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Suzuki R, Hamada K, Ohkuma R, Homma M, Tsurui T, Iriguchi N, Ishiguro T, Hirasawa Y, Ariizumi H, Kubota Y, Horiike A, Yoshimura K, Wada S, Yamochi T, Tsunoda T. Case Report: Combined pembrolizumab, 5-fluorouracil, and cisplatin therapy were remarkably effective in p16-positive squamous cell carcinoma of unknown primary. Front Oncol 2023; 13:1231986. [PMID: 37496666 PMCID: PMC10365966 DOI: 10.3389/fonc.2023.1231986] [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: 05/31/2023] [Accepted: 06/22/2023] [Indexed: 07/28/2023] Open
Abstract
Background Cancer of unknown primary (CUP) is a malignant tumor without a known primary lesion with a frequency of 3-5%. It can be divided into favorable and unfavorable prognosis subsets. While recommended treatments are available for the former group, there is no established treatment for the latter. Here, we report the effective treatment of a 32-year-old woman with p16-positive squamous cell CUP with pembrolizumab plus 5-fluorouracil and cisplatin therapy. Case presentation A 32-year-old woman presented with metastatic lesions in the liver, lung, bone, cervical region, abdominal region, and pelvic lymph nodes. She was diagnosed with p16-positive squamous cell carcinoma of unknown primary origin. The patient received pembrolizumab plus 5-fluorouracil and cisplatin therapy, which markedly reduced the metastasis and improved her Eastern Cooperative Oncology Group performance status after two courses. Conclusion This case report highlights the potential of pembrolizumab plus 5-fluorouracil and cisplatin therapy for treating CUP with an unfavorable prognosis. p16 positivity is worth examining for squamous cell carcinoma of unknown primary origin, and if present, this therapy should be considered a promising treatment option.
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Affiliation(s)
- Risako Suzuki
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kazuyuki Hamada
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Chest Surgery, Fukushima Medical University, Fukushima, Japan
| | - Ryotaro Ohkuma
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Mayumi Homma
- Department of Pathology, Showa University School of Medicine, Tokyo, Japan
| | - Toshiaki Tsurui
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nana Iriguchi
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomoyuki Ishiguro
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuya Hirasawa
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hirotsugu Ariizumi
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yutaro Kubota
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Atsushi Horiike
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kiyoshi Yoshimura
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Satoshi Wada
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Clinical Diagnostic Oncology, Clinical Research Institute of Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Toshiko Yamochi
- Department of Pathology, Showa University School of Medicine, Tokyo, Japan
| | - Takuya Tsunoda
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Rassy E, Labaki C, Chebel R, Boussios S, Smith-Gagen J, Greco FA, Pavlidis N. Systematic review of the CUP trials characteristics and perspectives for next-generation studies. Cancer Treat Rev 2022; 107:102407. [PMID: 35569387 DOI: 10.1016/j.ctrv.2022.102407] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Research on therapeutic strategies for patients with unknown primary cancer (CUP) has been underwhelming. This paper summarized and evaluated the CUP therapeutic research over the previous five years. Based on this evaluation, recommendations for clinical trial designs are made to improve the impact of CUP research on patients. METHODS Published and ongoing research were evaluated. PubMed was searched from January 1, 2015, to November 1, 2021. The start date of 2015 was chosen to identify research published after ESMO issued new diagnostic and therapeutic guidelines. The US National Library of Medicine indexed ongoing clinical trials. FINDINGS Of the 244 CUP studies indexed in PubMed, 11.9% were prospective studies, and 4.9% were clinical trials. The review protocol deemed 65 publications eligible for full-text review. Eleven studies evaluating therapeutic regimens were retained. The two prospective studies and non-randomized trials showed promising outcomes for site-specific treatments. Randomized clinical trials were less promising; however, the trials had recruitment challenges resulting in biased accrual and the inability to keep pace with advancing diagnostics and therapeutics. Most of the 35 ongoing studies were phase II single-arm trials assessing immune checkpoint inhibitors (ICI) or site-specific therapies among CUP patients with suspected favorable prognoses. CONCLUSION Our evaluation suggests two prospective clinical trial designs that addressed recent study design and recruitment challenges. A visionary approach uses a multi-arm, multistage randomized trial to address rapid advancements in diagnosis and therapy. A pragmatic approach utilizes a single-arm trial with historical controls to overcome comparison group and recruitment challenges.
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Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy, Villejuif, France.
| | | | - Roy Chebel
- University of Wisconsin-Madison, Wisconsin, USA
| | - Stergios Boussios
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, SE1 9RT London, UK
| | | | - F Anthony Greco
- Sarah Cannon Cancer Center and Research Institute, Tennessee Oncology, Nashville, TN, USA
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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.
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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.)
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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.
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