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Junior JNA, Preto DD'A, Lazarini MEZN, de Lima MA, Bonatelli M, Berardinelli GN, da Silva VD, Pinheiro C, Reis RM, Cárcano FM. PD-L1 expression and microsatellite instability (MSI) in cancer of unknown primary site. Int J Clin Oncol 2024; 29:726-734. [PMID: 38528294 PMCID: PMC11130030 DOI: 10.1007/s10147-024-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/18/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Cancer of unknown primary site (CUP) is a heterogeneous group of tumors for which the origin remains unknown. Clinical outcomes might be influenced by regulatory processes in its microenvironment. Microsatellite instability (MSI) is a predictive biomarker for cancer immunotherapy and its status, as well as co-occurrence with PD-L1 expression, is poorly evaluated. We aim to evaluate the expression of PD-L1 and the status of MSI in CUP and their possible associations with clinical-pathological features. METHODS The combined positive score (CPS) PD-L1 expression was evaluated by immunohistochemistry. MSI status was assessed using a hexa-plex marker panel by polymerase chain reaction followed by fragment analysis. RESULTS Among the 166 cases, MSI analysis was conclusive in 120, with two cases being MSI positive (1.6%). PD-L1 expression was positive in 18.3% of 109 feasible cases. PD-L1 expression was significantly associated with non-visceral metastasis and a dominance of nodal metastasis. The median overall survival (mOS) was 3.7 (95% CI 1.6-5.8) months and patients who expressed PD-L1 achieved a better mOS compared to those who did not express PD-L1 (18.7 versus 3.0 months, p-value: < .001). ECOG-PS equal to or more than two and PD-L1 expression were independent prognostic factors in multivariate analysis (2.37 and 0.42, respectively). CONCLUSION PD-L1 is expressed in a subset (1/5) of patients with CUP and associated with improved overall survival, while MSI is a rare event. There is a need to explore better the tumor microenvironment as well as the role of immunotherapy to change such a bad clinical outcome.
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Affiliation(s)
| | - Daniel D 'Almeida Preto
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, Brazil
- Barretos School of Health Sciences Dr. Paulo Prata - FACISB, Barretos, Brazil
| | | | | | - Murilo Bonatelli
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
| | | | | | - Céline Pinheiro
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
- Barretos School of Health Sciences Dr. Paulo Prata - FACISB, Barretos, Brazil
| | - Rui Manuel Reis
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
- Medical School, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- 3ICVS/3B's-PT Government Associate Laboratory, Braga, Portugal
| | - Flavio Mavignier Cárcano
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil.
- Oncoclinicas & Co - Medica Scientia Innovation Research (MEDSIR), Sao Paulo, Brazil.
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2
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Kato S, Gumas S, Adashek JJ, Okamura R, Lee S, Sicklick JK, Kurzrock R. Multi-omic analysis in carcinoma of unknown primary (CUP): therapeutic impact of knowing the unknown. Mol Oncol 2024; 18:956-968. [PMID: 35866362 PMCID: PMC10994241 DOI: 10.1002/1878-0261.13293] [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: 10/06/2021] [Revised: 05/11/2022] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
Carcinoma of unknown primary (CUP) is a difficult-to-manage malignancy. Multi-omic profiles and treatment outcome vs. degree of precision matching were assessed. Tumours underwent next-generation sequencing (NGS) [tissue and/or blood-derived cell-free DNA (cfDNA)]. Selected patients had transcriptome-based immune profiling and/or programmed cell death 1 ligand 1 (PD-L1) immunohistochemistry analysis. Patients could be reviewed by a Molecular Tumor Board, but physicians chose the therapy. Of 6497 patients in the precision database, 97 had CUP. The median number of pathogenic tissue genomic alterations was 4 (range, 0-25), and for cfDNA, was 2 (range, 0-9). Each patient had a distinct molecular landscape. Food and Drug Administration (FDA)-approved biomarkers included the following: PD-L1+ ≥ 1%, 30.9% of CUPs tested; microsatellite instability, 3.6%; tumour mutational burden ≥ 10 mutations·Mb-1, 23%; and neurotrophic receptor tyrosine kinase (NTRK) fusions, 0%. RNA-based immunograms showed theoretically druggable targets: lymphocyte activation gene 3 protein (LAG-3), macrophage colony-stimulating factor 1 receptor (CSF1R), adenosine receptor A2 (ADORA2) and indoleamine 2,3-dioxygenase 1 (IDO1). Overall, 56% of patients had ≥ 1 actionable biomarker (OncoKB database). To quantify the degree of matching (tumours to drugs), a Matching Score (MS; roughly equivalent to number of alterations targeted/total number of deleterious alterations) was calculated post hoc. Comparing evaluable treated patients [MS high, > 50% (N = 15) vs. low ≤ 50% (N = 47)], median progression-free survival was 10.4 vs. 2.8 months (95% CI 0.11-0.64; HR 0.27; P = 0.002); survival, 15.8 vs. 6.9 months (95% CI 0.17-1.16; HR 0.45; P = 0.09); and clinical benefit rate (stable disease ≥ 6 months/partial/complete response), 71% vs. 24% (P = 0.003). Higher MS was the only factor that predicted improvement in outcome variables after multivariate analysis. In conclusion, CUPs are molecularly complex. Treatments with high degrees of matching to molecular alterations (generally achieved by individualized combinations) correlated with improved outcomes.
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Affiliation(s)
- Shumei Kato
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of MedicineUC San Diego Moores Cancer CenterLa JollaCAUSA
| | - Sophia Gumas
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of MedicineUC San Diego Moores Cancer CenterLa JollaCAUSA
| | - Jacob J. Adashek
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer CenterThe Johns Hopkins HospitalBaltimoreMDUSA
| | | | - Suzanna Lee
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of MedicineUC San Diego Moores Cancer CenterLa JollaCAUSA
| | - Jason K. Sicklick
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of MedicineUC San Diego Moores Cancer CenterLa JollaCAUSA
- Division of Surgical Oncology, Department of SurgeryUC San Diego School of MedicineCAUSA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of MedicineUC San Diego Moores Cancer CenterLa JollaCAUSA
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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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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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5
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From Biology to Diagnosis and Treatment: The Ariadne’s Thread in Cancer of Unknown Primary. Int J Mol Sci 2023; 24:ijms24065588. [PMID: 36982662 PMCID: PMC10053301 DOI: 10.3390/ijms24065588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Cancer of unknown primary (CUP) encloses a group of heterogeneous tumours, the primary sites for which cannot be identified at the time of diagnosis, despite extensive investigations. CUP has always posed major challenges both in its diagnosis and management, leading to the hypothesis that it is rather a distinct entity with specific genetic and phenotypic aberrations, considering the regression or dormancy of the primary tumour; the development of early, uncommon systemic metastases; and the resistance to therapy. Patients with CUP account for 1–3% of all human malignancies and can be categorised into two prognostic subsets according to their clinicopathologic characteristics at presentation. The diagnosis of CUP mainly depends on the standard evaluation comprising a thorough medical history; complete physical examination; histopathologic morphology and algorithmic immunohistochemistry assessment; and CT scan of the chest, abdomen, and pelvis. However, physicians and patients do not fare well with these criteria and often perform additional time-consuming evaluations to identify the primary tumour site to guide treatment decisions. The development of molecularly guided diagnostic strategies has emerged to complement traditional procedures but has been disappointing thus far. In this review, we present the latest data on CUP regarding the biology, molecular profiling, classification, diagnostic workup, and treatment.
