异时性多原发恶性肿瘤1例临床病理分析并文献复习

Multiple primary malignant tumors: A case report of clinicopathological analysis and literature review

上海市浦东新区人民医院肿瘤科收治1例患有多原发恶性肿瘤(multiple primary malignant tumors,MPMTs)的患者。从初诊乳腺癌至今患者生存18余年。患者,女,45岁,2001年3月26日患者因“发现左侧乳房肿块3个月余”,遂行手术及术后化疗。2002年5月19日复查示:右乳占位考虑恶性肿瘤可能。给予术前新辅助化疗后行手术治疗,术后放化疗并口服三苯氧胺10年至2013年结束。2017年12月因“胸闷、气促1周”就诊上海华山医院行PET/CT检查,结果示:肺癌,肝及骨转移。2018年1月上海市浦东新区人民医院普外科行支气管动脉及肝动脉灌注化疗及栓塞术。至2019年7月1日,患者定期唑来膦酸保骨治疗。2018年3月肝动脉灌注化疗及栓塞术后患者未行相关基因检测,自行口服吉非替尼至2018年8月。右肺下叶、右肺上叶结节灶缩小,肝原低密度结节灶亦明显缩小。2018年10月18日患者因“间隙性排淡红色肉眼血尿”就诊,在局部麻醉下行膀胱镜检查+活检术,活检病理提示:膀胱非浸润性低级别乳头状尿路上皮癌。术后予吉西他滨1 g膀胱灌注化疗。2018年12月1日患者因右侧肢体麻木就诊于上海市浦东新区人民医院,上海市浦东新区人民医院头部CT示:左侧顶叶及右侧颞枕部低密度影,考虑患者脑转移。2018年12月3日至2019年6月21日患者脑部接受全脑放疗、口服吉非替尼、静脉化疗、口服AZD9291(血液检测提示EGFR基因T790M突变)等治疗后脑部病灶较前消退,肝脏病灶明显缩小,本例患者PFS时间尚未达到。各项肿瘤标志物较前下降,生活质量良好。多原发恶性肿瘤发病率较低,涉及病种较多,治疗上相对困难。在诊断上,对于新发病灶建议行病理检查排除多原发可能。靶向药物针对基因敏感突变的应用在治疗方法的选择上至关重要。多学科会诊(multi-disciplinary treatment,MDT)模式具有最大限度减少患者的误诊误治、缩短患者诊断和治疗等待时间、增加治疗方案的可选择性、制定最佳治疗手段的优势。

One patient with multiple primary malignant tumors(MPMTs)was treated at the Department of Oncology of Shanghai Pudong New Area People’s Hospital.Since the first diagnosis of breast cancer,patients have survived for more than 18 years.The patient,female,45 years old,underwent surgery and postoperative chemotherapy on March 26,2001 due to“the discovery of left breast mass for more than 3 months”.Review on May 19,2002 suggested that malignant tumor may be considered in the right breast.Preoperative neoadjuvant chemotherapy was followed by surgical treatment,postoperative chemoradiotherapy and oral tamoxifen for 10 years until 2013.In December 2017,the patient was admitted to Shanghai Huashan hospital due to“chest tightness and shortness of breath for 1 week”.PET/CT examination suggested lung cancer,liver and bone metastasis.In January 2018,bronchial artery and hepatic artery perfusion chemotherapy and embolization were performed in the general surgery department of our hospital.The patient has been treated regularly with zoledronic acid for bone preservation.In March 2018,patients received no relevant genetic test after hepatic artery perfusion chemotherapy and embolization and took gefitinib orally until August 2018.Nodules in the lower lobe of the right lung and the upper lobe of the right lung were reduced,and the original low-density nodules in the liver were also significantly reduced.On October 18,2018,the patient went to see a doctor for“interstitial discharge pink gross hematuria”and underwent cystoscopy under local anesthesia and biopsy.The biopsy pathology suggested that the patient had non-invasive low-level papillary urothelial carcinoma of the bladder.After surgery,gemcitabine was given 1 g bladder perfusion chemotherapy.On December 1,2018,the patient was admitted to our hospital due to numbness of the right limb.The head CT of our hospital showed low-density shadows in the left parietal lobe and right temporo-occipital region,and the brain metastasis of the patient was considered.During the period of December 3,2018 to June 21,2019,the brain lesions of the patient were resolved and the liver lesions were significantly reduced after the treatment of whole-brain radiotherapy,oral Gefitinib,intravenous chemotherapy and oral AZD9291(blood test revealed EGFR T790M mutation).In this case,the time of PFS has not yet reached.The tumor markers decreased and the quality of life was good.The incidence of multiple primary malignancies is relatively low,involving many diseases and relatively difficult to treat.In terms of diagnosis,it is recommended to select pathological examination for new lesions to exclude the possibility of multiple primary lesions.The application of targeted drugs to target gene sensitive mutations is very important in the selection of treatment methods.Multi-disciplinary treatment(MDT)mode has the advantages of minimizing misdiagnosis and mistreatment of patients,shortening the waiting time for diagnosis and treatment,increasing the selectivity of treatment plan,and formulating the best treatment method.