Identification Of Primary Tumor Research Articles

Positron emission tomography scan for a hepatic mass

A 66-year-old male patient who is hepatitis C RNA positive, without cirrhosis, has been found to have a mass on ultrasound examination of the liver. Physical examination is unremarkable. The hemoglobin, white cell count and platelet counts are normal. The alkaline phosphatase is mildly elevated to 212 U/L(normal <115), the AST 112 U/L, and the ALT 128 U/L. The CA 19-9 is 82 U/mL (normal < 55 U/mL) and the alpha fetoprotein 12 ng /mL. A CT scan of the abdomen shows a vague mass in segment V of the liver without definite arterial enhancement. An MRI of the abdomen is carried out with contrast but the mass is still indeterminate on T1 and T2 imaging.

Identification of Unknown Primary Tumors in Patients With Neuroendocrine Liver Metastases

For patients with neuroendocrine tumor (NET) liver metastases, resection of the primary tumor may prevent local complications (obstruction, ischemia, and bleeding) and improve survival. Despite preoperative evaluation, the primary tumor location may remain unknown. Retrospective cohort analysis of pathology database from January 1, 1993, to August 15, 2008. Academic medical center. One hundred twenty-three patients with NET liver metastases. Successful identification and resection of the primary tumor. Fifteen patients underwent surgical exploration. The primary tumor was located in 13 patients (86.7%) in the small intestine and resected in 12 patients. Primary tumors in the small intestine found during surgical exploration were significantly smaller than those identified preoperatively (1.38 vs 1.91 cm, P = .03) and were often multifocal (54.2% [n = 15]). Computed tomography (34.6% [n = 78]) and somatostatin receptor scintigraphy (26.2% [n = 42]) were not sensitive in locating a primary NET in the gastrointestinal tract. Colonoscopy was sensitive in detecting colonic NETs (86.7% [n = 15]). For patients with NET liver metastases and unknown primary tumor, surgical exploration effectively identifies and resects occult primary tumors that are often located in the small intestine. Primary tumors are usually small and multifocal, so careful palpation of the small intestine is essential. Before patients are considered for surgery, a multidisciplinary team assessment and evaluation consisting of computed tomography, somatostatin receptor scintigraphy, and upper and lower endoscopy should be done.

Identification of Unknown Primary Tumors in Patients With Neuroendocrine Liver Metastases

Background: For patients with neuroendocrine tumor (NET) liver metastases, resection of the primary tumor may prevent local complications (obstruction, ischemia, bleeding) and improve survival. Despite extensive evaluation, the primary tumor location may remain unknown. Methods: We performed a retrospective cohort analysis of a pathology database at a tertiary academic medical center from January 1, 1993 to August 15, 2008 and identified 123 patients with NET liver metastases. We sought to determine the utility of pre-operative evaluation for detecting the primary tumor in patients with well-differentiated NET liver metastases and whether laparoscopic or open exploration is effective for identifying an occult primary tumor. Results: Computed tomography (34.6%) and OctreoScan® (26.2%) were not sensitive in locating primary NETs in the gastrointestinal tract. Colonoscopy was sensitive in detecting colonic NETs (86.7%). Seventeen patients (13.8%) had occult primary tumors, and 15 underwent surgical exploration. The primary tumor was located in 13 cases (86.7%) in the small intestine and resected in 11. Primary tumors in the small intestine found during surgical exploration were significantly smaller than those identified pre-operatively (1.38 vs 1.91 cm, P = 0.03) and were often multifocal (54.2%). Conclusions: For patients with NET liver metastases and unknown primary, surgical exploration effectively identifies and resects occult primary tumors that are often located in the small intestine. Primary tumors are usually small and multifocal, so careful palpation of the small intestine is essential. Before patients are considered for surgery, a multidisciplinary team assessment and evaluation consisting of computed tomography, OctreoScan, and upper/lower endoscopy should be done.

