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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.
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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.
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Pouyiourou M, Mokry T, Feszler M, Teifke A, Kreft A, Krämer A. Cancer of unknown primary derived from regressed breast cancer. J Cancer Res Clin Oncol 2024; 150:229. [PMID: 38703270 PMCID: PMC11069480 DOI: 10.1007/s00432-024-05768-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Maria Pouyiourou
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Theresa Mokry
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Feszler
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andrea Teifke
- Department of Diagnostic and Interventional Radiology, University of Mainz, Mainz, Germany
| | - Andreas Kreft
- Institute of Pathology, University of Mainz, Mainz, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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3
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Lammert A, Abo-Madyan Y, Huber L, Ludwig S, Scherl C, Rotter N. [Cervical CUP Syndrome: Diagnosis and Therapy]. Laryngorhinootologie 2024; 103:371-382. [PMID: 38697084 DOI: 10.1055/a-2150-4834] [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: 05/04/2024]
Abstract
In CUP syndrome (CUP = cancer of unknown primary) there are 1 or more metastases of a primary tumor that cannot be localized despite extensive diagnostics. CUP syndrome accounts for 5% of all human malignancies, making it one of the 10 most common forms of cancer. In addition to inflammatory lymph node enlargement and benign changes such as cervical cysts, lymph node metastases are among the most common cervical masses. Cervical CUP syndrome is a histologically confirmed cervical lymph node metastasis with an unknown primary tumor. In addition to anamnesis, clinical examination and histological confirmation, diagnostics include radiological imaging using PET-CT and panendoscopy with histological primary tumor search. Treatment options include surgical therapy with neck dissection and chemoradiotherapy.
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Morimoto T, Hisamori S, Kinoshita H, Yamada Y, Teramoto Y, Sakamoto T, Kasahara K, Okumura S, Nishigori T, Tsunoda S, Obama K. A case of laparoscopic lymphadenectomy for adenocarcinoma of unknown primary incidentally detected as a solitary enlarged lymph node along the common hepatic artery. Surg Case Rep 2024; 10:91. [PMID: 38635102 PMCID: PMC11026353 DOI: 10.1186/s40792-024-01888-9] [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: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Even in cancer of unknown primary (CUP), which is rare clinical condition, solitary anterosuperior lymph node (LN) along the common hepatic artery (No.8a LN) enlargement diagnosed as metastatic adenocarcinoma has never been reported. CASE PRESENTATION A 68-year-old Japanese male, with a history of early gastric cancer that had been completely treated by endoscopic submucosal dissection 26 years ago, was detected a single enlarged nodule along the common hepatic artery, No.8a LN, incidentally by computed tomography performed for monitoring of interstitial pneumonia. Endoscopic ultra-sound-guided fine needle aspiration revealed that this nodule was adenocarcinoma suggestive of metastasis, but other imaging studies, including upper and lower gastrointestinal endoscopy, positron emission tomography, and ultrasonography did not detect any primary cancer. We have finally diagnosed as the LN metastasis of CUP and performed laparoscopic lymphadenectomy for this tumor. The tumor was approximately 5 cm in size, was in close proximity to the pancreas, and involved part of the right gastric artery and vein. LNs in the No.5 and No.8a areas, including this tumor, were dissected laparoscopically, and radical resection was achieved. The patient had no postoperative complication and was discharged on postoperative day 10. Immunohistopathological findings revealed that the tumor was poorly differentiated adenocarcinoma, and different from the histology of gastric cancer resected 26 years ago, although the tumor was suggestive of gastrointestinal origin. Imaging studies performed 2 and 6 months after discharge also did not reveal a primary site. CONCLUSION We reported a case of solitary No.8a LN adenocarcinoma of CUP. For diagnostic and therapeutic purposes, radical resection is recommended for single enlarged intra-abdominal LN of CUP.
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Affiliation(s)
- Tomonori Morimoto
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Hiromitsu Kinoshita
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yuki Teramoto
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takashi Sakamoto
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Keiko Kasahara
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shintaro Okumura
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tatsuto Nishigori
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shigeru Tsunoda
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Kazutaka Obama
- Department of Gastrointestinal Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Conway AM, Pearce SP, Clipson A, Hill SM, Chemi F, Slane-Tan D, Ferdous S, Hossain ASMM, Kamieniecka K, White DJ, Mitchell C, Kerr A, Krebs MG, Brady G, Dive C, Cook N, Rothwell DG. A cfDNA methylation-based tissue-of-origin classifier for cancers of unknown primary. Nat Commun 2024; 15:3292. [PMID: 38632274 PMCID: PMC11024142 DOI: 10.1038/s41467-024-47195-7] [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: 10/12/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Cancers of Unknown Primary (CUP) remains a diagnostic and therapeutic challenge due to biological heterogeneity and poor responses to standard chemotherapy. Predicting tissue-of-origin (TOO) molecularly could help refine this diagnosis, with tissue acquisition barriers mitigated via liquid biopsies. However, TOO liquid biopsies are unexplored in CUP cohorts. Here we describe CUPiD, a machine learning classifier for accurate TOO predictions across 29 tumour classes using circulating cell-free DNA (cfDNA) methylation patterns. We tested CUPiD on 143 cfDNA samples from patients with 13 cancer types alongside 27 non-cancer controls, with overall sensitivity of 84.6% and TOO accuracy of 96.8%. In an additional cohort of 41 patients with CUP CUPiD predictions were made in 32/41 (78.0%) cases, with 88.5% of the predictions clinically consistent with a subsequent or suspected primary tumour diagnosis, when available (23/26 patients). Combining CUPiD with cfDNA mutation data demonstrated potential diagnosis re-classification and/or treatment change in this hard-to-treat cancer group.
