Transcript Mrs PC, 63yo woman - Oncology Clinics Victoria

MRS PC, 63YO WOMAN
 Initially presented with chronic RIF pain
 Found to have cholelithiasis, underwent a laparoscopic cholecystectomy
 On the laparoscopy, nothing abnormal was noted in the abdomen
 The pain persisted
MEDICAL HISTORY
 Panic attacks
 Varicose veins
 Cholelithiasis
 Distant ex-smoker (ages 18-27)
FAMILY HISTORY
 Mother: ovarian ca (age 70+)
 Maternal aunt: breast ca (age ~70)
 Father: lung ca (smoker)
HOPC (CONT.)
 Went on to have transvaginal ultrasound, which showed a cystic lesion on the R) ovary
 CT and PET scan showed:

Large avid pelvic mass

Avid serosal/peritoneal areas elsewhere

Small volume ascites in the pelvis which was mildly avid
 Underwent laparotomy for radical debulking and biopsies
PATHOLOGY
 Histology showed multicystic mucinous cells on samples of:

Serosal surface of the ovaries and fallopian tubes

R) and L) parametria

R) pelvic side wall
 Staining:

Strong, diffuse CK7 and CDX2 positivity

Patchy CK20 positivity

ER negative
 Felt by pathologist to be of pancreatobiliary origin
DIAGNOSIS
 Adenocarcinoma of unknown primary
 Possibly pancreatobiliary source
 Distribution of disease not
TREATMENT
 Following surgery, was given chemotherapy
 FOLFOX + Avastin
 Had an adverse drug reaction to oxyplatin x2
 Maintenance treatment  Xeloda
 Achieved complete metabolic remission (on PET) for a period of 4-5 months
RECURRENCE
 6 weeks ago, PET showed:

Avid serosal/peritoneal deposits on sigmoid colon

Avid peritoneal fluid in the pelvis
 Started on chemotherapy

CBDCA + Paclitaxel + Avastin
TREATMENT COMPLICATIONS
Acute:
 Oxyplatin hypersensitivity
 Fatigue
 Dry skin
 Mucosal ulcers
 Occasional nausea
Permanent:
 Incisional hernia
 Peripheral neuropathy, stable

Manifest as paraesthesia and neuropathic pain in feet and fingers

Nil trouble with weakness, gait disturbance, unsteadiness, falls

Some trouble with getting out medications as a result
CARCINOMA OF UNKNOWN PRIMARY (CUP)
 Heterogenous group of metastatic cancers where the primary site cannot be found

Small primaries may remain undetected

Primaries may have regressed

Primaries may be incidentally removed in treatment for other conditions
 Accounts for 3% of cancer diagnoses
 As they are heterogenous, they vary widely in prognosis and response to specific treatments
CLASSIFYING CUP
 Clinical manifestations

i.e. isolated axillary lymphadenopathy in women vs. peritoneal disease
 Pathological examination

Cytology

Immunohistochemistry

Gene expression profiling
CYTOLOGY
 May differentiate tissue of origin but will not definitively determine primary site

SCC is likely to have come from respiratory tract, but may come from skin

Adenocarcinoma is particularly troublesome, as it may originate in many organs
 Very poorly differentiated cancers may not be identifiable
IMMUNOHISTOCHEMISTRY
 Involves stains for specific proteins which may help to predict the primary site
 CK7 and CK20 are commonly tested initially
 Results of initial stains inform selection of further stains
 The amount of tissue is often a limiting factor
 IHC staining algorithms have been shown to predict the primary site correctly in approximately two thirds of
cancers with KNOWN primary in blinded studies
GENE EXPRESSION PROFILING
 Tests gene expression of malignant cells using techniques such as rt-PCR and microarrays
 Focuses on genes which help delineate organ of origin
 Assays may test for up to 92 genes to delineate between up to 42 tumour types
 GEP assays have been shown to predict the primary site correctly in approximately 85% of cancers with
KNOWN primary in blinded studies (probably closer to 75% of CUP)
 In CUP studies, shows ~78% concordance with IHC predictions

When IHC is more definitive (i.e. predicts single tumour type), GEP is more highly concordant than when IHC is ambiguous