CUP

George Pentheroudakis

Professor of Oncology

Medical School, University of Ioannina

Greece

Characteristics

• Clinical absence of primary

• Especially aggressive

• Early dissemination

• Multiple metastases- unpredictable metastatic pattern

CUP Staging

CUP Therapeutic Approach

• Diagnostic approach for primary tumor

identification

• Rule out potentially treatable or curable tumors

• Identify favorable subsets – apply site specific treatment

• Unfavorable subsets- palliative empiric chemotherapy

Favorable subsets• Poorly differentiated carcinoma with midline nodal distribution

(extragonadal germ cell syndrome).

• Women with papillary adenocarcinoma of peritoneal cavity.

• Women with adenocarcinoma involving only axillary lymph nodes.

• Squamous cell carcinoma involving cervical lymph nodes.

• Poorly differentiated neuroendocrine carcinomas.

• Men with blastic bone metastases PSA+ (adenocarcinoma).

• Adenocarcinoma with a colon-profile (CK 20+, CK 7-, CDX 2+)

• Isolated inguinal adenopathy (squamous carcinoma).

Pavlidis N & Pentheroudakis G. The Lancet 379 : 1428-35, 2012

IS THIS REALLY

CUP?

Pavlidis N, Pentheroudakis G. Cancer of unknown primary site. Lancet. 2012 Apr 14;379(9824):1428-35.

Unfavorable Subsets

• Adenocarcinoma metastatic to the liver or other organs

• Non-papillary malignant ascites (adenocarcinoma)

• Multiple cerebral metastases (adeno or squamous Ca)

• Multiple lung/pleural metastases (adenocarcinoma)

• Multiple metastatic bone disease (adenocarcinoma)

• Squamous – cell carcinoma of the abdominal cavity

Lazaridis G, Pentheroudakis G et al .Cancer Treat Rev.

2008 Dec;34(8):693-700

VISCERAL CUP

What do we mean by “MOLECULAR

PROFILING ASSAYS”?

1. FIND THE TISSUE OF ORIGIN

Molecular assays may identify a primary site of

origin but does primary-specific therapy improve

outcomes?

2. FIND THE MOLECULAR TARGET

Does the screening for, and targeting of molecular

aberrations improve outcomes?

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Premise of “tissue of origin” classifierexample of Cancer Genetics platform

CUP

“Similarity Scores” a

Colorectal 88.2

Pancreas 4.4

NSCLC 2.3

Breast 2.1

Gastric 1.2

Kidney 0.6

HCC 0.3

Ovarian 0.3

Soft Tissue Sarcoma 0.1

NHL 0.1

Thyroid 0.1

Prostate 0.1

Melanoma 0.1

Bladder 0.1

Testicular Germ Cell 0.0

Adapted from

Cancergenetics.com

RNA profile2,000 genes

Compare

with known

tissue

profiles

a Similarity Scores of all possible primaries add up to 100

Premise: Each tumor

type has a distinct

molecular profile

Platformmolecule

class# genes

# of claimed

distinguishable

cancer types

BioTheranostics mRNA 92 ~50

Cancer Genetics mRNA ~2,000 15

Veridex mRNA 10 6

Agendia mRNA 495 9

Rosetta microRNA 48 25

EPICUPDNA

methylation

485,577 CpG

sites a38

a Examined in development phase (Moran et al 2016)

Dolled-Filhart and Rimm 2012 Cancer Cytopatholology

Research attention has focused on large panels of markers to identify tissue of origin

TOO classifiers: 10-2,000 genes analyzed simultaneously

Sarah Cannon trial examined TOO classifier-directed therapy

(enrolled 2008-2011)

a Biotheranostics (92-gene microarray)b Total of 26 different tissues of origin were predicted

CUP Treatment-naïve289 enrolled

TOO testing a

CRC FOLFOX(IRI) + bev

Ovary Carbo/Taxol + bev

Pancreas Gem + erlotinib

Prostate Androgen ablation

Others b Standard 1st-line Rx guidelines

TOO classifier-directed therapyNon-randomized

Hainsworth et al. JCO 2012

194 Received classifier-directed Rx (67% 194/289])

252 Successful assay (87% [252/289])

Varadhachary et al., Clin Cancer Res 2011

Hainsworth et al., J Clin Oncol 2013

Site-specific therapy for CUPs confers improved survival: Prospective studies

RCT to address whether TOO classifier-directed therapy can improve outcomes

French trial (GEFCAPI04)

Status: Enrolled ~200 pts (as of 04/2017)Estimated date to report primary outcome: 2018-2019

CUP (N = 223)

• Treatment-naïve

• Not limited to certain TOO profiles Gemcitabine

+ cisplatin

TOO testinga

with result unmasked

a Biotheranostics CancerTYPE ID. c Classifier-directed therapy is not publicly available

Data accessed from clinicaltrials.gov (NCT01540058) 4.11.2017

Classifier-directed therapy c

RPrimary

endpoint: PFS

TOO testinga

with result masked

Druggable targets in CUP tumors

➢ Foundation One

• Mutation analysis of 236 genes and rearrangements in 19 genes (NGS)

• N = 200 CUP tumors

➢ Caris Life Sciences

• Mutation analysis of 47 genes (eg, NGS); IHC 23 markers; FISH/CISH of 7

genes

• N = 1,806 CUP tumors

• But for many genes, a small subset of tumors was analyzed

Ross et al. JAMA Oncology 2015

Gatalica et al Oncotarget 2014

NSG = next generation sequencing

IHC = immunohistochemistry

FISH/CISH = fluorescence in situ hybridization

CUP aberrationsConway, Br J Cancer, 2019 Jan;120(2):141-153.