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Affiliation(s)
- Alicia-Marie Conway
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon P Pearce
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Alexandra Clipson
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Steven M Hill
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Francesca Chemi
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Dan Slane-Tan
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Saba Ferdous
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - A S Md Mukarram Hossain
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Katarzyna Kamieniecka
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Daniel J White
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | | | - Alastair Kerr
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Matthew G Krebs
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Gerard Brady
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK
| | - Caroline Dive
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK.
- Bioinformatics and Biostatistics Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK.
| | - Natalie Cook
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Dominic G Rothwell
- Nucleic Acid Biomarker Team, Cancer Research UK National Biomarker Centre, The University of Manchester, Manchester, UK.
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6
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Oka K, Futamura S, Harada T. Intrathecal Trastuzumab for HER2-Positive Cancer of Unknown Primary Leptomeningeal Metastasis: A Case Report. Cureus 2024; 16:e57322. [PMID: 38690464 PMCID: PMC11060115 DOI: 10.7759/cureus.57322] [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] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Cancer of unknown primary (CUP) and leptomeningeal metastasis are difficult conditions with limited treatment options. We report a case of CUP leptomeningeal metastasis that was refractory to empirical chemotherapy but achieved a favorable response to intrathecal trastuzumab after the identification of human epidermal growth factor receptor-2 (HER2) amplification. A 59-year-old woman was diagnosed with CUP with metastasis of a poorly differentiated carcinoma to the left axillary, anterior mediastinal, peritoneal, and bilateral supraclavicular lymph nodes. Leptomeningeal metastasis was confirmed shortly after she started empiric chemotherapy; empiric therapy with intrathecal methotrexate failed to relieve her symptoms. Meanwhile, the lymph node specimen tested positive for HER2 amplification. She underwent intrathecal trastuzumab, then her neurological symptoms resolved the following day. We suggest that intrathecal trastuzumab is an effective treatment for HER2-positive CUP leptomeningeal metastasis.
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Affiliation(s)
- Kohei Oka
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Shun Futamura
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Taishi Harada
- Department of Medical Oncology, Fukuchiyama City Hospital, Fukuchiyama, JPN
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Boys EL, Gao B, Grimison P, Sutherland S, MacKenzie KL, Reddel RR, Liu J. Retrospective analysis of clinical characteristics and outcomes of patients with carcinoma of unknown primary from three tertiary centers in Australia. Cancer Med 2024; 13:e7052. [PMID: 38523552 PMCID: PMC10961596 DOI: 10.1002/cam4.7052] [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: 10/18/2023] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Carcinoma of unknown primary (CUP) remains an important tumor entity and a disproportionate cause of cancer mortality. Little is known about the contemporary clinical characteristics, treatment patterns, and outcomes of CUP patients based on updated international classification guidelines. We evaluated a contemporary CUP cohort to provide insight into current clinical practice and the impact of tissue of origin assignment, site-specific and empirical therapy in a real-world setting. METHODS We conducted a retrospective cohort study of CUP patients, as defined by the updated European Society of Medical Oncology (ESMO) 2023 guidelines, across three tertiary referral centers in Australia between 2015 and 2022. We analyzed clinical characteristics, treatment patterns, and survival outcomes using the Kaplan-Meier method and Cox regression proportional hazard model between favorable and unfavorable risk groups. RESULTS We identified a total of 123 CUP patients (n = 86 unfavorable, n = 37 favorable risk as per the 2023 ESMO guidelines). Sixty-four patients (52%) were assigned a tissue of origin by the treating clinician. Median progression free survival (PFS) was 6.8 (95% confidence interval (CI) 5.1-12.1) months and overall survival (OS) 10.2 (95% CI 6.0-18.5) months. Unfavorable risk (hazard ratio [HR] 2.9, p = 0.006), poor performance status (HR 2.8, p < 0.001), and non-squamous histology (HR 2.5, p < 0.05) were associated with poor survival outcome. A total of 70 patients (57%) proceeded to systemic therapy. In patients with non-squamous histology and unfavorable risk, site-specific therapy compared to empirical chemotherapy did not improve outcome (median OS 8.2 vs. 11.8 months, p = 0.7). CONCLUSIONS In this real-world cohort, CUP presentations were heterogenous. Overall survival and rates of systemic treatment were poor. Poor performance status and unfavorable risk were associated with worse survival. For most patients, site-specific therapy did not improve survival outcome. Improved and timely access to diagnostic tests and therapeutics for this group of patients is urgently required.
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Affiliation(s)
- Emma L. Boys
- ProCan®, Children's Medical Research InstituteWestmeadNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Medical OncologyCrown Princess Mary Cancer CentreWestmeadNew South WalesAustralia
- Blacktown Cancer and Haematology Centre, Blacktown HospitalBlacktownNew South WalesAustralia
| | - Bo Gao
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Medical OncologyCrown Princess Mary Cancer CentreWestmeadNew South WalesAustralia
- Blacktown Cancer and Haematology Centre, Blacktown HospitalBlacktownNew South WalesAustralia
| | - Peter Grimison
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Chris O'Brien LifehouseSydneyNew South WalesAustralia
| | - Sarah Sutherland
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Chris O'Brien LifehouseSydneyNew South WalesAustralia
| | - Karen L. MacKenzie
- ProCan®, Children's Medical Research InstituteWestmeadNew South WalesAustralia
- School of Medical Science, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Roger R. Reddel
- ProCan®, Children's Medical Research InstituteWestmeadNew South WalesAustralia
- Sydney Medical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Jia Liu
- ProCan®, Children's Medical Research InstituteWestmeadNew South WalesAustralia
- The Kinghorn Cancer Centre, St Vincent's HospitalDarlinghurstNew South WalesAustralia
- School of Clinical Medicine, St Vincent's CampusUniversity of New South WalesSydneyNew South WalesAustralia
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8
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Pouyiourou M, Reitnauer LE, Ballhausen A, Alig AHS, Bleckmann A, Westphalen CB, Kloft M. Highlights of Translational and Molecular Research Presented at the European Society for Medical Oncology Annual Meeting 2023. Oncol Res Treat 2024; 47:149-153. [PMID: 38417407 DOI: 10.1159/000537940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
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
| | - Lea Elisabeth Reitnauer
- Department for Medicine A, Hematology, Oncology, Hemostaseology and Pneumology, University Hospital Muenster, Muenster, Germany
- West German Cancer Center, University Hospital Muenster, Muenster, Germany
| | - Alexej Ballhausen
- Department of Hematology, Oncology, And Cancer Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annabel Helga Sophie Alig
- Department of Hematology, Oncology, And Cancer Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Annalen Bleckmann
- Department for Medicine A, Hematology, Oncology, Hemostaseology and Pneumology, University Hospital Muenster, Muenster, Germany
- West German Cancer Center, University Hospital Muenster, Muenster, Germany
| | - Christoph Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Comprehensive Cancer Center (CCC Munich LMU), LMU University Hospital Munich, Munich, Germany
| | - Maximilian Kloft
- Department of Medical Oncology and Palliative Care, University Hospital of Giessen and Marburg, Giessen, Germany
- Department of Pathology, GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
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9
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Sun M, Xu B, Chen C, Zhu Y, Li X, Chen K. Tissue of origin prediction for cancer of unknown primary using a targeted methylation sequencing panel. Clin Epigenetics 2024; 16:25. [PMID: 38336771 PMCID: PMC10854167 DOI: 10.1186/s13148-024-01638-6] [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: 11/20/2023] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
RATIONALE Cancer of unknown primary (CUP) is a group of rare malignancies with poor prognosis and unidentifiable tissue-of-origin. Distinct DNA methylation patterns in different tissues and cancer types enable the identification of the tissue of origin in CUP patients, which could help risk assessment and guide site-directed therapy. METHODS Using genome-wide DNA methylation profile datasets from The Cancer Genome Atlas (TCGA) and machine learning methods, we developed a 200-CpG methylation feature classifier for CUP tissue of origin prediction (MFCUP). MFCUP was further validated with public-available methylation array data of 2977 specimens and targeted methylation sequencing of 78 Formalin-fixed paraffin-embedded (FFPE) samples from a single center. RESULTS MFCUP achieved an accuracy of 97.2% in a validation cohort (n = 5923) representing 25 cancer types. When applied to an Infinium 450 K array dataset (n = 1052) and an Infinium EPIC (850 K) array dataset (n = 1925), MFCUP achieved an overall accuracy of 93.4% and 84.8%, respectively. Based on MFCUP, we established a targeted bisulfite sequencing panel and validated it with FFPE sections from 78 patients of 20 cancer types. This methylation sequencing panel correctly identified tissue of origin in 88.5% (69/78) of samples. We also found that the methylation levels of specific CpGs can distinguish one cancer type from others, indicating their potential as biomarkers for cancer diagnosis and screening. CONCLUSION Our methylation-based cancer classifier and targeted methylation sequencing panel can predict tissue of origin in diverse cancer types with high accuracy.
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Affiliation(s)
- Miaomiao Sun
- Department of Pathology, Henan Key Laboratory of Tumor Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Xu
- Research and Development Division, Oriomics Biotech Inc, Hangzhou, China
| | - Chao Chen
- Department of Pathology, Henan Key Laboratory of Tumor Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Youjie Zhu
- Research and Development Division, Oriomics Biotech Inc, Hangzhou, China
| | - Xiaomo Li
- Research and Development Division, Oriomics Biotech Inc, Hangzhou, China.
| | - Kuisheng Chen
- Department of Pathology, Henan Key Laboratory of Tumor Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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10
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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: 0] [Impact Index Per Article: 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.
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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.
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11
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Longerich T, Stenzinger A, Schirmacher P. Molecular diagnostics of hepatobiliary and pancreatic neoplasias. Virchows Arch 2024; 484:263-272. [PMID: 38429607 PMCID: PMC10948571 DOI: 10.1007/s00428-024-03744-5] [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: 11/28/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 03/03/2024]
Abstract
Neoplasias of the hepatopancreatobiliary tract are growing in numbers, have the poorest prognosis of all major cancer entities, and thus represent a rising clinical problem. Their molecular diagnostic has dramatically improved, contributing to tumor subtyping, definition of malignancy, and uncovering cases with hereditary predisposition. Most of all, predictive molecular testing allows to identify cases amenable to treatment with the rising number of approved targeted drugs, immune-oncological treatment, and clinical trials. In this review, the current state of molecular testing and its contribution to clinical decision-making are outlined.
