1
|
Sivakumaran T, Cardin A, Callahan J, Wong HL, Tothill RW, Hicks RJ, Mileshkin LR. Evaluating the Utility of 18F-FDG PET/CT in Cancer of Unknown Primary. J Nucl Med 2024; 65:1557-1563. [PMID: 39237349 DOI: 10.2967/jnumed.123.267274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 08/13/2024] [Indexed: 09/07/2024] Open
Abstract
Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumors for which standardized diagnostic work-up fails to identify the primary site. We aimed to describe the Peter MacCallum Cancer Centre experience with 18F-FDG PET/CT in extracervical CUP with respect to detection of a primary site and its impact on management. A secondary aim was to compare overall survival (OS) in patients with and without a detected primary site. Methods: CUP patients treated between 2014 and 2020 were identified from medical oncology clinics and 18F-FDG PET/CT records. Information collated from electronic medical records included the suspected primary site and treatment details before and after 18F-FDG PET/CT. Clinicopathologic details and genomic analysis were used to determine the clinically suspected primary site and compared against 2 independent masked reads of 18F-FDG PET/CT images by nuclear medicine specialists to determine sensitivity, specificity, accuracy, and the rate of detection of the primary site. Results: We identified 147 patients, 65% of whom had undergone molecular profiling. The median age at diagnosis was 61 y (range, 20-84 y), and the median follow-up time was 74 mo (range, 26-83 mo). Eighty-two percent were classified as having an unfavorable CUP subtype as per international guidelines.18F-FDG PET/CT demonstrated a primary site detection rate of 41%, resulted in a change in management in 22%, and identified previously occult disease sites in 37%. Median OS was 16.8 mo for all patients and 104.7 and 12.1 mo for favorable and unfavorable CUP subtypes, respectively (P < 0.0001). Median OS in CUP patients when using 18F-FDG PET/CT, clinicopathologic, and genomic information was 19.8 and 8.5 mo when a primary site was detected and not detected, respectively (P = 0.016). Multivariable analysis of survival adjusted for age and sex remained significant for identification of a potential primary site (P < 0.001), a favorable CUP (P < 0.001), and an Eastern Cooperative Oncology Group status of 1 or less (P < 0.001). Conclusion: 18F-FDG PET/CT plays a complementary role in CUP diagnostic work-up and was able to determine the likely primary site in 41% of cases. OS is improved with primary site identification, demonstrating the value of access to diagnostic 18F-FDG PET/CT for CUP patients.
Collapse
Affiliation(s)
- Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia;
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Anthony Cardin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jason Callahan
- Melbourne Theranostic Innovation Centre, Melbourne, Victoria, Australia
| | - Hui-Li Wong
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard W Tothill
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Pathology and University of Melbourne Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia; and
| | - Rodney J Hicks
- Melbourne Theranostic Innovation Centre, Melbourne, Victoria, Australia
- University of Melbourne Department of Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Linda R Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Budczies J, Kazdal D, Menzel M, Beck S, Kluck K, Altbürger C, Schwab C, Allgäuer M, Ahadova A, Kloor M, Schirmacher P, Peters S, Krämer A, Christopoulos P, Stenzinger A. Tumour mutational burden: clinical utility, challenges and emerging improvements. Nat Rev Clin Oncol 2024; 21:725-742. [PMID: 39192001 DOI: 10.1038/s41571-024-00932-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 08/29/2024]
Abstract
Tumour mutational burden (TMB), defined as the total number of somatic non-synonymous mutations present within the cancer genome, varies across and within cancer types. A first wave of retrospective and prospective research identified TMB as a predictive biomarker of response to immune-checkpoint inhibitors and culminated in the disease-agnostic approval of pembrolizumab for patients with TMB-high tumours based on data from the Keynote-158 trial. Although the applicability of outcomes from this trial to all cancer types and the optimal thresholds for TMB are yet to be ascertained, research into TMB is advancing along three principal avenues: enhancement of TMB assessments through rigorous quality control measures within the laboratory process, including the mitigation of confounding factors such as limited panel scope and low tumour purity; refinement of the traditional TMB framework through the incorporation of innovative concepts such as clonal, persistent or HLA-corrected TMB, tumour neoantigen load and mutational signatures; and integration of TMB with established and emerging biomarkers such as PD-L1 expression, microsatellite instability, immune gene expression profiles and the tumour immune contexture. Given its pivotal functions in both the pathogenesis of cancer and the ability of the immune system to recognize tumours, a profound comprehension of the foundational principles and the continued evolution of TMB are of paramount relevance for the field of oncology.
Collapse
Affiliation(s)
- Jan Budczies
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
- Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
- Center for Personalized Medicine (ZPM), Heidelberg, Germany.
| | - Daniel Kazdal
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Michael Menzel
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Susanne Beck
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Klaus Kluck
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Christian Altbürger
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Constantin Schwab
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Aysel Ahadova
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Applied Tumour Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Matthias Kloor
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Applied Tumour Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter Schirmacher
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Solange Peters
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University, Lausanne, Switzerland
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Petros Christopoulos
- Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumour Diseases at Heidelberg University Hospital, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
- Translational Lung Research Center (TLRC) Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
- Center for Personalized Medicine (ZPM), Heidelberg, Germany.
| |
Collapse
|
3
|
Krämer A, Bochtler T, Pauli C, Shiu KK, Cook N, de Menezes JJ, Pazo-Cid RA, Losa F, Robbrecht DG, Tomášek J, Arslan C, Özgüroğlu M, Stahl M, Bigot F, Kim SY, Naito Y, Italiano A, Chalabi N, Durán-Pacheco G, Michaud C, Scarato J, Thomas M, Ross JS, Moch H, Mileshkin L. Molecularly guided therapy versus chemotherapy after disease control in unfavourable cancer of unknown primary (CUPISCO): an open-label, randomised, phase 2 study. Lancet 2024; 404:527-539. [PMID: 39096924 DOI: 10.1016/s0140-6736(24)00814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Patients with unfavourable subset cancer of unknown primary (CUP) have a poor prognosis when treated with standard platinum-based chemotherapy. Whether first-line treatment guided by comprehensive genomic profiling (CGP) can improve outcomes is unknown. The CUPISCO trial was designed to inform a molecularly guided treatment strategy to improve outcomes over standard platinum-based chemotherapy in patients with newly diagnosed, unfavourable, non-squamous CUP. The aim of the trial was to compare the efficacy and safety of molecularly guided therapy (MGT) versus standard platinum-based chemotherapy in these patients. This was to determine whether the inclusion of CGP in the initial diagnostic work-up leads to improved outcomes over the current standard of care. We herein report the primary analysis. METHODS CUPISCO was a phase 2, prospective, randomised, open-label, active-controlled, multicentre trial done at 159 sites in 34 countries outside the USA. Patients with central eligibility review-confirmed disease (acceptable histologies included adenocarcinoma and poorly differentiated carcinoma) and an Eastern Cooperative Oncology Group performance status of 0 or 1, evaluated by CGP, who reached disease control after three cycles of standard first-line platinum-based chemotherapy were randomly assigned 3:1 via a block-stratified randomisation procedure to MGT versus chemotherapy continuation for at least three further cycles. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT03498521, and follow-up is ongoing. FINDINGS From July 10, 2018, to Dec 9, 2022, 636 (42%) of 1505 screened patients were enrolled. Median follow-up in the treatment period was 24·1 months (IQR 11·6-35·6). Of 438 patients who reached disease control after induction chemotherapy, 436 were randomly assigned: 326 (75%) to the MGT group and 110 (25%) to the chemotherapy group. Median progression-free survival in the intention-to-treat population was 6·1 months (95% CI 4·7-6·5) in the MGT group versus 4·4 months (4·1-5·6) in the chemotherapy group (hazard ratio 0·72 [95% CI 0·56-0·92]; p=0·0079). Related adverse event rates per 100-patient-years at risk were generally similar or lower with MGT versus chemotherapy. INTERPRETATION In patients with previously untreated, unfavourable, non-squamous CUP who reached disease control after induction chemotherapy, CGP with subsequent MGTs resulted in longer progression-free survival than standard platinum-based chemotherapy. On the basis of these results, we recommend that CGP is performed at initial diagnosis in patients with unfavourable CUP. FUNDING F Hoffmann-La Roche.
Collapse
Affiliation(s)
- Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology-Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.
| | - Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology-Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Chantal Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland; Department of Pathology and Molecular Pathology, University Hospital of Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Kai-Keen Shiu
- UCLH Gastrointestinal Oncology Service, Cancer of Unknown Primary Service, University College London, Cancer Institute, London, UK
| | - Natalie Cook
- The Christie NHS Foundation Trust and Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Roberto A Pazo-Cid
- Medical Oncology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Ferran Losa
- Medical Oncology Department, Hospital de Sant Joan Despí Moisès Broggi, ICO Hospitalet, Barcelona, Spain
| | - Debbie Gj Robbrecht
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jiří Tomášek
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Cagatay Arslan
- Izmir University of Economics Medical Point Hospital, Izmir, Türkiye
| | - Mustafa Özgüroğlu
- Istanbul University Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Oncology, Istanbul, Türkiye
| | | | - Frédéric Bigot
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Angers, France
| | - Sun Young Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yoichi Naito
- Department of General Internal Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Antoine Italiano
- Institut Bergonie, Early Phase Trials and Sarcoma Units, Bordeaux, France
| | - Nasséra Chalabi
- Global Product Development Medical Affairs, F Hoffmann-La Roche, Basel, Switzerland
| | | | - Chantal Michaud
- Global Product Development Medical Affairs, F Hoffmann-La Roche, Basel, Switzerland
| | - Jeremy Scarato
- Global Product Development Medical Affairs, F Hoffmann-La Roche, Basel, Switzerland
| | - Marlene Thomas
- Global Product Development Medical Affairs, F Hoffmann-La Roche, Basel, Switzerland
| | - Jeffrey S Ross
- Pathology Group, Foundation Medicine, Cambridge, MA, USA; Upstate Medical University Departments of Pathology, Urology and Medicine (Oncology), Syracuse, NY, USA
| | - Holger Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland; Department of Pathology and Molecular Pathology, University Hospital of Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| |
Collapse
|
4
|
Mosele MF, Westphalen CB, Stenzinger A, Barlesi F, Bayle A, Bièche I, Bonastre J, Castro E, Dienstmann R, Krämer A, Czarnecka AM, Meric-Bernstam F, Michiels S, Miller R, Normanno N, Reis-Filho J, Remon J, Robson M, Rouleau E, Scarpa A, Serrano C, Mateo J, André F. Recommendations for the use of next-generation sequencing (NGS) for patients with advanced cancer in 2024: a report from the ESMO Precision Medicine Working Group. Ann Oncol 2024; 35:588-606. [PMID: 38834388 DOI: 10.1016/j.annonc.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Advancements in the field of precision medicine have prompted the European Society for Medical Oncology (ESMO) Precision Medicine Working Group to update the recommendations for the use of tumour next-generation sequencing (NGS) for patients with advanced cancers in routine practice. METHODS The group discussed the clinical impact of tumour NGS in guiding treatment decision using the ESMO Scale for Clinical Actionability of molecular Targets (ESCAT) considering cost-effectiveness and accessibility. RESULTS As for 2020 recommendations, ESMO recommends running tumour NGS in advanced non-squamous non-small-cell lung cancer, prostate cancer, colorectal cancer, cholangiocarcinoma, and ovarian cancer. Moreover, it is recommended to carry out tumour NGS in clinical research centres and under specific circumstances discussed with patients. In this updated report, the consensus within the group has led to an expansion of the recommendations to encompass patients with advanced breast cancer and rare tumours such as gastrointestinal stromal tumours, sarcoma, thyroid cancer, and cancer of unknown primary. Finally, ESMO recommends carrying out tumour NGS to detect tumour-agnostic alterations in patients with metastatic cancers where access to matched therapies is available. CONCLUSION Tumour NGS is increasingly expanding its scope and application within oncology with the aim of enhancing the efficacy of precision medicine for patients with cancer.