The role of Ga-68 DOTATOC PET/CT in the detection of primary tumors in CUP-syndrome of neuroendocrine tumors (NETs)

Aim: Detection of the primary tumor in CUP-syndrome is one of the most challenging issues in medical imaging but is mandatory for the choice of an adequate therapy. The useful ness of Ga-68 DOTATOC PET in NETs has been demonstrated by many investigators. One of the major disadvantages in the past was the lack of exact anatomic localisation of Ga-68 DOTATOC foci. We investigated the impact of coregistrated Ga-68 DOTATOC PET/CT imaging regarding identification and exact anatomic localisation of primary tumors in CUP-syndrome of NETs. Material and Methods: We investigated 23 consecutive Ga-68 DOTATOC PET/CT examinations of patients with CUP-syndrome of NETs, all of them with liver metastases (confirmed by biopsy from metastatic lesions). All patients were examined with a GE Discovery LS PET/CT scanner 20–40min post injection of 80–120 MBq of Ga-68 DOTATOC. We assessed whether a possible primary tumor could be identifed in the fused images of the combined PET/CT system.

Cervical lymph node metastases of unknown origin: primary tumor detection with whole-body positron emission tomography/computed tomography

Identification of primary tumor in patients with cervical lymph node metastasis of unknown primary (MUO) has a great impact on therapy approach and potentially on patient prognosis. To assess the diagnostic accuracy of combined positron emission tomography(PET)/computer tomography (CT) for primary tumor detection in cervical metastases of unknown origin compared to PET, CT, and PET+CT side-by-side evaluation. 39 consecutive patients (eight women, 31 men; mean age 59.9 ± 11.2 years) with MUO were enrolled in this study. PET/CT images were obtained 1 hour after injection of 350 MBq of fluorodeoxyglucose. Oral and intravenous contrast agents were administered in all patients to ensure diagnostic CT data. Fused PET/CT data were evaluated for primary tumor detection. Diagnostic accuracy was calculated and compared with CT alone, PET alone, and side-by-side PET+CT evaluation.Statistical analysis of differences in diagnostic performance between the different imaging procedures was based on the McNemar test. Fused PET/CT depicted the primary tumor in 11 of 39 (28%) patients. In 28(72%) patients, the primary tumor remained occult. CT revealed the primary in five(13%), PET alone in 10 (26%), and side-by-side evaluation of PET+CT in 10 (26%) of 39 patients. Statistical analysis showed no significant differences between the imaging modalities. PET, side-by-side PET+CT, and PET/CT revealed similar detection rates for primary tumors in cervical MUO patients. Therefore, cervical metastases of an unknown primary may be assessed with either of these imaging modalities. Detection rates with CT were substantially lower. Thus, inclusion of functional data for assessment of cervical MUO patients must be recommended.

Metastatic Esophageal Adenocarcinoma Presenting in the Iris

To report a case of metastatic esophageal adenocarcinoma presenting as an acute primary iris tumor of unknown origin. Interventional, clinicopathologic case report. A 47-year-old healthy man sought treatment for a three-week history of a progressively enlarging red spot on the left iris. Presentation, local and systemic evaluation, and treatment are described. Iris biopsy revealed the lesion represented metastasis, and a systemic evaluation later revealed the primary source as esophageal adenocarcinoma. The patient began systemic chemotherapy. Metastatic iris lesions can have atypical presentations. Tissue biopsy, tumor antigens, and a thorough systemic evaluation are crucial in identification of primary tumors in cases of unknown metastatic origin.

Molecular Imaging of Brain Tumors: A Bridge Between Clinical and Molecular Medicine?