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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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7
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New Genetic Technologies in Diagnosis and Treatment of Cancer of Unknown Primary. Cancers (Basel) 2022; 14:cancers14143429. [PMID: 35884492 PMCID: PMC9318615 DOI: 10.3390/cancers14143429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The NGS and other molecular techniques creates huge hopes for effective CUP patients treatment and to select them for molecularly targeted therapies (agnostic therapies) and immunotherapy. Development of diagnostic technologies and biologically targeted therapies could make CUP’ patients access to modern therapies and change their outcome. Abstract Cancer of unknown primary (CUP) represents a rare oncological and heterogeneous disease in which one or more metastases are present, but the location of the primary site is unknown. Pathological diagnosis, using immunohistochemistry, of such metastatic materials is challenging and frequently does not allow for determining the tissue of origin (ToO). The selection of systemic therapy in patients with CUP is usually based on empiric grounds, and the prognosis is generally unfavourable. New molecular techniques could identify the tissue of origin and be used to select systemic agnostic therapies in various malignancies with specific molecular abnormalities. Targetable driver mutations or gene rearrangements in cancer cells may be identified using various molecular assays, of which particularly valuable are next-generation sequencing techniques. These assays may identify tumour sources and allow personalized treatments. However, current guidelines for CUP management do not recommend routine testing of gene expression and epigenetic factors. This is mainly due to the insufficient evidence supporting the improvement of CUP’s prognosis by virtue of this approach. This review summarizes the advantages and disadvantages of new genetic techniques in CUP diagnostics and proposes updating the recommendations for CUP management.
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8
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Mei J, Wang H, Fan H, Ding J, Xu J. Case Report: Successful Immunotherapy Improved the Prognosis of the Unfavorable Subset of Cancer of Unknown Primary. Front Immunol 2022; 13:900119. [PMID: 35812375 PMCID: PMC9256999 DOI: 10.3389/fimmu.2022.900119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/23/2022] [Indexed: 12/15/2022] Open
Abstract
Background Cancer of unknown primary (CUP) is heterogeneous and has a wide variety of clinical presentations and a poor prognosis in most patients, with a median overall survival of only 6 months. The development of molecular profiling contributes to precision therapy, and targeted drugs and immune checkpoint inhibitors (ICIs) greatly promote individualized treatment. Case presentation Here, we reported a case of an unfavorable subset of CUP who had a long time of survival after the immunotherapy-prominent comprehensive treatment. A 48-year-old man presented with back pain and a cough. A diagnostic work-up showed bone marrow, multiple bones, and lymph node metastasis. Lymph node pathology implies metastatic poorly differentiated cancer. Next-generation sequencing (NGS) showed no special targets, but the tumor proportion score (TPS) of programmed death-ligand 1 (PD-L1) was 80% and the tumor mutation burden (TMB) was 16.7 per million bases. After two cycles of pembrolizumab 200 mg D1 plus nanoparticle albumin-bound (nab)-paclitaxel 200 mg D1&8 (q3w), PET-CT and bone marrow aspiration cytology showed a complete response (CR). Subsequently, pembrolizumab alone was used for three months. The left inguinal lymph nodes showed new metastasis. After two cycles of the combination treatment of pembrolizumab and (nab)-paclitaxel, a partial response (PR) was achieved. After seven months, retroperitoneal lymph nodes showed new metastasis, and the sequential treatment with radiotherapy and pembrolizumab exhibited encouraging efficacy. To date, the patient has survived nearly 40 months with the combination therapy. Conclusions The ICI-prominent comprehensive treatment provided clinical benefit for the reported case of CUP. Thus, CUP patients with markers of benefiting from immunotherapy should be actively treated with immunotherapy to improve their prognosis.
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Affiliation(s)
| | | | | | - Junli Ding
- *Correspondence: Junying Xu, ; Junli Ding,
| | - Junying Xu
- *Correspondence: Junying Xu, ; Junli Ding,
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9
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Guven DC, Stephen B, Sahin TK, Cakir IY, Erul E, Aksoy S. The Efficacy of Immune Checkpoint Inhibitors in Rare Tumors: A Systematic Review of Published Clinical Trials. Crit Rev Oncol Hematol 2022; 174:103700. [PMID: 35533815 DOI: 10.1016/j.critrevonc.2022.103700] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/22/2022] [Accepted: 05/02/2022] [Indexed: 02/08/2023] Open
Abstract
The immune checkpoint inhibitors (ICIs) entered treatment algorithms in most tumors. However, the data on the efficacy is limited in rare tumors with no phase III studies. We systemically reviewed the clinical trials evaluating the ICI efficacy in rare tumors and included a total of 47 clinical trials in this review. The ICIs demonstrated over 30% response rates in Merkel cell carcinoma and squamous cell carcinoma of the skin and became the standard of care. Additionally, the ICI efficacy was promising in thymic epithelial tumors and gestational trophoblastic neoplasia. In contrast, the ICI efficacy is limited in most sarcomas, germ cell tumors and low-grade neuroendocrine tumors. The ICI efficacy seemed to be improved with combinations targeting tumor microenvironment in sarcomas. The available evidence on ICI efficacy in rare tumors denote a need for better patient selection and novel combination strategies to improve outcomes.