Collapse
Affiliation(s)
- M F Mosele
- INSERM U981, Gustave Roussy, Villejuif; Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - C B Westphalen
- Comprehensive Cancer Center Munich & Department of Medicine III, University Hospital, LMU Munich, Munich
| | - A Stenzinger
- Institute of Pathology, University Hospital Heidelberg and Center for Personalized Medicine (ZPM), Heidelberg, Germany
| | - F Barlesi
- INSERM U981, Gustave Roussy, Villejuif; Department of Cancer Medicine, Gustave Roussy, Villejuif, France; Faculty of Medicine, Université Paris-Saclay, Kremlin Bicêtre
| | - A Bayle
- Faculty of Medicine, Université Paris-Saclay, Kremlin Bicêtre; Drug Development Department (DITEP), Gustave Roussy, Villejuif; Oncostat U1018, Inserm, Université Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif; Service de Biostatistique et Epidémiologie, Gustave Roussy, Villejuif
| | - I Bièche
- Department of Genetics, Institut Curie, INSERM U1016, Université Paris Cité, Paris, France
| | - J Bonastre
- Oncostat U1018, Inserm, Université Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif; Service de Biostatistique et Epidémiologie, Gustave Roussy, Villejuif
| | - E Castro
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre, Madrid
| | - R Dienstmann
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona; University of Vic-Central University of Catalonia, Vic, Spain; Oncoclínicas, São Paulo, Brazil
| | - A Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Heidelberg; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw; Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - F Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - S Michiels
- Oncostat U1018, Inserm, Université Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif; Service de Biostatistique et Epidémiologie, Gustave Roussy, Villejuif
| | - R Miller
- Department of Medical Oncology, University College London, London; Department of Medical Oncology, St Bartholomew's Hospital, London, UK
| | - N Normanno
- Scientific Directorate, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - J Reis-Filho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York
| | - J Remon
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - M Robson
- Breast Medicine and Clinical Genetics Services, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - E Rouleau
- Tumor Genetics Service, Medical Biology and Pathology Department, Gustave Roussy, Villejuif, France
| | - A Scarpa
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona-School of Medicine, Verona, Italy
| | - C Serrano
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona
| | - J Mateo
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona
| | - F André
- INSERM U981, Gustave Roussy, Villejuif; Department of Cancer Medicine, Gustave Roussy, Villejuif, France; Faculty of Medicine, Université Paris-Saclay, Kremlin Bicêtre.
| |
Collapse
|
5
|
Kim HM, Koo JS. Programmed death-ligand 1 expression in carcinoma of unknown primary. BMC Cancer 2024; 24:689. [PMID: 38844907 PMCID: PMC11155179 DOI: 10.1186/s12885-024-12437-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024] Open
Abstract
We examined the expression of programmed death-ligand 1 (PD-L1) in carcinoma of unknown primary (CUP) and its potential implications. Tissue microarrays were constructed for 72 CUP cases (histologic subtypes: 22 adenocarcinoma, 15 poorly differentiated carcinoma, 19 squamous cell carcinoma, and 14 undifferentiated carcinoma; clinical subtype: favorable type 17 [23.6%], unfavorable type 55 [76.4%]), with immunohistochemical staining performed for PD-L1 (22C3, SP142, SP263, and 28 - 8), CK7, and CK20 to determine the association between staining results and clinicopathological parameters. In CUP, the PD-L1 positivity rate was 5.6-48.6% (tumor cells [TC] or tumor proportion score [TPS]: 5.6-36.1%, immune cell score [IC]: 8.3-48.6%, combined positive score [CPS]: 16.7%) using different cutoff values for 22C3 (TPS ≥ 1%, CPS ≥ 10), SP142 (TC ≥ 50%, IC ≥ 10%), SP263, and 28 - 8 (TC and IC ≥ 1%). PD-L1 SP142 TC and PD-L1 SP263 IC showed the lowest (5.6%) and highest (48.6%) positivity rates, respectively. The PD-L1 positivity rate did not significantly differ based on the histologic subtype, clinical subtype, or CK7/CK20 across clones. Considering TC κ ≥ 1%, TC κ ≥ 50%, IC κ ≥ 1%, and IC κ ≥ 10%, the PD-L1 positivity rate was TC = 4.2-36.1% and IC = 9.7-48.6%; the overall agreement between antibodies ranged from 69.4 to 93.1%, showing fair or better agreement (κ ≥ 0.21). In CUP, PD-L1 positivity varied depending on antibodies and scoring systems, with no difference observed according to histologic or clinical subtypes.
Collapse
Affiliation(s)
- Hye Min Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ja Seung Koo
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea.
| |
Collapse
|
6
|
Junior JNA, Preto DD'A, Lazarini MEZN, de Lima MA, Bonatelli M, Berardinelli GN, da Silva VD, Pinheiro C, Reis RM, Cárcano FM. PD-L1 expression and microsatellite instability (MSI) in cancer of unknown primary site. Int J Clin Oncol 2024; 29:726-734. [PMID: 38528294 PMCID: PMC11130030 DOI: 10.1007/s10147-024-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/18/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Cancer of unknown primary site (CUP) is a heterogeneous group of tumors for which the origin remains unknown. Clinical outcomes might be influenced by regulatory processes in its microenvironment. Microsatellite instability (MSI) is a predictive biomarker for cancer immunotherapy and its status, as well as co-occurrence with PD-L1 expression, is poorly evaluated. We aim to evaluate the expression of PD-L1 and the status of MSI in CUP and their possible associations with clinical-pathological features. METHODS The combined positive score (CPS) PD-L1 expression was evaluated by immunohistochemistry. MSI status was assessed using a hexa-plex marker panel by polymerase chain reaction followed by fragment analysis. RESULTS Among the 166 cases, MSI analysis was conclusive in 120, with two cases being MSI positive (1.6%). PD-L1 expression was positive in 18.3% of 109 feasible cases. PD-L1 expression was significantly associated with non-visceral metastasis and a dominance of nodal metastasis. The median overall survival (mOS) was 3.7 (95% CI 1.6-5.8) months and patients who expressed PD-L1 achieved a better mOS compared to those who did not express PD-L1 (18.7 versus 3.0 months, p-value: < .001). ECOG-PS equal to or more than two and PD-L1 expression were independent prognostic factors in multivariate analysis (2.37 and 0.42, respectively). CONCLUSION PD-L1 is expressed in a subset (1/5) of patients with CUP and associated with improved overall survival, while MSI is a rare event. There is a need to explore better the tumor microenvironment as well as the role of immunotherapy to change such a bad clinical outcome.
Collapse
Affiliation(s)
| | - Daniel D 'Almeida Preto
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, Brazil
- Barretos School of Health Sciences Dr. Paulo Prata - FACISB, Barretos, Brazil
| | | | | | - Murilo Bonatelli
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
| | | | | | - Céline Pinheiro
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
- Barretos School of Health Sciences Dr. Paulo Prata - FACISB, Barretos, Brazil
| | - Rui Manuel Reis
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
- Medical School, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- 3ICVS/3B's-PT Government Associate Laboratory, Braga, Portugal
| | - Flavio Mavignier Cárcano
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil.
- Oncoclinicas & Co - Medica Scientia Innovation Research (MEDSIR), Sao Paulo, Brazil.
| |
Collapse
|
7
|
Tang L, Zhu Y, Du Y, Long X, Long Y, Tang Y, Liu J. Clinicopathologic features and genomic profiling of female axillary lymph node metastases from adenocarcinoma or poorly differentiated carcinoma of unknown primary. J Cancer Res Clin Oncol 2024; 150:256. [PMID: 38750402 PMCID: PMC11096249 DOI: 10.1007/s00432-024-05783-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Axillary lymph node metastases from adenocarcinoma or poorly differentiated carcinoma of unknown primary (CUPAx) is a rare disease in women. This retrospective study intended to examine the clinicopathological features of CUPAx and compared CUPAx genetically with axillary lymph node metastases from breast cancer (BCAx), investigating differences in their biological behavior. METHODS We conducted the clinical and prognostic analysis of 58 CUPAx patients in West China Hospital spanning from 2009 to 2021. Gemonic profiling of 12 CUPAx patients and 16 BCAx patients was conducted by the FoundationOne CDx (F1CDx) platform. Moreover, we also compared the gene mutation spectrum and relevant pathways between the two groups and both TCGA and COSMIC databases. RESULTS The majority of the 58 CUPAx patients were HR-/HER2- subtype. Most patients received mastectomy combined radiotherapy (50 Gy/25f). CUPAx patients who received mastectomy instead of breast-conserving surgery had a more favorable overall prognosis. Radiotherapy in chest wall/breast and supraclavicular/infraclavicular fossa was the independent prognostic factor (HR = 0.05, 95%CI = 0.00-0.93, P = 0.04). In 28 sequencing samples (CUPAx, n = 12, BCAx, n = 16) and 401 TCGA-BRCA patients, IRS2 only mutated in CUPAx (33.33%) but amplified in BCAx (11.11%) and TCGA-BRCA (1.5%). Pathway analysis revealed that BCAx had more NOTCH pathway mutations than CUPAx. Enrichment analysis showed that CUPAx enriched more in mammary development and PML bodies than BCAx, but less in the positive regulation of kinase activity. CONCLUSIONS More active treatment methods, like chemotherapy, mastectomy and postoperative radiotherapy, could improve the prognosis of CUPAx. The differential mutation genes of CUPAx and BCAx might be associated with their respective biological behaviors like invasiveness and prognosis.
Collapse
Affiliation(s)
- Liansha Tang
- Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan Province, China
- Biotherapy Clinical Research Center of Sichuan Province, Chengdu, 610041, China
| | - Yueting Zhu
- Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan Province, China
- Biotherapy Clinical Research Center of Sichuan Province, Chengdu, 610041, China
| | - Yang Du
- Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan Province, China
- Biotherapy Clinical Research Center of Sichuan Province, Chengdu, 610041, China
| | - Xiangyu Long
- Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan Province, China
- Biotherapy Clinical Research Center of Sichuan Province, Chengdu, 610041, China
| | - Yixiu Long
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong'an Road, Shanghai, 200032, China
| | - Yuan Tang
- Department of Pathology, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jiyan Liu
- Department of Biotherapy, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan Province, China.
- Biotherapy Clinical Research Center of Sichuan Province, Chengdu, 610041, China.
| |
Collapse
|
8
|
Zaun G, Borchert S, Metzenmacher M, Lueong S, Wiesweg M, Zaun Y, Pogorzelski M, Behrens F, Schildhaus HU, Virchow I, Kasper S, Schuler M, Theurer S, Liffers S. Comprehensive biomarker diagnostics of unfavorable cancer of unknown primary to identify patients eligible for precision medical therapies. Eur J Cancer 2024; 200:113540. [PMID: 38316065 DOI: 10.1016/j.ejca.2024.113540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Current guidelines recommend combination chemotherapy for treatment of patients with unfavorable cancer of unknown primary (CUP). Biomarker-guided targeted therapies may offer additional benefit. Data on the feasibility and effectiveness of comprehensive genomic biomarker profiling of CUP in a standard clinical practice setting are limited. METHODS This analysis included 156 patients with confirmed unfavorable CUP diagnosis according to ESMO guidelines, who were treated at the West German Cancer Center, Essen, Germany, from 2015 to 2021. Clinical parameters and outcome data were retrieved from the electronic hospital information system. Genomic biomarker analyses were performed in formalin-fixed paraffin-embedded tumor tissue whenever possible using the QIAseq Multimodal-Pancancer-Panel. RESULTS Non-squamous histologies, high tumor burden, and age above 60 years associated with poor survival outcome. Tissue availability restricted comprehensive biomarker analyses to 50 patients (32%), reflecting a major limitation in the real-world setting. In those patients a total of 24 potentially actionable alterations were identified in 17 patients (34% of profiled patients, 11% of total population). The most prevalent biomarkers were high tumor mutational burden and BRCA-mutations. CONCLUSION In a real-world setting precision medicine for patients with CUP is severely restricted by tissue availability, and a limited spectrum of actionable alterations. Progress for patients may require emphasizing the need for sufficient biopsies, and prospective exploration of blood-based biomarker profiling.