As the research on cellular changes has shed invaluable light on the pathophysiology and biochemistry of brain tumors, clinical and experimental use of molecular imaging methods is expanding and allows quantitative assessment. The term molecular imaging is defined as the in vivo characterization and measurement of biologic processes at the cellular and molecular level. Molecular imaging sets forth to probe the molecular abnormalities that are the basis of disease rather than to visualize the end effects of these molecular alterations and, therefore, provides different additional biochemical or molecular information about primary brain tumors compared to histological methods "classical" neuroradiological diagnostic studies. Common clinical indications for molecular imaging contain primary brain tumor diagnosis and identification of the metabolically most active brain tumor reactions (differentiation of viable tumor tissue from necrosis), prediction of treatment response by measurement of tumor perfusion, or ischemia. The interesting key question remains not only whether the magnitude of biochemical alterations demonstrated by molecular imaging reveals prognostic value with respect to survival, but also whether it identifies early disease and differentiates benign from malignant lesions. Moreover, an early identification of treatment success or failure by molecular imaging could significantly influence patient management by providing more objective decision criteria for evaluation of specific therapeutic strategies. Specially, as molecular imaging represents a novel technology for visualizing metabolism and signal transduction to gene expression, reporter gene assays are used to trace the location and temporal level of expression of therapeutic and endogenous genes. Molecular imaging probes and drugs are being developed to image the function of targets without disturbing them and in mass amounts to modify the target's function as a drug. Molecular imaging helps to close the gap between in vitro and in vivo integrative biology of disease.

Detection of small-bowel neuroendocrine tumors by video capsule endoscopy

Carcinoid tumors are the most common GI neuroendocrine tumors (NET). They often originate in the small intestine. The primary tumor is often difficult to locate, and resection in an early phase is recommended to prevent complications. This study evaluated the value of videocapsule endoscopy (VCE) in the detection of small-intestinal primary carcinoid tumor. Prospective descriptive study. Tertiary referral center. Twenty consecutive patients (13 men, 7 women; 60.5 +/- 9.3 years) with metastatic NET of unknown primary tumor. All patients underwent CT, enteroclysis, nuclear imaging, and VCE of the small bowel. CTs and enteroclysis did not detect a primary small-intestinal carcinoid tumor. Nuclear imaging demonstrated abnormalities in the abdominal area in 13 patients but was unable to relate this to an intestinal localization in any patient. VCE revealed a small-intestinal tumor in 9 patients. Three other patients showed external compression and erosions. At surgery, 5 patients had a small-intestinal carcinoid tumor, and, in 2 patients, a small-intestinal ischemic segment was present. The number of false-positive VCE findings was not clear, because not all patients underwent surgery. The absence of abnormalities at VCE in patients with abnormalities at nuclear imaging might be related to the presence of carcinoid tumor restricted to the mesenterium or to a false-negative VCE. VCE had a high diagnostic yield of 45% for identification of primary small-intestinal carcinoid tumors. Although nuclear imaging had a comparable diagnostic yield, it could not differentiate between intestinal and mesenterial localization of the carcinoid.

Identification of Primary Tumors of Brain Metastases by Infrared Spectroscopic Imaging and Linear Discriminant Analysis

This study applies infrared (IR) spectroscopy to distinguish normal brain tissue from brain metastases and to determine the primary tumor of four frequent brain metastases such as lung cancer, colorectal cancer, breast cancer, and renal cell carcinoma. Standard methods sometimes fail to identify the origin of brain metastases. As metastatic cells contain the molecular information of the primary tissue cells and IR spectroscopy probes the molecular fingerprint of cells, IR spectroscopy based methods constitute a new approach to determine the primary tumor of a brain metastasis. IR spectroscopic images were recorded by a FTIR spectrometer equipped with a macro sample chamber and coupled to a focal plane array detector. Unsupervised cluster analysis of IR images revealed variances within each sample and between samples of the same tissue type. Cluster averaged IR spectra of tissue classes with known diagnoses were selected to develop a metric with eight variables. These data trained a supervised classification model based on linear discriminant analysis that was used to identify the origin of 20 cryosections including one brain metastasis with an unknown primary tumor.

