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hilum, infiltrating the first portion of the pancreas.
Radiologic diagnosis of biliary neoplasm was made with
concomitant upper urinary tract urothelial carcinoma of the
left kidney. Urine cytology was negative. Flexible cystosco-
py was performed, and no lesion was found. Meanwhile,
biliary duct drainage and subsequent stent placement were
performed, with symptomatic resolution and improvement
of liver function, as investigated with blood tests.
Conflicts of interest: The authors have nothing to disclose.
Case Discussion: A Man with Two Synchronous and
Symptomatic Malignancies Related to Smoking: The
Case for Primary
Chemotherapy
Maria De Santis
a University of Warwick, Cancer Research Unit, Coventry, UK
b Ludwig Boltzmann Institute for Applied Cancer Research and ITR-Vienna,
Austria
1. Clinical features
This patient apparently suffers from two synchronous and
symptomatic malignancies. Otherwise, he appears fit, with
few comorbidities, but is a heavy smoker and so is likely to
have occult cardiovascular and pulmonary diseases. The
biliary neoplasm is the cause of abdominal pain, weight loss,
and jaundice. The tumour in the renal pelvis is the source of
gross haematuria.
The acute jaundice has been relieved by biliary tract
drainage and stent placement. As for the tiny lung nodule,
no firm conclusions asto the presence of distant metastases
are possible. So far, only radiologic diagnoses have been
obtained; histologic diagnosis is still missing for both
malignancies.
2. Discussion
Most intrahepatic cholangiocarcinomas are adenocarcino-
mas with variable desmoplastic reaction. After histology
has been secured, the treatment of choice for locally
advanced, inoperable, or metastasized biliary tract neo-
plasms is systemic chemotherapy. Objective response rates
with gemcitabine alone range from 7% to 27%, and palliation
can clearly be achieved; however, median survival is rarely
>8 mo .
The combination of gemcitabine plus cisplatin is active
and was well tolerated in most studies. The superiority of
gemcitabine plus cisplatin over gemcitabine alone was
shown in the multicentre ABC-02 trial, with a significant
overall survival benefit with combination therapy versus
gemcitabine alone (11.7 vs 8.1 mo), as was median
progression-free survival (8 vs 5 mo). Toxicity was compara-
ble in both groups with the exception of some more
haematologic toxicity with the combination .
Treatment of choice for urothelial cancer in the locally
advanced, perioperative, and metastatic settings is cisplat-
in-based chemotherapy. The gemcitabine and cisplatin
combination is generally the preferred standard option in
most centres around the world.
3. Treatment strategy
From the oncologic point of view, histology should be
secured before any firm conclusions are drawn and further
treatment decisions made. In particular, the biliary neo-
plasm apparently is not amenable to complete surgery.
Consequently, a biopsy should be sought before further
decisions can be made.
As for the tumour in the renal pelvis, in which urothelial
cancer is suspected and, indeed, is the most probable
histology, complete surgery seems possible and like a
reasonable way to proceed, even in a palliative situation
with regard to the biliary neoplasm. Surgery of the tumour
in the renal pelvis would secure the histology and remove
the source of symptoms (gross haematuria, pain in later
stage) and might stop local and distant spread.
In this particular patient case, gemcitabine and cisplatin
combination chemotherapy would fit for both malignan-
cies, apart from slight variations in the published schedules.
If cisplatin were not feasible, gemcitabine and carboplatin
combinations would be alternative options for both
malignancies, the biliary tract cancer and the urothelial
cancer of the renal pelvis.
Conflicts of interest: The author has nothing to disclose.
References
[1]
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[2]
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DOI of original article: .
* University of Warwick, Cancer Research Unit, Coventry CV4 7AL, UK.
E-mail address: .
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