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Affiliation(s)
- T Longerich
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69118, Heidelberg, Germany
| | - A Stenzinger
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69118, Heidelberg, Germany
| | - P Schirmacher
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69118, Heidelberg, Germany.
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12
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Xu M, Gu B, Zhang J, Xu X, Qiao Y, Hu S, Song S. Differentiation of cancer of unknown primary and lymphoma in head and neck metastatic poorly differentiated cancer using 18 F-FDG PET/CT tumor metabolic heterogeneity index. Nucl Med Commun 2024; 45:148-154. [PMID: 38095143 DOI: 10.1097/mnm.0000000000001797] [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: 01/11/2024]
Abstract
OBJECTIVE To explore the value of 18 F-FDG PET/CT tumor metabolic heterogeneity index (HI) and establish and validate a nomogram model for distinguishing head and neck cancer of unknown primary (HNCUP) from lymphoma with head and neck metastatic poorly differentiated cancer. METHODS This retrospective analysis was conducted on 1242 patients with cervical metastatic poorly differentiated cancer. 108 patients, who were clinically and pathologically confirmed as HNCUP or lymphoma, were finally enrolled. Two independent sample t-tests and χ 2 test were used to compare the clinical and imaging features. Binary logistic regression was used to screen for independent predictive factors. RESULTS Among the 108 patients), 65 patients were diagnosed with HNCUP and 43 were lymphoma. Gender ( P = 0.001), SUV max ( P < 0.001), SUV mean ( P < 0.001), TLG ( P = 0.012), and HI ( P < 0.001) had statistical significance in distinguishing HNCUP and lymphoma. Female ( OR = 4.546, P = 0.003) and patients with HI ≥ 2.37 ( OR = 3.461, P = 0.047) were more likely to be diagnosed as lymphoma. CONCLUSION For patients with cervical metastatic poorly differentiated cancer, gender and HI were independent predictors of pathological type. For such patients, clinical attention should be paid to avoid misdiagnosing lymphoma as HNCUP, which may delay treatment.
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Affiliation(s)
- Mingzhen Xu
- Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000)
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Bingxin Gu
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Jianping Zhang
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Xiaoping Xu
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Ying Qiao
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Silong Hu
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
| | - Shaoli Song
- Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000)
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Xuhui District, Shanghai, China
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13
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Al Assaad M, Shin N, Sigouros M, Manohar J, Antysheva Z, Kotlov N, Kiriy D, Nikitina A, Kleimenov M, Tsareva A, Makarova A, Fomchenkova V, Dubinina J, Boyko A, Almog N, Wilkes D, Escalon JG, Saxena A, Elemento O, Sternberg CN, Nanus DM, Mosquera JM. Deciphering the origin and therapeutic targets of cancer of unknown primary: a case report that illustrates the power of integrative whole-exome and transcriptome sequencing analysis. Front Oncol 2024; 13:1274163. [PMID: 38318324 PMCID: PMC10838960 DOI: 10.3389/fonc.2023.1274163] [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: 08/07/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024] Open
Abstract
Cancer of unknown primary (CUP) represents a significant diagnostic and therapeutic challenge, being the third to fourth leading cause of cancer death, despite advances in diagnostic tools. This article presents a successful approach using a novel genomic analysis in the evaluation and treatment of a CUP patient, leveraging whole-exome sequencing (WES) and RNA sequencing (RNA-seq). The patient, with a history of multiple primary tumors including urothelial cancer, exhibited a history of rapid progression on empirical chemotherapy. The application of our approach identified a molecular target, characterized the tumor expression profile and the tumor microenvironment, and analyzed the origin of the tumor, leading to a tailored treatment. This resulted in a substantial radiological response across all metastatic sites and the predicted primary site of the tumor. We argue that a comprehensive genomic and molecular profiling approach, like the BostonGene© Tumor Portrait, can provide a more definitive, personalized treatment strategy, overcoming the limitations of current predictive assays. This approach offers a potential solution to an unmet clinical need for a standardized approach in identifying the tumor origin for the effective management of CUP.
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Affiliation(s)
- Majd Al Assaad
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Nara Shin
- BostonGene Corporation, Waltham, MA, United States
| | - Michael Sigouros
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Jyothi Manohar
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | | | - Daria Kiriy
- BostonGene Corporation, Waltham, MA, United States
| | | | | | | | | | | | | | | | - Nava Almog
- BostonGene Corporation, Waltham, MA, United States
| | - David Wilkes
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Joanna G. Escalon
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Ashish Saxena
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Olivier Elemento
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Cora N. Sternberg
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - David M. Nanus
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Juan Miguel Mosquera
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY, United States
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14
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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.
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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
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15
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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: 0] [Impact Index Per Article: 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.
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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.
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16
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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.
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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.
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17
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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.
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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.
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18
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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.
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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
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19
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Abrudan R, Abrudan L, Pop O, Zaha DC. A Rare Case of an Occult Primary Tumor With a Profile of Colon Cancer and Synchronous Metastasis in the Lung, Liver, Bone, and Cerebellum: A Case Report and Literature Review. Cureus 2023; 15:e47824. [PMID: 37899904 PMCID: PMC10610348 DOI: 10.7759/cureus.47824] [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] [Accepted: 10/27/2023] [Indexed: 10/31/2023] Open
Abstract
Occult primary tumors, or cancers of unknown primary site (CUP), are an oncological pathology characterized by the presence of metastases but without being able to determine the presence of the primary tumor. These types of tumors are very rare, and they pose challenges for diagnosis and treatment. Colorectal cancer is the most common type of malignant tumor worldwide and the second most common cause of death. The most common sites of metastasis in colorectal cancer are hepatic and pulmonary. Relatively rare, patients develop brain and bone metastasis. We reported a rare case of an occult primary tumor with a profile of colon cancer and synchronous metastasis in the lung, liver, bone, and cerebellum developed in a woman who was only 51 years old.
