1
|
Hu H, Pan Q, Shen J, Yao J, Fu G, Tian F, Yan N, Han W. The diagnosis and treatment for a patient with cancer of unknown primary: A case report. Front Genet 2023; 14:1085549. [PMID: 36741314 PMCID: PMC9894331 DOI: 10.3389/fgene.2023.1085549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Background: Cancer of unknown primary (CUP) is a class of metastatic malignant tumors whose primary location cannot be determined. The diagnosis and treatment of CUP are a considerable challenge for clinicians. Herein, we report a CUP case whose corresponding primary tumor sites were successfully identified, and the patient received proper treatment. Case report: In February 2022, a 74-year-old woman was admitted to the Medical Oncology Department at Sir Run Run Shaw Hospital for new lung and intestinal tumors after more than 9 years of breast cancer surgery. After laparoscopically assisted right hemicolectomy, pathology revealed mucinous adenocarcinoma; the pathological stage was pT2N0M0. Results from needle biopsies of lung masses suggested poorly differentiated cancer, ER (-), PR (-), and HER2 (-), which combined with the clinical history, did not rule out metastatic breast cancer. A surgical pathology sample was needed to determine the origin of the tumor tissue, but the patient's chest structure showed no indications for surgery. Analysis of the tumor's traceable gene expression profile prompted breast cancer, and analysis of next-generation amplification sequencing (NGS) did not obtain a potential drug target. We developed a treatment plan based on comprehensive immunohistochemistry, a gene expression profile, and NGS analysis. The treatment plan was formulated using paclitaxel albumin and capecitabine in combination with radiotherapy. The efficacy evaluation was the partial response (PR) after four cycles of chemotherapy and two cycles combined with radiotherapy. Conclusion: This case highlighted the importance of identifying accurate primary tumor location for patients to benefit from treatment, which will provide a reference for the treatment decisions of CUP tumors in the future.
Collapse
Affiliation(s)
- Hong Hu
- Department of Medical Oncology, Qiantang Campus of Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qin Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jiaying Shen
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Junlin Yao
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Guoxiang Fu
- Department of Pathology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fengjuan Tian
- Department of Radiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Na Yan
- Key Laboratory of Digital Technology in Medical Diagnostics of Zhejiang Province, Dian Diagnostics Group Co., Ltd., Hangzhou, Zhejiang, China
| | - Weidong Han
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China,*Correspondence: Weidong Han, hanwd@ zju.edu.cn
| |
Collapse
|
2
|
Rassy E, Pavlidis N. The diagnostic challenges of patients with carcinoma of unknown primary. Expert Rev Anticancer Ther 2020; 20:775-783. [PMID: 32779501 DOI: 10.1080/14737140.2020.1807948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cancer of unknown primary (CUP) is a disease entity encompassing heterogeneous malignancies without a clinically-detectable anatomical primary. It is usually a poor prognosis malignancy with dismal prognosis where molecular and genetic testing were expected to be a major breakthrough. AREAS COVERED In this review, we provide an overview of the advances in the understanding of the carcinogenesis, biology, diagnosis and treatment of patients with CUP. This review focuses on the advantages and inconveniences of immunohistochemistry and CUP classifiers in assessing the progress in the management of CUP. EXPERT OPINION CUP classifiers were expected to gradually replace the classical multistep approach in identifying the culprit tumors to guide site-specific therapy. Immunohistochemistry staining led to the prediction of a single tissue of origin in 10.8-51%. CUP classifiers identified the primary site in 61-89% of these cases and were concordant with immunohistochemistry in 57.1-100%. Immunohistochemistry is cheap, fast and broadly available whereas CUP classifiers are less widely available and have not been validated in randomized control trials. The diagnostic recommendations consist of a standard pathology evaluation based on morphology and algorithmic immunohistochemistry assessment. Physicians should weigh in the input of the CUP classifier to the clinical picture and pathology investigations before performing additional investigations.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy Institute , Villejuif, France.,Department of Medical Oncology, Saint Joseph University , Beirut, Lebanon
