Does genomic profiling improve clinical outcome in carcinoma of unknown primary? - A systematic review

Does genomic profiling improve clinical outcome in carcinoma of unknown primary? - A systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Does genomic profiling improve clinical outcome in carcinoma of unknown primary? - A systematic review Anna Derrick, Sara de Vries, Claire Morgan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3970126/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The lack of adequate diagnostic pathways and treatment options remains an unmet clinical need for patients with cancer of unknown primary origin (CUP). The aim of this systematic review was to evaluate whether genomic profiling improves clinical outcome for CUP patients versus those who receive standard of care. The PRISMA guidelines were followed and research articles were systematically searched on: Medline, Embase, CINAHL, Trip database and Epistemonikos, yielding 232 papers. Eligible studies had to be (i) original research trials; (ii) patients diagnosed with CUP; (iii) cohort groups of more than thirty participants; and (iv) studies with available survival data. After removal of duplicates and application of in- and exclusion criteria, six studies were included. A manual citation search identified five additional studies. The modified Cochrane risk of bias tool was used to assess the quality of the included articles. An emerging theme was the predominance of single-arm non-randomised controlled trials (RCT) along with considerable heterogeneity in study design. Nine out of the 11 studies (82%) showed a trend towards improved overall & progression-free survival in the molecularly-tailored site-specific treatment groups. Survival benefit was less promising in one double-arm RCT and in a second agnostic study. Whilst this analysis shows a trend towards improved clinical outcome in molecularly-guided treatment groups, it is still uncertain whether genomic profiling contributes substantially to the management of CUP. Biological sciences/Cancer/Cancer of unknown primary Biological sciences/Genetics/Cancer genomics Carcinoma of unknown primary (CUP) genomic profiling clinical outcome systematic review Figures Figure 1 Introduction Cancer of unknown primary origin (CUP) is a heterogeneous group of malignancies for which the primary anatomical tumour site cannot be determined after a thorough clinical work-up and histological biopsy [ 1 ]. The majority of CUP patients have tumours that derive from epithelial cells; hence literature often refers to “carcinoma” of unknown primary origin [ 2 ]. CUP accounts for up to 5% of all cancer diagnoses and prognosis is poor [ 3 ]. Less than 25% of patients survive for one year [ 4 ] and clinical outcome of CUP is worse compared to patients with metastatic cancer from a known primary tumour site [ 5 ]. The lack of adequate treatment options remains an unmet clinical need for patients with CUP. The purpose of the clinical investigations and histological assessment is to identify those cancers that belong to the favourable CUP subgroups for which potentially curable treatment options are available. However, empiric chemotherapy such as taxane- or platinum-based regimens [ 1 ], may be the only form of therapy available for the unfavourable subgroup. Various molecular tests have been developed to identify a putative primary site of origin; the first-generation type of assays assess gene expression, microRNA expression or DNA-methylation status [ 2 ]. Other data suggest that CUP patients may clinically benefit from genomic tests that follow a tissue agnostic approach, by identifying potentially actionable genomic variants regardless of the primary tumour origin [ 2 ]. Recent genomic tests are based on next-generation sequencing employing large gene panels or whole exome sequencing [ 2 ]. However, there is considerable debate in the current literature on the clinical utility of tumour sequencing and gene signature profiling of CUP [ 1 , 6 ]. Whilst molecular tests may aid in diagnosis, it is uncertain if CUP patients also clinically benefit from genomic tumour profiling in terms of improved prognosis and survival. Two prospective studies showed improved survival of CUP patients treated with site-specific therapy compared to empiric regimens. The largest study consisted of 194 patients who received assay guided therapy which was compared to a retrospective cohort treated with empiric regimens [ 7 ]. This study found a significantly improved overall survival (OS) in the site-specific arm (hazard ratio 0.63; 95% CI 0.60–0.66). Another, smaller study showed a similar survival benefit in CUP patients treated with tailored therapies (n = 31) in comparison to patients who received empiric chemotherapy (n = 61) (hazard ratio 0.31; 95% CI 0.14–0.70) [ 8 ]. In contrast, two other studies [ 9 , 10 ] that addressed the clinical utility of molecularly guided site-specific treatment did not demonstrate improved survival of CUP patients. The first study [ 9 ] showed similar survival rates in the molecularly driven site-specific arm compared to the empiric treatment group (hazard ratio 1.03; 95% CI 0.68–1.56). However, the second study [ 10 ], which was a phase III randomised trial, (n = 243), did not show significant differences in survival between the two treatment arms (hazard ratio 0.92; 95% CI 0.69–1.23). Given the conflicting results in literature, a systematic review was performed to evaluate the clinical outcome in CUP patients who underwent genomic profiling versus those who only received the standard of care. Methods A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as a basis for a structured, systematic search, reporting, and critical review of the findings. Search strategy A computer-based literature search was performed in Medline, Embase, CINAHL, Trip database and Epistemonikos. The search strategy in Medline covered three groups of key words and terms: 1. "Neoplasms, unknown primary" OR "carcinoma of unknown primary" OR "cancer of unknown primary" OR "cancer of unknown primary origin" OR "carcinoma of unknown primary origin", 2. "Sequence Analysis, DNA" OR “next generation sequencing" OR "molecular testing" OR "genomic profiling" OR "genomic analysis" OR "genomic alterations" OR "targeted therap*" OR "whole genome sequencing" OR "exome sequencing", 3. "Outcome Assessment, Health Care" OR "clinical outcome" OR "survival" OR "overall survival" OR "progression-free survival". All studies were included that were published until 19 August 2023 (final search date) and written in the English language. An iterative search strategy was then applied using the same keywords and Medical Subject Headings (MeSH) terms across the different databases. Unpublished studies were not included. A subsequent manual citation search of reference lists in retrieved papers was also performed. The authors of the publications were not contacted for further information. Inclusion and exclusion criteria Publications were included that are original research studies, studied humans and were published in the English language with no restriction to age, gender, race, country or year of publication. Articles had to fulfil the following criteria to be eligible for inclusion in this review: (i) original research studies that must be randomised (RCT) or non-randomised controlled trials (NRCT); (ii) patients diagnosed with CUP, defined as metastatic carcinoma for which no primary source can be found after diagnostic investigations; (iii) cohort groups of more than thirty participants; and (iv) studies with available survival data assessing the clinical outcome in CUP patients whose tumours were tested using molecular assays and subsequently received site-specific or agnostic therapy based on the results of these molecular assays. Site-specific therapy refers to treatments directed to the molecularly predicted anatomical site of origin. Agnostic therapy is defined as regimens directed against potentially targetable genomic alterations regardless of the primary tumour site. The following exclusion criteria were applied: non-human or cell line studies, articles in languages other than English and studies exclusively focussing on non-carcinoma cancers (e.g. melanomas, lymphomas and sarcomas). Articles were excluded that used standard diagnostic tests (e.g. imaging) or non-molecular assays only (e.g. standard histology or immunohistochemistry). Further, studies were excluded that did not evaluate the clinical outcome in CUP patients. In addition, case reports, case series, narrative reviews, surveys, systematic reviews, meta-analyses, guidelines and reviews that contained duplicate data, were excluded. Articles published as conference abstracts-only or not available as full text were also excluded. Study selection An initial search of the databases selected relevant studies based first by title, then by abstract. Using the eligibility criteria, and inclusion and exclusion criteria, full text articles were obtained. Studies were included that evaluated the clinical outcome in CUP patient whose tumours were tested using molecular assays and subsequently treated according to