Re: [MOL] CUP Series Part 1 [03385] Medicine On Line


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Re: [MOL] CUP Series Part 1



Marty:  Did part 2 of this series come accross the mol line?  I knew this
was Barbs problem.  I try to find something for everyone at some point.
Take care and let me know.  Your friend, lillian


-----Original Message-----
From: Martin Auslander <fitecancer@earthlink.net>
To: mol-cancer@lists.meds.com <mol-cancer@lists.meds.com>
Date: Friday, February 26, 1999 10:26 AM
Subject: Re: [MOL] CUP Series Part 1


>DEar Lil,
>
>This information is very useful as you know my Barb is in that category,
>CUP, carcinoma of an unknown primary. Thank you. I believe there are
>others here who fall into that category. May I add, while the syndrome
>accounts for 3-5% of all cancers diagnosis, there is much hope that we
>should believe as well, that there are many treatments and drugs
>available. The key is to get the metastasis under control. In many cases
>the primary tumor over a period of time disappears. The essential
>treatment is in curing or controlling the metastais. Thank you again for
>this information.
>
>God Bless
>marty auslander
>
>> firefly wrote:
>>
>> Abstract
>>
>> Carcinoma of unknown primary site is a common clinical syndrome and
>> accounts for 3%-5 % of all cancer diagnoses. In addition to physical
>> examination, routine laboratory tests, and chest radiograph, patient
>> work-up should include computerized tomography of the abdomen and
>> directed evaluation based upon signs and symptoms. Routine
>> radiographic or endoscopic evaluation of asymptomatic areas is
>> unrewarding. A number of patient subsets with specific treatment
>> implications can be identified on the basis of clinical and pathologic
>> features. Identification and treatment of these subsets (totaling
>> approximately 40% of all patients with unknown primary tumors) is
>> detailed in this article. For the remainder of patients, empiric
>> chemotherapy is indicated unless performance status is poor. Recent
>> experience with taxane-containing regimens suggests higher response
>> rates and modest prolongation of survival. Ongoing trials are
>> evaluating other new antineoplastic agents, in hopes of further
>> improving therapy.
>>
>> Introduction
>>
>> Cancer of unknown primary site is a common clinical syndrome,
>> accounting for approximately 5% of all cancer diagnoses. Patients
>> usually arrive at medical attention due to systemic symptoms or
>> specific symptoms resulting from one or more sites of metastatic
>> involvement; they should be considered to have cancer of unknown
>> primary site after standard evaluation fails to identify the primary
>> tumor site. Since most patients with cancer of unknown primary site
>> have epithelial malignancy, the incidence of this syndrome increases
>> with age, and the most common histologic diagnosis is adenocarcinoma.
>>
>> Although this syndrome is relatively common, little attention has been
>> given to improving therapy. This results in part from widespread
>> nihilism regarding the prognosis of these patients. In addition, early
>> attempts at systemic therapy yielded low response rates and had
>> negligible effect on survival. However, it is now clear that this is a
>> heterogeneous group of patients, and contains subsets of patients who
>> benefit from specific treatment. Many of these patients can be
>> identified using clinical and pathologic criteria, and require
>> specific therapy. In the remaining patients who do not fit into any
>> specific "treatable subset," recent empiric therapies incorporating
>> new chemotherapeutic agents have yielded encouraging results, with
>> early reports indicating higher response rates and improved survival.
>>
>> In this review, the recommended clinical and pathologic evaluation of
>> the patient with cancer of unknown primary site is detailed.
>> Recommended treatment of specific subsets, as well as the evolving
>> role of empiric treatment for patients who do not fit into any
>> specific subset, are also discussed.
>>
>> Initial Diagnosis and Staging
>>
>> The typical patient with cancer of unknown primary site develops
>> symptoms at a metastatic site, and comes to the attention of the
>> medical oncologist after a biopsy has established a diagnosis of
>> metastatic cancer. All patients presenting with metastatic carcinoma
>> of unknown primary site should have a limited routine workup including
>> a thorough history, physical examination, complete blood counts,
>> chemistry profile, and chest radiograph. Localized symptoms should be
>> evaluated by directed radiologic or endoscopic procedures. In
>> addition, computerized tomography of the abdomen can identify a
>> primary site in 10% to 35% of patients, and is frequently useful in
>> identifying additional sites of metastatic disease.[1,2]
>>
>> Diagnostic Evaluation -- Generalized Approach
>>
>> Although overlap exists, subsequent clinical evaluation and treatment
>> is dictated by the results of the initial light microscopic diagnosis.
>> The four common histologic diagnoses are: adenocarcinoma (70%), poorly
>> differentiated carcinoma (20%), squamous carcinoma (10%), and poorly
>> differentiated neoplasm (5%).[3] Each of these four initial diagnoses
>> requires slightly different clinical and pathologic evaluations.
>>
>> If the histologic diagnosis is adenocarcinoma or poorly differentiated
>> carcinoma, additional diagnostic tests should be performed in certain
>> subsets. Men with bone metastases should have serum prostate specific
>> antigen (PSA) levels measured.[4] Women with clinical presentations
>> compatible with metastatic breast cancer should have mammography
>> performed. Men who are less than 50 years old with poorly
>> differentiated carcinoma should have measurement of serum human
>> chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels. If
>> the tumor is located in the mediastinum, retroperitoneum, or lymph
>> nodes, measurement of these serum tumor markers should be considered
>> in men older than 50 with poorly differentiated carcinoma, but the
>> clinical utility in this group is still controversial.[4] In patients
>> with squamous carcinoma, additional evaluation is often necessary.
>> Metastatic squamous cancer is most commonly found in cervical lymph
>> nodes. In these patients, a primary site in the head and neck region
>> is most probable, and direct endoscopic visualization of the entire
>> area (oropharynx, nasopharynx, hypopharynx, larynx) reveals a primary
>> site in the majority. In patients who have squamous cancer metastatic
>> to inguinal lymph nodes, careful evaluation of the perineal areas
>> (cervix, vagina, vulva, anus, rectum, penis) is required.
>>
>> What Not To Do
>>
>> Extensive radiologic evaluation of asymptomatic areas is rarely useful
>> in identifying a primary site, and often results in confusing or
>> false-positive information.[5] Endoscopy of the gastrointestinal tract
>> is also of low yield in asymptomatic patients, although small, occult
>> primary sites are occasionally identified.[5] These expensive tests
>> should therefore be avoided in asymptomatic patients. Similarly,
>> routine tumor markers (CEA, CA19-9, CA125, CA27-29) are non-specific
>> and should not be used to infer a primary site in this patient group.
>> If no primary site is identified by the above clinical evaluation, the
>> clinician should avoid the temptation to "guess" at a primary site
>> based on a suggestive clinical presentation. Rather, the patient
>> should be treated using guidelines for carcinoma of unknown primary
>> site.
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