Would like insight into this unknown primary and ques. re; Pet scan for possible pancreatic CA

	Asked by annabelle (Female; 59; Her mother died from hip fracture at 79, Father died in his early 80's from heart/dementia. Depression and anxiety history. Smoker in the recent past (quit in February) no drinking. Abnormal AST and ALT liver readings in 2003 - thought to be fatty liver. Alk Phos normal in 2003. Now: 260 Did not get annual check-ups, avoided doctors. Varicose vein leg procedure done in 1993. Tonselectomy in youth. Fatigue and depression/stress but otherwise OK. Recent: March 3 CT scan diagnosed with epigastric mass 15cm, 12cm, 9cm. Mult. Liver mets...8cm and smaller..pain. No ascites at the time of scan but came a few weeks later - no jaundice, CA9-19 is 49, CEA normal, Alpha Feto Protein normal, CA-125 elevated. Low lipase, normal amylase, normal bilirubin, high ferritin approx 400 - was normal few weeks proir. High B-12. TSH 7.99. Anemia mild before chemo, due to malnutrition - now after chemo moderate to severe - 3 transfusions to date. ; Relevant drugs:Is hospitalized. Heparin injections, chemotherapy: Oxaliplatin, Xeloda, Taxotere, Avastin, Tarceva. On TPN due to nausea and epigastric mass pressing on the stomach/duodenum. ) on Sat 03, May 2008 11:28am :
	My mother had PET scan below skull to mid-thigh. Uptake is 3.5 in liver mets with liver to lesion background ratio of 2.0...and max uptake of 10.5 in epigastric mass. Thyroid uptake at 11.9 Everything else, bones, intestines, kidneys, spleen etc...clean.Liver biopsy: small clusters of carcinoma in abundantly necrotic tissue. Neg stain for pancreatic cells or liver cells, CEA stain neg, Cd-10 neg (material very necrotic). Is the tumor highly malignant/aggressive based on the Pet scan? Does the PET tell us anything that can be helpful or is of some good news? She is diagnosed with unknown primary. Are there any other tests, slide stains, etc..that can help us find primary? They feel it could be pancreatic. However, the MD who did the EUS biopsy said this: "It's not likely pancreatic by size, location, lack of pancreatic duct dilation and tumor markers and cytology report." So if you have any insight into this, I would really appreciate it. Please let me know your opinion/thoughts. I don't like having her on so many chemos. I'd prefer to know and have a more targeted approach. Thanks!
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	Answer by Dr Paul S, MD (oncologist) on Sat 03, May 2008 10:10pm: Good day. The most common cancers found in the liver are usually the metastatic ones: those that come from other organs. These organs include the colon, rectum, pancreas, stomach, ovary (for females) and other structures that are located in the peri-ampullary area (duodenum, bile ducts, pancreas). If all the markers and other work ups turn out to be negative, and a diligent search for a primary lesion is conducted and did not yield any significant results, then the cancer can be labeled as a "cancer of unknown primary." Other tests that can be done would include CA19-9 tumor marker (will point out to a possible pancreatic CA) or CA125 (possible ovarian CA). The PET scan cannot tell much about the aggressiveness of the tumor but it can tell us the location of other tumors and possibly the site of the primary tumor. Treatment for such will be based on the most likely source, or treatment may be formulated based on the common regimen that can address all the possible primary tumors (e.g. chemotherapy drugs that can work for pancreatic, gastric, or colorectal cancers alike). Local treatment for the liver lesions can also be carried out in the form of TACE (trans-arterial chemoembolization). I hope all of you can get of the bottom of this soon and that her doctors can institute treatment based on their best possible judgement. Regards and God bless. Thank you for using our service.  If you are satisfied with the answer or if you want a detailed answer for your question, please make a donation and request for further clarifications.  Our oncologists will provide an elaborate answer for your clarification.   Please make a donation by clicking the button below. You may donate using funds from your PayPal account or Credit Card. Please rate my answer (select the stars below, no need to log in.)
