⚠ DIAGNOSTIC PHASE — TREATMENT PLAN NOT YET APPLICABLEDIAGNOSTIC PHASE — TREATMENT PLAN NOT YET APPLICABLE. Histology required before any therapy discussion (CHARTER §15.2 C7).
Patient
PZ-DIAG-CUP-001 · suspicion lineage: carcinoma
Tissues: liver, bone · Hypotheses: DIS-CUP, DIS-PDAC-OCCULT, DIS-CHOLANGIOCARCINOMA-OCCULT, DIS-NSCLC-OCCULT
67F presents with 8-week fatigue + 6 kg weight loss + new mid-thoracic back pain. CT abd/pelvis (with contrast): multiple liver lesion x4, largest 4.2 cm, hypovascular pattern. CT chest: no lung mass, small mediastinal nodes <1 cm. Bone scan + skeletal MRI: lytic+sclerotic mixed lesions T6, T9, right iliac wing. CEA 24 (mildly elevated), CA 19-9 280 (elevated), CA 125 38 (mildly elevated), AFP normal. Liver-mass biopsy histology: poorly-differentiated adenocarcinoma. IHC pattern: CK7-positive, CK20-negative, TTF-1-negative, GATA3-negative, ER-negative, p40-negative. Pattern is non-specific upper-GI / pancreaticobiliary / lung-non-small primary, but no primary tumor seen on diagnostic imaging. PET-CT revealed only known liver+bone+nodal disease, no FDG-avid primary visible. CUP per ESMO criteria. Tumor-of-origin classifier (e.g., CancerType ID, methylation panel) + comprehensive NGS for actionable drivers needed.
Matched workup: WORKUP-SUSPECTED-SOLID-TUMOR · Очікуваний термін: ~21 дnoв
Workup steps (5)
- 1lab Complete Blood Count with Differential
Baseline cytopenia assessment and ongoing monitoring of myelosuppression.
- 2lab Liver Function Tests
Assess hepatic function — baseline + during BR cycles + DAA therapy + HBV reactivation monitoring.
- 3lab Lactate Dehydrogenase
Tumor burden surrogate; rising LDH suggests transformation or progression in indolent lymphoma.
- 4imaging FDG PET/CT
Staging at diagnosis + response assessment after antiviral or chemoimmunotherapy. Detects transformation hotspots.
- 5histology Tissue biopsy + IHC panel + ancillary molecular
Histology + adequate tissue для immunohistochemistry + molecular profiling (NGS panel) — standard solid-tumor workflow.
Biopsy preferred: Image-guided core needle biopsy of primary lesion
IHC baseline: Pan-cytokeratin, Vimentin, Ki67
Питання що мають бути закриті (5)
- Чи це malignancy чи benign / inflammatory mimicker?
- Якщо malignancy — primary site чи metastasis з неknownго primary?
- Histologic subtype + grade?
- Stage за відповідною AJCC TNM системою?
- Actionable mutations присутno? (визначає targeted therapy options)
MDT brief
Discussion questions (1, 0 blocking)
DQ-DIFFERENTIAL
What is the differential diagnosis plan between hypotheses: DIS-CUP, DIS-PDAC-OCCULT, DIS-CHOLANGIOCARCINOMA-OCCULT, DIS-NSCLC-OCCULT? Which molecular / IHC tests differentiate them?
Multiple hypotheses — must be differentiated before treatment discussion.
→ pathologist
MDT talk tree (3 steps)
| # | Owner | Topic | Action |
|---|
| 1 | pathologist | Pathology confirmation | What is the differential diagnosis plan between hypotheses: DIS-CUP, DIS-PDAC-OCCULT, DIS-CHOLANGIOCARCINOMA-OCCULT, DIS-NSCLC-OCCULT? Which molecular / IHC tests differentiate them? |
| 2 | radiologist | Specialist review | Stage / restaging imaging + biopsy guidance — radiologist. |
| 3 | surgical_oncologist | Specialist review | Suspected solid tumor — resectability assessment, biopsy approach. |
Skills (required) — mandatory virtual specialists (2)
- Pathologist (general) required
Any suspicion requires biopsy — pathologist plans site selection, IHC panel, ancillary tests.
Owns: DQ-DIFFERENTIAL
- Radiologist required
Stage / restaging imaging + biopsy guidance — radiologist.
Skills (recommended) — for consideration (1)
Technical MDT skill metadata (3/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |