1
|
Wang Y, Huang Q, Zhong G, Lv J, Guo Q, Ma Y, Wang X, Zeng J. Sequential PET/CT and pathological biomarker crosstalk predict response to PD-1 blockers alone or combined with sunitinib in propensity score-matched cohorts of cancer of unknown primary treatment. Front Oncol 2023; 13:1191611. [PMID: 38205137 PMCID: PMC10777842 DOI: 10.3389/fonc.2023.1191611] [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: 03/22/2023] [Accepted: 10/26/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction The efficacy of immune checkpoint inhibitors (ICIs), including toripalimab and pembrolizumab, has not been confirmed in the treatment of cancer of unknown primary (CUP), which has a very poor prognosis. Combined with anti-angiogenic therapies, ICIs are hypothesized to be effective in prolonging overall survival. The study aims to give evidence on the treatment effects of sunitinib combined with ICIs, find pathological biomarkers associated with changes in volumetric 18F FDG PET/CT parameters, and investigate inner associations among these markers associated with response on PET/CT. Methods The study recruited patients receiving combined treatment (ICIs + sunitinib), compared the effects of combined treatment with those of separate treatment and age-matched negative controls, and analyzed propensity score-matched (PSM) pairs. Markers associated with survival were identified, and their inner associations were tested using structural equation modeling. Results A total of 292 patients were enrolled in the final analysis, with 53 patients receiving combined treatment. Survival analysis demonstrated significantly prolonged survival in either combined or separate treatment, with the combined arm showing better response when PSM-paired using pre-treatment whole-body PET/CT parameters. The angiogenic markers KDR and VEGF mediate the PD-1 blockade impact on volumetric value changes in positive and negative manners. Conclusion The anti-angiogenic agent sunitinib may potentiate PD-1 blockade by diminishing angiogenesis or its downstream effects. The combined separate treatment increased the survival of CUP patients, and the responses could be evaluated using volumetric PET/CT parameters.
Collapse
Affiliation(s)
- Youlong Wang
- Hainan Hospital of PLA General Hospital, Department of General Surgery, Haitang District, Sanya, China
| | - Qi Huang
- Department of Clinical Laboratory, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guanqing Zhong
- Department of Clinical Laboratory, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun Lv
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinzhi Guo
- Pancreas Center of Guangdong Provincial People’s Hospital, Guangzhou, China
| | - Yifei Ma
- Department of Spine Surgery, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Xinjia Wang
- Department of Spine Surgery, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Jiling Zeng
- Department of Nuclear Medicine, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Center, Guangzhou, China
| |
Collapse
|
2
|
Rassy E, Karam E, Adeleke S, Okoli S, Galante J, Boussios S, Pavlidis N. Immune checkpoint inhibitors in patients with cancers of unknown primary. Eur J Cancer 2023; 195:113377. [PMID: 37890352 DOI: 10.1016/j.ejca.2023.113377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Elie Rassy
- Gustave Roussy, Départements de Médecine Oncologique, F-94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, Institut national de la santé et de la recherche médicale (INSERM), U1018 Villejuif, France.
| | - Elias Karam
- Gustave Roussy, Départements de Médecine Oncologique, F-94805 Villejuif, France
| | - Sola Adeleke
- School of Cancer & Pharmaceutical Sciences, King's College London, London, United Kingdom; Department of Oncology, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Somto Okoli
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Joao Galante
- Department of Oncology, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King's College London, London SE1 9RT, UK; Kent Medway Medical School, University of Kent, Canterbury CT2 7LX, UK; AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
| | | |
Collapse
|
3
|
Ju Y, Choi GE, Lee MW, Jeong M, Kwon H, Kim DH, Kim J, Jin H, Lee KE, Hyun KY, Jang A. Identification of miR-143-3p as a diagnostic biomarker in gastric cancer. BMC Med Genomics 2023; 16:135. [PMID: 37328880 PMCID: PMC10273760 DOI: 10.1186/s12920-023-01554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/19/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) is among the most common types of gastrointestinal cancers and has a high incidence and mortality around the world. To suppress the progression of GC, it is essential to develop diagnostic markers. MicroRNAs regulate GC development, but a clearer insight into their role is needed before they can be applied as a molecular markers and targets. METHODS In this study, we assessed the diagnostic value of differentially expressed microRNAs as potential diagnostic biomarkers for GC using data for 389 tissue samples from the Cancer Genome Atlas (TCGA) and 21 plasma samples from GC patients. RESULTS The expression of hsa-miR-143-3p (also known as hsa-miR-143) was significantly downregulated in GC according to the TCGA data and plasma samples. The 228 potential target genes of hsa-miR-143-3p were analyzed using a bioinformatics tool for miRNA target prediction. The target genes correlated with extracellular matrix organization, the cytoplasm, and identical protein binding. Furthermore, the pathway enrichment analysis of target genes showed that they were involved in pathways in cancer, the phosphoinositide 3-kinase (PI3K)-protein kinase B (Akt) signaling pathway, and proteoglycans in cancer. The hub genes in the protein-protein interaction (PPI) network, were matrix metallopeptidase 2 (MMP2), CD44 molecule (CD44), and SMAD family member 3 (SMAD3). CONCLUSIONS This study suggests that hsa-miR-143-3p may be used as a diagnostic marker for GC, contributing via the pathways involved in the development of GC.
