Poorly differentiated squamous cell carcinoma of unknown primary location a case report of perineal presentation.

INTRODUCTION: Cancers of unknown primary origin (CUP) pose a significant clinical challenge, representing a small percentage (1 to 5 %) of overall cancer cases. The patient is a 31-year-old male who has been diagnosed with poorly differentiated infiltrating squamous cell carcinoma, which has been classified as CUP. The exceptional perineal presentation and diagnostic process serve as a reminder of the diverse nature of CUPs and the crucial role played by advanced imaging methods and a multidisciplinary approach. The inclusion of this case, the seventh one in the literature, deepens our understanding of CUPs. PRESENTATION OF CASE: A 31-year-old man came in with a gradual onset of perineal pain that had been worsening for the past six months. A nodular lesion in the urogenital triangle, infiltrating the bulbo spongiosus muscle, was surgically removed. The histopathology results confirmed a poorly differentiated squamous cell carcinoma. Despite conducting extensive examinations, the multidisciplinary team was unable to determine the source of the tumour, classifying it as CUP. One year post-surgery, the patient remains in complete remission. DISCUSSION: The management of CUPs can be challenging because of the variety of their origins and presentations. The importance of advanced imaging, pathological and biological techniques, as well as meticulous surgical intervention, is emphasized in this case, as it helps in avoiding unnecessary adjuvant therapies. CONCLUSION: This case highlights the significance of a customized and interdisciplinary approach in effectively managing CUPs, especially when they present in unusual ways. Timely surgical intervention, backed by comprehensive imaging and pathological analysis, can result in positive results.

Portuguese Consensus Recommendations for Next-Generation Sequencing of Lung Cancer, Rare Tumors, and Cancers of Unknown Primary Origin in Clinical Practice.

Next-generation sequencing (NGS) has been implemented in clinical oncology for diagnosis, prognosis, and therapeutic guidance. Among the various NGS applications in molecular oncology, we focused on the following topics: laboratory standards for targeted gene panels (somatic mutations) and therapeutic guidance based on NGS of lung cancer and rare cancers, namely sarcomas and cancers of unknown primary. Multiple quality control checkpoints should be addressed in the pre-analytical phase for good quality and interpretation of the NGS results. It includes tumor size and cellularity, tissue processing and decalcification, tumor fraction, tumor viability, fixatives, and staining. Communication between clinicians and laboratory support is also essential. In lung cancer, all patients with non-squamous non-small cell lung cancer should be tested with a NGS panel, and it should include not only genes with approved targeted therapies (ALK, BRAF, EGFR, MET, NTRK, RET, and ROS1) but also genes with potentially actionable genomic alterations (HER2 and KRAS). Since there is a lack of extensive knowledge regarding the use of NGS in rare tumors performing comprehensive genomic profiling, NGS panels to better manage the disease are recommended. Moreover, other patients with other incurable solid tumors may benefit from being included in biomarker-driven clinical trials. Multidisciplinary tumor boards with the participation of experts with the ability to integrate genomic profiling data are essential to tailor the best strategy for each patient. Considering that there are no national guidelines, this article aims to guide laboratory and clinical practice for the use of NGS in the context of lung cancer, rare tumors, and cancer of unknown primary in Portugal.

