Al-Bitar Ahmad, Tellawi Israa, Kamil Hazem, Al-Masalma Dana, Jeji Karam, Al-Mahasna Souheb
Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic.
Department of Oncology, Ibn Al-Nafees Hospital, Damascus, Syrian Arab Republic.
J Med Case Rep. 2025 Aug 2;19(1):382. doi: 10.1186/s13256-025-05423-8.
The occurrence of multiple primary cancers is increasing, largely due to better diagnostic tools and longer patient survival. However, managing these cases can be complex, especially when treatments such as chemotherapy lead to complications such as hepatitis B virus (HBV) reactivation, which carries a significant risk of severe illness and death.
We present the case of a 55-year-old Arab woman diagnosed with a rapidly growing triple-negative breast cancer, found to have a BRCA1/BRCA2 mutation. She began neoadjuvant chemotherapy, but the treatment was stopped early due to severe liver inflammation (transaminitis) and a sharp increase in hepatitis B virus levels, confirming hepatitis B virus reactivation. Antiviral therapy with entecavir was promptly started. Later, the patient developed rectal bleeding, leading to the diagnosis of a mid-rectal invasive adenocarcinoma. She underwent successful surgeries for both cancers: a right modified radical mastectomy and a rectal resection with colostomy. Pathology confirmed two distinct primary tumors. Despite initial concerns due to a positron emission tomography scan, subsequent biopsies showed no recurrence. The patient completed adjuvant radiation and, at a 3-year follow-up, remains healthy and disease-free.
This case highlights the intricate challenges of managing synchronous primary cancers and the life-threatening risk of hepatitis B virus reactivation during chemotherapy. It strongly emphasizes the need for routine hepatitis B virus screening before chemotherapy, careful monitoring of liver function and viral loads, and the immediate availability of antiviral treatment. A collaborative, multidisciplinary approach is essential for prioritizing treatments effectively and achieving good outcomes in patients with such complex cancer presentations.
多原发性癌症的发生率正在上升，这主要归因于更好的诊断工具和患者更长的生存期。然而，处理这些病例可能很复杂，尤其是当化疗等治疗导致诸如乙型肝炎病毒（HBV）再激活等并发症时，这会带来严重疾病和死亡的重大风险。
我们报告一例55岁的阿拉伯女性病例，她被诊断出患有快速生长的三阴性乳腺癌，发现存在BRCA1/BRCA2突变。她开始接受新辅助化疗，但由于严重的肝脏炎症（转氨酶升高）和乙型肝炎病毒水平急剧上升，治疗提前停止，证实为乙型肝炎病毒再激活。立即开始使用恩替卡韦进行抗病毒治疗。后来，患者出现直肠出血，导致诊断为直肠中段浸润性腺癌。她成功接受了两种癌症的手术：右改良根治性乳房切除术和直肠切除术并进行结肠造口术。病理证实为两个不同的原发性肿瘤。尽管正电子发射断层扫描最初引起担忧，但随后的活检显示没有复发。患者完成了辅助放疗，在3年的随访中，仍然健康且无疾病。
本病例突出了处理同步原发性癌症的复杂挑战以及化疗期间乙型肝炎病毒再激活的危及生命的风险。它强烈强调化疗前进行常规乙型肝炎病毒筛查、仔细监测肝功能和病毒载量以及立即提供抗病毒治疗的必要性。对于有效优先安排治疗并在患有此类复杂癌症表现的患者中取得良好结果而言，协作的多学科方法至关重要。