Collapse
Affiliation(s)
- Yeongdon Ju
- Medical Science Research Center, Pusan National University, Yangsan, 50612, Republic of Korea
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Go-Eun Choi
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Moon Won Lee
- Division of Gastroenterology, Pusan National University Hospital, Busan, 49241, Republic of Korea
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, 49241, Republic of Korea
| | - Myeongguk Jeong
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Hyeokjin Kwon
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Dong Hyeok Kim
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Jungho Kim
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Hyunwoo Jin
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Kyung Eun Lee
- Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan, 46252, Republic of Korea
| | - Kyung-Yae Hyun
- Department of Clinical Laboratory Science, Dong-Eui University, Busan, 47340, Republic of Korea.
| | - Aelee Jang
- Department of Nursing, University of Ulsan, Ulsan, 44610, Republic of Korea.
| |
Collapse
|
4
|
From Biology to Diagnosis and Treatment: The Ariadne’s Thread in Cancer of Unknown Primary. Int J Mol Sci 2023; 24:ijms24065588. [PMID: 36982662 PMCID: PMC10053301 DOI: 10.3390/ijms24065588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Cancer of unknown primary (CUP) encloses a group of heterogeneous tumours, the primary sites for which cannot be identified at the time of diagnosis, despite extensive investigations. CUP has always posed major challenges both in its diagnosis and management, leading to the hypothesis that it is rather a distinct entity with specific genetic and phenotypic aberrations, considering the regression or dormancy of the primary tumour; the development of early, uncommon systemic metastases; and the resistance to therapy. Patients with CUP account for 1–3% of all human malignancies and can be categorised into two prognostic subsets according to their clinicopathologic characteristics at presentation. The diagnosis of CUP mainly depends on the standard evaluation comprising a thorough medical history; complete physical examination; histopathologic morphology and algorithmic immunohistochemistry assessment; and CT scan of the chest, abdomen, and pelvis. However, physicians and patients do not fare well with these criteria and often perform additional time-consuming evaluations to identify the primary tumour site to guide treatment decisions. The development of molecularly guided diagnostic strategies has emerged to complement traditional procedures but has been disappointing thus far. In this review, we present the latest data on CUP regarding the biology, molecular profiling, classification, diagnostic workup, and treatment.
Collapse
|
5
|
Qi P, Sun Y, Liu X, Wu S, Wo Y, Xu Q, Wang Q, Hu X, Zhou X. Clinicopathological, molecular and prognostic characteristics of cancer of unknown primary in China: An analysis of 1420 cases. Cancer Med 2022; 12:1177-1188. [PMID: 35822433 PMCID: PMC9883567 DOI: 10.1002/cam4.4973] [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: 01/24/2022] [Revised: 05/23/2022] [Accepted: 06/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Cancer of unknown primary (CUP) is defined the presence of metastatic disease without an identified primary site. An unidentifiable primary site of cancer creates significant challenges for treatment selection. We aimed to describe the clinicopathological, molecular, and prognostic characteristics of Chinese CUP patients. METHODS Patients with oncologist-confirmed CUP were identified at Fudan University Shanghai Cancer Center from 2019 to 2020. Information on patient characteristics, tumor presentation, treatment, and outcome were retrospectively collected from the inpatient database and pathological consultation database for descriptive analysis. A multivariable logistic regression model was established to identify factors associated with patient prognosis. RESULTS A total of 1420 CUP patients were enrolled in this study. The baseline characteristics of the entire cohort included the following: median age (59 years old), female sex (45.8%), adenocarcinoma (47.7%), and poorly differentiated or undifferentiated tumors (92.1%). For the inpatient cohort, the most common sites where cancer spread included the lymph nodes (41.8%), bone (22.0%), liver (20.1%), and peritoneum/retroperitoneum (16.0%). A total of 77.4% and 58.2% of patients were treated with local therapy and systemic therapy, respectively. Four prognostic factors, including liver metastasis, peritoneal/retroperitoneal metastasis, number of metastatic sites (N ≥ 2), and systemic treatment, were independently associated with overall survival. Additionally, 24.8% (79/318) of patients received molecular testing, including PD-L1, human papillomavirus, genetic variation, and 90-gene expression tests for diagnosis or therapy selection. CONCLUSION Cancer of unknown primary remains a difficult cancer to diagnose and manage. Our findings improve our understanding of Chinese CUP patient characteristics, leading to improved care and outcomes for CUP patients.
Collapse
Affiliation(s)
- Peng Qi
- Department of PathologyFudan University Shanghai Cancer CenterShanghaiChina,Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina,Institute of PathologyFudan UniversityShanghaiChina,The Cancer of Unknown Primary Group of Pathology CommitteeChinese Research Hospital AssociationShanghaiChina
| | - Yifeng Sun
- The Canhelp Genomics Research CenterCanhelp Genomics Co., Ltd.HangzhouChina
| | - Xin Liu
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina,Department of Head & Neck Tumors and Neuroendocrine TumorsFudan University Shanghai Cancer CenterShanghaiChina
| | - Sheng Wu
- The Canhelp Genomics Research CenterCanhelp Genomics Co., Ltd.HangzhouChina
| | - Yixin Wo
- The Canhelp Genomics Research CenterCanhelp Genomics Co., Ltd.HangzhouChina
| | - Qinghua Xu
- The Cancer of Unknown Primary Group of Pathology CommitteeChinese Research Hospital AssociationShanghaiChina,The Canhelp Genomics Research CenterCanhelp Genomics Co., Ltd.HangzhouChina,The Institute of Machine Learning and Systems Biology, College of Electronics and Information EngineeringTongji UniversityShanghaiChina,Xuzhou Engineering Research Center of Medical Genetics and Transformation, Department of GeneticsXuzhou Medical UniversityXuzhouChina
| | - Qifeng Wang
- Department of PathologyFudan University Shanghai Cancer CenterShanghaiChina,Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina,Institute of PathologyFudan UniversityShanghaiChina,The Cancer of Unknown Primary Group of Pathology CommitteeChinese Research Hospital AssociationShanghaiChina
