Unknown primary adenocarcinoma: incidence of overinvestigation and natural history

Metastases of unknown primary site

Despite the fact that effective therapy does not currently exist for the majority of patients presenting with metastases of unknown primary site, the last decade has witnessed significant advances in the approach to this heterogeneous disease. The use of modern pathologic techniques that frequently provide better diagnostic precision and the recognition of specific subgroups with a favorable prognosis and responsiveness to treatment has improved the outcome for some patients. Currently the diagnostic strategy should emphasize the rapid identification of patients likely to benefit from available therapy, whereas clinical research should focus on the development of more effective treatments for those patients with unresponsive tumors. In the future, continued improvements in the molecular characterization of these tumors will likely enhance understanding of the metastatic process, allow for more specific definitions of cell lineage, and provide insights for better therapy.

Evaluation of six tumor markers in patients with carcinoma of unknown primary

We have retrospectively evaluated six serum tumor markers in 85 patients with carcinoma of unknown primary. The serum levels of carcinoembryonic antigen (CEA), CA 19-9, CA 15-3, CA 125, beta-chorionic gonadotropin (beta-HCG) and alpha-fetoprotein (AFP) were related with the histological pattern (undifferentiated carcinoma or adenocarcinoma), the number and the site of metastases, as well as the response to chemotherapy and the patients' survival. More than 40% of the patients had increased serum levels of all six tumor markers, except of AFP which was found to be increased in only 17% of them. Increased levels of CA 19-9 were related to metastatic adenocarcinoma, whereas CA 19-9 and CA 15-3 had a relationship with more advanced disease. Patients with liver involvement had higher mean levels of CEA and CA 19-9 as compared to those with nodal disease. None of these markers was found to have a predictive value for response to chemotherapy or survival. Although the present study has a retrospective nature, it allows us to conclude that patients with CUP have a nonspecific over-expression of the above serum tumor markers and that routine use of these markers does not offer any diagnostic or prognostic assistance.

Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy

We carried out a prospective study of the effectiveness of a diagnostic strategy in forty consecutively seen patients who had skeletal metastases of unknown origin. The diagnostic strategy consisted of the recording of a medical history; physical examination; routine laboratory analysis; plain radiography of the involved bone and the chest; whole-body technetium-99m-phosphonate bone scintigraphy; and computed tomography of the chest, abdomen, and pelvis. After this evaluation, a biopsy of the most accessible osseous lesion was done. The laboratory values were non-specific in all patients. The history and physical examination revealed the occult primary site of the malignant tumor in three patients (8 per cent): one patient who had carcinoma of the breast; one, of the kidney; and one, of the bladder. Plain radiographs of the chest established the diagnosis of carcinoma of the lung in seventeen patients (43 per cent). Computed tomography of the chest identified an additional six primary carcinomas of the lung (15 per cent). Computed tomography of the abdomen and pelvis established the diagnosis in five patients (13 per cent): three patients who had carcinoma of the kidney; one, carcinoma of the liver; and one, carcinoma of the colon. Examination of the biopsy tissue established the diagnosis in only three additional patients (8 per cent) and confirmed it in eleven others. On the basis of the biopsy alone, we were unable to identify the primary site of the malignant tumor in twenty-six (65 per cent) of the patients. In thirty-four (85 per cent) of the forty patients, the primary site was identified with the use of the diagnostic strategy described here, and only two additional occult malignant tumors were found on follow-up studies. Our diagnostic strategy was simple and highly successful for the identification of the site of an occult malignant tumor before biopsy in patients who had skeletal metastases of unknown origin.

Diagnostic strategy for bone and soft-tissue tumors

The diagnostic strategy to be used for a bone tumor depends on the ability of the clinician to make an accurate differential diagnosis on the basis of clinical information and plain radiographs. The clinician must be able to classify the patient as having a non-progressive or a progressive primary benign bone tumor, a primary malignant bone tumor, or a metastatic bone tumor. Only after assignment to one of these four categories can an effective diagnostic strategy ensue. If the clinical and radiographic information favors a diagnosis of malignant or aggressive benign bone tumor, the clinician should refer the patient to an experienced orthopaedic oncologist without performing additional diagnostic tests or a biopsy. If a soft-tissue mass is five centimeters in diameter or larger on physical examination, and especially if it is deep to the fascia, the patient should also be referred to an orthopaedic oncologist, without additional evaluation or biopsy, because of the relatively high probability that the mass is malignant.

Skeletal metastasis from occult carcinoma

We reviewed 177 patients with skeletal metastases, seen between 1984 and 1989, to define the characteristics of metastatic bone disease from an occult primary carcinoma. In 52 (30%) patients, the primary carcinomas could not be identified when the bone metastases were first diagnosed. This group was predominantly male, with intractable pain the most common symptom. The primary tumors were identified on antemortem evaluation in 28 (54%) patients after extensive examination. Among these, the primary tumor was in the lung in 9 patients, followed by liver (8), kidney (5), prostate (3), thyroid gland (2), and rectum (1). The identifiable occult malignancies possessed three common features: all were osteophilic tumors, all had a high incidence in the specific geographic area, and all were not amenable to early detection. The mean survival of these patients was 11 months. Current treatment modalities failed to affect the course of these patients, except for those with primary carcinomas of the kidney and prostate. This observation attests to our limitations in both the diagnosis and treatment of this problem. Efforts should be directed primarily toward excluding those common and/or treatable tumors only.