| | - Nicholas Pavlidis
- University of Ioannina , Ioannina, Greece.,European School of Oncology College , Milan, Italy
| |
Collapse
|
3
|
Rassy E, Pavlidis N. Progress in refining the clinical management of cancer of unknown primary in the molecular era. Nat Rev Clin Oncol 2020; 17:541-554. [PMID: 32350398 DOI: 10.1038/s41571-020-0359-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/14/2022]
Abstract
Cancer of unknown primary (CUP) is an enigmatic disease entity encompassing heterogeneous malignancies without a detectable primary tumour, despite a thorough diagnostic workup. A minority of patients with CUP (15-20%) can be assigned a putative primary tissue of origin according to clinical and histopathological findings and typically have a more favourable prognosis with the use of corresponding tumour type-specific therapies. Thus, the majority of patients with CUP have disease that cannot be assigned to a culprit primary tumour, are treated with empirical chemotherapy and have a poor prognosis. In the molecular era, the use of (epi)genomic or transcriptomic CUP classifiers and DNA or RNA sequencing offers two, sometimes overlapping, therapeutic strategies: tumour type-specific therapy and biomarker-guided therapy. Published data reveal that the accuracy of site-of-origin predictions made using CUP classifiers ranges between 54% and 98% when compared with the assignment made according to the recommended clinicopathological criteria. These advances have led to promising results in non-randomized prospective studies evaluating the efficacy of tumour type-specific therapy; however, the favourable outcomes were not confirmed in randomized controlled studies comparing this approach with standard empirical chemotherapy. Currently, the evidence supporting the use of biomarker-guided therapies is limited to case reports and small case series. In this Review, we discuss the clinical management of CUP in the era of precision medicine. We focus on the advances in understanding the biology of CUP, the implications for the diagnosis and classification of CUP according to the tissue of origin and the shift away from empirical therapy towards tailored therapy.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, Paris, France.
| | | |
Collapse
|
4
|
Rassy E, Bakouny Z, Choueiri TK, Van Allen EM, Fizazi K, Greco FA, Pavlidis N. The role of site-specific therapy for cancers of unknown of primary: A meta-analysis. Eur J Cancer 2020; 127:118-122. [PMID: 32007711 DOI: 10.1016/j.ejca.2019.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
Abstract
Cancers of unknown primary (CUP) are among the most common causes of death due to cancer, are associated with a poor prognosis and have few therapeutic options available. Molecularly-guided site-specific treatments were explored based on the assumption that CUP are similar in their response to treatment of predicted primary tumours. Given the discordant results between these studies, a meta-analysis using a random-effects model and the inverse variance method was performed. MEDLINE and conference abstracts of American Society of Clinical Oncology (ASCO) and European Society of Medical Oncology (ESMO) meetings were searched from inception until November 2019. A trend towards improved OS was noted with site-specific versus empiric treatment for CUP (HR = 0.73; 95% confidence interval (CI) 0.52-1.02). There was significant heterogeneity across the four studies (I [2] = 79%; p = 0.002) but no significant difference was noted between the treatment effect in the two subgroups (randomised vs. non-randomised; p = 0.07). The test for overall effect for progression free survival, which had only been reported for the two randomised studies, was not statistically significant (HR = 0.93; 95% CI 0.74-1.17), with little heterogeneity between studies (I [2] = 0%; p = 0.77). The results of this meta-analysis highlight the significant heterogeneity between the prospective studies comparing molecularly tailored to empiric therapy for CUP and the need for other randomised studies including only primary tumors with available effective therapies.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy Institute, Villejuif, France; Department of Medical Oncology, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon.
