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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front. Med.    2023, Vol. 17 Issue (2) : 220-230    https://doi.org/10.1007/s11684-023-0984-z
REVIEW
Rare tumors: a blue ocean of investigation
Shuhang Wang1, Peiwen Ma1, Ning Jiang1, Yale Jiang1, Yue Yu1, Yuan Fang1, Huilei Miao1, Huiyao Huang2, Qiyu Tang1, Dandan Cui1, Hong Fang1, Huishan Zhang2, Qi Fan1, Yuning Wang1, Gang Liu3, Zicheng Yu4, Qi Lei1, Ning Li1()
1. Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
2. Phase I Clinical Trial Center, Fujian Medical University Cancer Hospital/Fujian Cancer Hospital, Fuzhou 350014, China
3. Key Laboratory of Molecular Epigenetics of the Ministry of Education, Northeast Normal University, Changchun 130024, China
4. GenePlus-Shenzhen, Shenzhen 518118, China
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Abstract

Advances in novel drugs, therapies, and genetic techniques have revolutionized the diagnosis and treatment of cancers, substantially improving cancer patients’ prognosis. Although rare tumors account for a non-negligible number, the practice of precision medicine and development of novel therapies are largely hampered by many obstacles. Their low incidence and drastic regional disparities result in the difficulty of informative evidence-based diagnosis and subtyping. Sample exhaustion due to difficulty in diagnosis also leads to a lack of recommended therapeutic strategies in clinical guidelines, insufficient biomarkers for prognosis/efficacy, and inability to identify potential novel therapies in clinical trials. Herein, by reviewing the epidemiological data of Chinese solid tumors and publications defining rare tumors in other areas, we proposed a definition of rare tumor in China, including 515 tumor types with incidences of less than 2.5/100 000 per year. We also summarized the current diagnosis process, treatment recommendations, and global developmental progress of targeted drugs and immunotherapy agents on the status quo. Lastly, we pinpointed the current recommendation chance for patients with rare tumors to be involved in a clinical trial by NCCN. With this informative report, we aimed to raise awareness on the importance of rare tumor investigations and guarantee a bright future for rare tumor patients.

Keywords rare tumors      diagnosis flowchart      treatment strategy      clinical trials recommendation     
Corresponding Author(s): Ning Li   
Just Accepted Date: 17 March 2023   Online First Date: 26 April 2023    Issue Date: 26 May 2023
 Cite this article:   
Shuhang Wang,Peiwen Ma,Ning Jiang, et al. Rare tumors: a blue ocean of investigation[J]. Front. Med., 2023, 17(2): 220-230.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-023-0984-z
https://academic.hep.com.cn/fmd/EN/Y2023/V17/I2/220
Fig.1  Flowchart for rare-tumor diagnosis and necessary-treatment information collection. Patients with malignant or refractory rare tumor should undergo pathologic examination for disease classification and stage. NGS was recommended for rare tumor with poor prognosis, especially at late stage. These information could be utilized to provide proper treatment and time for clinical trials following the flowchart.
Rare tumor and their corresponding origin Five-year relative survival rate
Digestive system
SCC of pancreas 17.9
Cholangiocarcinoma of IBT 15.9
Adenocarcinoma of pancreas 15.1
Undifferentiated carcinoma of liver and IBT 8.9
Female genital system
Undifferentiated carcinoma of cervix uteri 14.6
Male genital system
Adenocarcinoma of paratestis 11.2
Hematopoietic system
AML NOS (FAB or WHO type) 19.6
Others
Mesothelioma of pleura and pericardium 19.9
Soft tissue sarcoma of heart 19.6
Retinoblastoma 5.4
Tab.1  Ten rare tumors with worst survival rates from different tissue origin
Fig.2  Estimated 5-year survival rate for rare tumors with different tissue origins based on data from the National Cancer Centre. Rare tumors from gastrointestinal tract, others (mostly from superficial tissues such as skin and eyes), and hematopoitic system had lower survival rates than rare tumors from other origins.
Fig.3  Comparison of recommended therapy in NCCN and CSCO for rare cancer. Target-therapy and immune-therapy recommendation are also listed. Based on the evidence level, recommendations were further classified into 1A/B, 2A/B, 3, and any.
