Unknown Primary Tumors: Newer Concepts and Approches “ 10 years experience of a Comprehensive Cancer Center” Valerio Ramazzotti S.C. Epidemiologia Roma

Unknown Primary Tumors:

Newer Concepts and Approches

“10 years experience of a Comprehensive Cancer Center”

Valerio Ramazzotti S.C. Epidemiologia

Roma 05/03/2010

CANCER OF UNKNOWN PRIMARY SITE

1. biopsy - proven malignancy; 2. histology not consistent with a primary tumor at biopsy site;3. unrevealing history, physical examination and usual examinations4. failure of additional diagnostic studies to identify primary site

Della Porta M.G. Department of Hematology Oncology, University of Pavia Medical School and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

Features:

From: Barry C. Lembersky, MD, and Lisa C. Thomas, MD

Carcinoma of Unknown Primary –Diagnosis by Light Microscopy

• Well differentiated adenocarcinoma (60%)• Squamous cell carcinoma (5%)• Poorly differentiated adenoca (15%)• Poorly differentiated carcinoma (20%)

From: Hainsworth J. Sarah Cannon Research Institute1 and Tennessee Oncology, PLLC,2 Nashville, Tennessee, USA

From: Barry C. Lembersky, MD, and Lisa C. Thomas, MD

Secondary and unspecified malignant neoplasm of lymph nodes ICD9CM CODE: 196

ICD9CM CODE: 197

Secondary malignant neoplasm of respiratory and digestive systems

ICD9CM CODE: 198

Secondary malignant neoplasm of other specified sites

ICD9CM CODE: 199

Malignant neoplasm without specification of site

It is generally reported that unknown primary tumours account for 5–10% of all neoplasms, and that they tend to have an unfavourable prognosis

Unknown Primary Tumours (ICD-O-9 codes 196–199)

Survival curves for biopsy-proven (n=543) and clinically diagnosed (n=156) unknown primary malignant tumours: Vaud and Neuchatel, Switzerland, 1984–1993 (1.7%; 2.3% of all sites, excluding 173)

From Levi F et al. European Journal of Cancer 38 (2002) 1810–1812

CART generated with the initial split on the presence or absence of liver metastases (default tree) (1000 consecutive patients with UPC)

From: K.R. Hess et al. Clinical Cancer Research, Vol. 5, 3403-3410. 1999

Kaplan-Meier survival curves of the 10 terminal subgroups generated from the default CART analysis

From: K.R. Hess et al. Clinical Cancer Research, Vol. 5, 3403-3410. 1999

ITALY: UNKNOWN PRIMARY TUMOURS (ICD9: 199). HOSPITAL ADMISSIONS BY YEAR

8000

8500

9000

9500

10000

10500

1999 2000 2001 2002 2003 2004 2005

http://www.salute.gov.it/ricoveriOspedalieri/ric_informazioni/sceltadia.jsp

ICD9CM CODE: 199 Malignant neoplasm without specification of site

Unknown Primary Tumours (ICD9 199) N. Hospital Admissions by Year. Italy. Men

5636

5280 52315121

4978 4917 4937

1999 2000 2001 2002 2003 2004 2005

All Malignant Tumours (ICD9 140-208)N. Hospital Admissions by Year. Italy. Men.

340621

329760 330076326715

320467

325198 323797

1999 2000 2001 2002 2003 2004 2005

Unnknown Primary Tumours (ICD9 199) Percents of All MalignantTumours by Year of Hospital Admission.

Italy. Men.

1,65

1,60 1,58 1,57 1,551,51 1,52

1999 2000 2001 2002 2003 2004 2005



ICD9CM CODE: 140-208 All Malignant Neoplasms

Unknown Primary Tumours (ICD9 199) N. Hospital Admissions by Year. Italy. Women

4541

4281

4131

3981 39964064

3959

1999 2000 2001 2002 2003 2004 2005

All malignant Tumours (ICD9 140-208). N. Hospitals Admissions by Year. Italy. Women.

269116

261682 261277258655

254674258249 257167

1999 2000 2001 2002 2003 2004 2005

Unknown Primary Tumours (ICD 199) Percents of All Malignant Tumours of Hospital Admissions by Year.

Italy. Women. 1,7

1,6

1,61,5

1,6 1,61,5

1999 2000 2001 2002 2003 2004 2005



ICD9CM CODE: 140-208 All Malignant Neoplasms

Unknow Primary Tumours (ICD9: 199). Hospital Admission by Region. 1999

0 500 1000 1500 2000 2500

VALLE D'AOSTA

BASILICATA

P.A. TRENTO

P.A. BOLZANO

MOLISE

CALABRIA

UMBRIA

ABRUZZO

MARCHE

FRIULI V.G.

LIGURIA

SARDEGNA

CAMPANIA

SICILIA

PUGLIA

PIEMONTE

TOSCANA

VENETO

EMILIA ROMAGNA

LAZIO

LOMBARDIA

Unknown Primary Tumours (ICD9: 199). Hospital Admissions by Region. 2000

0 200 400 600 800 1000 1200 1400 1600 1800 2000

VALLE D'AOSTA

BASILICATA

P.A. BOLZANO

P.A. TRENTO

MOLISE

CALABRIA

UMBRIA

SARDEGNA

ABRUZZO

MARCHE

LIGURIA

FRIULI V.G.

