Abstract Most patients with cancer of unknown primary (CUP) still receive platinum-based chemotherapy and have a poor prognosis, with overall survival of less than one year. Recent studies suggest improved outcomes with molecularly guided or site-specific therapies informed by molecular tissue profiling. Here, we analyzed ctDNA from 190 CUP patients using an integrated genomic and epigenomic assay to identify actionable alterations and predict tissue-of-origin (ToO). Integration of actionable biomarkers, ToO prediction and clinical data yielded diagnostic, prognostic or therapeutic information in 90% of unfavorable CUP cases and 88% of patients analyzed at first diagnosis. High ctDNA tumor fraction was associated with poorer prognosis in both favorable and unfavorable CUP. These findings highlight the clinical utility of ctDNA analysis for therapeutic decision-making in CUP and support its incorporation into the diagnostic work-up, particularly when tissue samples are unavailable or insufficient for molecular testing.

Oncological treatment in a substantial portion of patients with cancer of unknown primary (CUP) remains challenging due to limitations of conventional imaging and positron emission tomography/computed tomography with 18Fluor-fluorodeoxyglucose (18F-FDG-PET/CT). In head and neck-like CUP (HNCUP), several studies found significantly higher tracer-uptake and detection rates of primary tumors in 68Gallium-labeled fibroblast activation protein inhibitor-PET/CT (68Ga-FAPI-PET/CT). Here, we address a gap in CUP literature by retrospectively evaluating the diagnostic accuracy of both tracer in a head-to-head comparison of patients with single-site and oligometastatic extra-cervical CUP. 13 patients with extra-cervical CUP underwent both 18F-FDG- and 68Ga-FAPI-PET/CT. Suspicious PET-positive lesions were delineated using the volume of interest-technique (50

Measurable residual disease (MRD) can predict relapse in patients with advanced myelodysplastic neoplasms (MDS) or acute myeloid leukemia (AML). We report the long-term efficacy and safety of MRD-guided preemptive azacitidine treatment to prevent relapse in the phase 2 RELAZA2 trial. Patients with MDS or AML after either intensive chemotherapy only or consecutive allogeneic stem cell transplantation were prospectively screened for imminent relapse by molecular MRD assessment. Patients who became MRD positive (MRDpos) during screening received azacitidine for up to 2 years to prevent relapse. The primary endpoint was the proportion of patients alive and relapse-free six months after azacitidine start. Of 357 patients screened, 119 (33.3%) became MRDpos, of whom 95 (79.8%) were eligible for azacitidine treatment. The primary endpoint was met; 60 (63%) patients were relapse-free (95% confidence interval 54-71%, P<0.0001) six months after azacitidine initiation with no new safety signals. Of 60 patients achieving MRD response during the first six cycles of azacitidine, 31 (52%) maintained response without hematological relapse for ≥2 years following azacitidine initiation. The median treatment-free duration following azacitidine discontinuation was 20.8 months; the longest ongoing response was 104 months. After a median follow-up of 6.6 years, 15 initial responders (25%) remained alive and in remission. Among screened patients who remained continuously MRDneg, 60-month overall survival and relapse-free survival were 88% and 79%, respectively. Continuously MRDneg patients display a very favorable prognosis. A majority of MRDpos patients can be effectively treated with azacitidine with potential long-term remission even after termination of azacitidine. Clinicaltrials.gov: NCT01462578.

CUPISCO (ClinicalTrials.gov identifier: NCT03498521) demonstrated longer progression-free survival (PFS) with comprehensive genomic profiling (CGP) and subsequent molecularly guided therapies (MGTs), versus standard platinum-based chemotherapy, in patients with previously untreated, unfavorable cancer of unknown primary (CUP) who reached disease control after induction chemotherapy (three cycles). We report efficacy and safety after >1 year of additional follow-up. Eligible patients were randomly assigned (3:1) to MGT (investigator-chosen after discussion in a molecular tumor board) or three further cycles of chemotherapy. The primary end point was PFS. Secondary end points included overall survival (OS) and safety. At data cutoff (December 6, 2024), 436 patients were randomly assigned (326 to MGT; 110 to chemotherapy). Median follow-up was 37.0 months (range, 0.0-67.8). Updated median PFS was 6.1 months (95% CI, 4.7 to 6.5) with MGT and 4.4 months (95% CI, 4.2 to 6.4) with chemotherapy (hazard ratio [HR], 0.75 [95% CI, 0.59 to 0.95]; P = .017); median OS was 15.2 months (95% CI, 13.9 to 18.4) and 12.8 months (95% CI, 9.8 to 15.4), respectively (HR, 0.79 [95% CI, 0.61 to 1.02]; P = .0689). No new safety signals were identified. These updated results aligned with the primary analysis, demonstrating the benefit of CGP with subsequent MGT and highlighting the importance of incorporating CGP at initial diagnosis to guide treatment decisions for patients with unfavorable CUP.

