Metastatic cancer no primary, Romania Cancer Oranisations and Resources | CancerIndex

Cancer metastatic to liver. Colorectal cancer with liver metastases treatment, REVISTA FARMACIA

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A male patient, years-old, from urban area, presents at clinic in July History: April - he presents at the hospital for metastatic cancer no primary lymph nodes, surgically removed. Risk factors: non-smoker, without professional exposure, alcohol occasionally.

Comorbidities: surgery for repair of mitral valve after endocarditis and surgery for femural head avascular necrosis Computer tomography CT of cervical area, thorax and abdomen, in Aprilfound left pulmonary lesion without specificity, thin, 8 mm fluid accumulation in left costodiafragmatic sinus.

Suspect bone lesion on right iliac wing and sacroiliac articulation. Bilateral osteolytic lesions on hip head, accentuated on the right one suggestive for aseptic osteonecrosis - known from patient history. Bronhoscopy and cytology only offered indications about category of tumor SCLC or NSCLC - in our case without being able to orient us regarding exact histology adenocarcinoma, squamos, or large cell.

With results from PET-CT and bronhoscopy, and needing to asses exact tumor type, most accessible lesions are removed June - left thyroid lobe, left parotid and histopathology and IHC examination requested.

They proved to be metastasis of lung adenocarcinoma. After suspicion of bone metastasis on PET CT, scintigraphy is recommended to bring more details regarding bone lesions, which shows right hip head hyperfixation aseptic necrosis in revascularization statesuspicious hyperfixating lesion on right sacroiliac articulation, which needs monitoring.

No intervention is taken regarding the bone, with close monitoring of current lesions. Genetic tests: EGFR mutations exons 18, 19, 20, 21 - not present.

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Diagnostic Clinical suspicion of lung neoplasm, sustained by imagistic studies PET-CTand confirmed by histopathology and immunohistochemistry results. Final diagnostic: non small cell lung cancer adenocarcinoma metastatic cancer no primary left pulmonary lobe with pleural, bone, thyroid and salivary gland metastasis last two operatedstage IV.

Differential diagnostic: neoplasm metastatic cancer no primary thyroid and neoplasm of salivary gland - which were differentiated by immunohistochemistry. Treatment Because of present symptomatology and patient preference to start treatment as soon as possible, we opted metastatic metastatic cancer no primary no primary chemotherapy - platinum doublet.

He has undergone conformational RT on target volume and lymph nodes area, total dose 60 Gy, well supported. After finalizing RT, patient is continued on Alimta maintenance, with good results, that confirm the data from studies that registered the concept of switch maintenance pemetrexed.

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After 2 cycles -  neutropenia grade 3, required administration of filgrastim and human papillomavirus hpv uk of cycle 3 with 2 days ; mucositis grade 2 - symptomatic treatment. After 4 cycles - sensory peripheral neuropathy grade 2; sent to neurologic consult - symptomatic treatment. After 18 cycles, in January - neurologic symptoms occur - numbness and muscular weakness in right hand motor neuropathy grade 3 - initially considered a potential clinical sign of brain metastasis.

Neurologic consult shows right radial nerve palsy; it was recommended MRI for cerebral and cervical region. EMG showed axonal sensitive neuropathy in all limbs, axonal mononeuropathy of radial nerve metastatic cancer no primary important acute denervation suggestive for lesion of posterior interosseous nerve and recommends monitoring. Motor neuropathy is considered of mixed etiology, and treatment with Alimta is continued. Close term prognostic, as long as response to treatment is maintained, is good.

Medium term prognosis is relatively good.

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Long term prognosis is a reserved one. The patient has never smoked and it has been demonstrated that these patients have better prognostic and respond better to chemotherapy.

