Volume 5, Number 24; March 09, 2006
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Volume 5, Number 24; March 09, 2006 |
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Middle-aged female with pulmonary hypertension, swollen leg, and Bell's Palsy.
Recommended reading:
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Patient: 53 year old female being evaluated for pulmonary hypertension. Presenting with 10 months enormously swollen leg after cat bite, 3 months Bell's Palsy, current SOB.
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Session Handout:
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Clinical Question: 1) Are extended workups for cancers of unknown primary site worthwhile?
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Readings:
Link Directly to Fulltext Article at Science Direct
<11> Unique Identifier [PMID]: 15890271 Authors: Pavlidis N. Fizazi K. Institution: School of Medicine, Department of Medical Oncology, University of Ioannina, Greece. npavlid@cc.uoi.gr Title: Cancer of unknown primary (CUP). [Review] [45 refs]
Source: Critical Reviews in Oncology-Hematology. 54(3):243-50, 2005 Jun. Abstract: Carcinoma of unknown primary (CUP) is one of the 10 most frequent cancers worldwide. It constitutes 3-5% of all human malignancies. Patients with CUP present with metastases without an established primary site. CUP manifests as an heterogenous group of mainly epithelial cancers recognised by distinct clinicopathological entities. The diagnostic work-up includes extensive histopathology investigations and modern imaging technology. Nevertheless, the primary tumour remains undetected most of the time. Certain clinicopathological CUP entities are considered as favourable subsets responding to systemic platinum-based chemotherapy or managed by locoregional treatment. These subsets are: the poorly differentiated carcinomas involving the mediastinal-retroperitoneal nodes, peritoneal papillary serous adenocarcinomatosis in females, poorly differentiated neuroendocrine carcinomas, isolated axillary node adenocarcinomas in females or cervical nodal involvement by a squamous cell carcinoma. Patients who belong to the non-favourable subsets have a worse prognosis. [References: 45] Publication Type: Journal Article. Review.
Link Directly to Fulltext Article at Publisher <19> Unique Identifier [PMID]: 15169988 Authors: Mintzer DM. Warhol M. Martin AM. Greene G. Institution: Joan Karnell Cancer Center, Pennsylvania Hospital, Philadelphia, Pennsylvania 19106, USA. dmmonc@aol.com Title: Cancer of unknown primary: changing approaches. A multidisciplinary case presentation from the Joan Karnell cancer center of pennsylvania hospital.
Source: Oncologist. 9(3):330-8, 2004. Abstract: Cancer of unknown primary is a common clinical syndrome, accounting for 2%-5% of cancer patients. A representative case is presented. This heterogenous group of disorders includes entities such as poorly differentiated carcinoma of unknown primary, adenocarcinoma of unknown primary, neuroendocrine carcinoma of unknown primary, squamous cell carcinoma of unknown primary, poorly differentiated (not otherwise specified) cancer of unknown primary, and melanoma of unknown primary. It is crucial to identify those treatment-responsive presentations of unknown primary with the greatest potential for long-term survival. This discussion emphasizes newer approaches to the diagnosis and treatment of unknown primary cancer, including advances in pathology with immunoperoxidase and molecular genetic techniques, positron emission tomography, and published chemotherapeutic trials. With the increased sophistication of pathologic and radiologic techniques, the frequency of unknown primary cancers will likely continue to decline. Further, as newer and more targeted therapies for specific types of cancer are identified, the previously held nihilism regarding the search for and identification of the primary may become less supportable. Publication Type: Case Reports. Clinical Conference. Journal Article.
Link Directly to Fulltext Article at Publisher <31> Unique Identifier [PMID]: 12902422 Authors: Delgado-Bolton RC. Fernandez-Perez C. Gonzalez-Mate A. Carreras JL. Institution: Department of Nuclear Medicine, Hospital Clinico San Carlos, c/o Prof Martin Lagos s/n, Madrid 18040, Spain. delgadobolton@eresmas.com Title: Meta-analysis of the performance of 18F-FDG PET in primary tumor detection in unknown primary tumors.