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Affiliation(s)
- Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey.
| | - Bettzy Stephen
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Taha Koray Sahin
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ibrahim Yahya Cakir
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Enes Erul
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sercan Aksoy
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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10
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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: 8] [Impact Index Per Article: 4.0] [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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11
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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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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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13
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Zhang M, Zhao M, Jin LF, Shen WZ. Successful treatment using immunotherapy in combination with chemotherapy for metastatic squamous cell carcinoma of unknown primary origin with bulky abdominal mass: A case report. Medicine (Baltimore) 2021; 100:e28074. [PMID: 35049231 PMCID: PMC9191313 DOI: 10.1097/md.0000000000028074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/15/2021] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cancer of unknown primary (CUP) means that the primary focus cannot be found after preliminary clinical evaluation. It accounts for 2.3% to 5% of newly diagnosed cancer cases. Due to the lack of standard treatment, CUP is usually associated with poor prognosis and is the third to fourth most common cause of cancer-related deaths. PATIENT CONCERNS We report the case of a 42-year-old female patient who was admitted to the hospital for intermittent right abdominal pain and abdominal distension. Abdominal computed tomography (CT) showed a large abdominal mass of unknown origin, which was difficult to resect due to its close relationship with surrounding tissues. Twenty days later, the patient had enlarged left supraclavicular lymph nodes, and percutaneous biopsy revealed squamous cell carcinoma. In addition, next-generation sequencing (NGS) of tissue and blood samples showed immune-related mutations and PD-L1 expression. DIAGNOSES The patient was diagnosed with metastatic squamous cell carcinoma of unknown primary origin, with a bulky abdominal mass. INTERVENTIONS The patient was treated with carboplatin, albumin-binding paclitaxel, and immune checkpoint inhibitor (carilizumab). After 6 cycles, the patient was switched to maintenance treatment with carilizumab. OUTCOMES The general condition of the patient improved, and the lesion was significantly reduced. The treatment efficacy was assessed as partial remission according to Response Evaluation Criteria in Solid Tumors. The patient benefited from immunotherapy combined with chemotherapy. LESSONS There is no recommended standard treatment for most CUPs, which leads to their poor prognoses. By performing NGS for patients and targeting immune-related positive predictors, immunotherapy combined with chemotherapy may prolong the overall survival of patients. This case report suggests that immunotherapy combined with chemotherapy is feasible and effective in patients with CUP.
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14
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Kang S, Jeong JH, Yoon S, Yoo C, Kim KP, Cho H, Ryoo BY, Jung J, Kim JE. Real-world data analysis of patients with cancer of unknown primary. Sci Rep 2021; 11:23074. [PMID: 34845302 PMCID: PMC8630084 DOI: 10.1038/s41598-021-02543-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/15/2021] [Indexed: 01/08/2023] Open
Abstract
Cancer of unknown primary (CUP) is a heterogeneous malignancy in which the primary site of the tumor cannot be identified through standard work-up. The survival outcome of CUP is generally poor, and there is no consensus for treatment. Here, we comprehensively analyzed the real-world data of 218 patients with CUP (median age, 62 years [range, 19-91]; male, 62.3%). Next-generation sequencing was conducted in 22 (10%) patients, one of whom showed level 1 genetic alteration. Most (60.3%) patients were treated with empirical cytotoxic chemotherapy, and two patients received targeted therapy based on the NGS results. The median OS was 8.3 months (95% confidence interval [CI] 6.2-11.4), and the median progression-free survival of patients treated with chemotherapy was 4.4 months (95% CI 3.4-5.3). In multivariate Cox regression analysis, Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 or 1 and localized disease were significantly associated with favorable survival outcomes. Collectively, we found that CUP patients had a poor prognosis after standard treatment, and those with localized disease who received local treatment and those with better PS treated with multiple lines of chemotherapy had better survival outcomes. Targeted therapies based on NGS results are expected to improve survival outcomes.
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Affiliation(s)
- Sora Kang
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Ho Jeong
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Shinkyo Yoon
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Changhoon Yoo
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyu-Pyo Kim
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyungwoo Cho
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Baek-Yeol Ryoo
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Eun Kim
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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15
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Kato S, Weipert C, Gumas S, Okamura R, Lee S, Sicklick JK, Saam J, Kurzrock R. Therapeutic Actionability of Circulating Cell-Free DNA Alterations in Carcinoma of Unknown Primary. JCO Precis Oncol 2021; 5:PO.21.00011. [PMID: 34778692 PMCID: PMC8585281 DOI: 10.1200/po.21.00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 12/22/2022] Open
Abstract
Cancer of unknown primary (CUP) is a metastatic disease with unidentifiable primary tumor. Somatic alterations can be assessed noninvasively via liquid biopsies interrogating cell-free DNA (cfDNA). METHODS We evaluated 1,931 patients with CUP with a cfDNA next-generation sequencing panel (73-74 genes). RESULTS Overall, 1,739 patients (90%) had ≥ 1 cfDNA alteration. We then explored alteration actionability (per the levels of evidence from the OncoKB database); 825 patients (47.4% of 1,739) had level 1, level 2, or resistance/R1 alterations. Among 40 clinically annotated patients with CUP who had cfDNA evaluated, higher degrees of matching treatment to alterations (Matching Score > 50% v ≤ 50%) was the only variable predicting improved outcome: longer median progression-free survival (10.4 v 2.5 months; P = .002), overall survival (13.4 v 5.7 months; P = .07, trend), and higher clinical benefit rate (stable disease ≥ 6 months/partial response/complete response; 83% v 25%; P = .003). CONCLUSION In summary, cfDNA frequently reveals strong level-of-evidence actionable alterations in CUP, and high degrees of matching to therapy correlates with better outcomes.
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Affiliation(s)
- Shumei Kato
- Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, La Jolla, CA
| | | | - Sophia Gumas
- Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, La Jolla, CA
| | - Ryosuke Okamura
- Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, La Jolla, CA.,Department of Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Suzanna Lee
- Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, La Jolla, CA
| | - Jason K Sicklick
- Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, La Jolla, CA.,Department of Surgery, Division of Surgical Oncology, UC San Diego School of Medicine, San Diego, CA
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16
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Zhang Y, Xia L, Ma D, Wu J, Xu X, Xu Y. 90-Gene Expression Profiling for Tissue Origin Diagnosis of Cancer of Unknown Primary. Front Oncol 2021; 11:722808. [PMID: 34692498 PMCID: PMC8529103 DOI: 10.3389/fonc.2021.722808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
Cancer of unknown primary (CUP), in which metastatic diseases exist without an identifiable primary location, accounts for about 3-5% of all cancer diagnoses. Successful diagnosis and treatment of such patients are difficult. This study aimed to assess the expression characteristics of 90 genes as a method of identifying the primary site from CUP samples. We validated a 90-gene expression assay and explored its potential diagnostic utility in 44 patients at Jiangsu Cancer Hospital. For each specimen, the expression of 90 tumor-specific genes in malignant tumors was analyzed, and similarity scores were obtained. The types of malignant tumors predicted were compared with the reference diagnosis to calculate the accuracy. In addition, we verified the consistency of the expression profiles of the 90 genes in CUP secondary malignancies and metastatic malignancies in The Cancer Genome Atlas. We also reported a detailed description of the next-generation coding sequences for CUP patients. For each clinical medical specimen collected, the type of malignant tumor predicted and analyzed by the 90-gene expression assay was compared with its reference diagnosis, and the overall accuracy was 95.4%. In addition, the 90-gene expression profile generally accurately classified CUP into the cluster of its primary tumor. Sequencing of the exome transcriptome containing 556 high-frequency gene mutation oncogenes was not significantly related to the 90 genes analysis. Our results demonstrate that the expression characteristics of these 90 genes can be used as a powerful tool to accurately identify the primary sites of CUP. In the future, the inclusion of the 90-gene expression assay in pathological diagnosis will help oncologists use precise treatments, thereby improving the care and outcomes of CUP patients.