| | - Xichun Hu
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina,Department of Medical OncologyFudan University Shanghai Cancer CenterShanghaiChina
| | - Xiaoyan Zhou
- Department of PathologyFudan University Shanghai Cancer CenterShanghaiChina,Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina,Institute of PathologyFudan UniversityShanghaiChina,The Cancer of Unknown Primary Group of Pathology CommitteeChinese Research Hospital AssociationShanghaiChina
| |
Collapse
|
6
|
Chebly A, Yammine T, Boussios S, Pavlidis N, Rassy E. Chromosomal instability in cancers of unknown primary. Eur J Cancer 2022; 172:323-325. [PMID: 35820241 DOI: 10.1016/j.ejca.2022.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Alain Chebly
- Medical Genetics Unit (UGM), Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
| | - Tony Yammine
- Medical Genetics Unit (UGM), Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Stergios Boussios
- Faculty of Life Sciences and Medicine, School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 9RT, UK; Medway NHS Foundation Trust, Windmill Road, Gillingham, Kent, ME7 5NY, UK; AELIA Organization, 9th Km Thessaloniki, Thermi, 57001, Thessaloniki, Greece
| | | | - Elie Rassy
- Department of Cancer Medicine, Gustave Roussy Institute, Villejuif, France
| |
Collapse
|
7
|
Sun W, Wu W, Wang Q, Yao Q, Feng Q, Wang Y, Sun Y, Liu Y, Lai Q, Zhang G, Qi P, Sun Y, Qian C, Ren W, Luo Z, Chen J, Wang H, Xu Q, Zhou X, Sun W, Lin D. Clinical validation of a 90-gene expression test for tumor tissue of origin diagnosis: a large-scale multicenter study of 1417 patients. J Transl Med 2022; 20:114. [PMID: 35255924 PMCID: PMC8900384 DOI: 10.1186/s12967-022-03318-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/23/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Once malignancy tumors were diagnosed, the determination of tissue origin and tumor type is critical for clinical management. Although the significant advance in imaging techniques and histopathological approaches, the diagnosis remains challenging in patients with metastatic and poorly differentiated or undifferentiated tumors. Gene expression profiling has been demonstrated the ability to classify multiple tumor types. The present study aims to assess the performance of a 90-gene expression test for tumor classification (i.e. the determination of tumor tissue of origin) in real clinical settings. METHODS Formalin-fixed paraffin-embedded samples and associated clinicopathologic information were collected from three cancer centers between January 2016 and January 2021. A total of 1417 specimens that met quality control criteria (RNA quality, tumor cell content ≥ 60% and so on) were analyzed by the 90-gene expression test to identify the tumor tissue of origin. The performance was evaluated by comparing the test results with histopathological diagnosis. RESULTS The 1417 samples represent 21 main tumor types classified by common tissue origins and anatomic sites. Overall, the 90-gene expression test reached an accuracy of 94.4% (1338/1417, 95% CI: 0.93 to 0.96). Among different tumor types, sensitivities were ranged from 74.2% (head&neck tumor) to 100% (adrenal carcinoma, mesothelioma, and prostate cancer). Sensitivities for the most prevalent cancers of lung, breast, colorectum, and gastroesophagus are 95.0%, 98.4%, 93.9%, and 90.6%, respectively. Moreover, specificities for all 21 tumor types are greater than 99%. CONCLUSIONS These findings showed robust performance of the 90-gene expression test for identifying the tumor tissue of origin and support the use of molecular testing as an adjunct to tumor classification, especially to those poorly differentiated or undifferentiated tumors in clinical practice.
Collapse
Affiliation(s)
- Wei Sun
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China
| | - Wei Wu
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.1 East Road of Banshan, Hangzhou, Zhejiang, China
| | - Qifeng Wang
- Department of Pathology, Fudan University Shanghai Cancer Center, No.270 Dong'An Road, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Institute of Pathology, Fudan University, Shanghai, China
- The Cancer of Unknown Primary Group of Pathology Committee, Chinese Research Hospital Association, Shanghai, China
| | - Qian Yao
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China
| | - Qin Feng
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China
| | - Yue Wang
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China
| | - Yu Sun
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China
| | - Yunying Liu
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.1 East Road of Banshan, Hangzhou, Zhejiang, China
| | - Qian Lai
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.1 East Road of Banshan, Hangzhou, Zhejiang, China
| | - Gu Zhang
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.1 East Road of Banshan, Hangzhou, Zhejiang, China
| | - Peng Qi
- Department of Pathology, Fudan University Shanghai Cancer Center, No.270 Dong'An Road, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Institute of Pathology, Fudan University, Shanghai, China
- The Cancer of Unknown Primary Group of Pathology Committee, Chinese Research Hospital Association, Shanghai, China
| | - Yifeng Sun
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Chenhui Qian
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Wanli Ren
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Zhengzhi Luo
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Jinying Chen
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Hongying Wang
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
| | - Qinghua Xu
- The Cancer of Unknown Primary Group of Pathology Committee, Chinese Research Hospital Association, Shanghai, China
- The Canhelp Genomics Research Center, Canhelp Genomics Co., Ltd., Hangzhou, China
- The Institute of Machine Learning and Systems Biology, College of Electronics and Information Engineering, Tongji University, Shanghai, China
- Xuzhou Engineering Research Center of Medical Genetics and Transformation, Department of Genetics, Xuzhou Medical University, Xuzhou, China
| | - Xiaoyan Zhou
- Department of Pathology, Fudan University Shanghai Cancer Center, No.270 Dong'An Road, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
- Institute of Pathology, Fudan University, Shanghai, China.
- The Cancer of Unknown Primary Group of Pathology Committee, Chinese Research Hospital Association, Shanghai, China.
| | - Wenyong Sun
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.1 East Road of Banshan, Hangzhou, Zhejiang, China.
| | - Dongmei Lin
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, No.52 Fucheng Road, Wu Ke Song, Haidian District, Beijing, China.
