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van der Strate I, Kazemzadeh F, Nagtegaal ID, Robbrecht D, van de Wouw A, Padilla CS, Duijts S, Esteller M, Greco FA, Pavlidis N, Qaseem A, Snaebjornsson P, van Zanten SV, Loef C. International consensus on the initial diagnostic workup of cancer of unknown primary. Crit Rev Oncol Hematol 2023; 181:103868. [PMID: 36435296 DOI: 10.1016/j.critrevonc.2022.103868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although the incidence of Cancer of Unknown Primary (CUP) is estimated to be 1-2 % of all cancers worldwide, no international standards for diagnostic workup are yet established. Such an international guideline would facilitate international comparison, provide adequate incidence and survival rates, and ultimately improve care of patients with CUP. METHODS Participants for a four round modified Delphi study were selected via a CUP literature search in PubMed and an international network of cancer researchers. A total of 90 CUP experts were invited, and 34 experts from 15 countries over four continents completed all Delphi survey rounds. FINDINGS The Delphi procedure resulted in a multi-layer CUP classification for the diagnostic workup. Initial diagnostic workup should at least consist of history and physical examination, full blood count, analysis of serum markers, a biopsy of the most accessible lesion, a CT scan of chest/abdomen/pelvis, and immunohistochemical testing. Additionally, the expert panel agreed on the need of an ideal diagnostic lead time for CUP patients. There was no full consensus on the place in diagnostic workup of symptom-guided MRI or ultrasound, a PET/CT scan, targeted gene panels, immunohistochemical markers, and whole genome sequencing. INTERPRETATION Consensus was reached on the contents of the first diagnostic layer of a multi-layer CUP classification. This is a first step towards full consensus on CUP diagnostics, that should also include supplementary and advanced diagnostics.
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Affiliation(s)
- Iris van der Strate
- Department of Research and Development, Comprehensive Cancer Organization the Netherlands, Utrecht, the Netherlands.
| | - Fatemeh Kazemzadeh
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Debbie Robbrecht
- Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Agnes van de Wouw
- Department of Medical Oncology, VieCuri Medical Center, Venlo, the Netherlands
| | - Catarina S Padilla
- Department of Research and Development, Comprehensive Cancer Organization the Netherlands, Utrecht, the Netherlands
| | - Saskia Duijts
- Department of Research and Development, Comprehensive Cancer Organization the Netherlands, Utrecht, the Netherlands; Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Manel Esteller
- Josep Carreras Leukemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain; Centro de Investigacion Biomedica en Red Cancer (CIBERONC), Madrid, Spain; Institucio Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain; Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Barcelona, Catalonia, Spain
| | - F Anthony Greco
- Sarah Cannon Research Institute and Cancer Center, Tennessee Oncology, Nashville, TN, USA
| | - Nicholas Pavlidis
- Medical School, University of Ioannina, Stavros Niarchou Avenue, 45110, Ioannina, Greece
| | - Amir Qaseem
- American College of Physicians, Philadelphia, PA, USA
| | - Petur Snaebjornsson
- Department of Pathology, The Netherlands Cancer Institute, 1066 CX, Amsterdam, the Netherlands
| | - Sophie Veldhuijzen van Zanten
- Department of Radiology and Nuclear Medicine, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Caroline Loef
- Department of Research and Development, Comprehensive Cancer Organization the Netherlands, Utrecht, the Netherlands
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Extensive diagnostic work-up for patients with carcinoma of unknown primary. Clin Exp Metastasis 2021; 38:231-238. [PMID: 33515369 DOI: 10.1007/s10585-021-10073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
Patients with carcinoma of unknown primary (CUP) present with metastatic disease without an identified primary tumour. The unknown site of origin makes the diagnostic work-up and treatment challenging. Since little information is available regarding diagnostic work-up and treatment in daily practice, we collected and analysed these in a patient cohort with regard to the recommendations of the national CUP guideline. Data of 161 patients diagnosed with CUP in 2014 or 2015 were extracted from the Netherlands Cancer Registry (NCR) and supplemented with diagnostic work-up information from patient files and analysed. Patients underwent an average of five imaging studies during the diagnostic phase (range 1-17). From the tests as recommended in the national guideline on CUP, a chest X-ray was most commonly performed (73%), whereas a PET-CT was done in one out of four patients (24%). Biopsies were taken in 86% of the study population, with Cytokeratin 7 being the most frequently tested histopathological marker (73%). Less than half of patients received therapy (42%). CUP patients undergo extensive diagnostic work-up. The performance status did not influence the extent of the diagnostic work-up in CUP patients, but it was an important factor for receiving treatment.
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El Rassy E, Kattan J, Pavlidis N. A new entity of abdominal squamous cell carcinoma of unknown primary. Eur J Clin Invest 2019; 49:e13111. [PMID: 30908618 DOI: 10.1111/eci.13111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Elie El Rassy
- Department of Cancer Medicine, Gustave Roussy Institute, Villejuif, France.,Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Joseph Kattan
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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[2018 Consensus statement by the Spanish Society of Pathology and the Spanish Society of Medical Oncology on the diagnosis and treatment of cancer of unknown primary]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 52:33-44. [PMID: 30583830 DOI: 10.1016/j.patol.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
Cancer of unknown primary is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, cancer of unknown primary can account for 2-9% of all cancer patients, mostly 60-75 years old. This article reviews the main clinical, pathological and molecular studies conducted to analyse and determine the origin of cancer of unknown primary. The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed.
