Anne Jouinot

Integrated genomic characterization of adrenocortical carcinoma

Adrenocortical carcinomas (ACCs) are aggressive cancers originating in the cortex of the adrenal gland. Despite overall poor prognosis, ACC outcome is heterogeneous. We performed exome sequencing and SNP array analysis of 45 ACCs and identified recurrent alterations in known driver genes (CTNNB1, TP53, CDKN2A, RB1 and MEN1) and in genes not previously reported in ACC (ZNRF3, DAXX, TERT and MED12), which we validated in an independent cohort of 77 ACCs. ZNRF3, encoding a cell surface E3 ubiquitin ligase, was the most frequently altered gene (21%) and is a potential new tumor suppressor gene related to the β-catenin pathway. Our integrated genomic analyses further identified two distinct molecular subgroups with opposite outcome. The C1A group of ACCs with poor outcome displayed numerous mutations and DNA methylation alterations, whereas the C1B group of ACCs with good prognosis displayed specific deregulation of two microRNA clusters. Thus, aggressive and indolent ACCs correspond to two distinct molecular entities driven by different oncogenic alterations.

The 'omics' of adrenocortical tumours for personalized medicine

Pan-genomic analyses of genetic and epigenetic alterations and gene expression profiles are providing important new insights into the pathogenesis and molecular classification of cancers. The technologies and methods used for these studies are rapidly diversifying and improving. The use of such methodologies for the analysis of adrenocortical tumours has revealed clear transcriptomic (mRNA and microRNA expression profiles), epigenomic (DNA methylation profiles) and genomic (DNA mutations and chromosomal alterations) differences between benign and malignant tumours. Interestingly, genomic studies of adrenal cancers have also identified subtypes of malignant tumours, which demonstrate distinct patterns of molecular alterations and are associated with different clinical outcomes. These discoveries have created the opportunity for classifying adrenocortical tumours on the basis of molecular analyses. Following these genomic studies, efforts to develop new molecular tools that improve diagnosis and prognostication of patients with adrenocortical tumours have also been made. This Review describes the progress that has been made towards classification of adrenocortical tumours to date based on key genomic approaches. In addition, the potential for the development and use of various molecular tools to personalize the management of patients with adrenocortical tumours is discussed.

DNA methylation is an independent prognostic marker of survival in adrenocortical cancer.

Context Adrenocortical cancer (ACC) is an aggressive tumor with a heterogeneous outcome. Prognostic stratification is difficult even based on tumor stage and Ki67. Recently integrated genomics studies have demonstrated that CpG islands hypermethylation is correlated with poor survival. Objective The goal of this study was to confirm the prognostic value of CpG islands methylation on an independent cohort. Design Methylation was measured by methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA). Setting MS-MLPA was performed in a training cohort of 50 patients with ACC to identify the best set of probes correlating with disease-free survival (DFS) and overall survival (OS). These outcomes were validated in an independent cohort from 21 ENSAT centers. Patients The validation cohort included 203 patients (64% women, median age 50 years, 80% localized tumors). Main Outcome Measures DFS and OS. Results In the training cohort, mean methylation of 4 genes (PAX5, GSTP1, PYCARD, PAX6) was the strongest methylation marker. In the validation cohort, methylation was a significant prognostic factor of DFS (P < 0.0001) and OS (P < 0.0001). Methylation, Ki67, and ENSAT stage were combined in multivariate models. For DFS, methylation (P = 0.0005) and stage (P < 0.0001) but not Ki67 (P = 0.19) remained highly significant. For OS, methylation (P = 0.0006), stage (P < 0.0001), and Ki67 (P = 0.024) were independent prognostic factors. Conclusions Tumor DNA methylation emerges as an independent prognostic factor in ACC. MS-MLPA is readily compatible with clinical routine and should enhance our ability for prognostication and precision medicine.

Relation between hypermetabolism, cachexia, and survival in cancer patients: a prospective study in 390 cancer patients before initiation of anticancer therapy

