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Schipper L, Samsom K, Snaebjornsson P, Battaglia T, Bosch L, Lalezari F, Priestley P, Shale C, van den Broek A, Jacobs N, Roepman P, van der Hoeven J, Steeghs N, Vollebergh M, Marchetti S, Cuppen E, Meijer G, Voest E, Monkhorst K. Complete genomic characterization in patients with cancer of unknown primary origin in routine diagnostics. ESMO Open 2022; 7:100611. [PMID: 36463731 PMCID: PMC9808446 DOI: 10.1016/j.esmoop.2022.100611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In ∼3%-5% of patients with metastatic disease, tumor origin remains unknown despite modern imaging techniques and extensive pathology work-up. With long diagnostic delays and limited and ineffective therapy options, the clinical outcome of patients with cancer of unknown primary (CUP) remains poor. Large-scale genome sequencing studies have revealed that tumor types can be predicted based on distinct patterns of somatic variants and other genomic characteristics. Moreover, actionable genomic events are present in almost half of CUP patients. This study investigated the clinical value of whole genome sequencing (WGS) in terms of primary tumor identification and detection of actionable events, in the routine diagnostic work-up of CUP patients. PATIENTS AND METHODS A WGS-based tumor type 'cancer of unknown primary prediction algorithm' (CUPPA) was developed based on previously described principles and validated on a large pan-cancer WGS database of metastatic cancer patients (>4000 samples) and 254 independent patients, respectively. We assessed the clinical value of this prediction algorithm as part of routine WGS-based diagnostic work-up for 72 CUP patients. RESULTS CUPPA correctly predicted the primary tumor type in 78% of samples in the independent validation cohort (194/254 patients). High-confidence predictions (>95% precision) were obtained for 162/254 patients (64%). When integrated in the diagnostic work-up of CUP patients, CUPPA could identify a primary tumor type for 49/72 patients (68%). Most common diagnoses included non-small-cell lung (n = 7), gastroesophageal (n = 4), pancreatic (n = 4), and colorectal cancer (n = 3). Actionable events with matched therapy options in clinical trials were identified in 47% of patients. CONCLUSIONS Genome-based tumor type prediction can predict cancer diagnoses with high accuracy when integrated in the routine diagnostic work-up of patients with metastatic cancer. With identification of the primary tumor type in the majority of patients and detection of actionable events, WGS is a valuable diagnostic tool for patients with CUP.
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Affiliation(s)
- L.J. Schipper
- Department of Molecular Oncology, Netherlands Cancer Institute, Amsterdam,Oncode Institute, Utrecht, The Netherlands
| | - K.G. Samsom
- Department of Pathology, Netherlands Cancer Institute, Amsterdam
| | - P. Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam
| | - T. Battaglia
- Department of Molecular Oncology, Netherlands Cancer Institute, Amsterdam
| | - L.J.W. Bosch
- Department of Pathology, Netherlands Cancer Institute, Amsterdam
| | - F. Lalezari
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - P. Priestley
- Hartwig Medical Foundation Australia, Sydney, Australia
| | - C. Shale
- Hartwig Medical Foundation Australia, Sydney, Australia
| | | | - N. Jacobs
- Hartwig Medical Foundation, Amsterdam
| | | | | | - N. Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam
| | - M.A. Vollebergh
- Department of Gastroenterology, Netherlands Cancer Institute, Amsterdam
| | - S. Marchetti
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam
| | - E. Cuppen
- Oncode Institute, Utrecht, The Netherlands,Hartwig Medical Foundation, Amsterdam,Center for Molecular Medicine, UMC Utrecht, Utrecht
| | - G.A. Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam
| | - E.E. Voest
- Department of Molecular Oncology, Netherlands Cancer Institute, Amsterdam,Oncode Institute, Utrecht, The Netherlands,Department of Gastroenterology, Netherlands Cancer Institute, Amsterdam
| | - K. Monkhorst
- Department of Pathology, Netherlands Cancer Institute, Amsterdam,Correspondence to: Dr Kim Monkhorst, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel: +0205122948
