1
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De Velasco MA, Sakai K, Mitani S, Kura Y, Minamoto S, Haeno T, Hayashi H, Nishio K. A machine learning-based method for feature reduction of methylation data for the classification of cancer tissue origin. Int J Clin Oncol 2024:10.1007/s10147-024-02617-w. [PMID: 39292320 DOI: 10.1007/s10147-024-02617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/28/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Genome DNA methylation profiling is a promising yet costly method for cancer classification, involving substantial data. We developed an ensemble learning model to identify cancer types using methylation profiles from a limited number of CpG sites. METHODS Analyzing methylation data from 890 samples across 10 cancer types from the TCGA database, we utilized ANOVA and Gain Ratio to select the most significant CpG sites, then employed Gradient Boosting to reduce these to just 100 sites. RESULTS This approach maintained high accuracy across multiple machine learning models, with classification accuracy rates between 87.7% and 93.5% for methods including Extreme Gradient Boosting, CatBoost, and Random Forest. This method effectively minimizes the number of features needed without losing performance, helping to classify primary organs and uncover subgroups within specific cancers like breast and lung. CONCLUSIONS Using a gradient boosting feature selector shows potential for streamlining methylation-based cancer classification.
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Affiliation(s)
- Marco A De Velasco
- Department of Genome Biology, Faculty of Medicine, Kindai University, Ohnohigashi 377-2, Osaka-Sayama, 589-9511, Japan
| | - Kazuko Sakai
- Department of Genome Biology, Faculty of Medicine, Kindai University, Ohnohigashi 377-2, Osaka-Sayama, 589-9511, Japan
| | - Seiichiro Mitani
- Department of Medical Oncology, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Yurie Kura
- Department of Genome Biology, Faculty of Medicine, Kindai University, Ohnohigashi 377-2, Osaka-Sayama, 589-9511, Japan
| | - Shuji Minamoto
- Department of Molecular Tumor Pathobiology, Kindai University Graduate School of Medical Sciences, Osaka-Sayama, Japan
| | - Takahiro Haeno
- Department of Molecular Tumor Pathobiology, Kindai University Graduate School of Medical Sciences, Osaka-Sayama, Japan
| | - Hidetoshi Hayashi
- Department of Medical Oncology, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Kazuto Nishio
- Department of Genome Biology, Faculty of Medicine, Kindai University, Ohnohigashi 377-2, Osaka-Sayama, 589-9511, Japan.
- Department of Molecular Tumor Pathobiology, Kindai University Graduate School of Medical Sciences, Osaka-Sayama, Japan.
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2
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Harvey S, Stares M, Scott J, Thottiyil TJV, Conway A, Haigh R, Brown J, Knowles G, Dasgupta S, Shiu K, Mitchell C, Barrie C, Cook N, Clive S. Biomarkers of systemic inflammation provide additional prognostic stratification in cancers of unknown primary. Cancer Med 2024; 13:e6988. [PMID: 38404120 PMCID: PMC10895198 DOI: 10.1002/cam4.6988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Biomarkers of systemic inflammation have been shown to predict outcomes in patients with cancer of unknown primary (CUP). We sought to validate these findings in patients with confirmed CUP (cCUP) and explore their role alongside existing clinicopathological prognostic categories. PATIENTS AND METHODS CUP oncologist from across the United Kingdom were invited to include patients with cCUP referred to their local CUP multidisciplinary team. Patient demographics, clinical, pathological and outcome data were recorded and analysed. RESULTS Data were available for 548 patients from four CUP services. 23% (n = 124) of patients met clinicopathological criteria for favourable-risk cCUP. On multivariate analysis c-reactive protein (CRP) (p < 0.001) and the Scottish Inflammatory Prognostic Score (SIPS: combining albumin and neutrophil count) (p < 0.001) were independently predictive of survival. CRP and SIPS effectively stratified survival in patients with both favourable-risk and poor-risk cCUP based on clinicopathological features. CONCLUSIONS Biomarkers of systemic inflammation are reliable prognostic factors in patients with cCUP, regardless of clinicopathological subgroup. We recommend that CRP or SIPS are incorporated into routine clinical assessments of patients with cCUP as a tool to aid investigation and/or treatment decision-making across all groups. Established clinicopathological factors can then be used to inform management pathways and specific systemic anticancer therapy selection.
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Affiliation(s)
- Svenja Harvey
- University of Edinburgh, Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General HospitalEdinburghUK
| | - Mark Stares
- University of Edinburgh, Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General HospitalEdinburghUK
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
| | - Julie‐Anne Scott
- Experimental Cancer Medicine Team (ECMT)The Christie NHS Foundation TrustManchesterUK
| | | | - Alicia‐Marie Conway
- The University of Manchester, Cancer Research UK Manchester InstituteManchesterUK
- The Christie NHS Foundation TrustManchesterUK
| | - Rachel Haigh
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
| | - Jackie Brown
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
| | - Gillian Knowles
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
| | | | - Kai‐Keen Shiu
- University College London Hospitals NHS Foundation TrustLondonUK
| | | | - Colin Barrie
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
| | - Natalie Cook
- Experimental Cancer Medicine Team (ECMT)The Christie NHS Foundation TrustManchesterUK
| | - Sally Clive
- Edinburgh Cancer Centre, NHS LothianWestern General HospitalEdinburghUK
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3
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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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4
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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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5
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Bhatt A, Mishra S, Glehen O. Histopathological Evaluation and Molecular Diagnostic Tests for Peritoneal Metastases with Unknown Primary Site-a Review. Indian J Surg Oncol 2023; 14:15-29. [PMID: 37359927 PMCID: PMC10284789 DOI: 10.1007/s13193-022-01612-9] [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: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Cancer of unknown primary (CUP) is a well-studied entity with guidelines available for the management of patients with CUP. The peritoneum represents one of the metastatic sites in CUP, and peritoneal metastases (PM) could present as CUP. PM of unknown origin remains a poorly studied clinical entity. There is only one series of 15 cases, one population-based study, and few other case reports on this subject. Studies on CUP, in general, cover some common tumour histological types like adenocarcinomas and squamous carcinomas. Some of these tumours may have a good prognosis though majority have high-grade disease with a poor long-term outcome. Some of the histological tumour types commonly seen in the clinical scenario of PM like mucinous carcinoma have not been studied. In this review, we divide PM into five histological types-adenocarcinomas, serous carcinomas, mucinous carcinomas, sarcomas and other rare varieties. We provide algorithms to identify the primary tumour site using immunohistochemistry when imaging, and endoscopy fails to establish the primary tumour site. The role of molecular diagnostic tests for PM or unknown origin is also discussed. Current literature on site-specific systemic therapy based on gene expression profiling does not show a clear benefit of this approach over empirical systemic therapies.
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Affiliation(s)
- Aditi Bhatt
- Dept. of Surgical Oncology, Zydus Hospital, Thaltej, Ahmedabad 380054 India
| | - Suniti Mishra
- Dept. of Pathology, Sparsh Hospital, Bangalore, India
| | - Olivier Glehen
- Dept. of Surgical Oncology, Centre Hospitalier Lyon-Sud, Lyon, France
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6
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Brundu S, Napolitano V, Franzolin G, Lo Cascio E, Mastrantonio R, Sardo G, Cascardi E, Verginelli F, Sarnataro S, Gambardella G, Pisacane A, Arcovito A, Boccaccio C, Comoglio PM, Giraudo E, Tamagnone L. Mutated axon guidance gene PLXNB2 sustains growth and invasiveness of stem cells isolated from cancers of unknown primary. EMBO Mol Med 2023; 15:e16104. [PMID: 36722641 PMCID: PMC9994481 DOI: 10.15252/emmm.202216104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 02/02/2023] Open
Abstract
The genetic changes sustaining the development of cancers of unknown primary (CUP) remain elusive. The whole-exome genomic profiling of 14 rigorously selected CUP samples did not reveal specific recurring mutation in known driver genes. However, by comparing the mutational landscape of CUPs with that of most other human tumor types, it emerged a consistent enrichment of changes in genes belonging to the axon guidance KEGG pathway. In particular, G842C mutation of PlexinB2 (PlxnB2) was predicted to be activating. Indeed, knocking down the mutated, but not the wild-type, PlxnB2 in CUP stem cells resulted in the impairment of self-renewal and proliferation in culture, as well as tumorigenic capacity in mice. Conversely, the genetic transfer of G842C-PlxnB2 was sufficient to promote CUP stem cell proliferation and tumorigenesis in mice. Notably, G842C-PlxnB2 expression in CUP cells was associated with basal EGFR phosphorylation, and EGFR blockade impaired the viability of CUP cells reliant on the mutated receptor. Moreover, the mutated PlxnB2 elicited CUP cell invasiveness, blocked by EGFR inhibitor treatment. In sum, we found that a novel activating mutation of the axon guidance gene PLXNB2 sustains proliferative autonomy and confers invasive properties to stem cells isolated from cancers of unknown primary, in EGFR-dependent manner.