Na área da oncologia clínica, a sequenciação de nova geração (NGS) foi implementada com o objetivo de contribuir para o diagnóstico, prognóstico e orientação terapêutica. A utilização de NGS em oncologia molecular é vasta, focalizando-se estas recomendações nas: normas laboratoriais para painéis genéticos direcionados (mutações somáticas) e na orientação terapêutica baseada em NGS de cancro do pulmão e cancros raros, nomeadamente sarcomas e cancros de origem desconhecida. Para que sejam obtidos resultados de NGS com a qualidade que permita a sua correta interpretação, devem ser abordados múltiplos controlos de qualidade na fase pré-analítica que disponibilizem informação sobre o tamanho e celularidade do tumor, processamento e descalcificação de tecidos, fração tumoral, viabilidade do tumor, fixadores e coloração utilizados. A comunicação entre os diferentes intervenientes no processo, em particular entre os clínicos e o laboratório também contribui, de forma inequívoca, para a interpretação dos resultados de NGS. Todos os doentes com cancro do pulmão de não pequenas células não escamoso devem ser testados com um painel de NGS, que deve incluir não só genes com terapias dirigidas aprovadas (ALK, BRAF, EGFR, MET, NTRK, RET e ROS1), mas também genes com alterações genómicas identificadas como potenciais alvos terapêuticos (HER2 e KRAS). Dada a escassez de evidência científica sobre a utilização de NGS em tumores raros, recomenda-se a realização de painéis genómicos abrangentes que poderão contribuir para uma melhor gestão da doença. Adicionalmente, outros doentes, com outros tumores sólidos incuráveis, podem beneficiar da inclusão em ensaios clínicos orientados por biomarcadores. A realização de reuniões multidisciplinares com a participação de diferentes especialistas capazes de integrar dados dos perfis genómicos são fundamentais para a escolha da melhor estratégia para cada doente. Considerando que não existem recomendações nacionais, este artigo visa orientar a prática laboratorial e clínica para a utilização de NGS em tumores do pulmão, raros e cancros de origem primária desconhecida em Portugal.

Cutaneous metastasis on the nasal tip: first clinical sign of pulmonary carcinoid tumor.

Skin metastases are rare and may occur in the context of a known metastatic disease or be the first clinical sign of an underlying primary tumor. In the case of carcinoid neoplasms, determining whether the cutaneous tumor is primary or secondary and identifying the tumor origin in metastatic cases is not always an easy task. This is the report of a case of cutaneous metastasis presenting as the first clinical manifestation of a previously unknown pulmonary carcinoid tumor, including the discussion of histopathological and immunohistochemical findings that allowed an adequate diagnosis of the tumor etiology and reinforces the importance for dermatologists and dermatopathologists to be familiar with these findings.

Impact of PET/CT on clinical management in patients with cancer of unknown primary-a PET/CT registry study.

OBJECTIVE: To evaluate the impact of PET/CT on clinical management in patients with cancer of unknown primary (CUP). METHODS: A cohort of patients with CUP undergoing PET/CT was prospectively enrolled in a local PET/CT registry study between April 2013 and June 2018. Questionnaire data from referring physicians on intended patient management prior and after PET/CT were recorded including items on the intended treatment concept and intended additional diagnostics. Changes in management after PET/CT were recorded. Patient outcome of different cohorts was analyzed for overall survival drawn from patient records. RESULTS: One hundred fifty-five patients (53 female; 63.4 ± 12.1 years) were included. Intended therapeutic management was revised in 45.8% of patients after PET/CT, including major changes affecting the intended treatment goal in 26.5% of patients and minor changes (therapy adjustments) in 19.3% of patients. Invasive and additional diagnostic procedures were intended in 25.8% and 63.2% prior PET/CT and 13.5% and 6.5% after PET/CT. PET/CT-based curative therapy concepts were associated with significantly longer patient survival (4.7 ± 0.3 years) than palliative therapy concepts (1.8 ± 0.5 years, p = .0001). Patients with cervical CUP showed a significantly longer survival (4.3 ± 0.3 years) than patients with extracervical CUP (3.5 ± 0.5 years, p = .01). The identification of the primary did not significantly affect survival. CONCLUSION: This registry study confirms previous studies reporting that PET/CT significantly influences clinical management in patients with CUP, helping physicians to select a more individualized treatment and to avoid additional diagnostics. Furthermore, we could confirm that tumor localization and extent as shown by PET/CT have a significant impact on patient prognosis. KEY POINTS: • PET/CT significantly influences intended clinical management in patients with CUP, helping physicians to select a more individualized treatment and to avoid additional diagnostics. • Tumor localization and extent as shown by PET/CT have a significant impact on patient prognosis. • The identification of the primary tumor has no significant impact on overall patient survival.