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Schroten-Loef C, Verhoeven R, de Hingh I, van de Wouw A, van Laarhoven H, Lemmens V. Unknown primary carcinoma in the Netherlands: decrease in incidence and survival times remain poor between 2000 and 2012. Eur J Cancer 2018; 101:77-86. [DOI: 10.1016/j.ejca.2018.06.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/22/2018] [Accepted: 06/23/2018] [Indexed: 11/29/2022]
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2018 consensus statement by the Spanish Society of Pathology and the Spanish Society of Medical Oncology on the diagnosis and treatment of cancer of unknown primary. Clin Transl Oncol 2018; 20:1361-1372. [PMID: 29808414 PMCID: PMC6182632 DOI: 10.1007/s12094-018-1899-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 01/06/2023]
Abstract
Cancer of unknown primary (CUP) is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means that they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, CUP can account for 2–9% of all cancer patients, mostly 60–75 years old. This article reviews the main clinical, pathological, and molecular studies conducted to analyse and determine the origin of CUP.
The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed.
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Huang CY, Lu CH, Yang CK, Hsu HC, Kuo YC, Huang WK, Chen JS, Lin YC, Chia-Yen H, Shen WC, Chang PH, Yeh KY, Hung YS, Chou WC. A Simple Risk Model to Predict Survival in Patients With Carcinoma of Unknown Primary Origin. Medicine (Baltimore) 2015; 94:e2135. [PMID: 26632736 PMCID: PMC5059005 DOI: 10.1097/md.0000000000002135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Carcinoma of unknown primary origin (CUP) is characterized by diverse histological subtypes and clinical presentations, ranging from clinically indolent to frankly aggressive behaviors. This study aimed to identify prognostic factors of CUP and to develop a simple risk model to predict survival in a cohort of Asian patients.We retrospectively reviewed 190 patients diagnosed with CUP between 2007 and 2012 at a single medical center in Taiwan. The clinicopathological parameters and outcomes of our cohort were analyzed. A risk model was developed using multivariate logistic regression and a prognostic score was generated.The prognostic score was calculated based on 3 independent prognostic variables: the Eastern Cooperative Oncology Group (ECOG) scale (0 points if the score was 1, 2 points if it was 2-4), visceral organ involvement (0 points if no involvement, 1 point if involved), and the neutrophil-to-lymphocyte ratio (0 points if ≤3, 1 point if >3). Patients were stratified into good (score 0), intermediate (score 1-2), and poor (score 3-4) prognostic groups based on the risk model. The median survival (95% confidence interval) was 1086 days (500-1617, n = 42), 305 days (237-372, n = 75), and 64 days (44-84, n = 73) for the good, intermediate, and poor prognostic groups, respectively. The c-statistics using the risk model and ECOG scale for the outcome of 1-year mortality were 0.80 and 0.70 (P = 0.038), respectively.In this study, we developed a simple risk model that accurately predicted survival in patients with CUP. This scoring system may be used to help patients and clinicians determine appropriate treatments.
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Affiliation(s)
- Chen-Yang Huang
- From the Division of Hematology and Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University School of Medicine, Taoyuan (C-YH, C-KY, H-CH, Y-CK, W-KH, J-SC, Y-CL, C-YH, W-CS, Y-SH, W-CC); Division of Hematology and Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi (C-HL); Division of Hematology and Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung (P-HC, K-YY); and Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan (W-CC)
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Male pelvic squamous cell carcinoma of unknown primary origin. Case Rep Oncol Med 2014; 2014:953698. [PMID: 25478265 PMCID: PMC4247932 DOI: 10.1155/2014/953698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/24/2014] [Indexed: 11/18/2022] Open
Abstract
Pelvic squamous cell carcinoma of unknown primary origin has been described in several case reports of female patients. However, there have been no published reports describing male patients with pelvic squamous cell cancer of unknown primary origin. Our case describes a 52-year-old man who presented with right buttock pain, rectal urgency, and constipation. His physical examination demonstrated tenderness to palpation around his gluteal folds. Computed tomography scan of his abdomen and pelvis demonstrated a large mass in his retroperitoneum. The mass was determined to be squamous cell carcinoma of unknown primary origin. Additionally, the patient had small nodules in his right lower lung lobe and right hepatic lobe. The patient was treated with concomitant chemoradiation, including cisplatin and intensity-modulated radiation therapy, followed by carboplatin and paclitaxel. The patient achieved partial remission, in which he remained one year after his presentation. Our case is consistent with the literature which suggests that squamous cell carcinoma of unknown primary origin occurring outside of the head and neck region may have a more favorable prognosis than other carcinomas of unknown primary origin. Further studies are necessary to determine the most appropriate work-up, diagnosis, and optimal treatment strategies.
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