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Affiliation(s)
| | - Virginia Napolitano
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
| | | | - Ettore Lo Cascio
- Department of Biotechnological Sciences and Intensive CareUniversità Cattolica del Sacro CuoreRomeItaly
| | - Roberta Mastrantonio
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
| | | | - Eliano Cascardi
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | | | | | - Gennaro Gambardella
- Telethon Institute of Genetic and MedicinePozzuoliItaly
- Department of Electrical Engineering and Information TechnologyUniversity of Naples Federico IINaplesItaly
| | | | - Alessandro Arcovito
- Department of Biotechnological Sciences and Intensive CareUniversità Cattolica del Sacro CuoreRomeItaly
- Fondazione Policlinico Gemelli (FPG) – IRCCSRomeItaly
| | - Carla Boccaccio
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of OncologyUniversity of TurinTurinItaly
| | | | - Enrico Giraudo
- Candiolo Cancer InstituteFPO‐IRCCSTurinItaly
- Department of Science and Drug TechnologyUniversity of TurinTurinItaly
| | - Luca Tamagnone
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Fondazione Policlinico Gemelli (FPG) – IRCCSRomeItaly
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7
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Krämer A, Bochtler T, Pauli C, Baciarello G, Delorme S, Hemminki K, Mileshkin L, Moch H, Oien K, Olivier T, Patrikidou A, Wasan H, Zarkavelis G, Pentheroudakis G, Fizazi K. Cancer of unknown primary: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023; 34:228-246. [PMID: 36563965 DOI: 10.1016/j.annonc.2022.11.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- A Krämer
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - T Bochtler
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - C Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - G Baciarello
- Medical Oncology Department, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - S Delorme
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg
| | - K Hemminki
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and Biomedical Center, Charles University, Pilsen, Czech Republic
| | - L Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - K Oien
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - T Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - A Patrikidou
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - H Wasan
- Department of Cancer Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - G Zarkavelis
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece
| | | | - K Fizazi
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
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8
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Posner A, Prall OW, Sivakumaran T, Etemadamoghadam D, Thio N, Pattison A, Balachander S, Fisher K, Webb S, Wood C, DeFazio A, Wilcken N, Gao B, Karapetis CS, Singh M, Collins IM, Richardson G, Steer C, Warren M, Karanth N, Wright G, Williams S, George J, Hicks RJ, Boussioutas A, Gill AJ, Solomon BJ, Xu H, Fellowes A, Fox SB, Schofield P, Bowtell D, Mileshkin L, Tothill RW. A comparison of DNA sequencing and gene expression profiling to assist tissue of origin diagnosis in cancer of unknown primary. J Pathol 2023; 259:81-92. [PMID: 36287571 PMCID: PMC10099529 DOI: 10.1002/path.6022] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/02/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Cancer of unknown primary (CUP) is a syndrome defined by clinical absence of a primary cancer after standardised investigations. Gene expression profiling (GEP) and DNA sequencing have been used to predict primary tissue of origin (TOO) in CUP and find molecularly guided treatments; however, a detailed comparison of the diagnostic yield from these two tests has not been described. Here, we compared the diagnostic utility of RNA and DNA tests in 215 CUP patients (82% received both tests) in a prospective Australian study. Based on retrospective assessment of clinicopathological data, 77% (166/215) of CUPs had insufficient evidence to support TOO diagnosis (clinicopathology unresolved). The remainder had either a latent primary diagnosis (10%) or clinicopathological evidence to support a likely TOO diagnosis (13%) (clinicopathology resolved). We applied a microarray (CUPGuide) or custom NanoString 18-class GEP test to 191 CUPs with an accuracy of 91.5% in known metastatic cancers for high-medium confidence predictions. Classification performance was similar in clinicopathology-resolved CUPs - 80% had high-medium predictions and 94% were concordant with pathology. Notably, only 56% of the clinicopathology-unresolved CUPs had high-medium confidence GEP predictions. Diagnostic DNA features were interrogated in 201 CUP tumours guided by the cancer type specificity of mutations observed across 22 cancer types from the AACR Project GENIE database (77,058 tumours) as well as mutational signatures (e.g. smoking). Among the clinicopathology-unresolved CUPs, mutations and mutational signatures provided additional diagnostic evidence in 31% of cases. GEP classification was useful in only 13% of cases and oncoviral detection in 4%. Among CUPs where genomics informed TOO, lung and biliary cancers were the most frequently identified types, while kidney tumours were another identifiable subset. In conclusion, DNA and RNA profiling supported an unconfirmed TOO diagnosis in one-third of CUPs otherwise unresolved by clinicopathology assessment alone. DNA mutation profiling was the more diagnostically informative assay. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Atara Posner
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Owen Wj Prall
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tharani Sivakumaran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | | | - Niko Thio
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Andrew Pattison
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Shiva Balachander
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - Krista Fisher
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Samantha Webb
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Colin Wood
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Anna DeFazio
- The Westmead Institute for Medical Research, Sydney, NSW, Australia.,Department of Gynaecological Oncology, Westmead Hospital, Sydney, NSW, Australia.,The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Nicholas Wilcken
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Bo Gao
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | - Christos S Karapetis
- Department of Medical Oncology, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia
| | - Madhu Singh
- Department of Medical Oncology, Barwon Health Cancer Services, Geelong, VIC, Australia
| | - Ian M Collins
- Department of Medical Oncology, SouthWest HealthCare, Warrnambool and Deakin University, Geelong, VIC, Australia
| | - Gary Richardson
- Department of Medical Oncology, Cabrini Health, Melbourne, VIC, Australia
| | - Christopher Steer
- Border Medical Oncology, Albury Wodonga Regional Cancer Centre, Albury, NSW, Australia
| | - Mark Warren
- Department of Medical Oncology, Bendigo Health, Bendigo, VIC, Australia
| | - Narayan Karanth
- Division of Medicine, Alan Walker Cancer Centre, Darwin, NT, Australia
| | - Gavin Wright
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Scott Williams
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joshy George
- Department of Computational Sciences, The Jackson Laboratory, Farmington, Connecticut, USA
| | - Rodney J Hicks
- The St Vincent's Hospital Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Alex Boussioutas
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical, Research and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Benjamin J Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Huiling Xu
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Andrew Fellowes
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Stephen B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Penelope Schofield
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Psychology, and Iverson Health Innovation Research Institute, Swinburne University, Melbourne, VIC, Australia.,Behavioural Sciences Unit, Health Services Research and Implementation Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - David Bowtell
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Richard W Tothill
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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9
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Comprehensive genomic and epigenomic analysis in cancer of unknown primary guides molecularly-informed therapies despite heterogeneity. Nat Commun 2022; 13:4485. [PMID: 35918329 PMCID: PMC9346116 DOI: 10.1038/s41467-022-31866-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/06/2022] [Indexed: 11/09/2022] Open
Abstract
The benefit of molecularly-informed therapies in cancer of unknown primary (CUP) is unclear. Here, we use comprehensive molecular characterization by whole genome/exome, transcriptome and methylome analysis in 70 CUP patients to reveal substantial mutational heterogeneity with TP53, MUC16, KRAS, LRP1B and CSMD3 being the most frequently mutated known cancer-related genes. The most common fusion partner is FGFR2, the most common focal homozygous deletion affects CDKN2A. 56/70 (80%) patients receive genomics-based treatment recommendations which are applied in 20/56 (36%) cases. Transcriptome and methylome data provide evidence for the underlying entity in 62/70 (89%) cases. Germline analysis reveals five (likely) pathogenic mutations in five patients. Recommended off-label therapies translate into a mean PFS ratio of 3.6 with a median PFS1 of 2.9 months (17 patients) and a median PFS2 of 7.8 months (20 patients). Our data emphasize the clinical value of molecular analysis and underline the need for innovative, mechanism-based clinical trials. The identification of molecular biomarkers in cancer of unknown primary site (CUP) cases may enable the improvement of prognosis in these patients. Here, the authors integrate whole genome/exome, transcriptome and methylome data in 70 CUP patients, recommend therapies based on their analysis and report clinical outcome data.
