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Case history

image An 85-year-old woman with hypertension, ischaemic heart disease and chronic kidney disease presented with a 6 month history of anorexia, malaise and weight loss. She was compliant with antiplatelet and antihypertensive medications. She lived alone, spending most of the day resting, and required a twice-daily carer to help her wash and dress. Physical examination revealed hepatomegaly. Serum haematology and biochemistry showed normocytic anaemia (Hb 8.2 g/dl [normal range 11.5-16.5]); raised aspartate transaminase (262 IU/l [normal range 0-37]); raised creatinine (200 mol/l [normal range 45-84]); and an estimated glomerular filtration rate 21 ml/min (normal range 70-130) (similar to that measured 1 year previously). Abdominal ultrasound revealed a solitary liver lesion in segment VII measuring 4.2×3.7 cm, indicating a possible metastasis. Subsequent CT scanning confirmed three further bilobar metastatic lesions and multiple enlarged abdominal lymph nodes. Histology from an ultrasound-guided liver biopsy confirmed a poorly differentiated adenocarcinoma that stained positive for cytokeratin (CK) 7 and negative for CK20 and oestrogen receptor (ER). No primary tumour was identified on imaging. Comprehensive Geriatric Assessment (CGA) helped to determine optimal management strategies for her new oncological diagnosis, comorbidities and frailty. Supportive care was recommended in view of the unfavourable risk-benefit profile of systemic anticancer treatment. Her fatigue, social isolation and declining functional independence was managed with four-times-daily carer input, a 'meals-on-wheels' service and community-based palliative care.

What are the guidelines and evidence for investigating patients with metastatic disease of unknown primary?

What are the considerations when investigating a frail older patient with suspected cancer of unknown primary (CUP)?

How can prognosis be assessed in this patient?

What evidence-based treatment options are available for this patient?

What are the realistic goals for this patient?

How may CGA help identify and implement best supportive care for this patient?

What are the guidelines and evidence for investigating patients with metastatic disease of unknown primary?

NICE guidelines advise hospitals with a cancer centre to have a dedicated acute oncology service that ensures all patients with a malignancy of unidentified primary origin (MUO) are investigated appropriately (Table 8.1). Routine imaging by CT is supplemented by more dedicated investigations depending on the individual features of each case;1,2 for example, in a female with isolated axillary lymphadenopathy, breast imaging may be indicated.

Table 8.1Initial diagnostics for MUO (adapted from NICE guidelines2).

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