Collapse
Affiliation(s)
- Gregor Zaun
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.
| | - Sabrina Borchert
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Germany
| | - Martin Metzenmacher
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Smiths Lueong
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany; West German Cancer Center, Institute for Developmental Cancer Therapeutics, University Hospital Essen, Essen, Germany
| | - Marcel Wiesweg
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany; National Center for Tumor Diseases (NCT) West, Essen, Germany
| | - Yasmin Zaun
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Michael Pogorzelski
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Franziska Behrens
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Schildhaus
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Germany; Discovery Life Sciences, Kassel, Germany
| | - Isabel Virchow
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany; National Center for Tumor Diseases (NCT) West, Essen, Germany
| | - Stefan Kasper
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany; National Center for Tumor Diseases (NCT) West, Essen, Germany
| | - Martin Schuler
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany; National Center for Tumor Diseases (NCT) West, Essen, Germany
| | - Sarah Theurer
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Germany
| | - Sven Liffers
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany; West German Cancer Center, Institute for Developmental Cancer Therapeutics, University Hospital Essen, Essen, Germany
| |
Collapse
|
9
|
Heilmann AM, Riess JW, McLaughlin-Drubin M, Huang RSP, Hjulstrom M, Creeden J, Alexander BM, Erlich RL. Insights of Clinical Significance From 109 695 Solid Tumor Tissue-Based Comprehensive Genomic Profiles. Oncologist 2024; 29:e224-e236. [PMID: 37682776 PMCID: PMC10836312 DOI: 10.1093/oncolo/oyad251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 08/06/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND FoundationOneCDx is approved in the US and Japan as a companion diagnostic test to identify patients with cancer who may benefit from treatment with 30 drug therapies in the US and 23 in Japan. Tumor profiling with FoundationOneCDx also detects genomic findings with evidence of clinical significance that may inform clinical care decisions beyond companion diagnostic claims. This observational study reports the breadth and impact of clinical decision insights from FoundationOneCDx solid tumor profiles. MATERIALS AND METHODS Consecutive test result reports for patients with solid tumor diagnoses (n = 109 695) were retrospectively analyzed for clinically significant predictive, prognostic, and diagnostic genomic alterations and signatures, determined in accordance with professional guidelines. Interventional clinical trials with targeted therapies or immune checkpoint inhibitors were matched to tumor profiles based on evidence that the genomic finding may be an actionable, investigational, or hypothetical target in the patient's tumor type. RESULTS In 14 predefined cancer types (80.7% of analyzed solid tumors), predictive, prognostic, and diagnostic markers were reported in 47.6%, 13.2%, and 4.5% of samples, respectively, accounting for a total of 51.2% of tumor profiles. Pan-cancer predictive markers of tumor mutational burden (TMB) of 10 or more mutations per megabase, high microsatellite instability (MSI), or NTRK1/2/3 fusions were observed in 15.6%, 2.0%, and 0.1% of solid tumors, respectively. Most solid tumor profiles (89.2%) had genomic results that could theoretically inform decisions on the selection of immunotherapy and targeted therapy clinical trials. CONCLUSION For this real-world population of patients with FoundationOneCDx solid tumor profiles in the routine course of clinical care, clinically significant findings were reported for approximately half of patients with genomic results.
Collapse
Affiliation(s)
| | - Jonathan W Riess
- University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Lorkowski SW, Dermawan JK, Rubin BP. The practical utility of AI-assisted molecular profiling in the diagnosis and management of cancer of unknown primary: an updated review. Virchows Arch 2024; 484:369-375. [PMID: 37999736 DOI: 10.1007/s00428-023-03708-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023]
Abstract
Cancer of unknown primary (CUP) presents a complex diagnostic challenge, characterized by metastatic tumors of unknown tissue origin and a dismal prognosis. This review delves into the emerging significance of artificial intelligence (AI) and machine learning (ML) in transforming the landscape of CUP diagnosis, classification, and treatment. ML approaches, trained on extensive molecular profiling data, have shown promise in accurately predicting tissue of origin. Genomic profiling, encompassing driver mutations and copy number variations, plays a pivotal role in CUP diagnosis by providing insights into tumor type-specific oncogenic alterations. Mutational signatures (MS), reflecting somatic mutation patterns, offer further insights into CUP diagnosis. Known MS with established etiology, such as ultraviolet (UV) light-induced DNA damage and tobacco exposure, have been identified in cases of dedifferentiated/transdifferentiated melanoma and carcinoma. Deep learning models that integrate gene expression data and DNA methylation patterns offer insights into tissue lineage and tumor classification. In digital pathology, machine learning algorithms analyze whole-slide images to aid in CUP classification. Finally, precision oncology, guided by molecular profiling, offers targeted therapies independent of primary tissue identification. Clinical trials assigning CUP patients to molecularly guided therapies, including targetable alterations and tumor mutation burden as an immunotherapy biomarker, have resulted in improved overall survival in a subset of patients. In conclusion, AI- and ML-driven approaches are revolutionizing CUP management by enhancing diagnostic accuracy. Precision oncology utilizing enhanced molecular profiling facilitates the identification of targeted therapies that transcend the need to identify the tissue of origin, ultimately improving patient outcomes.
Collapse
Affiliation(s)
- Shuhui Wang Lorkowski
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Josephine K Dermawan
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Brian P Rubin
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
| |
Collapse
|
11
|
Pouyiourou M, Bochtler T, Coith C, Wikman H, Kraft B, Hielscher T, Stenzinger A, Riethdorf S, Pantel K, Krämer A. Frequency and Prognostic Value of Circulating Tumor Cells in Cancer of Unknown Primary. Clin Chem 2024; 70:297-306. [PMID: 38175594 DOI: 10.1093/clinchem/hvad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/02/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Cancer of unknown primary (CUP) is defined as a primary metastatic malignancy, in which the primary tumor remains elusive in spite of a comprehensive diagnostic workup. The frequency and prognostic value of circulating tumor cells (CTCs), which are considered to be the source of metastasis, has not yet been systematically evaluated in CUP. METHODS A total of 110 patients with a confirmed diagnosis of CUP according to the European Society for Medical Oncology (ESMO) guidelines, who presented to our clinic between July 2021 and May 2023, provided blood samples for CTC quantification using CellSearch methodology. CTC counts were correlated with demographic, clinical, and molecular data generated by comprehensive genomic profiling of tumor tissue. RESULTS CTCs were detected in 26% of all patients at initial presentation to our department. The highest CTC frequency was observed among patients with unfavorable CUP (35.5%), while patients with single-site/oligometastatic CUP harbored the lowest CTC frequency (11.4%). No statistically significant association between CTC positivity and the number of affected organs (P = 0.478) or disease burden (P = 0.120) was found. High CTC levels (≥5 CTCs/7.5 mL; 12/95 analyzed patients) predicted for adverse overall survival compared to negative or low CTC counts (6-months overall survival rate 90% vs 32%, log-rank P < 0.001; HR 5.43; 95% CI 2.23-13.2). CTC dynamics were also prognostic for overall survival by landmark analysis (log-rank P < 0.001, HR 10.2, 95% CI 1.95-52.9). CONCLUSIONS CTC frequency is a strong, independent predictor of survival in patients with CUP. CTC quantification provides a useful prognostic tool in the management of these patients.
Collapse
Affiliation(s)
- Maria Pouyiourou
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - Cornelia Coith
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harriet Wikman
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bianca Kraft
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Sabine Riethdorf
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Pantel
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
12
|
Miyamoto H, Kawakami F, Abe S, Sugita H, Matsui H. Comprehensive Cancer Genomic Profiling of Liver Metastasis Led to the Unexpected Identification of Colorectal Cancer. Intern Med 2024; 63:63-70. [PMID: 37164664 PMCID: PMC10824646 DOI: 10.2169/internalmedicine.1845-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023] Open
Abstract
Comprehensive genomic profiling (CGP) of a metastatic liver tumor biopsy specimen suggested that the patient, who was initially diagnosed with cholangiocarcinoma, had colorectal cancer. The identification of both FBXW7 and APC mutations is deemed characteristic of colorectal cancer. Indeed, subsequent colonoscopy revealed sigmoid colon carcinoma that led to tumor resection followed by systemic chemotherapy. CGP is principally used to identify agents that might potentially benefit the patient. However, results must be interpreted carefully to ensure consistency with the initial diagnosis.
Collapse
Affiliation(s)
- Hideaki Miyamoto
- Cancer Genome Center, Kumamoto University Hospital, Japan
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Fumi Kawakami
- Cancer Genome Center, Kumamoto University Hospital, Japan
- Department of Diagnostic Pathology, Kumamoto University Hospital, Japan
| | - Sakiko Abe
- Genetic Counseling Department, Kumamoto University Hospital, Japan
| | - Hiroki Sugita
- Department of Surgery, Kumamoto Regional Medical Center, Japan
| | - Hirotaka Matsui
- Cancer Genome Center, Kumamoto University Hospital, Japan
- Department of Molecular Laboratory Medicine, Faculty of Life Sciences, Kumamoto University, Japan
| |
Collapse
|
13
|
Westphalen CB, Federer-Gsponer J, Pauli C, Karapetyan AR, Chalabi N, Durán-Pacheco G, Beringer A, Bochtler T, Cook N, Höglander E, Jin DX, Losa F, Mileshkin L, Moch H, Ross JS, Sokol ES, Tothill RW, Krämer A. Baseline mutational profiles of patients with carcinoma of unknown primary origin enrolled in the CUPISCO study. ESMO Open 2023; 8:102035. [PMID: 37922692 PMCID: PMC10774891 DOI: 10.1016/j.esmoop.2023.102035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/31/2023] [Accepted: 09/13/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Patients with unfavorable carcinoma of unknown primary origin (CUP) have an extremely poor prognosis of ∼1 year or less, stressing the need for more tailored treatments, which are currently being tested in clinical trials. CUPISCO (NCT03498521) was a phase II randomized study of targeted therapy/cancer immunotherapy versus platinum-based chemotherapy in patients with previously untreated, unfavorable CUP, defined as per the European Society for Medical Oncology guidelines. We present a preliminary, descriptive molecular analysis of 464 patients with stringently diagnosed, unfavorable CUP enrolled in the CUPISCO study. MATERIALS AND METHODS Genomic profiling was carried out on formalin-fixed, paraffin-embedded tissue to detect genomic alterations and assess tumor mutational burden and microsatellite instability. RESULTS Overall, ∼32% of patients carried a potentially targetable genomic alteration, including PIK3CA, FGFR2, ERBB2, BRAFV600E, EGFR, MET, NTRK1, ROS1, and ALK. Using hierarchical clustering of co-mutational profiles, 10 clusters were identified with specific genomic alteration co-occurrences, with some mirroring defined tumor entities. CONCLUSIONS Results reveal the molecular heterogeneity of patients with unfavorable CUP and suggest that genomic profiling may be used as part of informed decision-making to identify the potential primary tumor and targeted treatment options. Whether stringently diagnosed patients with unfavorable CUP benefit from targeted therapies in a similar manner to those with matched known primaries will be a key learning from CUPISCO.
Collapse
Affiliation(s)
- C B Westphalen
- Comprehensive Cancer Center Munich & Department of Medicine III, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - C Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zürich, Switzerland
| | | | | | | | | | - T Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and University of Heidelberg, Heidelberg; Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - N Cook
- The University of Manchester and the Christie NHS Foundation Trust, Manchester, UK
| | | | - D X Jin
- Foundation Medicine, Inc., Cambridge, USA
| | - F Losa
- Hospital de Sant Joan Despí-Moisès Broggi, ICO-Hospitalet, Barcelona, Spain
| | - L Mileshkin
- Peter MacCallum Cancer Centre and the Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - H Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zürich, Switzerland
| | - J S Ross
- Foundation Medicine, Inc., Cambridge, USA; SUNY Upstate Medical University, Syracuse, USA
| | - E S Sokol
- Foundation Medicine, Inc., Cambridge, USA
| | - R W Tothill
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - A Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and University of Heidelberg, Heidelberg.
| |
Collapse
|
14
|
Ricco G, Seminerio R, Andrini E, Malvi D, Gruppioni E, Altimari A, Zagnoni S, Campana D, Lamberti G. BRAF V600E-mutated large cell neuroendocrine carcinoma responding to targeted therapy: a case report and review of the literature. Anticancer Drugs 2023; 34:1076-1084. [PMID: 36847048 DOI: 10.1097/cad.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Large cell neuroendocrine carcinoma (LCNEC) is a rare and aggressive high-grade neuroendocrine tumor, commonly arising in the lung or in the gastrointestinal tract, with a frequent proportion of unknown primary origin (20%). In the metastatic setting, platinum-based or fluoropyrimidine-based chemotherapeutic regimens are as considered the first-line treatment, despite the limited duration of response. To date, the prognosis of advanced high-grade neuroendocrine carcinoma remains poor, suggesting the need to explore new treatment strategies in this orphan tumor. The evolving molecular landscape of LCNEC, not yet been completely defined, could explain the heterogeneous response to different chemotherapeutic regimens and suggest that treatment strategy could be driven by molecular features. v-Raf murine sarcoma viral oncogene homolog B (BRAF) mutations, well described in melanoma, thyroid cancer, colon cancer and lung adenocarcinoma, account for approximately 2% of cases in lung LCNEC. Here, we describe the case of a patient with a BRAF V600E-mutated LCNEC of unknown primary origin who partially responded to BRAF/mitogen-activated protein kinase kinase inhibitors after standard treatment. Additionally, BRAF V600E circulating tumor DNA was used to monitor disease response. Thereafter, we reviewed the available literature about the role of targeted therapy in high-grade neuroendocrine neoplasms to provide insight for future research to identify patients with driver oncogenic mutations, who can potentially benefit from target therapy.