| |
Collapse
|
8
|
Rassy E, Boussios S, Pavlidis N. Genomic correlates of response and resistance to immune checkpoint inhibitors in carcinomas of unknown primary. Eur J Clin Invest 2021; 51:e13583. [PMID: 33970501 DOI: 10.1111/eci.13583] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/18/2021] [Accepted: 04/25/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cancers of unknown primary (CUP) are highly aggressive tumours with limited molecular characterization. These tumours can be particularly sensitive to immune checkpoint inhibitors (ICI) by mounting a seemingly more effective anti-tumour immune response. Unlike other tumour lineages, the biological basis and clinical efficacy of ICI in CUP remain largely unknown. MATERIALS AND METHODS The cBioPortal database was accessed to select eligible cases from the MSK-IMPACTTM Clinical Sequencing Cohort. The tumour cell genomic correlates of response and resistance to ICI in patients with CUP were compared to those with ICI-eligible tumours: cervical cancer, gastric cancer, renal cell carcinoma, hepatocellular carcinoma, non-small-cell lung cancer, melanoma, Merkel cell carcinoma and urothelial bladder cancer. RESULTS Among a total of 234 patients with CUP, the identified genomic alterations were mainly mutation correlates of resistance to ICI, notably mutations in oncogenic signalling pathways including KRAS, STK11 and EGFR (24.7%, 10.9% and 4.2%, respectively). Compared to other tumours considered eligible for ICI, CUP presents a higher prevalence of alterations in the oncogenic signalling pathways KRAS and STK11. CUP patients treated with ICI had similar median overall survival with and without genomic correlates of response and resistance to ICI. An exploratory analysis showed that patients with TMB >10 mutations had a trend for better outcomes. CONCLUSIONS A tumour mutation burden >10 mutations per megabase can provide a potential genomic correlate of response to ICI in patients with CUP. Further research is warranted to validate these findings.
Collapse
Affiliation(s)
- Elie Rassy
- Département de médecine oncologique, Gustave Roussy, Villejuif, F-94805, France
| | - Stergios Boussios
- Faculty of Life Sciences & Medicine, King's College London, School of Cancer & Pharmaceutical Sciences, London, UK.,Medway NHS Foundation Trust, Gillingham, UK.,AELIA Organization, 9th Km Thessaloniki - Thermi, Thessaloniki, Greece
| | | |
Collapse
|
9
|
Genomic alterations and possible druggable mutations in carcinoma of unknown primary (CUP). Sci Rep 2021; 11:15112. [PMID: 34302033 PMCID: PMC8302572 DOI: 10.1038/s41598-021-94678-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/15/2021] [Indexed: 12/14/2022] Open
Abstract
Carcinoma of Unknown Primary (CUP) is a heterogeneous and metastatic disease where the primary site of origin is undetectable. Currently, chemotherapy is the only state-of-art treatment option for CUP patients. The molecular profiling of the tumour, particularly mutation detection, offers a new treatment approach for CUP in a personalized fashion using targeted agents. We analyzed the mutation and copy number alterations profile of 1709 CUP samples deposited in the AACR Project Genomics Evidence Neoplasia Information Exchange (GENIE) cohort and explored potentially druggable mutations. We identified 52 significant mutated genes (SMGs) among CUP samples, in which 13 (25%) of SMGs were potentially targetable with either drugs are approved for the know primary tumour or undergoing clinical trials. The most variants detected were TP53 (43%), KRAS (19.90%), KMT2D (12.60%), and CDKN2A (10.30%). Additionally, using pan-cancer analysis, we found similar variants of TERT promoter in CUP and NSCLC samples, suggesting that these mutations may serve as a diagnostic marker for identifying the primary tumour in CUP. Taken together, the mutation profiling analysis of the CUP tumours may open a new way of identifying druggable targets and consequently administrating appropriate treatment in a personalized manner.
Collapse
|
10
|
Wong B, Vickers MM, Wheatley-Price P. The Diminishing Importance of Primary Site Identification in Cancer of Unknown Primary: A Canadian Single-Center Experience. Front Oncol 2021; 11:634563. [PMID: 33747958 PMCID: PMC7968101 DOI: 10.3389/fonc.2021.634563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/27/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cancer of unknown primary (CUP) describes patients with metastatic disease without an identified primary tumor site. Successful diagnosis and treatment of these patients remains difficult. Published guidelines on CUP have highlighted "favorable" subtype groups. We investigated a series of CUP patients to review adherence to guidelines, and identification of primary cancers or "favorable" subtypes. METHODS Patients with histologically confirmed CUP at an academic institution from 2012 to 2018 were identified. Patient demographics, tumor presentation, diagnostic work-up and treatment information were retrospectively collected from electronic data records for descriptive analysis and compared to published clinical guidelines. The primary endpoint was the proportion of patients where the primary site was identified. Multivariable logistic regression models were used to identify factors associated with primary site identification. Kaplan-Meier survival curves were used to determine factors associated with poorer OS. RESULTS Three hundred and five patients were included with a median follow-up time of 4.3 months. Primary tumor sites were identified in 109 patients (37.5%), which was most commonly lung cancer (33%). Statistical analyses did not identify any demographic or initial presentation factors associated with identifying the primary or not. More diagnostic tests did not increase the likelihood of primary site identification (P=0.44). Patients with an identified primary did not have longer OS than other patients (median 5.2 months vs. 4.7 months, P=0.47). 57 patients (18.7%) who had a defined "favorable" subtype experienced superior OS (36.6 months vs. 3.8 months; P<0.0001). Further, patients with good prognostic status who followed published treatment guidelines had longer OS (17.6 months vs. 13.2 months; P=0.04). CONCLUSIONS CUP remains a difficult cancer to diagnose and treat. These results suggest identifying the primary has less impact than anticipated, but particular efforts to identify patients with "favorable" subtypes of CUP is important prognostically.
Collapse
Affiliation(s)
- Boaz Wong
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael M. Vickers
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Paul Wheatley-Price
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| |
Collapse
|
11
|
Pavlidis N, Todorovic V, Rassy E, Khaled H, Peccatori F, Eniu A, Aapro M, Gligorov J. The management of patients with cancer of unknown primary in middle-income countries: an ESO-AROME survey. Future Oncol 2020; 17:151-157. [PMID: 33305604 DOI: 10.2217/fon-2020-0677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: To report on the management strategies in patients with cancer of unknown primary (CUP) in middle-income countries. Methods: We conceived a survey of 20 items concerning the management of patients with CUP in daily clinical practice. Only participants from lower- and higher-middle-income countries, as per the World Bank Classification, were eligible for this study. Results: The indications for the first-line treatment did not differ between the two economic regions, whereas those for second-line treatment were more prevalent in higher-middle-income countries. The use of targeted therapy based on immunohistochemistry alone was higher in lower-middle-income countries, although the access to CUP classifiers was similar between the two regions. Conclusions: Proper recommendations must ensure that the economic burden is minimized and that other benefits outweigh the limited survival benefit achieved in patients with CUP.