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Mo Y, Lin L, Zhang J, Zhong Y, Zhang T, Zhong C, Yan J, Kuang J, Guo Q, Tan J, Li D, Wu M. Confirmation of lung adenocarcinoma as the primary cancer with detection of EML4-ALK rearrangement using next-generation sequencing: a case study. Pathol Res Pract 2022; 238:154105. [PMID: 36099717 DOI: 10.1016/j.prp.2022.154105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/22/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022]
Abstract
We report a female patient, who presented as a carcinoma of unknown primary site with multiple tumors in breast, lung, stomach, and ovary, was confirmed to be lung adenocarcinoma as primary cancer through detecting EML4-ALK rearrangement by the next generation sequencing (NGS). The patient was treated with crizotinib and resulted in significant regression of the primary and metastatic tumors, but resistance to crizotinib was developed 5 months after the treatment. Targeted therapy was, therefore, switched to alectinib, one of the second-generation of anaplastic lymphoma kinase (ALK) inhibitors, with excellent therapeutic response till November 16th, 2021. This study suggested that NGS be recommended to detect ALK rearrangement in the patients with carcinoma of unknown primary site, and that resistance to targeted therapy with ALK inhibitors should be considered for personalized precision medicine.
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Affiliation(s)
- Yijun Mo
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Lina Lin
- School of Nursing, Guangzhou Xinhua University, Guangzhou, China.
| | - Jianhua Zhang
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China.
| | - Yan Zhong
- Department of Pathology, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Tao Zhang
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Chenghua Zhong
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jun Yan
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jun Kuang
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Quanwei Guo
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jianfeng Tan
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Dongfang Li
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Mengxi Wu
- Department of Thoracic Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
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Cox RE, Chakrabarti S. A Carcinoma of Unknown Primary (CUP) Patient Treated Successfully With Immunotherapy Upon Recognition of Deficient Mismatch Repair Signature on Liquid Biopsy: A Case Report. Cureus 2022; 14:e27184. [PMID: 36017278 PMCID: PMC9393345 DOI: 10.7759/cureus.27184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
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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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Yang Z, Cui W, Yu R, Dong X, Zhao J, Dai L, Ou Q, Bao H, Wu X, Wu C, Lai J. Altered Signaling Pathways Revealed by Comprehensive Genomic Profiling in Patients With Unknown Primary Tumors. Front Oncol 2022; 12:753311. [PMID: 35402276 PMCID: PMC8991684 DOI: 10.3389/fonc.2022.753311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/17/2022] [Indexed: 01/16/2023] Open
Abstract
Purpose Carcinoma of unknown primary (CUP) is a clinically aggressive disorder with early tumor dissemination. Identifying molecular traits of CUP can be not only beneficial for a better therapeutic approach but also potentially valuable for patients with general metastatic dissemination. Patients and Methods We retrospectively investigated a total of 35 unique CUP cases. Tumor tissue samples were available in 26 patients, and plasma samples were available in 22 patients. Targeted sequencing was performed with a panel of 416 pan cancer-related genes. Results A genomic landscape of the CUP cohort showed that TP53 mutation was the most frequently observed mutation while MYC amplification was the most common CNV. Aberrant TP53, RTK-RAS, and PI3K signaling pathways were also prevalent, identified in more than half of the cases with tumor tissue. Around 58% of the CUP cases harbored homologous recombinant repair (HRR) pathway gene alterations. The tumor mutational load of CUP patients with altered HRR pathway displayed a significant increase than that of patients with intact HRR. Clinically actionable mutations were identified in eight patients, which may benefit from targeted therapies. Eight patients were treated with platinum-based chemotherapy, showing different responses, HRR, and LOH status. Conclusion Collectively, our data have provided much-need insights into the treatment options for patients diagnosed with CUP in the era of precision medicine.
