Triple Primary Malignancy

Abstract

The occurrence of more than two primary malignant neoplasms in the same person has long been recognized as rare. Drooker (1), on analyzing the figures reported in the excellent review by Warren and Gates (2), states that multiple cancer constitutes 1.84 per cent of autopsied cases of malignancy, of which triple carcinomas comprise 2.9 per cent. In round figures, approximately one in two thousand cancer autopsies, or in twenty thousand routine autopsies, reveals more than two primary malignant lesions. In 1879 Billroth, reporting the earliest recognized cases of true multiple malignancy, postulated that each tumor must have a different histologic appearance, must arise in a different location, and must produce its own metastases. Mercanton, in 1893, added that there must be no reappearance on removal. In the numerous case reports and several general reviews that have appeared since, notably the contribution of Seecoff (19), these criteria have been discarded as too strict in that they would exclude early cancer of such characteristically non-metastasizing or late metastasizing types as basal-cell carcinomata or adenocarcinomata of the uterine fundus. Warren and Gates (2) emphasized that each tumor must afford a picture of malignancy, each must be distinct, and the probability of one being a metastasis of the other must be ruled out. They criticize many records of supposedly multiple malignant tumors, especially on this last score. For example, it is at present conceded that in bilateral breast cancers, the probability of metastasis to one breast from the other is very strong. Similarly we now recognize that many cases of coincident gastric and ovarian or multiple ovarian tumors may very well come under the category of metastases. In view of the newer concepts of the range of cellular anaplasia and metaplasia, numerous so-called carcinosarcomas, especially when of the same organ, may also be open to question. Moreover, lesions which ordinarily are either multiple or multicentric, as myelomas or certain hepatic carcinomas, are not usually to be included as multiple malignancies. Reasonably practical rules for establishing true multiplicity of new growths were formulated by Goetze (3). He suggested that the macroscopic and microscopic appearance of the tumors must be that of the usual carcinomas of the organs involved. To this he added that exclusion of metastasis must be certain, constituting the very crux of the problem, and that diagnosis might be confirmed by the character of metastasis in each case.