Oncology at Al-Samawah Dr.Ofail Nadeem Alhusseiny

1. Case presentation by Dr.Ofail Alhusseiny
CARCINOMA OF UNKNOWN
PRIMARY
‫محاف‬ ‫في‬ ‫التعليمي‬ ‫الحسين‬ ‫مستشفى‬‫المثنى‬ ‫ظة‬

4. A 45 y old female pt. presented to us as referred from AlNajaf to be
having:
a multiple bone secondaries (vertebral bodies T9,L3,L4 , multiple
pelvic and skull osteolytic lesions) and diagnosed as CUP
adenocarcinoma subtype via a vertebral bone lesion biopsy , she is
chiefly complaining of severe back pain and discomfort , she has no
any chest or urinary or GIT symptoms the abdomen is soft no
hepatomegaly or splenomegaly no any tenderness she has no any
gynecological problems she is married G5P5A0 she has negative
breast exam and smooth soft bilateral thyroid lobe consistency , her
CXR is clear , CT- abdomen (with no contrast) also clear, liver is
normal, both kidneys are normal other than a benign cyst in the
right kidney. She has no family history of any cancer, not a smoker,
no previous medical diseases or admissions. She received palliative
dose RT to the affected vertebrae.

8. U/S left breast:
It is of normal size and texture
there is 0.7x0.6 cm hypoechoic
mass surrounded by compressed
breast tissue no calcification the
mass seen in the lower lateral
quadrant the picture suggestive of
ca breast further investigations
needed No axillary LAP.

14. First to think of is the major problem here (bone met. And low
S.calcium in order to avoid future pathological fractures that is
majorly due to zometa drug S/E that she already took.
So advice for calcium supplement 1000mg daily +vit.D3 400 IU
And continue on zometa .
And since the previous protocol has no any benefit and goes
with CA breast and CA Ovary Now we need to change in to a
5FU based regimen in respect for CEA levels which is
reasonable and a preferred step.
Other DDX: ???

15. MULTIPLE MYELOMA—B2-microglubulin and bence jones protein and
bone marrow biopsy for plasmacyts percent infiltration.
LUNG CANCER ---TTF1 marker.
COLON CANCER--- Proper colonoscopy.
Gastric cancer-- OGD
CERVICAL CANCER --- Colposcopy.
CA pancreas --- CA 19-9.
Thyroid cancer ---- T3,T4,TSH, calcitonin

16. WHAT IS THE MOST USEFUL TEST
TO BE DONE TO REACH SUCH AN
UNKNOWN PRIMARY?

17. •18F-FDG enhanced PET scan

18. SUMMARY ABOUT CUP

19.  5% of all cancer patients, the primary origin of the tumor cannot be
identified. Cancer of unknown primary site (CUP) ranks among the 10
most common malignancies.
 The biology of the disease is unknown, and it is not clear if CUP
represents a distinct entity with specific genetic/phenotypic aberrations.
 less than 30% of patients have a primary site identified ante-mortem.
postmortem examination reveals a putative primary site in 60% to 80%
of all patients.
 Unfortunately, the majority of patients with CUP (approximately 85%)
are not included in those favorable patient subsets.

20. CLINICAL INVESTIGATIONS
All –CUP- patients should have :
1- A careful history taken.
2- Undergo a complete physical examination including head and neck, pelvic,
and rectal examination.
3-Routine laboratory evaluation (blood counts and chemistry profile), urine
analysis, and fecal occult blood test, although routine laboratory evaluation
seldom shows any characteristic abnormalities in this group of patients

21.  Radiological Studies
 Using CT scans of the abdomen and pelvis, a primary tumor can be
detected in 30% to 35% of patients.
 A CT scan of the thorax is also relevant in CUP patients, because lung
cancer is one of the most common primary tumors identified in patients
with CUP.
 In addition, CT scans can also be helpful in determining the extent of
metastatic disease. Contrast enhanced CT scan of thorax, abdomen, and
pelvis therefore constitutes the standard evaluation recommended in
patients with CUP.

22. Endoscopic examinations
Should be performed only in patients with specific symptoms or signs.
For example, patients with abdominal symptoms or occult blood in the
stool should undergo endoscopic examination of the gastrointestinal
tract.

23. Applied serological markers
PSA = Ca Prostate.
CA125= Ca Ovary.
CA 153= Ca breast.
CEA= GIT origin tumors and medullary thyroid carcinoma.
TTF1= Lung cancer.
AFP and beta-HCG = Germ cell tumors.
CA 19-9= Ca pancreas.

24. Histology and Immunohistochemistry
Pathologic evaluation has been reported to be the most specific and cost-
effective method to determine type and origin of CUP.
The overall dominant morphological pattern of CUP is:
1- Adenocarcinoma (50–70%).
2- Poorly differentiated carcinoma (15–20%).
3- Squamous cell carcinoma.
4- Undifferentiated malignant tumor.
5- Neuroendocrine carcinoma (each 5%).
The major problem is to distinguish between different specific types of
adenocarcinomas and undifferentiated carcinomas.

25. The primary site of metastatic adenocarcinoma is most frequently the
breast, colon, lung, ovary, pancreas, prostate, and stomach, with a high
representation of lung and pancreatic tumors.
Undifferentiated tumors include mostly: lymphomas, germ-cell and
neuroendocrine tumors.

26. For patients without an identified treatable primary tumor the use of empirical
chemotherapy using current drugs and schedules should be a matter of frank
discussion between patient and physician and there is no standard protocol.
Evaluation of performance status is important and for those who will be eligible for
chemotherapy a median survival of 7 to 12 months can be obtained, with 25% to
45% of the treated patients alive after one year from the time of diagnosis.
Survival rates at two years are around 5% to 20% compared with a median survival
of 2 - 3 months in an untreated population with unknown primary tumors.