Presentation
Sharp abdominal pain. Earlier on the day of admission, the patient underwent an endoscopic examination of the colon that demonstrated a suspicious lesion in the right colon, and biopsies were taken. The patient was referred for urgent non-contrast abdominal CT to rule out perforation. The patient's past history included small bowel resection and hysterectomy due to malignancies (pathology results are not available), and cholecystectomy.
Patient Data
Non contrast abdomen CT
Non-contrast CT examination shows free intra-abdominal air concentrated in the right gutter.
Circular bowel wall thickening in the proximal right colon corresponds to the suspicious lesion that was demonstrated on the endoscopic examination.
Additional findings for further evaluation:
right kidney pelvis is dilated with hyperdense content.
left breast mass in the lower inner quadrant.
The patient was treated conservatively for the perforation.
Chest and abdomen examination with contrast was performed on the next day for oncologic staging, with an additional delayed phase for collecting systems evaluation.
Perforation signs and findings on the right colon were unchanged from the previous examination.
Right kidney pelvic enhancing lesion is clearly demonstrated on the current multiphasic CT examination.
Left breast mass in the lower inner quadrant shows enhancement.
The right kidney pelvis lesion underwent an endoscopic transureteric biopsy.
The left breast lesion was evaluated with mammography and sonography, as described below.
Left breast mammography
Coarse calcifications in the left upper outer quadrant (BIRADS 4a) and spiculated mass in the left lower inner quadrant (BIRADS 5).
Left breast sonography
Sonographic evaluation of the left breast showed a hypoechogenic mass with irregular margins and acoustic shadow (BIRADS 5) in the area of 9 o'clock, 2 centimeters from the nipple (corresponding to the location of the mass in CT and mammography).
The mass was biopsied under ultrasound guidance.
Pathology reports
Pathology results confirm the presence of three synchronous primary malignancies in patients' right colon (moderately differentiated colonic adenocarcinoma), right kidney collecting system (low grade papillary urothelial carcinoma), and left breast (invasive ductal carcinoma).
Case Discussion
This case raises awareness of multiple primary malignancies and the crucial role of the radiologist in identifying these conditions, as many of these malignancies are clinically occult.
The prevalence of multiple primary malignancies is ~10% (range 2-17%). Multiple primary malignancies significantly change the patient's clinical management, and the patient may require further genetic consultation.