| | - Ziad Bakouny
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eliezer M Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karim Fizazi
- Department of Medical Oncology, Gustave Roussy Institute, Villejuif, France
| | - F Anthony Greco
- Sarah Cannon Cancer Center, Tennessee Oncology, Nashville, TN, USA
| | | |
Collapse
|
5
|
Kim CS, Hannouf MB, Sarma S, Rodrigues GB, Rogan PK, Mahmud SM, Winquist E, Brackstone M, Zaric GS. Survival outcome differences based on treatments used and knowledge of the primary tumour site for patients with cancer of unknown and known primary in Ontario. ACTA ACUST UNITED AC 2018; 25:307-316. [PMID: 30464680 DOI: 10.3747/co.25.4003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Patients with cancer of unknown primary (cup) have pathologically confirmed metastatic tumours with unidentifiable primary tumours. Currently, very little is known about the relationship between the treatment of patients with cup and their survival outcomes. Thus, we compared oncologic treatment and survival outcomes for patients in Ontario with cup against those for a cohort of patients with metastatic cancer of known primary site. Methods Using the Ontario Cancer Registry and the Same-Day Surgery and Discharge Abstract databases maintained by the Canadian Institute for Health Information, we identified all Ontario patients diagnosed with metastatic cancer between 1 January 2000 and 31 December 2005. Ontario Health Insurance Plan treatment records were linked to identify codes for surgery, chemotherapy, or therapeutic radiation related to oncology. Multivariable Cox regression models were constructed, adjusting for histology, age, sex, and comorbidities. Results In 45,347 patients (96.3%), the primary tumour site was identifiable, and in 1743 patients (3.7%), cup was diagnosed. Among the main tumour sites, cup ranked as the 6th largest. The mean Charlson score was significantly higher (p < 0.0001) in patients with cup (1.88) than in those with a known primary (1.42). Overall median survival was 1.9 months for patients with cup compared with 11.9 months for all patients with a known-primary cancer. Receipt of treatment was more likely for patients with a known primary site (n= 35,012, 77.2%) than for those with cup (n = 891, 51.1%). Among patients with a known primary site, median survival was significantly higher for treated than for untreated patients (19.0 months vs. 2.2 months, p < 0.0001). Among patients with cup, median survival was also higher for treated than for untreated patients (3.6 months vs. 1.1 months, p < 0.0001). Conclusions In Ontario, patients with cup experience significantly lower survival than do patients with metastatic cancer of a known primary site. Treatment is associated with significantly increased survival both for patients with cup and for those with metastatic cancer of a known primary site.
Collapse
Affiliation(s)
- C S Kim
- Department of Epidemiology and Biostatistics, Western University, London, ON
| | - M B Hannouf
- Department of Epidemiology and Biostatistics, Western University, London, ON
| | - S Sarma
- Department of Epidemiology and Biostatistics, Western University, London, ON
| | - G B Rodrigues
- Department of Radiation Oncology, London Regional Cancer Program, London, ON
| | - P K Rogan
- Department of Biochemistry, Western University, London, ON
| | - S M Mahmud
- Community Health Sciences and Pharmacy, University of Manitoba, Winnipeg, MB
| | - E Winquist
- Department of Oncology, Western University, London, ON
| | - M Brackstone
- Department of Surgery, Western University, London, ON
| | - G S Zaric
- Department of Epidemiology and Biostatistics, Western University, London, ON.,Richard Ivey School of Business, Western University, London, ON
| |
Collapse
|
6
|
Karapetis CS, Guccione L, Tattersall MHN, Gooden H, Vajdic CM, Lambert S, Robotin M, Mileshkin L, Schofield P. Perceptions of cancer of unknown primary site: a national survey of Australian medical oncologists. Intern Med J 2017; 47:408-414. [PMID: 28101916 DOI: 10.1111/imj.13373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/01/2016] [Accepted: 12/05/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite being the sixth most common cause of cancer death in Australia, cancer of unknown primary (CUP) site remains poorly understood. AIMS To describe practices relating to the diagnosis, investigation, classification, communication and management of CUP among medical oncologists. METHODS We invited all members of the Medical Oncology Group of Australia to participate in a national, anonymous online survey about CUP. The survey collected data regarding diagnosis acceptance, diagnostic tests, treatment protocols and communication practices around the diagnosis of CUP. RESULTS Three hundred and two oncologists were invited and 86 (28%) completed the survey. Eighty (93%) respondents were directly involved in the assessment of patients with CUP. Eighty-five (99%) respondents were prepared to make a diagnosis of CUP if, after appropriate diagnostic tests, the primary location could not be ascertained. Eighty-three percent would assign a primary site to obtain Pharmaceutical Benefits Schedule funding of medical therapy. Sixty-two percent did not have a specific treatment protocol designed for CUP. The majority of oncologists used serum tumour markers and computed tomography scans in the initial work-up, while 43% indicated they would use a positron emission tomography scan in the majority of cases. The majority would arrange mammography in female patients. Thematic analysis of responses to open-ended questions about how CUP is described identified little consistency in the language being used. CONCLUSION The approach to diagnosis, investigation and management of CUP by medical oncologists in Australia is variable. Many preferred to estimate the primary site and treat accordingly. Pharmaceutical Benefits Schedule restrictions may encourage the practice of 'best guessing'.