Source: Journal of Nuclear Medicine. 44(8):1301-14, 2003 Aug. Abstract: Detection of the primary tumor has a key role in the management of patients with unknown primary tumors (UPT). The aim of this study was to perform a meta-analysis of the literature to evaluate the accuracy of (18)F-FDG PET in primary tumor detection in patients with UPT. METHODS: Systematic methods were used to identify, select, and evaluate the methodologic quality of the studies as well as to summarize the overall findings of sensitivity, specificity, and detection capacity of the primary tumor. The search strategy consisted of identifying studies published between January 1994 and May 2001 indexed in MEDLINE and CANCERLIT. Studies identified by manually searching reference lists of retrieved studies or by reviewing abstracts from recent conference proceedings were also included. Inclusion criteria were studies that evaluated primary tumor detection with (18)F-FDG PET in patients with UPT. Exclusion criteria were duplicated studies or those outdated by subsequent ones. The statistical analysis included 95% confidence intervals (CI) of sensitivity and specificity, both in the pooled data and in the types of studies found. Variation in accuracy between studies was analyzed calculating the natural logarithm of the odds ratio (ln OR) due to study characteristics. Funnel plots of sensitivity and specificity and the summary receiver-operating-characteristic (ROC) curve were also represented. RESULTS: Fifteen studies met the inclusion criteria and were analyzed. Although sample sizes were small, compliance with the methodologic quality criteria was adequate. Heterogeneity analysis showed that differences in the study quality did not correlate with differences in study results. The 95% CI of sensitivity and specificity presented global homogeneity, estimating the sensitivity at 0.87 (95% CI, 0.81-0.92) and the specificity at 0.71 (95% CI, 0.64-0.78). The summary ROC curve showed a good relationship between sensitivity and specificity. The ln OR presented significant values in >75% of the studies. CONCLUSION: (18)F-FDG PET could be useful in patients with UPT for the detection of the primary tumor. (18)F-FDG PET has intermediate specificity and high sensitivity, indicating the existence of few false-negative results, an important feature in the management of oncologic patients that could suggest its utility in the initial stages of the management process. Publication Type: Journal Article. Meta-Analysis.
Link Directly to Fulltext article in Ovid <39> Unique Identifier [PMID]: 7575063 Authors: Schapira DV. Jarrett AR. Institution: Stanley S. Scott Cancer Center, Department of Medicine, Louisiana State University Medical Center, New Orleans, USA. Title: The need to consider survival, outcome, and expense when evaluating and treating patients with unknown primary carcinoma.[see comment]. Comments Comment in: Arch Intern Med. 1995 Oct 23;155(19):2035-6; PMID: 7575060
Source: Archives of Internal Medicine. 155(19):2050-4, 1995 Oct 23. Abstract: BACKGROUND: Patients who present with unknown primary carcinomas represent 10% to 15% of the patients with cancer who present to medical centers. Despite data in the literature indicating minimal success in determining the location of primary carcinomas, these patients continue to be evaluated exhaustively. Additionally, identification of the location of primary carcinomas does not often affect treatment. Clinical treatment and prognosis are only affected if a reevaluation of the pathologic findings yields a potentially curative diagnosis of an undifferentiated lymphoma, germ cell tumor, or a hormonally sensitive carcinoma. METHODS: Tumor registry files from January 1, 1990, through December 31, 1992, were retrospectively retrieved to identify adult patients who presented with metastasis of an unknown primary site at the H. Lee Moffitt Cancer Center and Research Institute, a 162-bed tertiary care cancer center specialty hospital affiliated with the University of South Florida College of Medicine, Tampa. Medical records were reviewed for age, sex, histologic findings of previous malignant growth, types and duration of symptoms, and mode of presentation. Fifty-six of the 199 patients were included in the study; 31 were men (55.4%) and 25 were women (44.6%), with ages ranging from 33 to 83 years. Diagnostic evaluations were reviewed and included data from procedures conducted at both the H. Lee Moffitt Cancer Center and at outside facilities. Diagnostic studies performed included barium swallow; intravenous pyelogram; mammogram; abdominal ultrasound; chest x-ray film; bone scan; magnetic resonance imaging; computed tomography of the head, chest, abdomen, and pelvis; laparotomy; bronchoscopy; gastroscopy; and colonoscopy. Information for the diagnostic test procedures was taken from the point of initial patient contact until the determination of metastatic disease. RESULTS: The primary cancer site was found in four (7.1%) of the 56 cases in the study and could not be classified as curable by systemic means. The average cost of diagnosis was $17,973, with 19.6% of the patients surviving for more than 1 year. The mean survival period was 8.1 months. A total of 410 tests were performed with only four tests correctly identifying the location of the primary tumor. CONCLUSIONS: Once a potentially curable malignancy has been excluded, there is little justification to support extensive diagnostic evaluation of the patient. Substantial costs are incurred and survival is often not significantly affected. It was estimated that 1.2 million new cancer cases would have occurred during 1994, with approximately 10% of these patients presenting with cancer of unknown primary origin. Based on cost assessments, investigation of these patients would exceed $1.5 billion. This clinical scenario is one where attention to outcome, clinical management, and expense should be carefully considered. Publication Type: Journal Article.
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Resident Report / Department of Medicine & Grady Branch Library Emory University School of Medicine 2005 Edition Participating Faculty: Carlos Del Rio MD / Joyce Doyle MD / Lorenzo Difrancesco MD / Erich Folch MD / Alicia Hidron MD
Contact:
Karl Woodworth
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