the results of these molecular tests. Data collection process All references were transferred to EndNote citation manager for removal of duplicates. The references were then exported to the Rayyan QCRI web-based software for screening and review of all articles. Screening of the articles was performed by SdV, and reviewed by AD and CM, first by checking the title and abstracts in order to exclude those studies that were irrelevant to the inclusion criteria and research question. Only those full-text articles were reviewed that met the eligibility and inclusion criteria. In addition, the final articles were manually checked for any duplicates. As studies were selected on the basis of their relevance to the research query, no scoring system was used. Data items The following variables were extracted from each study: 1) study design, i.e. whether RCT or NRCTs; 2) study type, i.e. whether prospective or retrospective studies; 3) number of participants; 4) type of molecular assay used to predict the primary tumour site and guide treatment; 5) predicted putative tumour site; 6) type of treatment received based on the results of the molecular assays and 7) clinical outcome or survival in months. After start of the review no further variables were added. Risk of bias After obtaining the relevant full-text articles, the modified Cochrane risk of bias tool [ 11 – 13 ] was applied to assess the quality of the included articles based on the differences in clinical outcome in CUP patients who received treatment guided by the results of molecular tests. The modified Cochrane risk of bias tool provides a framework for assessing risk of bias in the findings of both RCTs and NRCTs. The tool consists of five different domains addressing different types of bias that may influence the intervention’s effectiveness in clinical trials. Summary measures The primary outcome measure was the overall or progression-free survival in CUP patients whose tumours were tested using molecular assays and subsequently received site-specific or agnostic therapy based on the results of these molecular assays. The rationale for this endpoint is to measure the clinical effectiveness of molecularly guided treatment compared to the standard of care. Synthesis of results A synthesis without meta-analysis was performed [ 14 ]. Statistical analysis or pooling was not performed due to the variation in study design, single- versus double-arm studies, differences in type of molecular assays used and recording of the outcome measures. Instead, tabulation of the extracted data was performed to identify key features across the studies. Synthesis of results consisted of the interpretation of the outcome, differences and similarities between studies and assessment of the quality and strength of this synthesis. Results Study selection A systematic search was performed using Medline, Embase, CINAHL, Trip database and Epistemonikos databases which initially revealed 232 studies. Following removal of duplicates 177 titles and abstracts were screened resulting in a further full-text review of 24 articles of which 18 studies were excluded that did not meet the eligibility criteria. A manual search of reference lists revealed five additional papers that met the inclusion criteria and added to the 6 eligible articles. Overall, this resulted in 11 studies that were deemed suitable for the qualitative synthesis (Fig. 1 ). Study characteristics A summary of the study characteristics and variables of the reviewed articles is listed in Table 1. The number of study participants of each individual study varied from 38 to 1,931. The included studies originated from the following countries: six from the USA, three from Japan, one from Spain and one from Germany. Data items and variables such as study design, sample size, type of assay and measurement of clinical outcome, were not always explicitly stated in the 11 articles. Results of individual studies An overview of the main author findings for the eleven reviewed papers is presented in Table 2. The results of this systematic review highlight the considerable heterogeneity between the reviewed articles comparing the clinical outcome in CUP patients who received molecularly matched therapy versus the standard of care. The potential sources for the heterogeneity between the articles include the study design (i.e. RCT versus NRCT), lack of a control arm in some of the studies, type of tissue used (i.e. formalin-fixed paraffin-embedded, fresh-frozen versus cfDNA), the type of molecular platform used to predict the tissue of origin and response to therapy (i.e. ranging from DNA or RNA based microarrays, DNA-methylation, small versus large-panel NGS and PDL1 immunohistochemistry) and breakdown of predicted primary tumour sites. In addition, there is some variation in the way clinical outcome is recorded (i.e OS, progression-free survival versus use of a so-called “matching score”). However, despite the heterogeneity, several of the papers did show some similarities and overlap with regards to assay type and their approach to guide treatment. Overall, the reviewed articles can be broadly grouped into two categories: 1) Tissue-of-origin studies that use gene expression classifiers or NGS in order to chase the primary tissue of origin and guide site-specific treatment; 2) Agnostic studies that employ platforms to search for potentially druggable genomic alterations regardless of the primary tumour site. Tissue-of-origin studies Two prospective phase II NRCTs [ 7 , 15 ] assessed the OS as a primary endpoint in CUP patients whose tumour tissues were tested using 92- and 2000-gene commercially available and validated RT-PCR microarray assays, respectively, for the identification of the primary cancer site. All patients were diagnosed with metastatic carcinoma of unknown origin following clinical, radiological and histopathological work-up according to international guidelines [ 1 ]. Patients belonging to the so-called favourable CUP subsets, for which potentially curable treatments options are available, were excluded. If the microarray assay results were successful in assigning a potential primary tumour site, patients were subsequently treated with site-specific chemotherapy regimens that already exist for the analogous primary tumour types. Patients with unsuccessful assay results (i.e. assay could not predict a tissue of origin) were treated with standard, platinum-based empiric chemotherapy. All patients, both site-specific and empirically treated, were followed up and OS was recorded. In addition, the larger study [ 7 ] compared the clinical outcome of the site-specific arm (n = 194) to a historic cohort of CUP patients (n = 396) treated with empiric chemotherapy. Both studies found a significantly improved OS in CUP patients who received assay-predicted site-specific treatment versus the empiric group (hazard ratio 0.63; 95% CI 0.60–0.66 and hazard ratio 0.37; 95% CI 0.18–0.76 respectively) [ 7 , 15 ]. In contrast, a prospective phase II RCT [ 9 ] using a 3000-gene RT-PCR microarray, did not demonstrate a significant survival benefit in the assay-predicted treatment group; median OS for patients in the assay arm was only slightly lower (9.8 months) compared to those who received the empiric regimens (12.5 months) (hazard ratio 1.03; 95% CI 0.68–1.56) [ 9 ]. One of main the reasons for the differences in effect may be due to the molecular classifier requiring fresh biopsy tissue as opposed to formal-fixed paraffin-embedded which was used in all the other studies. The classifier is not commercially available or previously validated with independent samples [ 2 ]. Therefore, it is unclear whether the data from this study can be extrapolated to other molecular classifiers. Also, the patient mix and predicted primary tumour sites were different from the previous two NRCTs. The most common predicted tumour site in the RCT was lymphoma, which has a markedly different prognosis and treatment paradigms compared to carcinoma cancers. Further, randomisation was applied after assay results became available, patients were assigned to either site-specific or empiric chemotherapy [ 9 ]. However, the NRCT studies [ 7 , 15 ] did not implement a randomisation step in their study protocols. A NRCT study [ 16 ]retrospectively analyzed the OS in CUP patients (n = 88) whose tumours were tested using organ-specific immunohistochemistry and a small-panel gene assay ( KRAS, HER2 and EGFR ) for the identification of the tissue of origin. Despite the limited number of genes investigated, the authors found a significantly improved median OS (20.3 months) for patients treated with site-specific chemotherapy compared to those who received empiric regimens (hazard ratio 0.57; 95% CI 0.34–0.94). A tumour classifier based on DNA-methylation signatures was used and validated in a smaller double-arm, NRCT [ 8 ] which showed a survival benefit in CUP patients treated with site-specific therapies (n = 31) compared to patients who received empiric chemotherapy (n = 61) (hazard ratio 0.31; 95% CI 0.14–0.70). This study used DNA methylation-based tumour profiles, whereas all the aforementioned studies used RNA based