Nab-PIPAC: a phase IB study protocol of intraperitoneal cisplatin and nab-paclitaxel administered by pressurised intraperitoneal aerosol chemotherapy (PIPAC) in the treatment of advanced malignancies confined to the peritoneal cavity

Introduction: Intraperitoneal dissemination is a major problem resulting in very poor prognosis and a rapid marked deterioration in the quality of life of patients. Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is an emergent laparoscopic procedure aiming to maximise local efficacy and to reduce systemic side effects. Methods and analysis: Nab-PIPAC, a bicentre open-label phase IB, aims to evaluate safety of nab-paclitaxel and cisplatin association using in patients with peritoneal carcinomatosis (PC) of gastric, pancreatic or ovarian origin as ≥1 prior line of systemic therapy. Using a 3+3 design, sequential intraperitoneal laparoscopic application of nab-paclitaxel (7.5, 15, 25, 37.5, 52.5 and 70 mg/m2) and cisplatin (10.5 mg/m2) through a nebuliser to a high-pressure injector at ambient temperature with a maximal upstream pressure of 300 psi. Treatment maintained for 30 min at a pressure of 12 mm Hg and repeated4-6 weeks intervals for three courses total.A total of 6-36 patients are expected, accrual is ongoing. Results are expected in 2024.The primary objective of Nab-PIPAC trial is to assess tolerability and safety of nab-paclitaxel and cisplatin combination administered intraperitoneally by PIPAC in patients with PC of gastric, pancreatic or ovarian origin. This study will determine maximum tolerated dose and provide pharmacokinetic data. Ethic and dissemination: Ethical approval was obtained from the ethical committees of Geneva and Vaud (CCER-2018-01327). The study findings will be published in an open-access, peer-reviewed journal and presented at relevant conferences and research meetings. Trial registration number: NCT04000906.</p

Redefining cancer of unknown primary: Is precision medicine really shifting the paradigm?

The concept of Cancer of Unknown Primary (CUP) has evolved with the advent of medical oncology. CUP can be difficult to diagnose and represents 2 to 5% of new cancers, therefore not exceptionally rare. Within CUPs can be identified a subset of favourable prognosis tumours, however the vast majority of CUP patients belongs to a poor prognosis group. CUP features significant oncological challenges, such as unravelling biological and transversal issues, and most importantly, improving patient\u27s outcomes. In that regard, CUP patients’ outcomes regrettably showed minimal improvement for decades and CUP remains a cancer group of very poor prognosis. The biology of CUP has two main hypotheses. One is that CUP is a subgroup of a given primary cancer, where the primary is present but cannot be seen due to its small size. The other, the “true” CUP hypothesis, states that CUP share features that make them a specific entity, whatever their tissue of origin. A true biological signature has not yet been described, but chromosomal instability is a hallmark of poor prognosis CUP group. Precision oncology, despite achieving identifying the putative origin of the CUP, so far failed to globally improve outcomes of patients. Targeting molecular pathways based on molecular analysis in CUP management is under investigation. Immunotherapy has not shown ground-breaking results, to date. Accrual is also a crucial issue in CUP trials. Herein we review CUP history, biological features and remaining questions in CUP biology, the two main approaches of molecular oncology in CUP management, in order to draw perspectives in the enormous challenge of improving CUP patient outcomes

Lymphopenia combined with low TCR diversity (divpenia) predicts poor overall survival in metastatic breast cancer patients

Lymphopenia (< 1Giga/L) detected before initiation of chemotherapy is a predictive factor for death in metastatic solid tumors. Combinatorial T cell repertoire (TCR) diversity was investigated and tested either alone or in combination with lymphopenia as a prognostic factor at diagnosis for overall survival (OS) in metastatic breast cancer (MBC) patients. The combinatorial TCR diversity was measured by semi quantitative multi-N-plex PCR on blood samples before the initiation of the first line chemotherapy in a development (n = 66) and validation (n = 67) MBC patient cohorts. A prognostic score, combining lymphocyte count and TCR diversity was evaluated. Univariate and multivariate analyses of prognostic factors for OS were performed in both cohorts. Lymphopenia and severe restriction of TCR diversity called “divpenia” (diversity ≤ 33%) were independently associated with shorter OS. Lympho-divpenia combining lymphopenia and severe divpenia accurately identified patients with poor OS in both cohorts (7.6 and 10.6 vs 24.5 and 22.9 mo). In multivariate analysis including other prognostic clinical factors, lympho-divpenia was found to be an independent prognostic factor in the pooled cohort (p = 0.005) along with lack of HER2 and hormonal receptors expression (p = 0.011) and anemia (p = 0.009). Lympho-divpenia is a novel prognostic factor that will be used to improve quality of MBC patients’ medical care

