Diagnosis and investigations are directed at classifying the patient in one of the following groups:

♦ Potentially curable

♦ Effective palliation available

♦ No active treatment indicated

The following cancers are potentially curable when presenting as cancers of unknown primary site:

♦ Germ cell tumors

♦ Thyroid cancer

Effective palliation with chemotherapy is indicated if the patient is fit and the tumour is chemo-responsive.There is no convincing evidence

Diagnosis of metastatic cancer

Clinical evaluation and radiography

Cancer of unknown primary site

Primary identified

Serum plus histological tumour markers



Prostate Germ cell Hepatoma Ovary

Lymph node Other clinical presentation presentation


Exclude lymphoma

— Exclude breast and thyroid

Axillary node Exclude breast

Thorax, CNS, and liver Low yield of treatable primaries

Cervical node -

Exclude head and neck

Abdomen and pelvic Exclude ovary and prostate

Identification of treatable cancer of unknown primary site (reproduced with permission from the Oxford Textbook of Oncology, 1995).

that combinations are better than single agents but there have been very few randomized trials. Hormone therapy is valuable in breast, prostate, endometrial cancer. Thyroidectomy and radioactive iodine therapy can provide long-term disease control in thyroid cancers. Radiotherapy can provide useful palliation for painful bone metastases, brain metastases, and troublesome lymph node masses.

Patients for whom no active treatment is indicated are often the most difficult to manage. The situation should be discussed with the general practitioner and, if appropriate, referral should be made to community or hospice-based palliative care teams.

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