Deanna Ferreri, PhD

 detailed the progress in identification and understanding of DNA, RNA, and epigenetic markers of prognosis and responsiveness to therapy in adrenocortical carcinoma (ACC).

According to the authors of the review, ACC, a rare malignancy of the adrenal cortex, has limited therapeutic options, low response rates to drug therapies, and “heterogeneous clinical behaviour,” and there is currently no effective treatment for advanced stages of the disease. Thus, they wrote, “an individualized management approach could be therefore extremely relevant for these patients.”

Although studies have identified associations between molecular markers and prognosis, which may help to distinguish less and more aggressive subtypes and better inform therapy decisions, these workflows have not yet been implemented in routine ACC treatment, the authors said.

Potential applicability of prognostic markers to clinical practice

In an exhaustive table outlining tumor molecular profiling studies in ACC, the authors listed copy number and sequence variants at the DNA level, DNA epigenetic modifications including methylation status of specific genes, changes in messenger RNA expression, and changes in microRNA (miRNA) expression that have been identified in ACC.

They illustrated how these molecular markers cluster according to good, intermediate, or bad prognosis. However, there are obstacles in implementing analysis of these markers into routine clinical practice, such as the quality of material needed and complexity of the laboratory work and data analysis. They wrote, “the methods used to generate this ‘omics’ data are still too expensive and analysis workflow too complex to be implemented in a routine workflow.”

DNA sequence variants and DNA epigenetic modifications are the most implementable markers, the authors noted, but liquid biopsy is a promising method for analyzing prognostic markers such as circulating miRNAs or cell-free DNA. Liquid biopsy, they wrote, is non-invasive and can examine molecular changes “that can be traced back to the tumour.” In contrast, tumor tissue from biopsy or resection cannot “fully capture the mutation spectrum.”

Also deemed promising by the authors was a combination analysis of sequence variants, affected signaling pathways, methylation patterns, and clinical histopathological parameters, which was developed by research cited in their review.

Predictors of therapy response and new drug targets

Associations between molecular markers and response to current therapies have been studied. However, the authors wrote, “few molecular predictors of response to cytotoxic chemotherapies

have been proposed in ACC,” and “there are no promising DNA‐ or RNA-related biomarkers associated with the response to standard chemotherapies in ACC.”

Because of the low response rates to standard therapies, the reviewers said, “there is an urgent need for alternative therapies for aggressive ACCs.” Initial studies on immune checkpoint inhibitors reviewed by the authors had limited sample size and heterogeneous results. There have been few clinical studies on signaling pathways known to be deregulated in ACC in recent years, according to the authors. These included inhibitors of receptor tyrosine kinases or the mammalian target of rapamycin or insulin-like growth factor (IGF) pathways. The reviewers explained that the IGF pathway is deregulated in more than 90% of ACC cases. However, clinical research on a drug targeting the pathway (linsitinib) did not demonstrate any effect on progression-free or overall survival.

The authors noted that several clinical studies have demonstrated “small proportions of ACC patients showing a response to certain targeted therapy,” suggesting that subgroups of patients might benefit from treatment tailored to their tumor molecular markers.

Finally, they discussed preclinical studies that suggested genes involved in cell cycle regulation and the Wnt/𝛃-catenin pathway are promising targets for future development of drug therapies for ACC. For epigenetically targeted drugs, they said further research is required, and therapeutic options utilizing miRNA strategies have been tested only in cell culture thus far.

The reviewers closed by saying that although there is still no routine molecular analysis in clinical care of ACC they, “are convinced that there are methods that hold the potential to be implemented in a clinical routine workflow in the near future.” In particular, the authors expect that analysis of a combination of molecular profiles from tumor material and clinical and histopathological characteristics “will guide clinicians (and patients) for treatment decisions in the near future,” and that “liquid biopsy‐related approaches might represent promising tools in the field of prognostication and surveillance for ACC patients.”

Lippert J, Fassnacht M, Ronchi CL. The role of molecular profiling in adrenocortical carcinoma. Clin Endocrinol. November 8, 2021. doi:10.1111/cen.14629.

Articles

Processes used to identify and understand genetic markers detailing the prognosis and responsiveness to therapy in adrenocortical carcinoma (ACC) face a number of implementation barriers, limiting the potential for individualized ACC management.

Integrating Molecular Profiling of Adrenocortical Carcinoma Into Clinical Practice

New research shows promise for a strategy of 

 and drug screening of patient-derived cell cultures to help “guide personalized therapy” for neuroblastoma and other mutationally quiet cancers.