Collapse
Affiliation(s)
- Nicholas Pavlidis
- University of Ioannina, Niacrhos Avenue, Ioannina, 45 000, Greece.,European School of Oncology College, 20121, Milan, Italy
| | - Vladimir Todorovic
- Oncology & Radiotherapy Clinic, Clinical Center of Montenegro, University of Montenegro, 81000, Podgorica, Montenegro
| | - Elie Rassy
- Department of Medical Oncology, Institut Gustave Roussy, 94800, Villejuif, France.,Faculty of Medicine, Department of Oncology, Saint Joseph University, 11-5076, Beirut, Lebanon
| | - Hussein Khaled
- Medical Oncology Department, National Cancer Institute, Cairo University, 11796, Giza, Egypt
| | - Fedro Peccatori
- Fertility & Procreation Unit, Gynecologic Oncology Program, European Institute of Oncology IRCCS, 20141, Milan, Italy.,European School of Oncology, 20121, Milan, Italy
| | - Alex Eniu
- European School of Oncology College, 20121, Milan, Italy.,Hospital Riviera Chablais, 1847, Rennaz, Switzerland
| | - Matti Aapro
- European School of Oncology, 20121, Milan, Italy.,Breast Center, Genolier Cancer Centre, 1272, Genolier, Switzerland
| | - Joseph Gligorov
- Institut Universitaire de Cancerologie APHP-Sorbonne Université, 75006, Paris, France
| | | |
Collapse
|
12
|
Rassy E, Assi T, Boussios S, Kattan J, Smith-Gagen J, Pavlidis N. Narrative review on serous primary peritoneal carcinoma of unknown primary site: four questions to be answered. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1709. [PMID: 33490221 PMCID: PMC7812188 DOI: 10.21037/atm-20-941] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Serous peritoneal papillary carcinoma (SPPC) represents a particular cancer of unknown primary (CUP) entity that arises in the peritoneal surface lining the abdomen and pelvis without a discriminative primary tumor site. In this review, we discuss the validity of SPPC as a distinct entity. Clinically, patients with SPPC are older, have higher parity and later menarche, are more often obese and probably have poorer survival compared to those with primary ovarian cancer. Pathologically, SPPC is more anaplastic and multifocal, unlike primary ovarian cancer which is commonly unifocal. Biologically, it presents a higher expression of proliferative signals and similar cell cycle and DNA repair protein expression. These differences hint towards SPPC and primary ovarian cancer being as a spectrum of disease. Patients with SPPC are traditionally managed similarly to stage III–IV ovarian cancer. The recommended approach integrates aggressive cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, and systemic chemotherapy to remove the macroscopic tumor, eradicate the microscopic residual disease, and control the microscopic metastasis. However, the available evidence lacks proper randomized or prospective studies on SPPC and is limited to retrospective series. The diligent identification of SPPC is warranted to design specific clinical trials that eventually evaluate the impact of the new therapeutics on this distinct entity.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Cancer Medicine, Gustave Roussy Institut, Villejuif, France.,Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Tarek Assi
- Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Stergios Boussios
- Medway NHS Foundation Trust, Gillingham, Kent, UK.,AELIA Organization, 9th Km Thessaloniki-Thermi, Thessaloniki, Greece
| | - Joseph Kattan
- Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Julie Smith-Gagen
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | | |
Collapse
|
13
|
Rassy E, Pavlidis N. The diagnostic challenges of patients with carcinoma of unknown primary. Expert Rev Anticancer Ther 2020; 20:775-783. [PMID: 32779501 DOI: 10.1080/14737140.2020.1807948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cancer of unknown primary (CUP) is a disease entity encompassing heterogeneous malignancies without a clinically-detectable anatomical primary. It is usually a poor prognosis malignancy with dismal prognosis where molecular and genetic testing were expected to be a major breakthrough. AREAS COVERED In this review, we provide an overview of the advances in the understanding of the carcinogenesis, biology, diagnosis and treatment of patients with CUP. This review focuses on the advantages and inconveniences of immunohistochemistry and CUP classifiers in assessing the progress in the management of CUP. EXPERT OPINION CUP classifiers were expected to gradually replace the classical multistep approach in identifying the culprit tumors to guide site-specific therapy. Immunohistochemistry staining led to the prediction of a single tissue of origin in 10.8-51%. CUP classifiers identified the primary site in 61-89% of these cases and were concordant with immunohistochemistry in 57.1-100%. Immunohistochemistry is cheap, fast and broadly available whereas CUP classifiers are less widely available and have not been validated in randomized control trials. The diagnostic recommendations consist of a standard pathology evaluation based on morphology and algorithmic immunohistochemistry assessment. Physicians should weigh in the input of the CUP classifier to the clinical picture and pathology investigations before performing additional investigations.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy Institute , Villejuif, France.,Department of Medical Oncology, Saint Joseph University , Beirut, Lebanon
| | - Nicholas Pavlidis
- University of Ioannina , Ioannina, Greece.,European School of Oncology College , Milan, Italy
| |
Collapse
|
14
|
Khazzaka A, Rassy E, Pavlidis N. What can we learn from cancer of unknown primary in canine oncology? J Adv Res 2020; 24:495-500. [PMID: 32577312 PMCID: PMC7303049 DOI: 10.1016/j.jare.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/05/2020] [Indexed: 01/07/2023] Open
Abstract
Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumors that lack an identifiable primary site despite an extensive diagnostic work-up. It is a well-recognized entity that is characterized by early dissemination, aggressive clinical course, unpredictable metastatic pattern, intrinsic treatment resistance, and a dismal prognosis. Despite the molecular diagnostic workup and personalized therapy, the expected improvements in the diagnosis and treatment of CUP have not been achieved. Comparative oncology has a promising role in the exchange of knowledge and practices between humans and canines. Therefore, we intended to review the literature reporting on CUP in dogs in order to identify some interesting parallels and unique results that could be transposed to in-human research.