Subsets of tumors responsive to cisplatin or carboplatin combinations in patients with carcinoma of unknown primary site. A Hellenic Cooperative Oncology Group Study

In this retrospective analysis 48 patients with metastatic undifferentiated carcinoma, adenocarcinoma and epidermoid carcinoma of unknown origin were studied. The purpose of this analysis was to evaluate both the response rate and the toxicity of combination chemotherapy containing cisplatin or carboplatin, and to attempt to identify certain clinical subsets of patients sensitive to these drugs. Four patients were not evaluable and 13 (29.5%), eight of the 34 treated with regimens containing cisplatin and 5/14 with carboplatin-based chemotherapy, responded to treatment. Six of the 23 with undifferentiated tumours, 4/17 with adenocarcinomas and 3/8 with epidermoid cancers responded to chemotherapy. Four of 6 women with adenocarcinoma of the peritoneal cavity, 5/11 with undifferentiated carcinomas with midline distribution and 3/5 with epidermoid carcinomas of the cervical nodes responded. Seven patients achieved complete and six partial remissions. The mean duration of response was nine months; a number of patients enjoyed prolonged and/or durable remissions. Toxicity was tolerable. We conclude that: (a) both cisplatin and carboplatin are active agents in this syndrome with one-third of the evaluable patients responding, and (b) there may be chemosensitive subgroups, such as patients with peritoneal adenocarcinomatosis, undifferentiated carcinoma with midline distribution and metastatic epidermoid carcinoma of the neck nodes. The effectiveness of carboplatin in these patients and the responsiveness of metastatic epidermoid carcinoma of unknown origin have not been adequately dealt with in the literature.

Evaluation, prognosis, and medical treatment considerations of metastatic bone tumors

Metastatic cancer can cause severe pain and disability. Metastases can occur in any bone, but usually are located in the axial or proximal appendicular skeleton. The most frequently encountered primary tumors that spread to bone are those of the prostate, breast, kidney, lung, and thyroid. When the origin of the primary cancer is known, skeletal metastases are more often from breast or prostate. When the primary site is unknown, the lung and kidney should be suspected as sites of origin. The nonoperative management of skeletal metastases from multiple myeloma and from carcinomas of the prostate, breast, kidney, lung, and thyroid are discussed.

Monarthritis: an unusual presentation of renal cell carcinoma

Two cases of acute monarthritis secondary to asymptomatic renal cell carcinoma are described. This association has not previously been reported. The patients were initially thought to have a septic arthritis, but hot spots were seen on isotope bone scans and biopsy samples showed secondary neoplasms, which were later confirmed to be a result of renal cell carcinomas. The value of cytological examination of synovial fluid when there is clinical doubt as to the cause of a joint effusion is shown.

Phase II trial of cisplatin for adenocarcinoma of unknown primary site. IKZ/IKO Clinical Research Group

The activity of cisplatin against advanced metastatic adenocarcinoma of unknown primary site (ACUP) was evaluated in 21 patients. Cisplatin (100 mg/m2) was given as a 4-h continuous infusion every 3 weeks, with appropriate fluids and diuretics. The overall response rate was 19% with 1 complete remission for 12 months and 3 partial remissions lasting from 4 to 7 months. 7 patients achieved stable disease and in 9 patients the disease was progressive. The median duration of response was 6.5 months. The median survival 7.5 months. The median survival of the total patient group was 5 months (range 1-18 months). Toxicity comprised mainly nausea and vomiting, mild creatinine elevation and leukocytopenia. Slight ototoxicity was observed in 6 patients.

Metastatic tumors of unknown origin

The clinical appearance of metastatic lesions without an obvious primary source for the tumor is a common event. Tumor Registry figures and epidemiologic data grossly understate the actual frequency of unknown primaries, because primary sites are often "assigned" to patients on a best-guess basis without positive proof of a tumor's origin. In the majority of patients whose primary tumors have continued to elude detection, the extensive use of diagnostic imaging studies fails to produce information that alters the patients' clinical course. Rare exceptions will be cited, but these exceptions prove the general rule. Imaging studies should therefore be targeted for selected patients with disseminated malignancies in whom identification of their primary tumors could benefit quality of life or length of survival.

Pericardiocentesis for symptomatic malignant pericardial effusion: a study of 36 patients

We reviewed 36 cases of symptomatic malignant pericardial effusion managed with pericardiocentesis at our institution from 1982 to 1989. There were 13 men and 23 women, aged 49 +/- 12 years (range, 33-76 years). The commonest underlying tumours were lung cancer (12 cases, 33%) and breast cancer (11 cases, 30%). Pericardiocentesis was successful as the initial management in 34 of 36 patients (94%); one patient died as a result of the procedure and another required subxiphoid incision and tube drainage of the effusion. When intrapericardial sclerotherapy was performed, only three of 28 patients required repeat pericardiocentesis, and when sclerotherapy was not performed initially, four of seven patients had recurrent symptomatic effusions. Median survival following pericardiocentesis in breast cancer patients was 10 months (range, 0-36 months) and in all other malignancies was four months (range, 0-12 months). We conclude that pericardiocentesis with intrapericardial sclerotherapy provides good local control for symptomatic malignant pericardial effusion in the majority of patients. In spite of this, the median survival of such patients is poor, especially in patients with malignancies other than breast cancer, with few patients surviving more than a few months.