SCHEMATIC VIEW OF THE DEVELOPMENT OF CK-AML DRIVEN BY THE TP53 ABSENCE.: The occurrence of the first, often dominant negative TP53 mutation is quickly followed by the loss of the second TP53 allele and numerous further chromosomal aberrations.

Cancer of unknown primary (CUP) is a metastatic malignancy for which a primary site of origin cannot be identified despite a thorough and standardized diagnostic work-up, and accounts for 1–3

With platinum-based CTX, prognosis of patients (pts) with unfavourable CUP is poor; however, CGP may inform treatment strategies based on cancer genomics. The CUPISCO trial (NCT03498521) compared the efficacy and safety of molecularly guided therapy (MGT) vs standard platinum-based CTX in pts with newly diagnosed, unfavourable, non-squamous CUP. Pts had central eligibility review-confirmed CUP with ≥1 measurable lesion (investigator-assessed via RECIST v1.1). All had tumour tissue and/or blood CGP (Foundation Medicine, Inc.). After 3 induction CTX cycles, pts with disease control were randomised 3:1 to MGT (investigator’s choice from 12 regimens after molecular tumour board advice) or continuation with ≥3 more CTX cycles (category 1; shown here), stratified by gender and response to induction CTX. Pts with progressive disease received MGT (category 2). The primary endpoint was progression-free survival (PFS) in category 1 pts. Secondary endpoints included overall survival (OS), objective response rate (ORR), duration of response (DoR) and disease control rate (DCR). Safety was also assessed. Exploratory endpoints included quality of life (QoL). From Jul 2018–Dec 2022, 436 category 1 pts were randomised: 326 to MGT; 110 to CTX. Median PFS (intent-to-treat population) was 6.1 months (95% confidence interval [CI] 4.7–6.5) with MGT vs 4.4 months (4.1–5.6) with CTX (hazard ratio [HR] 0.72; 95% CI 0.56–0.92; P=0.0079). Median OS was 14.7 (95% CI 13.3–17.3) vs 11.0 months (9.7–15.4), respectively (HR 0.82; 95% CI 0.62–1.09; P=0.1779), though OS data were immature at cutoff. ΔORR was 9.6% (95% CI 2.4–16.8, P=0.0141) in favour of MGT, with similar DoR in each arm (HR 0.95; 95% CI 0.33–2.72). ΔDCR was 4.7% (95% CI –6.4–15.9; P=0.3922) in favour of MGT. Adverse event rates were generally similar with MGT vs CTX; no difference in QoL was observed. In pts with newly diagnosed, unfavourable, non-squamous CUP who responded to induction CTX, CGP with MGT improved PFS. Early CGP and MGT should be considered the new standard of care for these pts.