Dre Intidhar Labidi-Galy, chercheuse au Centre de recherche translationnelle en onco-hématologie de la Faculté de médecine de l’UNIGE et médecin aux HUG.<p>--------</p>Dr. Intidhar Labidi-Galy, a researcher at the Translational Research Centre in Onco-haematology at the UNIGE Faculty of Medicine and a physician at the HUG.

Dre Intidhar Labidi-Galy, chercheuse au Centre de recherche translationnelle en onco-hématologie de la Faculté de médecine de l’UNIGE et médecin aux HUG.--------Dr. Intidhar Labidi-Galy, a researcher at the Translational Research Centre in Onco-haematology at the UNIGE Faculty of Medicine and a physician at the HUG

Pathogenesis of ovarian cancer

Epithelial ovarian cancer (EOC) is a heterogeneous disease with five histotypes: serous (high-grade and low-grade), endometrioid, clear cell and mucinous carcinoma. New evidences suggest that the majority of EOC are of extra-ovarian origin. We used next-generation sequencing to investigate the cell of origin of high-grade serous ovarian carcinoma (HGSOC) and mucinous ovarian carcinoma (MOC). We analyzed exome-wide sequence and structural analyses of multiple tumor samples from five individuals with advanced stage sporadic HGSOC. Our results suggest that ovarian cancer is a disease of the fallopian tubes, with the development of p53 signatures and serous tubal intraepithelial carcinoma as early events. The subsequent formation of a cancer in the ovaries represents a seeding event from a primary tumor in the fallopian tube that already contains sequence and structural alterations in key driver genes, including TP53, PI3K pathway, and BRCA1/BRCA2 genes. Our work could have implication for screening and early diagnosis of HGSOC. In a separate work, we used unsupervised clustering of gene-expression profile of different histotype of ovarian tumors, their eutopic tissues (ovarian surface epithelium and fallopian tube) and single-cell RNA-sequencing of primordial germ cells (PGCs). We observed that mucinous ovarian tumors (borderline and carcinoma) cluster more closely to PGCs than their eutopic tissue of origin. Our work brings a new and plausible explanation of the clinical and epidemiologic characteristics of MOC and could help into developing new target therapies for this rare and chemoresistant tumor

Functional and phenotypical alterations of plasmacytoid dendritic cells and regulatory T cells in ovarian cancer

Le cancer de l’ovaire est immunogène et constitue un bon modèle pour étudier l’immunité antitumorale. Nous avons effectué une étude comparative et systématique de la fréquence, du phénotype, de la fonction et de l’impact sur la survie des cellules dendritiques plasmacytoïdes (pDC) et des lymphocytes T régulateurs (Treg) dans le sang, l’ascite et la tumeur. Nous avons observé que les pDC s’accumulent dans les ascites et sont présentes dans certaines tumeurs alors qu’elles sont profondément déplétées dans le sang des patientes. La présence de pDC associées aux tumeurs (TApDC) est un facteur pronostique indépendant associé à une survie sans progression (SSP) plus courte. De plus, les TApDC, mais pas les pDC d’ascite, sont altérées dans leur fonction innée principale de production d’IFN-α en réponse aux TLR ligands in vitro et induisent le développement de lymphocytes T CD4+ producteurs d’IL-10 responsables d’une tolérance immune favorisant la progression tumorale. Les Treg s’accumulent dans les ascites et les tumeurs de l’ovaire mais leur taux dans le sang est comparable aux donneurs sains. Leur accumulation dans les tumeurs et non dans les ascites est un facteur pronostique indépendant associé à une SSP plus longue. Les TATreg ont un phénotype activé et inhibent la production d’IL-10 par les lymphocytes T CD4+ conventionnels associés aux tumeurs. De façon intéressante, les patientes dont les tumeurs augmentent l’infiltration par les Treg Foxp3+ après chimiothérapie néoadjuvante ont une rechute retardée suggérant qu’en plus d’un effet antitumoral direct, la chimiothérapie induit une réponse immuneOvarian cancer (OC) is an immunogenic disease and represents a good model for studying antitumoral immunity. We performed a systematic comparison between plasmacytoid dendritic cells (pDC) and regulatory T cells (Treg) in blood, ascites, and tumors in term of frequencies, phenotypes, functions, and impact on outcome of OC patients. We found that pDC accumulate in ascites and are present in some tumors whereas they are profoundly depleted in patients’ blood. Their presence within tumors (but not ascites) is deleterious because associated with early relapse of OC patients. Moreover, Tumor associated pDC (TApDC) but not ascite pDC were altered in their innate function, i.e. the production of IFN-α in response to TLR ligands in vitro, and they induce the development of IL-10+ CD4+T cells. All these results suggest that TApDC but not ascite pDC induce immune tolerance allowing cancer progression. Treg accumulate in ascites and tumors but their levels in patients’ blood were not increased. Their accumulation in tumors, but not ascites, was an independent prognostic factor associated with delayed relapse. TATreg showed an activated phenotype and inhibit IL-10 production by CD4+conventional TAT cells. Interestingly, patients whose tumor infiltration by Foxp3+ Treg is increased after neoadjuvant chemotherapy showed delayed relapse suggesting that chemotherapy, in addition to its direct antitumoral effect, induces an immune respons