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10
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Blecua P, Davalos V, de Villasante I, Merkel A, Musulen E, Coll-SanMartin L, Esteller M. Refinement of computational identification of somatic copy number alterations using DNA methylation microarrays illustrated in cancers of unknown primary. Brief Bioinform 2022; 23:6582004. [PMID: 35524475 PMCID: PMC9487591 DOI: 10.1093/bib/bbac161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 03/30/2022] [Accepted: 04/10/2022] [Indexed: 11/14/2022] Open
Abstract
High-throughput genomic technologies are increasingly used in personalized cancer medicine. However, computational tools to maximize the use of scarce tissues combining distinct molecular layers are needed. Here we present a refined strategy, based on the R-package 'conumee', to better predict somatic copy number alterations (SCNA) from deoxyribonucleic acid (DNA) methylation arrays. Our approach, termed hereafter as 'conumee-KCN', improves SCNA prediction by incorporating tumor purity and dynamic thresholding. We trained our algorithm using paired DNA methylation and SNP Array 6.0 data from The Cancer Genome Atlas samples and confirmed its performance in cancer cell lines. Most importantly, the application of our approach in cancers of unknown primary identified amplified potentially actionable targets that were experimentally validated by Fluorescence in situ hybridization and immunostaining, reaching 100% specificity and 93.3% sensitivity.
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Affiliation(s)
- Pedro Blecua
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Veronica Davalos
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Izar de Villasante
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Angelika Merkel
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Eva Musulen
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain.,Department of Pathology, Hospital Universitari General de Catalunya-Grupo Quirónsalud, Sant Cugat del Vallès, Barcelona, Catalonia, Spain
| | - Laia Coll-SanMartin
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain
| | - Manel Esteller
- Josep Carreras Leukaemia Research Institute (IJC), Badalona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Cancer (CIBERONC), Madrid, Spain.,Institucio Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain.,Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Catalonia, Spain
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11
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Conway AM, Morris GC, Smith S, Vekeria M, Manoharan P, Mitchell C, Backen A, Oliveira P, Hubner RA, Lamarca A, McNamara MG, Valle JW, Cook N. Intrahepatic cholangiocarcinoma hidden within cancer of unknown primary. Br J Cancer 2022; 127:531-540. [PMID: 35484217 PMCID: PMC9345855 DOI: 10.1038/s41416-022-01824-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/29/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Many patients referred with a provisional diagnosis of cancer of unknown primary (pCUP) present with presumed metastatic disease to the liver. Due to the lack of definitive histological markers, intrahepatic cholangiocarcinoma (iCCA) may be overlooked. This study assessed the frequency of iCCA within a pCUP cohort. Methods A single UK cancer-center study of sequential patients referred with pCUP from January 2017 to April 2020. Baseline diagnostic imaging was reviewed independently by a radiologist and oncologist; those with radiological features of iCCA (dominant liver lesion, capsular retraction) were identified. Results Of 228 patients referred with pCUP, 72 (32%) had malignancy involving the liver. 24/72 patients had radiological features consistent with iCCA; they were predominantly female (75%) with an average age of 63 years and 63% had an ECOG PS ≤ 2. The median overall survival (OS) of the iCCA group and the remaining liver-involved CUP group were similar (OS 4.1 vs 4.4 months, p-value = 0.805). Patients, where a primary diagnosis was subsequently determined, had better OS (10.2 months, p-values: iCCA = 0.0279: cCUP = 0.0230). Conclusions In this study, 34% of patients with liver-involved pCUP, fulfilled the radiological criteria for an iCCA diagnosis. Consideration of an iCCA diagnosis in patients with CUP could improve timely diagnosis, molecular characterisation and treatment.
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Affiliation(s)
- Alicia-Marie Conway
- Cancer Research UK Manchester Institute Cancer Biomarker Centre, The University of Manchester, Manchester, UK.,Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Georgina C Morris
- School of Medical Sciences, University of Manchester, Manchester, UK
| | - Sarah Smith
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Monique Vekeria
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Prakash Manoharan
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Claire Mitchell
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Alison Backen
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Pedro Oliveira
- Department of Pathology, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK. .,Division of Cancer Sciences, University of Manchester, Manchester, UK.
| | - Natalie Cook
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK. .,Division of Cancer Sciences, University of Manchester, Manchester, UK.
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12
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Bochtler T, Wohlfromm T, Hielscher T, Stichel D, Pouyiourou M, Kraft B, Neumann O, Endris V, von Deimling A, Stenzinger A, Krämer A. Prognostic Impact of Copy Number Alterations and Tumor Mutational Burden in Carcinoma of Unknown Primary. Genes Chromosomes Cancer 2022; 61:551-560. [DOI: 10.1002/gcc.23047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- 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 Medical Oncology, National Center for Tumor Diseases (NCT) 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
| | - Thomas Hielscher
- Division of Biostatistics German Cancer Research Center (DKFZ) Heidelberg Germany
| | - Damian Stichel
- Institute of Neuropathology University of Heidelberg Heidelberg Germany
- Clinical Cooperation Unit Neuropathology German Cancer Research Center (DKFZ)
| | - 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
| | - Bianca Kraft
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V University of Heidelberg Heidelberg Germany
| | - Olaf Neumann
- Institute of Pathology University of Heidelberg Heidelberg Germany
| | - Volker Endris
- Institute of Pathology University of Heidelberg Heidelberg Germany
| | - Andreas von Deimling
- Institute of Neuropathology University of Heidelberg Heidelberg Germany
- Clinical Cooperation Unit Neuropathology German Cancer Research Center (DKFZ)
| | | | - 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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13
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Losa F, Fernández I, Etxaniz O, Giménez A, Gomila P, Iglesias L, Longo F, Nogales E, Sánchez A, Soler G. SEOM-GECOD clinical guideline for unknown primary cancer (2021). Clin Transl Oncol 2022; 24:681-692. [PMID: 35320504 PMCID: PMC8986666 DOI: 10.1007/s12094-022-02806-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/16/2022]
Abstract
Cancer of unknown primary site (CUP) is defined as a heterogeneous group of tumors that appear as metastases, and of which standard diagnostic work-up fails to identify the origin. It is considered a separate entity with a specific biology, and nowadays molecular characteristics and the determination of actionable mutations may be important in a significant group of patients. In this guide, we summarize the diagnostic, therapeutic, and possible new developments in molecular medicine that may help us in the management of this unique disease entity.
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Affiliation(s)
- Ferrán Losa
- Hospital de Sant Joan Despí Moisés Broggi-ICO Hospitalet, Barcelona, Spain.
| | | | - Olatz Etxaniz
- Hospital Germans Trias I Pujol -ICO Badalona, Barcelona, Spain
| | | | - Paula Gomila
- Hospital Miguel Servet (Zaragoza)/H, de Barbastro, Spain
| | | | - Federico Longo
- Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | | | - Antonio Sánchez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Gemma Soler
- Hospital Durán i Reynals-ICO Hospitalet, Barcelona, Spain
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14
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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.
