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 Table of Contents  
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 33-34

A case of synchronous dual malignancy with the index malignancy in the lower alveolus and a second primary malignancy in the left breast

1 Department of Surgical Oncology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Integrated Breast Care Centre, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission25-May-2020
Date of Decision30-May-2020
Date of Acceptance09-Jun-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Dr. Priyanka Gupta
Department of Integrated Breast Care and Centre, AIIMS, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_22_20

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Multiple primary malignancies are nowadays commonly detected due to better radiological techniques, greater awareness and an increase in number of elderly cancer survivors. We are reporting a rare case of patient having dual synchronous malignancy of carcinoma left lower alveolus and ductal carcinoma in left breast who presented to the department of surgical oncology and integrated breast care center. The patient is on regular follow-up, and currently, there was no evidence of recurrent or residual disease. No such case has ever been reported, and despite a thorough check on all, we are unable to find any previously reported case. Hence, to the best of our knowledge, this case is the first of its kind to have simultaneous presentation of synchronous dual malignancies involving left lower alveolar and left breast cancers.

Keywords: Alveolar and ductal carcinoma, squamous cell carcinoma, synchronous malignancy

How to cite this article:
Agarwal SP, Arya JK, Gupta P, Ravi B, Syed A. A case of synchronous dual malignancy with the index malignancy in the lower alveolus and a second primary malignancy in the left breast. J Med Evid 2020;1:33-4

How to cite this URL:
Agarwal SP, Arya JK, Gupta P, Ravi B, Syed A. A case of synchronous dual malignancy with the index malignancy in the lower alveolus and a second primary malignancy in the left breast. J Med Evid [serial online] 2020 [cited 2022 Nov 30];1:33-4. Available from: http://www.journaljme.org/text.asp?2020/1/1/33/290137

  Introduction Top

Multiple primary malignancies are uncommon and suggest genetic predisposition due to mutations in cell line and persistent exposure to one or more etiological risk factor(s); however, due to better diagnostic techniques they are now-a-days more frequently detected.

  Case Report Top

A 62-year-old female was referred to the department of surgical oncology with difficulty in chewing and mouth opening for 6 months. On examination, there was only one finger mouth opening. Ultrasound showed a 5 cm × 3 cm lesion over the lower alveolus extending anteriorly up to canine, posteriorly till second molar and laterally up to buccal mucosa. No lymph nodes were palpable in the cervical region. These findings were further confirmed on contrast-enhanced computed tomography neck and face which further showed underlying bony erosion of the mandible which was not visible on clinical examination, following which biopsy was done which showed squamous cell carcinoma of the lower alveolus. The patient also complained of lump in the left breast for 6 months and was referred to Integrated Breast Care Center. No history of radiation to the head-and-neck area before the examination was there. The breasts were examined, and triple assessment of bilateral breast was done. On examination, the left breast had a 3 cm × 3 cm lump. On mammography and ultrasound correlation, left breast BIRADS 5 (Breast Imaging Reporting and Data System) mass lesion was detected, and further, fine-needle aspiration cytology and biopsy from left breast lesion were done. Histopathology reported invasive carcinoma (modified Bloom–Richardson Grade III). Positron emission tomography–computed tomography was also done which showed metabolically active lesion in the left breast at 9 o'clock position and in the left retromolar trigone eroding the mandible. The clinical tumour, node and metastasis (TNM) stage of oral cavity was cT4aN0M0.

A team of doctors from different specialties including surgical oncology, anaesthesiology, breast onco-surgery, plastic and reconstructive surgery, radiation oncology and psychiatry was formed. The patient was admitted and planned for upfront surgery of oral cavity lesion and breast cancer. The patient consented for modified radical mastectomy (MRM) instead of breast conservation surgery. Left MRM was done by the breast onco-surgeon. Composite resection involving segmental mandibulectomy of the left lower canine to the ramus and modified radical neck dissection Type III was done by the team of surgical oncology. Reconstruction with tongue advancement flap and sternocleidomastoid rotation flap was done by the team of plastic and reconstructive surgery at the same time.

