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Suzuki R, Hamada K, Ohkuma R, Homma M, Tsurui T, Iriguchi N, Ishiguro T, Hirasawa Y, Ariizumi H, Kubota Y, Horiike A, Yoshimura K, Wada S, Yamochi T, Tsunoda T. Case Report: Combined pembrolizumab, 5-fluorouracil, and cisplatin therapy were remarkably effective in p16-positive squamous cell carcinoma of unknown primary. Front Oncol 2023; 13:1231986. [PMID: 37496666 PMCID: PMC10365966 DOI: 10.3389/fonc.2023.1231986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/22/2023] [Indexed: 07/28/2023] Open
Abstract
Background Cancer of unknown primary (CUP) is a malignant tumor without a known primary lesion with a frequency of 3-5%. It can be divided into favorable and unfavorable prognosis subsets. While recommended treatments are available for the former group, there is no established treatment for the latter. Here, we report the effective treatment of a 32-year-old woman with p16-positive squamous cell CUP with pembrolizumab plus 5-fluorouracil and cisplatin therapy. Case presentation A 32-year-old woman presented with metastatic lesions in the liver, lung, bone, cervical region, abdominal region, and pelvic lymph nodes. She was diagnosed with p16-positive squamous cell carcinoma of unknown primary origin. The patient received pembrolizumab plus 5-fluorouracil and cisplatin therapy, which markedly reduced the metastasis and improved her Eastern Cooperative Oncology Group performance status after two courses. Conclusion This case report highlights the potential of pembrolizumab plus 5-fluorouracil and cisplatin therapy for treating CUP with an unfavorable prognosis. p16 positivity is worth examining for squamous cell carcinoma of unknown primary origin, and if present, this therapy should be considered a promising treatment option.
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Affiliation(s)
- Risako Suzuki
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kazuyuki Hamada
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Chest Surgery, Fukushima Medical University, Fukushima, Japan
| | - Ryotaro Ohkuma
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Mayumi Homma
- Department of Pathology, Showa University School of Medicine, Tokyo, Japan
| | - Toshiaki Tsurui
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nana Iriguchi
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomoyuki Ishiguro
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuya Hirasawa
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hirotsugu Ariizumi
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yutaro Kubota
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Atsushi Horiike
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kiyoshi Yoshimura
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Clinical Immuno Oncology, Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Satoshi Wada
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Clinical Diagnostic Oncology, Clinical Research Institute of Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Toshiko Yamochi
- Department of Pathology, Showa University School of Medicine, Tokyo, Japan
| | - Takuya Tsunoda
- Division of Medical Oncology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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New rising entities in cancer of unknown primary: Is there a real therapeutic benefit? Crit Rev Oncol Hematol 2020; 147:102882. [DOI: 10.1016/j.critrevonc.2020.102882] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/04/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022] Open
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Evaluation of survival benefits by platinums and taxanes for an unfavourable subset of carcinoma of unknown primary: a systematic review and meta-analysis. Br J Cancer 2012; 108:39-48. [PMID: 23175147 PMCID: PMC3553519 DOI: 10.1038/bjc.2012.516] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Although chemotherapeutic regimens containing a taxane or platinum agent have been widely recommended for unfavourable carcinoma of unknown primary (CUP), no evidence exists for the superiority of any administered regimens. To date, the efficacy has been mostly assessed in the limited setting of phase II trials, and few attempts have been made to synthesise all available data for survival outcomes. Methods: Electronic databases were searched from 1980 to 2011. Survival results were combined for each pre-specified category of regimens using a random-effects model, and meta-regression models were used to adjust for heterogeneity in some known prognostic factors. Results: A total of 32 studies were included for meta-analysis. Tendency towards better survival outcome by platinums or taxanes was indicated. After adjustment for important prognostic factors, however, the difference between the platinum-based and non-platinum regimens became no longer significant. Survival benefits by the taxane-based regimens remained significant, with a prolonged median survival time of 1.52 months (P=0.03) and a higher 1-year survival rate of 6.25% (P=0.05), but the benefit did not sustain for 2 years. Conclusion: Although no effective therapies have been established, this meta-analysis helps to fill an important gap of evidence. However, caution should still be taken because of the potential unmeasured confounding.