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15
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Redefining cancer of unknown primary: Is precision medicine really shifting the paradigm? Cancer Treat Rev 2021; 97:102204. [PMID: 33866225 DOI: 10.1016/j.ctrv.2021.102204] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
The concept of Cancer of Unknown Primary (CUP) has evolved with the advent of medical oncology. CUP can be difficult to diagnose and represents 2 to 5% of new cancers, therefore not exceptionally rare. Within CUPs can be identified a subset of favourable prognosis tumours, however the vast majority of CUP patients belongs to a poor prognosis group. CUP features significant oncological challenges, such as unravelling biological and transversal issues, and most importantly, improving patient's outcomes. In that regard, CUP patients' outcomes regrettably showed minimal improvement for decades and CUP remains a cancer group of very poor prognosis. The biology of CUP has two main hypotheses. One is that CUP is a subgroup of a given primary cancer, where the primary is present but cannot be seen due to its small size. The other, the "true" CUP hypothesis, states that CUP share features that make them a specific entity, whatever their tissue of origin. A true biological signature has not yet been described, but chromosomal instability is a hallmark of poor prognosis CUP group. Precision oncology, despite achieving identifying the putative origin of the CUP, so far failed to globally improve outcomes of patients. Targeting molecular pathways based on molecular analysis in CUP management is under investigation. Immunotherapy has not shown ground-breaking results, to date. Accrual is also a crucial issue in CUP trials. Herein we review CUP history, biological features and remaining questions in CUP biology, the two main approaches of molecular oncology in CUP management, in order to draw perspectives in the enormous challenge of improving CUP patient outcomes.
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16
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Kato S, Alsafar A, Walavalkar V, Hainsworth J, Kurzrock R. Cancer of Unknown Primary in the Molecular Era. Trends Cancer 2021; 7:465-477. [PMID: 33516660 DOI: 10.1016/j.trecan.2020.11.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/21/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
Cancer of unknown primary (CUP) is a rare malignancy that presents with metastatic disease and no identifiable site of origin. Most patients have unfavorable features and attempts to treat based on tissue-of-origin identification have not yielded a survival advantage compared with empiric chemotherapy. Next-generation sequencing has revealed genomic alterations that can be targeted in selected cases, suggesting that CUP represents a unique malignancy in which the genomic aberrations may be integral to the diagnosis. Recent trials focusing on tailored combination therapy matched to the genomic alterations in each cancer are providing new avenues of clinical investigation. Here, we discuss recent findings on molecular aberrations in CUP and how the genomic and immune landscape can be leveraged to optimize therapy.
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Affiliation(s)
- Shumei Kato
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, CA, USA.
| | - Ahmed Alsafar
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Vighnesh Walavalkar
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - John Hainsworth
- Tennessee Oncology, PLLC, Nashville, TN, USA; Sarah Cannon Research Institute, Nashville, TN, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, CA, USA
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17
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Laprovitera N, Riefolo M, Ambrosini E, Klec C, Pichler M, Ferracin M. Cancer of Unknown Primary: Challenges and Progress in Clinical Management. Cancers (Basel) 2021; 13:cancers13030451. [PMID: 33504059 PMCID: PMC7866161 DOI: 10.3390/cancers13030451] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Patients with cancer of unknown primary site suffer the burden of an uncertain disease, which is characterized by the impossibility to identify the tissue where the tumor has originated. The identification of the primary site of a tumor is of great importance for the patient to have access to site-specific treatments and be enrolled in clinical trials. Therefore, patients with cancer of unknown primary have reduced therapeutic opportunities and poor prognosis. Advancements have been made in the molecular characterization of this tumor, which could be used to infer the tumor site-of-origin and thus broaden the diagnostic outcome. Moreover, we describe here the novel therapeutic opportunities that are based on the genetic and immunophenotypic characterization of the tumor, and thus independent from the tumor type, which could provide most benefit to patients with cancer of unknown primary. Abstract Distant metastases are the main cause of cancer-related deaths in patients with advanced tumors. A standard diagnostic workup usually contains the identification of the tissue-of-origin of metastatic tumors, although under certain circumstances, it remains elusive. This disease setting is defined as cancer of unknown primary (CUP). Accounting for approximately 3–5% of all cancer diagnoses, CUPs are characterized by an aggressive clinical behavior and represent a real therapeutic challenge. The lack of determination of a tissue of origin precludes CUP patients from specific evidence-based therapeutic options or access to clinical trial, which significantly impacts their life expectancy. In the era of precision medicine, it is essential to characterize CUP molecular features, including the expression profile of non-coding RNAs, to improve our understanding of CUP biology and identify novel therapeutic strategies. This review article sheds light on this enigmatic disease by summarizing the current knowledge on CUPs focusing on recent discoveries and emerging diagnostic strategies.
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Affiliation(s)
- Noemi Laprovitera
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40126 Bologna, Italy; (N.L.); (M.R.); (E.A.)
- Department of Life Sciences and Biotechnologies, University of Ferrara, 44121 Ferrara, Italy
| | - Mattia Riefolo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40126 Bologna, Italy; (N.L.); (M.R.); (E.A.)
| | - Elisa Ambrosini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40126 Bologna, Italy; (N.L.); (M.R.); (E.A.)
| | - Christiane Klec
- Division of Oncology, Medical University of Graz, 8036 Graz, Austria; (C.K.); (M.P.)
| | - Martin Pichler
- Division of Oncology, Medical University of Graz, 8036 Graz, Austria; (C.K.); (M.P.)
| | - Manuela Ferracin
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40126 Bologna, Italy; (N.L.); (M.R.); (E.A.)
- Correspondence: ; Tel.: +39-051-209-4714
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18
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Dermawan JK, Rubin BP. The role of molecular profiling in the diagnosis and management of metastatic undifferentiated cancer of unknown primary ✰: Molecular profiling of metastatic cancer of unknown primary. Semin Diagn Pathol 2020; 38:193-198. [PMID: 33309276 DOI: 10.1053/j.semdp.2020.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022]
Abstract
Cancer of unknown primary (CUP) refers to metastatic tumors for which the primary tumor of origin cannot be determined at the time of diagnosis, despite extensive clinicopathologic investigations. Molecular profiling is increasingly able to predict a probable primary tumor type for CUP when clinicopathologic workup is inconclusive. Numerous studies have explored the use of various molecular profiling techniques for identification of site/tissue of origin of CUP. These techniques include gene expression profiling utilizing microarray, reverse transcriptase polymerase chain reaction, RNA-sequencing, somatic gene mutation profiling with next-generation DNA sequencing, and epigenomics including DNA methylation profiling. Despite the generally poor prognosis of CUP, a minority of patients can expect to benefit from targeted therapy despite being agnostic to the tissue of origin. Studies have explored the use of various molecular profiling techniques to predict prognostic and therapeutic biomarkers, with the goal of improving outcome for patients with CUP. However, discordant results between non-randomized and randomized clinical trials in evaluating tumor-type specific therapies raise uncertainties of the benefits of molecularly-predicted tissue of origin-based treatment in routine clinical use. Nevertheless, the current overall trend is in favor of using molecular tools to refine the diagnosis and clinical management of patients with CUP. More large-cohort, randomized prospective studies are needed to assess and validate the utility and feasibility of molecular profiling to uncover potentially targetable genetic alterations. These efforts will also yield further biological insights into the biology and pathogenesis of CUP (Graphical Abstract).
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Affiliation(s)
- Josephine K Dermawan
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Brian P Rubin
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
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19
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Ye Q, Wang Q, Qi P, Chen J, Sun Y, Jin S, Ren W, Chen C, Liu M, Xu M, Ji G, Yang J, Nie L, Xu Q, Huang D, Du X, Zhou X. Development and Clinical Validation of a 90-Gene Expression Assay for Identifying Tumor Tissue Origin. J Mol Diagn 2020; 22:1139-1150. [PMID: 32610162 DOI: 10.1016/j.jmoldx.2020.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022] Open
Abstract
The accurate identification of tissue origin in patients with metastatic cancer is critical for effective treatment selection but remains a challenge. The aim of this study is to develop a gene expression assay for tumor molecular classification and integrate it with clinicopathologic evaluations to identify the tissue origin for cancer of uncertain primary (CUP). A 90-gene expression signature, covering 21 tumor types, was identified and validated with an overall accuracy of 89.8% (95% CI, 0.87-0.92) in 609 tumor samples. More specifically, the classification accuracy reached 90.4% (95% CI, 0.87-0.93) for 323 primary tumors and 89.2% (95% CI, 0.85-0.92) for 286 metastatic tumors, with no statistically significant difference (P = 0.71). Furthermore, in a real-life cohort of 141 CUP patients, predictions by the 90-gene expression signature were consistent or compatible with the clinicopathologic features in 71.6% of patients (101/141). Findings suggest that this novel gene expression assay could efficiently predict the primary origin for a broad spectrum of tumor types and support its diagnostic utility of molecular classification in difficult-to-diagnose metastatic cancer. Additional studies are ongoing to further evaluate the clinical utility of this novel gene expression assay in predicting primary site and directing therapy for CUP patients.
