Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) CUP 1 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • • References References • CUP 2 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Clinical evaluation Evidence Option � Complete history of the disease Type C Std. � Weight and weight loss Type C Std. � Performance status (Karnofsky / WHO scale) Type C Std. � Fiberoptic examination of H&N mucosa Type C Std. � Neck examination Type C Std. � Drawing of any lesions Type C Std. CUP 3 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Endoscopic evaluation Evidence Option � Fine needle aspirate (FNA). To be repeated in case Type C Std. of no diagnosis � Endoscopy under general anesthesia with biopsies Type C Std. of any suspicious site; if no abnormal mucosa, blind biospies of nasopharynx, base of tongue and pyriform sinus; ipsilateral tonsillectomy � Oesogastroscopy Type C Std. � Endoscopy with PET-directed biopsies Type 3 Invest. CUP 4 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Advanced clinical evaluation Evidence Option � Dental examination by oral surgeon Type C Std. � Nutritional assessment Type C Std. � Others (if required) Type C Indiv. CUP 5 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Laboratory tests Evidence Option � Hemogram, coagulation tests, liver enzymes, Type C Std. kidney function � Thyroid function: TSH Type C Std. CUP 6 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Imaging Evidence Option � Regional: CT scan (or MRI) 1 Type C Std. � Metastatic work-up: chest X-ray, thoracic spiral Type C Std. CT scan � Additional examination depending on previous Type C Std. findings � PET scan Type 3 Invest. 1 See guidelines for loco-regional imaging CUP 7 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Pathologic examination Evidence Option Standards of the British Royal College of Type C Std. Pathologists (endorsed by EORTC) 1 1 See pathology guidelines CUP 8 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • • References References • CUP 9 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Staging Evidence Option � TNM classification (5 th ed., 1997) Type C Std. � WHO International Classification of Diseases for Oncology (ICD-O 9 or ICD-O 10) Type C Std. CUP 10 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme TNM/AJCC 1997 Staging TNM/AJCC 1997 Staging � T0: patients with unknown primary tumor � Tx: patients whose tumor cannot be assessed or is not assessed CUP 11 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme TNM/AJCC 1997 Staging TNM/AJCC 1997 Staging • N0: no regional node metastasis • Nx: regional nodes cannot be assessed • N1: single ipsilateral node, ≤ 3 cm • N2a: single ipsilateral node, > 3 cm and ≤ 6 cm • N2b: multiple ipsilateral nodes, ≤ 6 cm • N2c: controlateral or bilateral nodes, ≤ 6 cm • N3: node > 6 cm CUP 12 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • • References References • CUP 13 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Primary treatment: general strategy Evidence Option � T0-N1 Ipsilateral ND ± RxTh (intergroup trial) 1 Type 3 Std. If previous inappropriate node excision, Type C Std. ipsilateral ND ± RxTh � T0-N2a/T0-N2b/T0-N3 Ipsilateral ND + RxTh (intergroup trial) Type 3 Std. � T0-N2c Bilateral ND + RxTh Type 3 Std. 1 See detailled protocol CUP 14 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Primary treatment: surgical procedure Evidence Option � Unilateral or bilateral (N2c) ND 1 Radical modified or radical ND 1 Type 3 Std. 1 extended radical ND may be required, e.g.N3 CUP 15 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Primary treatment: : pathologic examination pathologic examination Evidence Option Primary treatment Evidence Option Standards of the British Royal College College of of Type C Std Std. . Standards of the British Royal Type C Pathalogists Pathalogists ( ( endorsed endorsed by EORTC ) by EORTC ) 1 1 See See pathology guidelines pathology guidelines CUP 16 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Primary treatment: RxTh regimen Evidence Option � Target volumes (intergroup trial) 1 -Levels I-V ± pharyngeal and laryngeal - Invest. mucosa according to randomization � Target volumes (outside trial) - ipsilateral levels I-V (bilateral for pN2c) Type 3 Std. � Technique -conformal radiotherapy Type 3 Std. -IMRT radiotherapy Type 3 Invest. � Dose 2 -Level I-V: 60 Gy (64 Gy if high risk) Type 2 Std. -mucosa: 50 Gy Type 3 Std. � Fractionation -daily 2Gy/fraction Type 3 Std. � Concomitant chemo Type 2 Invest. 1 See detailled protocol 2 See guidelines for post-operative radiotherapy CUP 17 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • • References References • CUP 18 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Follow-up Evidence Option � Clinical examination -fiberoptic examination and neck palpation Type C Std. every 2 months (first 2 years), every 6 months (3 rd -5 th year), then every year (> 5 years) -dental examination every 6 months Type C Std. � Imaging -chest X-ray every year Type C Std. � Laboratory tests -thyroid function (TSH) every year Type C Std. � Evolution of late toxicity (EORTC/RTOG) scale Type C Std. CUP 19 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • References CUP 20 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Salvage treatment for recurrent disease Evidence Option � anyT-N0-M0 -Surgery ± RxTh Type 3 Std. -RxTh / brachytherapy Type 3 Std. � T0-anyN-M0 -ND ± RxTh Type 3 Indiv. -RxTh Type 3 Indiv. -Chemotherapy Type 3 Indiv. � AnyT-anyN-M0 Surgery ± RxTh Type 3 Indiv. Chemotherapy Type 3 Indiv. Best supportive care Type 3 Indiv. � Metastasis Chemotherapy Type 3 Std. Surgery Type 3 Indiv. Best supportive care Type 3 Indiv. CUP 21 Sept. 2001
Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Carcinoma of unknown primary (CUP) • Work-up procedure Work-up procedure • • TNM staging TNM staging • • Primary treatment Primary treatment • • Follow-up Follow-up • • Treatment of recurrent and/or Treatment of recurrent and/or metastatic metastatic disease disease • References CUP 22 Sept. 2001
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