Das CUP-Syndrom („cancer of unknown primary“) bedarf einer multimodalen Diagnostik, die alle beteiligten Fachdisziplinen einschließt. Die Diagnostik ist herausfordernd; jeweils hohe Fachexpertise ist notwendig. Konzeptionell basiert die heute eingesetzte CUP-Diagnostik auf der Sicherung der Malignomdiagnose sowie auf der Rückverfolgung des Tumors auf das Ursprungsgewebe (Identifizierung des „eigentlichen“ Tumortyps). Dieser Ansatz bedarf einer Integration verschiedener Diagnostikverfahren (bspw. Bildgebung, Morphologie einschl. Immunhistochemie und molekularer Verfahren), um eine hohe Spezifität der Diagnostik zu erreichen. Hierbei kann das molekulare Profil Hinweise auf den mutmaßlichen Primärtumor liefern und ist besonders hilfreich bei Patienten/-innen mit einer vorangegangenen Tumorerkrankung, um den klonalen Zusammenhang zwischen beiden Tumorerkrankungen aufzuklären. Gleichzeitig gewinnt auch die Identifizierung prädiktiver Biomarker und therapeutischer Zielstrukturen zunehmend an Bedeutung. Diese Konstellation beeinflusst den diagnostischen Arbeitsfluss und erfordert die Nutzung komplementärer Verfahren. Dabei wird der Einsatz molekularer Untersuchungen aus dem Blut, sog. Liquid Biopsies, zunehmend auch in der klinischen Routine eingesetzt. Aus biologischer und klinischer Sicht stellt sich die Frage, ob das Konzept der Rückverfolgung auf das Ursprungsgewebe und entsprechend daran ausgerichteter Therapie für alle Tumoren der heterogenen CUP-Gruppe sinnvoll ist oder ob ein neues diagnostisches Konzept notwendig ist, um das Überleben von betroffenen Patienten/-innen zu verbessern.

BACKGROUND: Cancer of unknown primary (CUP) is defined as a primary metastatic malignancy, in which the primary tumor remains elusive in spite of a comprehensive diagnostic workup. The frequency and prognostic value of circulating tumor cells (CTCs), which are considered to be the source of metastasis, has not yet been systematically evaluated in CUP. METHODS: A total of 110 patients with a confirmed diagnosis of CUP according to the European Society for Medical Oncology (ESMO) guidelines, who presented to our clinic between July 2021 and May 2023, provided blood samples for CTC quantification using CellSearch methodology. CTC counts were correlated with demographic, clinical, and molecular data generated by comprehensive genomic profiling of tumor tissue. RESULTS: CTCs were detected in 26% of all patients at initial presentation to our department. The highest CTC frequency was observed among patients with unfavorable CUP (35.5%), while patients with single-site/oligometastatic CUP harbored the lowest CTC frequency (11.4%). No statistically significant association between CTC positivity and the number of affected organs (P = 0.478) or disease burden (P = 0.120) was found. High CTC levels (>= 5 CTCs/7.5 mL; 12/95 analyzed patients) predicted for adverse overall survival compared to negative or low CTC counts (6-months overall survival rate 90% vs 32%, log-rank P < 0.001; HR 5.43; 95% CI 2.23-13.2). CTC dynamics were also prognostic for overall survival by landmark analysis (log-rank P < 0.001, HR 10.2, 95% CI 1.95-52.9). CONCLUSIONS: CTC frequency is a strong, independent predictor of survival in patients with CUP. CTC quantification provides a useful prognostic tool in the management of these patients.

BACKGROUND:Patients with unfavourable subset cancer of unknown primary (CUP) have a poor prognosis when treated with standard platinum-based chemotherapy. Whether first-line treatment guided by comprehensive genomic profiling (CGP) can improve outcomes is unknown. The CUPISCO trial was designed to inform a molecularly guided treatment strategy to improve outcomes over standard platinum-based chemotherapy in patients with newly diagnosed, unfavourable, non-squamous CUP. The aim of the trial was to compare the efficacy and safety of molecularly guided therapy (MGT) versus standard platinum-based chemotherapy in these patients. This was to determine whether the inclusion of CGP in the initial diagnostic work-up leads to improved outcomes over the current standard of care. We herein report the primary analysis. METHODS:CUPISCO was a phase 2, prospective, randomised, open-label, active-controlled, multicentre trial done at 159 sites in 34 countries outside the USA. Patients with central eligibility review-confirmed disease (acceptable histologies included adenocarcinoma and poorly differentiated carcinoma) and an Eastern Cooperative Oncology Group performance status of 0 or 1, evaluated by CGP, who reached disease control after three cycles of standard first-line platinum-based chemotherapy were randomly assigned 3:1 via a block-stratified randomisation procedure to MGT versus chemotherapy continuation for at least three further cycles. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT03498521, and follow-up is ongoing. FINDINGS:From July 10, 2018, to Dec 9, 2022, 636 (42%) of 1505 screened patients were enrolled. Median follow-up in the treatment period was 24·1 months (IQR 11·6-35·6). Of 438 patients who reached disease control after induction chemotherapy, 436 were randomly assigned: 326 (75%) to the MGT group and 110 (25%) to the chemotherapy group. Median progression-free survival in the intention-to-treat population was 6·1 months (95% CI 4·7-6·5) in the MGT group versus 4·4 months (4·1-5·6) in the chemotherapy group (hazard ratio 0·72 [95% CI 0·56-0·92]; p=0·0079). Related adverse event rates per 100-patient-years at risk were generally similar or lower with MGT versus chemotherapy. INTERPRETATION:In patients with previously untreated, unfavourable, non-squamous CUP who reached disease control after induction chemotherapy, CGP with subsequent MGTs resulted in longer progression-free survival than standard platinum-based chemotherapy. On the basis of these results, we recommend that CGP is performed at initial diagnosis in patients with unfavourable CUP. FUNDING:F Hoffmann-La Roche.

