Professor Martin Tattersall
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Common Problems with Morphine Use
Dressings for Malignant Wounds
Lymphoedema - Palliative Physiotherapy
Antidepressants in Palliative Care
Bowel Obstruction in Palliative Care
Secondary Malignancy
Table of Contents |
Aetiology: This condition may occur in tumours which have a tendency to metastasise early. In 15-25% of cases where the primary remains occult during the patient's life, it is not able to be found at autopsy. In this situation it may be that the primary has disappeared, or it may be that the tools we have at our disposal to find it are not adequate. The primary may have been removed or may have sloughed off skin or mucosa.
Incidence: The lifetime risk of having cancer with an unknown primary (CUP) in NSW is : for males 1:56; for females 1:77. In Australia it is the fourth most common cause of cancer death in males and the third most common in females.
Histology: There is a range of histological types:
Frequency of histological subtypes of cancer of unknown primary site:
| Adenocarcinoma | 22336 | ||
| Carcinoma | 11318 | ||
| Undifferentiated carcinoma | 16 | ||
| SCF | 6 | 4 | |
| Low cervical | 3 | 5 | |
| Ingiunal | 3 | 1 | |
| Sub-total | 13 | 26 | 39 |
| Skin and subcutaneous | 1 | 0 | 1 |
| Total | 143 | 143 | 286 |
From Kirsten, Chung, Leary, Ng, Hedley & Tattersall, 1987
When the presentation is with axillary lymph node involvement, the prognosis in women is better overall. These patients are treated as if the primary were breast. Mammography is negative in 50% of these cases. Other primary sites should also be considered, eg ovary and lung.
Weight loss is a prominent sign in about 35% of all cases.
Where the presentation is with liver secondaries, one cannot assume that the primary is in the gastro intestinal tract. Only 60% of these tumours are adenocarcinoma. At biopsy, which should be the first investigation, they may also be carcinoid or small cell.
Natural History:
Prognosis is generally poor with median survival of three to four months. Fewer than 25% of patients survive a year and fewer than 10% survive five years.Generally speaking, intensive search for the primary does not improve survival.
Primary sites
Primary sites / Number
- Lung 23
- Ovary* 11
- Breast* 10
- Colon 8
- Gastric 6
- Kidney 6
- Prostate* 5
- Pancreas 4
- Melanoma 3
- Adrenal 2
- Thyroid* 2
- Germ cell* 2
- Hepatoma 2
- Lymphoma* 2
- Mesothelioma 1
- Nasopharyngeal 1
- Total 88
From Kirsten, Chung, Leary, Ng, Hedley & Tattersall, 1987
Prognostic Factors:
- Good performance status
- Absence of excessive weight loss
- Age under 35
- Presentation with lymphadenopathy especially high cervical and axillary, tend to have a prolonged survival
- Number of sites involved - a higher number being associated with a worse prognosis.
Management:
About 10% of patients with CUP had treatable tumour types. Investigations are therefore aimed at identifying the treatable tumours.Treatable tumours which may present as cancer of unknown primary site:
Cure possible
- Germ cell tumours
- Hodgkin's disease
- Non-Hodgkin's lymphoma
- Thyroid cancer
- Trophoblastic tumours
Effective Palliation
Chemoresponsive (>50%):- Breast cancer
- Gastric cancer
- Head and neck cancer
- Ovarian cancer
- Sarcomas
- Small cell lung cancer
Hormonal treatment:
- Breast cancer
- Endometrial cancer
- Prostatic cancer
- Thyroid cancer
Tumours of Unknown Primary Site. Oxford Textbook of Oncology. Ed. Peekham MJ, Pinedo B, Vevareni V. (In prep).
Professor Martin Tattersall
Ludwig Institute for Cancer Research
University of Sydney
References:
1. Kirsten F, Chung HC, Leary JA, Ng AB, Hedley DW, Tattersall MHN. Metastatic Adeno or Undifferentiated Carcinoma from an Unknown Primary Site - Natural History and Guidelines for Identification of Treatable Subsets. Quarterly Journal of Medicine, New Series 62, No. 238, pp. 143-161, February, 1987.
2. Lindeman GJ, Tattersall MHN. Tumours of Unknown Primary Site. Oxford Textbook of Oncology. Ed. Peekham MJ, Pinedo B, Vevareni V. (In prep).
3. Holmes FF, Fouts TL (1970) Metastatic Cancer of Unknown Primary Site. Cancer 26:1431-5.
Discussion
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Secondary Malignancy |
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Secondary Malignancy Rosangela Almeida Victor, carolina@aquarius.com.br. Posted 28/10 22:54 I am brasilian student Molecular Biology, I am finding articles 'cancer head and neck' relative ambiental factores. I gratefull your help.
Cindy Spurgeon, spurgeon@tigernet.missouri.org Posted 07/11 2:49 My father was diagnosed about one month ago with cancer. His official diagnosis was tumor or unknown primary site. Metastasis was discovered in the pelvic bone as well as in both lungs. He has received a ten-day radiation treatment for palliation of bone pain. He is receiving MS-Contin for pain (having previously been on Duragesic transdermal therapy). Tests have been unable to discover cancer in either the colon or prostate. He has had CT scans and MRIs done. My main question is this, He is suffering from extreme nausea which appears to supersede even his pain as chief complaint. Do you think this could be indicative of brain metastasis? I don't really think it is related to the MS contin as he was nauseated prior to taking it. We are trying to decide whether or not a course of chemo would help, but find this discouraging because of the nausea it might induce. Please replay. I am a registered nurse, so I have some medical background. Cindy Spurgeon, spurgeon@tigernet.missouri.org Posted 07/11 2:50 My father was diagnosed about one month ago with cancer. His official diagnosis was tumor or unknown primary site. Metastasis was discovered in the pelvic bone as well as in both lungs. He has received a ten-day radiation treatment for palliation of bone pain. He is receiving MS-Contin for pain (having previously been on Duragesic transdermal therapy). Tests have been unable to discover cancer in either the colon or prostate. He has had CT scans and MRIs done. My main question is this, He is suffering from extreme nausea which appears to supersede even his pain as chief complaint. Do you think this could be indicative of brain metastasis? I don't really think it is related to the MS contin as he was nauseated prior to taking it. We are trying to decide whether or not a course of chemo would help, but find this discouraging because of the nausea it might induce. Please replay. I am a registered nurse, so I have some medical background. |
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