Clinical Pathology - Theses
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ItemImproving the diagnosis and treatment of cancer of unknown primary using genomic profiling and patient-derived organoids( 2023-04)Cancer of unknown primary (CUP) is a metastatic cancer for which a standard clinical investigation fails to identify a primary tissue of origin (TOO). Clinical decision-making is impaired without a primary TOO diagnosis since this is typically used to inform optimal patient care. Most CUP patients are treated with empirical chemotherapy leading to poor survival outcomes. Therefore, improved diagnostic and treatment options for CUP patients are needed. The diagnostic utility of targeted RNA and DNA profiling was investigated in a cohort of 215 CUP patients. A retrospective clinicopathology review was performed to assign a putative TOO diagnosis. Seventy-seven percent (166/215) of the cohort had insufficient clinicopathological evidence to support a TOO diagnosis, while the remaining 23% were putatively resolved and had a clinicopathology diagnosis assigned. A custom gene expression profiling (GEP) TOO classifier was applied. The clinicopathology-unresolved CUPs were more challenging to classify than the resolved CUPs, and only 56% had a high confidence TOO classification. Cancer-type specific DNA features, including mutations and mutational signatures, were investigated and provided diagnostic evidence to support a TOO in 31% of unresolved CUPs, while GEP classifications supported a diagnosis in 13%. A genomics-informed clinicopathology review could direct an unconfirmed TOO diagnosis in one-third of CUPs. The RNA and DNA profiled CUP cohort were also investigated for immune and genomic biomarkers that could direct immune checkpoint inhibitor (ICIs) treatment for CUPs. Sixteen percent of CUPs had a high tumour mutation burden, 33% had high expression of genes associated with immunotherapy response, and 47% of the TOO-resolved CUPs belonged to an ICI-responsive cancer type. Of a subset of 28 CUPs treated with ICIs, 8/28 (29%) responded to treatment, and all of the responders had a high gene expression score (7/8) and/or high tumour mutation burden (3/8), and most (5/8) belonged to ICI-responsive cancer types. Therefore, many CUP patients have molecular features indicative of ICI susceptibility. Whole genome sequencing (WGS) was explored in 30 CUPs with targeted DNA sequencing to identify additional diagnostic and therapeutic informative features. An 82% concordance of variants was detected between WGS and panel sequencing. WGS could detect additional genomic features, including mutational signatures. Actionable mutations and biomarkers were detected in 48% of cases by targeted DNA sequencing, while WGS increased this to 59%. Furthermore, 72% of CUPs could have a TOO assigned following genomics-informed iii histopathology assessment, of which a third resulted from WGS-identified features only, and all diagnostic features detected by targeted sequencing were supported by WGS. Although only assessed in a small subcohort, tumour DNA extracted from archival tissue and cell-free material could be sequenced to detect clinically relevant findings. Patient-derived organoids (PDOs) were attempted from fresh CUP tumours. PDOs were successfully derived from six of 20 tumour samples (30%). The PDOs were heterogenous, genomically and morphologically representative of the tumour and could be used for WGS. Anticancer compounds were selected for PDO drug screening based on molecular and clinically directed treatment. The PDO drug responses frequently concurred with genomic biomarkers, but multiple drug sensitivities were also unanticipated. By incorporating targeted DNA sequencing and GEP testing, many CUP patients had a putative TOO diagnosis assigned. The genomic tests were also used to identify molecular biomarkers for ICI treatment. When compared with WGS, there were specific diagnostic scenarios whereby WGS could improve the diagnosis and identify additional potentially useful therapies for patients. Additionally, CUP PDOs were used to test genomic-directed therapies through in vitro drug testing. Overall, the study provides insights into how genomic tests can improve the diagnosis and treatment of CUP.