Cancer of unknown origin Flashcards
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)
Investigations for SCC in inguinal nodes
Careful exmination of legs, vulva, penis, perneum for primary tumour
Pelvic exam
Protoscopy/colposcopy
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
Overall unknown primaries type of cell cancer
60% adenocarcinoma
30% poorly differentiated carcinoma
5% above neoplasm
5% SCC
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)
Germ cell tumour markers
AFP, HCG, ± PLAP (placental alkaline phosphatase)
Carcinoma tumour markers
Carcinoembryonic antigen (CEA), cytokeratin, epithelial membrane antigen (EMA)
Neuroendocrine tumour markers
Chromogranin, Neuron-specific enolase (NSE), synaptophysin
Thyroid cancer tumour markers
Thyroglobuylin - follicular + papillary thyroid carcinoma
Calcitonin - medullary thyroid carcinome
Melanoma tumour markers
S-100, vimentin, & NSE
Sarcoma tumour markers
Vimentin, Desmin, muscle-specific actin - rhabdomyosarcoma
Vimentin, Factor VIII antigen - angiosarcoma
Glioma marker
GFAP
Lymphoma tumour markers
CLA/CD45
How can immunophenotyping be done
mmunohistochemical staining, immunofluorescent staining or flow cytometr
Ways of originating cancers
Tumour markers from immunocytochemical staining
mmunophenotyping
Light miscriscopy
Electron microscopy
Histopathology
What immunohistochemical staining s\uggests HPV positive cerical cancer
p16
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