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Affiliation(s)
- Qing Ye
- Division of Life Sciences and Medicine, Department of Pathology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, People's Republic of China; Division of Life Sciences and Medicine, Intelligent Pathology Institute, University of Science and Technology of China, Hefei, People's Republic of China; Department of Pathology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China; Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China
| | - Qifeng Wang
- Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Peng Qi
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jinying Chen
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Yifeng Sun
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Shichai Jin
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Wanli Ren
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Chengshu Chen
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Mei Liu
- Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China
| | - Midie Xu
- Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Gang Ji
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jun Yang
- Department of Pathology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Ling Nie
- Department of Pathology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Qinghua Xu
- Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China; Canhelp Genomics Research Center, Hangzhou, Canhelp Genomics Co., Ltd., People's Republic of China; Institute of Machine Learning and Systems Biology, College of Electronics and Information Engineering, Tongji University, Shanghai, People's Republic of China.
| | - Deshuang Huang
- Institute of Machine Learning and Systems Biology, College of Electronics and Information Engineering, Tongji University, Shanghai, People's Republic of China
| | - Xiang Du
- Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xiaoyan Zhou
- Cancer of Unknown Primary Group, Pathology Committee, Chinese Research Hospital Association, Shanghai, People's Republic of China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.
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20
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Benvenuti S, Milan M, Geuna E, Pisacane A, Senetta R, Gambardella G, Stella GM, Montemurro F, Sapino A, Boccaccio C, Comoglio PM. Cancer of Unknown Primary (CUP): genetic evidence for a novel nosological entity? A case report. EMBO Mol Med 2020; 12:e11756. [PMID: 32511869 PMCID: PMC7338804 DOI: 10.15252/emmm.201911756] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/31/2022] Open
Abstract
Cancer of unknown primary (CUP) is an obscure disease characterized by multiple metastases in the absence of a primary tumor. No consensus has been reached whether CUPs are simply generated from cancers that cannot be detected or whether they are the manifestation of a still unknown nosological entity. Here, we report the complete expression and genetic analysis of multiple synchronous metastases harvested at warm autopsy of a patient with CUP. The expression profiles were remarkably similar and astonishingly singular. The whole exome analysis yielded a high number of mutations present in all metastases (fully shared), additional mutations (partially shared) accumulated one after another in a series, and few private mutations were unique to each metastasis. Surprisingly, the phylogenetic trajectory linking CUP metastases was atypical, depicting a common "stream", sprouting a series of linear "brooks", at variance from the extensive branched evolution observed in metastases from most cancers of known origin. The distinctive genetic and evolutionary features depicted suggest that CUP is a novel nosological entity.
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Affiliation(s)
- Silvia Benvenuti
- Molecular Therapeutics and Exploratory Research Laboratory, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
| | - Melissa Milan
- Molecular Therapeutics and Exploratory Research Laboratory, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
| | - Elena Geuna
- Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
| | - Alberto Pisacane
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
| | - Rebecca Senetta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gennaro Gambardella
- Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli (Naples), Italy.,University of Naples Federico II, Naples, Italy
| | - Giulia M Stella
- Department of Medical Sciences and Infectious Diseases, Unit of Respiratory System Diseases, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Filippo Montemurro
- Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
| | - Anna Sapino
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
| | - Carla Boccaccio
- Laboratory of Cancer Stem Cells, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy.,Department of Oncology, University of Turin Medical School, Candiolo (Turin), Italy
| | - Paolo M Comoglio
- Molecular Therapeutics and Exploratory Research Laboratory, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (Turin), Italy
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21
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Lombardo R, Tosi F, Nocerino A, Bencardino K, Gambi V, Ricotta R, Spina F, Siena S, Sartore-Bianchi A. The Quest for Improving Treatment of Cancer of Unknown Primary (CUP) Through Molecularly-Driven Treatments: A Systematic Review. Front Oncol 2020; 10:533. [PMID: 32457826 PMCID: PMC7225282 DOI: 10.3389/fonc.2020.00533] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/25/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Carcinomas of unknown primary (CUP) account for 3–5% of all malignancy and, despite a reduction in incidence, the overall survival has not improved over the last decade. Chemotherapy regimens have not provided encouraging results. New diagnostic technologies, such as next generation sequencing (NGS), could represent a chance to identify potentially targetable genomic alterations in order to personalize treatment of CUP and provide insights into tumor biology. Methods: A systematic review of studies of patients with CUP, whose tumor specimen was evaluated through a NGS panel, has been performed on June 10th, 2019 according to PRISMA criteria from PubMed, ASCO meeting library and Clinicaltrial.gov. We have identified potentially targetable alterations for which approved/off-label/in clinical trials drugs are available. Moreover, we have included case reports about CUP patients treated with targeted therapies driven by NGS results in order to explore the clinical role of NGS in this setting. Results: We have evaluated 15 publications of which eleven studies (9 full-text articles and 2 abstracts) have analyzed the genomic profiling of CUPs through NGS technology, with different platforms and with different patients cohorts, ranging from 16 to 1,806 patients. Among all these studies, 85% of patients demonstrated at least one molecular alteration, the most frequent involving TP53 (41.88%), KRAS (18.81%), CDKN2A (8.8%), and PIK3CA (9.3%). A mean of 47.3% of patients harbored a potentially targetable alteration for which approved/off-label/in clinical trials drugs were available. Furthermore, we have identified 4 case reports in order to evaluate the clinical relevance of a specific targeted therapy identified through NGS. Conclusions: NGS may represent a tool to improve diagnosis and treatment of CUP by identifying therapeutically actionable alterations and providing insights into tumor biology.
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Affiliation(s)
- Roberta Lombardo
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Federica Tosi
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Annunziata Nocerino
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Katia Bencardino
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Gambi
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo Ricotta
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Spina
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Salvatore Siena
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Andrea Sartore-Bianchi
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
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22
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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.
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Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, Paris, France.
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23
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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.
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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
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24
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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
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25
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Kolling S, Ventre F, Geuna E, Milan M, Pisacane A, Boccaccio C, Sapino A, Montemurro F. "Metastatic Cancer of Unknown Primary" or "Primary Metastatic Cancer"? Front Oncol 2020; 9:1546. [PMID: 32010631 PMCID: PMC6978906 DOI: 10.3389/fonc.2019.01546] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/20/2019] [Indexed: 01/10/2023] Open
Abstract
Cancer of unknown primary (CUP) is an umbrella term used to classify a heterogeneous group of metastatic cancers based on the absence of an identifiable primary tumor. Clinically, CUPs are characterized by a set of distinct features comprising early metastatic dissemination in an atypical pattern, an aggressive clinical course, poor response to empiric chemotherapy and, consequently, a short life expectancy. Two opposing strategies to change the dismal prognosis for the better are pursued. On the one hand, following the traditional tissue-gnostic approach, more and more sophisticated tissue-of-origin (TOO) classifier assays are employed to push identification of the putative primary to its limits with the clear intent of allowing tumor-site specific treatment. However, robust evidence supporting its routine clinical use is still lacking, notably with two recent randomized clinical trials failing to show a patient benefit of TOO-prediction based site-specific treatment over empiric chemotherapy in CUP. On the other hand, with regards to a tissue-agnostic strategy, precision medicine approaches targeting actionable genomic alterations have already transformed the treatment for many known tumor types. Yet, an unmet need remains for well-designed clinical trials to scrutinize its potential role in CUP beyond anecdotal case reports. In the absence of practice changing results, we believe that the emphasis on finding the presumed unknown primary tumor at all costs, implicit in the term CUP, has biased recent research in the field. Focusing on the distinct clinical features shared by all CUPs, we advocate adopting the term primary metastatic cancer (PMC) to denominate a distinct cancer entity instead. In our view, PMC should be considered the archetype of metastatic disease and as such, despite accounting for a mere 2–3% of malignancies, unraveling the mechanisms at play goes beyond improving the prognosis of patients with PMC and promises to greatly enhance our understanding of the metastatic process and carcinogenesis across all cancer types.