Collapse
Affiliation(s)
- Gianluca Ricco
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence
| | - Renata Seminerio
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence
| | - Elisa Andrini
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence
| | - Deborah Malvi
- Division of Pathology, Azienda Ospedaliero-Universitaria di Bologna
| | - Elisa Gruppioni
- Solid Tumor Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Annalisa Altimari
- Solid Tumor Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Zagnoni
- Solid Tumor Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Campana
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence
| | - Giuseppe Lamberti
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence
| |
Collapse
|
15
|
Le Tourneau C, André F, Helland Å, Mileshkin L, Minnaard W, Schiel A, Taskén K, Thomas DM, Veronese ML, Durán-Pacheco G, Leyens L, Rufibach K, Thomas M, Krämer A. Modified study designs to expand treatment options in personalised oncology: a multistakeholder view. Eur J Cancer 2023; 194:113278. [PMID: 37820553 DOI: 10.1016/j.ejca.2023.113278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 10/13/2023]
Abstract
Personalised oncology, whereby patients are given therapies based on their molecular tumour profile, is rapidly becoming an essential part of optimal clinical care, at least partly facilitated by recent advances in next-generation sequencing-based technology using liquid- and tissue-based biopsies. Consequently, clinical trials have shifted in approach, from traditional studies evaluating cytotoxic chemotherapy in largely histology-based populations to modified, biomarker-driven studies (e.g. basket, umbrella, platform) of molecularly guided therapies and cancer immunotherapies in selected patient subsets. Such modified study designs may assess, within the same trial structure, multiple cancer types and treatments, and should incorporate a multistakeholder perspective. This is key to generating complementary, fit-for-purpose and timely evidence for molecularly guided therapies that can be used as proof-of-concept to inform further study designs, lead to approval by regulatory authorities and be used as confirmation of clinical benefit for health technology assessment bodies. In general, the future of cancer clinical trials requires a framework for the application of innovative technologies and dynamic design methodologies, in order to efficiently transform scientific discoveries into clinical utility. Next-generation, modified studies that involve the joint efforts of all key stakeholders will offer individualised strategies that ultimately contribute to globalised knowledge and collective learning. In this review, we outline the background and purpose of such modified study designs and detail key aspects from a multistakeholder perspective. We also provide methodological considerations for designing the studies and highlight how insights from already-ongoing studies may address current challenges and opportunities in the era of personalised oncology.
Collapse
Affiliation(s)
- Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, INSERM U900 Research Unit, Paris-Saclay University, Paris, France
| | | | - Åslaug Helland
- Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Linda Mileshkin
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | | | | | - Kjetil Taskén
- Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - David M Thomas
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | | | | | - Lada Leyens
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | | | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.
| |
Collapse
|
16
|
Svoboda M, Lohajova Behulova R, Slamka T, Sebest L, Repiska V. Comprehensive Genomic Profiling in Predictive Testing of Cancer. Physiol Res 2023; 72:S267-S275. [PMID: 37888970 PMCID: PMC10669951 DOI: 10.33549/physiolres.935154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023] Open
Abstract
Despite the rapid progress in the field of personalized medicine and the efforts to apply specific treatment strategies to patients based on the presence of pathogenic variants in one, two, or three genes, patient response to the treatment in terms of positive benefit and overall survival remains heterogeneous. However, advances in sequencing and bioinformatics technologies have facilitated the simultaneous examination of somatic variants in tens to thousands of genes in tumor tissue, enabling the determination of personalized management based on the patient's comprehensive genomic profile (CGP). CGP has the potential to enhance clinical decision-making and personalize innovative treatments for individual patients, by providing oncologists with a more comprehensive molecular characterization of tumors. This study aimed to highlight the utility of CGP in routine clinical practice. Here we present three patient cases with various advanced cancer indicated for CGP analysis using a combination of SOPHiA Solid Tumor Solution (STS, 42 genes) for DNA and SOPHiA RNAtarget Oncology Solution (ROS, 45 genes and 17 gene fusions with any random partners) for RNA. We were able to identify actionable genomic alterations in all three cases, thereby presenting valuable information for future management of these patients. This approach has the potential to transform clinical practice and greatly improve patient outcomes in the field of oncology.
Collapse
Affiliation(s)
- M Svoboda
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University, Bratislava, Slovak Republic.
| | | | | | | | | |
Collapse
|
17
|
Pouyiourou M, Kraft BN, Wohlfromm T, Stahl M, Kubuschok B, Löffler H, Hacker UT, Hübner G, Weiss L, Bitzer M, Ernst T, Schütt P, Hielscher T, Delorme S, Kirchner M, Kazdal D, Ball M, Kluck K, Stenzinger A, Bochtler T, Krämer A. Nivolumab and ipilimumab in recurrent or refractory cancer of unknown primary: a phase II trial. Nat Commun 2023; 14:6761. [PMID: 37875494 PMCID: PMC10598029 DOI: 10.1038/s41467-023-42400-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023] Open
Abstract
Cancer of unknown primary has a dismal prognosis, especially following failure of platinum-based chemotherapy. 10-20% of patients have a high tumor mutational burden (TMB), which predicts response to immunotherapy in many cancer types. In this prospective, non-randomized, open-label, multicenter Phase II trial (EudraCT 2018-004562-33; NCT04131621), patients relapsed or refractory after platinum-based chemotherapy received nivolumab and ipilimumab following TMBhigh vs. TMBlow stratification. Progression-free survival (PFS) represented the primary endpoint; overall survival (OS), response rates, duration of clinical benefit and safety were the secondary endpoints. The trial was prematurely terminated in March 2021 before reaching the preplanned sample size (n = 194). Among 31 evaluable patients, 16% had a high TMB ( > 12 mutations/Mb). Overall response rate was 16% (95% CI 6-34%), with 7.7% (95% CI 1-25%) vs. 60% (95% CI 15-95%) in TMBlow and TMBhigh, respectively. Although the primary endpoint was not met, high TMB was associated with better median PFS (18.3 vs. 2.4 months) and OS (18.3 vs. 3.6 months). Severe immune-related adverse events were reported in 29% of cases. Assessing on-treatment dynamics of circulating tumor DNA using combined targeted hotspot mutation and shallow whole genome sequencing as part of a predefined exploratory analysis identified patients benefiting from immunotherapy irrespective of initial radiologic response.
Collapse
Affiliation(s)
- Maria Pouyiourou
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - Bianca N Kraft
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Timothy Wohlfromm
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Michael Stahl
- Department of Medical Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Boris Kubuschok
- Department of Internal Medicine II, Augsburg University Medical Center and Bavarian Cancer Research Center (BZKF), Partner Cite Augsburg, Augsburg, Germany
| | - Harald Löffler
- Department of Internal Medicine III, Marienhospital Stuttgart, Stuttgart, Germany
| | - Ulrich T Hacker
- Department of Medicine II, University Cancer Center Leipzig (UCCL), Leipzig University Medical Center, Leipzig, Germany
| | - Gerdt Hübner
- Department of Internal Medicine III, Ameos Krankenhausgesellschaft Ostholstein, Eutin, Germany
| | - Lena Weiss
- Department of Internal Medicine, Comprehensive Cancer Center, University of Munich, Munich, Germany
| | - Michael Bitzer
- Department of Gastroenterology, Hepatology and Infectiology, University Hospital Tübingen, Tübingen, Germany
| | - Thomas Ernst
- Department of Internal Medicine II, Jena University Hospital, Jena, Germany
| | | | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Delorme
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Daniel Kazdal
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Markus Ball
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Klaus Kluck
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Center for Personalized Medicine (ZPM), University of Heidelberg, Heidelberg, Germany
| | - Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany.
| |
Collapse
|
18
|
Zhao W, Zhao N, Zhang M, Li Z, Wang N, Shen W, Dong Y, Nie Y, Li Z. 2-Year survival benefit from immunotherapy for squamous cell cancer with cancer of unknown primary in mediastinum: a case report. Front Oncol 2023; 13:1242460. [PMID: 37886174 PMCID: PMC10598860 DOI: 10.3389/fonc.2023.1242460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023] Open
Abstract
Cancers of unknown primary (CUP) account for 2%-5% of all diagnosed cancers and are always characterized with fast-paced aggression, early metastasis, and unpredictable spread patterns Mediastinum metastasis with unknown primary origin is extremely rare and with a poor prognosis and short survival. There is no literature to refer to for its treatment. Here, we reported a case of squamous cell CUP in the mediastinum. A 50-year-old male patient was admitted after multi-line treatment of low differentiated squamous cell carcinoma in the mediastinum diagnosed 8 months before. In August 2019, the patient went to a local hospital for cough and dyspnea for 2 weeks. Then, he was diagnosed with squamous cell carcinoma of unknown primary origin with multiple lymph nodes metastasis. The patient was featured with programmed cell death-ligand 1 (PD-L1) expression strongly positive in 90% of tumor cells and the combined positive score of 90 and a tumor mutation burden of 1.79 MUts/Mb and microsatellite stable phenotype. The patient was treated with anti-programmed cell death-1 (PD-1) antibodies in combination with chemotherapy and responded to the treatment. The patient showed stable disease to multi-line immunotherapy for more than 7 months and finally got a clinical benefit of 2-year survival benefit. In conclusion, immunotherapy targeting PD-1/PD-L1 in combination with chemotherapy may play a crucial role in the later-line treatment and palliative care of CUP.
Collapse
Affiliation(s)
- Wei Zhao
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Nan Zhao
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Manze Zhang
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Zhihua Li
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Ning Wang
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Wennan Shen
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Yuemei Dong
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Yanli Nie
- Department of Gastrointestinal Medical Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaoxia Li
- Oncology Department, PLA Rocket Force Characteristic Medical Center, Beijing, China
| |
Collapse
|
19
|
Marumo Y, Yoshida T, Ina K, Matsunaga N, Furukawa Y, Kamiya A, Kataoka T, Kayukawa S. Diagnosis of a SMARCA4-deficient undifferentiated tumor using multigene panel testing: A case report. Clin Case Rep 2023; 11:e7854. [PMID: 37655132 PMCID: PMC10465722 DOI: 10.1002/ccr3.7854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/21/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023] Open
Abstract
Key Clinical Message SMARCA4-deficient thoracic carcinoma is a malignant tumor that may present as cancer of unknown primary. This tumor is refractory and requires a novel approach. In addition to identifying therapeutic targets, multigene panel testing can reveal novel genetic mutations, leading to more pathologically relevant diagnoses and appropriate tumor care. Abstract SMARCA4-deficient undifferentiated tumors are characterized by SMARCA4 inactivation. We present a case of a 74-year-old man with an undifferentiated tumor and a novel SMARCA4 mutation detected using multigene panel testing. The tumor was multiagent and refractory to three chemotherapy lines. The test results helped guide appropriate medical management.
