Supplementary Material for: Mixed Adenoneuroendocrine Carcinomas of the Gastrointestinal Tract: Targeted Next-Generation Sequencing Suggests a Monoclonal Origin of the Two Components

<b><i>Background:</i></b> Mixed adenoneuroendocrine carcinomas (MANECs) of the gastrointestinal tract are rare neoplasms characterized by coexisting exocrine and neuroendocrine neoplastic components. MANECs' histogenetic classification and molecular characterization remain unclear, significantly affecting the identification of innovative therapeutic options for these tumors. <b><i>Methods:</i></b> The exocrine and neuroendocrine components of 6 gastrointestinal MANECs were microdissected and subjected to the simultaneous mutation assessment in selected regions of 54 cancer-associated genes using Ion Torrent semiconductor-based next-generation sequencing. Sanger sequencing and immunohistochemistry were used as validation of the mutational status. <b><i>Results:</i></b> A total of 20 driver gene somatic mutations were observed among the 12 neoplastic components investigated. In 11 of 12 (91.7%) samples, at least one mutation was detected; 7 samples (58.3%) were found to have multiple mutations.<i> TP53</i> gene mutations were the most frequent genetic alterations observed in the series, occurring in 11/12 samples (91.7%). Somatic mutations in other genes were detected at lower frequencies: <i>ATM</i>, <i>CTNNB1</i>, <i>ERBB4</i>, <i>JAK3</i>, <i>KDR</i>, <i>KRAS</i>, <i>RB1</i>. <b><i>Conclusions:</i></b> Five of the 6 MANECs presented an overlapping mutational profile in both components, suggesting a monoclonal origin of the two MANEC components

Supplementary Material for: Efficacy and Safety of Lanreotide Autogel and Temozolomide Combination Therapy in Progressive Thoracic Neuroendocrine Tumors (carcinoid): Results from the Phase 2 ATLANT Study

Introduction: Lanreotide autogel (LAN) and temozolomide (TMZ) are guidelines-recommended monotherapies for thoracic neuroendocrine tumors (carcinoids; T-NETs) but prospective data for both combined and monotherapies are lacking. ATLANT (NCT02698410) evaluated efficacy and safety of LAN/TMZ in progressive T-NETs. Methods: ATLANT was a 12-month, Italian, phase 2, single-arm, open-label, multicenter pilot study. Eligible patients had unresectable, locally-advanced/metastatic, well-/moderately-differentiated T-NETs with radiological progression. Patients received subcutaneous LAN 120 mg every 28 days and oral TMZ 250 mg/day for 5 consecutive days every 28-day cycle. Main endpoints: disease control rate (DCR) at 9 months (primary; investigator-assessed), median progression-free survival (PFS), biomarkers and safety. Results: Patients: n=40; 60% male. Primary tumor site: lung (90%); thymus (10%). Carcinoid type: typical (20.0%), atypical (52.5%). DCR at 9 months was 35.0% (95% confidence interval [CI] 20.63–51.68) (non-acceptability threshold ≤10%, p<0.0001; not significantly above clinically relevant threshold ≥30%, p=0.2968). DCR between 7.5 and 10.5 months (sensitivity analysis) was 45.0% (95%CI 29.26–61.51) and clinically relevant (p=0.0320 at ≥30% threshold). Median PFS was 37.1 (95%CI 24.1–52.9) weeks. No association was observed between biomarker variations (chromogranin A, neuron-specific enolase, somatostatin receptor type-2, Ki-67, 6-O-methylguanine-DNA-methyl-transferase) and DCR or PFS. Most patients (97.5%) had treatment-emergent adverse events (TEAEs); 72.5% had treatment-related TEAEs. TEAEs were mainly grade 1/2. No unanticipated TEAEs were reported. Conclusions: This study showed that LAN/TMZ combination has promising efficacy in progressive T-NETs, and was well tolerated. Larger studies are warranted to support the clinical benefits of LAN/TMZ in patients with T-NETs

Supplementary Material for: Efficacy and Safety of Lanreotide Autogel and Temozolomide Combination Therapy in Progressive Thoracic Neuroendocrine Tumors (carcinoid): Results from the Phase 2 ATLANT Study

Introduction: Lanreotide autogel (LAN) and temozolomide (TMZ) are guidelines-recommended monotherapies for thoracic neuroendocrine tumors (carcinoids; T-NETs) but prospective data for both combined and monotherapies are lacking. ATLANT (NCT02698410) evaluated efficacy and safety of LAN/TMZ in progressive T-NETs. Methods: ATLANT was a 12-month, Italian, phase 2, single-arm, open-label, multicenter pilot study. Eligible patients had unresectable, locally-advanced/metastatic, well-/moderately-differentiated T-NETs with radiological progression. Patients received subcutaneous LAN 120 mg every 28 days and oral TMZ 250 mg/day for 5 consecutive days every 28-day cycle. Main endpoints: disease control rate (DCR) at 9 months (primary; investigator-assessed), median progression-free survival (PFS), biomarkers and safety. Results: Patients: n=40; 60% male. Primary tumor site: lung (90%); thymus (10%). Carcinoid type: typical (20.0%), atypical (52.5%). DCR at 9 months was 35.0% (95% confidence interval [CI] 20.63–51.68) (non-acceptability threshold ≤10%, p<0.0001; not significantly above clinically relevant threshold ≥30%, p=0.2968). DCR between 7.5 and 10.5 months (sensitivity analysis) was 45.0% (95%CI 29.26–61.51) and clinically relevant (p=0.0320 at ≥30% threshold). Median PFS was 37.1 (95%CI 24.1–52.9) weeks. No association was observed between biomarker variations (chromogranin A, neuron-specific enolase, somatostatin receptor type-2, Ki-67, 6-O-methylguanine-DNA-methyl-transferase) and DCR or PFS. Most patients (97.5%) had treatment-emergent adverse events (TEAEs); 72.5% had treatment-related TEAEs. TEAEs were mainly grade 1/2. No unanticipated TEAEs were reported. Conclusions: This study showed that LAN/TMZ combination has promising efficacy in progressive T-NETs, and was well tolerated. Larger studies are warranted to support the clinical benefits of LAN/TMZ in patients with T-NETs