Background: Cachexia is a major cause of death in cancer patients. The role of hypermetabolism in cancer cachexia remains unclear.Objective: We studied the relation between resting energy expenditure (REE), the estimated energy balance, clinical and biological markers of cachexia, and survival.Design: REE was measured with the use of indirect calorimetry in cancer patients before the initiation of anticancer therapies. Hypermetabolic, normometabolic, and hypometabolic patients were identified with the use of Boothbys standard. Weight loss, performance status (PS), C-reactive protein (CRP), albumin, the nutritional risk index, daily energy intake, energy balance (equal to daily energy intakes minus the REE), and survival were recorded.Results: Of 390 enrolled patients, 49% of subjects were hypermetabolic, 30% of subjects were normometabolic, and 21% of subjects were hypometabolic. Mean daily energy intakes did not differ significantly between the 3 groups. Hypermetabolic patients, compared with normometabolic patients, were more likely to have a negative energy balance [45% compared with 32%, respectively; OR: 1.74 (95% CI: 1.05, 2.91); P = 0.024], weight loss >5% [48% compared with 34%, respectively; OR: 1.83 (95% CI: 1.11, 3.04); P = 0.013], PS ≥2 [40% compared with 29%, respectively; OR: 1.70 (95% CI: 1.01, 2.88); P = 0.038], and CRP concentrations ≥10 mg/L [52% compared with 33%, respectively; OR: 2.2 (95% CI: 1.33, 3.66); P = 0.001]. In metastatic patients, compared with normometabolism, hypermetabolism was associated with a reduced median survival [14.6 compared with 21.4 mo, respectively; OR: 1.48 (95% CI: 1.01, 2.17); P = 0.044].Conclusions: Hypermetabolism is correlated with clinical and biological markers of cancer cachexia and is associated with a shorter survival in metastatic cancer patients. The development of therapeutic strategies that aim to blunt hypermetabolism appears warranted. This trial was registered at www.controlled-trials.com as ISRCTN46152275.

Clinical pharmacology, drug-drug interactions and safety of pazopanib: a review.

ABSTRACT Introduction: In the past decade, treatment options for metastatic renal cell carcinoma and soft-tissue sarcoma have expanded. Pazopanib was discovered during the screening of compounds that suppressed vascular endothelial growth factor receptor-2 (VEGFR-2). As other tyrosine kinase inhibitors (TKI), pazopanib is not totally specific for one target since it also inhibits stem-cell factor receptor (cKIT), platelet-derived growth factor receptors (PDGFRα, β), VEGFR-1 and −3. Areas covered: Clinical pharmacology, drug-drug interactions and safety data published on pazopanib, between January 2006 and April 2016, are reviewed. Expert opinion: This new therapy has been shown to improve progression-free survival compared with previous approaches, in renal cell cancer and soft-tissue sarcoma. However, some specific sub-populations, such as elderly patients, patients with brain metastases or with Eastern Cooperative Oncology Group Performance Status (ECOG PS) 2 or comorbidities, are poorly represented in pivotal pazopanib phase III studies. Pazopanib meets criteria defining therapies as candidates for therapeutic drug monitoring: large intra- and inter-patient pharmacokinetic variability, potential pharmacokinetic drug-drug interactions, pharmacokinetic/pharmacodynamic relationship and narrow therapeutic index. Knowledge of predictors that can be used to guide dosing regimens in the target population and in special populations needs to be improved.