Altérations fonctionnelles et phénotypiques des cellules dendritiques plasmacytoïdes et des lymphocytes T régulateurs dans le cancer de l’ovaire

Ovarian cancer (OC) is an immunogenic disease and represents a good model for studying antitumoral immunity. We performed a systematic comparison between plasmacytoid dendritic cells (pDC) and regulatory T cells (Treg) in blood, ascites, and tumors in term of frequencies, phenotypes, functions, and impact on outcome of OC patients. We found that pDC accumulate in ascites and are present in some tumors whereas they are profoundly depleted in patients’ blood. Their presence within tumors (but not ascites) is deleterious because associated with early relapse of OC patients. Moreover, Tumor associated pDC (TApDC) but not ascite pDC were altered in their innate function, i.e. the production of IFN-α in response to TLR ligands in vitro, and they induce the development of IL-10+ CD4+T cells. All these results suggest that TApDC but not ascite pDC induce immune tolerance allowing cancer progression. Treg accumulate in ascites and tumors but their levels in patients’ blood were not increased. Their accumulation in tumors, but not ascites, was an independent prognostic factor associated with delayed relapse. TATreg showed an activated phenotype and inhibit IL-10 production by CD4+conventional TAT cells. Interestingly, patients whose tumor infiltration by Foxp3+ Treg is increased after neoadjuvant chemotherapy showed delayed relapse suggesting that chemotherapy, in addition to its direct antitumoral effect, induces an immune responseLe cancer de l’ovaire est immunogène et constitue un bon modèle pour étudier l’immunité antitumorale. Nous avons effectué une étude comparative et systématique de la fréquence, du phénotype, de la fonction et de l’impact sur la survie des cellules dendritiques plasmacytoïdes (pDC) et des lymphocytes T régulateurs (Treg) dans le sang, l’ascite et la tumeur. Nous avons observé que les pDC s’accumulent dans les ascites et sont présentes dans certaines tumeurs alors qu’elles sont profondément déplétées dans le sang des patientes. La présence de pDC associées aux tumeurs (TApDC) est un facteur pronostique indépendant associé à une survie sans progression (SSP) plus courte. De plus, les TApDC, mais pas les pDC d’ascite, sont altérées dans leur fonction innée principale de production d’IFN-α en réponse aux TLR ligands in vitro et induisent le développement de lymphocytes T CD4+ producteurs d’IL-10 responsables d’une tolérance immune favorisant la progression tumorale. Les Treg s’accumulent dans les ascites et les tumeurs de l’ovaire mais leur taux dans le sang est comparable aux donneurs sains. Leur accumulation dans les tumeurs et non dans les ascites est un facteur pronostique indépendant associé à une SSP plus longue. Les TATreg ont un phénotype activé et inhibent la production d’IL-10 par les lymphocytes T CD4+ conventionnels associés aux tumeurs. De façon intéressante, les patientes dont les tumeurs augmentent l’infiltration par les Treg Foxp3+ après chimiothérapie néoadjuvante ont une rechute retardée suggérant qu’en plus d’un effet antitumoral direct, la chimiothérapie induit une réponse immun