, integrated genomic profiling and personalized preclinical tumor models to identify copy-number dependent drug susceptibilities in neuroblastoma. Using excess tumor tissue from pediatric patients with neuroblastoma undergoing surgery, researchers characterized single nucleotide and copy number variations, performed drug-response testing on patient-derived cell cultures, and investigated correlations between copy number and cytotoxicity of drug treatment.

The investigators noted that neuroblastoma is the most common pediatric extracranial malignant tumor, responsible for 15% of all deaths from cancer in children. The authors described neuroblastoma as a “mutationally quiet” cancer, with copy number variations (CNVs) more prevalent than single nucleotide variations (SNVs). They proposed that these CNVs “may reflect fundamental oncogenic dependencies that can be potentially exploited for cancer therapeutics.”

Matching the patient to a treatment in neuroblastoma is challenging, the authors wrote, because of the cancer’s “histologic and biologic heterogeneity,” and they suggested that  “therapeutic advancements for neuroblastoma may be better realized with a personalized approach.” PDCs could be used as personalized models of the patient’s tumor to allow rapid testing of multiple agents ex vivo, the authors said.

Genomic profiling was carried out on tumor tissue from 13 patients with a median age of 2.65 (range 1.45-7.80) using ThermoFisher’s Oncomine Childhood Cancer Research Assay (OCCRA) DNA panel. As the investigators expected, the mean incidence of single nucleotide variants (SNVs) was “infrequent” at 3.1 per case, however they found “frequent and heterogenous copy number variations (CNVs).” Copy number losses the authors called characteristic of neuroblastoma were detected in chromosome arms 1p and 11q, along with copy number gains in 17q.

Following genetic profiling, PDCs were screened using an established library of 418 kinase inhibitors. Overall, the authors noted the drug classes that resulted in the greatest cytotoxicity targeted cytoskeletal signaling, the cell cycle, angiogenesis, and the PI3K/Akt/mTOR signaling pathway.

Of the 418 compounds, 70 (16.7%) caused greater than 33% cytotoxicity and were therefore considered hits. The most common genes targeted by these 70 drugs included 

 (7%). For example, the pan-CDK inhibitors flavopiridol and dinaciclib, which the authors mentioned are in early-phase trials for neuroblastoma and advanced solid tumors, were among the hits.

Correlations between cytotoxicity and copy number: novel gene-drug associations

The investigators hypothesized that the extent of copy number changes would correlate with drug cytotoxicity, and they found “susceptibility to PI3K and cell cycle agents was significantly associated with copy number gains of PI3K and STAT family genes, particularly on 17q.” They found significant correlations between copy number and cytotoxicity in 1278 gene-drug pairs, including 49 drugs that were considered hits. Only 4 of these were expected associations based on drug library specifications.

In the other 1274 gene-drug pairs, correlations were observed despite not being expected. The authors say this suggested “a substantial number of novel gene-drug associations,” and they next verified these associations against six public datasets of gene-drug interactions and an 

 model. Of the 1278 gene-drug pairs, 19 (1.5%) were verified in at least 1 public dataset, though only 1 of these pairs was a hit (

The authors noted “the high incidence of hits among unverified top gene-drug pairs further suggested that important gene-drug relationships may exist among this group.”

The strongest correlations between copy number and drug cytotoxicity were found in 

 family genes, which the authors noted are “all on 17q and implicated in up to 70% of neuroblastomas.” Also frequent were correlations between 

 pathway genes and their inhibitors. The authors noted these drugs accounted for half of the top 20 drug hits, and that upregulation of this pathway “occurs in 62% of neuroblastomas and is a promising therapeutic target.”

The authors acknowledged the small number of cases in their study as a limitation, which could “limit the robustness of the gene-drug correlations identified, and the inherent inability to test every drug hit in individual patients.”

Wong RLY, Wong MRE, Kuick CH, et al. integrated genomic profiling and drug screening of patient-derived cultures identifies individualized copy number-dependent susceptibilities involving PI3K pathway and 17q genes in neuroblastoma. 

. Published online October 14, 2021. doi: 10.3389/fonc.2021.709525.

Using cell cultures from pediatric patients with neuroblastoma, researchers performed drug-response testing and investigated correlations between copy number and cytotoxicity of drug treatment. 





Researchers Report Promising Strategy to Develop Personalized Therapy for Neuroblastoma

 of patients (N = 104) with newly diagnosed diffuse large B-cell lymphoma (DLBCL) with unfavorable disease features who were treated with a standard immunochemotherapy combination, approximately half experienced muscle loss. However, the authors of the study said the observed muscle loss was “detrimental only if very pronounced.”