Empiric chemotherapy in patients with carcinoma of unknown primary site

Analysis of the results of chemotherapy in patients with carcinoma of unknown primary site is complicated by the small sizes of most treatment series and patient heterogeneity. Careful evaluation of clinical and pathologic information may identify patients with a relatively high likelihood of response to systemic therapy. This includes patients in whom immunohistochemical studies or electron microscopy, or both, suggest a likely tumor type responsive to systemic therapy, such as prostate cancer, lymphoma, or a neuroendocrine tumor. Clinical evaluation can also identify potentially responsive patients, particularly those with clinical features in common with the extragonadal germ cell tumor syndrome. For patients who do not fit into these more treatable categories, most combination chemotherapy programs have response rates of less than 30% and median survivals of less than one year. Randomized trials have not established any clearly superior chemotherapy program. Regimens containing both Adriamycin (doxorubicin) and mitomycin-C produce response rates of approximately 25% but are associated with the possibility of severe hematologic toxicity, and rarely a syndrome resembling the hemolytic-uremic syndrome. The choice between chemotherapy and supportive care only must be individualized, and the latter option is appropriate for many patients. More detailed clinical and pathologic analyses in conjunction with clinical trials, particularly employing newer diagnostic techniques, are vital to provide better prospective data from which to identify relevant clinical subsets that allow an estimate of an individual patient's likelihood of response and the suitability of systemic chemotherapy.

Carcinoma of unknown primary: identification of a treatable subset?

We initiated a phase II study with combination chemotherapy consisting of cisplatin, etoposide and bleomycin in a subset of patients with carcinomas of unknown primary site characterized by the presence of at least one of the following criteria: 1) age below 50 years; 2) clinical evidence of rapid tumour growth; 3) tumour located predominantly in a midline distribution; 4) good response to previous administered radiotherapy. In 34 evaluable patients an objective response rate of 53% (95% confidence limits 35%-70%) was achieved. For patients with poorly differentiated adenocarcinomas the response rate was 35%, and, in most instances, of short duration. A response rate of 79% including complete responses and long-term survivals was achieved in patients with undifferentiated carcinomas. This difference in response rate was statistically significant (p = 0.02). No supplementary prognostic factors predicting response to chemotherapy could be identified. One patient with an initial diagnosis of undifferentiated carcinoma proved to have a malignant lymphoma after additional immunohistochemical investigation. Until a better characterization of this syndrome is possible patients with undifferentiated carcinomas of unknown primary site should be challenged with cisplatin-based chemotherapy.

Diagnostic value of serum tumor markers in skeletal metastasis of carcinomas

Levels of serum tumor markers including tissue polypeptide antigen (TPA), CA 15-3, CA 19-9, squamous cell carcinoma antigen, carcinoembryonic antigen, alpha-fetoprotein, and PAP were measured in 26 patients with bone metastasis and in 9 patients with primary bone tumors. More than one markers was elevated in 19 of the 26 patients with bone metastasis, although there was no elevation of the markers in 3 patients with renal cell carcinoma. TPA was the most sensitive marker in the diagnosis of metastasis. CA 15-3 was also a sensitive marker in this study, since metastasis from breast carcinoma may be the most common of all metastases in the skeleton. On the other hand, alpha-fetoprotein was uniformly unresponsive except in one case of gastric cancer. Combinations of markers are valuable for metastasis screening tests. No definite correlations were found between the markers in this study. On the other hand, there was a slight elevation of the markers observed in two of the nine patients with primary bone lesions. Serum tumor markers are useful in the diagnosis of bone metastasis to differentiate it from primary bone lesions. Especially in solitary bone lesions, serum markers may be the only way to make a differential diagnosis between the two.

Fluorouracil, doxorubicin, cisplatin and altretamine in the treatment of metastatic carcinoma of unknown primary

Eighty-five patients, median age 55 years, with evolutive metastatic carcinoma of unknown primary (CUP) were included in this study. The treatment combination consisted of fluorouracil (5-FU) (600 mg/m2 in a 30 min infusion) days 1 and 8, doxorubicin (DXR) (30 mg/m2 by i.v. bolus injection) day 1 and cisplatin (CDDP) (80 mg/m2 in a 4-h infusion) day 1. Altretamine (HMM) (150 mg/m2) was administered orally days 2-8, therapy being resumed every 29 days. An objective response was noted in 18/85 patients (21%) with a median duration of response of 7 months. Thirty-three/77 patients (43%) who had tumor-related symptoms were relieved of their troubles. The overall median survival of patients was 7 months; the median survival of responders was 12.5 months. Toxicity occurred in one-third of patients (mainly digestive and hematologic), leading twice to a halt in treatment and to drug dose reduction in 26/77 (33%) evaluable patients. Such a regimen is of limited efficacy, has a non-negligible toxicity and appears of little interest in such a palliative situation.