Collapse
Affiliation(s)
- Aline Khazzaka
- Surgical Research Laboratory, Faculty of Medicine, Saint Joseph University, Lebanon
| | - Elie Rassy
- Department of Medical Oncology, Faculty of Medicine, Saint Joseph University, Lebanon
| | | |
Collapse
|
15
|
Rassy E, Pavlidis N. Progress in refining the clinical management of cancer of unknown primary in the molecular era. Nat Rev Clin Oncol 2020; 17:541-554. [PMID: 32350398 DOI: 10.1038/s41571-020-0359-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/14/2022]
Abstract
Cancer of unknown primary (CUP) is an enigmatic disease entity encompassing heterogeneous malignancies without a detectable primary tumour, despite a thorough diagnostic workup. A minority of patients with CUP (15-20%) can be assigned a putative primary tissue of origin according to clinical and histopathological findings and typically have a more favourable prognosis with the use of corresponding tumour type-specific therapies. Thus, the majority of patients with CUP have disease that cannot be assigned to a culprit primary tumour, are treated with empirical chemotherapy and have a poor prognosis. In the molecular era, the use of (epi)genomic or transcriptomic CUP classifiers and DNA or RNA sequencing offers two, sometimes overlapping, therapeutic strategies: tumour type-specific therapy and biomarker-guided therapy. Published data reveal that the accuracy of site-of-origin predictions made using CUP classifiers ranges between 54% and 98% when compared with the assignment made according to the recommended clinicopathological criteria. These advances have led to promising results in non-randomized prospective studies evaluating the efficacy of tumour type-specific therapy; however, the favourable outcomes were not confirmed in randomized controlled studies comparing this approach with standard empirical chemotherapy. Currently, the evidence supporting the use of biomarker-guided therapies is limited to case reports and small case series. In this Review, we discuss the clinical management of CUP in the era of precision medicine. We focus on the advances in understanding the biology of CUP, the implications for the diagnosis and classification of CUP according to the tissue of origin and the shift away from empirical therapy towards tailored therapy.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, Paris, France.
| | | |
Collapse
|
16
|
Bakow BR, Elco CP, LeGolvan M, Dizon D, Ollila TA. Molecular Profiles of Brain and Pulmonary Metastatic Disease in Cancer of Unknown Primary. Oncologist 2020; 25:555-559. [PMID: 32310333 DOI: 10.1634/theoncologist.2019-0798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/03/2020] [Indexed: 11/17/2022] Open
Abstract
Cancers of unknown primary (CUP) are histologically confirmed malignancies but for which further investigation cannot identify a primary site. Improvements in histopathologic modalities for diagnosis have lessened the frequency of CUPs to 3%-5% of all malignancies compared with historical estimates of 5%-10%. Despite this, there is an ongoing debate as to whether CUPs are malignancies where the primary is not found or if they are otherwise a fully separate entity. Improvements in molecular analysis holds promise for improved identification and treatment of CUPs with mixed preliminary results. Here we present a woman with CUP and metastases in her brain and lung. We performed genomic profiling to compare the molecular makeup of each site in order to establish treatment targets. KEY POINTS: Cancer of unknown primary remains a diagnostic and therapeutic challenge. Molecular analysis may provide improvements in diagnosis and novel treatment options. Different sites of metastatic disease have subtle variations in molecular profile. Sequencing of different sites may offer therapeutic options that are either already approved or available in clinical trial.
Collapse
Affiliation(s)
- Brianna R Bakow
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Internal Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Christopher P Elco
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Pathology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mark LeGolvan
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Pathology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Don Dizon
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Hematology and Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Thomas A Ollila
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Hematology and Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| |
Collapse
|
17
|
Alshareeda AT, Al-Sowayan BS, Alkharji RR, Aldosari SM, Al subayyil AM, Alghuwainem A. Cancer of Unknown Primary Site: Real Entity or Misdiagnosed Disease? J Cancer 2020; 11:3919-3931. [PMID: 32328196 PMCID: PMC7171483 DOI: 10.7150/jca.42880] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/31/2020] [Indexed: 01/03/2023] Open
Abstract
Metastasis is a late event in the progression of any tumour. However, invasive cancers are occasionally detected in the form of metastatic lesions without a clearly detectable primary tumour. Cancer of unknown primary site (CUP) is defined as a confirmed metastatic tumour, with unknown primary tumour site, despite the standardized diagnostic approach that includes clinical history, routine laboratory tests, and complete physical examination. Due to the lack of basic research on its primary causes, CUP is appropriately termed an 'orphan' cancer. Nevertheless, CUP accounts for 2-5% of diagnosed malignancies. To date, it is unclear whether CUP is an entity with primary dormancy as its hallmark or an entity with genetic abnormalities that cause it to manifest as a primary metastatic disease. In this review, we discuss different aspects of CUP, including its current diagnostic methods, angiogenesis effectors, relationship with cancer stem cells and current treatments.
