Carcinoma of unknown Primary

Question 1

Peritoneal seedlings (metastases) arise from which form of spread?
How about liver and lung metastasis?

Answer 1

Peritoneal seedlings arise from transcoelomic spread, whereas lung and liver metastasis arise through blood-borne spread of malignant cells.

Question 2

Pruritus in a patient with suspected malignant disease can be caused by?

Answer 2

Obstructive jaundice, uraemia, Hodgkin’s disease, allergy, dermatitis, neuropathy or drug reactions (often with opiates)

Question 3

List the adverse prognostic factors

Answer 3

Adenocarcinoma histology
Increasing number of involved organ sites
Hepatic or adrenal involvement, metastasis to bone, liver or adrenal glands.
Supraclavicular lymph node involvement
Male gender
Poor performance status
Weight loss (>10% of body mass)

Question 4

How is known primary tumours different from carcinoma of unknown primary?

Answer 4

Features distinguishing CUP from known primary tumours:

• early dissemination
• unpredictable pattern of metastasis
• aggressiveness
• Clinical absence of primary tumour
• absence of symptoms due to primary tumour

Question 5

50% of patients with CUP have multiple sites of metastasis, the rest having single sites. What sites are common?

Answer 5

Liver
Bone
Lung
Lymph nodes

Question 6

What are the cytology grades in cancer? Describe

Answer 6

C1-5
C1 - Sample inadequate for grading
C2 - Normal cells
C3 - Abnormal cells, but likely to be benign
C4 - highly suspicious of cancer
C5 - malignant cells

Question 7

What are the presenting features of pleural effusion?

Answer 7

Tachypnoea
Reduced expansion
Mediastinum shifted away (could also be normal)
Dull percussion - don’t say stony dull which points towards consolidation
Breath sounds - absent or reduced
Air entry - reduced
Bronchial breathing above level of effusion - aegophony
Whispering pectoriloquy
May have pleural rub above fluid

Question 8

What is used to classify Carcinoma or Unknown Primary?

Answer 8

Light microscopy.

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

Question 9

What are the findings indicating an empyema in a pleural fluid aspirate?

Answer 9

Empyema is an exudate with low pH (<7.2) and low glucose.

Question 10

What can cause confusion in someone with malignancy?

Answer 10

Hypercalcaemia (a medical emergency) or brain metastases.

Question 11

What is the most common metabolic complication of malignancy?

Answer 11

Hypercalcaemia.

It gives a poor prognosis

Question 12

Which cancers are the most common causes of Hypercalcaemia?

Answer 12

Breast, Lung (especially NSCLC - Squamous cell carcinoma) and multiple myeloma