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Affiliation(s)
- Ramona Abrudan
- Oncology, Faculty of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, University of Oradea, Oradea, ROU
| | - Luca Abrudan
- Radiation Oncology, Radiotherapy Laboratory, County Clinical Emergency Hospital Bihor, Oradea, ROU
| | - Ovidiu Pop
- Pathology, Department of Morphological Sciences, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, ROU
| | - Dana Carmen Zaha
- Laboratory Medicine, Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, ROU
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20
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Edsjö A, Holmquist L, Geoerger B, Nowak F, Gomon G, Alix-Panabières C, Ploeger C, Lassen U, Le Tourneau C, Lehtiö J, Ott PA, von Deimling A, Fröhling S, Voest E, Klauschen F, Dienstmann R, Alshibany A, Siu LL, Stenzinger A. Precision cancer medicine: Concepts, current practice, and future developments. J Intern Med 2023; 294:455-481. [PMID: 37641393 DOI: 10.1111/joim.13709] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Precision cancer medicine is a multidisciplinary team effort that requires involvement and commitment of many stakeholders including the society at large. Building on the success of significant advances in precision therapy for oncological patients over the last two decades, future developments will be significantly shaped by improvements in scalable molecular diagnostics in which increasingly complex multilayered datasets require transformation into clinically useful information guiding patient management at fast turnaround times. Adaptive profiling strategies involving tissue- and liquid-based testing that account for the immense plasticity of cancer during the patient's journey and also include early detection approaches are already finding their way into clinical routine and will become paramount. A second major driver is the development of smart clinical trials and trial concepts which, complemented by real-world evidence, rapidly broaden the spectrum of therapeutic options. Tight coordination with regulatory agencies and health technology assessment bodies is crucial in this context. Multicentric networks operating nationally and internationally are key in implementing precision oncology in clinical practice and support developing and improving the ecosystem and framework needed to turn invocation into benefits for patients. The review provides an overview of the diagnostic tools, innovative clinical studies, and collaborative efforts needed to realize precision cancer medicine.
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Affiliation(s)
- Anders Edsjö
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Office for Medical Services, Region Skåne, Lund, Sweden
- Division of Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Genomic Medicine Sweden (GMS), Kristianstad, Sweden
| | - Louise Holmquist
- Department of Clinical Genetics, Pathology and Molecular Diagnostics, Office for Medical Services, Region Skåne, Lund, Sweden
- Genomic Medicine Sweden (GMS), Kristianstad, Sweden
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
- INSERM U1015, Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | | | - Georgy Gomon
- Department of Molecular Oncology and Immunology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Catherine Alix-Panabières
- Laboratory of Rare Human Circulating Cells, University Medical Center of Montpellier, Montpellier, France
- CREEC, MIVEGEC, University of Montpellier, Montpellier, France
| | - Carolin Ploeger
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
- Centers for Personalized Medicine (ZPM), Heidelberg, Germany
| | - Ulrik Lassen
- Department of Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France
- INSERM U900 Research Unit, Saint-Cloud, France
- Faculty of Medicine, Paris-Saclay University, Paris, France
| | - Janne Lehtiö
- Department of Oncology Pathology, Karolinska Institutet, Science for Life Laboratory, Stockholm, Sweden
| | - Patrick A Ott
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Andreas von Deimling
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Fröhling
- Division of Translational Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Emile Voest
- Department of Molecular Oncology and Immunology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Oncode Institute, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Frederick Klauschen
- Institute of Pathology, Charite - Universitätsmedizin Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- BIFOLD - Berlin Institute for the Foundations of Learning and Data, Berlin, Germany
- Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Munich Partner Site, Heidelberg, Germany
| | | | | | - Lillian L Siu
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
- Centers for Personalized Medicine (ZPM), Heidelberg, Germany
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21
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Koike S, Kobayashi N, Miyazawa M, Yamashita N. Rapid progressive spontaneous hemothorax caused by carcinoma of unknown primary: A very rare case. Respirol Case Rep 2023; 11:e01215. [PMID: 37711652 PMCID: PMC10497902 DOI: 10.1002/rcr2.1215] [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: 08/01/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
We present a very rare case of spontaneous hemothorax which was caused by carcinoma of unknown primary. To the best of our knowledge, there are no other such cases reported worldwide. The patient was 72-year-old male who was referred to our department for massive hemothorax. We undertook surgical treatment for haemostasis, and found multiple tumours which led to the diagnosis of carcinoma of unknown primary as the cause of haemorrhage. The tumours increased and grew rapidly after surgery and hemothorax progressed despite our treatment. The patient died from disseminated intravascular coagulation caused by continuous bleeding on postoperative day 19.