Identification of primary tumors of brain metastases by SIMCA classification of IR spectroscopic images

Brain metastases are secondary intracranial lesions which occur more frequently than primary brain tumors. The four most abundant types of brain metastasis originate from primary tumors of lung cancer, colorectal cancer, breast cancer and renal cell carcinoma. As metastatic cells contain the molecular information of the primary tissue cells and IR spectroscopy probes the molecular fingerprint of cells, IR spectroscopy based methods constitute a new approach to determine the origin of brain metastases. IR spectroscopic images of 4 by 4 mm 2 tissue areas were recorded in transmission mode by a FTIR imaging spectrometer coupled to a focal plane array detector. Unsupervised cluster analysis revealed variances within each cryosection. Selected clusters of five IR images with known diagnoses trained a supervised classification model based on the algorithm soft independent modeling of class analogies (SIMCA). This model was applied to distinguish normal brain tissue from brain metastases and to identify the primary tumor of brain metastases in 15 independent IR images. All specimens were assigned to the correct tissue class. This proof-of-concept study demonstrates that IR spectroscopy can complement established methods such as histopathology or immunohistochemistry for diagnosis.

Immunocytochemical identification of carcinomas of unknown primary in serous effusions

Metastases from carcinomas of unknown primary site (CUP) in serous effusion are a common clinical problem. Immunocytochemistry was applied as an adjunct to the cytological diagnosis of metastatic carcinomas in serous effusions. Subjects of this study were 118 pleural, 53 peritoneal, and 9 pericardial effusions from 180 patients routinely investigated in the Institute of Cytopathology. Specimens were primarily stained according to Papanicolaou (Pap). The avidin-biotin-complex method (ABC) was secondarily applied for the visualization of immunologic reactions. We have used a panel of six monoclonal antibodies (CK 5/6, CK 7, CK 20, CA 125, TTF-1, and cdx 2) so as to identify the primary tumor site of metastatic carcinoma cells in serous effusions. Applying an algorithm of immunocytochemical marker constellations, we were able to correctly diagnose primary tumor sites in 86 of 101 (85.1%) patients with CUP syndromes. The best result was achieved for the identification of metastatic carcinomas of the ovaries (94.7%) and the lungs (88.1%). We established an algorithm comprising six immunocytochemical markers that enabled a correct diagnosis of primary tumor sites in 85.1%. The panel studied could be useful in diagnostic routine for the identification of primary tumors of unknown origin metastatic to the serous membranes.

Intraductal Papilloma of the Breast: F-18 FDG PET Demonstration

F-18 FDG PET is a useful imaging modality in breast carcinoma for detection of recurrent disease, unsuspected regional and distant metastases, and in monitoring cancer response to therapy. Although preliminary results showed PET capable of differentiating benign from malignant diseases, the role of PET in primary breast tumor identification has limitations with the small size and certain histologic characteristics of the tumors, and inflammatory and infectious processes. To the list of false-positive PET results, the authors add a case of intraductal papilloma incidentally detected by PET during staging of intestinal adenocarcinoma.

Follow-up of stage B and C colorectal cancer in the United States and France

The optimal postoperative follow-up strategy for patients with resected Dukes' Stage B and C colorectal cancer is controversial. Recently published guidelines support a minimal regimen of carcinoembryonic antigen measurements every 2 to 3 months for at least 2 years, history and physical examination every 3 to 6 months for 3 years, then annually, and colonoscopy every 3 to 5 years. Based on documented practice on the part of surgeons, this regimen would be regarded as intensive. Analyses of relapses following adjuvant therapy support an even more aggressive schedule, with the goal of maximizing the proportion of patients who may be operated on with curative intent (currently about 20% of those who relapse). Additional considerations that may influence the approach to such patients include the identification of second primary tumors (2% over 7 years observation), and the known improvement in quality of life and survival associated with early versus delayed initiation of chemotherapy. However, with the annual investment of resources estimated to be as high as 175 million dollars in the United States alone, a systematic study of such interventions is needed to provide support survival, quality of life, and economic evidence.