profiles [ 7 , 15 , 16 ]. In addition the most common primary tumour site in this study was breast cancer as opposed to pancreaticobiliary and gastric carcinoma in the other three studies [ 7 , 15 , 16 ], which are generally less responsive to chemotherapy and have poorer prognosis. Agnostic studies Actionable genomic alterations were investigated in six studies using next-generation sequencing regardless of the primary tumour site (Table 1) [ 17 – 22 ]. In addition, five out of the six studies assessed the effect of immunotherapy on clinical outcome in CUP patients [ 17 , 19 – 22 ]. A single-arm phase II trial [ 18 ] was conducted assessing the clinical impact in CUP patients (n = 97) who received site-specific and molecularly targeted therapy according to NGS tumour signatures. An empiric treatment arm was not added; however, outcome was compared to survival data of a historical CUP cohort who received empiric treatment (median OS 12.5 months) [ 9 ]. Median OS and PFS were 13.7 (hazard ratio 0.63; 95% CI 0.38–1.05) and 5.2 months (hazard ratio 0.58; 95% CI 0.36–0.92) respectively. The PFS appears statistically significant whereas OS did not show a substantial difference compared to survival data of a historical CUP cohort treated with empiric chemotherapy. However, the authors still considered it to be an improvement [ 18 ]. Retrospective analyses of survival data were undertaken in two studies [ 20 , 22 ]. Tumour tissues (FFPE material) of CUP patients were assessed for targetable genomic alterations using large-panel NGS and eligibility for immune-checkpoint inhibitor therapy. One study [ 20 ] found a significantly improved PFS in CUP patients who received molecularly guided therapy (n = 30) compared to those who received standard systemic treatment options (n = 17) (4.3 versus 1.9 months; p = 0.0094). In contrast, the other study [ 22 ] did not show a significant survival benefit in CUP patients treated with molecularly matched therapies as opposed to the standard of care (23.6 versus 14.7 months in OS; hazard ratio 0.568; 95% CI 0.268–1.205; p = 0.13). Although clinical outcome was assessed in a completely different way in the two studies (i.e. PFS versus OS), one of the reasons for the lack of survival benefit may be the relatively small number of CUP patients eligible for targeted treatment (n = 17) compared to the empiric arm (n = 78). One of the reasons for the survival advantage may be the introduction of a Molecular Tumour Board (MTB) [ 20 ]. All participants were referred to a MTB which consisted of a panel of experts including medical oncologists, molecular biologists and pathologists, for molecular testing and evaluation of molecular stratified therapies before commencement of treatment. The three single-arm studies [ 17 , 19 , 21 ] assessed the treatment outcome in CUP patients whose tumours were tested on a respectively 236–405 gene, 73–74 gene and 182–595 gene panel NGS platform, using cell-free DNA (cfDNA) only or combined with FFPE tumour tissue. Microsatellite instability status, tumour mutational burden and PDL1 expression were also evaluated. The authors also introduced a more standardised way of reporting success rates of genomic alterations that were matched to available therapies, which is called the “matching score” (MS) [ 17 ]. MS is the proportion of actionable genomic alterations that are matched to Food and Drug Administration-approved targeted treatments in a single patient. Treatment is considered successfully matched if ≥ 1 drug in the treatment regimen can be matched to ≥ 1 alteration, or a protein is expressed by immunohistochemistry (e.g. PDL1 expression, mismatch repair protein expression). Participants were stratified into those who received treatment with MS of either > 50% or ≤ 50%; the higher the matching score, the better the match [ 19 ]. Both studies found a significantly improved PFS in patients with high (> 50%) compared to those with low MS of ≤ 50%. In all three studies only the PFS was statistically significant in patients with high MS of > 50% compared to those with low scores of ≤ 50%. Discussion Although molecular tests may aid in diagnosis, it is uncertain if CUP patients also clinically benefit from genomic tumour profiling. Therefore, a systematic review was conducted to critically appraise the current literature for evidence of survival benefit in CUP patients following molecular tumour profiling. Nine out of the eleven studies assessed in the final review (82%) show a trend towards improved OS and PFS in the molecularly tailored site-specific treatment groups. These nine studies were all observational NRCTs. In contrast, survival benefit was less promising and not statistically significant in the only available double-arm RCT [ 9 ] and in a second agnostic study [ 22 ]. The lack of improved survival outcomes was also demonstrated in a previous phase III double-arm RCT [ 10 ]. As the paper was available as a conference abstract-only, the study was not included in the final review. One of the emerging themes of this review is the distinction between tissue-of-origin and agnostic studies. Five out of the eleven studies [ 7 – 9 , 15 , 16 ] explored the tissue-of-origin concept, which assumes that CUP are similar in their response to treatment of the analogous primary tumours. Of note, the five studies were all published in the years preceding the widespread use of NGS, hence most of the studies used first-generation molecular assays. Despite the substantial heterogeneity between the studies, four (out of five) NRCTs [ 7 , 8 , 15 , 16 ] show promising results for site-specific treatment. These studies all show a trend towards a significantly improved OS in the molecularly guided, site-specific treatment groups. However, this effect (OS) was less promising and not statistically significant in the only RCT conducted [ 9 ]. The second major theme of this review is the predominance of phase II, single-arm trials in four out of the six included agnostic studies [ 17 – 19 , 21 ]. Although these four agnostic studies all show a trend towards an improved PFS in the molecularly guided treatment groups, OS was not statistically significant. Two out of six agnostic studies that did use an empiric control group [ 20 , 22 ] demonstrated a variable survival benefit in the molecularly targeted treatment group. It is worth noting that the diagnostic criteria of CUP and the use of several different molecular assays were not always clearly stated in the included studies. This, may have led to systematic differences in how patients were treated (i.e. performance bias). Systematic differences in baseline characteristics between molecularly-guided and empiric treatment arms may also have occurred due to the breakdown of putative tumour sites and over-representation of less-responsive tumour types such as pancreaticobiliary and gastric carcinomas with poorer prognosis. In addition, given the relatively low prevalence of CUP cases, most studies faced significant challenges in recruiting adequate numbers of CUP patients, particularly with regards to CUP patients in the molecularly guided treatment arm. Limitations The modified Cochrane risk of bias tool [ 11 , 13 ] was used to assess the quality of the included articles. As the majority of included studies were observational single-arm NCRTs, we believe the lack of a randomisation step has generated selection bias. Furthermore, a limitation of this review is the inconsistent way clinical outcome is recorded (i.e. OS, PFS versus matching scores) which made direct comparison challenging. In addition, the considerable variation in study design, tissue type and molecular classifiers used, hindered interpretation and synthesis of the results. At the review-level, a potential limitation was that studies published in languages other than English were excluded from the systematic review and as such, some articles may have been missed. Conclusions This review highlights the challenges in assessing the role of molecular testing of CUP due to the considerable heterogeneity in study design and molecular platforms used. Whilst this analysis shows a trend towards improved clinical outcomes in molecularly-guided site-specific patients, it is still uncertain whether genomic profiling contributes substantially to the management of CUP. Future studies consisting of double- or multi-arm RCTs are required to answer this specific research question. Declarations Data Availability Statement - Data analysed during this study can be found within the published article. Code Availability - Not applicable Acknowledgements - Not applicable Author Contributions - SdV acquired data, interpreted the results, and drafted the manuscript. AVD and CM reviewed data acquisition and interpretation of the results, revised the manuscript and approved the final version. Funding SdV was financially supported by Health Education Improvement Wales (HEIW) to undertake the Genomic Medicine MSc at Swansea University from which this research stemmed. Ethical Approval - Ethical approval was not required due to the systematic review nature of the study. Competing Interests - The authors declare no competing interests. References Fizazi K, Greco FA, Pavlidis N, Daugaard G, Oien K, Pentheroudakis G. Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;26 Suppl 5:v133-8. Lee MS, Sanoff HK. Cancer of unknown primary. Bmj. 2020;371:m4050. Jones W, Allardice G, Scott I, Oien K, Brewster D, Morrison DS. Cancers of unknown primary diagnosed during hospitalization: a population-based study. BMC Cancer. 2017;17(1):85. Schroten-Loef C, Verhoeven RHA, de Hingh I, van de Wouw AJ, van Laarhoven HWM, Lemmens V. Unknown primary carcinoma in the Netherlands: decrease in incidence and survival times remain poor between 2000 and 2012. Eur J Cancer. 2018;101:77-86. Rassy E, Parent P, Lefort F, Boussios S, Baciarello G, Pavlidis N. New rising entities in cancer of unknown primary: Is there a real therapeutic benefit? Crit Rev Oncol Hematol. 2020;147:102882. NICE. Metastatic malignant disease of unknown primary origin in adults: diagnosis and management 2010 [Available from: https://www.nice.org.uk/guidance/cg104. Hainsworth JD, Rubin MS, Spigel DR, Boccia RV, Raby S, Quinn R, Greco FA. Molecular gene expression profiling to predict the tissue of origin and direct site-specific therapy in patients with carcinoma of unknown primary site: a prospective trial of the Sarah Cannon research institute. J Clin Oncol. 2013;31(2):217-23. Moran S, Martínez-Cardús A, Sayols S, Musulén E, Balañá C, Estival-Gonzalez A, et al. Epigenetic profiling to classify cancer of unknown primary: a multicentre, retrospective analysis. Lancet Oncol. 2016;17(10):1386-95. Hayashi H, Kurata T, Takiguchi Y, Arai M, Takeda K, Akiyoshi K, et al. Randomized Phase II Trial Comparing Site-Specific Treatment Based on Gene Expression Profiling With Carboplatin and Paclitaxel for Patients With Cancer of Unknown Primary Site. Journal of Clinical Oncology. 2019;37(7):570-9. Fizazi K, Penel, N., Baciarello, G., Allouache, D., Daugaard, G., Van de Wouw, A., Soler, G., Vauleon, E., Chaigneau, L., Janssen, R., Losa Gaspa, F., Morales Barrera, R., Balana, C., Tosi, D., Cauffert, B., Schnabel, C., Marineau, G., Culine, S., Borget, I. A phase III trial of empiric chemotherapy with cisplatin and gemcitabine or systemic treatment tailored by molecular gene expression analysis in patients with carcinomas of an unknown primary (CUP) site (GEFCAPI 04). Annals of Oncology. 2019;30. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Bmj. 2011;343:d5928. Drucker AM, Fleming P, Chan AW. Research Techniques Made Simple: Assessing Risk of Bias in Systematic Reviews. J Invest Dermatol. 2016;136(11):e109-e14. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Bmj. 2016;355:i4919. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. Bmj. 2020;368:l6890. Yoon HH, Foster NR, Meyers JP, Steen PD, Visscher DW, Pillai R, et al. Gene expression profiling identifies responsive patients with cancer of unknown primary treated with carboplatin, paclitaxel, and everolimus: NCCTG N0871 (alliance). Ann Oncol. 2016;27(2):339-44. Hasegawa H, Ando M, Yatabe Y, Mitani S, Honda K, Masuishi T, et al. Site-specific Chemotherapy Based on Predicted Primary Site by Pathological Profile for Carcinoma of Unknown Primary Site. Clin Oncol (R Coll Radiol). 2018;30(10):667-73. Sicklick JK, Kato S, Okamura R, Schwaederle M, Hahn ME, Williams CB, et al. Molecular profiling of cancer patients enables personalized combination therapy: the I-PREDICT study. Nat Med. 2019;25(5):744-50. Hayashi H, Takiguchi Y, Minami H, Akiyoshi K, Segawa Y, Ueda H, et al. Site-Specific and Targeted Therapy Based on Molecular Profiling by Next-Generation Sequencing for Cancer of Unknown Primary Site: A Nonrandomized Phase 2 Clinical Trial. JAMA oncology. 2020;6(12):1931-8. Kato S, Weipert C, Gumas S, Okamura R, Lee S, Sicklick JK, et al. Therapeutic Actionability of Circulating Cell-Free DNA Alterations in Carcinoma of Unknown Primary. JCO precision oncology. 2021;5. Tarawneh TS, Rodepeter FR, Teply-Szymanski J, Ross P, Koch V, Thölken C, et al. Combined Focused Next-Generation Sequencing Assays to Guide Precision Oncology in Solid Tumors: A Retrospective Analysis from an Institutional Molecular Tumor Board. Cancers. 2022;14(18). Kato S, Gumas S, Adashek JJ, Okamura R, Lee S, Sicklick JK, Kurzrock R. Multi-omic analysis in carcinoma of unknown primary (CUP): therapeutic impact of knowing the unknown. Molecular oncology. 2022. Fusco MJ, Knepper TC, Balliu J, Cueto AD, Laborde JM, Hooda SM, et al. Evaluation of Targeted Next-Generation Sequencing for the Management of Patients Diagnosed with a Cancer of Unknown Primary. Oncologist. 2022;27(1):e9-e17. Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations There is no duality of interest Supplementary Files Table1.xlsx Table 1: Summary of study characteristics and variables. Table2.xlsx Table 2: Summary of study findings. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3970126","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":275276187,"identity":"bb4b4094-01d6-48a2-a6dc-c681ee094260","order_by":0,"name":"Anna Derrick","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYHACAyCWYJBgb0ARTSBCC88B0rQANUmgKsKthb+BeePjyj0W8pIznz+T+LmjTg4o8vADY1saTi0SB9iKDc88kzCcLZ1jJtl75rAxUMRYgrEtB7ezDvCYSTYckEiQk85hu8HbdiCx4QCDGQNjWwVOHfIHeMx/grVIHn92829bXf38A+zf8GoxANrCCNIiLcFgdpu3jTkBJMKAz2GGh9mKQQ4znNmTY/5btu2w4cbDPMUSCedwe1/uePPGjw0H6uQljh9/bPi2rU5e7nj7xg8fypJxe58Zq0gCbg2jYBSMglEwCogAAFE/T1xja5sDAAAAAElFTkSuQmCC","orcid":"","institution":"Swansea University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Derrick","suffix":""},{"id":275276188,"identity":"3fc5a6b1-57c7-4dbd-9451-b499be6a3720","order_by":1,"name":"Sara de Vries","email":"","orcid":"","institution":"The Royal Glamorgan Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"de Vries","suffix":""},{"id":275276189,"identity":"55daf50a-3f5f-446c-a9ce-f845f4dd6510","order_by":2,"name":"Claire Morgan","email":"","orcid":"","institution":"Swansea University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Morgan","suffix":""}],"badges":[],"createdAt":"2024-02-19 13:51:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3970126/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3970126/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51834789,"identity":"d4d8b8d3-9e93-444e-81c9-bb3ce242de89","added_by":"auto","created_at":"2024-02-29 20:22:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20936,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram describing the systematic search strategy, including the identification, screening and inclusion of relevant studies.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3970126/v1/47b38c376a7e6aff8bbb367a.png"},{"id":57267977,"identity":"22a5d2fc-026f-4321-bc41-dc0a7367cbd6","added_by":"auto","created_at":"2024-05-28 11:43:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":418191,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3970126/v1/13c0b811-41a8-4e1f-a0dc-1db4754c67c5.pdf"},{"id":51834792,"identity":"4ab7b5a3-07e2-4a00-8b50-8f0ca84e70e2","added_by":"auto","created_at":"2024-02-29 20:22:15","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13058,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Summary of study characteristics and variables.\u003c/p\u003e","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3970126/v1/e37bd379598e6a3476743386.xlsx"},{"id":51834790,"identity":"091a48c7-c45a-451f-a597-1619c561a9aa","added_by":"auto","created_at":"2024-02-29 20:22:15","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16926,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Summary of study findings.\u003c/p\u003e","description":"","filename":"Table2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3970126/v1/71cdd0c0cadd3870c0b7e2ca.xlsx"}],"financialInterests":"There is no duality of interest","formattedTitle":"Does genomic profiling improve clinical outcome in carcinoma of unknown primary? - A systematic review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer of unknown primary origin (CUP) is a heterogeneous group of malignancies for which the primary anatomical tumour site cannot be determined after a thorough clinical work-up and histological biopsy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The majority of CUP patients have tumours that derive from epithelial cells; hence literature often refers to \u0026ldquo;carcinoma\u0026rdquo; of unknown primary origin [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. CUP accounts for up to 5% of all cancer diagnoses and prognosis is poor [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Less than 25% of patients survive for one year [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and clinical outcome of CUP is worse compared to patients with metastatic cancer from a known primary tumour site [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lack of adequate treatment options remains an unmet clinical need for patients with CUP. The purpose of the clinical investigations and histological assessment is to identify those cancers that belong to the favourable CUP subgroups for which potentially curable treatment options are available. However, empiric chemotherapy such as taxane- or platinum-based regimens [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], may be the only form of therapy available for the unfavourable subgroup.