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Affiliation(s)
- Yi Zhang
- Department of Pathology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Xia
- Department of Pathology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Dawei Ma
- Department of Pathology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Wu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyu Xu
- Department of Pathology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Youtao Xu
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
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17
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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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18
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Rosenkranz AA, Slastnikova TA. Epidermal Growth Factor Receptor: Key to Selective Intracellular Delivery. BIOCHEMISTRY (MOSCOW) 2021; 85:967-1092. [PMID: 33050847 DOI: 10.1134/s0006297920090011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Epidermal growth factor receptor (EGFR) is an integral surface protein mediating cellular response to a number of growth factors. Its overexpression and increased activation due to mutations is one of the most common traits of many types of cancer. Development and clinical use of the agents, which block EGFR activation, became a prime example of the personalized targeted medicine. However, despite the obvious success in this area, cancer cure remains unattainable in most cases. Because of that, as well as the result of the search for possible ways to overcome the difficulties of treatment, a huge number of new treatment methods relying on the use of EGFR overexpression and its changes to destroy cancer cells. Modern data on the structure, functioning, and intracellular transport of EGFR, its natural ligands, as well as signaling cascades triggered by the EGFR activation, peculiarities of the EGFR expression and activation in oncological disorders, as well as applied therapeutic approaches aimed at blocking EGFR signaling pathway are summarized and analyzed in this review. Approaches to the targeted delivery of various chemotherapeutic agents, radionuclides, immunotoxins, photosensitizers, as well as the prospects for gene therapy aimed at cancer cells with EGFR overexpression are reviewed in detail. It should be noted that increasing attention is being paid nowadays to the development of multifunctional systems, either carrying several different active agents, or possessing several environment-dependent transport functions. Potentials of the systems based on receptor-mediated endocytosis of EGFR and their possible advantages and limitations are discussed.
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Affiliation(s)
- A A Rosenkranz
- Faculty of Biology, Lomonosov Moscow State University, Moscow, 119234, Russia. .,Institute of Gene Biology, Russian Academy of Sciences, Moscow, 119334, Russia
| | - T A Slastnikova
- Institute of Gene Biology, Russian Academy of Sciences, Moscow, 119334, Russia
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19
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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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20
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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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21
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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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22
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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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23
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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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24
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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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25
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Alshareeda AT, Al-Sowayan BS, Alkharji RR, Aldosari SM, Al subayyil AM, Alghuwainem A. Cancer of Unknown Primary Site: Real Entity or Misdiagnosed Disease? J Cancer 2020; 11:3919-3931. [PMID: 32328196 PMCID: PMC7171483 DOI: 10.7150/jca.42880] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/31/2020] [Indexed: 01/03/2023] Open
Abstract
Metastasis is a late event in the progression of any tumour. However, invasive cancers are occasionally detected in the form of metastatic lesions without a clearly detectable primary tumour. Cancer of unknown primary site (CUP) is defined as a confirmed metastatic tumour, with unknown primary tumour site, despite the standardized diagnostic approach that includes clinical history, routine laboratory tests, and complete physical examination. Due to the lack of basic research on its primary causes, CUP is appropriately termed an 'orphan' cancer. Nevertheless, CUP accounts for 2-5% of diagnosed malignancies. To date, it is unclear whether CUP is an entity with primary dormancy as its hallmark or an entity with genetic abnormalities that cause it to manifest as a primary metastatic disease. In this review, we discuss different aspects of CUP, including its current diagnostic methods, angiogenesis effectors, relationship with cancer stem cells and current treatments.
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Affiliation(s)
- Alaa T. Alshareeda
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Batla S. Al-Sowayan
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Reem R. Alkharji
- Research Department, Health Sciences Research Centre, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sahar M. Aldosari
- Cytogenetic and Molecular Genetics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah M. Al subayyil
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Ayidah Alghuwainem
- Stem Cells and Regenerative Medicine Unit, Cell Therapy & Cancer Research Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
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26
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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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27
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Genomic profiling in oncology clinical practice. Clin Transl Oncol 2020; 22:1430-1439. [PMID: 31981077 DOI: 10.1007/s12094-020-02296-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/08/2020] [Indexed: 02/04/2023]
Abstract
The development of high-throughput technologies such as next-generation sequencing for DNA sequencing together with the decrease in their cost has led to the progressive introduction of genomic profiling in our daily practice in oncology. Nowadays, genomic profiling is part of genetic counseling, cancer diagnosis, molecular characterization, and as a biomarker of prognosis and response to treatment. Furthermore, germline or somatic genomic characterization of the tumor may provide new treatment opportunities for patients with cancer. In this review, we will summarize the clinical applications and limitations of genomic profiling in oncology clinical practice, focusing on next-generation sequencing.