In the study, investigators sought to understand how treatments for curable lymphoma affect the musculoskeletal system. They based their observations on measurable changes in the psoas, which is a flexor muscle extending from the lower back to the femur. “Factors that affect muscle loss are mostly related to immunochemotherapy and not disease features prior to therapy per se,” they concluded.

The investigators evaluated muscle loss in patients treated with etoposide phosphate, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin hydrochloride, and rituximab (R-DA-EPOCH).

The standard of care for DLBCL is the combination therapy rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), and with this, DLBCL is “curable in a majority of newly diagnosed patients,” the authors wrote. However, they said, “a substantial proportion” of patients with DLBCL who have aggressive disease or poor prognostic disease features “might benefit from more intensive therapeutic approaches.”

Previous studies have reported improved outcomes with the R-DA-EPOCH treatment regimen in these patients.

The authors noted that sarcopenia (muscle loss) or cancer-induced cachexia (weight loss, muscle wasting) at baseline have been associated with poorer outcomes in patients with various cancers including non-Hodgkin lymphoma; and skeletal muscle loss during chemotherapy has been associated with negative prognosis in gastrointestinal cancers.

To the authors’ knowledge, their study is the first to assess muscle mass dynamics during immunochemotherapy and prognostic associations in patients with lymphoid malignancies.

Investigators assessed the effect of R-DA-EPOCH immunochemotherapy on skeletal muscle mass by measuring psoas muscle area (PMA) in patients who had available baseline and end-of-treatment computed tomography scans.

The study included patients with unfavorable prognostic features who were treated with R-DA-EPOCH between 2005 and 2019. Unfavorable prognostic features were defined as “a very high proliferative index Ki-67+ ≥ 80% and/or International Prognostic Index (IPI) ≥ 2 points.” Ki-67 is a marker that is strongly associated with tumor cell proliferation and IPI helps to predict outcomes in patients with cancer.

“Small but Significant” Muscle Mass Loss

The authors reported that more than half (57.7%) of patients experienced muscle loss, and the mean loss was 5%. Median psoas area measurement was 1238 mm2 at baseline and 1099 mm2 at the end of treatment, “with a small but significant decline during the immunochemotherapy period.”

In their multivariate model, investigators identified the following as contributors to psoas muscle mass loss: higher body surface area (odds ratio [OR] 17.98 for each 1 m2), the number of cycles with required dose reduction (OR, 2.86, for each additional cycle), and worse response to therapy (OR, 3.09, for each response category increment).

They theorized that because R-DA-EPOCH is dosed according to body surface area, the association between body surface area and muscle loss could be “a consequence of higher delivered absolute drug doses.” Further, the number of cycles with required dose reduction could indicate “poor immunochemotherapy tolerance” or “weaker hematopoietic reserve” (bodily ability to produce blood cells), both of which could be important predictors of psoas muscle loss/improvement, they said.

Median overall survival (OS) and progression-free survival (PFS) were not reached over the median 46-month follow-up of the study. The investigators found that PMA loss of 21% or greater, which occurred in 24% of patients, was associated with significantly worse OS and PFS.

These associations amounted to a significant, approximately 3-fold increase in the risk of death or progression after adjustment for age, sex, IPI score, and response to treatment. Lack of response to treatment (progressive or stable disease vs partial or complete remission) was also associated with poorer OS and PFS.

Also, the authors reported that baseline PMA parameters characteristic of more aggressive tumor behavior, body mass index, age, and gender did not predict loss of muscle mass during immunochemotherapy, based on study findings.

They concluded that “muscle mass loss occurs in approximately half of R-DA-EPOCH–treated [patients with] newly diagnosed DLBCL with unfavorable disease features, and if pronounced, this is associated with worse clinical outcomes independently of achieved response to therapy.” Because they found “profound negative prognostic implications” with pronounced muscle loss, “a question emerges whether active strategies aimed at muscle mass improvement like physiotherapy and intensive nutritional support might improve outcomes in this subgroup of patients.”

Lucijanic M, Huzjan Korunic R, Sedinic M, Kusec R, Pejsa V. More pronounced muscle loss during immunochemotherapy is associated with worse clinical outcomes in newly diagnosed patients with diffuse large B-cell lymphoma with unfavorable features. 

. 2021;17:1037-1044. doi:10.2147/TCRM.S323749

Investigators in a retrospective study of patients with diffuse large B-cell lymphoma (DLBCL) sought to understand the correlation between muscle loss and immunochemotherapy. 

Investigators Document Muscle Loss During Immunochemotherapy for DLBCL

Authors of a bi-institutional, retrospective study on 188 patients with stage III-IV diffuse large B-cell 

 (DLBCL) reported that consolidative radiation therapy (RT) improved progression-free survival (PFS) in both bulky and nonbulky disease.