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Affiliation(s)
- Zhen Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Cui
- Department of Colorectal Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Ruoying Yu
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Xinhua Dong
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian Zhao
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Lu Dai
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Qiuxiang Ou
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Hua Bao
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Xue Wu
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, Canada
| | - Chuanxin Wu
- Department of Thoracic Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jinhuo Lai
- Department of Medical Oncology, Fujian Medical University Union Hospital, Fuzhou, China
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Yulian ED, Hwei LRY, Tambun R, Siswoyo AD, Ham MF, Suroyo I. Comprehensive evaluation on cancer of unknown primary site and how we managed it: A case report. Int J Surg Case Rep 2022; 93:106954. [PMID: 35339815 PMCID: PMC8961183 DOI: 10.1016/j.ijscr.2022.106954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/13/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Cancer of unknown primary site (CUP) is metastatic cancer without primary tumor found from comprehensive medical history, physical examination, and regular laboratory examination. Eighty percent of CUP include unfavorable groups with 3 to 6 months of median survival despite chemotherapy treatment. Case presentation A 52-year-old male was presented with a chief complaint of a recurrent lump in the neck and axilla. After comprehensive examinations over three years, the primary site of the metastatic tumor could not be found. Therefore, this patient was diagnosed with cancer of an unknown primary site. Clinical discussion In patient with CUP, more precise therapy can only begin when the exact form of cancer is identified. However, the delay in diagnosis would worsen the patient's condition, as treatment measures cannot be implemented. Conclusion Trimodal modalities including surgery, chemotherapy, and radiotherapy are suitable for CUP with squamous cell carcinoma proven in immunohistochemistry evaluation. Precise therapy for patients with CUP can only begin when the exact form of cancer is identified. Although PET/CT is suitable to assess the complete body state for CUP, other radiological and histopathology modalities are needed to confirm the diagnosis. Trimodal modalities including surgery, chemotherapy, and radiotherapy are required for CUP with squamous cell carcinoma.
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Affiliation(s)
- Erwin Danil Yulian
- Division of Surgical Oncology, Department of Surgery, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
| | - Lie Rebecca Yen Hwei
- Division of Surgical Oncology, Department of Surgery, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Renaningtyas Tambun
- Department of Anatomical Pathology, Sint Carolus Hospital, Jakarta, Indonesia
| | - Alvita Dewi Siswoyo
- Department of Radiology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Maria Fransisca Ham
- Department of Anatomical Pathology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Indrati Suroyo
- Department of Radiology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia
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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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Stirnweiss A, Dholaria H, Oommen J, Hardy K, Jevon G, Beesley AH, Kotecha RS. Case Report: Long-Term Survival of a Pediatric Patient With an Intra-Abdominal Undifferentiated Carcinoma of Unknown Primary. Front Oncol 2021; 11:590913. [PMID: 34041014 PMCID: PMC8141844 DOI: 10.3389/fonc.2021.590913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022] Open
Abstract
An 8-year and 10-month-old boy presented following 2 weeks of abdominal pain, vomiting, constipation, and rectal pain. A diffuse lower-abdominal mass was felt upon palpation, with radiological findings confirming the presence of a large, multilobulated intraperitoneal mass with mesenteric lymphadenopathy and hepatic metastatic disease. A biopsy of the mass revealed anatomical pathological findings consistent with a diagnosis of intra-abdominal undifferentiated carcinoma of unknown primary (CUP). The patient was treated with six cycles of carboplatin and gemcitabine prior to surgery. Following incomplete resection of the tumor, four further cycles were administered resulting in resolution of the pelvic mass, but progression in the right and left lobes of the liver. Therapy was accordingly adjusted, with administration of six cycles of ifosfamide and doxorubicin followed by 1 year of metronomic vinorelbine and cyclophosphamide maintenance therapy. The patient remains in remission 7 years from completion of therapy. Whole exome sequencing revealed missense mutations in the DNA-repair and chromatin-remodeling genes FANCM and SMARCD2, and a tumor-derived cell line revealed a complex karyotype suggesting chromosomal instability. CUP is an extremely rare diagnosis in the pediatric population, previously reported during adolescence. This report provides detailed characterization of CUP in a young child and in the absence of defined therapeutic guidelines for pediatric CUP, the successful treatment strategy described should be considered for similar cases.