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Amela EY, Lauridant-Philippin G, Cousin S, Ryckewaert T, Adenis A, Penel N. Management of “unfavourable” carcinoma of unknown primary site: Synthesis of recent literature. Crit Rev Oncol Hematol 2012; 84:213-23. [DOI: 10.1016/j.critrevonc.2012.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 02/01/2012] [Accepted: 03/14/2012] [Indexed: 10/28/2022] Open
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Møller AKH, Pedersen KD, Gothelf A, Daugaard G. Paclitaxel, cisplatin and gemcitabine in treatment of carcinomas of unknown primary site, a phase II study. Acta Oncol 2010; 49:423-30. [PMID: 20397773 DOI: 10.3109/02841860903544592] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The present study was conducted to evaluate the efficacy and toxicity of a combination of paclitaxel, cisplatin and gemcitabine in patients with carcinoma of unknown primary site (CUP). PATIENTS AND METHODS Patients with CUP, ECOG performance status 0-1 and age between 18 and 65 years old were treated with paclitaxel 175 mg/m(2) day 1, cisplatin 75 mg/m(2) day 1 and gemcitabine 1000 mg/m(2) day 1 and 8 in a three-week schedule. RESULTS Ninety-eight patients were enrolled between 1998 and 2008. Ninety-one patients had target lesions according to the RECIST guidelines. The overall response rate was 42.9% (39 patients), including five complete responses (5.5%) and 34 partial responses (37.4%). The median survival time was 10.7 months, and the survival rates at one and two years were 42% and 14%, respectively. The most frequent grade 3 or more adverse events were neutropenia and thrombocytopenia. There were 3 treatment-related deaths. CONCLUSIONS Combination of paclitaxel, cisplatin and gemcitabine is an active regimen in patients with CUP with response and survival rates at least similar to other platinum- and taxane-containing regimens. The treatment was well tolerated by most patients although neutropenia and thrombocytopenia were relatively common. The present regimen represents an attractive regimen in younger CUP patients with a good performance status.
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Isik M, Seker MM, Odabas H, Kos FT, Uncu D, Zengin N. Gemcitabine and cisplatin in patients with carcinoma of unknown primary site. Med Oncol 2010; 28:591-6. [PMID: 20300978 DOI: 10.1007/s12032-010-9465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 02/17/2010] [Indexed: 12/01/2022]
Abstract
The optimal therapy for carcinoma of unknown primary site (CUPS) is still under investigation. In this retrospective trial, we reported the response rates and overall and progression free survival of 23 CUPS patients that were treated with gemcitabine and cisplatin. The mean age of the patients was 54.95 (32-77). Sixteen (69.6%) of them were males and 7(30.4%) females. Totally 109 cycles with a mean of 6 were administered. Thirteen of 23 patients (56.5%) presented with only one metastatic site, and the liver is the most frequent metastatic site (39.1%). Histologic types were adenocarcinoma in 14 patients (60.8%), squamous carcinoma in 1 patient (4.8%), epithelioid cancer in 3 patients (13%) and undifferentiated cancer in 5 patients (21.7%). Three patient achieved a CR (13%), 4 patients achieved a PR (17.4%) and 8 patients had SD (34.8%) with an overall 30.4% response rate. However, 8 patients had progressive disease with a percentage of 34.8%. The median follow-up time was 10 months (3-42 months). The mean and median survival was 12.5 (3-42) months and 10 months (range, 3-42 months) and progression free survival was 5.5 months (range, 0-23 months). Gemcitabine plus cisplatin may be an effective treatment of CUPS. Therefore additional trials are needed especially with new chemotherapeutics.
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Affiliation(s)
- Metin Isik
- Department of Medical Oncology, Ankara Numune Education and Research Hospital, Sihhiye, 06100, Ankara, Turkey.
