| Abstract|| |
A double malignancy involving a solid organ and hematopoieteic system is rare. We report an interesting case of gastric adenocarcinoma with subsequent development of acute myeloid leukemia, in the absence of any therapeutic intervention.
Keywords: Gastric carcinoma, leukemia, multiple primary cancer
|How to cite this article:|
Pradhan S, Sherpa M. Gastric carcinoma and acute myeloid leukemia: A case report of a double malignancy. Indian J Pathol Microbiol 2018;61:583-4
| Introduction|| |
Multiple primary cancer (MPC) is a specific malignant tumor type, manifesting as more than one primary tumor diagnosed in the same patient, either simultaneously or sequentially. There have been many reports in the literature, of MPCs involving solid organs, but a double malignancy involving the hematopoietic system, and a solid organ is a less common finding. Development of secondary leukemia after chemotherapy and radiotherapy is also a well-known fact. Here, we report a rare case of untreated gastric carcinoma with the sequential development of acute myeloid leukemia (AML).
| Case Report|| |
An elderly, belonging to the Lepcha tribe, presented to our hospital in April 2016, with complaints of a burning sensation in the upper abdomen and generalized weakness. Endoscopy showed a large ulceroproliferative growth involving the body of the stomach, with overlying slough. Computed tomography scan revealed a malignant gastric mass with adjacent infiltration to the transverse colon near the splenic flexure, along with small anterior perigastric lymphadenopathy. On biopsy, a diagnosis of gastric Adenocarcinoma, intestinal type was confirmed, [Figure 1].
|Figure 1: (a) Adenocarcinoma, intestinal type, (b) myeloblasts in peripheral blood smear, (c) myeloblasts in bone marrow aspirate, (d) blasts showing positive myeloperoxidase stain|
Click here to view
Hematological examination revealed a total leukocyte count of 19 × 103/cumm, with 60% neutrophils, 37% lymphocytes, and 3% monocytes. The hemoglobin was 9.5 g/dL, and platelet count was normal. Our patient did not undergo any kind of surgical or medical intervention. However, the patient opted for alternative therapy with Tibetan medicine, which has a common use among the tribes of this region. Regular monthly follow-up showed decreasing hemoglobin levels up to 5.4 g/dL, whereupon he was transfused with packed red blood cells. The total leukocyte and platelet counts were normal.
In January 2017, total leukocyte count was found to be 39.3 × 103/cumm. Peripheral blood smear revealed the predominance of myeloblasts (70%). Bone marrow aspiration and biopsy examination showed hypercellularity with 90% myeloblasts. The blasts showed positive staining for Myeloperoxidase and Sudan Black stains. A final diagnosis of AML, M1 type was given.
| Discussion|| |
MPCs occurring in the same patient have been previously reported in the literature. Certain criteria have been laid down to diagnose two separate malignant neoplasms, which include: (1) each tumor must be clearly malignant, (2) each tumor must be geographically separate and distinct, and (3) the possibility that the second tumor represents a metastasis should be excluded from the study.,
MPC may develop synchronously or metachronously.. Our case falls within the metachronous category, with the secondary malignancy of myeloid leukemia occurring 8 months after the primary tumor. Commonly involved solid organs in MPC include stomach, colon, breast, and esophagus. Hematological malignancies coexisting with other primaries in MPC are multiple myeloma, myelodysplastic syndrome, nonhodgkin lymphoma, and chronic myelogenous leukemia.
Gastric carcinomas with secondary hematological malignancies such as lymphomas and chronic myeloid leukemia have been frequently reported., However, development of AML in a gastric carcinoma patient without any therapy is rarely documented. Our patient, without any form of medical or surgical intervention, subsequently developed secondary hematological malignancy within 8 months following diagnosis of a solid primary malignancy.
The incidence of gastric carcinoma is increasing and has become a leading cause of mortality in this region, the majority of the cases involving people belonging to the Bhutia and Lepcha tribes. Such high rates of stomach cancer could be due to the fact that the people belonging to these tribes consume high amounts of salted and smoked meat along with a variety of fermented food such as Gundruk (dried and decayed leaves of mustard oil plant and spinach), Sinki (radish that is decayed and dried), and Kinema (fermented soya beans).
Most patients present at an advanced stage of the disease, where treatment options are limited. The use of alternative therapy, especially Tibetan therapy, is very common among the tribal population of the region. Treatment in Tibetan medicine is individualized and uses multiple modalities, chiefly herbal and mineral-based formulas of pills, powders, decoction, and pastes in combination with advice on diet and lifestyle conditions, mental and spiritual inclinations, and social and environmental factors. Some of the known Tibetan medicines used for the treatment of gastric cancer are Sangdak Dharyaken, Gawa Chudruk, Dashel Dhuetsema, Khyunga, and Gurgum Chusum. Our patient was also taking such therapy in the form of oral tablets. The association between such medications and development of any malignancy has, till date, not been described in the literature. Thus, the present case falls within a unique category with respect to the development of AML in untreated gastric carcinoma and occurrence of malignancy in a patient undergoing alternative therapy.
Financial support and sponsorship
Conflicts of interest
| References|| |
Nagura E, Kawashima K, Yamada K. Multiple primary cancers associated with hematological malignancies. Jpn J Clin Oncol 1985;15 Suppl 1:211-22.
Smith MA, McCaffrey RP, Karp JE. The secondary leukemias: Challenges and research directions. J Natl Cancer Inst 1996;88:407-18.
Fraumeni JF Jr., Curtis RE, Edwards BK, Tucker MA. Introduction. In: Curtis RE, Freedman DM, Ron E, Ries LA, Hacker DG, Edwards BK, et al
., editors. New Malignancies among Cancer Survivors: SEER Cancer Registries, 1997-2000. Bethesda, MD: National Cancer Institute; 2006.
Meher Lakshmi K, Triveni B, Sai Mallikarjun S, Sree Lakshmi S. Synchronous double malignancy: Acute lymphoblastic leukemia and carcinoma rectum. J Med Sci Res 2015 3:134-6.
Ławniczak M, Gawin A, Jaroszewicz-Heigelmann H, Rogoza-Mateja W, Raszeja-Wyszomirska J, Białek A, et al.
Synchronous and metachronous neoplasms in gastric cancer patients: A 23-year study. World J Gastroenterol 2014;20:7480-7.
Cui Y, Liu T, Zhou Y, Ji Y, Hou Y, Jin W, et al.
Five cases report of solid tumor synchronously with hematologic malignancy. Cancer Res Treat 2012;44:63-8.
Butala A, Kalra J, Rosner F. Chronic myelocytic leukemia and gastric cancer in the same patient. J Natl Med Assoc 1989;81:457-9.
Kim WJ, Lee WS, Kwon SJ, Kim I. A case of acute leukemia complicated with gastric cancer. Korean J Clin Pathol 2001;21:323-6.
Verma Y, Pradhan PK, Gurung N, Sapkota SD, Giri P, Sundas P, et al.
Population-based cancer incidence in Sikkim, India: Report on ethnic variation. Br J Cancer 2012;106:962-5.
Bauer-Wu S, Lhundup T, Tidwell T, Lhadon T, Ozawa-de Silva C, Dolma J, et al.
Tibetan medicine for cancer: An overview and review of case studies. Integr Cancer Ther 2014;13:502-12.
Department of Pathology, Sikkim Manipal Institute of Medical Sciences, 5th Mile Tadong, Gangtok - 737 101, Sikkim
Source of Support: None, Conflict of Interest: None