\u003c/p\u003e \u003cp\u003eVarious molecular tests have been developed to identify a putative primary site of origin; the first-generation type of assays assess gene expression, microRNA expression or DNA-methylation status [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Other data suggest that CUP patients may clinically benefit from genomic tests that follow a tissue agnostic approach, by identifying potentially actionable genomic variants regardless of the primary tumour origin [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recent genomic tests are based on next-generation sequencing employing large gene panels or whole exome sequencing [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, there is considerable debate in the current literature on the clinical utility of tumour sequencing and gene signature profiling of CUP [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Whilst molecular tests may aid in diagnosis, it is uncertain if CUP patients also clinically benefit from genomic tumour profiling in terms of improved prognosis and survival. Two prospective studies showed improved survival of CUP patients treated with site-specific therapy compared to empiric regimens. The largest study consisted of 194 patients who received assay guided therapy which was compared to a retrospective cohort treated with empiric regimens [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This study found a significantly improved overall survival (OS) in the site-specific arm (hazard ratio 0.63; 95% CI 0.60\u0026ndash;0.66). Another, smaller study showed a similar survival benefit in CUP patients treated with tailored therapies (n\u0026thinsp;=\u0026thinsp;31) in comparison to patients who received empiric chemotherapy (n\u0026thinsp;=\u0026thinsp;61) (hazard ratio 0.31; 95% CI 0.14\u0026ndash;0.70) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, two other studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] that addressed the clinical utility of molecularly guided site-specific treatment did not demonstrate improved survival of CUP patients. The first study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] showed similar survival rates in the molecularly driven site-specific arm compared to the empiric treatment group (hazard ratio 1.03; 95% CI 0.68\u0026ndash;1.56). However, the second study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which was a phase III randomised trial, (n\u0026thinsp;=\u0026thinsp;243), did not show significant differences in survival between the two treatment arms (hazard ratio 0.92; 95% CI 0.69\u0026ndash;1.23).\u003c/p\u003e \u003cp\u003eGiven the conflicting results in literature, a systematic review was performed to evaluate the clinical outcome in CUP patients who underwent genomic profiling versus those who only received the standard of care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as a basis for a structured, systematic search, reporting, and critical review of the findings.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy\u003c/h2\u003e \u003cp\u003eA computer-based literature search was performed in Medline, Embase, CINAHL, Trip database and Epistemonikos. The search strategy in Medline covered three groups of key words and terms: \u003cb\u003e1.\u003c/b\u003e \"Neoplasms, unknown primary\" OR \"carcinoma of unknown primary\" OR \"cancer of unknown primary\" OR \"cancer of unknown primary origin\" OR \"carcinoma of unknown primary origin\", \u003cb\u003e2.\u003c/b\u003e \"Sequence Analysis, DNA\" OR \u0026ldquo;next generation sequencing\" OR \"molecular testing\" OR \"genomic profiling\" OR \"genomic analysis\" OR \"genomic alterations\" OR \"targeted therap*\" OR \"whole genome sequencing\" OR \"exome sequencing\", \u003cb\u003e3.\u003c/b\u003e \"Outcome Assessment, Health Care\" OR \"clinical outcome\" OR \"survival\" OR \"overall survival\" OR \"progression-free survival\". All studies were included that were published until 19 August 2023 (final search date) and written in the English language. An iterative search strategy was then applied using the same keywords and Medical Subject Headings (MeSH) terms across the different databases. Unpublished studies were not included. A subsequent manual citation search of reference lists in retrieved papers was also performed. The authors of the publications were not contacted for further information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003ePublications were included that are original research studies, studied humans and were published in the English language with no restriction to age, gender, race, country or year of publication. Articles had to fulfil the following criteria to be eligible for inclusion in this review: (i) original research studies that must be randomised (RCT) or non-randomised controlled trials (NRCT); (ii) patients diagnosed with CUP, defined as metastatic carcinoma for which no primary source can be found after diagnostic investigations; (iii) cohort groups of more than thirty participants; and (iv) studies with available survival data assessing the clinical outcome in CUP patients whose tumours were tested using molecular assays and subsequently received site-specific or agnostic therapy based on the results of these molecular assays. Site-specific therapy refers to treatments directed to the molecularly predicted anatomical site of origin. Agnostic therapy is defined as regimens directed against potentially targetable genomic alterations regardless of the primary tumour site.\u003c/p\u003e \u003cp\u003eThe following exclusion criteria were applied: non-human or cell line studies, articles in languages other than English and studies exclusively focussing on non-carcinoma cancers (e.g. melanomas, lymphomas and sarcomas). Articles were excluded that used standard diagnostic tests (e.g. imaging) or non-molecular assays only (e.g. standard histology or immunohistochemistry). Further, studies were excluded that did not evaluate the clinical outcome in CUP patients. In addition, case reports, case series, narrative reviews, surveys, systematic reviews, meta-analyses, guidelines and reviews that contained duplicate data, were excluded. Articles published as conference abstracts-only or not available as full text were also excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eAn initial search of the databases selected relevant studies based first by title, then by abstract. Using the eligibility criteria, and inclusion and exclusion criteria, full text articles were obtained. Studies were included that evaluated the clinical outcome in CUP patient whose tumours were tested using molecular assays and subsequently treated according to the results of these molecular tests.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection process\u003c/h2\u003e \u003cp\u003eAll references were transferred to EndNote citation manager for removal of duplicates. The references were then exported to the Rayyan QCRI web-based software for screening and review of all articles. Screening of the articles was performed by SdV, and reviewed by AD and CM, first by checking the title and abstracts in order to exclude those studies that were irrelevant to the inclusion criteria and research question. Only those full-text articles were reviewed that met the eligibility and inclusion criteria. In addition, the final articles were manually checked for any duplicates. As studies were selected on the basis of their relevance to the research query, no scoring system was used.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData items\u003c/h2\u003e \u003cp\u003eThe following variables were extracted from each study: 1) study design, i.e. whether RCT or NRCTs; 2) study type, i.e. whether prospective or retrospective studies; 3) number of participants; 4) type of molecular assay used to predict the primary tumour site and guide treatment; 5) predicted putative tumour site; 6) type of treatment received based on the results of the molecular assays and 7) clinical outcome or survival in months. After start of the review no further variables were added.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias\u003c/h2\u003e \u003cp\u003eAfter obtaining the relevant full-text articles, the modified Cochrane risk of bias tool [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] was applied to assess the quality of the included articles based on the differences in clinical outcome in CUP patients who received treatment guided by the results of molecular tests. The modified Cochrane risk of bias tool provides a framework for assessing risk of bias in the findings of both RCTs and NRCTs. The tool consists of five different domains addressing different types of bias that may influence the intervention\u0026rsquo;s effectiveness in clinical trials.