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Phase II trials in patients with carcinoma of unknown primary: a pooled data analysis. Invest New Drugs 2009; 28:178-84. [PMID: 19424663 DOI: 10.1007/s10637-009-9261-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 04/24/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The management of carcinoma of unknown primary site remains debatable. The literature data consists of about 29 phase-II studies investigating 38 regimens, providing a broad range of response rates (RR). METHODS We performed a pooled published data analysis to identify the factors influencing RR in these 29 studies. RESULTS In front-line treatment, the overall RR was 31% (430/1,380). At least nine factors significantly influenced the reported RR, excluding drugs under investigation, such as the impact factor of the journal, single-centre study, some eligibility criteria, central radiological review, sample size calculation based on statistical hypothesis and stratification. Two drugs seem to improve RR: cisplatin and doxorubicin. Two drugs seem to be associated with a worse RR: irinotecan and carboplatin. CONCLUSIONS This pooled data analysis illustrates that in a phase II trial setting, it is impossible to attribute the variation in RR solely to the modification of drugs under investigation.
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Greco FA, Pavlidis N. Treatment for Patients With Unknown Primary Carcinoma and Unfavorable Prognostic Factors. Semin Oncol 2009; 36:65-74. [DOI: 10.1053/j.seminoncol.2008.10.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yonemori K, Ando M, Yunokawa M, Hirata T, Kouno T, Shimizu C, Tamura K, Katsumata N, Hirakawa A, Matsumoto K, Yamanaka Y, Arioka H, Fujiwara Y. Irinotecan plus carboplatin for patients with carcinoma of unknown primary site. Br J Cancer 2009; 100:50-5. [PMID: 19088717 PMCID: PMC2634680 DOI: 10.1038/sj.bjc.6604829] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/03/2008] [Accepted: 11/21/2008] [Indexed: 11/23/2022] Open
Abstract
Carcinoma of unknown primary site (CUP) is rarely encountered in clinical practice and optimal chemotherapy has not yet been established. This phase II study was conducted to evaluate the efficacy and toxicity of combined irinotecan+carboplatin therapy in chemotherapy-naive patients with CUP. Irinotecan was administered at 60 mg m(-2) as a 90-min intravenous infusion on days 1, 8 and 15. Carboplatin was administered at an area-under-the curve of 5 mg ml(-1) min as a 60-min intravenous infusion on day 1. This cycle was repeated every 28 days for up to six cycles. Forty-five patients were enrolled in the study. An intent-to-treat analysis revealed an objective response rate to the treatment of 41.9% (95% confidence interval, 27.0-57.9%). The median time to progression was 4.8 months and the median survival was 12.2 months. The 1- and 2-year survival rates were 44 and 27%, respectively. The most frequent grade 3 or more severe adverse events were leukopaenia (21%), neutropaenia (33%), anaemia (25%) and thrombocytopaenia (20%). Thus, the combination of irinotecan plus carboplatin was found to be active in patients with CUP. Therefore, the regimen may be one of the potentially available chemotherapeutic options for community standard of care in patients with a good performance status.
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Affiliation(s)
- K Yonemori
- Breast and Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
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Pimiento JM, Teso D, Malkan A, Dudrick SJ, Palesty JA. Cancer of unknown primary origin: a decade of experience in a community-based hospital. Am J Surg 2007; 194:833-7; discussion 837-8. [PMID: 18005780 DOI: 10.1016/j.amjsurg.2007.08.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 10/22/2022]
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Abstract
Cancer of unknown primary site (CUP) is not a rare tumour. It accounts as the seventh to eighth most frequently diagnosed cancer in a general medical oncology service. Since CUP is not a homogeneous disease and it consists of different favourable and unfavourable sub-sets, treatment of each clinicopathological entity requires a unique approach. The spectrum of therapeutic management includes both locoregional and systemic therapy and should intend to offer optimal benefit to favourable CUP patients and palliative care to unfavourable cases. This review article provides both a historical outline of CUP treatment as well as a helpful therapeutic guide to every oncologist who treats CUP patients.
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Affiliation(s)
- Nicholas Pavlidis
- Department of Medical Oncology, School of Medicine, University of Ioannina, Ioannina, Greece.