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Affiliation(s)
- Anja Stirnweiss
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Hetal Dholaria
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, WA, Australia
| | - Joyce Oommen
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | | | - Gareth Jevon
- Department of Anatomical Pathology, Perth Children's Hospital, Perth, WA, Australia
| | - Alex H Beesley
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Rishi S Kotecha
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, WA, Australia.,Curtin Medical School, Curtin University, Perth, WA, Australia
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Wenzel C, Herold S, Wermke M, E. Aust D, B. Baretton G. Routine Molecular Pathology Diagnostics in Precision Oncology. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0025. [PMID: 33536117 PMCID: PMC8287073 DOI: 10.3238/arztebl.m2021.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 12/01/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Technical advances in the field of molecular genetics permit precise genomic characterization of malignant tumors. This has not only improved our understanding of tumor biology but also paved the way for molecularly stratified treatment strategies in routine clinical practice. METHODS A selective search of PubMed to identify literature on molecular pathology methods, their indications, the challenges associated with molecular findings, and future developments. RESULTS Tumors can be characterized with the aid of immunohistochemistry, in-situ hybridization, and sequencing of DNA or RNA. The benefits of molecularly stratified tumor treatment have been demonstrated by randomized clinical trials on numerous tumor entities, e.g., non-small-cell lung cancer, colorectal cancer, and breast cancer. Therefore, initiation of specific treatment for these entities should be preceded by molecular pathology biomarker analyses, generally carried out on tumor tissue. Randomized controlled trials and non-controlled studies show that enhanced progression-free survival ensues if the pharmacological treatment is oriented on the findings of molecular pathology diagnostics. In next-generation sequencing, numerous relevant gene sequences or even whole genes can be sequenced in parallel, dispensing with complex staged diagnostics and reducing the use of biomaterials. These new methods also complement the currently relevant predictive biomarkers by permitting the investigation of genetic alterations presently of interest in the context of clinical studies. Prior to widespread routine clinical application, however, sequencing of large gene panels or whole genomes or exomes need to be even more stringently validated. CONCLUSION Quality-assured molecular pathology assays are universally available for the determination of currently relevant predictive biomarkers. However, the integration of extensive genomic analyses into routine molecular pathology diagnostics represents a future challenge in precision oncology.
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Affiliation(s)
- Carina Wenzel
- Institute of Pathology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden
| | - Sylvia Herold
- Institute of Pathology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden
| | - Martin Wermke
- Medical Department I, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden: Dr. med. Martin Wermke
| | - Daniela E. Aust
- Institute of Pathology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden
| | - Gustavo B. Baretton
- Institute of Pathology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden
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Huey RW, Smaglo BG, Estrella JS, Matamoros A, Overman MJ, Varadhachary GR, Raghav KP. Cancer of Unknown Primary Presenting as Bone-Predominant or Lymph Node-Only Disease: A Clinicopathologic Portrait. Oncologist 2021; 26:e650-e657. [PMID: 33524217 PMCID: PMC8018327 DOI: 10.1002/onco.13700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/21/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cancer of unknown primary (CUP) presenting as bone-predominant (BCUP) or lymph node-only disease (LNCUP) represents two clinically distinct subsets of nonvisceral CUP. These present a diagnostic challenge with a large differential of putative primary cancers and defy the "one-treatment-fits-all" approach. MATERIALS AND METHODS We identified patients with BCUP (n = 29) and LNCUP (n = 63) using a prospectively collected CUP database and tumor registry of patients seen at MD Anderson Cancer Center between 2001 to 2017. Clinicopathological characteristics, treatments, and outcomes were abstracted. A control group of non-BCUP/LNCUP cases (n = 443) from the database was used for