Challenges of tumor-agnostic approach (SHIVA): First randomized trial comparing molecularly targeted vs other

in tumor-agnostic setting

Solid tumor(N = 741

screened)

Investigator choice d

Molecular profiling a

a Targeted NGS, IHC, copy number alterationb Most exclusions due to incomplete molecular profile (n ~240), no targetable alteration (n ~200), other (n~100).

Included only patients with molecular alteration in one of 3 pathways (hormone receptor, PI3K/AKT/mTOR, RAF/MEK)c One of 10 regimens: erlotinib, lapatinib plus trastuzumab, sorafenib, imatinib, dasatinib, vemurafenib, everolimus,

abiraterone, letrozole, tamoxifen.d Almost all received cytotoxic therapies (monotherapy, n=70; combination, n=19; none, n=3)

Molecularly targeted agent c

Primary endpoint

PFS

R

Targetable alteration identified

and randomized (n=195) b

Open

label

Le Tourneau et al Lancet Oncology 2015

SHIVA: Failed to meet primary endpoint of PFS

Potential reasons cited by investigators:

• Treatment based on single (vs multiple) molecular alteration

• Mostly monotherapy• Limited choice of

targeted agents a

a For example, dual MTORC inhibitor may be better than everolimus

to target PI3K/AKT/mTOR pathway

NOTE: only 2 patients in control arm received molecularly targeted agent

HR 0.88 (p =.41)

Molecular targeted

therapy

MD choice

RR = 4.1% experimental vs 3.4% control

*Tissue sample suitable for initial diagnosis of CUP at study site, confirmation of CUP diagnosis and generation of Foundation One comprehensive genomic profile at central

laboratory‡Sample suitable for analysis of circulating tumour DNA using FoundationACT assay

CUPISCO Trial

Inclusion criteria

• Histologically confirmed

CUP (non-specific subset)

• No prior lines of therapy

• ECOG PS 0–1

• ≥1 measurable lesion

N=790

Induction

Carboplatin + paclitaxel or

cisplatin + gemcitabine

(3 cycles)

Non-responders

PD or intolerable

toxicity

n=318 (40%)

Responders

CR, PR or SD

n=472 (60%)

Investigator choice

(following Molecular

Tumour Board advice)

n=354

Alectinib (ALK or RET rearrangements)

Erlotinib + bevacizumab (EGFR Mut+)

Trastuzumab + pertuzumab + continued

induction chemo (ERBB2)

Vismodegib (PTCH1, SUFU or SMO)

Vemurafenib + cobimetinib (BRAF MutV600)

Ipatasertib (AKT1 or PI3K)

Olaparib (BRCA1, BRCA2 or HRD)

Atezolizumab (TMB high or MSI-high)

Atezolizumab + continued induction

chemo (patients with no other option)

R

3:1

n=118

Investigator choice

(following Molecular

Tumour Board advice)Assigned as per randomised arm

Carboplatin + paclitaxel or

cisplatin + gemcitabine (3 cycles)Screening

Genomic profiling

Tissue* and blood‡

plus select biomarkers

(e.g. PD-L1)

Primary endpoint: pooled PFS from 9

molecularly guided regimens vs chemo in

responders to induction chemo [PFS1]

Secondary endpoint: OS

Category 1

Category 2

Mutational burden in CUP

• Evaluation of MSI and TMB in 5991 CUP tumours.

• High TMB varied by histological subtype but

ranged:

• 6.1% in neuroendocrine CUP

• 21.6% in squamous CUP.

• 2.9% MSI-H

• Chalmers et al, Genome Med. 2017; 9(1): 1–14.

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• 389 patients with CUP: tumour mutation burden (TMB), PDL1 status, MSI.

• 28% of samples had one or more factors that may indicate a response to immunotherapy.

• High PDL-1 expression was found in TIL (63%) and cancer cells (21%) with co-expression in 16% of cases

• Xiu et al, Ann Oncol. 2017; 28 (suppl_5): v22–v42.10.1093.

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Immune response in CUP

miRNA CUP SIGNATURE• N=150 CUP

• Compare the expression of a library of 900

microRNAs between:

- CUPs biologically classified

- Metastases from equivalent known primary

tumours (KPM)

• IS THERE A miRNA CUP SIGNATURE?

Pentheroudakis et al, Clin Exp

Metastasis 2013;30(4):431-9 24

Suggested use of Molecular AssaysClin Cancer Res 2013;19:4027-4033

CUP AlgorithmClinical Presentation

Initial Clinical/Diagnostic Evaluation and Biopsy

Standard Pathology, Immunohistochemistry Stains

Anatomical Primary Site Not Identified Anatomical Primary Site Identified

Favorable Subset CUP Site Specific Therapy

Specific Treatment for Subset

Tissue of Origin Molecular Profiler on Selected Tumors

Single Tissue of Origin Diagnosed Single Tissue of Origin Not Diagnosed

Clinical Trial or

Site Specific Therapy

Clinical Trial or Pick the Target NGS assay or

Empiric Therapy

Poor Risk

THANK YOU

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