NICE suggest that the following investigations to patients with metastatic disease of unknown origin (MUO) should be offered, as clinically appropriate, guided by the patient's symptoms:
comprehensive history and physical examination including breast, nodal areas, skin, genital, rectal and pelvic examination
full blood count; urea, electrolytes and creatinine; liver function tests; calcium; urinalysis; lactate dehydrogenase
chest X-ray
myeloma screen (when there are isolated or multiple lytic bone lesions)
symptom-directed endoscopy
computed tomography (CT) scan of the chest, abdomen and pelvis
prostate-specific antigen (PSA) in men
cancer antigen 125 (CA125) in women with peritoneal malignancy or ascites
alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) (particularly in the presence of midline nodal disease)
testicular ultrasound in men with presentations compatible with germ-cell tumours
biopsy and standard histological examination, with immunohistochemistry where necessary, to distinguish carcinoma from other malignant diagnoses.
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