Collapse
Affiliation(s)
- Yoshiaki Marumo
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
- Department of Hematology and OncologyNagoya City UniversityNagoyaJapan
| | - Takashi Yoshida
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
| | - Kenji Ina
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
- Department of Geriatric MedicineShinseikai Daiichi HospitalNagoyaJapan
| | - Naohiro Matsunaga
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
- Department of Hematology and OncologyNagoya City UniversityNagoyaJapan
| | - Yuki Furukawa
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
| | - Ayumi Kamiya
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
| | - Takae Kataoka
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
| | - Satoshi Kayukawa
- Department of Clinical OncologyNagoya Memorial HospitalNagoyaJapan
| |
Collapse
|
20
|
van Mourik A, Tonkin-Hill G, O'Farrell J, Waller S, Tan L, Tothill RW, Bowtell D, Fox S, Fellowes A, Fedele C, Schofield P, Sivakumaran T, Wong HL, Mileshkin L. Six-year experience of Australia's first dedicated cancer of unknown primary clinic. Br J Cancer 2023; 129:301-308. [PMID: 37225894 PMCID: PMC10338450 DOI: 10.1038/s41416-023-02254-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Diagnosis and management of cancers of unknown primary (CUP) remain challenging. This study examines the referral patterns, management and outcomes of patients referred to Australia's first dedicated CUP clinic. METHODS Retrospective medical record review was conducted for patients seen at the Peter MacCallum Cancer Centre CUP clinic between July 2014 and August 2020. Overall survival (OS) was analysed for patients with a CUP diagnosis where treatment information was available. RESULTS Of 361 patients referred, fewer than half had completed diagnostic work-up at the time of referral. A diagnosis of CUP was established in 137 (38%), malignancy other than CUP in 177 (49%) and benign pathology in 36 (10%) patients. Genomic testing was successfully completed in 62% of patients with initial provisional CUP and impacted management in 32% by identifying a tissue of origin or actionable genomic alteration. The use of site-specific, targeted therapy or immunotherapy was independently associated with longer OS compared to empirical chemotherapy. CONCLUSION Our specialised CUP clinic facilitated diagnostic work-up among patients with suspected malignancy and provided access to genomic testing and clinical trials for patients with a CUP diagnosis, all of which are important to improve outcomes in this patient population.
Collapse
Affiliation(s)
- Arielle van Mourik
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Gina Tonkin-Hill
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - John O'Farrell
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Shohei Waller
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Lavinia Tan
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
| | - Richard W Tothill
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Department of Clinical Pathology and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
| | - David Bowtell
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Stephen Fox
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Department of Clinical Pathology and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Andrew Fellowes
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Penelope Schofield
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Department of Psychology, and Iverson Health Innovation Research Institute Swinburne University, Melbourne, VIC, Australia
- Behavioural Sciences Unit, Health Services Research and Implementation Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
| | - Hui-Li Wong
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia.
| | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
21
|
Huang Y, Pfeiffer SM, Zhang Q. Primary tumor type prediction based on US nationwide genomic profiling data in 13,522 patients. Comput Struct Biotechnol J 2023; 21:3865-3874. [PMID: 37593720 PMCID: PMC10432138 DOI: 10.1016/j.csbj.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
Timely and accurate primary tumor diagnosis is critical, and misdiagnoses and delays may cause undue health and economic burden. To predict primary tumor types based on genomics data from a de-identified US nationwide clinico-genomic database (CGDB), the XGBoost-based Clinico-Genomic Machine Learning Model (XC-GeM) was developed to predict 13 primary tumor types based on data from 12,060 patients in the CGDB, derived from routine clinical comprehensive genomic profiling (CGP) testing and chart-confirmed electronic health records (EHRs). The SHapley Additive exPlanations method was used to interpret model predictions. XC-GeM reached an outstanding area under the curve (AUC) of 0.965 and Matthew's correlation coefficient (MCC) of 0.742 in the holdout validation dataset. In the independent validation cohort of 955 patients, XC-GeM reached 0.954 AUC and 0.733 MCC and made correct predictions in 77% of non-small cell lung cancer (NSCLC), 86% of colorectal cancer, and 84% of breast cancer patients. Top predictors for the overall model (e.g. tumor mutational burden (TMB), gender, and KRAS alteration), and for specific tumor types (e.g., TMB and EGFR alteration for NSCLC) were supported by published studies. XC-GeM also achieved an excellent AUC of 0.880 and positive MCC of 0.540 in 507 patients with missing primary diagnosis. XC-GeM is the first algorithm to predict primary tumor type using US nationwide data from routine CGP testing and chart-confirmed EHRs, showing promising performance. It may enhance the accuracy and efficiency of cancer diagnoses, enabling more timely treatment choices and potentially leading to better outcomes.
Collapse
Affiliation(s)
| | | | - Qing Zhang
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, United States
| |
Collapse
|
22
|
Normanno N, De Luca A, Abate RE, Morabito A, Milella M, Tabbò F, Curigliano G, Masini C, Marchetti P, Pruneri G, Guarneri V, Frassineti GL, Fasola G, Adamo V, Daniele B, Berardi R, Feroce F, Maiello E, Pinto C. Current practice of genomic profiling of patients with advanced solid tumours in Italy: the Italian Register of Actionable Mutations (RATIONAL) study. Eur J Cancer 2023; 187:174-184. [PMID: 37167765 DOI: 10.1016/j.ejca.2023.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The Italian Register of Actionable Mutations (RATIONAL) is a multicentric, observational study collecting next-generation sequencing (NGS)-based tumour profiling data of patients with advanced solid tumours. METHODS The study enrols patients who had available an NGS-based tumour profiling (Pathway-A) or undergo comprehensive genomic profiling (CGP) with FoundationOne CDx assays within the trial (Pathway-B). The primary endpoint was the rate of actionable mutations identified. RESULTS Sequencing data were available for 738 patients in Pathway-A (218) and -B (520). In Pathway-A, 154/218 (70.6%) tests were performed using NGS panels ≤52 genes, and genomic alterations (GAs) were found in 164/218 (75.2%) patients. In Pathway-B, CGP revealed GAs in 512/520 (98.5%) patients. Levels I/II/III actionable GAs according to the European Society of Medical Oncology Scale for Clinical Actionability of molecular Targets (ESCAT) were identified in 254/554 (45.8%) patients with non-small-cell lung cancer, cholangiocarcinoma, colorectal, gastric, pancreatic and breast cancer. The rate of patients with level I GAs was similar in Pathways A and B (69 versus 102). CGP in Pathway-B revealed a higher number of patients with level II/III GAs (99 versus 20) and potentially germline pathogenic/likely pathogenic variants (58 versus 15) as compared with standard testing in Pathway-A. In patients with cancer of unknown primary, CGP detected OncoKB levels 3B/4 GAs in 31/58 (53.4%) cases. Overall, 67/573 (11.7%) of patients received targeted therapy based on genomic testing. CONCLUSION The Italian Register of Actionable Mutations represents the first overview of genomic profiling in Italian current clinical practice and highlights the utility of CGP for identifying therapeutic targets in selected cancer patients.
Collapse
Affiliation(s)
- Nicola Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy.
| | - Antonella De Luca
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Riziero Esposito Abate
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Alessandro Morabito
- Thoracic Department, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Michele Milella
- U.O.C. Oncology, Azienda Ospedaliera Universitaria Integrata, University and Hospital Trust of Verona, Verona, Italy
| | - Fabrizio Tabbò
- Department of Oncology, Università degli Studi di Torino, AOU San Luigi, Orbassano, Italy
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy; Division of Early Drug Development, European Institute of Oncology IRCCS, Milano, Italy
| | - Cristina Masini
- Medical Oncology, Comprehensive Cancer Centre IRCCS - AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Paolo Marchetti
- Istituto Dermopatico dell'Immacolata (IDI-IRCCS), Roma, Italy
| | - Giancarlo Pruneri
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - Valentina Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Oncology 2, Istituto Oncologico Veneto (IOV) IRCCS, Padova, Italy
| | - Giovanni L Frassineti
- Department of Medical Oncology-IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Gianpiero Fasola
- Department of Medical Oncology, University Hospital of Udine, Udine, Italy
| | - Vincenzo Adamo
- Scientific Direction Oncology Department, Papardo Hospital, Messina, Italy
| | | | | | - Florinda Feroce
- Surgical Pathology Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Evaristo Maiello
- Oncology Unit, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Carmine Pinto
- Medical Oncology, Comprehensive Cancer Centre IRCCS - AUSL Reggio Emilia, Reggio Emilia, Italy
| |
Collapse
|
23
|
Abou-Ghaida J, Ali AA, Anasseri S, Walker L, Barber T. Adenocarcinoma of an Unknown Primary Site: Presentation, Diagnosis, and Management. Cureus 2023; 15:e41074. [PMID: 37519592 PMCID: PMC10375925 DOI: 10.7759/cureus.41074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Carcinoma of unknown primary (CUP) is a rare metastatic disease in which a primary tumor site cannot be identified. CUP is a diagnosis of exclusion requiring prior workup to identify a primary site. We present a case of a 64-year-old male with vague abdominal pain, a history of gastroesophageal reflux disease (GERD), gastritis, esophagitis, hepatitis C, alcoholic pancreatitis, liver hemangioma, and Warthin tumor, and family history of cancer that was found to have CUP. The diagnosis was made after an extensive workup was done including serum tumor markers, computed tomography (CT) and ultrasound (US) imaging, flow cytometry, and an array of immunohistochemistry stains positive for only cytokeratin 7.
Collapse
Affiliation(s)
- Jaafar Abou-Ghaida
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Adya A Ali
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Sheela Anasseri
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Leslie Walker
- Family Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Tye Barber
- Family Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| |
Collapse
|
24
|
Comparison of PD-L1 expression in squamous cell cancer of unknown primary and oropharyngeal squamous cell carcinoma. Eur Arch Otorhinolaryngol 2023; 280:1991-1997. [PMID: 36576530 PMCID: PMC9988788 DOI: 10.1007/s00405-022-07775-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/01/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE The tumorigenesis of squamous cell cancer of unknown primary (SCCUP) in the head and neck area has not been decoded so far, while poor survival rates and limited therapeutic options pose a serious challenge. The aim of this project was to investigate immunological characteristics of SCCUPs and compare them to oropharyngeal squamous cell carcinoma (OPSCC). METHODS PD-L1 expression (TC) was examined by immunohistochemistry in 50 lymph node metastases of SCCUP and 47 primaries of OPSCC. CD3 + and CD8 + lymphocytic infiltration was measured in 5 high power fields. Expression of p16 and HPV ISH were assessed. RESULTS SCCUP demonstrated a significantly higher expression of PD-L1 than OPSCC. In p16-negative SCCUPs PD-L1 proved to be an independent prognostic factor to prioritize high-risk patients. CONCLUSIONS Immunologic differences between SCCUP and OPSCC were detected. A higher PD-L1 expression in SCCUP could potentially facilitate further evaluation of checkpoint inhibitor therapy.
Collapse
|
25
|
From Biology to Diagnosis and Treatment: The Ariadne’s Thread in Cancer of Unknown Primary. Int J Mol Sci 2023; 24:ijms24065588. [PMID: 36982662 PMCID: PMC10053301 DOI: 10.3390/ijms24065588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Cancer of unknown primary (CUP) encloses a group of heterogeneous tumours, the primary sites for which cannot be identified at the time of diagnosis, despite extensive investigations. CUP has always posed major challenges both in its diagnosis and management, leading to the hypothesis that it is rather a distinct entity with specific genetic and phenotypic aberrations, considering the regression or dormancy of the primary tumour; the development of early, uncommon systemic metastases; and the resistance to therapy. Patients with CUP account for 1–3% of all human malignancies and can be categorised into two prognostic subsets according to their clinicopathologic characteristics at presentation. The diagnosis of CUP mainly depends on the standard evaluation comprising a thorough medical history; complete physical examination; histopathologic morphology and algorithmic immunohistochemistry assessment; and CT scan of the chest, abdomen, and pelvis. However, physicians and patients do not fare well with these criteria and often perform additional time-consuming evaluations to identify the primary tumour site to guide treatment decisions. The development of molecularly guided diagnostic strategies has emerged to complement traditional procedures but has been disappointing thus far. In this review, we present the latest data on CUP regarding the biology, molecular profiling, classification, diagnostic workup, and treatment.