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Affiliation(s)
- Sachie Koike
- Department of Thoracic SurgeryJapanese Red Cross Society Nagano hospitalNaganoJapan
- Division of General Thoracic Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Nobutaka Kobayashi
- Department of Thoracic SurgeryJapanese Red Cross Society Nagano hospitalNaganoJapan
| | - Masahisa Miyazawa
- Department of Thoracic SurgeryJapanese Red Cross Society Nagano hospitalNaganoJapan
| | - Naho Yamashita
- Department of pathologyJapanese Red Cross Society Nagano hospitalNaganoJapan
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22
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Kazdal D, Menzel M, Budczies J, Stenzinger A. [Molecular tumor diagnostics as the driving force behind precision oncology]. Dtsch Med Wochenschr 2023; 148:1157-1165. [PMID: 37657453 DOI: 10.1055/a-1937-0347] [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: 09/03/2023]
Abstract
Molecular pathological diagnostics plays a central role in personalized oncology and requires multidisciplinary teamwork. It is just as relevant for the individual patient who is being treated with an approved therapy method or an individual treatment attempt as it is for prospective clinical studies that require the identification of specific therapeutic target structures or complex biomarkers for study inclusion. It is also of crucial importance for the generation of real-world data, which is becoming increasingly important for drug development. Future developments will be significantly shaped by improvements in scalable molecular diagnostics, in which increasingly complex and multi-layered data sets must be quickly converted into clinically useful information. One focus will be on the development of adaptive diagnostic strategies in order to be able to depict the enormous plasticity of a cancer disease over time.
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23
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Rimer H, Jensen MS, Dahlsgaard-Wallenius SE, Eckhoff L, Thye-Rønn P, Kristiansen C, Hildebrandt MG, Gerke O. 2-[18F]FDG-PET/CT in Cancer of Unknown Primary Tumor-A Retrospective Register-Based Cohort Study. J Imaging 2023; 9:178. [PMID: 37754942 PMCID: PMC10532746 DOI: 10.3390/jimaging9090178] [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: 06/28/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
We investigated the impact of 2-[18F]FDG-PET/CT on detection rate (DR) of the primary tumor and survival in patients with suspected cancer of unknown primary tumor (CUP), comparing it to the conventional diagnostic imaging method, CT. Patients who received a tentative CUP diagnosis at Odense University Hospital from 2014-2017 were included. Patients receiving a 2-[18F]FDG-PET/CT were assigned to the 2-[18F]FDG-PET/CT group and patients receiving a CT only to the CT group. DR was calculated as the proportion of true positive findings of 2-[18F]FDG-PET/CT and CT scans, separately, using biopsy of the primary tumor, autopsy, or clinical decision as reference standard. Survival analyses included Kaplan-Meier estimates and Cox proportional hazards regression adjusted for age, sex, treatment, and propensity score. We included 193 patients. Of these, 159 were in the 2-[18F]FDG-PET/CT group and 34 were in the CT group. DR was 36.5% in the 2-[18F]FDG-PET/CT group and 17.6% in the CT group, respectively (p = 0.012). Median survival was 7.4 (95% CI 0.4-98.7) months in the 2-[18F]FDG-PET/CT group and 3.8 (95% CI 0.2-98.1) in the CT group. Survival analysis showed a crude hazard ratio of 0.63 (p = 0.024) and an adjusted hazard ratio of 0.68 (p = 0.087) for the 2-[18F]FDG-PET/CT group compared with CT. This study found a significantly higher DR of the primary tumor in suspected CUP patients using 2-[18F]FDG-PET/CT compared with patients receiving only CT, with possible immense clinical importance. No significant difference in survival was found, although a possible tendency towards longer survival in the 2-[18F]FDG-PET/CT group was observed.
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Affiliation(s)
- Heidi Rimer
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Melina Sofie Jensen
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | | | - Lise Eckhoff
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
| | - Peter Thye-Rønn
- Department of Medicine, Center of Diagnostics, Odense University Hospital, Svendborg Hospital, 5700 Svendborg, Denmark
| | - Charlotte Kristiansen
- Department of Oncology, University Hospital of Southern Denmark, Lillebælt Hospital, 7100 Vejle, Denmark
| | - Malene Grubbe Hildebrandt
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, 5000 Odense, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, 5000 Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, 5000 Odense, Denmark
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24
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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.
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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
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25
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Zaun G, Weber M, Metzenmacher M, Wiesweg M, Hilser T, Zaun Y, Liffers S, Pogorzelski M, Virchow I, Eberhardt W, Theurer S, Sabbah TA, Reissig TM, Stuschke M, Kürten C, Hussain T, Lang S, Kasper S, Fendler W, Herrmann K, Schuler M. SUV max Above 20 in 18F-FDG PET/CT at Initial Diagnostic Workup Associates with Favorable Survival in Patients with Cancer of Unknown Primary. J Nucl Med 2023:jnumed.122.265161. [PMID: 37321823 DOI: 10.2967/jnumed.122.265161] [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: 11/08/2022] [Revised: 04/04/2023] [Indexed: 06/17/2023] Open
Abstract
Cancer of unknown primary (CUP) is a heterogeneous entity with a limited prognosis. Novel prognostic markers are needed for patient stratification in prospective clinical trials exploring innovative therapies. Methods: In CUP patients treated at the West German Cancer Center Essen, the prognostic value of 18F-FDG PET/CT at the initial diagnostic workup was analyzed by comparing overall survival (OS) in patients who underwent 18F-FDG PET/CT with those who did not. Results: Of 154 patients with a CUP diagnosis, 76 underwent 18F-FDG PET/CT at the initial diagnostic workup. The median overall survival (OS) of the full analysis set was 20.0 mo. Within the PET/CT subgroup, an SUVmax above 20 was associated with significantly superior OS (median OS, not reached vs. 32.0 mo; hazard ratio, 0.261; 95% CI, 0.095-0.713; P = 0.009). Conclusion: Our retrospective work shows that an SUVmax above 20 on 18F-FDG PET/CT at the initial diagnostic workup is a favorable prognostic factor in patients with CUP. This finding deserves further prospective studies for validation.