Rhabdomyosarcoma, presenting as disseminated malignancy from an unknown primary site: a retrospective study of ten pediatric cases

From 1962-1984, ten children were referred to St. Jude Children's Hospital with a metastatic poorly differentiated malignancy; extensive diagnostic workup had failed to disclose the site of the primary tumor. Multiple skeletal metastases as well as bone marrow involvement were common findings. Erythrocytes were detected in the cytoplasm of tumor cells in several cases, and cytochemical stains confirmed that these phagocytic cells did not have features of mononuclear phagocytes. Establishing a pathologic diagnosis in these cases was difficult, and most special studies including cytochemistry and electron microscopy were not helpful in elucidating the diagnosis. A diagnosis of rhabdomyosarcoma was made at presentation in six cases. In the remaining cases, the diagnosis of rhabdomyosarcoma was subsequently made after rebiopsy of new tumor masses during the course of the illness, by ultrastructural examination of a cell line derived from the tumor or at postmortem examination. Based on initial symptoms, clinical features, and postmortem findings, the primary tumor sites were assumed to be in the middle ear, paravertebral area, base of skull, retrobulbar space, chest wall, and retropancreatic area. In four patients the disease was confined to bone marrow, lymph nodes, and meninges so that a primary site could not be assigned. The approach to pediatric patients presenting with disseminated malignancy from an occult primary site should consist of an aggressive pursuit of a specific diagnosis and establishment of a primary site to better direct therapy, particularly for those children whose tumors may be responsive to specific therapy.

Treatment and prognosis of metastatic carcinoma of unknown primary: analysis of 100 patients

One hundred patients with metastatic carcinoma of unknown primary were analyzed to assess the importance of prognostic factors on survival. Patients were treated with cytostatic combinations, single drugs, or symptomatic care only. Response in the treatment groups ranged from 10% to 33%. The median survival of all patients was 124 days. In a univariate analysis good performance status, the presence of lymph node metastases, and the absence of liver metastases favorably influenced survival. In a Cox proportional hazards model, good performance status contributed significantly to a better survival. In addition there was a trend for female patients, patients with lymph node metastases, and patients without liver metastases to survive longer. These patient subsets deserve optimal treatment despite the dismal prognosis of this disease.

The changing incidence of cancer in adults in New South Wales

Data from the New South Wales (NSW) Central Cancer Registry comprising all new cases of cancer registered in persons aged 15 years and over for the 10-year period 1973 to 1982 were examined using log-linear regression to determine whether the incidence of cancer had been changing in NSW. Allowing for the altered age and sex structure of the population over this period, the annual incidence rate for all sites combined increased significantly by 1.7% in men and 1.0% in women. Cancers which had increased at a rate significantly greater than that for all sites combined were those of unknown primary site (8.7% per year), lung (in women only, 5.6%), kidney (4.5%), bladder (2.7%) and rectum (2.6%) and lymphomas (2.6%). Other cancers which showed a significantly increased incidence rate per se were testis (3.5%), larynx (3.2%), prostate (2.1%), colon (1.7%), brain (1.6%), leukaemias (1.3%) and lung (in men only, 0.7%). Cancers which had decreased significantly in incidence were those of oesophagus (-2.2%), cervix uteri (-2.0%) and stomach (-1.4%). No significant change in incidence over the 10 years had occurred for cancers of the corpus uteri, breast, ovary or pancreas.

Tumour marker immunoreactivity in adenocarcinoma

To determine whether variations in the expression of tumour related antigen can predict the origin of tumours, the immunoreactivity of a series of adenocarcinomas from a wide range of sites was studied with a panel of monoclonal antibodies with specificity for carcinoembryonic antigen, carcinoembryonic antigen with non-specific cross reacting antigen co-specificity, epithelial membrane antigen, OC 125, and OC 19.9. A range of reactivity was seen in tumours from most sites. No distinctive results were identified for a particular site of origin. Some patterns of consistent positivity or negativity for the panel of antisera used were seen, however, which if applied to metastatic deposits have the potential to assist prediction of the site of origin. These results also imply that immunohistological reactivity should be considered in the selection of a tumour marker for serological monitoring.

Metastatic cancer with unknown primary

Close cooperation between an experienced pathologist and oncologist is essential in the management of patients with unknown primary carcinoma. A comprehensive pathological examination is crucial and, with undifferentiated tumors, this will include immunohistology and/or electron microscopy. Ample properly processed tissue therefore must be provided. Time-consuming and costly radiographic and imaging studies should be avoided. No matter how extensive the evaluation, in a majority of cases, the primary site will never be found, so a selective search for treatable tumors is most appropriate and cost-effective. With adenocarcinomas, this will include prostate, breast, and ovary; for undifferentiated tumors, small cell bronchogenic carcinoma, lymphomas, and germ cell tumors. Table 4 summarizes recommended studies for diagnosing unknown primary undifferentiated or adenocarcinomas. Women with adenocarcinoma in axillary nodes without a primary site should be treated as having breast cancer. Estrogen and progesterone receptor assays are to be obtained on the axillary biopsy. High and midcervical nodes with metastatic squamous cell carcinoma can be treated effectively and, not infrequently, cured with surgery and radiation therapy, even if the primary site never is detected. If doubt remains, treatment should be selected that offers the best chance of significant palliation or cure--for example, cisplatin-based chemotherapy in possible extragonadal germ cell tumors.