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Shaw PHS, Adams R, Jordan C, Crosby TDL. A Clinical Review of the Investigation and Management of Carcinoma of Unknown Primary in a Single Cancer Network. Clin Oncol (R Coll Radiol) 2007; 19:87-95. [PMID: 17305260 DOI: 10.1016/j.clon.2006.09.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Carcinoma of unknown primary (CUP) is a common encounter in oncological practice and represents 2.0-6.0% of all invasive malignancies. Evidence to support particular therapeutic strategies in this patient population is scarce, and empirical therapies are frequently derived from research on patients where the primary tumour site is known. MATERIALS AND METHODS This retrospective study reviewed the management of all patients recorded to have a diagnosis of CUP in a single cancer centre over a period of 12 months. Health records were reviewed documenting the CUP subtype, the investigations carried out both in the referring cancer unit and subsequently at the cancer centre and the recommended treatment (type and regimen), together with survival. The outcomes were examined in respect to a number of prognostic factors. Statistical tests were considered significant at P < 0.05. RESULTS One hundred and sixty-six patients were recorded to have a diagnosis of CUP, representing 3.7% of all referrals to the cancer centre. The median age of patients was 68 years (range 32-94 years), and 52.0% were women. The three most common CUP subgroups were CUP-liver/multiple sites (25.0%), CUP-bone (21.0%) and CUP-brain (16.0%). The remaining subgroups occurred at frequencies of less than 10% each. Histological confirmation was only obtained in 55.0% of cases. Even within a single subtype, 41 patients with CUP-liver/multiple sites underwent a total of 19 different investigations before any treatment being given. Forty-seven (28.0%) patients received radiotherapy, 30 (18.0%) received chemotherapy and 58 (35.0%) received supportive care alone. Nine different 5-fluorouracil-containing regimens were used in 11 patients treated with chemotherapy for CUP-liver. The overall median survival for all patients was 4.0 months. Survival was better in patients with a good performance status (0-1) and absent liver metastases (median survival 15.0 months; 95% confidence interval 8.0-22.1) and those who received chemotherapy (median survival 13.0 months; 95% confidence interval 7.4-18.6). Multivariate analysis confirmed female gender (P = 0.006), a good performance status (0/1) (P < 0.0001) and absent liver metastases (P = 0.002) as favourable prognostic indicators. CONCLUSIONS The appropriate management of patients with CUP is unclear and this study revealed a high degree of variation in clinical practice. This area is in urgent need of clinical research to ensure that the treatment of CUP is evidence based. Until such time, clinical recommendations are suggested for the investigation and treatment of such patients. Therapeutic progress will be facilitated by designating a clinical lead for CUP in each clinical network.
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Affiliation(s)
- P H S Shaw
- Department of Clinical Oncology, Velindre Hospital NHS Trust, Cardiff, UK.
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Iglseder S. [Palliative chemotherapy and CUP-syndrome: medical intentions versus patients' attitudes in decision making]. Wien Med Wochenschr 2006; 156:283-7. [PMID: 16830247 DOI: 10.1007/s10354-006-0290-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 03/08/2006] [Indexed: 11/28/2022]
Abstract
The following case report is about a 55 year old male patient with CUP-syndrome. After developing a malignant bowel obstruction he received five cycles of a palliative chemotherapy with oxaliplatin and irinotecan. The focus is on medical intentions and goals concerning palliative chemotherapy and on discussing patients' attitudes towards chemotherapy. Communication is identified as fundamental skill in shared decision making. On the one hand it improves Patients' satisfaction and palliative care and on the other hand it reduces psychological and existential suffering. In tumors of unknown primary site regimens with different combinations of Platin, Taxol, Etoposide, Irinotecan and Gemcitabine showed responses up to 46% and a survival benefit with an overall median survival up to 12 months and even long term survival.
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Affiliation(s)
- Stephan Iglseder
- Palliativstation, Krankenhaus der Elisabethinen, Linz, Osterreich.