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSummary measures\u003c/h2\u003e \u003cp\u003eThe primary outcome measure was the overall or progression-free survival in CUP patients whose tumours were tested using molecular assays and subsequently received site-specific or agnostic therapy based on the results of these molecular assays. The rationale for this endpoint is to measure the clinical effectiveness of molecularly guided treatment compared to the standard of care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSynthesis of results\u003c/h3\u003e\n\u003cp\u003eA synthesis without meta-analysis was performed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Statistical analysis or pooling was not performed due to the variation in study design, single- versus double-arm studies, differences in type of molecular assays used and recording of the outcome measures. Instead, tabulation of the extracted data was performed to identify key features across the studies. Synthesis of results consisted of the interpretation of the outcome, differences and similarities between studies and assessment of the quality and strength of this synthesis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eA systematic search was performed using Medline, Embase, CINAHL, Trip database and Epistemonikos databases which initially revealed 232 studies. Following removal of duplicates 177 titles and abstracts were screened resulting in a further full-text review of 24 articles of which 18 studies were excluded that did not meet the eligibility criteria. A manual search of reference lists revealed five additional papers that met the inclusion criteria and added to the 6 eligible articles. Overall, this resulted in 11 studies that were deemed suitable for the qualitative synthesis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy characteristics\u003c/h2\u003e \u003cp\u003eA summary of the study characteristics and variables of the reviewed articles is listed in Table\u0026nbsp;1. The number of study participants of each individual study varied from 38 to 1,931. The included studies originated from the following countries: six from the USA, three from Japan, one from Spain and one from Germany. Data items and variables such as study design, sample size, type of assay and measurement of clinical outcome, were not always explicitly stated in the 11 articles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eResults of individual studies\u003c/h2\u003e \u003cp\u003eAn overview of the main author findings for the eleven reviewed papers is presented in Table\u0026nbsp;2. The results of this systematic review highlight the considerable heterogeneity between the reviewed articles comparing the clinical outcome in CUP patients who received molecularly matched therapy versus the standard of care. The potential sources for the heterogeneity between the articles include the study design (i.e. RCT versus NRCT), lack of a control arm in some of the studies, type of tissue used (i.e. formalin-fixed paraffin-embedded, fresh-frozen versus cfDNA), the type of molecular platform used to predict the tissue of origin and response to therapy (i.e. ranging from DNA or RNA based microarrays, DNA-methylation, small versus large-panel NGS and PDL1 immunohistochemistry) and breakdown of predicted primary tumour sites. In addition, there is some variation in the way clinical outcome is recorded (i.e OS, progression-free survival versus use of a so-called \u0026ldquo;matching score\u0026rdquo;).\u003c/p\u003e \u003cp\u003eHowever, despite the heterogeneity, several of the papers did show some similarities and overlap with regards to assay type and their approach to guide treatment. Overall, the reviewed articles can be broadly grouped into two categories: 1) Tissue-of-origin studies that use gene expression classifiers or NGS in order to chase the primary tissue of origin and guide site-specific treatment; 2) Agnostic studies that employ platforms to search for potentially druggable genomic alterations regardless of the primary tumour site.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTissue-of-origin studies\u003c/h2\u003e \u003cp\u003eTwo prospective phase II NRCTs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] assessed the OS as a primary endpoint in CUP patients whose tumour tissues were tested using 92- and 2000-gene commercially available and validated RT-PCR microarray assays, respectively, for the identification of the primary cancer site. All patients were diagnosed with metastatic carcinoma of unknown origin following clinical, radiological and histopathological work-up according to international guidelines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients belonging to the so-called favourable CUP subsets, for which potentially curable treatments options are available, were excluded. If the microarray assay results were successful in assigning a potential primary tumour site, patients were subsequently treated with site-specific chemotherapy regimens that already exist for the analogous primary tumour types. Patients with unsuccessful assay results (i.e. assay could not predict a tissue of origin) were treated with standard, platinum-based empiric chemotherapy. All patients, both site-specific and empirically treated, were followed up and OS was recorded. In addition, the larger study [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] compared the clinical outcome of the site-specific arm (n\u0026thinsp;=\u0026thinsp;194) to a historic cohort of CUP patients (n\u0026thinsp;=\u0026thinsp;396) treated with empiric chemotherapy. Both studies found a significantly improved OS in CUP patients who received assay-predicted site-specific treatment versus the empiric group (hazard ratio 0.63; 95% CI 0.60\u0026ndash;0.66 and hazard ratio 0.37; 95% CI 0.18\u0026ndash;0.76 respectively) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, a prospective phase II RCT [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] using a 3000-gene RT-PCR microarray, did not demonstrate a significant survival benefit in the assay-predicted treatment group; median OS for patients in the assay arm was only slightly lower (9.8 months) compared to those who received the empiric regimens (12.5 months) (hazard ratio 1.03; 95% CI 0.68\u0026ndash;1.56) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. One of main the reasons for the differences in effect may be due to the molecular classifier requiring fresh biopsy tissue as opposed to formal-fixed paraffin-embedded which was used in all the other studies. The classifier is not commercially available or previously validated with independent samples [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, it is unclear whether the data from this study can be extrapolated to other molecular classifiers. Also, the patient mix and predicted primary tumour sites were different from the previous two NRCTs. The most common predicted tumour site in the RCT was lymphoma, which has a markedly different prognosis and treatment paradigms compared to carcinoma cancers. Further, randomisation was applied after assay results became available, patients were assigned to either site-specific or empiric chemotherapy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the NRCT studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] did not implement a randomisation step in their study protocols.\u003c/p\u003e \u003cp\u003eA NRCT study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]retrospectively analyzed the OS in CUP patients (n\u0026thinsp;=\u0026thinsp;88) whose tumours were tested using organ-specific immunohistochemistry and a small-panel gene assay (\u003cem\u003eKRAS, HER2\u003c/em\u003e and \u003cem\u003eEGFR\u003c/em\u003e) for the identification of the tissue of origin. Despite the limited number of genes investigated, the authors found a significantly improved median OS (20.3 months) for patients treated with site-specific chemotherapy compared to those who received empiric regimens (hazard ratio 0.57; 95% CI 0.34\u0026ndash;0.94).\u003c/p\u003e \u003cp\u003eA tumour classifier based on DNA-methylation signatures was used and validated in a smaller double-arm, NRCT [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] which showed a survival benefit in CUP patients treated with site-specific therapies (n\u0026thinsp;=\u0026thinsp;31) compared to patients who received empiric chemotherapy (n\u0026thinsp;=\u0026thinsp;61) (hazard ratio 0.31; 95% CI 0.14\u0026ndash;0.70). This study used DNA methylation-based tumour profiles, whereas all the aforementioned studies used RNA based profiles [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition the most common primary tumour site in this study was breast cancer as opposed to pancreaticobiliary and gastric carcinoma in the other three studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which are generally less responsive to chemotherapy and have poorer prognosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAgnostic studies\u003c/h2\u003e \u003cp\u003eActionable genomic alterations were investigated in six studies using next-generation sequencing regardless of the primary tumour site (Table\u0026nbsp;1) [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition, five out of the six studies assessed the effect of immunotherapy on clinical outcome in CUP patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA single-arm phase II trial [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was conducted assessing the clinical impact in CUP patients (n\u0026thinsp;=\u0026thinsp;97) who received site-specific and molecularly targeted therapy according to NGS tumour signatures. An empiric treatment arm was not added; however, outcome was compared to survival data of a historical CUP cohort who received empiric treatment (median OS 12.5 months) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Median OS and PFS were 13.7 (hazard ratio 0.63; 95% CI 0.38\u0026ndash;1.05) and 5.2 months (hazard ratio 0.58; 95% CI 0.36\u0026ndash;0.92) respectively. The PFS appears statistically significant whereas OS did not show a substantial difference compared to survival data of a historical CUP cohort treated with empiric chemotherapy. However, the authors still considered it to be an improvement [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRetrospective analyses of survival data were undertaken in two studies [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Tumour tissues (FFPE material) of CUP patients were assessed for targetable genomic alterations using large-panel NGS and eligibility for immune-checkpoint inhibitor therapy. One study [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] found a significantly improved PFS in CUP patients who received molecularly guided therapy (n\u0026thinsp;=\u0026thinsp;30) compared to those who received standard systemic treatment options (n\u0026thinsp;=\u0026thinsp;17) (4.3 versus 1.9 months; p\u0026thinsp;=\u0026thinsp;0.0094). In contrast, the other study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] did not show a significant survival benefit in CUP patients treated with molecularly matched therapies as opposed to the standard of care (23.6 versus 14.7 months in OS; hazard ratio 0.568; 95% CI 0.268\u0026ndash;1.205; p\u0026thinsp;=\u0026thinsp;0.13). Although clinical outcome was assessed in a completely different way in the two studies (i.e. PFS versus OS), one of the reasons for the lack of survival benefit may be the relatively small number of CUP patients eligible for targeted treatment (n\u0026thinsp;=\u0026thinsp;17) compared to the empiric arm (n\u0026thinsp;=\u0026thinsp;78). One of the reasons for the survival advantage may be the introduction of a Molecular Tumour Board (MTB) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. All participants were referred to a MTB which consisted of a panel of experts including medical oncologists, molecular biologists and pathologists, for molecular testing and evaluation of molecular stratified therapies before commencement of treatment.\u003c/p\u003e \u003cp\u003eThe three single-arm studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] assessed the treatment outcome in CUP patients whose tumours were tested on a respectively 236\u0026ndash;405 gene, 73\u0026ndash;74 gene and 182\u0026ndash;595 gene panel NGS platform, using cell-free DNA (cfDNA) only or combined with FFPE tumour tissue. Microsatellite instability status, tumour mutational burden and PDL1 expression were also evaluated. The authors also introduced a more standardised way of reporting success rates of genomic alterations that were matched to available therapies, which is called the \u0026ldquo;matching score\u0026rdquo; (MS) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. MS is the proportion of actionable genomic alterations that are matched to Food and Drug Administration-approved targeted treatments in a single patient. Treatment is considered successfully matched if\u0026thinsp;\u0026ge;\u0026thinsp;1 drug in the treatment regimen can be matched to \u0026ge;\u0026thinsp;1 alteration, or a protein is expressed by immunohistochemistry (e.g. PDL1 expression, mismatch repair protein expression). Participants were stratified into those who received treatment with MS of either \u0026gt;\u0026thinsp;50% or \u0026le;\u0026thinsp;50%; the higher the matching score, the better the match [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Both studies found a significantly improved PFS in patients with high (\u0026gt;\u0026thinsp;50%) compared to those with low MS of \u0026le;\u0026thinsp;50%. In all three studies only the PFS was statistically significant in patients with high MS of \u0026gt;\u0026thinsp;50% compared to those with low scores of \u0026le;\u0026thinsp;50%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough molecular tests may aid in diagnosis, it is uncertain if CUP patients also clinically benefit from genomic tumour profiling. Therefore, a systematic review was conducted to critically appraise the current literature for evidence of survival benefit in CUP patients following molecular tumour profiling. Nine out of the eleven studies assessed in the final review (82%) show a trend towards improved OS and PFS in the molecularly tailored site-specific treatment groups. These nine studies were all observational NRCTs. In contrast, survival benefit was less promising and not statistically significant in the only available double-arm RCT [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and in a second agnostic study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The lack of improved survival outcomes was also demonstrated in a previous phase III double-arm RCT [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As the paper was available as a conference abstract-only, the study was not included in the final review.\u003c/p\u003e \u003cp\u003eOne of the emerging themes of this review is the distinction between tissue-of-origin and agnostic studies. Five out of the eleven studies [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] explored the tissue-of-origin concept, which assumes that CUP are similar in their response to treatment of the analogous primary tumours. Of note, the five studies were all published in the years preceding the widespread use of NGS, hence most of the studies used first-generation molecular assays. Despite the substantial heterogeneity between the studies, four (out of five) NRCTs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] show promising results for site-specific treatment. These studies all show a trend towards a significantly improved OS in the molecularly guided, site-specific treatment groups. However, this effect (OS) was less promising and not statistically significant in the only RCT conducted [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe second major theme of this review is the predominance of phase II, single-arm trials in four out of the six included agnostic studies [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although these four agnostic studies all show a trend towards an improved PFS in the molecularly guided treatment groups, OS was not statistically significant. Two out of six agnostic studies that did use an empiric control group [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] demonstrated a variable survival benefit in the molecularly targeted treatment group.\u003c/p\u003e \u003cp\u003eIt is worth noting that the diagnostic criteria of CUP and the use of several different molecular assays were not always clearly stated in the included studies. This, may have led to systematic differences in how patients were treated (i.e. performance bias). Systematic differences in baseline characteristics between molecularly-guided and empiric treatment arms may also have occurred due to the breakdown of putative tumour sites and over-representation of less-responsive tumour types such as pancreaticobiliary and gastric carcinomas with poorer prognosis. In addition, given the relatively low prevalence of CUP cases, most studies faced significant challenges in recruiting adequate numbers of CUP patients, particularly with regards to CUP patients in the molecularly guided treatment arm.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe modified Cochrane risk of bias tool [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] was used to assess the quality of the included articles. As the majority of included studies were observational single-arm NCRTs, we believe the lack of a randomisation step has generated selection bias. Furthermore, a limitation of this review is the inconsistent way clinical outcome is recorded (i.e. OS, PFS versus matching scores) which made direct comparison challenging. In addition, the considerable variation in study design, tissue type and molecular classifiers used, hindered interpretation and synthesis of the results. At the review-level, a potential limitation was that studies published in languages other than English were excluded from the systematic review and as such, some articles may have been missed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis review highlights the challenges in assessing the role of molecular testing of CUP due to the considerable heterogeneity in study design and molecular platforms used. Whilst this analysis shows a trend towards improved clinical outcomes in molecularly-guided site-specific patients, it is still uncertain whether genomic profiling contributes substantially to the management of CUP. Future studies consisting of double- or multi-arm RCTs are required to answer this specific research question.