Serum thyroglobulin in the investigation of patients presenting with metastases

Serum thyroglobulin (Tg) is often very elevated in patients with metastatic thyroid carcinoma and, in 18 out of 40 patients examined, serum Tg was found to exceed 400 micrograms/l. In only two of 55 patients with benign nodular thyroid disease did serum Tg exceed 400 micrograms/l. In patients presenting with metastases of unknown origin, the finding of a very elevated serum Tg concentration may therefore be of value as an indicator that the metastases are due to thyroid carcinoma. During a period in which 128 new patients with differentiated thyroid carcinoma were seen, in five who presented with metastatic disease the initial estimation of serum Tg had proved useful in suggesting the thyroid origin of the metastases.

5-Fluorouracil, doxorubicin and mitomycin C (FAM) combination chemotherapy for metastatic adenocarcinoma of unknown primary

The prognosis of patients with adenocarcinoma of unknown primary (ACUP) is dismal. Various chemotherapy regimens have yielded disappointing response rates and survival. Based on a promising report of Goldberg et al. (J Clin Oncol 1986, 4, 395-399) we performed a phase II study with 5-fluorouracil, adriamycin and mitomycin C (FAM). Only three out of 22 evaluable patients achieved a partial response (14%) for a duration of 22, 30 and 74+ weeks. Median survival was 54+ weeks (range 35-74+ weeks) for responding patients and 33+ weeks (range 9-74+ weeks) for all treated patients. One patient (5%) developed mitomycin C induced hemolytic uremic syndrome. FAM cannot be recommended for routine use in patients with ACUP.

Metastatic adenocarcinoma of unknown primary site. A randomized study of two combination chemotherapy regimens

Of 101 patients with symptomatic adenocarcinoma or undifferentiated carcinoma of unknown primary site, 95 were evaluable for the effects of two randomized chemotherapy regimens. Forty-eight patients received combination doxorubicin and mitomycin C (DM) and 47 received combination cisplatin, vinblastine and bleomycin (PB). Response rates were not significantly different between the two treatment groups, 42% for DM and 32% for PVB, with an overall response rate of 37.1%. Survival differences for DM and PVB treated groups were not significantly different, with 18 weeks and 25 weeks median survivals respectively. Toxicities were unequal for the two treatment groups with increased haematological toxicity for DM and greater gastrointestinal toxicity for PVB. The authors conclude both therapies were of limited efficacy in the treatment of ACUP patients and emphasize that only symptomatic patients should be considered for such therapies.

ACUPS (adenocarcinoma of unknown primary site): a clinical and cost benefit analysis

A retrospective review of 287 patients with a diagnosis of adenocarcinoma unknown primary site was performed. These patients represented 2.9% of the new referrals to the Westmead Department of Radiation Oncology between the years 1979 and 1985. Age, sex, and survival characteristics of the study population are presented. Tissue biopsy procedures are reviewed and the uniform necessity of open biopsy is questioned in the light of recent advances in FNA (fine needle aspirate) techniques. A semi-quantitative analysis of the monetary cost of the investigation of these patients has been performed. This has been correlated with the objective and symptomatic benefit accrued by the patient population. A higher incidence of speculative, low-yield investigations has been demonstrated for those patients referred from general medical and surgical units. Ante-mortem identification of the primary site remains the exception rather than the rule in this and other series. This fact, coupled with an inability of therapeutic intervention to alter the natural history of the disease means the cost and toxicity of investigation and treatment of these patients must influence approaches to their management.

The clinical features and natural history of malignant liver tumours

As a broad generalization, there appears to be little intrinsic difference in the biological behaviour of the common malignant liver tumours in respect of presentation, clinical course, clinical features and prognosis. Whatever the tumour's origin, patients present with some combination of abdominal pain, hepatomegaly, weight-loss and general malaise and death occurs within 3 years of the onset of symptoms. It is the state of the non-tumorous liver (cirrhotic/non-cirrhotic) and the anatomical site of the tumour (as with hilar cholangiocarcinomas) that are responsible for any significant differences. Metastatic carcinoid tumours, epithelioid haemangioendotheliomas, stage IV-S neuroblastomas and the fibrolamellar variant of HCC are exceptions to this rule with a genuinely better prognosis.

Fiberoptic bronchoscopy and pleural effusion of unknown origin

We reviewed our experience with fiberoptic bronchoscopy (FOB) in patients with pleural effusion of unknown origin. Seventy patients underwent FOB for the investigation of pleural effusion between 1978 and 1983. Those with a second reason for FOB, a mass on chest roentgenogram, or lobar atelectasis were excluded. Forty five patients remained: 28 patients with unexplained pleural effusion after pleural fluid analysis and pleural biopsy (UPE), and 17 patients with malignant pleural fluid cytology and/or pleural biopsy but no known primary tumor (MPE). In the UPE group, only one FOB demonstrated malignancy, despite a final diagnosis of tumor in seven. No other specific diagnoses were made by FOB in this group. In the MPE group, FOB demonstrated bronchogenic carcinoma in two; ultimately, five patients were found to have a bronchogenic neoplasm. Although pleural effusion of unknown origin is frequently caused by bronchogenic carcinoma, FOB in the absence of other indications for this procedure is rarely diagnostic and should not be routinely employed.

