Introduction
Synchronous tumor indicates two or more primary tumors diagnosed simultaneously (or) within 6 months to each other and Secondary or metachronous cancer denotes tumors developing more than six months after detection of a primary tumor. 1 It has been found that there has been increase in the incidence of gastric carcinoma due to sedentary life styles and environmental exposure. The incidence of synchronous gastric carcinoma with Renal cell carcinoma is quite low and concomitant treatment is rare.2 Also the number of long term survivors of gastrectomy increases the incidence of secondary malignancies after gastrectomy.3 So here we present a case of synchronous Gastric cancer and Renal cell carcinoma with concomitant gastrectomy and nephrectomy and adjuvant chemotherapy.
Case Report
A 70 year old male presented with abdominal pain, weight loss, vomiting, difficulty in eating both solid and liquid food & malena since 20 days. On clinical examination patient’s conjunctiva is pale and his blood investigation shows Hemoglobin of 6 g/dl and Normocytic normochromic anemia in peripheral smear. Upper GI endoscopy shows ulceroproliferative growth in the antrum extending into pylorus with complete Gastric outlet obstruction. Endoscopic gastric biopsy shows features of mucinous adenocarcinoma with invasion into muscularis propria. Abdominal CT scan shows a hyper vascular tumor in the Left kidney measuring 9x6x5 cms. Further subtotal gastrectomy and Radical left nephrectomy were performed. Subtotal gastrectomy was performed which shows circumferential grey white firm mass involves the gastric antrum infiltrating the muscularis layer (Figure 1).
Bits from the gastric mass under 40x H&E – reveals pleomorphic tumor cells (Figure 2). The final pathology report shows Gastric mucinous adenocarcinoma. (Stage: T2a N1 Mx)
Figure 2
H&E in 40x shows Pleomorphic tumour cells – round to oval with vesicular nucleus with prominent nucleoli.
Left nephrectomy specimen shows grey yellow to grey brown mass measuring 8x6cm in the lower pole of kidney which shows variegated appearance. (Figure 3)
Figure 3
Left nephrectomy specimen shows grey yellow to grey brown mass in the lower pole of kidney.
Bits from the renal mass under 40x H&E – reveals individual tumour cells with clear cytoplasm with peripherally pushed nucleus (Figure 4). The final pathology report denotes clear cell type Renal cell carcinoma. (Stage: T3a N1 Mx)
Discussion
The incidence of gastric cancer with a second, synchronously presenting primary cancer varies from 2.0-10.9%. Colorectal, lung, and liver cancers are frequently reported in the medical literature. However, synchronous RCC is rare. The incidence ranges from 0.11 - 0.37%, and the male-to-female ratio is 2:1.4
The incidence of synchronous cancer is higher in early-stage gastric cancers than in the advanced stages of the disease. Gastrointestinal symptoms are the most common clinical manifestations in patients with synchronous cancer of the stomach and kidney.5 Unstable genetic status- microsatellite instability is a risk factors for second primary cancers in patients with gastric cancer. Negative TP53 and RAS mutations have been reported in patients with alimentary tract malignancies.6 Also the MSI-positive colorectal carcinoma have better prognosis than those with MSI-negative colorectal carcinoma.7 The 10-Year survival rates are 69% and 40% for gastric cancer patients without and with a second primary cancer.8
Conclusion
In conclusion our case highlights a rare occurrence of synchronous double malignancy consisting of gastric adenocarcinoma(T2a) with renal cell carcinoma (T3a). It is appreciated that simultaneously both Subtotal gastrectomy and Radical nephrectmoy can be performed without any major surgical complications. Our case report also alerts the treating physician to search for any synchronous cancers in the patient suffering from gastric cancer.