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e - Data analysed during this study can be found within the published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability\u003c/strong\u003e - Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e- Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e - \u003cstrong\u003eSdV\u003c/strong\u003e acquired data, interpreted the results, and drafted the manuscript. \u003cstrong\u003eAVD and CM\u003c/strong\u003e reviewed data acquisition and interpretation of the results, revised the manuscript and approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eSdV was financially supported by Health Education Improvement Wales (HEIW) to undertake the Genomic Medicine MSc at Swansea University from which this research stemmed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e- Ethical approval was not required due to the systematic review nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e- The authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFizazi K, Greco FA, Pavlidis N, Daugaard G, Oien K, Pentheroudakis G. Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;26 Suppl 5:v133-8.\u003c/li\u003e\n\u003cli\u003eLee MS, Sanoff HK. Cancer of unknown primary. Bmj. 2020;371:m4050.\u003c/li\u003e\n\u003cli\u003eJones W, Allardice G, Scott I, Oien K, Brewster D, Morrison DS. Cancers of unknown primary diagnosed during hospitalization: a population-based study. BMC Cancer. 2017;17(1):85.\u003c/li\u003e\n\u003cli\u003eSchroten-Loef C, Verhoeven RHA, de Hingh I, van de Wouw AJ, van Laarhoven HWM, Lemmens V. Unknown primary carcinoma in the Netherlands: decrease in incidence and survival times remain poor between 2000 and 2012. Eur J Cancer. 2018;101:77-86.\u003c/li\u003e\n\u003cli\u003eRassy E, Parent P, Lefort F, Boussios S, Baciarello G, Pavlidis N. New rising entities in cancer of unknown primary: Is there a real therapeutic benefit? Crit Rev Oncol Hematol. 2020;147:102882.\u003c/li\u003e\n\u003cli\u003eNICE. Metastatic malignant disease of unknown primary origin in adults: diagnosis and management 2010 [Available from: https://www.nice.org.uk/guidance/cg104.\u003c/li\u003e\n\u003cli\u003eHainsworth JD, Rubin MS, Spigel DR, Boccia RV, Raby S, Quinn R, Greco FA. Molecular gene expression profiling to predict the tissue of origin and direct site-specific therapy in patients with carcinoma of unknown primary site: a prospective trial of the Sarah Cannon research institute. J Clin Oncol. 2013;31(2):217-23.\u003c/li\u003e\n\u003cli\u003eMoran S, Mart\u0026iacute;nez-Card\u0026uacute;s A, Sayols S, Musul\u0026eacute;n E, Bala\u0026ntilde;\u0026aacute; C, Estival-Gonzalez A, et al. Epigenetic profiling to classify cancer of unknown primary: a multicentre, retrospective analysis. Lancet Oncol. 2016;17(10):1386-95.\u003c/li\u003e\n\u003cli\u003eHayashi H, Kurata T, Takiguchi Y, Arai M, Takeda K, Akiyoshi K, et al. Randomized Phase II Trial Comparing Site-Specific Treatment Based on Gene Expression Profiling With Carboplatin and Paclitaxel for Patients With Cancer of Unknown Primary Site. Journal of Clinical Oncology. 2019;37(7):570-9.\u003c/li\u003e\n\u003cli\u003eFizazi K, Penel, N., Baciarello, G., Allouache, D., Daugaard, G., Van de Wouw, A., Soler, G., Vauleon, E., Chaigneau, L., Janssen, R., Losa Gaspa, F., Morales Barrera, R., Balana, C., Tosi, D., Cauffert, B., Schnabel, C., Marineau, G., Culine, S., Borget, I. A phase III trial of empiric chemotherapy with cisplatin and gemcitabine or systemic treatment tailored by molecular gene expression analysis in patients with carcinomas of an unknown primary (CUP) site (GEFCAPI 04). Annals of Oncology. 2019;30.\u003c/li\u003e\n\u003cli\u003eHiggins JP, Altman DG, G\u0026oslash;tzsche PC, J\u0026uuml;ni P, Moher D, Oxman AD, et al. The Cochrane Collaboration\u0026apos;s tool for assessing risk of bias in randomised trials. Bmj. 2011;343:d5928.\u003c/li\u003e\n\u003cli\u003eDrucker AM, Fleming P, Chan AW. Research Techniques Made Simple: Assessing Risk of Bias in Systematic Reviews. J Invest Dermatol. 2016;136(11):e109-e14.\u003c/li\u003e\n\u003cli\u003eSterne JA, Hern\u0026aacute;n MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Bmj. 2016;355:i4919.\u003c/li\u003e\n\u003cli\u003eCampbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. Bmj. 2020;368:l6890.\u003c/li\u003e\n\u003cli\u003eYoon HH, Foster NR, Meyers JP, Steen PD, Visscher DW, Pillai R, et al. Gene expression profiling identifies responsive patients with cancer of unknown primary treated with carboplatin, paclitaxel, and everolimus: NCCTG N0871 (alliance). Ann Oncol. 2016;27(2):339-44.\u003c/li\u003e\n\u003cli\u003eHasegawa H, Ando M, Yatabe Y, Mitani S, Honda K, Masuishi T, et al. Site-specific Chemotherapy Based on Predicted Primary Site by Pathological Profile for Carcinoma of Unknown Primary Site. Clin Oncol (R Coll Radiol). 2018;30(10):667-73.\u003c/li\u003e\n\u003cli\u003eSicklick JK, Kato S, Okamura R, Schwaederle M, Hahn ME, Williams CB, et al. Molecular profiling of cancer patients enables personalized combination therapy: the I-PREDICT study. Nat Med. 2019;25(5):744-50.\u003c/li\u003e\n\u003cli\u003eHayashi H, Takiguchi Y, Minami H, Akiyoshi K, Segawa Y, Ueda H, et al. Site-Specific and Targeted Therapy Based on Molecular Profiling by Next-Generation Sequencing for Cancer of Unknown Primary Site: A Nonrandomized Phase 2 Clinical Trial. JAMA oncology. 2020;6(12):1931-8.\u003c/li\u003e\n\u003cli\u003eKato S, Weipert C, Gumas S, Okamura R, Lee S, Sicklick JK, et al. Therapeutic Actionability of Circulating Cell-Free DNA Alterations in Carcinoma of Unknown Primary. JCO precision oncology. 2021;5.\u003c/li\u003e\n\u003cli\u003eTarawneh TS, Rodepeter FR, Teply-Szymanski J, Ross P, Koch V, Th\u0026ouml;lken C, et al. Combined Focused Next-Generation Sequencing Assays to Guide Precision Oncology in Solid Tumors: A Retrospective Analysis from an Institutional Molecular Tumor Board. Cancers. 2022;14(18).\u003c/li\u003e\n\u003cli\u003eKato S, Gumas S, Adashek JJ, Okamura R, Lee S, Sicklick JK, Kurzrock R. Multi-omic analysis in carcinoma of unknown primary (CUP): therapeutic impact of knowing the unknown. Molecular oncology. 2022.\u003c/li\u003e\n\u003cli\u003eFusco MJ, Knepper TC, Balliu J, Cueto AD, Laborde JM, Hooda SM, et al. Evaluation of Targeted Next-Generation Sequencing for the Management of Patients Diagnosed with a Cancer of Unknown Primary. Oncologist. 2022;27(1):e9-e17.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Carcinoma of unknown primary (CUP), genomic profiling, clinical outcome, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-3970126/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3970126/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe lack of adequate diagnostic pathways and treatment options remains an unmet clinical need for patients with cancer of unknown primary origin (CUP). The aim of this systematic review was to evaluate whether genomic profiling improves clinical outcome for CUP patients versus those who receive standard of care.\u003c/p\u003e \u003cp\u003e The PRISMA guidelines were followed and research articles were systematically searched on: Medline, Embase, CINAHL, Trip database and Epistemonikos, yielding 232 papers. Eligible studies had to be (i) original research trials; (ii) patients diagnosed with CUP; (iii) cohort groups of more than thirty participants; and (iv) studies with available survival data. After removal of duplicates and application of in- and exclusion criteria, six studies were included. A manual citation search identified five additional studies. The modified Cochrane risk of bias tool was used to assess the quality of the included articles.\u003c/p\u003e \u003cp\u003eAn emerging theme was the predominance of single-arm non-randomised controlled trials (RCT) along with considerable heterogeneity in study design. Nine out of the 11 studies (82%) showed a trend towards improved overall \u0026amp; progression-free survival in the molecularly-tailored site-specific treatment groups. Survival benefit was less promising in one double-arm RCT and in a second agnostic study. Whilst this analysis shows a trend towards improved clinical outcome in molecularly-guided treatment groups, it is still uncertain whether genomic profiling contributes substantially to the management of CUP.\u003c/p\u003e","manuscriptTitle":"Does genomic profiling improve clinical outcome in carcinoma of unknown primary? - A systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 20:22:10","doi":"10.21203/rs.3.rs-3970126/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5125b88f-f28b-4353-be1d-35565bed7705","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":29015538,"name":"Biological sciences/Cancer/Cancer of unknown primary"},{"id":29015539,"name":"Biological sciences/Genetics/Cancer genomics"}],"tags":[],"updatedAt":"2024-05-28T11:35:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-29 20:22:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3970126","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3970126","identity":"rs-3970126","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}