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Affiliation(s)
- Stefan Kolling
- Department of Investigative Clinical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Ferdinando Ventre
- Department of Investigative Clinical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Elena Geuna
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Melissa Milan
- Laboratory of Exploratory Research and Molecular Cancer Therapy, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Alberto Pisacane
- Unit of Pathology, Candiolo Cancer Institute, FPO- IRCCS, Candiolo, Italy
| | - Carla Boccaccio
- Laboratory of Cancer Stem Cell Research, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.,Department of Oncology, University of Turin Medical School, Candiolo, Italy
| | - Anna Sapino
- Unit of Pathology, Candiolo Cancer Institute, FPO- IRCCS, Candiolo, Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
| | - Filippo Montemurro
- Multidisciplinary Oncology Outpatient Clinic, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
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26
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Bochtler T, Krämer A. Does Cancer of Unknown Primary (CUP) Truly Exist as a Distinct Cancer Entity? Front Oncol 2019; 9:402. [PMID: 31165045 PMCID: PMC6534107 DOI: 10.3389/fonc.2019.00402] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/29/2019] [Indexed: 12/12/2022] Open
Abstract
Cancer of unknown primary (CUP) designates an enigmatic cancer entity with histologic confirmation of malignancy from a metastasis but no identifiable primary tumor in spite of a thorough diagnostic work-up. In this review, we discuss the validity of CUP as a distinct cancer entity as well as diagnostic pitfalls. As arguments against a distinct entity, the diagnosis of CUP is erroneous in some cases. Diagnostic pitfalls include incomplete diagnostics, uncertainty in classifying a lesion as either primary or metastasis and mistaking a relapse of an antecedent malignancy as CUP due to histologic and immunohistologic disparities. Given the high frequency of prior malignancies in CUP patients, relapse of an antecedent cancer should always be carefully excluded. Gene expression profiling-based classifier assays aim at aligning the molecular profile of CUP patients with established primary cancer patterns for highest congruency in order to identify the putative primary and treat accordingly. However, the spectrum of predicted putative primaries by molecular techniques is somewhat at odds with the primaries identified in autopsy series. Also, a first randomized clinical trial did not show superiority of primary-tailored therapy over unspecific platinum-based chemotherapy. CUP cases share an aggressive clinical course, atypical metastasis pattern, rapid progression of metastases, a generally poor response to chemotherapy and dismal outcome as distinct clinical features. Metastatic spread appears to take place in the early stages of tumor evolution, with CUP metastases subsequently undergoing genetic evolution toward a chromosomally highly complex and instable karyotype independent from the primary tumor. In clinical practice, the diagnosis of CUP is valid when no primary tumor is detectable. Treatment should ideally offer broad spectrum coverage across numerous malignancies and be well-established in CUP as is the case for carboplatin/paclitaxel and cisplatin / gemcitabine in particular, but it should also cover the most likely putative primary. The diligent diagnosis of CUP is warranted for clinical trials, making the eligibility process particularly laborious. In conclusion, we deem CUP a distinct cancer entity and the diagnosis accurate in most patient cases.
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Affiliation(s)
- Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, German Cancer Research Center, University Hospital Heidelberg, Heidelberg, Germany.,Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, German Cancer Research Center, University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
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27
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Bochtler T, Endris V, Leichsenring J, Reiling A, Neumann O, Volckmar AL, Kirchner M, Allgäuer M, Schirmacher P, Krämer A, Stenzinger A. Comparative genetic profiling aids diagnosis and clinical decision making in challenging cases of CUP syndrome. Int J Cancer 2019; 145:2963-2973. [PMID: 30963573 DOI: 10.1002/ijc.32316] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/15/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023]
Abstract
Cancer of unknown primary (CUP) denotes cancer cases where metastatic spread is histologically confirmed, but no respective primary tumor can be identified. The challenging diagnosis of CUP is further complicated in cases with previously identified malignancies or with dubious clonal relationship between metastatic sites due to ambiguous histology. Our study aims at elucidating clonal relationships by comparing the respective mutational spectra. Targeted next-generation sequencing (NGS) employing formalin-fixed and paraffin-embedded (FFPE) tumor tissue was performed on 174 consecutive CUP patients. Among these, 43/174 (24.7%) patients had a documented prior malignancy. Data on pairwise targeted NGS testing to address clonal relationships between the previous malignancy and the presumed CUP (n = 11) or between different CUP metastatic sites (n = 7) was available in 18 patients. NGS could clarify clonal relationships in 16/18 cases. Among the 11 CUP patients with antecedent malignancies, four cases were clonally independent of the previous malignancy but harbored deleterious germline mutations in BRCA/BAP1/ATM genes. Seven CUP cases were clonally related to the antecedent malignancy, changing the CUP diagnosis to relapse of the prior malignancy. In the seven CUP cases, with doubtfully related metastatic sites, NGS confirmed clonal relationship in five cases and was inconclusive in two. In conclusion, NGS proved an efficient tool to elucidate clonal relationships in clinically challenging CUP cases. Our study cautions against a premature diagnosis of CUP. Relapses of antecedent malignancies should be carefully considered. CUPs clonally independent from the antecedent malignancy should raise a red flag of a potential cancer-predisposing germline mutation.
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Affiliation(s)
- Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jonas Leichsenring
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Reiling
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna-Lena Volckmar
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
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28
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Conway AM, Mitchell C, Kilgour E, Brady G, Dive C, Cook N. Molecular characterisation and liquid biomarkers in Carcinoma of Unknown Primary (CUP): taking the 'U' out of 'CUP'. Br J Cancer 2019; 120:141-153. [PMID: 30580378 PMCID: PMC6342985 DOI: 10.1038/s41416-018-0332-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023] Open
Abstract
Cancers of Unknown Primary (CUP) comprise a heterogeneous clinical entity of confirmed metastatic cancer where the primary site of origin is undetectable. It has a poor prognosis with limited treatment options. CUP is historically under-researched; however, understanding its biology has the potential to not only improve treatment and survival by implementation of biomarkers for patient management, but also to greatly contribute to our understanding of carcinogenesis and metastasis across all cancer types. Here we review the current advances in CUP research and explore the debated hypotheses underlying its biology. The evolution of molecular profiling and tissue-of-origin classifiers have the potential to transform the diagnosis, classification and therapeutic management of patients with CUP but robust evidence to support widespread use is lacking. Precision medicine has transformed treatment strategy in known tumour types; in CUP, however, there remains a clinical need for a better understanding of molecular characteristics to establish the potential role of novel or existing therapeutics. The emergence of liquid biopsies as a source of predictive and prognostic biomarkers within known tumour types is gaining rapid ground and this review explores the potential utility of liquid biopsies in CUP.
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Affiliation(s)
- Alicia-Marie Conway
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK
- The University of Manchester, Oxford Road, Manchester, UK
- Cancer Research UK Manchester Institute, Alderley Park, Alderley Edge, Macclesfield, Cheshire, SK10 4TG, UK
| | - Claire Mitchell
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK
- The University of Manchester, Oxford Road, Manchester, UK
| | - Elaine Kilgour
- The University of Manchester, Oxford Road, Manchester, UK
- Cancer Research UK Manchester Institute, Alderley Park, Alderley Edge, Macclesfield, Cheshire, SK10 4TG, UK
| | - Gerard Brady
- The University of Manchester, Oxford Road, Manchester, UK
- Cancer Research UK Manchester Institute, Alderley Park, Alderley Edge, Macclesfield, Cheshire, SK10 4TG, UK
| | - Caroline Dive
- The University of Manchester, Oxford Road, Manchester, UK
- Cancer Research UK Manchester Institute, Alderley Park, Alderley Edge, Macclesfield, Cheshire, SK10 4TG, UK
| | - Natalie Cook
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.