CAMPANIA

SICILIA

PUGLIA

VENETO

LAZIO

PIEMONTE

EMILIA ROMAGNA

TOSCANA

LOMBARDIA


0 200 400 600 800 1000 1200 1400 1600 1800 2000

VALLE D'AOSTA

P.A. TRENTO

P.A. BOLZANO

BASILICATA

MOLISE

CALABRIA

UMBRIA

ABRUZZO

FRIULI V.G.

LIGURIA

SARDEGNA

MARCHE

SICILIA

CAMPANIA

PUGLIA

TOSCANA

VENETO

LAZIO

PIEMONTE

EMILIA ROMAGNA

LOMBARDIA


0 200 400 600 800 1000 1200 1400 1600 1800 2000

VALLE D'AOSTA

BASILICATA

P.A. BOLZANO

P.A. TRENTO

MOLISE

CALABRIA

UMBRIA

ABRUZZO

MARCHE

LIGURIA

FRIULI V.G.

SARDEGNA

CAMPANIA

PUGLIA

SICILIA

VENETO

TOSCANA

EMILIA ROMAGNA

PIEMONTE

LAZIO

LOMBARDIA



Unknown Primary Tumours (ICD9: 199). Hospital Admissions by Region.

2003

0 200 400 600 800 1000 1200 1400 1600 1800

VALLE D'AOSTA

P.A. TRENTO

BASILICATA

P.A. BOLZANO

CALABRIA

UMBRIA

ABRUZZO

MOLISE

FRIULI V.G.

MARCHE

LIGURIA

CAMPANIA

SARDEGNA

PUGLIA

SICILIA

VENETO

TOSCANA

LAZIO

PIEMONTE

EMILIA ROMAGNA

LOMBARDIA

Unknown Primary Tumours (ICD9: 199). Hospital Admissions by Region.

2004

0 200 400 600 800 1000 1200 1400 1600 1800

VALLE D'AOSTA

BASILICATA

P.A. TRENTO

P.A. BOLZANO

UMBRIA

CALABRIA

MARCHE

MOLISE

FRIULI V.G.

ABRUZZO

CAMPANIA

LIGURIA

SARDEGNA

PUGLIA

SICILIA

VENETO

LAZIO

EMILIA ROMAGNA

PIEMONTE

TOSCANA

LOMBARDIA


0 200 400 600 800 1000 1200 1400 1600 1800

VALLE D'AOSTA

BASILICATA

P.A. TRENTO

P.A. BOLZANO

UMBRIA

CALABRIA

MARCHE

FRIULI V.G.

MOLISE

ABRUZZO

CAMPANIA

SARDEGNA

LIGURIA

SICILIA

PUGLIA

VENETO

LAZIO

PIEMONTE

EMILIA ROMAGNA

TOSCANA

LOMBARDIA



1999

Regional Hospitals; 500;

45%NCI IRE; 75; 7%

Private Hospitals; 247;

22%

University/IRCCS/

Others; 286; 26%

2000


45%

NCI IRE; 44; 5%


21%

University/IRCCS/ Others;

249; 29%

2001


47%

University /IRCCS/

Others; 214; 25%

NCI IRE; 61; 7%


21%

2002


51%University /IRCCS/

Others; 232; 26%

NCI IRE; 35; 4%


19%

Lazio Region. Unknown Primary Tumours (ICD9 Code 199). N. Admissions by Hospital Typology and Year. (1)


Modificata


2003


51%University /IRCCS/

Others; 202; 24%

NCI IRE; 42; 5%


20%

2004


61%

University /IRCCS/

Others; 151; 21%

NCI IRE; 18; 2%


16%

2005


57%University/

IRCCS /Others; 155;

21%

NCI IRE; 18; 2%


20%

Lazio Region. Unknown Primary Tumours (ICD9 Code 199). N. Admissions by Hospital Typology and Year. (2)


Modificata


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 199). N. PATIENTS AND HOSPITAL ADMISSIONS BY AGE CLASSES AND GENDER.

TIME PERIOD 1995-2007

0 0 0 0212

337176

263

173

250

123157

0100200300400500600700

N. Patients (men) N. Admissions(men)

N. Patients(women)

N. Admissions(women)

0-14 15-64 65+


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 199). N. PATIENTS BY TYPOLOGY OF DRG. TIME PERIOD 1995-2007

21031%

47469%

SURGERY MEDICINE

IRE. UNKNOWN PRIMARY SITE (ICD9 199). N. PATIENTS BY RESIDENCE AREA.TIME PERIOD 1995-2007

Lazio14721%

Rome37155%

Extra Region16624%


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 199). N. ADMISSIONS BY TYPOLOGY OF DRG. TIME PERIOD

1995-2007

22622%

78178%

SURGERY MEDICINE

IRE. UNKNOWN PRIMARY TUMOURS (ICD9 199). N. ADMISSIONS BY DEPARTMENT. TIME PERIOD 1995-2007

50 45 373

3511 1 14

324371

475 11

451 1 1 5


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 196-199).