Tumores hepáticos primarios malignos no hepatocarcinoma ni colangiocarcinoma / Primary malignant hepatic tumors other than hepatocarcinoma or cholangiocarcinoma: a series of cases

Background: There are several types of primary malignant hepatic tumors (PMHT) other than hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC): they are infrequent and poorly known. Imaging studies could help characterize the lesions and may guide the diagnosis. However, the definitive diagnosis of PMHT is made by pathology. Aim: To review a registry of liver biopsies performed to diagnose hepatic tumors. Patients and Methods: Review of a pathology registry of liver biopsies performed for the diagnosis of liver tumors. Among these, 25 patients aged 57 ± 17 years, 60% males, in whom a liver tumor other than a HCC or CC was diagnosed, were selected for review. The medical records of these patients were reviewed to register their clinical characteristics, imaging and the pathological diagnosis performed during surgery and/ or with the percutaneous liver biopsy. Results: Ten patients (40%) had neuroendocrine tumors, six (24%) had a lymphoma and four (16%) had hepatic hemangioendothelioma. Angiosarcoma and sarcomatoid carcinoma were diagnosed in one patient each. In 22 patients (88%), neither clinical features nor imaging studies gave the correct diagnosis. Four patients (16%) had chronic liver disease. The most frequent symptoms were weight loss in 28% and abdominal pain in 24%. Conclusions: The most common PMHT other than HCC and CC were neuroendocrine tumors and lymphomas. Imaging or clinical features were not helpful to reach the correct diagnosis.

Primary cystic neuroendocrine tumor of the liver: case report / Tumor neuroendócrino quístico primario de hígado: reporte de un caso

Background: 85% of neuroendocrine tumors (NET) originate in the gastrointestinal tract, which is why their primary hepatic location is very rare; NETs most frequently cause metastases to the liver; so when diagnosed, a hepatic NET is considered initially metastatic. Diagnosis of primary hepatic neuroendocrine tumors (PHNET) should be performed by excluding extrahepatic NETs and through histological confirmation. The objective of this article is to present a case of PHNET. Clinical case: 75-year-old male patient, who presented asthenia, adynamia, abdominal pain in the right hypochondrium, six-month weight loss, with a right subcostal palpable tumor. Imaging studies reported a lesion in the right hepatic lobe, multilobulated, heterogeneous, with poorly defined margins and with cystic areas. It was performed diagnostic laparotomy and then a hepatic tumorectomy, whose product measured 16.0 x 10.0 x 6.5 cm, with two cystic cavities of 13.2 and 11.5 cm of hematic content. Microscopically, cells with neuroendocrine differentiation, with positive immunoreactivity to chromogranin were observed. It was diagnosed well-differentiated neuroendocrine neoplasm, with cystic degeneration. Conclusions: Even though it is excluded a NET from an extrahepatic primary site, the tumor etiology of an important proportion of patients with PHNET will be due to an unknown primary tumor that will become apparent over time; hence, the need to follow up as long as possible.

Introducción: 85% de los tumores neuroendocrinos (TNE) se originan del tracto gastrointestinal, su localización hepática primaria muy rara; los TNE con mayor frecuencia causan metástasis al hígado; por esto, cuando se diagnóstica un TNE hepático es considerado inicialmente metastásico. El diagnóstico de tumor neuroendocrino primario de hígado (TNEPH) debe realizarse mediante la exclusión de tumores neuroendócrinos extrahepáticos y la confirmación histológica. El objetivo de este artículo es presentar un caso con TNEHP. Caso clínico: paciente de sexo masculino, de 75 años de edad, quien presentó astenia, adinamia, dolor abdominal en hipocondrio derecho y pérdida de peso de 6 meses de evolución, con tumor palpable subcostal derecho. Los estudios de imagen reportaron lesión en lóbulo hepático derecho, multilobulada, márgenes mal definidos, heterogénea y con áreas quísticas. Se realizó laparotomía diagnóstica y tumorectomía hepática que midió 16.0 x10.0 x 6.5 cm, con dos cavidades quísticas de 13.2 y 11.5 cm de contenido hemático. Microscópicamente se observaron células con diferenciación neuroendócrina, inmunoreactivas a cromogranina. Se estableció el diagnóstico de neoplasia neuroendócrina bien diferenciada, con degeneración quística. Conclusiones: aunque se excluya un TNE de sitio primario extrahepático, la etiología tumoral de una proporción considerable de pacientes con TNEPH será a causada por un tumor primario no conocido que se hará evidente con el tiempo; de ahí la necesidad de hacer seguimiento el máximo tiempo posible.

