Cancer of Unknown Primary I Case 1: Imaging I Case 2,3: Markers I Case 4: Management

Case 1
PET)/CT may contribute to the management of patients with cervical adenopathies from CUP and those with a single CUP metastasis. For other CUPs, the role of FDG–PET is limited, making this imaging procedure not mandatory in the initial systematic work-up
For a liver malignancy, it is important to R/O primary liver malignancy as well las mets form other site such as GI or breast particularly in females.
Thorough physical examination (including head and neck, rectal, pelvic and breast examination), basic blood and biochemical analyses, and computed tomography (CT) scans of thorax, abdomen and pelvis constitute a minimal basic work-up
Reference: http://www.nccn.org/profession....als/physician_gls/pd

case 2
CK7+ and CK20- immunohistochemistry pattern is seen in breast cancer, lung cancer, mesothelioma, ovarian serous, uterine adenocarcinoma, salivary gland, thyroid and pancreatic cancer.
Colorectal adenocarcinoma is usually CK7- and CK20+. So although a colonoscopy might be indicated, in this case it is not a priority and can be considered if the other tests failed to reveal a primary site.
Reference: Fizazi K, Greco FA, Pavlidis N, ESMO Guidelines Committee. Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015 Sep;26 Suppl 5:v133-8. doi: 10.1093/annonc/mdv305. PMID: 26314775.

case3
CK7+ and CK20- which is likely to be a lung primary. Lung adenocarcinomas are TTF1+ expressed in over 70% of lung adenocarcinomas and is an important stain in CUP.
Other CK7+ and CK20- are breast cancer, mesothelioma, ovarian serous, uterine adenocarcinoma, salivary gland, thyroid and pancreatic cancer.
Peritoneal mesothelioma is an uncommon malignancy. Often, WT1 and Calretinin are positive in Mesothelioma and are suggestive of the diagnosis in this patient.
Ovarian serous carcinoma is another possibility in this patient. Patients with Ovarian serous carcinoma are also CK7+/CK20-; however, they will normally express PAX8 and WT1.
This is a highly aggressive tumor that occurs most often in the pleura (70%) and peritoneum (30%).
Fizazi K, Greco FA, Pavlidis N, ESMO Guidelines Committee. Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015 Sep;26 Suppl 5:v133-8. doi: 10.1093/annonc/mdv305. PMID: 26314775.
Reference: Hassan R, et al. Current treatment options and biology of peritoneal mesothelioma: meeting summary of the first NIH peritoneal mesothelioma conference. Ann Oncol 2006;17(11):1615-9


case 4
For localized adenocarcinoma (or carcinoma NOS) in the inguinal node(s), a thorough exam is needed to establish a primary. Given that the bilateral inguinal lymph nodes are the only site of disease, local therapy with more surgery should be offered. Adjuvant RT (+/- chemotherapy) could be considered if clinically indicated However, one needs to weigh the benefit of adjuvant therapy with the risk of lymphedema (especially if radiation is given).
Reference: http://www.nccn.org/profession....als/physician_gls/pd

• Category

  Unknown Primary