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Some data suggest the opportunity to include these patients in a different subgroup 2. In this case, although EGFR mutation was not detected, and there were numerous initial metastasis sites, response to treatment and survival are very good present time: 1 year and 8 months. Evolution In JanuaryCT TAP - without tumoral lesions in mediastinum, pleural or lung; no enlarged lymph nodes, no lesions suspected for metastasis, right iliac wing - 7 mm lesion suggestive for osteoblastoma a rare primary neoplasm of bone, categorized as a benign bone tumor that is closely related to osteoid osteoma.

Patient will receive 21 days cycles of maintenance chemotherapy until the disease progression or inacceptable toxicity.

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Regarding maintenance with pemetrexed Alimtathere are two important studies that demonstrate the role of this drug in continuous and switch maintenance. In Paramount study, Pemetrexed continuation maintenance therapy was well tolerated and it was obtained a superior overall survival compared with placebo. This study demonstrated that continuous maintenance is an effective treatment strategy for patients with advanced non squamous non small-cell lung cancer and good performance status that did not progress during pemetrexed-cisplatin induction therapy 3.

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The benefit of switch maintenance was demonstrated by JMEN study. Both groups received vitamin B12 and folic acid, as is standard for Alimta. The trial was clearly positive for demonstrating a benefit in progression-free survival as well as higher response rates achieved in patients overall who received Alimta after initial platinum-based doublet. The conclusion of this study was that maintenance therapy with pemetrexed is well tolerated and offers improved progression-free and overall survival compared with placebo in patients with advanced non-small-cell lung cancer 4.

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The maintenance with pemetrexed was chosen because EGFR was not present, testing ALK was not performed because at the time of diagnosis, the test was not available in Romania. At this moment, ALK test determination is taken into consideration because now is possible metastatic cancer no primary be performed in Romania not also ROS1 test and if it will be positive, treatment with ALK inhibitors is indicated 5,6.

A study by Kalikaki et al. In our case, despite the negative EGFR mutation status, patient had a good evolution because he was a nonsmoker and the histology was adenocarcinoma. In the future, if the patient will have progressive disease even if Metastatic cancer no primary is not mutated and ALK has not rearrangement, patient can receive erlotinib in the second and third line 9, Immunotherapy could be a therapeutic option taking in consideration the disease evolution and patient performance status, nivolumab registration trial CheckMate or pembrolizumab data from trial KEYNOTElatter requiring testing for PD-L1 expression, being at this moment used for treatment of metastatic NSCLC if evolution occur after chemotherapy or target therapy 12, Unfortunately, in the long run, resistance to almost all therapies is developed - including in immunotherapy, as suggested by data Case particularities This is a classical case vignette for the switch maintenance with pemetrexed.

Other particularity is that this case confirms the good response of adenocarcinoma to pemetrexed and also better response to treatment for nonsmokers.

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Our case has demonstrated that association between chemotherapy and radiotherapy is beneficial and in sequential association. The late, complete remission 1 year and 8 month from diagnostic is another particularity which should be high­lighted.

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A particularity is also the atypical metastasis discovered metastatic cancer no primary PET-CT metastasis of thyroid lobe and salivary gland. We can cite for fine feature rare toxicity to Alimta treatment right hand motor neuropathy but its etiology is likely confounding. Bibliografie 1. Reck, S. Popat, N. Non-small cell lung cancer in never smokers: a clinical entity dysbiosis probiotics be identified, Clinics Sao Paulo.

Luis G. JCO July 8, Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomised, double-blind, phase 3 study. JMEN Lancet. Kerr, L. Bubendorf, M. Ann Oncol 25 9 : Crizotinib in ROS1-rearranged non-small-cell lung cancer.

N Engl J Med. Epub Sep Grigorescu, C. Lung Cancer ; Efficacy and safety of erlotinib versus chemotherapy in second-line treatment of patients with advanced, non-small-cell lung cancer with poor prognosis TITAN : a randomised multicentre, open-label, phase 3 study.

Lancet Oncol.

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Epub Jan Second line treatment in advanced non-small cell lung cancer NSCLC : comparison of efficacy of erlotinib and chemotherapy. N Engl J Med ; Hossein Borghaei, D. Edward B. Garon, Naiyer A.

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