Cancer of unknown origin Flashcards by Hannah Nolan

Investigations for anaplastic carcinoma in cervical nodes

CXR; sputum cytology (most reliable in small cell lung cancer)
Thyroid scan + needle biopsy
Nasopharyngeal assessment
Consider diagnosis of undifferentiated lymphoma (exclude with immunophenotyping)

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Investigations for SCC in inguinal nodes

Careful exmination of legs, vulva, penis, perneum for primary tumour
Pelvic exam
Protoscopy/colposcopy

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Metastatic adenocarcinoma investigations

Oestrogen and progesterone receptor expression by tumour in females
Serum PSA + acid phosphatase in males
AFP and hCG
Poorly differentiated lymphoma? exclude with immunophenotyping

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Overall unknown primaries type of cell cancer

60% adenocarcinoma
30% poorly differentiated carcinoma
5% above neoplasm
5% SCC

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Light microscopy -> signet, melanin, mucin, psammoma bodies where orgiinate

Signet ring cells (favour gastric primary)
Presence of melanin (favour melanoma)
Presence of mucin is common in gut/lung/breast/endometrial cancers, less common in ovarian cancer and rare in renal cell or thyroid cancers
Presence of Psammoma bodies (calcospherites) is a feature of ovarian cancer (mucin positive) and thyroid cancer (mucin negative)

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Germ cell tumour markers

AFP, HCG, ± PLAP (placental alkaline phosphatase)

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Carcinoma tumour markers

Carcinoembryonic antigen (CEA), cytokeratin, epithelial membrane antigen (EMA)

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Neuroendocrine tumour markers

Chromogranin, Neuron-specific enolase (NSE), synaptophysin

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Thyroid cancer tumour markers

Thyroglobuylin - follicular + papillary thyroid carcinoma
Calcitonin - medullary thyroid carcinome

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Melanoma tumour markers

S-100, vimentin, & NSE

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Sarcoma tumour markers

Vimentin, Desmin, muscle-specific actin - rhabdomyosarcoma
Vimentin, Factor VIII antigen - angiosarcoma

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Glioma marker

GFAP

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Lymphoma tumour markers

CLA/CD45

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How can immunophenotyping be done

mmunohistochemical staining, immunofluorescent staining or flow cytometr

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Ways of originating cancers

Tumour markers from immunocytochemical staining
mmunophenotyping
Light miscriscopy
Electron microscopy
Histopathology

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What immunohistochemical staining s\uggests HPV positive cerical cancer

p16

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Investigations into metastatic cancer

liver and renal function tests, full blood count, chest radiography, CT of the abdomen and pelvis, and mammography in women. Depending on the clinical situation, additional studies might include sputum cytology, CT of the chest, breast ultrasonography, or gastrointestinal endoscopy.

Median survival from unknown primary metastatic cancer

8 months

Physical exams in metastatic cancer

History Palpate thyroid, breasts, lymph nodes, liver and prostate - PR exam
FIT test
Gential exam, pelvic and testes

most common sites of mets

lung, bone, lymph nodes, and liver

Cervical cancer treatemtn

Local excision using loop diathermy is performed for CIN 2/3 confined to the visible ectocervix
Loop biopsy is performed for CIN 3 with disease extending into cervical canal
Simple hysterectomy is performed for micro-invasive disease
Stage IB or 2 cervical cancers are treated by radical hysterectomy with pelvic lymphadenectomy or pelvic radiotherapy. Both methods are equally effective
Stage 2B and 3 should be treated with pelvic radiotherapy and patients treated with curative intent typically receive chemoradiotherapy with cisplatin as a radiation sensitizer
Stage 4 and recurrent disease are treated with chemotherapy. Radiotherapy can be used to treat specific site of metastasis.
Chemotherapy alone has no role in the adjuvant treatment of cervical cancer

What is neutropenic sepsis defined as

Pyrexia >38 degrees on one reading
>37.5 on 2 readings over an hour
Rigor
Unexplained hypotension or tachycardia
Neutrophil count <1 x 10^9

Initial management of neutropenic sepsis

Blood cultures - peripheral and from hickman if present
MSU, CXR swab for culture - throat, Hickman site etc
Commence empirical antibiotics - taz/gentamycin
FBC, biochem, coag screen
Keep platelets >20 x109L

Worse outcome features of neutropenic sepsis

Diarrhoea
Hypotension
Coagulopathy
Presence of more than one organ failure

10 red flag symptoms of cancer

Persistent cough or hoarseness Change in appearance of a mole Persistent chang in bowel habit Sore that doesnt heal Persistent difficulty swallowing UNexplained weight loss Persistent change in bladder habbits Unexplained lump Persistent unexplained pain Unexplained bleeding

Which tests can be useful on ascitic fluid

Albumin Amylase Cytology Glucose LDH Microscopy, culture and sensitivity pH

How is analgesia often given in cancer

Subcutaneously

What medication can improve bowel obstruction symptons ad why

Steroids - reduce inflammation and oedmea at sight

What drug can be used for nausea in bowel obstruciton and what cant

Haloperidol SC Metoclopramide CNAT use - promimetic, stimulates GI peristalsis

What is a carcinoma of unknown origin

Unique entity where a primary tumour is able to metastases before primary tumouyr large enough to be identified Malignant tumour from epithelial system of body Adenocarcinoma of uncertain origin, occult primary malgnancy

Unknown origin vs known praimary tumours

Early dissemination Clinical absence primary tumour UNpredicatble metastatic pattern Greater aggressiveness Absence of symptoms due to primary tumour

Epide miology of cancer of unknwon origin

2.3-4.5% of all cancers are from an unknown primary 8-20 patients per 100,000 population per year 7th-8th most frequent form of cancer Median age at presentation is 60 years 4th commonest cause of cancer death in both males and females 50% of patients present with multiple sites of involvement The rest have a single site: liver, bones, lungs, lymph nodes

Primary site diagnsosi

Most never found even at autospy Most frequently lung, panreas, GI and gyane

Prognostic factors cancer of unknown origin

Poorly differentiated carcinoma, SCC, neuroendocrine Lymph node involvement No. metastatic sites Female sex - men worse Performance status Weight loss >10% Serum markes eg alk phos, LDH, CEA

Approach to cancer of unkown primary

Search for primary site Rule out potnetially treatable or curable tumours CHARAVTERISE SPECIFIC CLINOPATHOLogical entity Treat th patient - favourable subset -> curative intent Unfavourable -> palleative intent

What patients should not be missed because of potential curative intent

Predominantly nodal metastases of poorly differentiated carcinomas Females with peritoneal carcinomatosis of high grade serous histological type adenocarcinoma

Common causes of transudate

Failure - heart failure Liver failure Kidney failure Thyroid failure Resp fairure - rare Meigs syndrome

Factors influencing treatment choice in metastatic cancer

Age Perfomrance status Comobidities Organ impairment Paitent priorities

What is pleurocentesis

Chest drain for pleural effusion

Staging of unknown primary cancer

Whole body PET-CT scan

What is meigs syndrome

triad of benign ovarian tumor (usually a fibroma), ascites (accumulation of fluid in the abdominal cavity), and pleural effusion (fluid around the lungs). Resecting th eovarian tumour resolves symptoms