The search for the primary tumor in patients with skeletal metastases of unknown origin

Forty-six patients who had been evaluated because of skeletal metastases of unknown origin, were reviewed. Twenty-six of the patients were referred to an orthopedic surgeon before confirmation of the metastases by biopsy; 20 others were referred to an oncology clinic after a diagnosis of bone metastases had been established. A simple diagnostic sequence consisting of a medical history, physical examination, routine laboratory studies, chest roentgenogram, technetium 99m phosphonate bone scintigram, and intravenous pyelogram identified the site of the primary tumor in 14 patients; 7 of the primaries were lung carcinomas, 4 were hypernephromas, 2 were breast carcinomas, and 1 was a prostate carcinoma. In two other patients, the histologic findings from the biopsy study were diagnostic; one had a thyroid carcinoma and one, a prostate carcinoma. Further extensive diagnostic workups revealed the site of origin in only four additional patients; two had hypernephromas which were discovered by computed axial tomography of the abdomen; one had an ovarian carcinoma and one had a hepatoma, both of which were found at laparotomy. On the basis of this study, a simple diagnostic strategy is recommended for patients with histopathologically confirmed skeletal metastases of unknown origin: medical history, physical examination, routine laboratory studies, chest radiograph, and technetium 99m phosphonate bone scintigram, followed by computed axial tomographic examination of the abdomen and pelvis. In female patients, it may be judicious to use mammography. If this regimen fails to reveal the primary site, it is unlikely that it will be identified with further extensive diagnostic procedures.

An analysis of 1539 patients with cancer of unknown primary site

A retrospective review of 1539 patients with cancer of unknown primary site seen at Yale-New Haven Hospital from 1922 to 1981 was performed. Information was obtained from the Tumor Registry. The method of diagnosis, patient characteristics, year of diagnosis, histologic features, treatment received, and survival were analyzed. The most common cell type was adenocarcinoma. Survival overall was poor, with a median survival of 5 months for the entire group. Age and year of diagnosis did not appear to significantly influence survival. Closer examination of a small subset of those patients with squamous cell carcinoma revealed a very high male:female ratio, possibly related to tobacco and alcohol abuse. Nearly 9% of these patients were found to have a history of one or more unrelated malignancies.

Cost-effectiveness in the diagnosis and treatment of carcinoma of unknown primary origin

Between 2% and 9% of patients with cancer present with metastatic nonsquamous cell carcinoma of unknown primary origin. Traditionally, a series of investigations is undertaken to locate the primary origin of the tumour, although many of these tests are often painful or distressing to patients, unsuccessful in locating the primary site and costly to the health care system. Moreover, even if a tumour is found it usually cannot be treated surgically. However, a small number of cancers of unknown primary origin can be cured, arrested or effectively palliated with systemic treatment. This study compares the costs and outcomes of the current practice of comprehensively searching for the primary tumour with those of an alternative, limited approach that identifies only the primary tumours for which relatively effective systemic therapy exists. Decision trees were constructed for the two diagnostic approaches and their associated therapeutic options. Costs and probabilities were integrated with published data on the survival of patients with each type of cancer. The results indicate that the comprehensive diagnostic strategy may increase 1-year survival rates from 11.0% to 11.5%. On the basis of Ontario cost data it is calculated that the additional costs of a comprehensive search for 1000 patients will range from approximately $2 million to $8 million, depending on the subsequent treatment strategy.

Metastatic carcinoma from unknown primary site: the experience of a large oncology centre

The case records of patients presenting with metastases from an unknown primary cancer (MUP) have been reviewed. Important prognostic variables were performance status and the presence of disease in more than one system. Patients of poor performance status and disease in multiple organs had a median survival of one month and 87% were dead within three months. Those patients of good performance status and disease apparent in only one organ had a median survival of seven months. Patients with carcinoma confined to lymph nodes in the high cervical region who received treatment with radiotherapy had 3- and 5-year survival rates of 26% and 17% respectively.

Application of DNA flow cytometry to paraffin-embedded archival material for the study of aneuploidy and its clinical significance

By using a recently developed flow cytometric method we have analyzed cellular DNA content of paraffin-embedded histological material from cancer patients. This method allows the retrospective study of tumors from patients whose clinical outcome is already known, and we have applied it to ovarian cancers, stage II breast cancers, and to metastatic adenocarcinoma of unknown primary site. In addition to knowledge of patient survival, comprehensive information was available about other prognostic determinants and treatment received, and we have used multivariate analysis in an attempt to determine the prognostic significance of cellular DNA content. In ovarian cancer, it is a major prognostic variable except in stage IV disease, whereas in metastatic adenocarcinoma of unknown primary site cellular DNA content has no influence on survival. For stage II breast cancer the situation is more complex and requires larger numbers to be studied. However, aneuploid tumors tend to have more extensive involvement of axillary lymph nodes and a poorer overall disease-free survival. This influence of DNA content on disease-free survival appears to be confined to premenopausal patients, and has no effect on patient survival following disease recurrence. Although we need to study more patients and more tumor types, taken together the results so far show a generally more favorable prognosis for patients with diploid tumors, except in the presence of recurrent or metastatic disease. The better prognosis associated with diploid tumors could be due to the fact that they are more commonly found in earlier clinical stages rather than to their being inherently less aggressive than aneuploid tumors.

