Introduction

Double primary malignancies are occurrence malignant process in two different anatomically defined organ sites with different histology concurrently or sequentially. Double primary malignancies have been described since last century and more frequently documented in visceral, gynecological and endocrine malignancies. Rationale for more reporting of double primary malignancies would be increased survival of general population, increased awareness regarding cancer detection and advancement in cancer screening and diagnosis.^[1] Depending on the time between tumor diagnoses, there are two categories of double primary malignancies.^[2] Synchronous malignancies are those in which a secondary tumor develops at the same time as the primary tumor or within six months of it, whereas metachronous malignancies are those in which the secondary tumor develops more than six months after the primary tumor.^[2]

Case summary

48-year-old female, farmer by occupation, no addiction history, normotensive, non-diabetic, referred to our center by family physician for-shortness of breath in recently diagnosed carcinoma of breast. 

Clinical details documented as-

1. Cough-for 2 months dry, intermittent, with minimal white sputum production.
2. Shortness of breath on exertion in the last 2 months, initially grade 1 and progressed to grade IV and associated with drastically change in quality of life leading to inability to perform routine activities due to shortness of breath. Loss of appetite and weight loss over period of 4months
3. Weakness and myalgia with fatigability for 4 months

Clinical Examination Documented as-

Restless, dry oral mucosa, cyanosis

Heart rate-130/min Respiratory rate: 46/bpm, BP-160/90 mmhg

PsO2: 71@ room air resting & 89-91% @ 14 litres/minute oxygen with reservoir bag

Respiratory system examination revealed- bilateral breath sounds normal, bilateral crepitation’s heard on both lung fields

Nervous system examination- higher functions normal, no neurological

abnormality

Cardiovascular and gastrointestinal systems were normal

Her husband disclosed that she was diagnosed as case of infiltrating ductal carcinoma of left breast 6 months back. She undergone mastectomy left side with one follow up chemotherapy cycle. After first chemotherapy cycle, she developed loss of appetite, weakness and myalgia and they decided for prolongation of chemotherapy cycle to avoid further worsening of general health condition. Subsequently, she developed dry cough and breathlessness which was progressive and worsened over 2 months of initial symptoms to bedridden stage. She has consulted to local family physician and took chest x-rays. We have reassessed chest imaging and observed normal chest x-ray taken at one month (Figure 1) and two month (Figure 2) interval, and mammography reports showing micro lobulated irregular mass lesion in inner quadrant with left breast with rest of the parenchyma showing micro calcifications (Figure 3). She was referred by family physician to our centre for worsening of dyspnoea. Her chest x-ray done by family physician shown right middle zone lobulated mass and left paracradiac nodular opacity (Figure 4). As patients’ general health is deteriorating and underestimation of bilateral lung pathology in previous hospital visits by general physicians, we have repeated chest X-ray and documented more advanced and predominant parenchymal abnormalities in bilateral middle and lower lung in bilateral lung in all zones (Figure 5).

Laboratory Examination Documented as-

Hemoglobin-10.3 gm% total white blood cells- 3000/mm³ Polymorphs-70%, Platelet count-190000/uL

CRP- 45 mg/L (0-6 mg/L), random blood sugar level-144 mg% HbA1C-5.70 %

LDH-1080 IU/L (70-470 IU/L), Uric acid-3.4 mg (3.5-7.5 mg/dL)

Serum electrolytes: Sodium-131 meq/L (135-145 meq/L) Potassium-3.8 meq/L (3.5-5.5 meq/L) Ionic calcium-1.32 meq/L (1.09-1.36 meq/L)

D-dimer- 568 ng/ml (<500 ng/ml)

IL-6-4.75 pg/ml (0.00-7.00 pg/ml)

Thyroid functions-normal

Liver and kidney functions- normal

Induced Sputum examination for acid fast bacilli was negative and TB Gene Xpert MTB/RIF were negative for MTB genome.

As patient’s tropical workup is negative and showing leucopoenia with raised CRP titre, we have started her on oxygen supplementation with target oxygen saturation above 90 % and intravenous methylprednisolone, Injection meropenem and moxifloxacin and supportive care with intravenous saline. Her general health improved on day 3 of hospitalization and we have done HRCT thorax to rule out opportunistic infection or pneumonia after chemotherapy.

HRCT Thorax suggestive of

1. bilateral, peripheral and central multifocal nodular masses and cannon ball opacities
2. central right lung mass with narrowing of right main stem bronchus
3. right middle lobe mass with narrowing of intermediate bronchus
4. right lower lobe parenchymal mass with collapse of bronchial luminal opening
5. left hilar mass