[The scheme of diagnosis and treatment on metastatic cervical carcinomas from an unknown primary].

SummaryMetastatic cervical carcinomas from unknown primary（MCCUP） are a group of metastatic carcinomas of cervical lymph nodes which could not be managed to find their origins. The diagnosis of MCCUP includes pathological diagnosis of metastatic cervical carcinomas, search of the primary cancer, the stage of（T0） NM. For unknown primary, there are some uncertainties of treatment on MCCUP. The methods of diagnosis and treatment on MCCUP should be renewed with the development of clinical medicine.

Unknown primary large-cell neuroendocrine tumor.

Large-cell neuroendocrine tumors (NETs) are poorly differentiated malignancies of rare incidence and aggressive nature. NETs mostly arise in the lung followed by the gastrointestinal tract, although they are potentially ubiquitous throughout the body. Primary unknown NET has a worse prognosis and shorter survival comparing with other NETs, with limited available data in the literature concerning this subgroup. The authors report the case of large-cell NET with supraclavicular lymph node presentation. Total excisional biopsy revealed an enlarged adenopathy 18 × 15 × 10 mm, which was extensively infiltrated by a solid malignant neoplasm composed of large cells with granular chromatin, nuclear pseudo-inclusions, high mitotic index, and focal necrosis, with a Ki 67 index 25-30% and positive immunohistochemical study for the expression of cytokeratin 8/18, chromogranin, synaptophysin, and thyroid transcriptional factor-1 (TTF-1). There was no evidence of primary location apart from two infracentimetric lung lesions that could not be accessed for biopsy and were negative at both somatostatin receptor scintigraphy and positron emission tomography. The NET relapsed with three mediastinal masses, so the patient was started on chemotherapy with carboplatin and etoposide with initial total response. Early progression showed no response to further chemotherapy regimens (temozolomide, oral etoposide); therefore, the patient was treated with local radiotherapy. This patient has an atypical long survival (54 months) compared to the literature data. In fact, there are few long-term survivors of large-cell NET and they are all related to complete surgical resection.

Diagnostic value of diffusion-weighted imaging and 18F-FDG-PET/CT for the detection of unknown primary head and neck cancer in patients presenting with cervical metastasis.

BACKGROUND AND PURPOSE: Head and neck squamous cell carcinoma (HNSCC) may present with cervical metastases without an apparent primary tumor. Detecting the primary tumor results in more targeted treatment. Acquisition of DWI is improving with less artifacts and image distortion. We assessed the diagnostic value of DWI and 18F-FDG-PET/CT for detecting primary tumors in patients presenting with nodal metastasis of an unknown primary HNSCC. MATERIALS AND METHODS: For this retrospective study we included 31 patients (male/female ratio = 23/8, median age = 66 years, age range = 40-80 years) who presented with a pathologically proven cervical nodal metastasis from HNSCC without overt primary tumor location between January 2013 and November 2016 and underwent both DWI and 18F-FDG-PET/CT. Both modalities were assessed qualitatively and quantitatively. With ROC analysis we determined the optimal cut-off for imaging parameters in separating occult malignancy from benign tissue. RESULTS: Qualitative analysis of MRI including DWI resulted in a sensitivity of 81.3% (95%CI) = 53.7-95.0) and specificity of 73.3% (95%CI = 44.8-91.1). With qualitative scoring of 18F-FDG-PET/CT a sensitivity and specificity of 93.8% (95%CI = 67.8-99.7) and 73.3% (95%CI = 44.8-91.1) were found. With quantitative analysis sensitivity and specificity of SUVmax were 81.3% (95%CI = 53.6-95.0) and 93.3% (95%CI = 66.0-99.7), respectively. Combining DWI and 18F-FDG-PET/CT resulted in a sensitivity of 93.8% (95%CI = 67.7-99.7%) and specificity of 60.0% (95%CI = 32.9-82.5%). CONCLUSION: In this study on HNSCC patients presenting with clinically UP lesions the diagnostic accuracy of qualitative analysis with DWI and 18F-FDG-PET/CT and quantitative analysis of 18F-FDG-PET/CT using SUVmax were high. Adding DWI did not improve the accuracy of 18F-FDG-PET/CT.