Hepatic tumors in Saudi Arabia. A practical approach to diagnosis

All cases of liver tumor referred to the King Faisal Specialist Hospital and Research Centre in Saudi Arabia during 2.5 years were reviewed. Hepatocellular carcinoma, 104 cases, was considerably more common than metastatic carcinoma with unknown primary, 15 cases. Lymphoma presenting as liver tumor occurred in three cases and there were no cases of cholangiocarcinoma. There were only two cases of benign tumor, both hemangioma. Hepatocellular carcinoma was characterized by a male predominance of 6:1, positive hepatitis B surface antigen in 60%, presentation with an enlarged, hard liver in over 90%, a systolic-diastolic bruit over the mass in 45%, a single highly echogenic lesion in the right lobe on ultrasound in 80%, and rapid progression. The serum AST (aspartate aminotransferase, serumglutamic oxalacetic transaminase [SGOT]) was abnormal in 97% and was higher than the alanine aminotransferase (ALT) in 93% of cases compared with 17% in 100 consecutive cases of chronic active hepatitis. Sixty-six percent of patients with hepatocellular carcinoma had serum AFP greater than 200 ng/ml. Excluding five cases of germ cell tumor (none involving the liver), and pregnant patients, serum AFP was less than 200 ng/ml in all other patients in whom it was measured between 1979 and 1981. A practical approach to the diagnosis of hepatocellular carcinoma is outlined. Biopsy does not appear to be indicated in many cases of advanced hepatocellular carcinoma.

Role of the CT scanner in the management of cancer

Although the diagnostic scope of computed tomography has widened considerably in recent years, assessment of patients with suspected or known malignant disease remains the major reason for body CT referrals in the United Kingdom. This paper sets out to define important advantages and limitations of CT in cancer diagnosis, addressing the topics of primary diagnosis, staging, and patient follow up. There is relatively little information on the influence of CT on patient management in oncology but reported studies indicate that CT directly alters clinical decisions in 14-30% of patients. This aspect requires further evaluation and is of particular relevance when considering the appropriate use of high cost technology.

Adenocarcinoma of unknown primary site. The Brooke Army Medical Center experience

A retrospective analysis of 56 tumor board records carrying the diagnosis of adenocarcinoma of unknown primary site (ACUPS) was completed. The cohort represents 1.7% of the registrations during the period from 1971-1981. The liver was the most common site from which a biopsy specimen was taken for diagnosis. The lung and pancreas were the most frequent proven primary sites. Eighteen cases went to autopsy. Primaries remained undetected in five (27%). Three of 37 patients treated with chemotherapy responded (8%). All cases to survive for longer than 24 months were well-differentiated adenocarcinomas (median survival, 6 months). The median survival of the entire cohort was 4 months. The survival difference between well-differentiated histology and less-differentiated histology was not significant (P = 0.076). The search for the primary includes investigation of the patients' signs and symptoms and limited screening tests. Treatment has not been proven to alter the natural history of ACUPS and must be weighed against toxicity.

Metastatic adenocarcinoma of unknown primary site: abnormalities of cellular DNA content and survival

Using a new flow cytometric technique we measured the cellular DNA content of tumour biopsies taken from 152 patients presenting with metastatic adenocarcinoma or undifferentiated carcinoma of unknown primary site. One hundred and six (70%) contained populations of cells with an abnormal cellular DNA content and the remainder were diploid. The incidence of aneuploidy was similar for the two sexes and bore no obvious relationship to the various patterns of metastatic involvement. Median survival of patients with diploid tumours was 4.2 months and for patients with aneuploid tumours, 4.8 months. Nine of the 46 patients with diploid tumours (i.e. 18%) survived for more than 2 yr compared to 10 of 106 (9%) of those with aneuploid tumours. These results indicate that the incidence of aneuploidy in this heterogeneous group of patients is similar to that reported for adenocarcinomas of known histogenesis, such as breast or colorectal cancer. In contrast to many of these tumour types, however, patients with metastatic adenocarcinomas of unknown primary which are diploid do not on the whole have a more favourable prognosis.

Metastatic carcinoma with an unknown primary

The patient is a 54-year-old white female who was well until 3 weeks prior to admission when she noted vague right upper quadrant pain exacerbated by meals. She lost 12 lbs over that period of time. She complained as well of posterior scalp, left hip, and back pain on initial presentation. Physical examination at the time of admission to hospital showed a middle-aged female in no acute distress. Her vital signs were normal. There was a 1.5 X 1.5-cm firm, tender nodule over the occiput. There was no peripheral adenopathy. The breasts, lungs, and heart were normal. The liver was 14 cm in span. The remainder of the physical examination including a pelvic examination was unremarkable. On admission, the only abnormal laboratory studies were SGOT 106, SGPT 139, and alkaline phosphatase 190. Her chest X ray, flat plate of the abdomen, and mammograms were all normal.

Carcinoma of unknown primary site. A prudent approach

The patient with carcinoma of unknown primary site deserves prompt and efficient evaluation in an effort to locate a primary tumor in a treatable location. Early collaboration between clinician and pathologist is essential. The needs of patient and family must be considered, and the hospital stay should not be extended by unnecessary diagnostic tests that have no purpose other than delineation of extent of disease. Specific chemotherapy regimens should be instituted if evaluation reveals a potentially responsive tumor. All patients should receive palliative therapy directed at relief of symptoms and pain and improved quality of life. Refinement of immunologic and cytochemical techniques for primary tumor site localization, along with advances in the therapy of colonic, pancreatic, lung, and ovarian carcinomas, should make the outlook for the patient with carcinoma with an occult primary site considerably brighter.