Collapse
Affiliation(s)
- Alaa T. Alshareeda
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Batla S. Al-Sowayan
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Reem R. Alkharji
- Research Department, Health Sciences Research Centre, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sahar M. Aldosari
- Cytogenetic and Molecular Genetics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah M. Al subayyil
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Ayidah Alghuwainem
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| |
Collapse
|
18
|
Bochtler T, Reiling A, Endris V, Hielscher T, Volckmar AL, Neumann O, Kirchner M, Budczies J, Heukamp LC, Leichsenring J, Allgäuer M, Kazdal D, Löffler H, Weichert W, Schirmacher P, Stenzinger A, Krämer A. Integrated clinicomolecular characterization identifies RAS activation and CDKN2A deletion as independent adverse prognostic factors in cancer of unknown primary. Int J Cancer 2020; 146:3053-3064. [PMID: 31970771 DOI: 10.1002/ijc.32882] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/26/2022]
Abstract
Cancer of unknown primary (CUP) denotes a malignancy with histologically confirmed metastatic spread while the primary tumor remains elusive. Here, we address prognostic and therapeutic implications of mutations and copy number variations (CNVs) detected in tumor tissue in the context of a comprehensive clinical risk assessment. Targeted panel sequencing was performed in 252 CUP patients. 71.8% of patients had unfavorable CUP according to ESMO guidelines. 74.7% were adeno- and 13.7% squamous cell carcinomas. DNA was extracted from microdissected formalin-fixed, paraffin-embedded tissues. For library preparation, mostly multiplex PCR-based Ion Torrent AmpliSeq™ technology with Oncomine comprehensive assays was used. Most frequent genetic alterations were mutations/deletions of TP53 (49.6%), CDKN2A (19.0%) and NOTCH1 (14.1%) as well as oncogenic activation of KRAS (23.4%), FGFR4 (14.9%) and PIK3CA (10.7%). KRAS activation was predominantly found in adenocarcinomas (p = 0.01), PIK3CA activation in squamous cell carcinomas (p = 0.03). Male sex, high ECOG score, unfavorable CUP, higher number of involved organs and RAS activation predicted decreased event-free and overall survival in multivariate analysis. Deletions of CDKN2A were prognostically adverse regarding overall survival. TP53 mutations did not significantly influence prognosis in the overall cohort, but worsened prognosis in otherwise favorable CUP subtypes. Although not standard in CUP, for 17/198 (8.6%) patients molecularly targeted treatment was recommended and 10 patients (5.1%) were treated accordingly. In conclusion, besides the identification of drug targets, panel sequencing in CUP is prognostically relevant, with RAS activation and CDKN2A deletion emerging as novel independent risk factors in a comprehensive assessment with clinicopathological data.
Collapse
Affiliation(s)
- Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Reiling
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,German Cancer Consortium (DKTK), Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anna-Lena Volckmar
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Jonas Leichsenring
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Kazdal
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Harald Löffler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Marienhospital Stuttgart, Stuttgart, Germany
| | - Wilko Weichert
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,German Cancer Consortium (DKTK), Germany.,Institute of Pathology, Technical University Munich, Munich, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,German Cancer Consortium (DKTK), Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
19
|
New rising entities in cancer of unknown primary: Is there a real therapeutic benefit? Crit Rev Oncol Hematol 2020; 147:102882. [DOI: 10.1016/j.critrevonc.2020.102882] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/04/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022] Open
|
20
|
Exploring the biological hallmarks of cancer of unknown primary: where do we stand today? Br J Cancer 2020; 122:1124-1132. [PMID: 32042068 PMCID: PMC7156745 DOI: 10.1038/s41416-019-0723-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/18/2019] [Indexed: 01/07/2023] Open
Abstract
Cancer of unknown primary (CUP) affects a small percentage of the general population. Nonetheless, a substantial number of these patients have a poor prognosis and consequently succumb to their illness within a year of diagnosis. The natural history of CUP is characterised by early metastasis from the unknown primary site, aggressive course and resistance to conventional chemotherapy. Unfortunately, the processes by which this orphan disease originates and progresses have not been fully elucidated and its biology remain unclear. Despite the conceptual progress in genetic and molecular profiling made over the past decade, recognition of the genetic and molecular abnormalities involved in CUP, as well as the identification of the tissue of origin remain unresolved issues. This review will outline the biology of CUP by exploring the hallmarks of cancer in order to rationalise the complexities of this enigmatic syndrome. This approach will help the reader to understand where research efforts currently stand and the pitfalls of this quest.
Collapse
|
21
|
Rassy E, Bakouny Z, Choueiri TK, Van Allen EM, Fizazi K, Greco FA, Pavlidis N. The role of site-specific therapy for cancers of unknown of primary: A meta-analysis. Eur J Cancer 2020; 127:118-122. [PMID: 32007711 DOI: 10.1016/j.ejca.2019.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
Abstract
Cancers of unknown primary (CUP) are among the most common causes of death due to cancer, are associated with a poor prognosis and have few therapeutic options available. Molecularly-guided site-specific treatments were explored based on the assumption that CUP are similar in their response to treatment of predicted primary tumours. Given the discordant results between these studies, a meta-analysis using a random-effects model and the inverse variance method was performed. MEDLINE and conference abstracts of American Society of Clinical Oncology (ASCO) and European Society of Medical Oncology (ESMO) meetings were searched from inception until November 2019. A trend towards improved OS was noted with site-specific versus empiric treatment for CUP (HR = 0.73; 95% confidence interval (CI) 0.52-1.02). There was significant heterogeneity across the four studies (I [2] = 79%; p = 0.002) but no significant difference was noted between the treatment effect in the two subgroups (randomised vs. non-randomised; p = 0.07). The test for overall effect for progression free survival, which had only been reported for the two randomised studies, was not statistically significant (HR = 0.93; 95% CI 0.74-1.17), with little heterogeneity between studies (I [2] = 0%; p = 0.77). The results of this meta-analysis highlight the significant heterogeneity between the prospective studies comparing molecularly tailored to empiric therapy for CUP and the need for other randomised studies including only primary tumors with available effective therapies.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy Institute, Villejuif, France; Department of Medical Oncology, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon.