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28
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Nikanjam M, Arguello D, Gatalica Z, Swensen J, Barkauskas DA, Kurzrock R. Relationship between protein biomarkers of chemotherapy response and microsatellite status, tumor mutational burden and PD-L1 expression in cancer patients. Int J Cancer 2019; 146:3087-3097. [PMID: 31479512 PMCID: PMC7051881 DOI: 10.1002/ijc.32661] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/12/2022]
Abstract
Chemotherapy and checkpoint inhibitor immunotherapies are increasingly used in combinations. We determined associations between the presence of anti‐PD‐1/PD‐L1 therapeutic biomarkers and protein markers of potential chemotherapy response. Data were extracted from a clinical‐grade testing database (Caris Life Sciences; February 2015 through November 2017): immunotherapy response markers (microsatellite instability‐high [MSI‐H], tumor mutational burden‐high [TMB‐H], and PD‐L1 protein expression) and protein chemotherapy response markers (excision repair complementation group 1 [ERCC1], topoisomerase 1 [TOPO1], topoisomerase 2 [TOP2A], thymidylate synthase [TS], tubulin beta 3 [TUBB3], ribonucleotide reductase regulatory subunit M1 [RRM1] and O‐6‐methyl guanine DNA methyltransferase [MGMT]). Relationships were determined by the Mantel‐Haenszel chi‐squared test or Fischer's exact tests. Overall, 28,034 patients representing a total of 40 tumor types were assessed. MSI‐H was found in 3.3% of patients (73% were also TMB‐H), TMB‐H, 8.4% (28.3% were also MSI‐H) and PD‐L1 expression in 11.0% of patients (5.1% were also MSI‐H; 16.4% were also TMB‐H). Based on concurrent biomarker expression, combinations of immunotherapy with platinum (ERCC1 negativity) or with doxorubicin, epirubicin or etoposide (TOP2A positivity) have a higher probability of response, whereas combinations with irinotecan or topotecan (TOPO1 positivity), with gemcitabine (RRM1 negativity), and fluorouracil, pemetrexed or capecitabine (TS negativity) may be of less benefit. The potential for immunotherapy and taxane (TUBB3 negativity) combinations is present for MSI‐H but not TMB‐H or PD‐L1‐expressing tumors; for temozolomide and dacarbazine (MGMT negative), PD‐L1 is frequently coexpressed, but MSI‐H and TMB‐H are not associated. Protein markers of potential chemotherapy response along with next‐generation sequencing for immunotherapy response markers can help support rational combinations as part of an individualized, precision oncology approach. What's new? With the emerging success of immunotherapy of cancers, combinations with conventional chemotherapies are increasingly being tested in clinical trials. Here the authors examined concurrent biomarker expression of checkpoint (PD‐1/PD‐L1) blockade immunotherapy and various cytotoxic chemotherapies to determine which chemotherapeutic agents will best synergize with immunotherapy. They predict that combining platinum or doxorubicin, epirubicin, or etoposide treatments with PD‐1/PD‐L1 inhibitors would have a higher probability of response than other treatments, supporting a rational combination strategy in a possibly individualized treatment approach.
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Affiliation(s)
- Mina Nikanjam
- Center for Personalized Cancer Therapy, Division of Hematology and Oncology, University of California San Diego Moores Cancer Center, San Diego, CA
| | | | | | | | - Donald A Barkauskas
- Department of Preventive Medicine, Biostatistics Division, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Division of Hematology and Oncology, University of California San Diego Moores Cancer Center, San Diego, CA
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29
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Yao JH, Wang AS, Wang XJ, Zhang L, Zhu Y, Ou YR, Wang ZS, Yang Y. Complete response to crizotinib in a metastatic adenocarcinoma of unknown primary harboring MET amplification and NTRK1 co-occurring mutation. Onco Targets Ther 2019; 12:4261-4267. [PMID: 31213843 PMCID: PMC6549664 DOI: 10.2147/ott.s202739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/17/2019] [Indexed: 11/23/2022] Open
Abstract
Carcinomas of unknown primary (CUPs) have poor prognosis due to the paucity of data on their clinical characteristics and laboratory features, and empirical chemotherapy still remains the critical management for this kind of disease. This study aimed to present the knowledge of treating an elderly man with metastatic adenocarcinoma of unknown primary and also with a history of long-term hypertension and renal cysts. He was identified to harbor mesenchymal-epithelial transition factor (MET) gene amplification and neurotrophic tyrosine receptor kinase 1 (NTRK1) gene co-occurring mutation by targeted next-generation sequencing analysis upon the progression of empirical chemotherapy. He was then treated with a standard dose of crizotinib (250 mg, twice daily), which exhibited a satisfactory complete response (CR) of the targeted lesions after 1 month of treatment. When the number of renal cysts increased and renal inadequacy occurred after treatment for 2 months, crizotinib was reduced to half-dose (250 mg, once daily), and still conferred maintenance of CR for another 6.5 months and good quality life of the patient. These results suggested that treatments based on driver genes rather than primary tumor types could be a promising manipulation for achieving better treatment outcome, and a half-dose of crizotinib might be both effective and tolerable for MET-overexpressed CUPs with underlying renal diseases.
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Affiliation(s)
- Jing-Hao Yao
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - An-Sheng Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - Xiao-Jing Wang
- Department of Respiration, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China.,Anhui Clinical and Preclinical Key Laboratory of Respiratory Diseases, Bengbu 233004, People's Republic of China
| | - Lu Zhang
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - Yue Zhu
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - Yu-Rong Ou
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - Zi-Shu Wang
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
| | - Yan Yang
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, People's Republic of China
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30
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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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31
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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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32
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Li M, Li H, Hong G, Tang Z, Liu G, Lin X, Lin M, Qi L, Guo Z. Identifying primary site of lung-limited Cancer of unknown primary based on relative gene expression orderings. BMC Cancer 2019; 19:67. [PMID: 30642283 PMCID: PMC6332677 DOI: 10.1186/s12885-019-5274-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/03/2019] [Indexed: 01/11/2023] Open
Abstract
Background Precise diagnosis of the tissue origin for metastatic cancer of unknown primary (CUP) is essential for deciding the treatment scheme to improve patients’ prognoses, since the treatment for the metastases is the same as their primary counterparts. The purpose of this study is to identify a robust gene signature that can predict the origin for CUPs. Methods The within-sample relative gene expression orderings (REOs) of gene pairs within individual samples, which are insensitive to experimental batch effects and data normalizations, were exploited for identifying the prediction signature. Results Using gene expression profiles of the lung-limited metastatic colorectal cancer (LmCRC), we firstly showed that the within-sample REOs in lung metastases of colorectal cancer (CRC) samples were concordant with the REOs in primary CRC samples rather than with the REOs in primary lung cancer. Based on this phenomenon, we selected five gene pairs with consistent REOs in 498 primary CRC and reversely consistent REOs in 509 lung cancer samples, which were used as a signature for predicting primary sites of metastatic CRC based on the majority voting rule. Applying the signature to 654 primary CRC and 204 primary lung cancer samples collected from multiple datasets, the prediction accuracy reached 99.36%. This signature was also applied to 24 LmCRC samples collected from three datasets produced by different laboratories and the accuracy reached 100%, suggesting that the within-sample REOs in the primary site could reveal the original tissue of metastatic cancers. Conclusions The result demonstrated that the signature based on within-sample REOs of five gene pairs could exactly and robustly identify the primary sites of CUPs.
