Devita, Hellman, and Rosenberg's Cancer

LWBK1006-35 LWW-Govindan-Review November 24, 2011 11:26

480 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

cell tumors. The biopsy revealed poorly differentiated carcinoma, though

cytogenetic testing revealed isochromosome 12p. Abnormalities of chro-

mosome 12 such as i(12p) and del (12p) or multiple copies of 12p are

useful in the diagnosis of germ cell tumors in this setting.

Answer 35.6. The answer is B.

The patient presents with adenocarcinoma of unknown primary with liver

metastasis. Her tumor stains positive for CK20 and CDX2, and negative

for CK 7; this pattern is suggestive of colorectal primary and colonoscopy

should be performed. Lung cancers are typically CK 7 positive and CK20

negative and TTF-1 staining is seen in approximately 75% of lung adeno-

carcinomas. ER positivity is suggestive of breast cancer, but up to 15% of

patients are negative for ER, PR, and HER2-neu. Breast cancers are typ-

ically CK 7 positive, unlike this patient. Pancreatic cancers are typically

CK 7 positive and CA 19-9 positive.

Answer 35.7. The answer is C.

Isolated axillary adenopathy in a woman is suggestive of occult breast

cancer, and the IHC features also suggest breast cancer. Since the mam-

mogram and ultrasound are negative, the next step would be MRI of the

breasts. Even when MRI and PET are negative for a primary lesion, mod-

ified radical mastectomy has been recommended in such patients and an

occult primary has been identified in 44% to 80% of patients after mas-

tectomy.

Answer 35.8. The answer is D.

The incidence of both ovarian carcinoma and primary peritoneal carci-

nomatosis is increased in women with BRCA1 mutations. These patients

often have a family history of breast and ovarian cancer. Prophylactic

oophorectomy can prevent ovarian cancer, but these patients can still

present with primary peritoneal carcinomatosis. Clinical features include

elevated CA-125, but no identifiable primary on imaging or even laparo-

tomy. They share the same histologic features as ovarian cancer, such as

papillary serous features and psammoma bodies. They are treated using

the same guidelines as advanced ovarian cancer with surgical cytoreduc-

tion followed by chemotherapy.

Answer 35.9. The answer is D.

This patient has metastatic squamous cell carcinoma of unknown primary,

with upper cervical lymph node involvement. When upper or middle cer-

vical lymph nodes are involved, a primary tumor in the head and neck

should be suspected. Clinical evaluation should include examination of

the oropharynx, hypopharynx, nasopharynx, and larynx, as well as upper

esophagus, by direct endoscopy. Any suspicious areas should be biopsied.

PET scans are useful in this setting, and can help identify primary tumor

sites.