| | - Ziad Bakouny
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eliezer M Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karim Fizazi
- Department of Medical Oncology, Gustave Roussy Institute, Villejuif, France
| | - F Anthony Greco
- Sarah Cannon Cancer Center, Tennessee Oncology, Nashville, TN, USA
| | | |
Collapse
|
22
|
Rassy E, Zanaty M, Azoury F, Pavlidis N. Advances in the management of brain metastases from cancer of unknown primary. Future Oncol 2019; 15:2759-2768. [PMID: 31385529 DOI: 10.2217/fon-2019-0108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Cancer of unknown primary accounts for 3-5% of all cancers for which an adequate investigation does not identify the primary tumor. The particular subset of brain metastasis in cancer of unknown primary (BMCUP) is a clinical challenge that lacks standardized diagnostic and therapeutic options. It is diagnosed predominantly in male patients in the sixth decade of age with complaints of headache, neurological dysfunction, cognitive and behavioral disturbances and seizures. The therapeutic approach to patients with BMCUP relies on local control and systemic treatment. Surgery or stereotactic radiosurgery and/or whole brain radiation therapy seems to be the cornerstone of the treatment approach to BMCUP. Systemic therapy remains essential as cancers of unknown primary are conceptually metastatic tumors. The benefits of chemotherapy were disappointing whereas those of targeted therapies and immune checkpoint inhibitors remain to be evaluated. In this Review, we address the advances in the diagnosis and treatment of BMCUP.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Mario Zanaty
- Department of Neurosurgical Surgery, University of Ioawa, Ioawa City, IA, USA
| | - Fares Azoury
- Department of Radiation Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
| | | |
Collapse
|
23
|
Awadallah SF, Bowling MR, Sharma N, Mohan A. Malignant pleural effusion and cancer of unknown primary site: a review of literature. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:353. [PMID: 31516899 DOI: 10.21037/atm.2019.06.33] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Malignant pleural effusions (MPE) are most frequently (50-65%) noted from lung and breast cancers. They are commonly unilateral and are reflective of poorer prognosis. Cancer of unknown primary (CUP) account for 4-5% of all invasive cancers. These are metastatic tumors in which the primary is unknown despite an extensive medical evaluation. About 11% of MPE are from CUP. These MPEs present a clinical dilemma to physicians as there is a paucity of literature on their management and no consensus or guideline statement. This paper provides an overview of MPE from CUP in regard to diagnosis, prognosis, and treatment options. A selective search was performed in Medline and PubMed, with the keywords "Malignant pleural effusion" and "Cancer of unknown primary" up to December 2018. A review of literature would suggest that a thoracentesis is the first step in all cases but additional work up such as thoracoscopy & pleural biopsies is frequently warranted. With advances in immunohistochemical staining and biomarker development, MPE with CUP maybe profiled in a similar manner as lung cancer. Similarly, liquid biopsy or identification of circulating tumor cell free DNA may have a role in the work up of CUP in the future. There is some experience in managing these patients with gene directed therapies and immune checkpoint inhibitors, however, with mixed results. Given the poor prognosis associated with MPE from CUP, symptom alleviating measures such as indwelling pleural catheters should be part of the management strategy.
Collapse
Affiliation(s)
- Saed Fathi Awadallah
- Division of Pulmonary, Critical Care and Sleep Medicine, East Carolina University-Brody School of Medicine, Greenville, North Carolina, USA
| | - Mark R Bowling
- Division of Pulmonary, Critical Care and Sleep Medicine, East Carolina University-Brody School of Medicine, Greenville, North Carolina, USA
| | - Nitika Sharma
- Division of Hematology/Oncology, Department of Medicine, East Carolina University-Brody School of Medicine, Greenville, North Carolina, USA
| | - Arjun Mohan
- Division of Pulmonary, Critical Care and Sleep Medicine, East Carolina University-Brody School of Medicine, Greenville, North Carolina, USA
| |
Collapse
|
24
|
El Rassy E, Kattan J, Pavlidis N. A new entity of abdominal squamous cell carcinoma of unknown primary. Eur J Clin Invest 2019; 49:e13111. [PMID: 30908618 DOI: 10.1111/eci.13111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Elie El Rassy
- Department of Cancer Medicine, Gustave Roussy Institute, Villejuif, France.,Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Joseph Kattan
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | | |
Collapse
|
25
|
Pavlidis N, Rassy E, Smith‐Gagen J. Cancer of unknown primary: Incidence rates, risk factors and survival among adolescents and young adults. Int J Cancer 2019; 146:1490-1498. [DOI: 10.1002/ijc.32482] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/07/2019] [Accepted: 05/23/2019] [Indexed: 01/08/2023]
Affiliation(s)
| | - Elie Rassy
- Department of Medical OncologyInstitut Gustave Roussy Villejuif France
- Department of Hematology‐Oncology, Faculty of MedicineSaint Joseph University Beirut Lebanon
| | | |
Collapse
|
26
|
Rassy E, Kattan J, Pavlidis N. Familial cancer of unknown primary. Int J Clin Oncol 2019; 24:1328-1331. [PMID: 31203526 DOI: 10.1007/s10147-019-01491-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 06/10/2019] [Indexed: 01/07/2023]
Abstract
Cancer of unknown primary site (CUP) is a deadly disease diagnosed through metastases at various organs without primary tumor identification. Despite the major molecular and technological advances, the carcinogenesis of CUP remains enigmatic which hampers adequate study design of treatments leading to survival improvement. To date, the pathogenesis of CUP is still debatable with one hypothesis considering CUP simply a group of metastatic tumors with unidentified primaries and another considering it a distinct entity with specific genetic and phenotypic aberrations. Familial CUP seems to favor the first hypothesis due to common genetic predisposition factors between known primaries and CUP. Two clinical implications may be withdrawn from the pathogenesis of familial clustering of CUP. The detailed family history and environmental risk factors may orient towards the primary tumor identification. Smoking avoidance and adherence to general population guidelines for cancer screening would be strongly encouraged.
Collapse
Affiliation(s)
- Elie Rassy
- Department of Cancer Medicine, Gustave Roussy Institut, Villejuif, France
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Joseph Kattan
- Department of Cancer Medicine, Gustave Roussy Institut, Villejuif, France
| | - Nicholas Pavlidis
- Emeritus Professor, University of Ioannina, Niarchos Avenue, 45110, Ioannina, Greece.
| |
Collapse
|
27
|
Liquid biopsy: a new diagnostic, predictive and prognostic window in cancers of unknown primary. Eur J Cancer 2018; 105:28-32. [PMID: 30388661 DOI: 10.1016/j.ejca.2018.09.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 01/07/2023]
Abstract
Cancer of unknown primary (CUP) is a heterogeneous group of metastatic cancers characterised by early dissemination of metastases in the absence of any identifiable primary site. Most patients with CUP have poor prognosis with the traditional diagnostic and treatment modalities. Recognising the putative primary tumour is hypothesised to ameliorate the prognosis of patients with CUP by guiding treatment decisions. The active efforts in molecular oncology have shown that gene expression profiling is able to identify the primary tumour site and to determine targetable mutations. In this regard, liquid biopsy opens a new diagnostic, predictive and prognostic window in CUP that may lead to substantial improvement in the management of patients with CUP.
Collapse
|