Unknown primary large-cell neuroendocrine tumor

Large-cell neuroendocrine tumors (NETs) are poorly differentiated malignancies of rare incidence and aggressive nature. NETs mostly arise in the lung followed by the gastrointestinal tract, although they are potentially ubiquitous throughout the body. Primary unknown NET has a worse prognosis and shorter survival comparing with other NETs, with limited available data in the literature concerning this subgroup. The authors report the case of large-cell NET with supraclavicular lymph node presentation. Total excisional biopsy revealed an enlarged adenopathy 18 × 15 × 10 mm, which was extensively infiltrated by a solid malignant neoplasm composed of large cells with granular chromatin, nuclear pseudo-inclusions, high mitotic index, and focal necrosis, with a Ki 67 index 25-30% and positive immunohistochemical study for the expression of cytokeratin 8/18, chromogranin, synaptophysin, and thyroid transcriptional factor-1 (TTF-1). There was no evidence of primary location apart from two infracentimetric lung lesions that could not be accessed for biopsy and were negative at both somatostatin receptor scintigraphy and positron emission tomography. The NET relapsed with three mediastinal masses, so the patient was started on chemotherapy with carboplatin and etoposide with initial total response. Early progression showed no response to further chemotherapy regimens (temozolomide, oral etoposide); therefore, the patient was treated with local radiotherapy. This patient has an atypical long survival (54 months) compared to the literature data. In fact, there are few long-term survivors of large-cell NET and they are all related to complete surgical resection.

Classifying brain metastases by their primary site of origin using a radiomics approach based on texture analysis: a feasibility study.

OBJECTIVE: To examine the capability of MRI texture analysis to differentiate the primary site of origin of brain metastases following a radiomics approach. METHODS: Sixty-seven untreated brain metastases (BM) were found in 3D T1-weighted MRI of 38 patients with cancer: 27 from lung cancer, 23 from melanoma and 17 from breast cancer. These lesions were segmented in 2D and 3D to compare the discriminative power of 2D and 3D texture features. The images were quantized using different number of gray-levels to test the influence of quantization. Forty-three rotation-invariant texture features were examined. Feature selection and random forest classification were implemented within a nested cross-validation structure. Classification was evaluated with the area under receiver operating characteristic curve (AUC) considering two strategies: multiclass and one-versus-one. RESULTS: In the multiclass approach, 3D texture features were more discriminative than 2D features. The best results were achieved for images quantized with 32 gray-levels (AUC = 0.873 ± 0.064) using the top four features provided by the feature selection method based on the p-value. In the one-versus-one approach, high accuracy was obtained when differentiating lung cancer BM from breast cancer BM (four features, AUC = 0.963 ± 0.054) and melanoma BM (eight features, AUC = 0.936 ± 0.070) using the optimal dataset (3D features, 32 gray-levels). Classification of breast cancer and melanoma BM was unsatisfactory (AUC = 0.607 ± 0.180). CONCLUSION: Volumetric MRI texture features can be useful to differentiate brain metastases from different primary cancers after quantizing the images with the proper number of gray-levels. KEY POINTS: • Texture analysis is a promising source of biomarkers for classifying brain neoplasms. • MRI texture features of brain metastases could help identifying the primary cancer. • Volumetric texture features are more discriminative than traditional 2D texture features.

