South Asian Journal of Cancer

: 2017  |  Volume : 6  |  Issue : 4  |  Page : 194--195

Triple primary malignancies in head-and-neck region: A report of four cases

Manjari Shah1, Rashi Agarwal2, Sweety Gupta3, Shashank Srinivasan4, Prekshi Chaudhary2, Sandeep Agarwal5, Sudarsan De1,  
1 Department of Radiation Oncology, Jaypee Hospital, Noida, India
2 Department of Radiation Oncology, Max Super Speciality Hospital, Delhi-NCR, Delhi, India
3 Department of Radiation Oncology, All Institute of Medical Science, Rishikesh, Uttrakhand, India
4 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
5 Department of Radiation Oncology, Max Super Speciality Hospital, Delhi, India

Correspondence Address:
Dr. Manjari Shah
Department of Radiation Oncology, Jaypee Hospital, Noida

How to cite this article:
Shah M, Agarwal R, Gupta S, Srinivasan S, Chaudhary P, Agarwal S, De S. Triple primary malignancies in head-and-neck region: A report of four cases.South Asian J Cancer 2017;6:194-195

How to cite this URL:
Shah M, Agarwal R, Gupta S, Srinivasan S, Chaudhary P, Agarwal S, De S. Triple primary malignancies in head-and-neck region: A report of four cases. South Asian J Cancer [serial online] 2017 [cited 2020 Apr 6 ];6:194-195
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Full Text

Dear Editor,

Patients presented with head and neck malignancy after being treated are in high risk to develop multiple cancers. The frequency of double primary cancers found in an individual has been increasing. However, synchronous or metachronous triple primary cancers have rarely been reported. Meta-analyses show the frequency of second primary tumor as 3%–5%, a third tumor as 0.5%, and a fourth tumor (QT) as 0.3%.[1],[2] A better overall and prolonged survival due to early diagnosis and improved treatment are one of the known possible reasons for rising incidence of multiple primary tumors, and other reason could be the persistent carcinogenic influence on the mucosa, genetic instability, chemoradiotherapy, and prolonged survival after some primary tumors.[3]

Four patients with triple primary malignancy of head-and-neck region were included in this study. Patients were diagnosed and treated at Max Super Speciality Hospital, Delhi-NCR, having a biopsy-proven first and subsequent primary tumor. A thorough clinical, radiological, and histopathological means were used to exclude a metastasis from first primary tumor. The Warren and Gates criteria have been used to designate a case as multiple primary tumors. The data collected and analyzed with respect to location of primary tumor, histopathology, time elapsed between two tumors, treatment received, and the outcome for the all primary tumors [Figure 1], [Figure 2], [Figure 3], [Figure 4].{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Earlier in this group of patients' palliative systemic chemotherapy was treatment of choice because reirradiation and resurgery were not considered to be feasible. Patients managed with systemic chemotherapy had a median survival of only about 6–8 months, and a cure was unlikely.[4] Hereby, we are treating our patients with intensity-modulated radiotherapy/image-guided radiotherapy) and concurrent chemotherapy with or without surgery. Two of the four patients were on follow-up 2 and 3 years after the treatment of third malignancies and then lost to follow-up. One patient developed metastatic disease 4 years after the treatment of third malignancy and one patient died from acute respiratory distress syndrome with septicemia after the treatment of third malignancy.

The management of second and third malignancies remains a challenge but with judicious patient selection and use of appropriate treatment modalities the patients can be successfully treated. We further need an improvement of our knowledge of the risk and pattern of second and subsequent malignancies so that we can offer the best management to our patients.

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Conflicts of interest

There are no conflicts of interest.


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2National Cancer Institute. SEER Program Code Manual. 3rd ed. Bethesda (MD): National Cancer Institute; 1998.
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