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Affiliation(s)
- Gregor Zaun
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany;
| | - Manuel Weber
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Martin Metzenmacher
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Thomas Hilser
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Yasmin Zaun
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Sven Liffers
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Michael Pogorzelski
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Isabel Virchow
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Wilfried Eberhardt
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Sarah Theurer
- Institute of Pathology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Tanja Abu Sabbah
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Timm M Reissig
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiation Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; and
| | - Cornelius Kürten
- Department of Otorhinolaryngology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Timon Hussain
- Department of Otorhinolaryngology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Wolfgang Fendler
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
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26
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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.
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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
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27
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Kurz FT, Delorme S. [Radiological imaging in CUP syndrome]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:346-353. [PMID: 37186291 DOI: 10.1007/s00117-023-01145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/17/2023]
Abstract
PROBLEM If no obvious primary tumour is detectable in metastatic tumours (cancer of unknown primary, CUP), it should nevertheless be identified if possible, as specific therapy achieves better results than empirical, palliative treatment of CUP. METHODOLOGY The new guideline of the European Society of Medical Oncology (ESMO) defines algorithms for the evaluation of CUP, in which radiological and nuclear imaging procedures play a central role. Important clues to a possible primary tumour are the size and morphology of foci and the presence of a dominant lesion, as well as the pattern of hematogeneous metastatic spread in affected organs, and the anatomical distribution of affected lymph nodes. CONCLUSION In patients with metastases, imaging plays an important role in identifying a possible primary tumour, but the diagnosis must be made with knowledge of the clinical and immunohistochemical results. In difficult cases, there should be interdisciplinary consultation between reference oncology, radiology, and pathology on the presence of CUP.
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Affiliation(s)
- Felix T Kurz
- Abt. Radiologie (E010), Deutsches Krebsforschungszentrum (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
| | - Stefan Delorme
- Abt. Radiologie (E010), Deutsches Krebsforschungszentrum (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
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28
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Bochtler T, Pouyiourou M, Krämer A. [Cancer of unknown primary-The new ESMO guidelines]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:329-335. [PMID: 36930265 DOI: 10.1007/s00117-023-01126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The European Society of Medical Oncology (ESMO) recently published extensively revised guidelines on cancer of unknown primary (CUP). The new version contains the following relevant amendments: with respect to diagnostics of CUP, the current guidelines aim for a more precise and standardized definition of CUP by establishing diagnostic algorithms. Recommendations for molecular diagnostics of cancer tissue have also been implemented. With respect to CUP classification, the favorable category has been revised. A carcinoma with immunohistochemistry typical for renal cell carcinoma (renal-like CUP) was introduced in the new definition of favorable subtypes, for which a specific treatment is indicated. Based on a newly defined oligometastatic situation a subgroup with localized cancer potentially curatively treatable with surgery and/or radiotherapy was introduced into the CUP classification. With respect to treatment of CUP, the current guidelines present options beyond empirical chemotherapy, which is still the standard of care treatment, and pinpoint indications and predictive biomarkers for targeted and immune checkpoint inhibitor treatment. RELEVANT UPDATES The European Society of Medical Oncology (ESMO) recently published extensively revised guidelines on the CUP syndrome. The new version contains the following relevant amendments: the current guidelines aim for a more precise and standardized definition of CUP by establishing diagnostic algorithms with respect to the diagnostics of CUP syndrome. Recommendations for molecular diagnostics of cancer tissue have also been implemented. The classification of the CUP syndrome has also been revised. A carcinoma with immunohistochemistry typical for renal cell carcinoma (renal-like CUP) was introduced in the new definition of favorable subtypes, for which a specific treatment is indicated. Based on a newly defined oligometastatic situation a local potentially curatively treatable with surgery and/or radiotherapy subgroup was introduced into the CUP classification. With respect to treatment of the CUP syndrome, the current guidelines present options beyond empirical chemotherapy, which is still the gold standard treatment, and pinpoint indications and predictive biomarkers for targeted and immune checkpoint inhibitor treatment. SCHLUSSFOLGERUNG The aim of this review is to present the current state of diagnostics, classification and treatment of CUP syndrome, with a focus on recent developments and revisions implemented in the current ESMO guidelines.
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Affiliation(s)
- Tilmann Bochtler
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg, Medizinische Onkologie, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Maria Pouyiourou
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
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Pauli C. [CUP syndrome-diagnostics from the perspective of pathology]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:336-345. [PMID: 37079060 PMCID: PMC10129915 DOI: 10.1007/s00117-023-01143-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
PROBLEM Histologic and immunohistologic workup of tumor material from metastases of a previously unknown primary tumor is important for identifying their origin, but is often insufficient for this purpose without clinical oncologic and radiologic evaluation. PROCEDURE In the initial cancer of unknown primary (CUP) situation, histologic and immunohistochemical workup together with clinicoradiologic correlations contribute significantly to the identification of the primary tumor. There are now accepted guidelines to follow when there is an initial CUP situation. Molecular diagnostic tools can be used to investigate changes at the nucleic acid level, which can provide clues about the primary tumor, including potential targets for therapy. If, despite broad and interdisciplinary diagnostics, it is not possible to identify the primary tumor, the diagnosis is CUP syndrome. If a true CUP situation is present, it is important to assign the tumor to a tumor class or a specific therapy-sensitive subgroup as best as possible so that the best possible treatment can be given. However, for a final assignment to a primary tumor or a final classification as CUP, a comparison with medical oncological and imaging findings is indispensable. CONCLUSION When CUP is suspected, close interdisciplinary collaboration between pathology, medical oncology, and imaging is essential to achieve a viable classification as CUP or identification of a presumptive primary tumor, in the interest of providing the most specific and effective therapy for affected individuals.