0

50

100

150

200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

N. PATIENTS: tot. 1671 N. ADMISSIONS: tot. 2059

ICD9CM CODE: 196 Secondary and unspecified malignant neoplasm of lymph nodes ICD9CM CODE: 197 Secondary malignant neoplasm of respiratory and digestive systems ICD9CM CODE: 198 Secondary malignant neoplasm of other specified sites ICD9CM CODE: 199 Malignant neoplasm without specification of site

IRE. UNKNOWN PRIMARY TUMOURS (ICD9 196-199). N. PATIENTS BY ICD9 CODE. TIME PERIOD 1995-2007. WOMEN

206235

135

262

206 222184

221

196 197 198 199

MEN WOMEN


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 196-199). N. ADMISSIONS BY ICD9 CODE AND GENDER. TIME

PERIOD 1995-2007

233 265

155

424

218 257198

309

196 197 198 199

MEN WOMEN


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 CODE 196-199). N. ADMISSIONS

BY TYPOLOGY OF DRG. TIME PERIOD 1995-2007

95646%

110354%

SURGERY MEDICINE


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 CODE 196-199). N. ADMISSIONS BY DEPARTMENT. TIME PERIOD 1995-2007

342

194

74 42

178

25 262

403 406

768 21 11 10 3 1 7

192

2


IRE. UNKNOWN PRIMARY TUMOURS (ICD9 CODE 196-199). PRINCIPAL PROCEDURES FROM HOSPITAL ADMISSIONS (FREQUENCY>9). TIME PERIOD 1995-2007

0 50 100 150 200 250 300

LaparoscopyOther total excision of thymus

ElectrocardiogramPercutaneous abdominal drainageRadical neck dissection, bilateral

Diagnostic ultrasound of abdomen and retroperitoneumColonoscopy

Microscopic examination of specimen Routine chest x-ray, so described

Excision of axillary lymph nodeMagnetic resonance imaging of other and unspecified sites

Excision or destruction of peritoneal tissueOther destruction of lesion of liver

Other chest x-rayRadical excision of other lymph nodes

Closed [percutaneous][needle] biopsy of lungComputerized axial tomography of abdomen

Partial hepatectomyOther

Simple excision of other lymphatic structureMagnetic resonance imaging of brain and brain stem

Computerized axial tomography of thoraxOther excision or destruction of lesion or tissue of brain

Exploratory laparotomyRadical neck dissection, not otherwise specified

Other radiotherapeutic procedureOther local excision of lesion or tissue of lung

Radical groin dissectionBiopsy of lymphatic structure

Excision of deep cervical lymph nodeRadical excision of iliac lymph nodes

Radical excision of skin lesionInjection or infusion of other therapeutic substance

Radical neck dissection, unilateralTranspleural thoracoscopy

Closed (percutaneous) [needle] biopsy of liverRadical excision of axillary lymph nodes

Other computerized axial tomographyInjection of cancer chemotherapeutic substance

CODE: 196 Secondary and unspecified malignant neoplasm of lymph nodes ICD9CM CODE: 197 Secondary malignant neoplaICD9CM sm of respiratory and digestive systems ICD9CM CODE: 198 Secondary malignant neoplasm of other specified sites ICD9CM CODE: 199 Malignant neoplasm without specification of site

IRE. UNKNOWN PRIMARY TUMOURS. FURTHER HOSPITAL ADMISSIONS WITH PRINCIPAL DIAGNOSIS V58 vs ALL UPT

196-199 V58

196-199 V58

IRE. UNKNOWN PRIMARY TUMOURS. HOSPITAL ADMISSIONS. PRINCIPAL DIAGNOSIS V58 vs ALL UPT

78%

22%

196-199 V58

IRE. UNKNOWN PRIMARY TUMOURS. FURTHER HOSPITAL ADMISSIONS: ICD9 CODE V58

ICD9CM CODE: V580 Encounter for radiotherapy ICD9CM CODE: V581 Encounter for antineoplastic chemotherapy and immunotherapy

IRE. UNKNOWN PRIMARY TUMOURS. DISTRIBUTION OF SECONDARY DIAGNOSES IN HOSPITAL ADMISSIONS FOR

ICD9 CODE: V58

19613%

19724%

19816%

19947%

ICD9CM CODE: V580 Encounter for radiotherapy ICD9CM CODE: V581 Encounter for antineoplastic chemotherapy and immunotherapy

Conclusions (1)

For unknown primary tumours, hospital discharge data are crucial in clinical care, especially when they are included in the framework of a hospital-based cancer registry (HCR).

Even though HCR is not suitable to compute population incidence or prevalence data, it is a valid tool for hospital administration.

Conclusions (2)

Documents

Unknown Primary Tumors: Newer Concepts and Approches “ 10 years experience of a Comprehensive Cancer Center” Valerio Ramazzotti S.C. Epidemiologia Roma