Follow-up of stage B and C colorectal cancer in the United States and France.

The optimal postoperative follow-up strategy for patients with resected Dukes' Stage B and C colorectal cancer is controversial. Recently published guidelines support a minimal regimen of carcinoembryonic antigen measurements every 2 to 3 months for at least 2 years, history and physical examination every 3 to 6 months for 3 years, then annually, and colonoscopy every 3 to 5 years. Based on documented practice on the part of surgeons, this regimen would be regarded as intensive. Analyses of relapses following adjuvant therapy support an even more aggressive schedule, with the goal of maximizing the proportion of patients who may be operated on with curative intent (currently about 20% of those who relapse). Additional considerations that may influence the approach to such patients include the identification of second primary tumors (2% over 7 years observation), and the known improvement in quality of life and survival associated with early versus delayed initiation of chemotherapy. However, with the annual investment of resources estimated to be as high as 175 million dollars in the United States alone, a systematic study of such interventions is needed to provide support survival, quality of life, and economic evidence.

Imaging the peritoneum for malignant processes

•. A clear understanding of peritoneal anatomy is necessary for the identification of peritoneal metastatic disease and primary tumours. •. Peritoneal metastases disseminate through the peritoneum in four ways: (1) direct spread along the peritoneal reflections; (2) intraperitoneal seeding; (3) lymphatic extension; and (4) embolic haematogenous spread. •. Metastatic peritoneal involvement is far more common than peritoneal primary malignancy. •. Primary peritoneal neoplasms are rare and are most often malignant. They arise from mesenchymal elements, and include mesothelioma and sarcoma. •. CT is relatively specific at identifying peritoneal malignancy but has relatively low sensitivity. •. CT remains the imaging modality of choice for the diagnosis, staging and follow‐up of peritoneal malignancy. MRI is gaining importance and has the advantages of multiplanar imaging and lack of ionizing radiation.

The detection of unknown primary tumors in patients with cervical metastases by dual-head positron emission tomography.

A dilemma may occur in relation to patients with cervical metastases appearing as the first sign of malignancy in the head and neck region. In these patients, the location of the involved lymph nodes may indicate the location of the primary tumor. However, in two or three per cent of the patients, the primary tumor cannot be identified in the diagnostic workup. The aim of the present study was to investigate the possibility of identification of primary tumors in patients with cervical metastases of unknown origin, by the use of 2-(fluorine-18)fluoro-deoxy-D-glucose (FDG) dual-head positron emission tomography (PET). Ten consecutive patients with a cervical metastases of unknown origin were studied with FDG, using a dual-head PET camera. After the injection of 185 MBq (5 mCi) of FDG, images were performed of the head, neck and chest. In addition, endoscopy and biopsies were carried out with knowledge of the PET study. In patients in whom a primary tumor could not be identified, a follow-up of at least 6 months was used as a control. In five out of 10 patients a primary tumor was identified by FDG-PET. In one patient multiple sites of uptake were seen, and this was found to be consistent with non-Hodgkin lymphoma. In five patients, additional sites of increased uptake were found, these being consistent with unknown metastatic disease. Finally, in six patients, the initial treatment plan was changed due to the PET result in five of them. In one patient, the primary tumor was resected revealing a lesion with a diameter of 6 mm. The detection of FDG in patients with cervical metastases of unknown origin by the use of a dual-head PET camera is a valuable diagnostic tool in the identification of primary lesions.