Detection and monitoring of circulating tumor DNA in adrenocortical carcinoma

Adrenocortical carcinomas (ACC) are rare but aggressive tumors. Currently, the single curative approach is complete surgery. Prognosis, response to treatment and recurrence remain unpredictable, which stresses the need for new biomarkers (Else et al. 2014). Recent exome sequencing approaches of tumors identified in 60% of ACC recurrent somatic mutations in 20 genes (Assié et al. 2014a,b, Juhlin et al. 2015, Zheng et al. 2016). Somatic mutations can be used as surrogate biomarkers for detecting circulating tumor DNA (ctDNA) in blood. This ctDNA corresponds to fragments of DNA released directly by tumor cells into the blood stream among the circulating cell-free DNA (ccfDNA). Discrimination of ctDNA from ccfDNA of non-tumoral origin is based on the detection of somatic mutations, specific of cancer cells. The amount of ccfDNA and the detection of ctDNA largely depend on tumor type and disease stage (Bettegowda et al. 2014). In ACC, ctDNA detection has been recently reported in one patient (Creemers et al. 2017). However, beyond this proof of concept, the proportion of ACC patients with detectable ctDNA is not established. The aim of this study was to assess to which extent ctDNA can be detected in ACC patients, using two highly sensitive techniques: deep NGS and droplet digital PCR (ddPCR). We also assessed the evolution of ctDNA during the course of the disease. We prospectively and randomly included 11 patients with ACC. For four patients, blood was sampled before primary surgery, for three patients at the time of a small relapse or metastasis occurring <2 years after primary surgery, and for four patients in the setting of a rapidly growing metastatic disease. Median age was 48 (range 31–81 years). Six patients had glucocorticoids hypersecretion. Two patients had androgen hypersecretion, while two patients presented no hypersecretion (Table 1). All patients were informed of the project, and signed a written consent for the genetic study of the tumor. A prior agreement from the local ethics committee was obtained, under the COMETE–TACTIC framework. Tumor and leukocytes DNA were extracted for each patient. Next-generation sequencing (NGS) workflow based on a custom AmpliSeq (Thermofisher) panel was designed for sequencing the 20 genes known to be frequently mutated in ACCs, using a Ion Torrent PGM Sequencer (Life Technologies). Seventeen somatic mutations were detected in eight patients (Table 1). TP53 (5 hits) and CTNNB1 (3 hits) were the most affected genes, followed by NF1 (2 hits) and single-hit mutations in TERT, RPL22, ATRX, MED12 and MEN1. Four patients had more than one somatic mutation, ranging from 2 to 6. Tumor cellularity, clonality and heterozygosity status were assessed with our R algorithm TARGOMICS (Garinet et al. 2017, data not shown). Three patients presented no mutations in the genes studied. For the eight patients with at least one somatic mutation identified in the tumor, ccfDNA was extracted from plasma collected either before surgery or at the time of relapse, metastases or follow-up obtained after double centrifugation of 20 mL of blood (BCT Cell-Free DNA Blood Collection Tube). Concentrations were variable, from 3 to 422 ng/mL of plasma (Table 1). For each patient, tumor mutations were searched in ccfDNA either by deep sequencing or by ddPCR. A library with a unique amplicon harboring the mutation was subsequently prepared for each patient relative to the mutation identified in the tumor DNA and sequenced with an expected depth of 100,000×. Four mutations were detected by NGS, in two patients, 1 and 7 (Table 1). Notably, these patients displayed massively metastatic diseases, with a rapid evolution. Allelic ratios in tumors indicated that these mutations were present in all tumor cells. Concentrations of ccfDNA were high −17 and 422 ng/mL. For patient 1, the three somatic mutations – in RB1, TP53 and CTNNB1 genes – were 3 25

Les biothérapies des cancers colorectaux métastatiques en 2014

The treatment of metastatic colorectal cancer has been transformed during the last decade with biotherapies, two of them were marketed in 2013. Four agents are monoclonal antibodies, while the fifth agent is a tyrosine kinase inhibitor. Two agents are inhibitors of the EGF-receptor pathway, cetuximab and panitumumab, and have as class-toxicity, cutaneous toxicity. The other three agents are bevacizumab, aflibercept and regorafenib, and interact with angiogenesis, they are associated with a risk of vascular toxicity, mainly hypertension. These agents participate to an improvement of disease control at the metastatic stage, and in some cases, favour the curative surgical resection of metastases. Their use is discussed in multidisciplinary meetings dedicated to gastrointestinal cancers, in the presence of liver surgeons.

1528PRELATIONSHIP BETWEEN REST METABOLISM AND PERFORMANCE STATUS IN CANCER PATIENTS: A PROSPECTIVE STUDY IN 161 PATIENTS

ABSTRACT Aim: The WHO Performance Status (PS) of cancer patients (pts) correlates with survival and with anticancer treatments tolerability. However, PS is subject to inter-observer variability and is not sensitive to detect pts with high-risk of treatment toxicity. We studied the relationship between Rest Metabolic Rate (RMR) and PS. Methods: A prospective observational, monocentric study was conducted. Before treatment initiation, RMR was measured using indirect calorimetry (Fitmate®, Cosmed srl) and compared to estimated RMR obtained by the modified Harris and Benedict equation. Hypermetabolics (Hm) pts were defined as having measured RMR ≥110% of calculated RMR and Not Hypermetabolics (NoHm) pts Results: A total of 161 consecutive pts were analyzed : 58% males, median age : 64 years (20-94). Primary tumor: genito-urinary (23%) gastro-intestinal (20%), lung (17%); 10% were PS ≥3; median weight loss : 4.1% (-14.9–+18.5); mean energetic gap: +80 kcal/d; mean RMR : 1676 kcal/d; 60% of the pts were Hm with mean RMR= 1815 kcal/d vs 1433 kcal/d in NoHm pts (P 5% in 52% vs 32% of the pts (p = 0.03). Hm pts had more inflammation: a1-GP 1.5 vs 1.1 g/L (t=3.41, p Conclusions: Hypermetabolism may account for cancer-induced asthenia and development of cachexia. The measurement of RMR allows to detect pts at high-risk of malnutrition amongst pts with PS Disclosure: All authors have declared no conflicts of interest.