Intraoperative finding was 5 cm × 4 cm ulceroproliferative growth at the left lower alveolus, extending anteriorly from the left first premolar, posteriorly involving the retromolar trigone, medially extending on the floor of the mouth and laterally going into the lower gingivobuccal sulcus with extension on buccal mucosa.

The total operative time was approximately 4 h. The breast and oral cavity specimens were sent to the pathology department. The TNM stage for alveolar cancer was T4aN0Mx and for breast cancer was T2N0Mx. The post-operative patient was stable and discharged on the 7th day. The patient was further sent to the radiation oncology department after 6 weeks for adjuvant radiotherapy (RT).

  Discussion Top

Multiple primaries were first reported by Billroth and Reimer. The patient with a known cancer may have second primary malignancy (SPM) which is defined as malignant neoplasm in a patient with a known cancer.[1] There are few criteria laid down by Warren and Gates that help in the diagnosis of SPM which are; tumor should present a definite picture of malignancy; each tumour should be histologically distinct; the possibility that one is a metastasis of the other must be excluded, and if present in the same organ, they must be at least be 2 cm apart. If the tumours are in the same location, then they should be separated in time by at least 5 years.[2]

The North American Association of Central Cancer Registries has classified multiple primary tumours into two categories: (a) synchronous, in which the cancers occur at the same time (the Surveillance, Epidemiology and End Results Program definition is within 6 months), and (b) metachronous, in which the cancers follow in sequence, that is, more than 6 months apart.[3]

'Field cancerisation' is thought to be common carcinogen- induced multiple cancers in an exposed epithelial surface and is theorised to be the pathophysiology behind the occurrence of multiple primary malignancies in the head-and-neck region.[4]

Other possible causal factors include tumor and patient characteristics including persistent carcinogen exposure from environment, progressive ozone depletion and effects of ionizing radiation, increased use of organ transplant, and the increasing use of newer treatment modalities like hormonal manipulation, target therapies, genetic manipulation, immunomodulators, HER2 receptor positivity, low estrogen receptor expression level, and BRCA1 or BRCA2 mutation, along with mutation in tumor suppressor genes such as p16, p53, PTEN, and Rb gene has an effect on the risk of secondary primary malignancy.[5],[6],[7]

  Conclusion Top

The present case of synchronous dual primary malignancy of the lower alveolus and breast was confirmed by immunohistochemistry and pathological analysis. Simultaneous removal of resectable primary malignancies should be attempted, and RT/chemotherapy should be considered. A regular follow-up after treatment of such patients should be performed.


This study has been seen and approved by all authors; it is an original contribution that is not previously published; it is not under consideration for publication elsewhere.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Billroth T, Reimer G. The general surgical pathology and therapy. 51 Lectures-A handbook for students and doctors, 14th Edition, Berlin:1889;908  Back to cited text no. 1
Warren S, Gates O. Multiple primary malignant tumors: A survey of the literature and statistical study. Am J Cancer 1932;16:1358-414.  Back to cited text no. 2
Howe HL, editor. A Review of the Definition for Multiple Primary Cancers in the United States. Workshop Proceedings from December 4–6, 2002, in Princeton, New Jersey. Springfield (IL): North American Association of Central Cancer Registries; 2003.  Back to cited text no. 3
Hsieh WC, Chen YM, Perng RP. Temporal relationship between cancers of the lung and upper aerodigestive tract. Jpn J Clin Oncol 1997;27:63-6.  Back to cited text no. 4
Mehdi I, Shah AH, Moona MS, Verma K, Abussa A, Elramih R, et al. Synchronous and metachronous malignant tumours expect the un-expected. J Pak Med Assoc 2010;60:905-9.  Back to cited text no. 5
Acharya P, Ramakrishna A, Kanchan T, Magazine R. Dual primary malignancy: A rare organ combination. Case Rep Pulmonol 2014;2014:760631.  Back to cited text no. 6
Marcheselli R, Marcheselli L, Cortesi L, Bari A, Cirilli C, Pozzi S, et al. Risk of second primary malignancy in breast cancer survivors: A nested population-based case-control study. J Breast Cancer 2015;18:378-85.  Back to cited text no. 7


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