CUP is a clinico-pathological syndrome of many specific cancer types and predictable responses to therapies once classified Alwin Krämer Clinical Cooperation Unit Molecular Hematology/Oncology German Cancer Research Center and Dept. of Internal Medicine V, University of Heidelberg

Patients with Disseminated Adeno- or Undifferentiated CUP Have Low Survival Rates Minnie Pearl Cancer Research Network - 396 CUP Patients Treated in Phase II Studies Survival 1.0 0.8 0.6 0.4 0.2 12 24 36 48 60 72 84 96 108 120 1 year survival: 38% 5 year survival: 10% 10 year survival: 8% Median survival: 9.1 months N = 396 Greco, F.A., Hainsworth, J.D.: Cancer of unknown primary site, in DeVita VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology (ed 9). Philadelphia, P.A., J.B. Lippincott, 2011, pp 2033-51.

Primary Sites Determined at Autopsy 884 Patients with Cancer of Unknown Primary 12 Studies, 1944-2000 0.8% Breast 1.2% Bladder/Ureter 10% Other 6% Stomach 27% Lung 7% Genital system 7% Bowel 8% Liver/Bile duct 8% Kidney/Adrenal 24% Pancreas Pentheroudakis, Greco, Pavlidis, Eur J Cancer 2007

CUP Subsets – ESMO Classification Patient with a carcinoma of unknown primary (CUP) Favorable prognosis CUP subset Poor prognosis CUP subset Women with isolated axillary lymph node metastases from adenocarcinoma Women with papillary serous carcinoma restricted to the peritoneum Squamous cell carcinoma restricted to cervical / inguinal lymph nodes Adenocarcinoma with lower gastrointestinal profile Poorly differentiated CUP with midline distribution Neuroendocrine CUP Metastatic melanoma of unknown primary Men with osteoblastic metastases and elevated serum prostate-specific antigen CUP restricted to a single metastatic site PS ≤ 1 Normal LDH PS ≥ 2 and / or Elevated LDH Favorable prognosis: Median survival = 12 months Poor prognosis: Median survival = 4 months Consider 2-drug chemotherapy Chemotherapy or best supportive care Specific treatment Fizazi et al., on behalf of the ESMO Guidelines Committee: Cancers of unknown primary site: ESMO clinical guidelines for diagnosis, treatment and follow-up. Ann Oncol. 26: v133-v138, 2015

Overall Survival in Patients with CUP Syndrome Median survival is ~8 to 12 months and depends on several prognostic factors1 Select patients with favourable subsets of CUP have a median overall survival time of 12 to 36 months1 4 8 12 16 20 24 28 32 36 Time since diagnosis (months) The percentage of cancers diagnosed as CUP has decreased, however, this has not been matched with an improvement in median survival2 CUP: cancer of unknown primary. 1. NCCN Guidelines: Occult Primary (CUP). Version 1.2019; 2. Urban, D. et al. (2013) Br J Cancer 109:1318-24.

CUP Subsets – ESMO Classification Known primary Favorable prognosis CUP subset Median overall survival Median overall survival Women with isolated axillary lymph node metastases from adenocarcinoma Women with papillary serous carcinoma restricted to the peritoneum Adenocarcinoma with lower gastrointestinal profile Poorly differentiated CUP with midline distribution Neuroendocrine CUP CUP restricted to a single metastatic site Mean 5-year survival rate 72% Mean 5-year survival rate 85% 36 months 38 months 20-24 months 24 months 12 months 15.5 months 16 months 33 months Pavlidis and Pentheroudakis, Lancet 379: 1428-1435, 2012

Gene Expression Profiling to Predict the Tissue of Origin and Direct Site-specific Therapy in CUP Patients Hainsworth et al., J Clin Oncol 31: 217-223, 2013

Gene Expression Profiling to Predict the Tissue of Origin and Direct Site-specific Therapy in CUP Patients Overall Survival Hainsworth et al., J Clin Oncol 31: 217-223, 2013

DNA Methylation Profiling in CUP DNA methylation profiling to predict the tissue of origin and direct site-specific therapy in CUP patients n=31 n=61 Retrospective analysis p=0.0051 Moran et al., Lancet Oncol 2016

Gene Expression Profiling in CUP Molecular Characterization Gene Expression Profiling Identifies Responsive Patients Treated with Carboplatin, Paclitaxel and Everolimus Response rate Progression-free survival Overall survival Yoon et al., Ann Oncol 2016

Overall Survival and Progression-free Survival Hayashi et al., J Clin Oncol 2019

Clonal Relationship Between Prior Cancer and Presumed CUP ⅔ Consecutive CUP cases 8/2016 – 6/2018 n = 175 Antecedent malignancy 44 /175 25.1% ⅓ Bochtler et al., Int J Cancer 2019