DISCUSSION
Synchronous tumors are a challenge to surgeons because concomitant surgeries may be required, potentially resulting in prolonged surgery time and postoperative hospitalization. However, two-stage surgery may involve a risk of malignant disease progression. Kurul et al. reported the case of a 56-year-old female who suffered from triple primary tumors of the breast, non-small cell cancer, and melanoma.4The patient underwent concomitant mastectomy and melanoma excision; stereotactic radiotherapy for lung cancer was performed thereafter. Stereotactic radiotherapy resulted in a few complications and controlled the lung cancer; hence, a two-stage operation was performed.
In the present case, a huge mass originating from the ovary developed; this indicates a potentially longer operation time. To the best of our knowledge, breast cancer and synchronous lung cancer with such huge primary mucinous cystadenoma treated with concomitant surgery have never been reported previously. Regarding operation for multiple cancers, Shoji et al. reported the safety and feasibility of concomitant operation of breast cancer and synchronous lung cancer.5 We initially considered performing radical mastectomy concomitant with video-assisted thoracic surgery (VATS) wedge resection for possible malignant tumor and tumor metastases prevention. After a discussion with a thoracic surgeon, gynecologist, and the patient, we decided to perform concomitant surgery due to the following reasons: First, the patient’s condition was stable, without systemic disease, and an Eastern Cooperative Oncology Group score of 0. Second, each surgery requires about 60–90 minutes, and we expected that the concomitant surgery could be completed within 4 hours. The risk of prolonged general anesthesia time is relatively low and was considered acceptable in this case. Third, the patient had to receive adjuvant chemotherapy for breast cancer, which might have an impact on the subsequent surgery. Thereafter, we performed VATS with wedge resection first due to the right lateral operative position. Radical mastectomy and debulking surgery were performed concurrently with the patient positioned supine. The surgery was completed uneventfully within 4 hours as expected, and adjuvant chemotherapy for breast cancer was prescribed thereafter. A case study reported that synchronous tumors of the ovary and endometrium are tumors with a good prognosis, especially in the early stages. The 5-year and 10-year survival rates were reportedly 85.9% and 80.3%, respectively, and the survival rate depends on the FIGO stage, the tumor’s histology, and its association with adjuvant treatment.6 Moreover, we arranged adjuvant treatment to achieve better outcomes.
In conclusion, we demonstrated a successful concomitant operation for triple primary tumors, which has never been reported. Six months after treatment, the patient was active, and no tumor recurrence was reported. Multiple primary malignant tumors present a challenge when developing therapeutic plans. Concomitant surgery requires comprehensive preoperative evaluation and discussion with other specialists.