A 68-year-old man attended the emergency department at the weekend with sudden onset of pain in his right arm after minor trauma. He had a number of other non-specific symptoms including general malaise and weight loss. X-rays revealed an undisplaced pathological fracture of the right humerus and other bone metastases. A set of routine blood tests was requested, though not reviewed. The patient was discharged home the same day with a sling by a junior member of the orthopaedic team who also arranged referral to a multidisciplinary team (MDT).
How can this patient's cancer be categorized for appropriate referral and ongoing care?
What organizational shortcomings might exist that would prevent this patient receiving optimal care?
What system of immediate care should established for patients such as this?
How should the subsequent care of patients on the MUO/CUP spectrum be organized (see Table 3.1)?
How has the paradigm for treatment of CUP changed recently?
Table 3.1Definitions following NICE Clinical Guidelines CG104. |Favorite Table|Download (.pdf) Table 3.1 Definitions following NICE Clinical Guidelines CG104.
Malignancy of undefined primary origin (MUO)
Metastatic malignancy identified on the basis of a limited number of tests, without an obvious primary site, before comprehensive investigation.
Provisional carcinoma of unknown primary origin (provisional CUP, pCUP)
Metastatic epithelial or neuroendocrine malignancy identified on the basis of histology or cytology, with no primary site detected despite a selected initial screen of investigations, before specialist review and possible further specialized investigations.
Confirmed carcinoma of unknown primary origin (confirmed CUP, cCUP)
Metastatic epithelial or neuroendocrine malignancy identified on the basis of final histology, with no primary site detected despite a selected initial screen of investigations, specialist review, and further specialized investigations as appropriate.
How should this patient's cancer be categorized for appropriate referral and ongoing care?
This patient provides an example of a common dilemma. He almost certainly has cancer, but in current practice there is uncertainty about how he should be further investigated, who should be responsible for this task, and who should coordinate delivery of services for his ancillary needs of information, support and symptom control.
He has features of metastatic bone disease, but has not undergone any subsequent tests designed to characterize the disease more precisely. The differential diagnosis is broad, ranging from a primary bone tumour (with metastases), to myeloma, to the most common scenario of bone metastases from a recognized primary such as kidney, stomach or lung. Ultimately, if carcinoma is confirmed but all other investigations are completed without a primary site being identified, the patient would be classified as having cancer of unknown primary (CUP). In terms of initial care, a similar dilemma is frequently encountered when patients present de novo with other common manifestations of metastatic cancer, such as malignant liver disease, malignant ascites, malignant pleural effusions, brain metastases, ...