Fig.4  Detailed information on treatment recommendations for rare tumors and their efficacies summarized based on updated NCCN and CSCO guidelines. First-line treatments for rare tumors are summarized based on types of therapy (chemotherapy, immunotherapy, and targeted therapy). Chemotherapy was the principal choice based on previous experience with certain histological types. Checkpoint inhibitors were utilized with high tumor-mutation burdens. As for targeted therapy, most of the recommendations fell into the 2A category (labeled with *), suggesting a great need for evidence supporting precise therapies in rare tumors. Notably, pleuropulmonary blastoma and sarcomatoid carcinoma of lung followed the guidelines of NSCLC without enrollment in phase 3 trials.
Gene Alterations FDA approved drugs Indications
ALK Fusions Crizotinib, ceritinib, alectinib, brigatinib Inflammatory myofibroblastic tumor with ALK translocation
CDK4 Amplification Palbociclib Well-differentiated/dedifferentiated liposarcoma (WD-DDLS) for retroperitoneal sarcomas
MTOR E2014K, E2419K, Q2223K Everolimus, sirolimus Recurrent angiomyolipoma, lymphangioleiomyomatosis
RET Fusions Selpercatinib, pralsetinib, cabozantinib, vandetanib RET fusion positive solid tumors
NTRK Fusions Larotrectinib, entrectinib Advanced/metastatic soft tissue sarcoma: first line: NTRK positive
EZH2 A682G, A692V, Y646C, Y646F, Y646H, Y646N, Y646S Tazemetostat Epithelioid sarcoma
CSF-1R / Pexidartinib Tenosynovial giant cell tumor/pigmented villonodular synovitis
Multi-target tyrosine kinase inhibitor VEGFR, PDGFR, FGFR, c-KIT, etc. Sorafenib, imatinib Desmoid tumors (aggressive): first line; dermatofibrosarcoma protuberans (DFSP) with fibrosarcomatous transformation (imatinib)
Rigorafenib Advanced/metastatic soft tissue sarcoma: subsequent lines
Bevacizumab Systemic therapy for alveolar soft part sarcoma, solitary fibrous tumor
PazoPanib, anlotinib Advanced/metastatic soft tissue sarcoma: first line (patients ineligible for IV systemic therapy); subsequent lines
Tab.2  Approved targeted drugs for rare tumor in China and worldwide
Fig.5  Targetable alterations in rare tumors defined by an annual incidence < 2.5/100 000 in Chinese population compared with global data.
Fig.6  Proper time for clinical-trial enrollment summarized for patients with rare tumor. Horizontal axis refers to the current disease. Patient status: 1, pre-operation or systemic therapy; 1.1, resectable (including neoadjuvant therapy); 1.2, unresectable; 1.3, metastasis. 2, post-operation; 2.1, R0 resection (N0 or in situ); 2.2, R1 resection (N+); 2.3, R2 resection (macroscopic residual tumor); 3, recurrence or refractory (later line therapy). Recommendation levels were further divided by 3 classes, represented by different colors at right corner, where 1 stands for strongly recommended or solely preferred, 2 stands for preferred along with other treatment, 3 stands for not considered or recommended specifically. Vertical axis listed specific subtypes of rare tumors. Abbreviation: Ad, adenocarcinoma; SNUC, sino nasal undifferentiated carcinoma; ITAC, intestinal-type adenocarcinoma of the nasal cavity and sinuses; EBT, ectopic breast tissue; IBT: intrahepatic biliary tract; PSC, pulmonary sarcomatoid carcinoma; Sc, squamous cell carcinoma; GTD, gestational trophoblastic disease; Uc, undifferentiated carcinoma; SCST, sex cord stromal tumors; TMT, teratoma with malignant transformation; PRSCC, prostate small cell carcinoma; NSGCT, non-seminomatous germ-cell tumors; SGCT, seminomatous germ cell tumor; RCC, renal cell carcinoma with variants; TCC, transitional cell cancer of pelvis, ureter and urethra; SCBC, small cell bladder cancer; NET, neuroendocrine tumors; PPB, pleuropulmonary blastoma; PCNC, primary cutaneous neuroendocrine carcinoma; ACC, adrenocortical carcinoma; BCC, basal cell carcinoma; STS, soft tissue sarcoma; ERMS, embryonal rhabdomyosarcoma; ARMS, alveolar rhabdomyosarcoma.
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