•Treating ALK+ NSCLC in pregnancy is delicate due to scarce data on tyrosine kinase inhibitors (TKI) fetotoxicity.•Postpartum period might render ALK+ NSCLC patients especially vulnerable to toxicity.•This is the first case of globus pallidus necrosis while on TKI therapy in ALK+ NSCLC.•Patients with previous pneumonitis from other TKI can tolerate exposure to brigatinib.

Introduction: About 20% of all cancer of unknown primary (CUP) cases can be classified into favorable subgroups, which are defined by either obvious analogies to certain cancers with a known primary or amenability to local ablative treatment. In the updated European Society for Medical Oncology (ESMO) guidelines for diagnosis and treatment of CUP, the definition of favorable subgroups has been revised according to the latest scientific findings. In particular, the definition and treatment of oligometastatic CUP have undergone considerable changes in recent years. Thus, we delineate the current diagnostic and therapeutic standards for the two favorable CUP subtypes single-site/oligometastatic and head/neck CUP.Methods: The classification, diagnostic workup, and treatment of single-site and oligometastatic CUP are summarized based on the current ESMO and American Society of Clinical Oncology (ASCO) guidelines together with a literature review.Conclusions: Single-site and oligometastatic CUP is defined by the presence of a maximum of five metastases that are amenable to local ablative treatment. Median overall survival is favorable and exceeds 4 years after local ablation of all detectable metastases. Lymph node metastases in the head and neck region represent a frequent scenario of single-site CUP. They usually originate from human papillomavirus (HPV)-associated squamous cell carcinoma in the oropharynx. Diagnostic workup comprises computed tomography (CT), magnetic resonance imaging (MRI) if necessary, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), followed by panendoscopy and biopsies of suspicious mucosal sites. Neck dissection, potentially followed by adjuvant radiotherapy, and definitive radiotherapy represent equally effective oncological treatment options with respect to a favorable prognosis.

Als CUP-Syndrom („cancer of unknown primary“) bezeichnet man eine Krebserkrankung, die histologisch aus Metastasengewebe gesichert ist, bei der aber trotz ausführlicher Diagnostik kein Primärtumor nachgewiesen werden kann. Damit handelt es sich beim CUP-Syndrom um eine Ausschlussdiagnose. Aktuell hat die European Society of Medical Oncology (ESMO) stark überarbeitete Leitlinien zum CUP-Syndrom herausgegeben. Folgende relevante Aktualisierungen sind vorgenommen worden: Bei der Diagnose des CUP-Syndroms zielen die neuen Leitlinien darauf ab, die Erkrankung präziser zu definieren und die Diagnose anhand von Algorithmen besser zu standardisieren. Auch wird die molekulare Diagnostik am Tumorgewebe in den neuen Empfehlungen verankert. Die Klassifikation des CUP-Syndroms wurde ebenfalls überarbeitet. Zum einen wurde bei der Neudefinition der günstigen Untergruppen, für die eine spezifische Behandlung indiziert ist, das Karzinom mit nierenzellkarzinomtypischer Immunhistochemie („renal-like CUP“) neu aufgenommen. Zum anderen wurde eine lokal mittels Operation und/oder Strahlentherapie potenziell kurativ behandelbare Subgruppe basierend auf einer neu definierten oligometastasierten Situation in die CUP-Klassifikation eingeführt. Bezüglich der Therapie der CUP-Syndrome zeigen die aktuellen Leitlinien auf, in welchen Indikationen jenseits der empirischen Chemotherapie, die immer noch den therapeutischen Goldstandard darstellt, auch Immuntherapien und zielgerichtete Therapien zum Einsatz kommen können. Ziel dieser Übersichtsarbeit ist es, den aktuellen Stand der Diagnostik, Klassifikation und Therapie des CUP-Syndroms aufzuzeigen und dabei insbesondere die aktuellen Entwicklungen und die in den revidierten ESMO-Leitlinien vorgenommenen Änderungen darzustellen.