Collapse
|
26
|
Brundu S, Napolitano V, Franzolin G, Lo Cascio E, Mastrantonio R, Sardo G, Cascardi E, Verginelli F, Sarnataro S, Gambardella G, Pisacane A, Arcovito A, Boccaccio C, Comoglio PM, Giraudo E, Tamagnone L. Mutated axon guidance gene PLXNB2 sustains growth and invasiveness of stem cells isolated from cancers of unknown primary. EMBO Mol Med 2023; 15:e16104. [PMID: 36722641 PMCID: PMC9994481 DOI: 10.15252/emmm.202216104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 02/02/2023] Open
Abstract
The genetic changes sustaining the development of cancers of unknown primary (CUP) remain elusive. The whole-exome genomic profiling of 14 rigorously selected CUP samples did not reveal specific recurring mutation in known driver genes. However, by comparing the mutational landscape of CUPs with that of most other human tumor types, it emerged a consistent enrichment of changes in genes belonging to the axon guidance KEGG pathway. In particular, G842C mutation of PlexinB2 (PlxnB2) was predicted to be activating. Indeed, knocking down the mutated, but not the wild-type, PlxnB2 in CUP stem cells resulted in the impairment of self-renewal and proliferation in culture, as well as tumorigenic capacity in mice. Conversely, the genetic transfer of G842C-PlxnB2 was sufficient to promote CUP stem cell proliferation and tumorigenesis in mice. Notably, G842C-PlxnB2 expression in CUP cells was associated with basal EGFR phosphorylation, and EGFR blockade impaired the viability of CUP cells reliant on the mutated receptor. Moreover, the mutated PlxnB2 elicited CUP cell invasiveness, blocked by EGFR inhibitor treatment. In sum, we found that a novel activating mutation of the axon guidance gene PLXNB2 sustains proliferative autonomy and confers invasive properties to stem cells isolated from cancers of unknown primary, in EGFR-dependent manner.
Collapse
Affiliation(s)
| | - Virginia Napolitano
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
| | | | - Ettore Lo Cascio
- Department of Biotechnological Sciences and Intensive CareUniversità Cattolica del Sacro CuoreRomeItaly
| | - Roberta Mastrantonio
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
| | | | - Eliano Cascardi
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | | | | | - Gennaro Gambardella
- Telethon Institute of Genetic and MedicinePozzuoliItaly
- Department of Electrical Engineering and Information TechnologyUniversity of Naples Federico IINaplesItaly
| | | | - Alessandro Arcovito
- Department of Biotechnological Sciences and Intensive CareUniversità Cattolica del Sacro CuoreRomeItaly
- Fondazione Policlinico Gemelli (FPG) – IRCCSRomeItaly
| | - Carla Boccaccio
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of OncologyUniversity of TurinTurinItaly
| | | | - Enrico Giraudo
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of Science and Drug TechnologyUniversity of TurinTurinItaly
| | - Luca Tamagnone
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Fondazione Policlinico Gemelli (FPG) – IRCCSRomeItaly
| |
Collapse
|
27
|
Pisacane A, Cascardi E, Berrino E, Polidori A, Sarotto I, Casorzo L, Panero M, Boccaccio C, Verginelli F, Benvenuti S, Dellino M, Comoglio P, Montemurro F, Geuna E, Marchiò C, Sapino A. Real-world histopathological approach to malignancy of undefined primary origin (MUO) to diagnose cancers of unknown primary (CUPs). Virchows Arch 2023; 482:463-475. [PMID: 36346458 PMCID: PMC9640798 DOI: 10.1007/s00428-022-03435-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 11/10/2022]
Abstract
The aim of this study is to envisage a streamlined pathological workup to rule out CUPs in patients presenting with MUOs. Sixty-four MUOs were classified using standard histopathology. Clinical data, immunocytochemical markers, and results of molecular analysis were recorded. MUOs were histologically subdivided in clear-cut carcinomas (40 adenocarcinomas, 11 squamous, and 3 neuroendocrine carcinomas) and unclear-carcinoma features (5 undifferentiated and 5 sarcomatoid tumors). Cytohistology of 7/40 adenocarcinomas suggested an early metastatic cancer per se. In 33/40 adenocarcinomas, CK7/CK20 expression pattern, gender, and metastasis sites influenced tissue-specific marker selection. In 23/40 adenocarcinomas, a "putative-immunophenotype" of tissue of origin addressed clinical-diagnostic examinations, identifying 9 early metastatic cancers. Cell lineage markers were used to confirm squamous and neuroendocrine differentiation. Pan-cytokeratins were used to confirm the epithelial nature of poorly differentiated tumors, followed by tissue and cell lineage markers, which identified one melanoma. In total, 47/64 MUOs (73.4%) were confirmed CUP. Molecular analysis, feasible in 37/47 CUPs (78.7%), had no diagnostic impact. Twenty CUP patients, mainly with squamous carcinomas and adenocarcinomas with putative-gynecologic-immunophenotypes, presented with only lymph node metastases and had longer median time to progression and overall survival (< 0.001), compared with patients with other metastatic patterns. We propose a simplified histology-driven workup which could efficiently rule out CUPs and identify early metastatic cancer.
Collapse
Affiliation(s)
- Alberto Pisacane
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Eliano Cascardi
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy.
- Department of Medical Sciences, University of Turin, 10100, Turin, Italy.
| | - Enrico Berrino
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
- Department of Medical Sciences, University of Turin, 10100, Turin, Italy
| | - Alessio Polidori
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Ivana Sarotto
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Laura Casorzo
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Mara Panero
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Carla Boccaccio
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
- Department of Oncology, University of Turin Medical School, 10060, Candiolo, Turin, Italy
| | | | - Silvia Benvenuti
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Miriam Dellino
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Paolo Comoglio
- IFOM, FIRC Institute of Molecular Oncology, 20019, Milan, Italy
| | | | - Elena Geuna
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
| | - Caterina Marchiò
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
- Department of Medical Sciences, University of Turin, 10100, Turin, Italy
| | - Anna Sapino
- Candiolo Cancer Institute, FPO-IRCCS, 10060, Candiolo, Turin, Italy
- Department of Medical Sciences, University of Turin, 10100, Turin, Italy
| |
Collapse
|
28
|
Krämer A, Bochtler T, Pauli C, Baciarello G, Delorme S, Hemminki K, Mileshkin L, Moch H, Oien K, Olivier T, Patrikidou A, Wasan H, Zarkavelis G, Pentheroudakis G, Fizazi K. Cancer of unknown primary: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023; 34:228-246. [PMID: 36563965 DOI: 10.1016/j.annonc.2022.11.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- A Krämer
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - T Bochtler
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - C Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - G Baciarello
- Medical Oncology Department, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - S Delorme
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg
| | - K Hemminki
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and Biomedical Center, Charles University, Pilsen, Czech Republic
| | - L Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - K Oien
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - T Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - A Patrikidou
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - H Wasan
- Department of Cancer Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - G Zarkavelis
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece
| | | | - K Fizazi
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
| |
Collapse
|
29
|
Jiao XD, Qin BD, Wang Z, Liu K, Wu Y, Ling Y, Qin WX, Wang MM, Yuan LY, Barreto SG, Kim AW, Mak K, Li H, Xu YY, Qiu XM, Wu M, Jin M, Xu LC, Zhong Y, Yang H, Chen XQ, Zeng Y, Shi J, Zhu WY, Ding QQ, Jia W, Liu SF, Zhou JJ, Shen H, Yao SH, Guo ZJ, Li T, Zhou PJ, Dong XW, Lu WF, Coleman RL, Akce M, Akladios C, Puccetti F, Zang YS. Targeted therapy for intractable cancer on the basis of molecular profiles: An open-label, phase II basket trial (Long March Pathway). Front Oncol 2023; 13:860711. [PMID: 36910668 PMCID: PMC9995917 DOI: 10.3389/fonc.2023.860711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/02/2023] [Indexed: 02/25/2023] Open
Abstract
Purpose We evaluated he effects of molecular guided-targeted therapy for intractable cancer. Also, the epidemiology of druggable gene alterations in Chinese population was investigated. Materials and methods The Long March Pathway (ClinicalTrials.gov identifier: NCT03239015) is a non-randomized, open-label, phase II trial consisting of several basket studies examining the molecular profiles of intractable cancers in the Chinese population. The trial aimed to 1) evaluate the efficacy of targeted therapy for intractable cancer and 2) identify the molecular epidemiology of the tier II gene alterations among Chinese pan-cancer patients. Results In the first stage, molecular profiles of 520 intractable pan-cancer patients were identified, and 115 patients were identified to have tier II gene alterations. Then, 27 of these 115 patients received targeted therapy based on molecular profiles. The overall response rate (ORR) was 29.6% (8/27), and the disease control rate (DCR) was 44.4% (12/27). The median duration of response (DOR) was 4.80 months (95% CI, 3.33-27.2), and median progression-free survival (PFS) was 4.67 months (95% CI, 2.33-9.50). In the second stage, molecular epidemiology of 17,841 Chinese pan-cancer patients demonstrated that the frequency of tier II gene alterations across cancer types is 17.7%. Bladder cancer had the most tier-II alterations (26.1%), followed by breast cancer (22.4%), and non-small cell lung cancer (NSCLC; 20.2%). Conclusion The Long March Pathway trial demonstrated a significant clinical benefit for intractable cancer from molecular-guided targeted therapy in the Chinese population. The frequency of tier II gene alterations across cancer types supports the feasibility of molecular-guided targeted therapy under basket trials.
Collapse
Affiliation(s)
- Xiao-Dong Jiao
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bao-Dong Qin
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhan Wang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ke Liu
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ying Wu
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yan Ling
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Wen-Xing Qin
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Miao-Miao Wang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ling-Yan Yuan
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | | | - Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Kimberley Mak
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Hao Li
- Department of Medical Oncology, Shanghai Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yuan-Yuan Xu
- Department of Surgical Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Ming Qiu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Min Wu
- Department Gynecology and Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Jin
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li-Chao Xu
- Department of Interventional Radiology, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Yi Zhong
- Department of Medical Oncology, Shanghai Traditional Chinese Medicine-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hui Yang
- Department of Medical Oncology, Suzhou Municipal Hospital, Nanjing Medical University, Suzhou, China
| | - Xue-Qin Chen
- Department of Medical Oncology, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Zeng
- Department of Pathology, Shanghai Tongji Hospital, Shanghai Tongji University, Shanghai, China
| | - Jun Shi
- Department of Gastrointestinal Surgery, Changzhou No.2 People's Hospital, Nanjing Medical University, Changzhou, China
| | - Wen-Yu Zhu
- Department of Medical Oncology, Changzhou No.2 People's Hospital, Nanjing Medical University, Changzhou, China
| | - Qing-Qing Ding
- Department of Geriatric Oncology, Jiangsu Provincial People's Hospital, Nanjing Medical University, Nanjing, China
| | - Wei Jia
- Department of Respiratory, Shanghai Traditional Chinese Medicine-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Su-Fen Liu
- Department of Gynecology, Changzhou No.2 People's Hospital, Nanjing Medical University, Changzhou, China
| | - Jun-Jing Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Wuxi No.4 People's Hospital, Jiangnan University, Wuxi, China
| | - Hong Shen
- Department of Medical Oncology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Hua Yao
- Department of Thoracic Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhao-Ji Guo
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ting Li
- Department of Medical Oncology, Shanghai Cancer Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Pei-Juan Zhou
- Department of Traditional Chinese Medicine, Shanghai Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xue-Wei Dong
- Department of Gastrointestinal Surgery, The First People's Hospital of Changzhou, Soochow University, Changzhou, China
| | - Wen-Feng Lu
- Department of Integrative Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Robert L Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mehmet Akce
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Chérif Akladios
- Department of Obstetrics and Gynecology, University of Strasbourg, Strasbourg, France
| | - Francesco Puccetti
- Department of Gastrointestinal Surgery, San Raffaele Hospital IRCCS, Milan, Italy
| | - Yuan-Sheng Zang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|
30
|
Sheng J, Pan H, Han W. Immunochemotherapy achieved a complete response for metastatic adenocarcinoma of unknown primary based on gene expression profiling: a case report and review of the literature. Front Immunol 2023; 14:1181444. [PMID: 37153561 PMCID: PMC10154565 DOI: 10.3389/fimmu.2023.1181444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cancer of unknown primary (CUP) is a malignant and aggressive tumor whose primary origin is still unknown despite thorough evaluation. CUP can be life-threatening with a median overall survival of less than 1 year based on empirical chemotherapy. Gene detection technology advances the driver gene detection of malignant tumors and the appropriate precise therapy. Immunotherapy has ushered in a new era in cancer therapy, changing the way advanced tumors, including CUP, are treated. Combined with comprehensive clinical and pathological investigations, molecular analysis of the original tissue and detection of potential driver mutations may provide therapeutic recommendations for CUP. Case presentation A 52-year-old female was admitted to hospital for dull abdominal pain, with peripancreatic lesions below the caudate lobe of the liver and posterior peritoneal lymph nodes enlargement. Conventional biopsy under endoscopic ultrasonography and laparoscopic biopsy both revealed poorly differentiated adenocarcinoma based on immunohistochemical series. To help identify tumor origin and molecular characteristics, 90-gene expression assay, tumor gene expression profiling with Next-generation sequencing (NGS) method and Immunohistochemical expression of PD-L1 were employed. Although no gastroesophageal lesions discovered by gastroenteroscopy, the 90-gene expression assay yielded a similarity score and prompted the most likely primary site was gastric/esophagus cancer. NGS revealed high TMB (19.3mutations/Mb) but no druggable driver genes identified. The Dako PD-L1 22C3 assay IHC assay for PD-L1 expression revealed a tumor proportion score (TPS) of 35%. Given the presence of negative predictive biomarkers for immunotherapy, including adenomatous polyposis coli (APC) c.646C>T mutation at exon 7 and Janus kinase 1(JAK1), the patient received immunochemotherapy instead of immunotherapy alone. She was successfully treated with nivolumab plus carboplatin and albumin-bound nanoparticle paclitaxel for six cycles and nivolumab maintenance, which achieved a complete response (CR) maintained for 2 years without severe adverse events. Conclusions This case highlights the value of multidisciplinary diagnosis and individual precision treatment in CUP. Further investigation is needed as an individualized treatment approach combining immunotherapy and chemotherapy based on tumor molecular characteristics and immunotherapy predictors is expected to improve the outcome of CUP therapy.