- The University of Manchester, Oxford Road, Manchester, UK.
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29
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Kriegsmann J, Kriegsmann M, Kriegsmann K, Longuespée R, Deininger SO, Casadonte R. MALDI Imaging for Proteomic Painting of Heterogeneous Tissue Structures. Proteomics Clin Appl 2018; 13:e1800045. [PMID: 30471204 DOI: 10.1002/prca.201800045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 11/07/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To present matrix-assisted laser desorption/ionization (MALDI) imaging as a powerful method to highlight various tissue compartments. EXPERIMENTAL DESIGN Formalin-fixed paraffin-embedded (FFPE) tissue of a uterine cervix, a pancreas, a duodenum, a teratoma, and a breast cancer tissue microarray (TMA) are analyzed by MALDI imaging and by immunohistochemistry (IHC). Peptide images are visualized and analyzed using FlexImaging and SCiLS Lab software. Different histological compartments are compared by hierarchical cluster analysis. RESULTS MALDI imaging highlights tissue compartments comparable to IHC. In cervical tissue, normal epithelium can be discerned from intraepithelial neoplasia. In pancreatic and duodenal tissues, m/z signals from lymph follicles, vessels, duodenal mucosa, normal pancreas, and smooth muscle structures can be visualized. In teratoma, specific m/z signals to discriminate squamous epithelium, sebaceous glands, and soft tissue are detected. Additionally, tumor tissue can be discerned from the surrounding stroma in small tissue cores of TMAs. Proteomic data acquisition of complex tissue compartments in FFPE tissue requires less than 1 h with recent mass spectrometers. CONCLUSION AND CLINICAL RELEVANCE The simultaneous characterization of morphological and proteomic features in the same tissue section adds proteomic information for histopathological diagnostics, which relies at present on conventional hematoxylin and eosin staining, histochemical, IHC and molecular methods.
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Affiliation(s)
- Jörg Kriegsmann
- Proteopath GmbH, Trier 54296, Germany.,MVZ for Histology, Cytology and Molecular Diagnostics, Trier 54296, Germany
| | - Mark Kriegsmann
- Institute of Pathology, Heidelberg University, Heidelberg 69120, Germany
| | - Katharina Kriegsmann
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University, Heidelberg 69120, Germany
| | - Rémi Longuespée
- Institute of Pathology, Heidelberg University, Heidelberg 69120, Germany
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Binder C, Matthes KL, Korol D, Rohrmann S, Moch H. Cancer of unknown primary-Epidemiological trends and relevance of comprehensive genomic profiling. Cancer Med 2018; 7:4814-4824. [PMID: 30019510 PMCID: PMC6144156 DOI: 10.1002/cam4.1689] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/21/2018] [Indexed: 01/08/2023] Open
Abstract
Background Cancer of unknown primary (CUP) is a distinct clinicopathological entity with poor prognosis, frequently resistant to chemotherapy. Comprehensive genomic profiling (CGP) by next‐generation sequencing potentially identifies novel treatment options for CUP patients. The objective of this study was to determine incidence and survival trends and to discuss the value of CGP in CUP patients. Methods Age‐standardized incidence rates (ASR) per 100 000 were calculated for 2935 CUP patients from 1981 to 2014 using cancer registry data of the canton of Zurich, Switzerland. Kaplan–Meier survival curves were estimated for sex, age, and histological groups. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HR). A literature review was conducted to assess the current use of CGP in CUP patients. Results ASR of CUP increased from 10.3 to 17.6 between 1981 and 1997 and decreased to 5.8/100 000 in 2014. Mean overall survival remained stable. Mortality was significantly lower for patients with squamous cell carcinoma (HR 0.48 [95% CI, 0.41‐0.57]) and neuroendocrine carcinoma (0.75 [0.63‐0.88]) and higher for unclassified neoplasms (1.25 [1.13‐1.66]) compared to adenocarcinomas. The literature review identified 10 studies using CGP of CUP tissue. Clinically relevant mutations were identified in up to 85% of CUP patients, of which 13%‐64% may benefit from currently available drugs. Conclusions CUP incidence decreased probably due to improved diagnostics, but mortality did not improve over the last 34 years. CGP testing may help to identify molecular signatures in CUP patients and enable targeted treatment.
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Affiliation(s)
- Carmen Binder
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.,Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Katarina Luise Matthes
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.,Cancer Registry Zurich and Zug, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Korol
- Cancer Registry Zurich and Zug, University Hospital Zurich, Zurich, Switzerland
| | - Sabine Rohrmann
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.,Cancer Registry Zurich and Zug, University Hospital Zurich, Zurich, Switzerland
| | - Holger Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
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Clynick B, Dessauvagie B, Sterrett G, Harvey NT, Allcock RJN, Saunders C, Erber W, Meehan K. Genetic characterisation of molecular targets in carcinoma of unknown primary. J Transl Med 2018; 16:185. [PMID: 29973234 PMCID: PMC6032776 DOI: 10.1186/s12967-018-1564-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Carcinoma of unknown primary (CUP) is a metastatic epithelial malignancy in the absence of an identifiable primary tumour. Prognosis for patients with CUP is poor because treatment options are generally limited to broad spectrum chemotherapy. A shift towards personalised cancer management based on mutation profiling offers the possibility of new treatment paradigms. This study has explored whether actionable, oncogenic driver mutations are present in CUP that have potential to better inform treatment decisions. METHODS Carcinoma of unknown primary cases (n = 21) were selected and DNA was isolated from formalin-fixed paraffin embedded sections prior to amplification and sequencing. Two distinct yet complementary targeted gene panels were used to assess variants in up to 76 known cancer-related genes for the identification of biologically relevant and actionable mutations. RESULTS Variants were detected in 17/21 cases (81%) of which 11 (52%) were potentially actionable with drugs currently approved for use in known primary cancer types or undergoing clinical trials. The most common variants detected were in TP53 (47%), KRAS (12%), MET (12%) and MYC (12%). Differences at the molecular level were seen between common CUP histological subtypes. CUP adenocarcinomas and poorly differentiated carcinomas harboured the highest frequency of variants in genes involved in signal transduction pathways (e.g. MET, EGFR, HRAS, KRAS, and BRAF). In contrast, squamous cell carcinoma exhibited a higher frequency of variants in cell cycle control and DNA repair genes (e.g. TP53, CDKN2A and MLH1). CONCLUSION Taken together, mutations in biologically relevant genes were detected in the vast majority of CUP tumours, of which half provided a potentially novel treatment option not generally considered in CUP.
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Affiliation(s)
- B. Clynick
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
| | - B. Dessauvagie
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- PathWest Laboratory Medicine, Fiona Stanley Hospital, 11 Robin Warren Dive, Murdoch, WA 6150 Australia
| | - G. Sterrett
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, J Block, Hospital Ave, Nedlands, WA 6009 Australia
| | - N. T. Harvey
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, J Block, Hospital Ave, Nedlands, WA 6009 Australia
| | - R. J. N. Allcock
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, J Block, Hospital Ave, Nedlands, WA 6009 Australia
| | - C. Saunders
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000 Australia
- Fiona Stanley Hospital, 11 Robin Warren Dive, Murdoch, WA 6150 Australia
| | - W. Erber
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
- PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, J Block, Hospital Ave, Nedlands, WA 6009 Australia
| | - K. Meehan
- School of Biomedical Sciences (M504), The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
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32
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El Rassy E, Pavlidis N. The current evidence for a biomarker-based approach in cancer of unknown primary. Cancer Treat Rev 2018; 67:21-28. [DOI: 10.1016/j.ctrv.2018.04.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/17/2022]
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Kriegsmann J, Casadonte R, Kriegsmann K, Longuespée R, Kriegsmann M. Mass spectrometry in pathology - Vision for a future workflow. Pathol Res Pract 2018; 214:1057-1063. [PMID: 29910062 DOI: 10.1016/j.prp.2018.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 04/23/2018] [Accepted: 05/11/2018] [Indexed: 02/09/2023]
Abstract
Mass spectrometric (MS) techniques are applied in various areas of medical diagnostics. For the detection of microbiological germs and genetic mutations, MS is a method used in routine. Since MS also allows the analysis of proteins and peptides, it seems an ideal candidate to supplement histopatholological diagnostics. Matrix-assisted laser desorption/ionization time-of-flight Imaging MS links molecular analysis of numerous analytes with morphological information about their spatial distribution in cells or tissues. Herein, we review principle MS techniques as well as potential applications in pathology and discuss our vision for a future workflow.