Metastatic malignant disease of unknown origin

The charts of 106 patients with metastasis from an unknown primary cancer were reviewed to formulate a more appropriate investigative strategy than is presently employed. The spinal column was the most common site for initial presentation of metastatic disease (26.5 percent). The primary tumor was identified before death in 31.3 percent of patients and after death in 6.6 percent. Lung cancer was found in 40 percent of patients with identified primary tumors. Diagnostic studies directed at specific symptoms had a significantly greater yield. Electroencephalograms, gallium scans, thyroid scans, and mammograms were not useful as screening studies. Conversely, bone scans were positive in 46.5 percent of asymptomatic patients and in 88 percent of symptomatic patients. Chest roentgenograms were suggestive of malignant tumors in 43.6 percent of patients. Results of liver scans were predictable on the basis of changes in the alkaline phosphatase level and clinical liver examination. History and physical examination should clearly document the stage of disease, evaluate possible primary sites, and rule out impending acute complications. Chest roentgenograms and bone scans should be obtained early and open biopsy of accessible lesions scheduled promptly. Efforts should be directed at ruling out the more treatable malignant tumors. Further work-up is then indicated only by the development of specific symptomatology. Since median patient survival after initial presentation is only 6.6 months, prolonged hospitalization for numerous nonproductive diagnostic tests seems inappropriate.

Prostatic cancer presenting as metastatic adenocarcinoma of undetermined origin. Immunodiagnosis by prostatic acid phosphatase

Adenocarcinoma of the prostate may occasionally present as distant metastatic disease. This tumor, if accurately identified, is amendable to effective treatment with hormonal manipulations. We have seen nine patients with prostatic cancer presenting as metastatic adenocarcinoma of undetermined origin: two presented with involvement in the lung and the mediastinum, five with left supraclavicular lymphadenopathy and two with known prostatic cancer with stable disease presented with supraclavicular lymphadenopathy. By employing an immunoperoxidase technique using prostatic acid phosphatase as the marker for the prostatic cells, we demonstrated the presence of the prostatic enzyme antigen in the paraffin embedded tissues from the metastatic tumor. This finding directed further investigation of the prostate gland leading to the discovery of the primary tumor in all nine patients. It may be beneficial to use this technique in all male patients with adenocarcinoma of undetermined primary site.

VAC (vincristine, adriamycin, cyclophosphamide) chemotherapy for metastatic carcinoma from an unknown primary site

Twenty patients presenting with metastatic carcinoma from an unknown primary site were studied. All patients were treated with a triple chemotherapy regimen of vincristine, adriamycin and cyclophosphamide repeated at three-week intervals. The response rate was 50%, and the four patients achieving complete response are alive and disease-free at 13, 16, 36 and 39 months. Toxicity was minimal and the majority of patients' performance status improved with the chemotherapy. VAC chemotherapy is indicated for patients with metastases, particularly of soft tissues originating from a carcinoma from an unknown primary site.

An ultrastructural analysis of breast carcinoma presenting as isolated axillary adenopathy

Metastatic adenocarcinoma in the axillary lymph nodes of a female patient often originates from a primary tumor in the ipsilateral breast. Mastectomy may be recommended if adenocarcinoma is found in the axillary nodes even when the primary tumor is not clinically detectable. In these circumstances, the recommendation for mastectomy should be based on the firm histologic diagnosis of adenocarcinoma. In the present report, five female patients are discussed who presented with axillary lymphadenopathy without clinically evident breast masses or mammographic evidence of malignancy. Axillary lymph node biopsies, performed in each patient, were inconclusive after conventional light microscopic examination. Electron microscopy established the diagnosis of adenocarcinoma. These findings were complemented by sex steroid analyses of the tumors where possible. Each patient underwent ipsilateral mastectomy, and in each specimen an occult breast carcinoma was found. The necessity of making a precise tissue diagnosis in all cases of metastatic cancer from an unknown primary is stressed, and special techniques to accomplish this must be considered preoperatively. This is particularly important in the female patient with metastatic breast carcinoma in an isolated axillary lymph node, since ipsilateral mastectomy may be curative.

Metastatic adenocarcinoma of unknown primary site: analysis of 245 patients seen at The Johns Hopkins Hospital from 1965--1979

A retrospective review of 245 patient with metastatic adenocarcinomas of unknown primary site (ACUP) seen at The Johns Hopkins Hospital from 1965--1979 was undertaken. The median survival was 3.1 months. Age, sex, race, and year of diagnosis did not appear to influence survival. Patients having their major site(s) of disease above the diaphragm experienced a significantly longer survival than patients whose disease was below the diaphragm (5.3 versus 2.3 months, P less than 0.05). As a group, patients treated with chemotherapy had no improvement in survival. However, the small number of patients treated with either cyclophosphamide or doxorubicin or both drugs had a median survival of greater than 9 months compared to 2.6 months for untreated or local radiotherapy-treated patients and 3.2 months for patients treated with 5-fluorouracil.