Collapse
Affiliation(s)
- Jin Sheng
- Department of Medical Oncology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongming Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weidong Han
- Department of Medical Oncology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Weidong Han,
| |
Collapse
|
31
|
Posner A, Prall OW, Sivakumaran T, Etemadamoghadam D, Thio N, Pattison A, Balachander S, Fisher K, Webb S, Wood C, DeFazio A, Wilcken N, Gao B, Karapetis CS, Singh M, Collins IM, Richardson G, Steer C, Warren M, Karanth N, Wright G, Williams S, George J, Hicks RJ, Boussioutas A, Gill AJ, Solomon BJ, Xu H, Fellowes A, Fox SB, Schofield P, Bowtell D, Mileshkin L, Tothill RW. A comparison of DNA sequencing and gene expression profiling to assist tissue of origin diagnosis in cancer of unknown primary. J Pathol 2023; 259:81-92. [PMID: 36287571 PMCID: PMC10099529 DOI: 10.1002/path.6022] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/02/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Cancer of unknown primary (CUP) is a syndrome defined by clinical absence of a primary cancer after standardised investigations. Gene expression profiling (GEP) and DNA sequencing have been used to predict primary tissue of origin (TOO) in CUP and find molecularly guided treatments; however, a detailed comparison of the diagnostic yield from these two tests has not been described. Here, we compared the diagnostic utility of RNA and DNA tests in 215 CUP patients (82% received both tests) in a prospective Australian study. Based on retrospective assessment of clinicopathological data, 77% (166/215) of CUPs had insufficient evidence to support TOO diagnosis (clinicopathology unresolved). The remainder had either a latent primary diagnosis (10%) or clinicopathological evidence to support a likely TOO diagnosis (13%) (clinicopathology resolved). We applied a microarray (CUPGuide) or custom NanoString 18-class GEP test to 191 CUPs with an accuracy of 91.5% in known metastatic cancers for high-medium confidence predictions. Classification performance was similar in clinicopathology-resolved CUPs - 80% had high-medium predictions and 94% were concordant with pathology. Notably, only 56% of the clinicopathology-unresolved CUPs had high-medium confidence GEP predictions. Diagnostic DNA features were interrogated in 201 CUP tumours guided by the cancer type specificity of mutations observed across 22 cancer types from the AACR Project GENIE database (77,058 tumours) as well as mutational signatures (e.g. smoking). Among the clinicopathology-unresolved CUPs, mutations and mutational signatures provided additional diagnostic evidence in 31% of cases. GEP classification was useful in only 13% of cases and oncoviral detection in 4%. Among CUPs where genomics informed TOO, lung and biliary cancers were the most frequently identified types, while kidney tumours were another identifiable subset. In conclusion, DNA and RNA profiling supported an unconfirmed TOO diagnosis in one-third of CUPs otherwise unresolved by clinicopathology assessment alone. DNA mutation profiling was the more diagnostically informative assay. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
Collapse
Affiliation(s)
- Atara Posner
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Owen Wj Prall
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | | | - Niko Thio
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Andrew Pattison
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Shiva Balachander
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Krista Fisher
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Samantha Webb
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Colin Wood
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Anna DeFazio
- The Westmead Institute for Medical Research, Sydney, NSW, Australia.,Department of Gynaecological Oncology, Westmead Hospital, Sydney, NSW, Australia.,The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Nicholas Wilcken
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Bo Gao
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Christos S Karapetis
- Department of Medical Oncology, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia
| | - Madhu Singh
- Department of Medical Oncology, Barwon Health Cancer Services, Geelong, VIC, Australia
| | - Ian M Collins
- Department of Medical Oncology, SouthWest HealthCare, Warrnambool and Deakin University, Geelong, VIC, Australia
| | - Gary Richardson
- Department of Medical Oncology, Cabrini Health, Melbourne, VIC, Australia
| | - Christopher Steer
- Border Medical Oncology, Albury Wodonga Regional Cancer Centre, Albury, NSW, Australia
| | - Mark Warren
- Department of Medical Oncology, Bendigo Health, Bendigo, VIC, Australia
| | - Narayan Karanth
- Division of Medicine, Alan Walker Cancer Centre, Darwin, NT, Australia
| | - Gavin Wright
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Scott Williams
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joshy George
- Department of Computational Sciences, The Jackson Laboratory, Farmington, Connecticut, USA
| | - Rodney J Hicks
- The St Vincent's Hospital Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Alex Boussioutas
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical, Research and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Benjamin J Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Huiling Xu
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Andrew Fellowes
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Stephen B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Penelope Schofield
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Psychology, and Iverson Health Innovation Research Institute, Swinburne University, Melbourne, VIC, Australia.,Behavioural Sciences Unit, Health Services Research and Implementation Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - David Bowtell
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Richard W Tothill
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
32
|
Tissue and liquid biopsy profiling reveal convergent tumor evolution and therapy evasion in breast cancer. Nat Commun 2022; 13:7495. [PMID: 36470901 PMCID: PMC9723105 DOI: 10.1038/s41467-022-35245-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
Pathological and genomic profiling have transformed breast cancer care by matching patients to targeted treatments. However, tumors evolve and evade therapeutic interventions often through the acquisition of genomic mutations. Here we examine patients profiled with tissue (TBx) and liquid biopsy (LBx) as part of routine clinical care, to characterize the tumor evolutionary landscape and identify potential vulnerabilities in the relapsed setting. Real-world evidence demonstrates that LBx is utilized later in care and identifies associations with intervening therapy. While driver events are frequently shared, acquired LBx alterations are detected in a majority of patients, with the highest frequency in ER+ disease and in patients with longer biopsy intervals. Acquired mutations are often polyclonal and present at lower allelic fractions, suggesting multi-clonal convergent evolution. In addition to well-characterized resistance mutations (e.g., ESR1, NF1, RB1, ERBB2), we observe a diversity of rarer but potentially targetable mutations (e.g., PIK3CA, HRAS/NRAS/KRAS, FGFR1/2/3, BRAF) and fusions (e.g., FGFR1/2, ERBB2, RET), as well as BRCA1/2 reversions through a variety of mechanisms, including splice alterations and structural deletions. This study provides insights on treatment and selection-driven tumor evolution and identifies potential combinatorial treatment options in advanced breast cancer.
Collapse
|
33
|
Cancer-of-Unknown-Primary-Origin: A SEER-Medicare Study of Patterns of Care and Outcomes among Elderly Patients in Clinical Practice. Cancers (Basel) 2022; 14:cancers14122905. [PMID: 35740574 PMCID: PMC9221531 DOI: 10.3390/cancers14122905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Cancer-of-unknown-primary-origin (CUP) is challenging to diagnose and treat, and little is known about its diagnostic work-up, treatment, and outcomes in routine healthcare. We examined data from elderly patients (at least 66 years old) diagnosed with CUP in real-world US clinical practice, using the Surveillance, Epidemiology, and End Results–Medicare-linked database. Only half of elderly patients with CUP received all three diagnostic work-up procedures (biopsy, immunohistochemistry, and imaging), as recommended by guidelines. Patients who received all three diagnostic work-up procedures were more likely to receive any type of anticancer treatment, and patients who did not receive full diagnostic work-up had shorter median overall survival, particularly with increasing age. Overall, these results suggest that further studies are needed to understand why many patients given a diagnosis of CUP do not receive complete diagnostic work-up or treatment. Further research into improving diagnostic work-up and treatment effectiveness in patients diagnosed with CUP is required. Abstract Knowledge of contemporary patterns of cancer-of-unknown-primary-origin (CUP) diagnostic work-up, treatment, and outcomes in routine healthcare is limited. Thus, we examined data from elderly patients diagnosed with CUP in real-world US clinical practice. From the Surveillance, Epidemiology, and End Results–Medicare-linked database, we included patients ≥ 66 years old with CUP diagnosed between 1 January 2013 and 31 December 2015. We analyzed baseline demographics, clinical characteristics, methods of diagnostic work-up (biopsy, immunohistochemistry, imaging), treatment-related factors, and survival. CUP diagnosis was histologically confirmed in 2813/4562 patients (61.7%). Overall, 621/4562 (13.6%) patients received anticancer pharmacotherapy; among these, 97.3% had a histologically confirmed tumor and 83.1% received all three procedures. Among those with a histologically confirmed tumor, increasing age, increasing comorbidity score, not receiving all three diagnostic measures, and having a not-further specified histologic finding of only ‘malignant neoplasm’ were all negatively associated with receipt of anticancer pharmacotherapy. Median overall survival was 1.2 months for all patients. Median time between CUP diagnosis and treatment initiation was 41 days. Limited diagnostic work-up was common and most patients did not receive anticancer pharmacotherapy. The poor outcomes highlight a substantial unmet need for further research into improving diagnostic work-up and treatment effectiveness in CUP.
Collapse
|
34
|
Blecua P, Davalos V, de Villasante I, Merkel A, Musulen E, Coll-SanMartin L, Esteller M. Refinement of computational identification of somatic copy number alterations using DNA methylation microarrays illustrated in cancers of unknown primary. Brief Bioinform 2022; 23:6582004. [PMID: 35524475 PMCID: PMC9487591 DOI: 10.1093/bib/bbac161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 03/30/2022] [Accepted: 04/10/2022] [Indexed: 11/14/2022] Open
Abstract
High-throughput genomic technologies are increasingly used in personalized cancer medicine. However, computational tools to maximize the use of scarce tissues combining distinct molecular layers are needed. Here we present a refined strategy, based on the R-package 'conumee', to better predict somatic copy number alterations (SCNA) from deoxyribonucleic acid (DNA) methylation arrays. Our approach, termed hereafter as 'conumee-KCN', improves SCNA prediction by incorporating tumor purity and dynamic thresholding. We trained our algorithm using paired DNA methylation and SNP Array 6.0 data from The Cancer Genome Atlas samples and confirmed its performance in cancer cell lines. Most importantly, the application of our approach in cancers of unknown primary identified amplified potentially actionable targets that were experimentally validated by Fluorescence in situ hybridization and immunostaining, reaching 100% specificity and 93.3% sensitivity.
