Improving survival in metastatic carcinoma of unknown origin

Role of miRNA in carcinogenesis and biomarker selection: a methodological view

miRNAs, their involvement in cancer development and their potential to be robust biomarkers of diagnosis, staging, prognosis and response to therapy are reviewed. In small RNA animal biogenesis, miRNA genes in the nucleus are transcribed to generate long primary transcripts (pri-miRNAs), which are first cropped by RNase-III-type enzyme Drosha to release hairpin intermediates (pre-miRNAs) in the nucleus. Pre-miRNA is then exported to the cytoplasm by exportin-5. Following arrival in the cytoplasm, pre-miRNAs are subjected to the second processing step (dicing) to release the mature miRNA duplex, which is then separated: one strand becomes the mature miRNA and the other is degraded. These tiny miRNAs induce messenger degradation, translational repression or both. However, there is no evidence to demonstrate that these two mechanisms exist in the regulation of the same gene. Since a miRNA can target numerous mRNAs, often in combination with other miRNAs, these miRNAs operate a highly complex regulatory network. The specific function in most mammalian miRNAs is unknown. However, data suggest that miRNA genes, approximately 1% of all human genes, regulate protein production for 20-30% or more of all genes. miRNA expression profiles are effective for classifying solid and hematologic human cancers, and have shown great promise for early cancer detection. This is of great importance for effective treatment before the cells metastasize; therefore, tumors can be surgically resected. Computer-based prediction approaches of miRNAs and their targets, and biological validation techniques for ascertaining these predictions, currently play a central role in the discovery of miRNAs and in elucidating their function. Guidelines have been established for the identification and annotation of new miRNAs to distinguish them from other RNAs, especially siRNAs. These guidelines take into account factors such as transcript structure, conservation and processing, and a centralized, searchable database of all possible miRNA sequence information and annotation for humans and of more than 38 other species. Two approaches are used to characterize miRNAs: studying expression of known miRNAs by hybridization-based techniques (e.g., northern blots, RNase protection, primer extension, real-time, quantitative PCR and microarrays) or discovery of novel miRNAs molecules by cloning and sequencing. Owing to their adaptability and high throughput, microarrays may prove to be the preferred platform for whole-genome miRNA expression analysis.

Implications of micro-RNA profiling for cancer diagnosis

Micro-RNAs (miRNAs) are a large class of small non-coding RNAs that regulate protein expression in eucaryotic cells. Initially believed to be unique to the nematode Caenorhabditis elegans, miRNAs are now recognized to be important gene regulatory elements in multicellular organisms and have been implicated in a variety of disease processes, including cancer. Advances in expression technologies have facilitated the high-throughput analysis of small RNAs, identifying novel miRNAs and showing that these genes may be aberrantly expressed in various human tumors. These studies suggest that miRNA expression profiling can be correlated with disease pathogenesis and prognosis, and may ultimately be useful in the management of human cancer.

Cancer of unknown primary: clinicopathologic correlations

Cancer of unknown primary origin (CUP) accounts for 5-10% of all malignant tumors at presentation and remains the death certificate diagnosis in 0.5-5% of patients. We investigated CUP patients whose primary site remained unknown throughout the entire clinical course. We reviewed 9,436 consecutive autopsies performed between 1984 and 1999 at the Mayo Clinic, matched with 177,167 cancer patients treated in the same time period. Sixty-four patients who died of CUP underwent postmortem examination. Antemortem pathologic diagnoses were obtained in 57 patients, agreed with postmortem diagnoses in 98%, and included adenocarcinoma (n=44), undifferentiated carcinoma (n=7), squamous cell carcinoma (n=3), and others (n=3). Autopsy located the primary site in 35 patients (55%). Common primary sites were lung (n=8), the pancreaticobiliary (n=13) and GI tracts (n=9). Of 43 patients evaluated for tumor-specific therapy, only six received no further oncologic treatment and untreated patients survived a median of 57 (range 10-280) days, compared with 225 (range 19-1,129) days for patients treated with chemotherapy and/or radiotherapy (n=37). Our findings show that (1) autopsy studies provide a valuable tool for quality control in the setting of CUP, and (2) treated patients have a small but significant survival benefit.