Short summary

Metastasis is the leading cause of death in cancer patients. Biopsies are often difficult to obtain from metastatic sites and the cancer cells heterogeneity in the tissue is a challenge for analyzing their molecular profile and selecting the optimal treatment for individual patients. The isolation and propagation of cancer stem cells in fluids (e.g. ascites and pleural effusion) can be used to obtain high-quality molecular profiling, leading to a better understanding of the treatment resistance.

Rationale

Background

Tumor cell-derived cultures in 3D are valuable models for predicting therapeutic response. Recent studies have demonstrated that tumor organoids (tumoroids) recapitulate the histology, gene expression and genomic profile of the original tumor. Screening of drug sensitivity has been performed in tumoroids established from gastrointestinal cancers, demonstrating their potential for implementation in clinical practice as a guide for individualized medicine. One of the main challenges is to capture the large heterogeneity of tumors in vivo. While most subclones of a tumor might appear sensitive to a drug, it just takes one or two cells for the therapy to be ineffective. Tumoroids are usually established from resected tissue of the primary tumor. Consequently, diverging properties and potential therapeutic resistance acquired at the metastatic sites are ignored. Advanced stages of disease with dissemination to the lungs or the peritoneal cavity (ascites) often give rise to accumulation of fluid containing tumor aggregates. These tumor cells have been demonstrated to be a major source of disease recurrence; however, their origin and phenotypes are poorly understood. Enhanced treatment efficacy might be achieved by testing the chemosensitivity of tumoroids derived from ascites or pleural fuid prior to the patient's treatment delivery. Tumoroids are a faster and less expensive strategy to evaluate therapeutic response compared to murine xenografts models, while maintaining the original tumor features better than 2D cultures systems. Therefore, the use of tumoroids is a promising tool to delineate personalized treatment strategies and improve patient prognosis.

Preliminary experience

The Department of Oncology, Vejle Hospital has initiated two clinical trials recruiting patients with metastatic colorectal and pancreatic cancer, NCT03251612 [15] and NCT03821870, respectively. So far 46 out of 90 patients with bowel cancer and 5 patients out of 30 with pancreatic cancer have been included in the clinical trials. Based on 3 fine-needle biopsies taken from metastasis, tumoroid cultures were established for each patient. Subsequently, these cultures are subjected to a drug screen including chemotherapies already approved as standard treatment in Denmark. The purpose of the trials is to systematically identify the most potent treatment for the individual patient, based on the response of the cultured tumoroids. In the first feasibility step, a total of 19 biopsy sessions were performed in 10 cases; and in seven, the biopsy, tumoroid formation and sensitivity testing was successful. A notable challenge is obtaining sufficient viable tumor tissue resulting in increased culture times or the need for re-biopsies. Therefore, the establishment of tumoroid cultures was only successful for approximately half of the patients. At the Department of Clinical Genetics, Vejle Hospital, the facilities to culture tumoroids are established. Optimizing the workflow and the tumoroid culture protocol will provide a higher success rate, and ultimately lead to the benefit of a higher number of patients with metastatic cancer.

Hypothesis

Ascites and pleural effusion contain tumor cells from metastatic lesions. These tumor cells can be isolated and propagated in vitro in a 3-dimensional environment, resembling the original tumor. These tumor models are representative of the patient disease and can be used to predict prognosis and drug response.

Purpose

The purpose of this study is to 1) optimize the workflow of tumoroid establishment from ascites/pleural effusion or metastasis obtained from patients with metastatic cancer; 2) determine the molecular profiles of the tumoroids; 3) identify molecular predictors of drug response; and 4) establish a biobank of tumoroids for later drug screening.

Description of the cohort

Patients (men and women aged 18 years or older) with progressive metastatic cancer with clinical indication to be submitted to collection of ascites/pleural effusion.

Inclusion criteria

• Patient (>18 years) with histologically-proven metastatic malignant disease

• Presence of ascites, pleural effusion or metastasis available for biopsy

• Planned drain of ascites or pleural effusion or biopsy from metastasis as part of standard treatment or treatment in other protocols

• Ability to understand and the willingness to sign a written informed consent document

• Consent to translational research and biobank.

Exclusion criteria

Patients with any clinically significant medical condition which, in the opinion of the treating physician, makes it undesirable for the patient to participate in the study or which could jeopardize compliance with study requirements including, but not limited to: ongoing or active infection, significant uncontrolled hypertension or heart/lung disease, severe psychiatric illness situations.

Data and biological material

The following information about the patient will be acquired from the electronic medical records: diagnosis, serological markers and histopathology of the biopsy or resected tumor, genetic test results, treatments as well as follow-up information about response to therapy (including toxicity and side-effects), disease-free and overall survival time, date of relapse or death, the metastasis or recurrence final diagnosis and their histopathological and genetic characteristics. Furthermore, patient's date of birth, body mass index, smoking status and alcohol intake, family or personal history of cancer, age of menarche and menopause, number of pregnancies and full term births, use of contraceptives or hormone therapy, comorbidities and the associated medication may be retrieved.

Ascites, pleural effusion and metastatic biopsies will be collected.

Collaborating researchers and departments

Department of Clinical Genetics, Vejle Hospital

• Molecular Biologist Mads Jørgensen, PhD
• Researcher Cecilie Abildgaard, PhD
• Researcher Luisa Matos Do Canto Alvim, PhD
• Molecular Biologist Annabeth H. Petersen, PhD

Department of Oncology, Vejle Hospital

• Chief Physician Lars Henrik Jensen, MD, PhD
• Professor Karina Dahl Steffensen

Department of Pathology, Vejle Hospital

• Chief Physician Jan Lindebjerg, MD, PhD