[MRI findings and pathological features of occult breast cancer].

Objective: To investigate the magnetic resonance imaging (MRI) findings and clinicopathological features of primary lesions in patients with occult breast cancer (OBC). Methods: The imaging reports from the Breast Imaging Reporting and Data System in 2013 were retrospectively analyzed to investigate the morphology and the time signal intensity curve (TIC) of breast lesions in patients with OBC. The clinical and pathological characteristics of these patients were also included. Results: A total of 34 patients were enrolled. Among these patients, 24 patients underwent modified radical mastectomy and 18 of them had primary breast carcinoma in pathological sections. MRI detected 17 cases of primary lesions, including six masse lesions with a diameter of 0.6-1.2 cm (average 0.9 cm), and 11 non-mass lesions with four linear distributions, three segmental distributions, three focal distributions, and one regions distribution. Five patients had TIC typeⅠprimary lesions, ten had TIC type Ⅱ primary lesions, and two had TIC type Ⅲ primary lesions. Among all 34 cases, 23 of them had complete results of immunohistochemistry: 11 estrogen receptor (ER) positive lesions (47.8%), tenprogesterone receptor (PR) positive lesions (43.5%), seven human epidermal growth factor receptor 2 (HER-2) positive lesions (30.4%), and 20high expression(>14%) of Ki-67 (87.0%). The proportion of type luminal A was 4.3%, type luminal B was 43.5%, triple negative breast cancer (TNBC) was 30.4%, and HER-2 over expression accounted for 21.7%. Conclusions: The primary lesions of OBC usually manifested as small mass lesions, or focal, linear or segmental distribution of non-mass lesions. The positive rate of ER and PR was low, but the positive rate of HER-2 and the proliferation index of Ki-67 was high. Type luminal B is the most common molecular subtype.

MRI findings and pathological features of occult breast cancer / 中华肿瘤杂志

Objective@#To investigate the magnetic resonance imaging (MRI) findings and clinicopathological features of primary lesions in patients with occult breast cancer (OBC).@*Methods@#The imaging reports from the Breast Imaging Reporting and Data System in 2013 were retrospectively analyzed to investigate the morphology and the time signal intensity curve (TIC) of breast lesions in patients with OBC. The clinical and pathological characteristics of these patients were also included.@*Results@#A total of 34 patients were enrolled. Among these patients, 24 patients underwent modified radical mastectomy and 18 of them had primary breast carcinoma in pathological sections. MRI detected 17 cases of primary lesions, including six masse lesions with a diameter of 0.6-1.2 cm (average 0.9 cm), and 11 non-mass lesions with four linear distributions, three segmental distributions, three focal distributions, and one regions distribution. Five patients had TIC typeⅠprimary lesions, ten had TIC type Ⅱ primary lesions, and two had TIC type Ⅲ primary lesions. Among all 34 cases, 23 of them had complete results of immunohistochemistry: 11 estrogen receptor (ER) positive lesions (47.8%), tenprogesterone receptor (PR) positive lesions (43.5%), seven human epidermal growth factor receptor 2 (HER-2) positive lesions (30.4%), and 20high expression(>14%) of Ki-67 (87.0%). The proportion of type luminal A was 4.3%, type luminal B was 43.5%, triple negative breast cancer (TNBC) was 30.4%, and HER-2 over expression accounted for 21.7%.@*Conclusions@#The primary lesions of OBC usually manifested as small mass lesions, or focal, linear or segmental distribution of non-mass lesions. The positive rate of ER and PR was low, but the positive rate of HER-2 and the proliferation index of Ki-67 was high. Type luminal B is the most common molecular subtype.

Combined p16 and p53 expression in cervical cancer of unknown primary and other prognostic parameters : A single-center analysis.

