Asymptomatic Synchronous Quintuple Primary Cancers ( ovary, endometrium, ascending colon, rectum,lung)

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• Synchronous quintuple primary cancers
• Asymptomatic
• MSH2 gene
• MLH1 gene
• Lynch syndrome

"All of the above-mentioned cancers were considered to be primary tumors, so a diagnosis of synchronous quintuple primary cancers was made. Her tumors were classified as stage Ia for ovarian cancer, stage Ib for endometrial cancer, stage IIIb for colon cancer, stage I for rectal cancer, and stage IIIa for lung cancer."

"The results showed that expression of MLH1 was absent in the rectal cancer, although its expression was normal in the other cancers (fig. 3a–e). For MSH2, expression was noted in normal tissues, but its expression was absent in the ovarian, endometrial, colon, and rectal cancers. However, the lung cancer did not show decreased expression of MSH2 (fig. 3f–j)."

"Although this case did not meet the diagnostic criteria for hereditary non-polyposis colorectal cancer (Amsterdam Criteria II), an abnormality of DNA mismatch repair genes was involved in four of the five cancers. This suggests that our patient is very likely to have Lynch syndrome [17]."

Abstract
We encountered a 46-year-old woman with synchronous quintuple primary cancers. She did not present with any symptoms, and her tumors were discovered at a gynecological screening. She had clear cell adenocarcinoma of the right ovary, moderately differentiated endometrioid adenocarcinoma of the endometrium, moderately differentiated adenocarcinoma of the ascending colon, well-differentiated adenocarcinoma of the rectum, and poorly differentiated papillary adenocarcinoma of the left lung. A fluorodeoxyglucose-positron emission tomography and other imaging techniques were extremely useful for the diagnosis of multiple primary cancers. Moreover, MSH2 protein expression was absent in the tumors of the ovary, endometrium, ascending colon, and rectum, while the rectal cancer also lacked MLH1 protein. These findings suggested that an abnormality of DNA mismatch repair genes was responsible for carcinogenesis.

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 Established Facts
• Reports about quintuple primary cancer are extremely rare. Moreover, no one reported a patient with synchronous five primary cancers in five different organs in the literature in English.

 Novel Insights• This is the first report in English of a patient with synchronous five primary cancers in five different organs.
• An abnormality of DNA mismatch repair genes (MSH2 and MLH1) was considered to be responsible for carcinogenesis.
• Fluorodeoxyglucose-positron emission tomography (FDG-PET) and other imaging techniques were extremely useful for the diagnosis of asymptomatic multiple primary cancers.

 IntroductionMultiple primary cancers commonly occur in the head and neck, upper gastrointestinal tract, and respiratory tract [1]. Among gynecological tumors, combined involvement of the ovary and endometrium is most common. When different primary tumors are found in several organs, multiple primary cancers are diagnosed and are classified according to the timing of detection as synchronous or metachronous [1]. There have been a few reports of triple or quadruple primary cancer, but reports about quintuple primary cancer are extremely rare. We encountered a patient with asymptomatic synchronous quintuple primary cancers of dissimilar histologies that had developed in five organs: ovary, endometrium, ascending colon, rectum and lung...........

"All of the above-mentioned cancers were considered to be primary tumors, so a diagnosis of synchronous quintuple primary cancers was made. Her tumors were classified as stage Ia for ovarian cancer, stage Ib for endometrial cancer, stage IIIb for colon cancer, stage I for rectal cancer, and stage IIIa for lung cancer."