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A - MSRA Cancer Care [1] > [40] Cancer of Unknown Primary > Flashcards

[40] Cancer of Unknown Primary Flashcards

1
Q

How will cancer often present?

A

As a result of symptoms due to the primary site of the tumour

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2
Q

Why might cancer not always present as a result of symptoms due to the primary site of the tumour?

A

Because sometimes the cancer is able to metastasise before the primary site is large enough to be detected

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3
Q

How to carcinomas of unknown primary (CUP) differ from known primary tumours?

A

They tend to have early dissemination, unpredictable metastatic pattern, aggressive nature, and an absence of symptoms from the primary site

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4
Q

What is CUP defined as?

A

The detection of one or more sites of metastatic tumours for which investigations have failed to identify the primary site

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5
Q

What % of cancers are CUP?

A

Up to 5%

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6
Q

What is the median age of presentation of CUP?

A

60 years

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7
Q

What % of patients with CUP present with multiple sites of presentation?

A

50%

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8
Q

What are the most common sites of presentation of CUP?

A
  • Liver
  • Bones
  • Lungs
  • Lymph nodes
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9
Q

What is the usual histological diagnosis in CUP?

A

Adenocarcinoma or poorly differentiated carcinoma

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10
Q

What will happen with different tumours, with respect to spread?

A

They will spread in different patterns

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11
Q

What might the differing spread of different tumours be related to?

A

Chemokine and their receptors expression by the tumour and stromal cells

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12
Q

What will the clinical presentation of CUP depend on?

A

The location of disease sites

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13
Q

What non-specific symptoms are common in CUP?

A
  • Anorexia
  • Weight loss
  • Fatigue
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14
Q

What is step 1 in the approach to patients with CUP?

A

Search for primary site

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15
Q

What is step 2 in the approach to patients with CUP?

A

Rule out potentially treatable or curable tumours

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16
Q

What is step 3 in the approach to patients with CUP?

A

Characterise the specific clinicopathological entity, and then treat the patient

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17
Q

In what manner should patients with favourable subsets of CUP be treated?

A

Consider curative intent

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18
Q

In what manner should patients with unfavourable subsets of CUP be treated?

A

Palliative intent

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19
Q

What % of patients with CUP have a primary site identified antemortem?

A

20%

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20
Q

What % of patients with CUP have an unidentified primary site at postmortem?

A

70%

21
Q

Where are primary sites most frequently detected in CUP?

A
  • Lung
  • Pancreas
  • GI
  • Gynaecological
22
Q

What initial investigations are done in CUP?

A
  • Complete history and physical examination
  • FBC
  • Serum biochemistry and liver function
  • Serum tumour markers
  • Urinalysis and stool testing for occult blood
  • Chest x-ray
  • Symptom-directed endoscopy
  • Imaging of thorax, abdomen, and pelvis (MRI, CT, or PET)
  • Biopsy for histology (any site of disease)§w
23
Q

What can CUP be classified into on the basis of light microscopy?

A
  • Well to moderately differentiated adenocarcinoma
  • Poorly or undifferentiated adenocarcinoma
  • Squamous cell carcinoma
  • Undifferentiated carcinoma
24
Q

What malignancies can be identified by immunohistochemistry?

A
  • Neuroendocrine tumours
  • Lymphomas
  • Germ cell tumours
  • Melanomas
  • Sarcomas
  • Serous tumours (ovarian, peritoneal, uterine)
  • Embryonal malignancies
25
Q

Who should patients with CUP be referred to to advise on required investigations?

A

Oncologist

26
Q

Why should patients with CUP be referred to an oncologist for advice on investigations?

A

There should be concern about over-investigating the patient

27
Q

Why should there be concern about over-investigating the patient with CUP?

A

It will have a cost effect, and potentially can delay the initiation of appropriate treatment for the patient

28
Q

What needs to be balanced when investigating CUP?

A

The need for sufficient tests to plan the management and the treatment of the disease

29
Q

How are patients with CUP with an incurable malignancy that is widely metastatic treated?

A

The combination systemic chemotherapy that is most appropriate

30
Q

What will the choice of treatment depend on in incurable CUP that is widely metastatic?

A

The best assessment of the likely primary site and consideration of the performance status of the patient

31
Q

Where is radiotherapy useful in incurable CUP?

A

For specific sites of pain or discomfort

32
Q

What is the aim of treatment for incurable CUP?

A

Palliative, to improve quality of life

33
Q

When might treatment be discontinued in incurable CUP?

A

If the patient is no longer gaining benefit or improvement in symptoms

34
Q

What is the prognosis for patients with well or moderated differentiated adenocarcinoma of unknown primary?

A

Poor

35
Q

Why do patients with well or moderate differentiated adenocarcinoma of unknown primary have a poor prognosis?

A

Because 90% have low response rate to chemotherapy

36
Q

What can patients with potential ovarian or peritoneal sites respond very well too?

A

Appropriate chemotherapy

37
Q

What % of patients with potential ovarian or peritoneal sites achieve complete remission on appropriate chemotherapy?

A

40%

38
Q

How can patients with axillary lymph node metastasis in CUP be treated?

A

As breast cancer, and may require a modified radical mastectomy

39
Q

What % of patients with CUP have poorly differentiated carcinoma or adenocarcinoma?

A

30%

40
Q

Why is having poorly differentiated carcinoma or adenocarcina shit?

A
  • Demonstrate poor response to systemic chemotherapy
  • Poor outcome and short survival
  • Younger median age (40 years)
  • Rapid progression of symptoms
41
Q

What are the most common sites of involvement of poorly differentiated carcinoma or adenocarcinoma CUP?

A
  • Lymph nodes
  • Mediastinum
  • Retroperitoneum
42
Q

What can rarely happen with poorly differentiated carcinoma or adenocarcinoma CUP?

A

Excellent responses and improved survival

43
Q

What can predict which patients with poorly differentiated carcinoma or adenocarcinoma will have excellent responses?

A

No identified factors to predict this

44
Q

What treatment should be considered for patients with CUP with a single site of metastasis?

A

Surgical resection and treatment with radiotherapy

45
Q

What is the advantage of surgical resection and radiotherapy in CUP patients with a single site of metastasis?

A

Can produce significant periods of disease-free survvival in some patients

46
Q

What should the presence of osteoblastic bone metastasis in a male patient be considered for?

A

Empirical hormone therapy (regardless of PSA)

47
Q

What is the median survival for a patient with CUP?

A

6-9 months

48
Q

What is the median survival for a patient with CUP with 1-2 sites of involvement, non-adenocarcinoma, and no involvement of liver, bone, or adrenal gland?

A

40 months

i dont think you really have to know this lol

49
Q

What are the adverse prognostic factors for CUP?

A
  • Adenocarcinoma histology
  • Increasing number of involved organ sites
  • Hepatic or adrenal involvement
  • Supraclavicular lymph node involvement
  • Male gender
  • Poor performance status
  • Weight loss (>10% of body mass)

A - MSRA Cancer Care [1] (47 decks)

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