BACKGROUND AND PURPOSE: Cervical cancer of unknown primary (CUP) represents an uncommon and heterogeneous subentity of head and neck cancer. However, both optimal diagnostics and therapy remain unclear. An improved understanding of the underlying pathology is essential to enable future tailored therapies and optimized outcomes. MATERIALS AND METHODS: We retrospectively analyzed 53 patients with head and neck CUP and 48 available cervical lymph node specimens. All patients have received radiotherapy between 2007 and 2015. Preradiotherapy involved lymph node specimens were analyzed for p16 and p53 immunoreactivity. The prognostic relevance of the combined p16 and p53 status and other clinical parameters were examined by univariate and multivariate analyses. RESULTS: Median patient age was 61.5 years and median irradiation dose to the involved nodal levels was 66 Gy. Of the 48 evaluated specimens, 13 (27%) were p16-positive and 31 (64.6%) p53-positive. After a median follow up of 32.9 months, patients with p16-negative and simultaneously p53-positive tumors showed a significantly inferior tumor-specific survival (TSS) compared to those with either p16+/p53-, p16+/p53+, or p16-/p53- (univariate: p = 0.055, multivariate: p = 0.038). Other factors with an adverse impact on TSS in the univariate analysis were smoking history (p = 0.032) and nodal stage (p = 0.038). CONCLUSIONS: The combined p16- and p53-expression status in cervical metastases of CUP may represent a simple method for risk stratification. Further validation of these biomarkers in large prospective trials is essential to design rational trials for CUP treatment optimization.

Value of immunohistochemistry for determining the primary site of adenocarcinoma cells in pleural effusion cell block / 肿瘤研究与临床

Objective To explore the clinical significance of immunohistochemistry (IHC) for determining the primary site of adenocarcinoma cells in pleural effusion cell block. Methods One hundred and eight cases of pleural effusion diagnosed as adenocarcinoma were collected by using liquid-based cytology from January 2013 to June 2016 in Yuncheng Central Hospital. Sediment cells were gathered through centrifuging and paraffin block was made, then 94 cases were selected for IHC detection. Results Among 94 cases of adenocarcinoma diagnosed by using liquid-based cytology, 92 cases were still diagnosed as adenocarcinoma by IHC, including 70 cases of lung source, 2 cases of breast, 6 cases of ovary, 8 cases of alimentary canal, 1 case of peritoneal serouspapillary carcinoma, and 5 cases of unknown source. The other 2 cases were diagnosed as mesothelial cells and mesothelial tumors respectively. Conclusion Pleural effusion cells block and multiple IHC can improve the tumor cell detection for the judgement of the benign and malignant tumor cells and differential diagnosis to find the primary site of tumors.

Cutaneous metastases in a patient with no previous diagnosis of cancer: diagnostic challenge

Abstract: On rare occasions, skin lesions are the first local of metastatic manifestation of internal malignancies. In case of no previous diagnosis of these tumors, the approach of suspicious skin lesions becomes a challenge, especially in differentiating cutaneous metastases and adnexal primary neoplasms. Currently, besides epidemiologic, dermoscopic and histopathologic aspects, the evaluation also integrates immunohistochemical exams and cell markers such as p40 and p63, highly specific for skin metastases. This article describes the case of cutaneous metastases as the sole obvious sign of breast cancer in a previously asymptomatic woman. The diagnosis was made by the finding of neoplastic cells in the dermis and immunohistochemistry compatible with ductal carcinoma.

Optimal Treatment Decision for Brain Metastases of Unknown Primary Origin: The Role and Timing of Radiosurgery.