Collapse
Affiliation(s)
- Christos S Karapetis
- Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lisa Guccione
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Martin H N Tattersall
- Sydney Medical School and Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Helen Gooden
- Cancer Australia, Sydney, New South Wales, Australia
| | - Claire M Vajdic
- Cancer Epidemiology Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Sylvie Lambert
- Ingram School of Nursing, St Mary's Research Centre, McGill University, Montreal, Quebec, Canada
| | - Monica Robotin
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia.,Faculty of Medicine, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Mileshkin
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Penelope Schofield
- Department of Psychological Sciences, School of Health Sciences, Swinburne University, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Ferrone CR, Ting DT, Shahid M, Konstantinidis IT, Sabbatino F, Goyal L, Rice-Stitt T, Mubeen A, Arora K, Bardeesey N, Miura J, Gamblin TC, Zhu AX, Borger D, Lillemoe KD, Rivera MN, Deshpande V. The Ability to Diagnose Intrahepatic Cholangiocarcinoma Definitively Using Novel Branched DNA-Enhanced Albumin RNA In Situ Hybridization Technology. Ann Surg Oncol 2014; 23:290-6. [PMID: 25519926 DOI: 10.1245/s10434-014-4247-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) often is a diagnosis determined by exclusion. Distinguishing ICC from other metastatic adenocarcinomas based on histopathologic or immunohistochemical analysis often is difficult and requires an extensive workup. This study aimed to determine whether albumin, whose expression is restricted to the liver, has potential as a biomarker for ICC using a novel and highly sensitive RNA in situ hybridization (ISH) platform. METHODS Modified branched DNA probes were developed for albumin RNA ISH. The study evaluated 467 patient samples of primary and metastatic lesions. RESULTS Of the 467 samples evaluated, 83 were ICCs, 42 were hepatocellular carcinomas (HCCs), and 332 were nonhepatic carcinomas including tumors arising from the perihilar region and bile duct, pancreas, stomach, esophagus, colon, breast, ovary, endometrium, kidney, and urinary bladder. Albumin RNA ISH was highly sensitive for cancers of liver origin, staining positive in 82 (99 %) of 83 ICCs and in 42 HCCs (100 %). Perihilar and distal bile duct carcinomas as well as carcinomas arising at other sites tested negative for albumin. Notably, 6 (22 %) of 27 intrahepatic tumors previously diagnosed as carcinomas of undetermined origin tested positive for albumin. CONCLUSIONS Albumin RNA ISH is a sensitive and highly specific diagnostic tool for distinguishing ICC from metastatic adenocarcinoma to the liver or carcinoma of unknown origin. Albumin RNA ISH could replace the extensive diagnostic workup, leading to timely confirmation of the ICC diagnosis. Additionally, the assay could serve as a guide to distinguish ICC from perihilar adenocarcinoma.
Collapse
Affiliation(s)
| | - David T Ting
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammed Shahid
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Division of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Lipika Goyal
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Travis Rice-Stitt
- Division of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ayesha Mubeen
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kshitij Arora
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Division of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Nabeel Bardeesey
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John Miura
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Andrew X Zhu
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Darrell Borger
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Miguel N Rivera
- Division of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Division of Pathology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
8
|
Daud AI. Reply to M.-E. Percival et al and L.B. Saltz. J Clin Oncol 2013; 31:2515-6. [DOI: 10.1200/jco.2013.49.6703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Adil I. Daud
- University of California, San Francisco, San Francisco, CA
| |
Collapse
|
9
|
Percival ME, Colevas AD. Biased View of the Role of Site-Specific Therapy in Carcinoma of Unknown Primary. J Clin Oncol 2013; 31:2512-3. [DOI: 10.1200/jco.2013.49.5036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
10
|
Saltz LB. Role of Expression Profiling in Carcinoma of Unknown Primary Remains Unknown. J Clin Oncol 2013; 31:2513-4. [DOI: 10.1200/jco.2013.49.2264] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|