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Affiliation(s)
- Mengyao Li
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Hongdong Li
- Department of Bioinformatics, Gannan Medical University, Ganzhou, 341000, China.
| | - Guini Hong
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Zhongjie Tang
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Guanghao Liu
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Xiaofang Lin
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Mingzhang Lin
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China
| | - Lishuang Qi
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, 150086, China
| | - Zheng Guo
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Department of Bioinformatics, Fujian Medical University, Fuzhou, 350001, China. .,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, 350001, China.
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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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Abstract
Genomic information is increasingly being incorporated into clinical cancer care. Large-scale sequencing efforts have deepened our understanding of the genomic landscape of cancer and contributed to the expanding catalog of alterations being leveraged to aid in cancer diagnosis, prognosis, and treatment. Genomic profiling can provide clinically relevant information regarding somatic point mutations, copy number alterations, translocations, and gene fusions. Genomic features, such as mutational burden, can also be measured by more comprehensive sequencing strategies and have shown value in informing potential treatment options. Ongoing clinical trials are evaluating the use of molecularly targeted agents in genomically defined subsets of cancers within and across tumor histologies. Continued advancements in clinical genomics promise to further expand the application of genomics-enabled medicine to a broader spectrum of oncology patients.
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Affiliation(s)
- Alison Roos
- Integrated Cancer Genomics Division, Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Sara A Byron
- Integrated Cancer Genomics Division, Translational Genomics Research Institute, Phoenix, AZ, USA.
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[2018 Consensus statement by the Spanish Society of Pathology and the Spanish Society of Medical Oncology on the diagnosis and treatment of cancer of unknown primary]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 52:33-44. [PMID: 30583830 DOI: 10.1016/j.patol.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
Cancer of unknown primary is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, cancer of unknown primary can account for 2-9% of all cancer patients, mostly 60-75 years old. This article reviews the main clinical, pathological and molecular studies conducted to analyse and determine the origin of cancer of unknown primary. The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed.
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36
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Hainsworth JD, Greco FA. Cancer of Unknown Primary Site: New Treatment Paradigms in the Era of Precision Medicine. Am Soc Clin Oncol Educ Book 2018; 38:20-25. [PMID: 30231392 DOI: 10.1200/edbk_100014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- John D Hainsworth
- From the Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN
| | - F Anthony Greco
- From the Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN
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37
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Devereaux KA, Charu V, Zhao S, Charville GW, Bangs CD, van de Rijn M, Cherry AM, Natkunam Y. Immune checkpoint blockade as a potential therapeutic strategy for undifferentiated malignancies. Hum Pathol 2018; 82:39-45. [PMID: 30539796 DOI: 10.1016/j.humpath.2018.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/19/2018] [Accepted: 06/29/2018] [Indexed: 12/25/2022]
Abstract
Undifferentiated malignancies (UMs) encompass a diverse set of aggressive tumors that pose not only a diagnostic challenge but also a challenge for clinical management. Most tumors in this category are currently treated empirically with nonspecific chemotherapeutic agents that yield extremely poor clinical response. Given that UMs are inherently genetically unstable neoplasms with the potential for immune dysregulation and increased neoantigen production, they are likely to be particularly amenable to immune checkpoint inhibitors, which target programmed cell death protein 1 (PD-1) or its ligands, PD-L1 and PD-L2, to promote T-cell antitumor activity. Aberrant expression of PD-L1 and, more recently, chromosomal 9p24.1/CD274(PD-L1)/PDCD1LG2(PD-L2) alterations can be used as biomarkers to predict responsiveness to checkpoint inhibitors. Here we evaluated 93 cases previously diagnosed as an "undifferentiated" malignancy and found that 56% (52/93) of UMs moderately to strongly express PD-L1 by immunohistochemistry (IHC). Concurrent CD274(PD-L1) and PDCD1LG2(PD-L2) fluorescence in situ hybridization (FISH) was performed on 24 of these cases and demonstrates a genetic gain at both loci in 62.5% of UMs. Genetic alterations at the CD274(PD-L1) and PDCD1LG2(PD-L2) loci were found to be completely concordant by FISH. Overall, we found that a significant proportion of UMs express PD-L1 and provide molecular support for using checkpoint inhibitors as a treatment approach for this class of tumors.
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Affiliation(s)
- Kelly A Devereaux
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Shuchun Zhao
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gregory W Charville
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Charles D Bangs
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Matt van de Rijn
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Athena M Cherry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yasodha Natkunam
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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38
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Liquid biopsy: a new diagnostic, predictive and prognostic window in cancers of unknown primary. Eur J Cancer 2018; 105:28-32. [PMID: 30388661 DOI: 10.1016/j.ejca.2018.09.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 01/07/2023]
Abstract
Cancer of unknown primary (CUP) is a heterogeneous group of metastatic cancers characterised by early dissemination of metastases in the absence of any identifiable primary site. Most patients with CUP have poor prognosis with the traditional diagnostic and treatment modalities. Recognising the putative primary tumour is hypothesised to ameliorate the prognosis of patients with CUP by guiding treatment decisions. The active efforts in molecular oncology have shown that gene expression profiling is able to identify the primary tumour site and to determine targetable mutations. In this regard, liquid biopsy opens a new diagnostic, predictive and prognostic window in CUP that may lead to substantial improvement in the management of patients with CUP.
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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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40
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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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2018 consensus statement by the Spanish Society of Pathology and the Spanish Society of Medical Oncology on the diagnosis and treatment of cancer of unknown primary. Clin Transl Oncol 2018; 20:1361-1372. [PMID: 29808414 PMCID: PMC6182632 DOI: 10.1007/s12094-018-1899-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 01/06/2023]
Abstract
Cancer of unknown primary (CUP) is defined as a heterogeneous group of tumours that present with metastasis, and in which attempts to identify the original site have failed. They differ from other primary tumours in their biological features and how they spread, which means that they can be considered a separate entity. There are several hypotheses regarding their origin, but the most plausible explanation for their aggressiveness and chemoresistance seems to involve chromosomal instability. Depending on the type of study done, CUP can account for 2–9% of all cancer patients, mostly 60–75 years old. This article reviews the main clinical, pathological, and molecular studies conducted to analyse and determine the origin of CUP.
The main strategies for patient management and treatment, by both clinicians and pathologists, are also addressed.
