Multiple Cancers in a Patient with Systemic Sclerosis and Aggravated Interstitial Lung Disease by Chemotherapy
A 52-year-old female patient was referred to our hospital because of narrow feces. The patient had the symptom of narrow feces. During the first visit, she was diagnosed with sigmoid colon and was later hospitalized for surgery. The patient has been taking meloxicam (15 mg) for her knee pain in the past 3 years (prescribed by private clinic). No particular family factor is observed.\nThe patient only showed chronic ill looking apperance when she was first hospitalized. The blood pressure level was 118/83 mm Hg with pulse rate of 90/min, and respiratory rate of 20/min, body temperate was 36.9℃. There was no findings on conjunctiva blanching reaction and scleral icterus. The lung sound was clear. The abdomen was flat with normal bowel sound. There was no abdomen mass and tenderness. Digital rectal examination showed tarry stool.\nPeripheral blood test when the patient was first hospitalized: The white blood cell was 6,460/mm3 (neutrophil 63.5%, lymphocyte 25.1%), hemoglobin 13.1 g/dL, platelet 169,000/mm3. Serum biochemistry showed the blood urea nitrogen level of 9.0 mg/dL and creatine 0.65 mg/dL, total protein 7.8 g/dL, albumin 3.7 mg/dL, aspartate aminotransferase/alanine aminotransferase 25/17 IU/L, a total bilirubin of 0.43 mg/dL, sodium 138 mEq/L, potassium 4.1 mEq/L, lactate dehydrogenase 427 IU/L, C-response protein 0.73 mg/L (range, <5 mg/L), carcinoembryonic antigen 2.49 ng/mL (range, 0.5 ng/mL), cancer antigen 19-9 24.15 U/mL (range, <39 U/mL).\nNo particular manifestation during simple chest radiography. Simple abdominal radiography showed a considerable amount of fecal impact. Abdomen computed tomography (CT) scan showed about 4.3 cm sized eccentric wall thickening with pericolic infiltration in sigmoid colon (). Chest CT scan showed a ground glass opacity and reticular opacities in both lower lobes on admission (). Positron emission tomography (PET) CT showed an immensely localized fluorodeoxyglucose (FDG) uptake (SUVmax 8.4) in sigmoid colon. There was mild crystalline FDG uptake around the intestine and on the frontal sacrum. There was severe FDG uptake on both sides of thyroid lobes (Rt, 8.6; Lt, 6.9) and mild FDG uptake at the lower part of pleural in the lower lobes on both sides of lung.\nColonoscopy has proceeded up to the end of ileum and removed 3 polyps (0.4 cm/0.3 cm/0.2 cm) in the middle of ascending colon. The examination also found 3 cm sized circumferential ulcerative and fungating mass at anal verge 17.20 cm ().\nLaparoscopic anterior resection was performed because there was no distant metastasis on PET CT. The size of tumor was 8.3×5.3×1.5 cm and it has infiltrated up to subseroa (pT3) in depth. The length of resection margin was 12.5 cm to upper end and 5.5 cm bottom end and 11 cm towards mesentery. There was no lymph node metastasis. No infiltration to adjacent nerves and blood vessels. But, there was infiltration to lymphatic channel.\nAfterwards, FOLFOX was performed 5 times as adjuvant chemotherapy. The patient complained of dry cough in the process of 4th chemotherapy. The patient had exertional dyspnea one month prior to the 5th chemotherapy. In comparison with the first observation, chest CT showed the interval progression of the ground glass opacity in both lower lobes (). Pulmonary function test showed restrictive lung disease manifestations with forced vital capacity (FVC) 53%, forced expiratory volume in one second (FEV1) 64%, FEV1/FVC 90%, DLco 44%. Brochoalverolar lavage showed the result of neutrophil 2%, lymphocyte 10%, eosinophil 17%, macrophage 68%, and mesothelial 3%. Chest CT found no legional mass. PET CT did not find any suspicious FDG uptake. However, transbronchial lung biopsy (TBLB) at Rt. lower lung showed adenocarcinoma (poorly differentiated, cytokeratin [CK]-7[+]/CK-20[-]/thyroid transcription factor 1[+]/CDX-2[-]) ().\nAfter seeing strong FDG uptake at both thyroid lobes from PET CT (Rt, 8.6; Lt, 6.9) and the test result of T3 0.86 ng/mL (range, 0.6-1.8 ng/mL), T4 7.29 µg/dL (range, 5.4-11.7 µg/dL), free T4 0.99 ng/dL (range, 0.89-1.76 ng/dL), thyroid-stimulating hormone (TSH) 2.61 mIU/L (range, 0.55-4.78 mIU/L), TSH-R-Ab 0.23 IU/L (range, 0-9 IU/L), anti-thyroglobulin-Ab 349.78 U/mL (range, <115 U/mL), thyroid peroxidase Ab 1,823.09 U/mL (range, <34 U/mL), Tg 186.4 ng/mL (range, 1.3-31.8 ng/mL), ultrasonography was given. There was 5×7×8 mm sized ganglion in the middle of right lobe. Also, malignant nodule was found. Fine needle aspiration biopsy (FNAB) was given afterwards and the patient was diagnosed with papillary thyroid carcinoma.\nAutoimmune examination was given and the result was antinuclear antibody positive (type: nucleolar and homogeneous, 1:1,600), rheumatoid arthritis factor 36.7 (range, 0.20), anti-cyclic citrullinated peptide Ab (-), anti-neutrophil cytoplasmic antibody (-), anti-DNA Ab (-), C3 100 mg/dL (range, 76.139 mg/dL), C4 19.5 mg/dL (range, 12.37 mg/dL), anti-SS-A (+), anti-RO (+), anti Scl-70 (+), anti-ribosomal-P (+). The patient was diagnosed with SSc.\nAfter adjuvant chemotherapy, chest CT showed the aggravation of interstitial lung disease caused by SSc. The patient's condition was improved after 14 days of prednisolone 60 mg prescription. As of now, the patient is being monitored on an outpatient basis.