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	Follow up: Clarification / Comment by annabelle on Sat 03, May 2008 10:38pm: Thank you. As I wrote in the history portion. An epigastric mass 15 x 14 x 9cm is present adjacent to liver. Most markers came back very low or negative. Ca19-9 49, CEA normal, AFP normal, Ca-125 elevated. It is mostly cystic with soft tissue component. What would be considered a diligent search for a primary lesion. I'd like to know what they could do to try and find out. Any special stains for pathology? Any other tumor marker tests missed? Do you think it could be pancreatic? Clarification / Comment by Dr Paul S, MD on Mon 05, May 2008 12:49am: With all the tests done, I believe that your doctors may have already done a diligent search for the primary tumor but here are some more pointers. You may inquire regarding the suitability of the biopsy specimen for immunostaining (as you mentioned, some are too necrotic to be stained). Biopsy acquired through needle aspiration sometimes may not be ideal to receive special staining. A good specimen to do immunostaining on are large biopsies from an open surgical biopsy or core biopsy. I also agree that a pancreatic origin may be unlikely given the negative EUS and CA19-9 tumor markers. Other staining that can be done if the tissue is suitable are stains for mesenchymal tumors (e.g. desmin, CD117). A larger biopsy may be warranted to have a suitable specimen for these special staining. Regards. Clarification / Comment by Dr Paul S, MD on Mon 05, May 2008 12:49am: With all the tests done, I believe that your doctors may have already done a diligent search for the primary tumor but here are some more pointers. You may inquire regarding the suitability of the biopsy specimen for immunostaining (as you mentioned, some are too necrotic to be stained). Biopsy acquired through needle aspiration sometimes may not be ideal to receive special staining. A good specimen to do immunostaining on are large biopsies from an open surgical biopsy or core biopsy. I also agree that a pancreatic origin may be unlikely given the negative EUS and CA19-9 tumor markers. Other staining that can be done if the tissue is suitable are stains for mesenchymal tumors (e.g. desmin, CD117). A larger biopsy may be warranted to have a suitable specimen for these special staining. Regards. Clarification / Comment by admin on Wed 14, May 2008 12:48pm: Visitors to this page have searched for the following: ask an oncologist ask oncologist pain swollen lymph nod in neck hodgkin's"" and ""itching"" and ""only symptom"" how can a doctor tell by looking at a an ultrasound that a cyst on the tail on the pancreas is just a cyst? sister has pancreatic cancer,should i get ct scan dr heinrik m what do i ask my oncologist? when you get a pet ct scan the whole body does skull to your tights does do the chest too ask an oncologist com i fainted after surgery for ovarian cancer what does this mean 6mm pulmonary nodule ovarian cancer history cin 3 loop diathermy cancerous cells folfox lymph nodes swell neck questions for your oncologist if you had 3 catscans in 4 months and the swollen lyphnodes had no change questions i should be asking my sons oncologist why doesn't every women get a c-125 test bone density test to see if there is any more cancerin body tuma in lymph nodes www.askanoncologistnow.com reactive lymph nodes"" ""ovarian cancer"" 4cm ovarian cyst bilateral painful red, black and blue marks on my legs cancer in the spine, brain, sholder bowel and liver life expectancy statistic of male breast cancer in zambia from 2000 to 2007 swollen glands,face,one side 62 yr old woman - very tired what questions to ask oncologist about breast cancer treatment what to do when your dog is diganoised with prostate cancer ovarian cancer"" ""my symptoms"" chemo for grade 1 breast cancer how long for my grade 1 breast cancer to grow to 5cm im feeling tired all the time and pains in my vigina positve breast biopsy questions to ask your breast oncologist about chemo therapy what to ask my oncologist about breast cancer why am i getting a small recurring lump on the lower, rear side of neck chance of dying from stage 4 non hotchkins cancer kemo og c125 pain in neck groin and bottom of feet now arms what could this be small pea sized lump on the back of my neck below my hairline syptoms red skin at base of tail bone www.ask color of breast milk from a smoking mother a thickness at right side of waist with a dull occasional aching with blood in urine after thyroid cancer can you get cancer on your ovaries? after tumor removed thyroid still hard to breathe ask a oncolgist basal cell casenoma calcification left apex lung radiation lumpectomy can you get night sweats with pancreatic problems can you have leep cone while menstruating? cancer cells in stomach lining prognosis ""metastatic breast"" cause severely swollen lymph nodes occiput behind ears cervical cancer give you pain in the groin and bottom of your feet cluster of red spots below the hairline on sides of neck does a small hard lump on my prostate gland indicate cancer dull pain in area under left armpit in 60 year old male ear pain for 12 months plus swollen glands on neck feels like lump in throat malignant melanoma arm felt a hard pop frontal lobe of brain now sore follicular lymphoma sore left shoulder, tired, weight loss, night sweats had a mri of spine can with tell anything with pancreas hard lump at back of neck hairline how serious is lung cancer (that has spread to the lymph nodes) in a 51 year old (non smoker) male? i have a lump on the left side of my throat near the gland and burning pain in my feet if my mother died of pancreatic cancer, what can i do to stay healthy im 22 could i have pancreatic cancer life expectency of matasized throat cancer lung cancer in lining of lungs that seeds have dropped to his bones lymph nodes and hysterecromy lymphoma right flank swelling pain malignant (gastric cancer)/ kemo therapy my mri showen a growth or cyst on my t band or artery going through my hip my occipital bone have swollen and they are hurtin what should i do? night sweats, breast discharge, dilated duct nodular sclerosing lymphoma recurrence stomach and back ache ovarian cyst should i see oncologist pain between shoulder blades, flank pain, swollen lymph node under left arm pit persistent low grade fever low grade constant ""lump in her neck"" questions to ask an oncologist about brain tumors right back ache radiate leg cancer show me lymph gland diagram for side of face small pea size knots on back of neck a few are sore to touch stomach bleeds metastic breast cancer symptoms itching ""liver mets"" symptoms of matasized breast cancer to lungs the oncologist said the biopsy came back non-reactive bengin tx for petrous apex granuloma what is prognosis when breast cancer ha spread to the bones Clarification / Comment by Unregistered on Sun 21, Dec 2008 12:05pm: She did not have cancer, an infected gallbladder with gallstones and cysts in the liver. How could they miss this? She died from an abscess infection in her stomach. (peritonitis) - She also exsanguiated b/c they gave too much heparin and she vomited blood 2 days before her death and also had bad hematuria and dark stools the day before. I have lost all faith in medicine.
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