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42
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Gatalica Z, Xiu J, Swensen J, Vranic S. Comprehensive analysis of cancers of unknown primary for the biomarkers of response to immune checkpoint blockade therapy. Eur J Cancer 2018; 94:179-186. [DOI: 10.1016/j.ejca.2018.02.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/16/2018] [Accepted: 02/20/2018] [Indexed: 01/15/2023]
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43
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Immunohistochemistry for Diagnosis of Metastatic Carcinomas of Unknown Primary Site. Cancers (Basel) 2018; 10:cancers10040108. [PMID: 29621151 PMCID: PMC5923363 DOI: 10.3390/cancers10040108] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023] Open
Abstract
Immunohistochemistry has become an essential ancillary examination for the identification and classification of carcinomas of unknown primary site (CUPs). Over the last decade, the diagnostic accuracy of organ- or tumour-specific immunomarkers and the clinical validation of effective immunohistochemical panels has improved significantly. When dealing with small sample sizes, diagnostic accuracy is crucial, particularly in the current era of targeted molecular and immune-based therapies. Effective systematic use of appropriate immunohistochemical panels enables accurate classification of most of the undifferentiated carcinomas as well as careful preservation of tissues for potential molecular or other ancillary tests. This review discusses the algorithmic approach to the diagnosis of CUPs using CK7 and CK20 staining patterns. It outlines the most frequently used tissue-specific antibodies, provides some pitfalls essential in avoiding potential diagnostic errors and discusses the complementary tools, such as molecular tumour profiling and mutation-specific antibodies, for the improvement of diagnosis and prediction of the treatment response.
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44
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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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45
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Moran S, Martinez-Cardús A, Boussios S, Esteller M. Precision medicine based on epigenomics: the paradigm of carcinoma of unknown primary. Nat Rev Clin Oncol 2017; 14:682-694. [PMID: 28675165 DOI: 10.1038/nrclinonc.2017.97] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Epigenetic alterations are a common hallmark of human cancer. Single epigenetic markers are starting to be incorporated into clinical practice; however, the translational use of these biomarkers has not been validated at the 'omics' level. The identification of the tissue of origin in patients with cancer of unknown primary (CUP) is an example of how epigenomics can be incorporated in clinical settings, addressing an unmet need in the diagnostic and clinical management of these patients. Despite the great diagnostic advances made in the past decade, the use of traditional diagnostic procedures only enables the tissue of origin to be determined in ∼30% of patients with CUP. Thus, development of molecularly guided diagnostic strategies has emerged to complement traditional procedures, thereby improving the clinical management of patients with CUP. In this Review, we present the latest data on strategies using epigenetics and other molecular biomarkers to guide therapeutic decisions involving patients with CUP, and we highlight areas warranting further research to engage the medical community in this unmet need.
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Affiliation(s)
- Sebastián Moran
- Cancer Epigenetics and Biology Program (PEBC), Bellvitge Biomedical Research Institute (IDIBELL), Avinguda Gran Via 199-203, 08908 L'Hospitalet del Llobregat, Barcelona, Spain
| | - Anna Martinez-Cardús
- Cancer Epigenetics and Biology Program (PEBC), Bellvitge Biomedical Research Institute (IDIBELL), Avinguda Gran Via 199-203, 08908 L'Hospitalet del Llobregat, Barcelona, Spain
| | - Stergios Boussios
- Department of Medical Oncology, Ioannina University Hospital, Niarxou Avenue, 45110 Ioannina, Greece
| | - Manel Esteller
- Cancer Epigenetics and Biology Program (PEBC), Bellvitge Biomedical Research Institute (IDIBELL), Avinguda Gran Via 199-203, 08908 L'Hospitalet del Llobregat, Barcelona, Spain.,Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Carrer de la Feixa Llarga, s/n, 08908 L'Hospitalet, Spain.,Institucio Catalana de Recerca i Estudis Avançats (ICREA), Passeig Lluís Companys 23, 08010 Barcelona, Spain
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46
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Kato S, Krishnamurthy N, Banks KC, De P, Williams K, Williams C, Leyland-Jones B, Lippman SM, Lanman RB, Kurzrock R. Utility of Genomic Analysis In Circulating Tumor DNA from Patients with Carcinoma of Unknown Primary. Cancer Res 2017. [PMID: 28642281 DOI: 10.1158/0008-5472.can-17-0628] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Carcinoma of unknown primary (CUP) is a rare and difficult-to-treat malignancy, the management of which might be improved by the identification of actionable driver mutations. We interrogated 54 to 70 genes in 442 patients with CUP using targeted clinical-grade, next-generation sequencing of circulating tumor DNA (ctDNA). Overall, 80% of patients exhibited ctDNA alterations; 66% (290/442) ≥1 characterized alteration(s), excluding variants of unknown significance. TP53-associated genes were most commonly altered [37.8% (167/442)], followed by genes involved in the MAPK pathway [31.2% (138/442)], PI3K signaling [18.1% (80/442)], and the cell-cycle machinery [10.4% (46/442)]. Among 290 patients harboring characterized alterations, distinct genomic profiles were observed in 87.9% (255/290) of CUP cases, with 99.7% (289/290) exhibiting potentially targetable alterations. An illustrative patient with dynamic changes in ctDNA content during therapy and a responder given a checkpoint inhibitor-based regimen because of a mismatch repair gene anomaly are presented. Our results demonstrate that ctDNA evaluation is feasible in CUP and that most patients harbor a unique somatic profile with pharmacologically actionable alterations, justifying the inclusion of noninvasive liquid biopsies in next-generation clinical trials. Cancer Res; 77(16); 4238-46. ©2017 AACR.
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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, California.
| | - Nithya Krishnamurthy
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, California
| | | | - Pradip De
- Avera Cancer Institute, Sioux Falls, South Dakota
| | | | | | | | - Scott M Lippman
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, California
| | | | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, California
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47
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Uzunoglu S, Erdogan B, Kodaz H, Cinkaya A, Turkmen E, Hacibekiroglu I, Sari A, Ozen A, Usta U, Cicin I. Unknown primary adenocarcinomas: a single-center experience. Bosn J Basic Med Sci 2016; 16:292-297. [PMID: 27455119 DOI: 10.17305/bjbms.2016.1495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 12/12/2022] Open
Abstract
This study aimed to elucidate the clinical and prognostic characteristics of a homogeneous group of patients with cancer of unknown primary (CUP). Between 1999 and 2014, CUP was diagnosed in 159 (1.3%) of 11,742 cancer patients at Trakya University Hospital (Edirne, Turkey). Ninety-seven (61%) of the 159 patients were retrospectively reviewed. Among these, 61 (62.8%) patients with adenocarcinoma were included in this study. The most frequently predicted primary tumor site was the lung (37.7%), and 59% of the patients were smokers. There was a significant relationship between smoking and the lung as a potential primary cancer site (p = 0.042). The most frequent site of metastasis was the liver (60.7%). The median number of metastases per patient was two, but patients with liver metastases had a median of five metastases. The overall median survival time was 7 months. Median survival was significantly longer in patients with a predicted primary site than in patients without the predicted site (7 vs. 6 months, respectively; p = 0.038). When the patients with predicted ovarian and peritoneal tumors were excluded from the comparison, the statistical p value was still close to significant (p = 0.07). Multivariate analysis revealed that smoking, liver metastasis, serum alkaline phosphatase ≥92 U/L, and progression in response to chemotherapy were independent predictors of a poor prognosis. The present study identified several independent prognostic factors in patients with unknown primary adenocarcinomas who received chemotherapy. Smoking, the presence of liver metastasis, and response to chemotherapy were independent risk factors for both progression-free and overall survival.