Endometriosis-associated ovarian carcinomas: insights into pathogenesis, diagnostics, and therapeutic targets—a narrative review

Endometriosis is a benign gynecologic condition affecting up to one woman out of ten of reproductive age. It is defined by the presence of endometrial-like tissue in localizations outside of the uterine cavity. It often causes symptoms such as chronic pain, most frequently associated with the menstrual cycle, and infertility, but may also be oligo- or asymptomatic. There is evidence that some ovarian carcinoma (OC) histotypes, mainly the ovarian clear cell (OCCC) and endometrioid (EnOC) carcinoma, may arise from endometriosis. The most frequent genomic alterations in these carcinomas are mutations in the AT-rich interacting domain containing protein 1A (ARID1A) gene, a subunit of the SWI/SNF chromatin remodeling complex, and alterations in the phosphatidylinositol 3-kinase (PI3K)/AKT/mTOR pathway, which frequently co-occur. In ARID1A deficient cancers preclinical experimental data suggest different targetable mechanisms including epigenetic regulation, cell cycle, genomic instability, the PI3K/AKT/mTOR pathway, inflammatory pathways, immune modulation, or metabolic alterations as potential precision oncology approaches. Most of these strategies are relying on the concept of synthetic lethality in which tumors deficient in ARID1A are more sensitive to the different compounds. Some of these approaches are currently being or have recently been investigated in early clinical trials. The remarkably frequent occurrence of these mutations in endometriosis-associated ovarian cancer, the occurrence in a relatively young population, and the high proportion of platinum-resistant disease certainly warrants further investigation of precision oncology opportunities in this population. Furthermore, advanced knowledge about oncogenic mutations involved in endometriosis-associated ovarian carcinomas may be potentially useful for early cancer detection. However, this approach may be complicated by the frequent occurrence of somatic mutations in benign endometriotic tissue as recent studies suggest. In this narrative review of the current literature, we will discuss the data available on endometriosis-associated ovarian carcinoma, with special emphasis on epidemiology, diagnosis and molecular changes that could have therapeutic implications and clinical applicability in the future

Characteristics of long-survivor metastatic melanoma after polychemotherapy and interferon: a retrospective study

BACKGROUND: The development of immunotherapy and tyrosine kinase inhibitors dramatically improved the prognosis of metastatic melanoma. Consequently, chemotherapy is now rarely used. Here, we describe the characteristics of long-surviving patients with metastatic melanoma treated with immunochemotherapy. MATERIAL AND METHODS: We retrieved retrospective clinical and pathological data for patients diagnosed with metastatic melanoma between January 1993 and December 2015 who received the CVD-INF (cisplatin, vinblastine, dacarbazine, and interferon α-2b) regimen at the Hôpitaux Universitaires de Genève. We estimated their progression-free survival and overall survival. This ad hoc study’s primary aim was to describe the clinical and biological characteristics of long-term survivors, defined as patients surviving more than two years after immunochemotherapy initiation. The spatial distribution pattern of CD8+ T cells (inflamed, excluded, or desert) was immunohistochemically determined. RESULTS: Ninety patients received CVD-INF. Their median age at metastatic melanoma diagnosis was 55 years (20–75). Their median progression-free survival was 2.8 months, and median overall survival was 7.2 months. Eleven (12%) patients were long-term survivors. In multivariate analysis, central nervous system metastases (hazard ratio [HR]: 2.66; 95% confidence interval [CI]: 1.43–4.95; p = 0.001), multiple metastases (HR: 1.82; 95% CI: 1.01–3.29; p = 0.047), and elevated lactate dehydrogenase (LDH) (HR: 1.92; 95% CI: 1.12–3.30; p = 0.016) were independently associated with shorter survival. Most long-survivors (6/8; 75%) had a tumour-inflamed pattern compared to 25% of non-long survivors (5/20; Fisher’s test p = 0.030). CONCLUSIONS: A subset of patients with metastatic melanoma and a tumour-inflamed phenotype treated with CVD-INF survived over two years. Factors associated with prolonged survival are consistent with those previously reported in metastatic melanoma