Incidental Intraoperative Discovery of Colonic Growth in a Patient with Esophageal Carcinoma– Lessons Learnt!

Abstract

Presentation of more than one malignancy at the intial time of diagnosis is rare. Recently we encountered a patient who was diagnosed with carcinoma esophagus found to have another incidental growth in his right colon at the time of surgery. When managed appropriately such patients do well depending on the stage of their malignancy. Here in this article we have reviewed the literature pertaining to multiple primary malignancy. Keywords Double malignancy . Carcinoma esophagus . Carcinoma colon Case ReportA 54-year-old man presented with complaints of progressive dysphagia and weakness for the past 2 months. Dysphagia was more for solid food than liquid diet. He also had history of loss of appetite and loss of weight, about 5 kg in 2 months. He was a known smoker and alcoholic. On general physical examination, he revealed pallor; otherwise his general condition was unremarkable. Abdominal examination did not reveal any organomegaly or free fluid and was essentially normal. His routine blood counts revealed anemia (hemoglobin 8 g/dl). His renal and liver function tests were reported as normal.Upper gastrointestinal endoscopy revealed ulcerative lesion in the esophagus, starting at 30 cm from incisor and extending up to 35 cm. Biopsy from the ulcer was called out as squamous cell carcinoma. Contrast-enhanced computerized tomography of the thorax and upper abdomen showed wall thickening, involving midthoracic esophagus at the level of the fifth and sixth thoracic vertebrae, with no periesophageal disease or distant metastasis. He was taken up for transthoracic esophagectomy with cervical esophagogastric anastomosis. The right fifth intercostal space approach was used for complete circumferential mobilization of thoracic esophagus from thoracic inlet to diaphragmatic hiatus along with periesophageal lymph nodes. The abdomen was opened by midline supraumbilical laparotomy incision for mobilization of the stomach based on the right gastroepiploic and right gastric vessels. During laparotomy, a strictorous growth involving cecum and ascending colon was incidentally discovered (Fig. 1). Hence, the therapeutic plan was changed to include right radical hemicolectomy with ileocolic anastomosis. After completing ileocolic anastomosis, the gastric tube was prepared and cervical esophagus was mobilized through curved cervical incision. The esophagus was divided and the gastric tube was passed through the posterior mediastinum to the neck. An esophagogastric anastomosis was performed in a single layer.The final histopathology report was called out as adenosquamous carcinoma of the esophagus, involving the muscular wall with no nodal metastasis and tumor-free margins (stage pT2N0M0 , Fig. 2); hemicolectomy specimen was reported as moderately differentiated adenocarcinoma colon with mucinous component, all the lymph nodes and both the cut margins were free of tumor (Astler Coller staging B2). Postoperatively, he was referred to the medical oncology department for adjuvant chemotherapy. He completed 6 months of FOLFOX chem...