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Affiliation(s)
- Sernaz Uzunoglu
- Department of Medical Oncology, Faculty of Medicine, Trakya University, Edirne, Turkey.
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48
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Liu C, Ding L, Sun B, Wu S. Bilateral breast adenocarcinomas with EML4-ALK fusion in a patient with multiple metastases successfully treated with crizotinib: is lung the primary site? Onco Targets Ther 2016; 9:3589-93. [PMID: 27366096 PMCID: PMC4913993 DOI: 10.2147/ott.s104583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Breast metastases from non-mammary cancers are rare, especially when they appear synchronously. Clinically, it is vitally important to accurately diagnose these patients, as this will directly influence their treatment and survival. We present a very rare and complex case of bilateral breast adenocarcinomas with an EML4-ALK fusion, which was diagnosed as bilateral breast metastases of non-small-cell lung cancer by immunohistochemistry and comprehensive genomic investigation. The patient was successfully treated with an ALK inhibitor (crizotinib); symptoms improved quickly after initiation of crizotinib therapy, and a partial response was observed after 3 months. The experience of diagnosis and treatment of this case indicates the importance and necessity of genomic investigations in such patients, and suggests that we need to consider the rare possibility of this kind of metastasis in order to provide optimal treatment.
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Affiliation(s)
- Chao Liu
- Department of Radiation Oncology, 307 Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University, Beijing, People's Republic of China; Department of Radiation Oncology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, People's Republic of China
| | - Lijuan Ding
- Department of Radiation Oncology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, People's Republic of China
| | - Bing Sun
- Department of Radiation Oncology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, People's Republic of China
| | - Shikai Wu
- Department of Radiation Oncology, 307 Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University, Beijing, People's Republic of China; Department of Radiation Oncology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, People's Republic of China
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49
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Gatalica Z, Bilalovic N, Palazzo JP, Bender RP, Swensen J, Millis SZ, Vranic S, Von Hoff D, Arceci RJ. Disseminated histiocytoses biomarkers beyond BRAFV600E: frequent expression of PD-L1. Oncotarget 2016; 6:19819-25. [PMID: 26110571 PMCID: PMC4637323 DOI: 10.18632/oncotarget.4378] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/29/2015] [Indexed: 12/25/2022] Open
Abstract
The histiocytoses are rare tumors characterized by the primary accumulation and tissue infiltration of histiocytes and dendritic cells. Identification of the activating BRAFV600E mutation in Erdheim-Chester disease (ECD) and Langerhans cell histiocytosis (LCH) cases provided the basis for the treatment with BRAF and/or MEK inhibitors, but additional treatment options are needed. Twenty-four cases of neoplastic histiocytic diseases [11 extrapulmonary LCH, 4 ECD, 4 extranodal Rosai-Dorfman disease (RDD), 3 follicular dendritic cell sarcoma (FDCS), 1 histiocytic sarcoma (HS) and 1 blastic plasmacytoid dendritic cell neoplasm (BPDCN)] were analyzed using immunohistochemical and mutational analysis in search of biomarkers for targeted therapy. BRAF V600E mutations were detected in 4/11 LCH and 4/4 ECD cases. A pathogenic PTEN gene mutation and loss of PTEN protein expression were identified in the case of HS. Increased expression of PD-L1 (≥2+/≥5%) was seen in 3/4 ECD, 7/8 LCH, 3/3 FDCS and 1/1 HS, with overall 81% concordance between 2 antibodies used in the study (SP142 vs. MAB1561 clone). These results show for the first time significant expression of the PD-L1 immune checkpoint protein in these disorders, which may provide rationale for addition of immune check-point inhibitors in treatment of disseminated and/or refractory histiocytoses.
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Affiliation(s)
| | - Nurija Bilalovic
- Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Juan P Palazzo
- Department of Pathology, Anatomy, and Cell Biology, Jefferson Medical College, Philadelphia, Pennsylvania, USA
| | | | | | | | - Semir Vranic
- Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Daniel Von Hoff
- Department of Oncology, Virginia G. Piper Cancer Center at Scottsdale Healthcare/TGen, Scottsdale, Arizona, USA
| | - Robert J Arceci
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Ronald Matricaria Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, Arizona, USA
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50
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Economopoulou P, Mountzios G, Pavlidis N, Pentheroudakis G. Cancer of Unknown Primary origin in the genomic era: Elucidating the dark box of cancer. Cancer Treat Rev 2015; 41:598-604. [PMID: 26033502 DOI: 10.1016/j.ctrv.2015.05.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 12/18/2022]
Abstract
Cancer of Unknown Primary (CUP) comprises a heterogeneous disease group with diagnosis of metastatic malignancy in the absence of an identifiable primary site after diagnostic work up. CUP may either resemble a specific primary tumor site sharing common clinicopathological characteristics and prognosis, or present as a distinct disease entity with undifferentiated pathological features, usually bearing dismal prognosis. Diagnosis and management have traditionally been based on clinicopathological characteristics and therapeutic strategies have been mainly empirical. In the last decade, the advent of massive gene sequencing and the advances in genomic technologies have shed light on the genomic landscape of CUP. Several gene panel tests are currently commercially available and are used in an effort to correlate the genomic characteristics of a specific CUP tumor to those of a known primary tumor, guiding thus therapeutic management. Nevertheless, these efforts are hampered by the rarity of CUP and the inability to validate the results of such tests due to the paucity of randomized clinical trials. In the current work, we provide an overview of CUP with emphasis on the impact of the genome sequencing technologies on diagnosis and management of these tumors. We also discuss potential implications of genomics for the future treatment of CUP and address the challenges of the implementation of these therapeutic strategies in routine clinical practice.
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Affiliation(s)
- Panagiota Economopoulou
- Medical Oncology Unit, 2nd Department of Internal Medicine, Propaideutic, Attikon University Hospital, Haidari, Greece
| | - Giannis Mountzios
- Medical Oncology Dpt, University of Athens School of Medicine, Athens, Greece
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