Download Joint Hospital Grand Round

Joint Hospital Surgical
Grand Round
21st July, 2012
RH
Liver Secondaries with
Occult Primary
How far should we go?
Dr Chan Man Pan
Caritas Medical Centre
Terminology

Different terms has been used by
investigators
 Unknown
or occult primary tumor, Metastasis
of unknown origin, Tumor of unidentified
origin….
 Currently, the most widely accepted term is
“Cancer of Unknown Primary” (CUP)
Definition
Pavlidis, N., et. al. (2003). Diagnostic and therapeutic management of cancer of an unknown primary.
European Journal of Cancer, 39(14), 1990-2005.
Magnitude of problem
Pavlidis, N., et. al. (2003). Diagnostic and therapeutic management of cancer of an unknown primary.
European Journal of Cancer, 39(14), 1990-2005.
Epidemiology





Annual age-adjusted incidence is 7 – 12 cases
per 100,000 population / year in USA
Median age at presentation ~ 60 years old
Slightly male predominant
No obvious aetiological or risk factor can be
identified
Commonly presented as lymph node or liver
metastasis
Pavlidis, N. et. al. (2009). Carcinoma of unknown primary (CUP). Critical reviews in
oncology/hematology, 69(3), 271-8.
Lazaridis, G., et. al (2008). Liver metastases from cancer of unknown primary (CUPL): a retrospective
analysis of presentation, management and prognosis in 49 patients and systematic review of the
literature. Cancer treatment reviews, 34(8), 693-700.
Liver secondaries with occult
primary
Aggressive and resistant disease with a
grim outcome……
 How far should we go in investigating?
 Does surgery have a role?

How far should we go?
Searching for primary is meaningful only if
management can be affected
 Chance of successfully locating the
primary?

Armamentarium
History taking & physical exam
 Basic blood test, Urinalaysis, Fecal occult
blood
 Serum tumor markers
 Imaging (CXR CT PET MRI Mammography)
 Endoscopy
 Histology

Tumour marker
Non specific elevation of multiple markers in majority of CUP patient
Pavlidis, N., et. al.(2003). Diagnostic and therapeutic management of cancer of an unknown primary.
European Journal of Cancer, 39(14), 1990-2005.
Tumour marker

Routine measurement of epithelial tumour
markers is not recommended
 However, in some cases, it might be
diagnostically helpful—eg, beta-HCG and AFP
are increased in patients with poorly
differentiated carcinoma of midline distribution,
as are PSA in men with bone metastases
 CA-125 in women with primary serous
peritoneal adenocarcinoma, and CA15-3 in
women with isolated axillary adenocarcinoma.
Pavlidis N, et. al. (2012). Cancer of Unknown Primary site. Lancet. 14;379(9824):1428-35
PET CT
Kwee, Thomas C.et. al. (2009). Combined FDG-PET/CT for the detection of unknown primary tumors:
systematic review and meta-analysis. European Radiology. 19(3):731-744.
PET CT
Kwee, Thomas C.et. al. (2009). Combined FDG-PET/CT for the detection of unknown primary tumors:
systematic review and meta-analysis. European Radiology. 19(3):731-744.
PET CT
Kwee, Thomas C.et. al. (2009). Combined FDG-PET/CT for the detection of unknown primary tumors:
systematic review and meta-analysis. European Radiology. 19(3):731-744.
PET CT
Kwee, Thomas C.et. al. (2009). Combined FDG-PET/CT for the detection of unknown primary tumors:
systematic review and meta-analysis. European Radiology. 19(3):731-744.
PET scan VS PET CT
Gutzeit, A. et al. (2005). Unknown primary tumors: detection with dual-modality PET/CT--initial
experience. Radiology, 234(1), 227-34.
Whole body MRI

No published data on this topic
Diagnostic Endosocpy

Panendoscopy, OGD, Colonoscopy,
bronchoscopy
 Guided
by Clinical and Laboratory finding
 GI
endoscopy in patients with abdominal symptoms
or fecal occult blood + ve, or histology point to a GI
tract origin

Pavlidis, N. et. al. (2009). Carcinoma of unknown primary (CUP). Critical reviews in
oncology/hematology, 69(3), 271-8.
 Endoscopic
studies of asymptomatic areas identify
the primary tumour in less than 10% of such cases

Gaber AO, et al. (1983). Metastatic malignant disease of unknown origin. Am J Surg.
145:493-497
Pavlidis N, et. al. (2012). Cancer of Unknown Primary site. Lancet. 14;379(9824):1428-35
In searching for primary
Primary tumor can only be located in 20%
to 30% of case (with combination of
imaging, endoscopy and histology)
 Most common primary site is lung,
colorectal and pancreas

Pavlidis, N., et. al. (2010). Cancer of unknown primary site: 20 questions to be answered. Annals of
oncology: official journal of the European Society for Medical Oncology / ESMO, 21 Suppl
7(Supplement 7), vii303-7
Prognostic factors
Lazaridis, G., et. al (2008). Liver metastases from cancer of unknown primary (CUPL): a retrospective
analysis of presentation, management and prognosis in 49 patients and systematic review of the
literature. Cancer treatment reviews, 34(8), 693-700.
Prognostic factors
Prognostic factor

Certain histological subgroup are more
amenable to treatment
 Liver
biopsy is essential as a primary
diagnostic procedure.
Neuroendocrine carcinoma with
liver metastasis
Pancreas, right hemicolon and small
intestine are most frequent primary site
 Surgical resection in curative intent can
offer survival benefit in selected cases

5
year survival rate 60-80%
Pavel, M., et al. (2012). ENETS Consensus Guidelines for the management of patients with liver and other
distant metastases from neuroendocrine neoplasms of foregut, midgut, hindgut, and unknown primary.
Neuroendocrinology, 95(2), 157-76.
The American surgeon; Jun 2004
Median follow up 9 months
Median Disease free survival 6.5 months
Summary

How far should we go in investigating?
PET/PET-CT
Hawksworth et al, (2004) Surgical and Ablative Treatment for Metastatic Adenocarcinoma to the liver from
Unknown Primary tumor. The American surgeon, 70(6), 512 - 517
Summary

How far should we go in management
A
multidisciplinary approach
 More studies are needed
Thank you