Identification makes diagnosis the key to effective treatment. The better the diagnosis, the better the chances of effective therapy leading to remission or substantial palliative benefit.
By definition CUP appears once it has spread beyond its point of origin. Anyone presenting with symptoms of cancer will be subjected to many tests. There is no "check list" of examinations and tests but the following are likely at different stages until the origin of the cancer is determined or it is judged to be impossible to find: medical history, a complete physical examination, tumour biopsy (a sample of tissue taken for examination - see below), chest X-rays, blood cell analysis, urine and stool analysis, radiographic imaging using scans such as CT.
Why so many tests? Some tests (and more detail is shown on the next page) are more likely to show particular cancers and the oncologist will also want to use different sources to gather as much evidence as possible about the origin of the cancer for treatment. The presentation of the cancer spread and what the tests reveal will determine which Multi-Disciplinary Team (MDT) take responsibility for the patient's hospital treatment and care.
The biopsy. The cancer specialist will decide which of the following is best and the sample of tissue will be analysed by a pathologist using a microscope and chemical tests:
- Punch Biopsy. This is where, for example with possible skin cancer, the doctor very simply remove a small piece of skin with an instrument that looks like a tiny apple corer
- Fine-Needle Aspiration (FNA). Multiple samples of tissue or fluid are removed through a small bore needle guided into the cancerous tissue. This is more likely to be used to help determine whether a patient has cancer rather than for determining the primary site.
- Core Needle Biopsy. A larger bore needle is used allowing a more generous specimen and therefore a more accurate diagnosis. See this link http://imaginis.com/breasthealth/biopsy/core.asp for details in relation to breast cancer.
- Incisional Biopsy. A small wedge of tissue is removed providing a good sample for examination.
- Excisional Biopsy. This is when an entire suspect area is removed.
A biopsy is usually performed as an outpatient procedure. However, some biopsies - such as biopsy of an internal organ - require a general anaesthetic and an overnight stay in hospital.
Each tumour is unique and each patient is unique.
The oncologist will not be working alone – the clinician that you see will be gathering information from a team of experts in different fields. This is particularly the case with CUP where the cancer cells may be “poorly differentiated”. It may help you to think of this as being like a crime scene. The oncologist, like the detective, will be calling-in the different agencies – like the fingerprint expert or in this case the pathologist – and gathering and evaluating all the evidence trying to prove various parts of your anatomy guilty or innocent.
Click here to order the Macmillan Cancerbackup booklet on CUP. It is free of charge to health and social care professionals and those affected by cancer. (On the order page search for Cancer of Unknown Primary or look under cancer type.) Or call 0800 500 800 in the UK to order.
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