Hello there, it's my first time writing on this forum.
My mother who is 54yo, otherwise healthy, was complaining for about 3-4 weeks of random night sweats, fever, and persistent cough. She has a 20 year history of smoking 1.5 ppd.
Initial chest xray revealed enlarged right hilar area. Chest CT revealed multi nodular enlargements in mediastinal, subcarinal and hilar lymph. Initial suspection was lymphoma. Bronchoscopy was clear. Transbronchial biopsy was clear. Whole body MRI and PET/CT confirmed results of multinodular involvement in thoracic area only. Mediastinal biopsy came back as an adenocarcinoma not well differentiated, with an IHC profile that is CD 7 +, all other markers were negative. Her routine blood work is normal (CBC, Electrolyte, liver, renal, thyroid, etc...). Blood cancer markers negative with exception of CEA at 11.1 and CA19.9 at 102.
Given her history of smoking, both oncologists we consulted are treating this is a "hidden" lung primary. Two thoracic surgeons advised against dissecting the involved lymph nodes, given the complexity and multinodular involvement. Every imaging/diagnostic test we did and repeated seems to indicate that the cancer is localized in the mid-to-right thoracic area (para-hilar, mediastinal, carinal, para-tracheal).
It's a very confusing case and to be honest it's giving all the drs a big scratch of the head.
The plan now is to do 2 sessions of induction chemo (cisplatin + Alimta), re-evaluate lymph nodes, most likely proceed with chemoradiation (IMRT or 3D). Has anyone come across any similar cases in real practice? Any ideas or suggestions? I was only able to find litterature on T0N2M0 cases that resemble symptomatically and diagnostically my mom's situation.
Thanks alot and God Bless you all.
Reply # - June 8, 2013, 05:45 PM
Reply To: Adenocarcinoma of unknown primary
It sounds like a reasonable thing to do. When there is no identified primary cancer and the nodal pattern is suggestive of a primary lung cancer, it's reasonable to proceed with treating the case as a lung cancer, using the specific agents as guided by the histologic subtype (adenocarcinoma vs. squamous, etc.).
Good luck.
-Dr. West
Reply # - June 9, 2013, 01:17 AM
Reply To: Adenocarcinoma of unknown primary
Thank you for your reply Dr. West.
I still don't understand why a surgeon cannot remove those lymph nodes via VATS or TEMLA. He said he can only access them via Thoracotomy and it's too big of an operation to put her through, although she has a performance status of 0/1. In the few case-studies I came across in resembeling T0N1 or T0N2, resection was predominantly the 1st choice, although in 2 of them chemoradiation also had favorable outcomes. Lymph node groups affected are right hilar, mediasinal, right lower paratracheal and subcarinal.
I know that the general prognosis for CUP is grim, but in the few similar cases I read about localized mediastinal lymphadenocarcinomas the prognosis seems better than diffuse/metastasized CUPs if agressive radical multimodality treatment approaches are employed.
What are your thoughts on this?
Reply # - June 9, 2013, 01:53 PM
Reply To: Adenocarcinoma of unknown primary
Well, a metastatic cancer is going to have a shorter survival than one that has only spread regionally. A cancer that is regionally contained can potentially be treated with curative intent. Beyond that, however, I would say that such cases are so individualized that there's no way to speak to any standard approach for CUP cases.
-Dr. West