Endgames Case report

A 46 year old man with carcinoma of unknown primary site

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5144 (Published 02 August 2012) Cite this as: BMJ 2012;345:e5144
  1. E Liniker, academic clinical fellow, medical oncology 1,
  2. S Al-Jilaihawi, foundation year 2 doctor2,
  3. D Propper, consultant medical oncologist 2,
  4. S Slater, consultant medical oncologist2,
  5. S Pacey, honorary consultant in medical oncology1
  1. 1Department of Oncology, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
  2. 2Barts Cancer Institute, Queen Mary University of London, London, UK
  1. Correspondence to: S Pacey simonpacey{at}medschl.cam.ac.uk

A 46 year old white man presented via the general medical on-call team with hypotensive collapse and melaena. Emergency oesophagogastroduodenoscopy after initial resuscitation showed bleeding duodenal ulcers that were amenable to endoscopic injection. On subsequent questioning by the admitting doctor, he reported gradually increasing abdominal girth, weight loss, and intermittent abdominal pain over the past two years. Systematic review yielded no further symptoms. His medical history was unremarkable and the only drug that he currently took was paracetamol. He smoked 15 cigarettes a day (20 pack years) and had no history of excess alcohol use.

Positive findings on examination were nodular hepatomegaly (2 cm below the costal margin) and a firm fixed 2 cm nodule at the umbilicus. He had no signs of chronic liver disease, and external genitalia and digital rectal examination were normal. There was no palpable lymphadenopathy and the remainder of the physical examination (including comprehensive skin examination for melanoma) was normal.

Computed tomography showed widespread liver omental and splenic deposits, consistent with metastases, and a 2 cm umbilical nodule. The primary source of the metastatic disease was not apparent.

Percutaneous biopsy of the umbilical nodule was performed. The provisional histology report confirmed that it was malignant and the patient was referred for an oncology opinion.


  • 1 What further investigations are needed?

  • 2 How might the biopsy inform patient management?

  • 3 What factors affect prognosis?


1 What further investigations are needed?

Short answer

Detailed histological examination of the tumour biopsy should be requested and the patient’s fitness for chemotherapy assessed. …

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