Zusammenfassung Einleitung Bis zu 20 % aller CUP-Erkrankungen („cancer of unknown primary“) können einer prognostisch günstigen Subgruppe zugeordnet werden. In den neuen Leitlinien der European Society for Medical Oncology (ESMO) für die Diagnostik und Therapie des CUP-Syndroms wurde die Definition günstiger Subgruppen überarbeitet und an die aktuelle wissenschaftliche Literatur angepasst. Insbesondere die Definition und Therapie von oligometastasierten CUP-Syndromen hat in den vergangenen Jahren einen starken Wandel erfahren. Ziel dieses Übersichtsartikels ist es, die aktuellen diagnostischen und therapeutischen Standards für lokal begrenzte/oligometastasierte sowie für CUP-Syndrome im Kopf-Hals-Bereich darzustellen. Methoden Basierend auf den aktuellen Leitlinien der ESMO und American Society of Clinical Oncology (ASCO) sowie einer ergänzenden Literaturrecherche werden Einteilung, Diagnostik und Therapie von lokal begrenzten und oligometastasierten CUP-Syndromen sowie CUP-Syndromen im Kopf-Hals-Bereich dargestellt. Schlussfolgerung Das lokal begrenzte/oligometastasierte CUP-Syndrom wird durch die Anwesenheit von höchstens 5 Metastasen, die ablativ behandelt werden können, definiert. Nach entsprechender Therapie haben lokal begrenzte/oligometastasierte CUP-Syndrome im Vergleich zur größeren Gruppe prognostisch ungünstiger CUP-Syndrome eine viel bessere Prognose; das mediane Gesamtüberleben liegt bei > 4 Jahren. Zervikale Lymphknotenmetastasen als häufiger Spezialfall des lokal begrenzten CUP-Syndroms gehen meist von mit dem humanen Papillomvirus (HPV) assoziierten Plattenepithelkarzinomen des Oropharynx aus. Diagnostisch erfolgen eine Computertomographie (CT), ggf. eine Magnetresonanztomographie (MRT) sowie eine Fluordesoxyglukose-Positronen-Emissions-Tomographie/Computertomographie (FDG-PET/CT) mit anschließender Panendoskopie inkl. gezielter Biopsien. Die „neck dissection“ mit ggf. adjuvanter Radiotherapie und die definitive Radiotherapie gelten als gleichwertig hinsichtlich einer günstigen onkologischen Prognose.

Cancer of unknown primary has a dismal prognosis, especially following failure of platinum-based chemotherapy. 10-20% of patients have a high tumor mutational burden (TMB), which predicts response to immunotherapy in many cancer types. In this prospective, non-randomized, open-label, multicenter Phase II trial (EudraCT 2018-004562-33; NCT04131621), patients relapsed or refractory after platinum-based chemotherapy received nivolumab and ipilimumab following TMB high vs. TMB low stratification. Progression-free survival (PFS) represented the primary endpoint; overall survival (OS), response rates, duration of clinical benefit and safety were the secondary endpoints. The trial was prematurely terminated in March 2021 before reaching the preplanned sample size ( n = 194). Among 31 evaluable patients, 16% had a high TMB ( > 12 mutations/Mb). Overall response rate was 16% (95% CI 6-34%), with 7.7% (95% CI 1-25%) vs. 60% (95% CI 15-95%) in TMB low and TMB high , respectively. Although the primary endpoint was not met, high TMB was associated with better median PFS (18.3 vs. 2.4 months) and OS (18.3 vs. 3.6 months). Severe immune-related adverse events were reported in 29% of cases. Assessing on-treatment dynamics of circulating tumor DNA using combined targeted hotspot mutation and shallow whole genome sequencing as part of a predefined exploratory analysis identified patients benefiting from immunotherapy irrespective of initial radiologic response.