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Affiliation(s)
- Jörg Kriegsmann
- MVZ for Histology, Cytology and Molecular Diagnostics Trier, Trier, Germany; Proteopath GmbH, Trier, Germany
| | | | - Katharina Kriegsmann
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Rémi Longuespée
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mark Kriegsmann
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.
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Yamasaki M, Funaishi K, Saito N, Sakano A, Fujihara M, Daido W, Ishiyama S, Deguchi N, Taniwaki M, Ohashi N, Hattori N. Putative lung adenocarcinoma with epidermal growth factor receptor mutation presenting as carcinoma of unknown primary site: A case report. Medicine (Baltimore) 2018; 97:e9942. [PMID: 29443782 PMCID: PMC5839817 DOI: 10.1097/md.0000000000009942] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RATIONALE Only a few cases of putative lung adenocarcinoma presenting as carcinoma of unknown primary site (CUP) with epidermal growth factor receptor (EGFR) mutation have been reported, and the efficacy of EGFR-tyrosine kinase inhibitors (TKIs) for these cases is unclear. PATIENT CONCERNS AND DIAGNOSES A 67-year-old man complained of paresis of the right lower extremity, dysarthria, and memory disturbance. Computed tomography and magnetic resonance imaging showed multiple brain tumors with brain edema and swelling of the left supraclavicular, mediastinal, and upper abdominal lymph nodes. Moreover, a metastatic duodenal tumor was detected via upper gastrointestinal endoscopy examination. The biopsy specimen of the lesion was examined and was diagnosed as adenocarcinoma with CK7 and TTF-1 positivity. Finally, the case was diagnosed as EGFR mutation-positive putative lung adenocarcinoma presenting as CUP. INTERVENTIONS AND OUTCOMES Oral erlotinib, an EGFR-TKI, was administered at 150 mg daily. Five weeks later, the brain lesions and several swollen lymph nodes showed marked improvement, and the symptoms of the patient also improved. Three months later, the duodenal lesion was undetected on upper gastrointestinal endoscopy. After an 8-month follow-up, the patient was well with no disease progression. LESSONS Putative lung adenocarcinoma presenting as CUP may have EGFR mutation, and EGFR-TKI therapy may be effective for such malignancy.
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Affiliation(s)
- Masahiro Yamasaki
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Kunihiko Funaishi
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Naomi Saito
- Department of Respiratory Medicine, Mazda Hospital, Aki-gun
| | | | - Megumu Fujihara
- Department of Pathology, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital
| | - Wakako Daido
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Sayaka Ishiyama
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Naoko Deguchi
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Masaya Taniwaki
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
| | - Nobuyuki Ohashi
- Department of Respiratory Disease, Hiroshima Red Cross Hospital & Atomic Bomb Survivors Hospital, Naka-ku
- Ohashi Clinic, Naka-ku
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan
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Abstract
In cancer of unknown primary (CUP), metastases are clinically and histologically confirmed, but the primary tumor site remains elusive after extensive work-up. CUPs make up for 2-3% of all epithelial malignancies. The two prevailing histologies are adenocarcinomas and undifferentiated carcinomas, whereas squamous cell carcinomas, neuroendocrine carcinomas and rare histologies account for the remaining 10%. The diagnostic work-up in CUP relies strongly on a detailed immunohistological (IHC) analysis in order to characterize the tumor type, nowadays aided by molecular techniques. Diagnostics also include a thorough clinical examination, a basic lab draw with the most relevant tumor markers, and cross sectional imaging. Additional PET-CT is recommended in cervical lymph nodes suggestive of head and neck cancer and in limited metastases potentially treatable in curative intent. As for treatment, it is paramount to identify patients who fall into one of the six well defined "favorable" subset categories, namely extragonadal germ cell tumors, adenocarcinoma with isolated unilateral axillary lymph nodes in female patients, squamous cell carcinoma with neck lymph nodes, squamous cell carcinoma with inguinal lymph nodes, serous papillary peritoneal carcinomatosis in females and blastic bone metastasis in males with elevated PSA. These subsets are distinct both regarding the required treatment and the comparably favorable prognosis. Within the remaining "unfavorable" group, patients of colon and renal cancer type should be identified based on IHC and clinical picture, since the prognosis of these patients seems to improve with the use of therapy tailored to the presumed primary as well. For the few patients with limited metastases it should be assessed whether they are candidates for surgery, radiotherapy or surgery followed by irradiation in curative intent. The remaining majority of patients are treated with empiric palliative chemotherapy, typically a platinum - paclitaxel combination, though the level of evidence for this therapy recommendation is low. Gemcitabine alone or in combination can be used as an alternative. Decoding of the molecular profiles in CUP offers the prospect of targeted therapy with novel agents. However, there appears to be no uniform molecular pattern for CUP, and the observed molecular diversity thus poses a challenge to respective clinical trials.
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Affiliation(s)
- Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology / Oncology, German Cancer Research Center (DKFZ) and Department of Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine V, Hematology / Oncology, University of Heidelberg, Heidelberg, Germany
| | - Harald Löffler
- Clinical Cooperation Unit Molecular Hematology / Oncology, German Cancer Research Center (DKFZ) and Department of Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine III, Oncology / Hematology / Palliative Care, Marienhospital Stuttgart, Stuttgart, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology / Oncology, German Cancer Research Center (DKFZ) and Department of Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine V, Hematology / Oncology, University of Heidelberg, Heidelberg, Germany.
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Bielčiková Z, Jakabová A, Pinkas M, Zemanová M, Kološtová K, Bobek V. Circulating tumor cells: what we know, what do we want to know about them and are they ready to be used in clinics? Am J Transl Res 2017; 9:2807-2823. [PMID: 28670371 PMCID: PMC5489883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/30/2017] [Indexed: 06/07/2023]
Abstract
Circulating tumor cells (CTC) present in peripheral blood are assigned precursors of advanced tumor disease. Simplicity of blood withdrawal procedure adds practically an unlimited possibility of the CTC-monitoring and the advantages of the repeated biopsies over time. CTC got prognostic, predictive and diagnostic status with the technologic advance. Although the clinical utility of CTC has reached the high evidence, the significance of CTC testing was presented in the treatment strategy mostly with palliative intention. We report on the experiences with the CTC-testing in the CLIA-like laboratory working with the size-based CTC separation and in vitro culture. The data is presented in the form of case reports in patients with breast (BC), colorectal (CRC), prostate (PC) and lung cancer (NSCLC) to support the clinical utility of CTC during the neoadjuvant, adjuvant and palliative treatment. The presented findings support the evidence for liquid biopsy clinical implementation and enhance the ability of malignant disease monitoring and the treatment efficacy prediction.
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Affiliation(s)
- Zuzana Bielčiková
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 499/212808 Prague, Czech Republic
| | - Anna Jakabová
- Department of Laboratory Genetics, University Hospital Kralovske Vinohrady, Srobarova 5010034 Prague, Czech Republic
| | - Michael Pinkas
- Department of Laboratory Genetics, University Hospital Kralovske Vinohrady, Srobarova 5010034 Prague, Czech Republic
| | - Milada Zemanová
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 499/212808 Prague, Czech Republic
| | - Katarína Kološtová
- Department of Laboratory Genetics, University Hospital Kralovske Vinohrady, Srobarova 5010034 Prague, Czech Republic
| | - Vladimír Bobek
- Department of Laboratory Genetics, University Hospital Kralovske Vinohrady, Srobarova 5010034 Prague, Czech Republic
- Third Department of Surgery, First Faculty of Medicine, Charles University in Prague and University Hospital MotolPrague, V Uvalu 84, 15006 Prague
- Department of Thoracic Surgery, Masaryk’s Hospital in Usti nad Labem, Krajska Zdravotni a.s., Socialni Pece 3316/12A40113 Usti nad Labem, Czech Republic
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