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Affiliation(s)
- Chantal Pauli
- Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Rämistrasse 100, 8091, Zürich, Schweiz.
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Weiss L, Heinrich K, Zhang D, Dorman K, Rühlmann K, Hasselmann K, Klauschen F, Kumbrink J, Jung A, Rudelius M, Mock A, Ormanns S, Kunz WG, Roessler D, Beyer G, Corradini S, Heinzerling L, Haas M, von Bergwelt-Baildon M, Boeck S, Heinemann V, Westphalen CB. Cancer of unknown primary (CUP) through the lens of precision oncology: a single institution perspective. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04741-y. [PMID: 37062035 PMCID: PMC10374717 DOI: 10.1007/s00432-023-04741-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/02/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE For patients with cancer of unknown primary (CUP), treatment options are limited. Precision oncology, the interplay of comprehensive genomic profiling (CGP) and targeted therapies, aims to offer additional treatment options to patients with advanced and hard-to-treat cancers. We aimed to highlight the use of a molecular tumor board (MTB) in the therapeutic management of CUP patients. METHODS In this single-center observational study, CUP patients, presented to the MTB of the Comprehensive Cancer Center Munich LMU, a tertiary care center, were analyzed retrospectively. Descriptive statistics were applied to describe relevant findings. RESULTS Between June 2016 and February 2022, 61 patients with unfavorable CUP were presented to the MTB, detected clinically relevant variants in 74% (45/61) of patients, of which 64% (29/45) led to therapeutic recommendation. In four out of 29 patients (14%), the treatment recommendations were implemented, unfortunately without resulting in clinical benefit. Reasons for not following the therapeutic recommendation were mainly caused by the physicians' choice of another therapy (9/25, 36%), especially in the context of worsening of general condition, lost to follow-up (7/25, 28%) and death (6/25, 24%). CONCLUSION CGP and subsequent presentation to a molecular tumor board led to a high rate of therapeutic recommendations in patients with CUP. Recommendations were only implemented at a low rate; however, late GCP diagnostic and, respectively, MTB referral were found more frequent for the patients with implemented treatment. This contrast underscores the need for early implementation of CGP into the management of CUP patients.
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Affiliation(s)
- L Weiss
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - K Heinrich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - D Zhang
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - K Dorman
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - K Rühlmann
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - K Hasselmann
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - F Klauschen
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - J Kumbrink
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - A Jung
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - M Rudelius
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - A Mock
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Steffen Ormanns
- Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - W G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - D Roessler
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - G Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - S Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - L Heinzerling
- Department of Dermatology, University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - M Haas
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - M von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - S Boeck
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - V Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - C B Westphalen
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany.
- Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
- Bavarian Cancer Research Center (BZKF), Munich, Germany.
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Pouyiourou M, Regnery S, Bochtler T, Herfarth K, Krämer A. [Cancer of unknown primary (CUP)-single-site, oligometastatic, and in the head and neck region]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:358-365. [PMID: 36944857 DOI: 10.1007/s00117-023-01133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION About 20% of all cancer of unknown primary (CUP) cases can be classified into favorable subgroups, which are defined by either obvious analogies to certain cancers with a known primary or amenability to local ablative treatment. In the updated European Society for Medical Oncology (ESMO) guidelines for diagnosis and treatment of CUP, the definition of favorable subgroups has been revised according to the latest scientific findings. In particular, the definition and treatment of oligometastatic CUP have undergone considerable changes in recent years. Thus, we delineate the current diagnostic and therapeutic standards for the two favorable CUP subtypes single-site/oligometastatic and head/neck CUP. METHODS The classification, diagnostic workup, and treatment of single-site and oligometastatic CUP are summarized based on the current ESMO and American Society of Clinical Oncology (ASCO) guidelines together with a literature review. CONCLUSIONS Single-site and oligometastatic CUP is defined by the presence of a maximum of five metastases that are amenable to local ablative treatment. Median overall survival is favorable and exceeds 4 years after local ablation of all detectable metastases. Lymph node metastases in the head and neck region represent a frequent scenario of single-site CUP. They usually originate from human papillomavirus (HPV)-associated squamous cell carcinoma in the oropharynx. Diagnostic workup comprises computed tomography (CT), magnetic resonance imaging (MRI) if necessary, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), followed by panendoscopy and biopsies of suspicious mucosal sites. Neck dissection, potentially followed by adjuvant radiotherapy, and definitive radiotherapy represent equally effective oncological treatment options with respect to a favorable prognosis.
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Affiliation(s)
- Maria Pouyiourou
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Sebastian Regnery
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Tilmann Bochtler
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Medizinische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg, Heidelberg, Deutschland
| | - Klaus Herfarth
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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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.
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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,
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