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Year : 2013  |  Volume : 2  |  Issue : 2  |  Page : 56

Reply to: Metastasis to left scapula with unknown primary: Approach to pathological diagnosis

1 Command Military Dental Centre (South Command), Pune, Maharashtra, India
2 Department of Surgery, Narayani Hridulaya and Research Centre, Ahemdabad, India
3 Department of Pathology, Government Medical College, Trivendrum, Kerela, India

Date of Web Publication15-Apr-2013

Correspondence Address:
Kanaram Choudhary
Command Military Dental Centre (South Command), Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-330X.110486

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How to cite this article:
Choudhary K, Choudhary B, Nambyar A. Reply to: Metastasis to left scapula with unknown primary: Approach to pathological diagnosis. South Asian J Cancer 2013;2:56

How to cite this URL:
Choudhary K, Choudhary B, Nambyar A. Reply to: Metastasis to left scapula with unknown primary: Approach to pathological diagnosis. South Asian J Cancer [serial online] 2013 [cited 2019 Oct 23];2:56. Available from:


In a recent issue, an interesting case titled "Metastasis to left scapula with unknown primary: Approach to pathological diagnosis" was published by Shiasta et al. [1] In this case, the final diagnosis was given as metastatic adenocarcinoma, probably arising from the lungs. The majority of metastatic carcinomas of unknown primaries (MCUPs) in adults are adenocarcinomas and undifferentiated carcinomas, but the relative number of each differs depending on age and sex. [2] Huebner et al., in a case study of a series of 343 patients found that 40% of the metastatic tumors were adenocarcinoma, 28% were undifferentiated carcinoma, 14% were squamous cell carcinoma, and the remainder were poorly differentiated tumors. [3] Patients with visceral metastasis of carcinoma below the diaphragm had a poor prognosis and responded poorly to chemotherapy. [4]

It is also important to identify carcinomas that can be treated by chemotherapy or hormonal manipulation or both, especially metastasis from breast and prostate. [5] For the final diagnosis, analysis of immunohistochemical (IHC) markers are of utmost importance. Therefore, treatment should be started from the lung and breast, depending on the gender. [5] To rule out lung adenocarcinoma, IHC panel of CK 7, CK 14, CK 20, and TTF-1 is very important. Because some mucinous adenocarcinomas are CK 20 positive, staining with mucicarmine may be fruitful. However, in the published case, CK 20 was negative. CK 20 positivity is extensively reported in colorectal cancer; in such a case, high resolution computed tomography can give better result than ultrasonography. In the published case, routine hematoxylin and eosin staining gave impression of paraganglionoma that has been ruled out by IHC. The expression of CK7 and CK20 is distinctive to glandular epithelia. This may include tumors like colorectal, pancreatic, or bronchoalveolar adenocarcinomas, as well as adenocarcinomas of the salivary glands. [6] TTF-1 is a nuclear tissue-specific protein transcription factor, found only in thyroid/thyroid tumors regardless of histological types, as well as in adenocarcinomas (75%), non-small cell carcinomas (63%), and small cell carcinomas (90%) of the lung. [7],[8] Therefore, in the present case, TTF-1 staining would have given evidence in favor of lung adenocarcinoma. It has been noted in previous studies that no lung adenocarcinomas were CK20 positive, but almost all were CK7 positive, and 70% of the cases were TTF-1 positive. [9] Although salivary gland adenocarcinoma rarely metastasizes and is clinically evident, it should be included in differential diagnosis. Because rapid metastasis of salivary gland adenocarcinoma into the lung, brain, and multiple osseous site has been reported in literature. [10],[11] Here, staining with CK 7/14 and TTF-1 is useful. Salivary adenocarcinomas are positive for CK 7/14, negative for TTF-1, and negative for CK 20. [6] In conclusion, IHC markers with advanced radiological investigations are mainstay in the diagnosis of occult or unknown primaries.

  References Top

1.Vasenwala SM, Ansari HA, Haider N, Sabir Ab, Ur Rehman A. Metastasis to left scapula with unknown primary: Approach to pathological diagnosis. South Asian J Cancer 2013;2:2.  Back to cited text no. 1
  Medknow Journal  
2.Hainsworth JD, Greco FA. Poorly differentiated carcinoma and poorly differentiated adenocarcinoma of unknown primary tumor site. Semin Oncol 1993;20:279-86.  Back to cited text no. 2
3.Huebner G, Tamme C, Schouber C. Prognostically different subgroup in patient with carcinoma of unknown primary. J Chemother Infect Dis Malig 1989;1:816.  Back to cited text no. 3
4.Kambhu SA, Kelsen DP, Fiore J, Niedzwiecki D, Champman D, Vinciquerra V, et al. Metastatic adenocarcinoma of unknown primary site: Prognostic variables and treatment results. Am J Clin Oncol 1990;13:55-60  Back to cited text no. 4
5.David D. Diagnostic Immunohistochemistry, 2 nd ed. Edinburgh: Churchill Livingstone Elsevier; 2006.  Back to cited text no. 5
6.Meer S, Altini M. CK7+/CK20- immunoexpression profile is typical of salivary gland neoplasia. Histopathology 2007;51:26-32.  Back to cited text no. 6
7.DiLoreto C, Di Lauro V, Puglisi F, Damante G, Fabbro D, Beltrami CA. Immunocytochemical expression of tissue specific transcription factor-1 in lung carcinoma. J Clin Pathol 1997;50:30-2.  Back to cited text no. 7
8.Stahlman MT, Gray ME, Whitsett JA. Expression of thyroid transcription factor-1 TTF-1 and fetal and neonatal lung. J Histochem Cytochem 1996;44:673-8.  Back to cited text no. 8
9.Chhieng DC, Cangiarella JF, Zakowski MF, Goswami S, Cohen JM, Yee HT. Use of thyroid transcription factor 1, PE-10, and cytokeratins 7 and 20 in discriminating between primary lung carcinomas and metastatic lesions in fine-needle aspiration biopsy specimens. Cancer 2001;93:330-6.  Back to cited text no. 9
10.Eltt T, Kleinheinz J, Mehrotra R, Schwarz S, Reichert TE, Driemel O. The buccal minor salivary glands as starting point for a metastasizing adenocarcinoma: Report of a case. Head Face Med 2008;4:16.  Back to cited text no. 10
11.Rajeev R, Beena VT, Choudhary K, Divya G. Adenocarcinoma (NOS) of buccal mucosa metastasising to lung and frontal lobe of the brain: Report of a rare case. Oral Surgery 2012;5:127-31.  Back to cited text no. 11


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