synchronous triple primary in a 60year male, presenting to us with a complaint of dysphasia for 4 months and bilateral neck nodes for 2 months. On examination, patient had bilateral large fixed nodes. On Fiber optic laryngoscopy patient was found to have growth right lateral wall of nasopharynx and an ulcerated fungating growth at soft palate and uvula. On upper gastrointestinal endoscopy, patient was found to have circumferential growth obstructing the lumen at 30cm. The lesion at all Detection of a second primary at the time of initial work-up of patients with head and neck cancers is rare and it has an important bearing on management planning. All three sites were biopsied and which were proved to be squamous cell carcinoma on histopathology. As all the malignancies, could not be included in radiotherapy portal, the treatment plan changed from curative to palliative intent with informed consent by patient.

Discussion
Multiple squamous cell carcinomas (SCCs) frequently arise in the Aero-digestive tract. SCC associated with triple tumors occurs in only 0.5%, quadruple tumors in 0.3% of malignant tumors. The incidence of multiple synchronous primary malignancies has been reported between 3% and 13%. This unusually high rate is attributed to the process of field concretization in which an anatomical region is exposed to a surface carcinogen and multifocal areas undergo irreversible change to multifocal malignancies. Lau WF et al. [1] reported nine patients (8.5%) to have synchronous primary tumors including two patients with triple primaries and one with quadruple lesions.
The additional tumors were in the following sites: esophagus (6), tonsil (2), floor of mouth (1), nasopharynx (1), bronchus (1), palate (1), and oropharynx (1). The treatment plans were changed in all nine patients. Németh Z et al. [2] reported a case of Quadruple cancer, including triple cancers in the head and neck region developed metachronous after a urinary bladder primary. Shaha et al. [3] in a series of 140 patients found synchronous multiple primary in 18 patients, eight patients had head and neck cancer, seven had carcinoma lung, and three carcinoma esophagus. Two patients had synchronous triple primaries. Martin Granizo R et al. [4] reported a case of quintuple cancers, two located in the genitourinary tract and three arising on the upper aero digestive tract, two synchronous squamous cell carcinomas of the oral mucosa and carcinoma larynx. Watanabe A et al. [5] in a series of 127 patients reported 11.4% associated SCCHNs among patients with esophageal carcinoma.
Of these, the index antecedent tumor was SCCHN in 49 and EC in 78 patients. One hundred and fifteen patients developed double cancer, 9 patients developed triple cancers and 3 patients developed fourth cancers. The interval between the first and the second cancer in metachronous cancers cases was average 25.5 months, while most cases developing malignancy in 4 years, making screening mandatory within 4 years. Ogawa T et al. [6] reported that average of multiple primary cancer patients was higher than single cancer patient (65 vs 62.7 years).

Conclusion
Detection of a synchronous primary tumor at the time of initial work-up is crucial both for management and outcome.