BACKGROUND: Up to 15% of all patients with brain metastases have no clearly detected primary site despite intensive evaluation, and this incidence has decreased with the use of improved imaging technology. Radiosurgery has been evaluated as one of the treatment modality for patients with limited brain metastases. In this study, we evaluated the effectiveness of radiosurgery for brain metastases from unknown primary tumors. METHODS: We retrospectively evaluated 540 patients who underwent gamma knife radiosurgery (GKRS) for brain metastases radiologically diagnosed between August 1992 and September 2007 in our institution. First, the brain metastases were grouped into metachronous, synchronous, and precocious presentations according to the timing of diagnosis of the brain metastases. Then, synchronous and precocious brain metastases were further grouped into 1) unknown primary; 2) delayed known primary; and 3) synchronous metastases according to the timing of diagnosis of the primary origin. We analyzed the survival time and time to new brain metastasis in each group. RESULTS: Of the 540 patients, 29 (5.4%) presented precocious or synchronous metastases (34 GKRS procedures for 174 lesions). The primary tumor was not found even after intensive and repeated systemic evaluation in 10 patients (unknown primary, 34.5%); found after 8 months in 3 patients (delayed known primary, 1.2%); and diagnosed at the same time as the brain metastases in 16 patients (synchronous metastasis, 55.2%). No statistically significant differences in survival time and time to new brain metastasis were found among the three groups. CONCLUSION: Identification of a primary tumor before GKRS did not affect the patient outcomes. If other possible differential diagnoses were completely excluded, early GKRS can be an effective treatment option for brain metastases from unknown primary tumor.

Ovarian carcinoma presenting as cutaneous nasal metastasis

Abstract Metastatic ovarian cancer uncommonly presents with skin metastasis. When present, skin metastases of ovarian cancer are usually localized in the vicinity of the primary tumor. We report a case of a 58-year-old woman with a rapid growing erythematous, well-defined nodule localized on the left nasal ala. A skin biopsy was performed and histopathological and immunohistochemical findings were compatible with a cutaneous metastasis of adenocarcinoma. A systematic investigation revealed a bilateral ovarian cystadenocarcinoma associated with visceral dissemination, likely associated with nose cutaneous metastasis. We report a very uncommon case because of the presentation of ovarian carcinoma as cutaneous metastasis. To our knowledge, this atypical localization on the nose has not been described yet in the literature.

Optimal Treatment Decision for Brain Metastases of Unknown Primary Origin: The Role and Timing of Radiosurgery

BACKGROUND: Up to 15% of all patients with brain metastases have no clearly detected primary site despite intensive evaluation, and this incidence has decreased with the use of improved imaging technology. Radiosurgery has been evaluated as one of the treatment modality for patients with limited brain metastases. In this study, we evaluated the effectiveness of radiosurgery for brain metastases from unknown primary tumors. METHODS: We retrospectively evaluated 540 patients who underwent gamma knife radiosurgery (GKRS) for brain metastases radiologically diagnosed between August 1992 and September 2007 in our institution. First, the brain metastases were grouped into metachronous, synchronous, and precocious presentations according to the timing of diagnosis of the brain metastases. Then, synchronous and precocious brain metastases were further grouped into 1) unknown primary; 2) delayed known primary; and 3) synchronous metastases according to the timing of diagnosis of the primary origin. We analyzed the survival time and time to new brain metastasis in each group. RESULTS: Of the 540 patients, 29 (5.4%) presented precocious or synchronous metastases (34 GKRS procedures for 174 lesions). The primary tumor was not found even after intensive and repeated systemic evaluation in 10 patients (unknown primary, 34.5%); found after 8 months in 3 patients (delayed known primary, 1.2%); and diagnosed at the same time as the brain metastases in 16 patients (synchronous metastasis, 55.2%). No statistically significant differences in survival time and time to new brain metastasis were found among the three groups. CONCLUSION: Identification of a primary tumor before GKRS did not affect the patient outcomes. If other possible differential diagnoses were completely excluded, early GKRS can be an effective treatment option for brain metastases from unknown primary tumor.

Cutaneous metastasis of unknown primary presenting as massive and invasive abdominal lesion: an elective approach

Abstract: We describe herein what is to our knowledge the first reported case of an invasive cutaneous metastasis with unknown primary, electively treated solely with electrochemotherapy. We describe a female patient with a large, invasive and painful lesion in her hypogastric region, extending up to the pubic area. The cutaneous biopsy and instrumental and laboratory analyses, all failed to reveal the primary site. A final diagnosis of cutaneous metastasis with unknown primary was made and treatment was performed with electrochemotherapy. Our case highlights the importance of interdisciplinary choices in clinical practice to cope with the lack of a primary site and to improve quality of life, since no standardized therapy exists for these classes of patients.