They noted that most patients with DLBCL present with stage III-IV disease. Modern therapies—especially those that include rituximab, such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine [Oncovin], and prednisone)—have “contributed greatly to improving the survival rate,” they wrote

, was conducted because the role of consolidative RT in advanced-stage DLBCL “is not fully established.” Use of RT has been questioned, they wrote, “particularly as it exposes patients to a separate array of potential toxicities,” in addition to systemic therapy. However, since the 10-year overall survival (OS) rate for patients with stage II-IV DLBCL receiving R-CHOP alone is approximately 43.5%, the authors argued, “further efforts are warranted to improve outcomes” for patients with advanced disease.

The investigators addressed this knowledge gap by recruiting treatment-naive patients whose stage III-IV DLBCL (bulky or nonbulky disease) was diagnosed between April 1999 and January 2011and who had a complete clinical response to systemic therapy. Patients who had central nervous system involvement or those with relapsed or refractory disease were excluded from the study.

Thirty-six percent of patients presented with stage III DLBCL, and 64% with stage IV disease. Most (79%) had received R-CHOP as their systemic therapy, 9% were treated with another rituximab-based regimen, and 12% were treated without rituximab.

Thirty-six percent of patients received consolidative RT after systemic therapy, and 64% received only systemic therapy. The median follow-up time was 4.1 years.

Patients who received consolidative RT were more likely to have bulky disease (69%) vs those treated with systemic therapy alone (53%). No other significant between-group differences in patient characteristics were observed.

According to Kaplan-Meier curves constructed by the investigators, the patients receiving consolidative RT showed improved PFS, OS, and local control compared with the chemotherapy group. Median PFS in the chemotherapy group was 4.9 years, and OS was 6.6 years. Neither median PFS nor OS were reached in the consolidative RT group, and median time to local failure was not reached for either group.

The authors said their analysis suggested the addition of RT provided a 36.5% absolute benefit in 5-year PFS (85.9% in RT group vs 49.2% in chemotherapy only group), a 14.5% absolute benefit in 5-year OS (87.4% vs 72.9%), and a 37.0% absolute benefit in five-year local control (91.9% vs 54.9%).

In univariate analysis, the authors said, the use of consolidative RT was associated with a significant improvement in PFS (HR, 0.22).In multivariate analysis adjusting for differences in International Prognostic Index, tumor size, systemic therapy regimen, and extranodal involvement, the association between consolidative RT and PFS persisted (HR, 0.23; 95% CI, 0.10-0.52), whereas the association between RT and OS lost statistical significance. The association between RT and local control persisted (HR, 0.20; 95% CI, 0.07-0.59) when adjusted for study site, tumor size, and number of cycles.

The investigators defined bulky disease in this study as 5 cm or larger in tumor diameter for the largest mass observed upon initial staging imaging, noting, “The definition of bulky disease from the standpoint of consolidation is a topic of ongoing debate, but the existing body of literature points to tumor size affecting treatment outcomes.”

In both bulky and nonbulky disease, PFS significantly improved in patients receiving consolidative RT vs systemic therapy alone. No differences in OS were observed.

“For patients with stage III-IV DLBCL who achieve clinical complete response after systemic therapy, consolidative RT improves PFS for all patients, including those with the nonbulky disease,” the investigators concluded, adding their results “corroborate earlier retrospective studies.”

They acknowledged limitations including varied RT dosing across patients and lack of imaging standardization.

Although improvements in survival outcomes provided by rituximab have “led some to question the utility of consolidative RT,” the authors said that their study provides evidence supporting the use of consolidative RT in patients with advanced-stage DLBCL and complete response after chemotherapy and contributes to a growing body of research on the subject.

Syed YA, Jiang C, Switchenko J, et al. Improved progression-free survival for bulky and nonbulky advanced stage diffuse large B-cell lymphoma with consolidative radiation therapy: a bi-institutional analysis. 

. Published online August 11, 2021. doi:10.7759/cureus.17107

This new study shows that consolidative radiation therapy may be of benefit to  persons with diffuse large B-cell lymphoma, both bulky and nonbulky disease. 

Deanna Ferreri, PhD

Articles

Integrating Molecular Profiling of Adrenocortical Carcinoma Into Clinical Practice

Researchers Report Promising Strategy to Develop Personalized Therapy for Neuroblastoma

Investigators Document Muscle Loss During Immunochemotherapy for DLBCL

Consolidative Radiation Therapy Improves Progression-Free Survival in DLBCL