Episode 008: Metastatic Cancer of “Origin TBD”

What this episode covers

Not to be confused with “carcinoma of unknown primary,” in this episode of metastatic disease of “origin TBD”, we discuss the workup of a mass noted incidentally on imaging. This is a very high yield topic often faced on solid oncology consults! Major Points Covered: Mass found incidentally on imaging → we need to stage always Initial Workup: Reasonable to get CBC, CMP, UA, PSA (if male) Low blood counts, maybe marrow involvement Cr elevated concern for obstruction possibly LFTs elevated concern for mass in the biliary/pancreas region UA w/ hematuria → maybe bladder But bottom line you’re gonna get a scan, which scan to get though? Recommend referencing NCCN guidelines to determine additional staging scans Create an account on nccn.org and look at guidelines by tumor type Not all cancers require a PET/CT scan There are newer modalities for imaging other than FDG PET including PSMA PET (prostate), Auxumin PET (prostate), and DOTATE PET (neuroendocrine) Certain cancers can be diagnosed on imaging alone (RCC and HCC) Some cancers require Brain MRI for staging What to biopsy? FNA often adequate for solid tumors but may need core if non diagnostic Need core or ideally excisional if highly concerned for lymphoma Always try to biopsy the site that will upstage Distant lymph nodes or other metastatic sites What about tumor markers? We use this for treatment monitoring, not for diagnostic purposes Important to establish a baseline to follow, special circumstances for diagnostic purposes to consider below: PSA in male if concerned about prostate cancer AFP helpful if concerned for HCC → liver masses in a cirrhotic AFP and b-HCG if concerned for testicular → young or middle aged male with mediastinal mass Molecular testing not necessarily needed at the time of biopsy  Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCall Instagram: @TheFellowOnCall Listen in on: Apple Podcast, Spotify, and Google Podcast