Carcinoma of Unknown Primary Site
- Carcinomas of unknown primary site (CUPS) (fig121) account for up to 3% of neoplasm's
primary proved to be Lymphoma
- Common sites of presentation include nodes, liver, bone and lung.
- There may be a single affected node with no evident source of the tumour even after
biopsy with no evidence of residual tumour once the node is removed.
- Usually there is widespread metastatic disease.
- Patients with tumours categorized as 'poorly differentiated or undifferentiated neoplasm's' form an important subgroup: a proportion of them will have a NHL, which may be curable with the correct chemotherapy.
Estimation of tumour types
Adenocarcinoma specific subgroup
Poorly differentiated carcinoma: lymphoma, melanoma, sarcoma
SCC head &neck tumours
- Symptoms related to tumour such as easy fatigability and non-specific pain.
- Full history and
- Clinical examination including pelvis, rectum
- Nasopharyngeal space (for SCC cervical node)
- Chemistry, and complete metastatic work up as: CT scan chest, abdomen and pelvis.
- Adequate biopsy of malignant tissue (not simple FNA) with immunohistochemistry-chromosomal analysis in biopsies
- May be specific to a good number of malignancies
- Mammogram in women > 45 years
- Endoscopy, colonoscopy (adenocarcinoma) and tumour
without the exception of PSA
- May give an indication of possible primary site but rarely definitive:
- Free, Total and Ratio PSA
- CEA (lung / colon)
- CA125 (80% of ovarian tumours)
- BHCG (germ cell)
- AFP (germ cell / hepatocellular carcinoma)
- CA19.9 (pancreas)
Since there is no cure, then treat symptomatically: Radiotherapy to painful bone
Steroids to improve a sense of well being and appetite, analgesics, etc. However, postmenopausal women with adenocarcinoma may respond to tamoxifen and radiotherapy
if primary tumour originates in the breast.
Observation until primary is known
Non-SCC the commonest tumours are lung, colon, prostate and breast.
- On this basis 5-fluorouracil is an appropriate drug to include in a regimen
Axillary nodes may arise from an occult breast primary, or Supracalvicular
Lymph node metastasis from ca. breast before and after treatment
(Fig 29a, 29,b).
- Axillary clearance for control of nodal disease.
- A trial of hormone therapy for prostate cancer may be successful.
Squamous Cell Carcinoma
Neck nodes may respond well to radical neck dissection +/- radiotherapy, with up to 50% 5-year survival.
Inguinal nodes may arise from anal carcinoma.
- Locoregional surgery +/- postoperative radiotherapy
wgich may be curative.
Overall grave prognosis
Malignant Neck Node
(fig 12, table 13)
Malignant lymph node in the neck from an unknown primary
- Search for Head & Neck malignancies, thyroid
ENT examination. special attention should be given to Nasopharynx, oropharynx, larynx,(fig 25,26)-Chest (? Pancoast's tumour) (fig24)
huge lymphadenopathy from papillary thyroid carcinoma
- Neck node metastasis from lung carcinoma
- Abdomen (Virchow's node)
- Testes (Testicular tumour)
- Other lymph node sites (Lymphoma) (fig 26,27,28)
- Melanomas,(fig 132) floor of the mouth, lips, A advanced SCC of the orbit (Eye) ,Thyroid ( fig 26)
in the left cervical region before and after RT, results were
FNAC(Fine Needle Aspiration Cytology) of lymph node or Open biopsy usually gives very good information that may lead to the primary crcinoma.
Do tests according to the results of biopsies
- If SCC
- 'blind' biopsy of Nasopharynx
- Adenocarcinoma-gastroscopy, abdominal ultrasound, abdominal CT, colonoscopy, laparoscopy
- Melanoma-may have a regressed primary, but look for other metastases on CXR, liver ultrasound
- Tumour marker analysis