comparison. Kaplan-Meier method was used to estimate overall survival and compared using log-rank test. RESULTS In this cohort, 64% and 60% patients had disseminated disease at diagnosis and 39% and 23% had Culine poor-risk disease in BCUP and LNCUP, respectively. Median overall survival (OS) for BCUP was 14.5 months and for LNCUP was 32.6 months. For BCUP, gemcitabine plus platinum was the most common initial chemotherapy (54%). For LNCUP, carboplatin plus paclitaxel was the most common initial chemotherapy (38%). Radiation was given to 74% of patients with BCUP and 37% of those with LNCUP. On multivariate analysis, poor-risk Culine group (hazard ratio [HR], 1.76; p < .001) and high neutrophil-to-lymphocyte ratio (HR, 2.38, p < .001) were associated with worse OS. CONCLUSION BCUP and LNCUP are rare subsets within CUP with varying prognosis. Poor-risk Culine group and high neutrophil-to-lymphocyte ratio are associated with poor survival. Select patients with limited metastases can have long-term survival with aggressive multimodality treatment. Careful clinicopathological review can facilitate chances of site-directed therapy. IMPLICATIONS FOR PRACTICE Cancer of unknown primary (CUP) rarely presents as bone-predominant (BCUP) or lymph node-only (LNCUP) disease. This article describes a cohort of each and compares with a larger CUP cohort. Patients with BCUP have unique issues with fractures and pain, often receiving radiation. Overall survival of 14.5 months was similar to a larger CUP comparison cohort. Patients with LNCUP had improved overall survival at 32.6 months, with longer survival in patients without disseminated disease. Culine poor-risk group and neutrophil-to-lymphocyte ratio were associated with worse overall survival. Tips regarding diagnosis and management of these rare malignant subsets are provided.
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Affiliation(s)
- Ryan W. Huey
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Brandon G. Smaglo
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jeannelyn S. Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aurelio Matamoros
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Michael J. Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Gauri R. Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kanwal P.S. Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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11
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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: 3] [Impact Index Per Article: 0.8] [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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Rassy E, Pavlidis N. The diagnostic challenges of patients with carcinoma of unknown primary. Expert Rev Anticancer Ther 2020; 20:775-783. [PMID: 32779501 DOI: 10.1080/14737140.2020.1807948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cancer of unknown primary (CUP) is a disease entity encompassing heterogeneous malignancies without a clinically-detectable anatomical primary. It is usually a poor prognosis malignancy with dismal prognosis where molecular and genetic testing were expected to be a major breakthrough. AREAS COVERED In this review, we provide an overview of the advances in the understanding of the carcinogenesis, biology, diagnosis and treatment of patients with CUP. This review focuses on the advantages and inconveniences of immunohistochemistry and CUP classifiers in assessing the progress in the management of CUP. EXPERT OPINION CUP classifiers were expected to gradually replace the classical multistep approach in identifying the culprit tumors to guide site-specific therapy. Immunohistochemistry staining led to the prediction of a single tissue of origin in 10.8-51%. CUP classifiers identified the primary site in 61-89% of these cases and were concordant with immunohistochemistry in 57.1-100%. Immunohistochemistry is cheap, fast and broadly available whereas CUP classifiers are less widely available and have not been validated in randomized control trials. The diagnostic recommendations consist of a standard pathology evaluation based on morphology and algorithmic immunohistochemistry assessment. Physicians should weigh in the input of the CUP classifier to the clinical picture and pathology investigations before performing additional investigations.
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Affiliation(s)
- Elie Rassy
- Department of Medical Oncology, Gustave Roussy Institute , Villejuif, France.,Department of Medical Oncology, Saint Joseph University , Beirut, Lebanon
| | - Nicholas Pavlidis
- University of Ioannina , Ioannina, Greece.,European School of Oncology College , Milan, Italy
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