Carcinoma of unknown primary
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Target Audience: Oncology fellows and Oncologists Carcinoma of unknown primary is a challenging scenario often encountered in Oncology practice. This slide presentation discusses favorable and unfavorable presentations of CUP and it's management
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Carcinoma of unknown primary
- 1. CARCINOMA OF UNKNOWN PRIMARY Target Audience: Oncologists, Oncology Fellows Archer Board Reviews www.CcsWorkshop.com
- 18. Pathology
- 22. Immunohistochemistry - Cytokeratins (CKs)
- 24. Immunohistochemistry Other Markers Tissue Marker Diagnosis TTF-1 Lung, Thyroid CDX-2 GI tract Gross Cystic Disease Fibrous Protein 15 (GCDFP) Breast ER, PR Breast BRST1 Breast Thyroglobulin Thyroid cancer PSA Prostate cancer Calretinin, Mesothelin Mesothelioma Chromogranin, Synaptophysin, Neuron specific enolase Neuroendocrine cancer URO III, thrombomodulin Urothelial Ca/ Bladder Ca Beta-HCG Germ cell tumor Alpha-Feto-protein HCC, germ cell tumor S-100, HMB 45 Melanoma Leucocyte common antigen Lymphoma
- 25. CUP Imaging
- 26. Imaging Studies in CUP Imaging Diagnostic Value Chest X-Ray Pre-Requisite test CT chest/ abdomen/ pelvis 40% accuracy/ guidance to biopsy Mammogram Low sensitivity MRI ( breast) 60% accuracy Barium Studies Not Useful PET/CT scan Useful in certain situations
- 28. CUP Endoscopy
- 31. How often can the Primary be Identified?
- 39. Poorly differentiated carcinoma with midline distribution ( Extra-gonadal germ cell syndrome) Favorable subset
- 41. Women with papillary adenocarcinoma of peritoneal cavity (Peritoneal adeno-carcinomatosis/ papillary) Favorable subset
- 45. Isolated Axillary Nodal Adeno-carcinoma in women Favorable subset
- 48. Chemotherapy followed by hormone therapy where indicated
- 49. Squamous cell carcinoma involving cervical lymph nodes Favorable Subset
- 55. Neuroendocrine Carcinoma of Unknown Primary Favorable Subset
- 80. Extra slides for use
Notas do Editor
- "carcinoma" is tumor tissue derived from putative epithelial cells
- "carcinoma" is tumor tissue derived from putative epithelial cells
- "carcinoma" is tumor tissue derived from putative epithelial cells
- Caveat 1. Especially, in poorly or undifferentiated tumors – staining patterns can be very abnormal… ….some poorly differentiated carcinomas lose all specific markers and are negative for keratin markers as well.
- Antibodies to intermediate filament proteins (vimentin, keratin, and desmin) are also useful to distinguish between lymphoma and other neoplasms. LYMPHOMAS can be positive for vimentin but are negative for keratin and desmin. keratin – CHARECTERESTIC FOR for benign and malignant epithelial tissue ( CARCINOMA) respectively . Desmin is charecterestic for muscular tissues ( sarcoma) However, none of these staining patterns are completely specific for antbroad type of cancer….… some sarcomas can stain for keratin and some carcinomas may stain for vimentin. Conversely, some poorly differentiated carcinomas lose all specific markers and are negative for keratin markers also!!!
- Caveat 1. Especially, in poorly or undifferentiated tumors – staining patterns can be very abnormal…
- Caveat 1. Especially, in poorly or undifferentiated tumors – staining patterns can be very abnormal…
- Caveat 1. Especially, in poorly or undifferentiated tumors – staining patterns can be very abnormal…
- Caveat 1. Especially, in poorly or undifferentiated tumors – staining patterns can be very abnormal…
- Persistent cough/ hemoptyisis, cxr showing mass etc – bronchoscopy Colonoscopy when altered bowel movements, constipation, rectal bleeding, iron deficiency anemia
- This slide is for Poorly differentiated CUP with midline distribution Men with poorly differentiated carcinoma of midline distribution : Extragonadal germ cell tumors Patients typically have some of the following characteristics Young age Male gender Predominant tumor location in the mediastinum or retroperitoneum Marked elevation of the serum tumor markers hCG or AFP Presence of 12p chromosomal gain (isochromosome 12p) on molecular genetic analysis Tumor immunohistochemical staining for octamer binding transcription factor 4 (also called POU domain class 5 transcription factor). Responsive to Cisplatin-based chemotherapy (BEP) .
- Outcomes are similar to ovarian cancer at equivalent stage. Respond well to chemotherapy regimens that are effective in the treatment of advanced epithelial ovarian cancer. Taxane/platinum regimens have proven superior for advanced ovarian cancer and should be the treatment of choice for these patients. For bulky disease surgical debulking followed by chemotherapy .
- MAMMO / MRI if +ve for lump – go with standard treatment. If negative for lump , go with complete ALND + ipsilateral mastectomy or complete ALND/ Whole breast radiation . This followed by chemotherapy. Chemotherapy followed by hormone therapy where indicated. Post-mastectomy radiation is indicated if more than 5 axillary nodes test positive.
- Regional lymph nodes (N)NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node involvement. N1: Unilateral metastasis in lymph node(s), ≤ 6 cm in greatest dimension, above the supraclavicular fossa N2: Bilateral metastasis in lymph node(s), ≤ 6 cm in greatest dimension, above the supraclavicular fossa N3: Metastasis in lymph node(s) > 6 cm and/or to supraclavicular fossa N3a: >6 cm N3b: Extension to the supraclavicular fossa
- Regional lymph nodes (N)NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node involvement. N1: Unilateral metastasis in lymph node(s), ≤ 6 cm in greatest dimension, above the supraclavicular fossa N2: Bilateral metastasis in lymph node(s), ≤ 6 cm in greatest dimension, above the supraclavicular fossa N3: Metastasis in lymph node(s) > 6 cm and/or to supraclavicular fossa N3a: >6 cm N3b: Extension to the supraclavicular fossa