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Sève P, Stankovic K, Charhon A, Broussolle C. Les carcinomes de primitif inconnu. Rev Med Interne 2006; 27:532-45. [PMID: 16545500 DOI: 10.1016/j.revmed.2006.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Accepted: 01/06/2006] [Indexed: 10/25/2022]
Abstract
PURPOSE Carcinoma of unknown primary site is a common clinical syndrome, accounting for 2% of cancer patients. Diagnosis is a recurrent challenge for internists. Treatment is difficult and prognosis is still poor. This review presents one synthesis of diagnosis strategies and therapeutic trials. It envisages the interest of new molecular biology methods as well as therapeutic perspectives. CURRENT KNOWLEDGE AND KEY POINTS Pathologic examination completed with immunohistochemical tests, and, depending on cases, with electron microscopy, cytogenetics, and molecular biology is a key-point for diagnosis. Diagnosis work-up, based on histological type and on individualization of some clinical presentation, proceeds in three steps. Positron emission tomography is recommended when a curative treatment is planed, particularly in cases of isolated metastasis. Functional status analysed using the performance status and simple biologic parameters (serum lactate dehydrogenase, serum alkaline phosphatase) permit us to assess prognosis. Chemotherapy is offered for patients with a good general health status. FUTURE PROSPECTS AND PROJECTS Further evaluation of positron emission tomography, as well as cost-benefit analyses, is warranted. Further randomised trials are necessary to determine the optimal chemotherapy regimen in good-risk patients and the interest of chemotherapy in patients with poor-risk disease. Gene expression profiling and proteomic evaluation, as well as pharmacogenomic offer new investigation fields.
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Affiliation(s)
- P Sève
- Service de médecine interne, Hôtel-Dieu, hospices civils de Lyon, 1, place de l'Hôpital, 69288 Lyon cedex 02, France.
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Palmeri S, Lorusso V, Palmeri L, Vaglica M, Porta C, Nortilli R, Ferraú F, Comella G, Massidda B, Danova M. Cisplatin and gemcitabine with either vinorelbine or paclitaxel in the treatment of carcinomas of unknown primary site. Cancer 2006; 107:2898-905. [PMID: 17109447 DOI: 10.1002/cncr.22379] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND : To date, the standard treatment for patients who have carcinoma of unknown primary site has not been established. METHODS : In this randomized Phase II study, 66 previously untreated patients (33 patients per arm) with carcinomas of unknown primary site received cisplatin (35 mg/m2) and gemcitabine (1000 mg/m2) with either paclitaxel (70 mg/m2) or vinorelbine (25 mg/m2), and all drugs were administered intravenously on Days 1 and 8 of a 21-day cycle. Twenty-nine patients (44%) presented with > or =2 involved sites. The pathologic diagnosis was mainly adenocarcinoma (48 patients; 72.7%) and squamous carcinoma (7 patients; 10.6%). RESULTS : In the first arm, 16 patients (48.5%) experienced an objective response, and 9 patients (27.2%) had disease stabilization. In the vinorelbine-containing arm, 14 patients (42.3%) experienced an objective response, and 8 patients (24.2%) had disease stabilization. The median response duration and the median time to progression were similar in both treatment arms; the median overall survival was 9.6 months (95% confidence interval, 7.11-12.09 months) for patients who received the cisplatin/gemcitabine/paclitaxel regimen and 13.6 months (95% confidence interval, 6.61-20.59 months) for patients who received the vinorelbine combination. Grade 3 and 4 toxicities were more frequent in the paclitaxel-containing arm. CONCLUSIONS : Both combinations satisfied the 2-step design, demonstrating antitumor activity without relevant differences in response rates or response duration; however, the vinorelbine-containing regimen yielded superior results both in terms of overall survival (13.6 months vs 9.6 months) and in terms of treatment tolerability. Therefore, according to a pick the winner attitude, the combination of cisplatin/gemcitabine/vinorelbine may be considered in the design of future randomized, Phase III trials for patients with carcinomas of unknown primary site.
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Affiliation(s)
- Sergio Palmeri
- Department of Oncology, Division of Medical Oncology, University of Palermo, Palermo, Italy.
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