Collapse
Affiliation(s)
- Pedro Blecua
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Veronica Davalos
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Izar de Villasante
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Angelika Merkel
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Eva Musulen
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain.,Department of Pathology, Hospital Universitari General de Catalunya-Grupo Quirónsalud, Sant Cugat del Vallès, Barcelona, Catalonia, Spain
| | - Laia Coll-SanMartin
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Manel Esteller
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Cancer (CIBERONC), Madrid, Spain.,Institucio Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain.,Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Catalonia, Spain
| |
Collapse
|
35
|
Losa F, Fernández I, Etxaniz O, Giménez A, Gomila P, Iglesias L, Longo F, Nogales E, Sánchez A, Soler G. SEOM-GECOD clinical guideline for unknown primary cancer (2021). Clin Transl Oncol 2022; 24:681-692. [PMID: 35320504 PMCID: PMC8986666 DOI: 10.1007/s12094-022-02806-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/16/2022]
Abstract
Cancer of unknown primary site (CUP) is defined as a heterogeneous group of tumors that appear as metastases, and of which standard diagnostic work-up fails to identify the origin. It is considered a separate entity with a specific biology, and nowadays molecular characteristics and the determination of actionable mutations may be important in a significant group of patients. In this guide, we summarize the diagnostic, therapeutic, and possible new developments in molecular medicine that may help us in the management of this unique disease entity.
Collapse
Affiliation(s)
- Ferrán Losa
- Hospital de Sant Joan Despí Moisés Broggi-ICO Hospitalet, Barcelona, Spain.
| | | | - Olatz Etxaniz
- Hospital Germans Trias I Pujol -ICO Badalona, Barcelona, Spain
| | | | - Paula Gomila
- Hospital Miguel Servet (Zaragoza)/H, de Barbastro, Spain
| | | | - Federico Longo
- Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | | | - Antonio Sánchez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Gemma Soler
- Hospital Durán i Reynals-ICO Hospitalet, Barcelona, Spain
| |
Collapse
|
36
|
Yang Z, Cui W, Yu R, Dong X, Zhao J, Dai L, Ou Q, Bao H, Wu X, Wu C, Lai J. Altered Signaling Pathways Revealed by Comprehensive Genomic Profiling in Patients With Unknown Primary Tumors. Front Oncol 2022; 12:753311. [PMID: 35402276 PMCID: PMC8991684 DOI: 10.3389/fonc.2022.753311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/17/2022] [Indexed: 01/16/2023] Open
Abstract
Purpose Carcinoma of unknown primary (CUP) is a clinically aggressive disorder with early tumor dissemination. Identifying molecular traits of CUP can be not only beneficial for a better therapeutic approach but also potentially valuable for patients with general metastatic dissemination. Patients and Methods We retrospectively investigated a total of 35 unique CUP cases. Tumor tissue samples were available in 26 patients, and plasma samples were available in 22 patients. Targeted sequencing was performed with a panel of 416 pan cancer-related genes. Results A genomic landscape of the CUP cohort showed that TP53 mutation was the most frequently observed mutation while MYC amplification was the most common CNV. Aberrant TP53, RTK-RAS, and PI3K signaling pathways were also prevalent, identified in more than half of the cases with tumor tissue. Around 58% of the CUP cases harbored homologous recombinant repair (HRR) pathway gene alterations. The tumor mutational load of CUP patients with altered HRR pathway displayed a significant increase than that of patients with intact HRR. Clinically actionable mutations were identified in eight patients, which may benefit from targeted therapies. Eight patients were treated with platinum-based chemotherapy, showing different responses, HRR, and LOH status. Conclusion Collectively, our data have provided much-need insights into the treatment options for patients diagnosed with CUP in the era of precision medicine.
Collapse
Affiliation(s)
- Zhen Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Cui
- Department of Colorectal Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Ruoying Yu
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Xinhua Dong
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian Zhao
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Lu Dai
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Qiuxiang Ou
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Hua Bao
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Xue Wu
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Chuanxin Wu
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jinhuo Lai
- Department of Medical Oncology, Fujian Medical University Union Hospital, Fuzhou, China
| |
Collapse
|
37
|
Kato Y, Shimazu K, Fukuda K, Yoshida T, Taguchi D, Shinozaki H, Nanjyo H, Shibata H. Two Cases of ALK-Altered Cancers of Unknown Primary Diagnosed by Immunohistochemistry. Case Rep Oncol 2022; 15:21-26. [PMID: 35221965 PMCID: PMC8832189 DOI: 10.1159/000521157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/23/2021] [Indexed: 11/19/2022] Open
Abstract
Cancer of unknown primary (CUP) accounts for 5% of all malignancies. Patients with CUP may live averagely for 8 months after diagnosis, and thus, rapid and reasonable diagnosis is necessary. Among patients with CUP, anaplastic lymphoma kinase (ALK)-overexpressing CUPs, whose primary sites were confirmed to be the lungs (Lung-CUP) by using antibodies against cytokeratin 7, thyroid transcription factor-1, and Napsin A, along with clinical characteristics progressed rapidly and were very sensitive to the ALK inhibitor alectinib. The incidence of ALK alteration in Lung-CUP is 19%. Consequently, it is advised that Lung-CUP be examined by immunohistochemistry (IHC) with an anti-ALK antibody. Alternative examinations, such as a cancer genome test, require as much as 2 months to complete, whereas IHC can be completed within days. In this report, a rapid assessment by IHC led to alectinib treatment, which resulted in good outcomes in 2 cases of Lung-CUP. Alectinib was effective for ALK-altered Lung-CUPs.
Collapse
Affiliation(s)
- Yoriko Kato
- Department of Clinical Oncology, Akita University, Akita, Japan
| | | | - Koji Fukuda
- Department of Clinical Oncology, Akita University, Akita, Japan
| | - Taichi Yoshida
- Department of Clinical Oncology, Akita University, Akita, Japan
| | - Daiki Taguchi
- Department of Clinical Oncology, Akita University, Akita, Japan
| | - Hanae Shinozaki
- Department of Clinical Oncology, Akita University, Akita, Japan
| | - Hiroshi Nanjyo
- Department of Pathology, Akita University Hospital, Akita, Japan
| | | |
Collapse
|
38
|
Sugiyama K, Izumika A, Iwakoshi A, Nishibori R, Sato M, Shiraishi K, Hattori H, Nishimura R, Kitagawa C. Successful Alectinib Treatment for Carcinoma of Unknown Primary with EML4-ALK Fusion Gene: A Case Report. ACTA ACUST UNITED AC 2021; 28:1938-1945. [PMID: 34064158 PMCID: PMC8161847 DOI: 10.3390/curroncol28030180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/15/2021] [Accepted: 05/18/2021] [Indexed: 12/02/2022]
Abstract
Gene alteration in anaplastic lymphoma kinase (ALK) is rare, and the efficacy of ALK inhibitors in the treatment of carcinoma of unknown primary (CUP) with ALK alteration remains unclear. The patient was a 56-year-old woman who presented with cervical lymph node swelling. Computed tomography revealed paraaortic, perigastric, and cervical lymph node swelling; ascites; a liver lesion; and a left adrenal mass. A cervical lymph node biopsy was performed, and pathological diagnosis of an undifferentiated malignant tumor was conducted. Finally, the patient was diagnosed with CUP and treated with chemotherapy. To evaluate actionable mutations, we performed a multigene analysis, using a next-generation sequencer (FoundationOne® CDx). It revealed that the tumor harbored an echinoderm microtubule-associated protein-like 4 (EML4) and ALK fusion gene. Additionally, immunohistochemistry confirmed ALK protein expression. Alectinib, a potent ALK inhibitor, was recommended for the patient at a molecular oncology conference at our institution. Accordingly, alectinib (600 mg/day) was administered, and the multiple lesions and symptoms rapidly diminished without apparent toxicity. The administration of alectinib continued for a period of 10 months without disease progression. Thus, ALK-tyrosine kinase inhibitors should be considered in patients with CUP harboring the EML4-ALK fusion gene.
Collapse
Affiliation(s)
- Keiji Sugiyama
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
- Correspondence: ; Tel.: +81-529-511-111
| | - Ai Izumika
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
| | - Akari Iwakoshi
- Department of Pathology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.)
| | - Riko Nishibori
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
| | - Mariko Sato
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
| | - Kazuhiro Shiraishi
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
| | - Hiroyoshi Hattori
- Department of Clinical Genetics, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan;
| | - Rieko Nishimura
- Department of Pathology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.)
| | - Chiyoe Kitagawa
- Department of Medical Oncology, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-Ku, Nagoya 460-0001, Japan; (A.I.); (R.N.); (M.S.); (K.S.); (C.K.)
| |
Collapse
|
39
|
Stirnweiss A, Dholaria H, Oommen J, Hardy K, Jevon G, Beesley AH, Kotecha RS. Case Report: Long-Term Survival of a Pediatric Patient With an Intra-Abdominal Undifferentiated Carcinoma of Unknown Primary. Front Oncol 2021; 11:590913. [PMID: 34041014 PMCID: PMC8141844 DOI: 10.3389/fonc.2021.590913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022] Open
Abstract
An 8-year and 10-month-old boy presented following 2 weeks of abdominal pain, vomiting, constipation, and rectal pain. A diffuse lower-abdominal mass was felt upon palpation, with radiological findings confirming the presence of a large, multilobulated intraperitoneal mass with mesenteric lymphadenopathy and hepatic metastatic disease. A biopsy of the mass revealed anatomical pathological findings consistent with a diagnosis of intra-abdominal undifferentiated carcinoma of unknown primary (CUP). The patient was treated with six cycles of carboplatin and gemcitabine prior to surgery. Following incomplete resection of the tumor, four further cycles were administered resulting in resolution of the pelvic mass, but progression in the right and left lobes of the liver. Therapy was accordingly adjusted, with administration of six cycles of ifosfamide and doxorubicin followed by 1 year of metronomic vinorelbine and cyclophosphamide maintenance therapy. The patient remains in remission 7 years from completion of therapy. Whole exome sequencing revealed missense mutations in the DNA-repair and chromatin-remodeling genes FANCM and SMARCD2, and a tumor-derived cell line revealed a complex karyotype suggesting chromosomal instability. CUP is an extremely rare diagnosis in the pediatric population, previously reported during adolescence. This report provides detailed characterization of CUP in a young child and in the absence of defined therapeutic guidelines for pediatric CUP, the successful treatment strategy described should be considered for similar cases.
Collapse
Affiliation(s)
- Anja Stirnweiss
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Hetal Dholaria
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, WA, Australia
| | - Joyce Oommen
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | | | - Gareth Jevon
- Department of Anatomical Pathology, Perth Children's Hospital, Perth, WA, Australia
| | - Alex H Beesley
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Rishi S Kotecha
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, WA, Australia.,Curtin Medical School, Curtin University, Perth, WA, Australia
| |
Collapse
|
40
|
Redefining cancer of unknown primary: Is precision medicine really shifting the paradigm? Cancer Treat Rev 2021; 97:102204. [PMID: 33866225 DOI: 10.1016/j.ctrv.2021.102204] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
The concept of Cancer of Unknown Primary (CUP) has evolved with the advent of medical oncology. CUP can be difficult to diagnose and represents 2 to 5% of new cancers, therefore not exceptionally rare. Within CUPs can be identified a subset of favourable prognosis tumours, however the vast majority of CUP patients belongs to a poor prognosis group. CUP features significant oncological challenges, such as unravelling biological and transversal issues, and most importantly, improving patient's outcomes. In that regard, CUP patients' outcomes regrettably showed minimal improvement for decades and CUP remains a cancer group of very poor prognosis. The biology of CUP has two main hypotheses. One is that CUP is a subgroup of a given primary cancer, where the primary is present but cannot be seen due to its small size. The other, the "true" CUP hypothesis, states that CUP share features that make them a specific entity, whatever their tissue of origin. A true biological signature has not yet been described, but chromosomal instability is a hallmark of poor prognosis CUP group. Precision oncology, despite achieving identifying the putative origin of the CUP, so far failed to globally improve outcomes of patients. Targeting molecular pathways based on molecular analysis in CUP management is under investigation. Immunotherapy has not shown ground-breaking results, to date. Accrual is also a crucial issue in CUP trials. Herein we review CUP history, biological features and remaining questions in CUP biology, the two main approaches of molecular oncology in CUP management, in order to draw perspectives in the enormous challenge of improving CUP patient outcomes.
Collapse
|