To-Labeled Monoclonal Anti-Carcinoembryonic Antigen Antibody (BW 431/26): Clinical Results in the Detection of Colorectal Carcinomas and Recurrences

With the introduction of 99mTc-labeled monoclonal antibodies against carcinoembryonic antigen (CEA) a clinically relevant extension can be expected in the diagnosis of colorectal tumors by immunoscintigraphy (IS). This study comprises a total of 49 patients (primary colorectal tumors, occult neoplasms, and suspicious recurrences), in whom IS with 99mTc monoclonal antibody (MAb) BW 431/26 was performed. After injection of 1100 MBq 99mTc MAb BW 431/26 a whole-body scan was performed in anterior and posterior projection 5 1/2 h later, and SPECT of the abdominal region was done after 6 and 24 h. In the course of primary tumor identification (n = 20) all coloscopically diagnosed and operatively verified carcinomas were confirmed and correctly localized by IS (n = 11). In three patients with positive IS and suspicious coloscopic findings surgery was refused by patients and relatives. In five cases IS was true negative and in 1 case false positive. In the diagnosis of recurrences (n = 29) IS showed an uptake in computer-tomographically and coloscopically suspicious areas in 17 cases. In 12 cases IS was rated negative (11 true-negative findings in scar and granulation tissue, 1 false-negative finding in para-aortal lymph nodes). Elevated serum CEA levels were found only in 17 of 31 patients with true-positive IS. In postoperative cancer care IS with 99mTc-labeled anti-CEA antibody plays a preeminent role in the exclusion or identification of colorectal recurrences.

New horizons in lung cancer diagnosis.

Lung cancer is rarely diagnosed and treated while still localized. Sputum cytology allows detection of radiologically occult tumors but conventional endoscopic procedures frequently prove inadequate for localization. It is the purpose of this report to outline the endoscopic observations and methods we have developed in successfully localizing 17 consecutive, radiologically occult carcinomas discovered in the sputum of 15 patients. A detailed examination of the upper respiratory tract demonstrated occult tumors in two patients. A segment by segment fiberbronchoscopic study under anesthesia allows multiple brushings and meticulous handling of specimens. Lesion localization is provided as well as identification of synchronous second primary tumors. Biopsies at the lobar spur and carina assist in determining the proximal extent of carcinoma in situ at potential surgical margins. Newer methods should enhance our recognition of inapparent carcinoma in situ allowing more efficient and more accurate tumor localization and a better appreciation of its extent.

75se-selenomethionine in the scintiscan diignosis of primary hepatocellular carcinoma.

Forty-eight patients with ;cold areas' on (99m)Tc sulphur colloid liver scintiscans were scanned again using (75)Se-selenomethionine. In 11 patients with primary hepatocellular carcinoma considerable uptake of (75)Se-selenomethionine could be demonstrated in the area of the tumour and uptake of (75)Se-selenomethionine was also observed over extrahepatic metastases in two of these cases. In contrast uptake was low in cholangiocellular carcinoma, Kupffer cell sarcoma, and secondary hepatic deposits (excepting melanoma metastases). No cause for the ;cold area' on the (99m)Tc scan could be discovered in 16 of 25 patients with cirrhosis and in these patients the uptake of the two isotopes in the area of the ;false positive' filling defect was almost equal. Positive identification of primary hepatocellular tumours using this dual scanning technique can be of value in determining and assessing treatment by surgery or cytotoxic therapy.

RADIOISOTOPE SCANNING IN HEPATIC CIRRHOSIS.

The primary application of radioisotope scanning technics to the liver has involved the differentiation of non-functioning masses from the normal functioning liver parenchyma (1, 2, 4, 7). In most cases, therefore, this technic has been concerned with the identification of primary and metastatic tumors. In the present study, attention has been focused not on visualization as an end in itself, but rather on what information radioisotope scanning can contribute to all other data available in the cirrhotic patient. With this object in mind, consideration must be given to what information scanning can provide. In Figure 1 four factors are observed that may contribute useful information. First, the outline of the liver may be seen. In addition, when there is normal distribution the actual size of the liver may be estimated by reconstructing the effective dimensions through measurement of the areas of the scan at three successive cut-off levels (13). Second, the position of the body wall is illustrated on the s...