Impact of Molecular Alterations and Targeted Therapy in Appendiceal Adenocarcinomas

Appendiceal adenocarcinomas (AAs) are rare and this has limited their molecular understanding. The purpose of this study was to characterize the molecular profile of AA and explore the role of targeted therapy against cyclooxygenase (COX-2) and epidermal growth factor receptor (EGFR). Targeted therapy against COX-2 and EGFR appeared to provide no clinical benefit, and well and moderately differentiated AA were molecularly distinct from poorly differentiated AA.

Abstract

Background.

Appendiceal adenocarcinomas (AAs) are rare and this has limited their molecular understanding. The purpose of our study was to characterize the molecular profile of AA and explore the role of targeted therapy against cyclooxygenase-2 (COX-2) and epidermal growth factor receptor (EGFR).

Patients and Methods.

We performed a retrospective review of 607 patients with AA at a single institution. A total of 149 patients underwent molecular testing for at least one of the following: activating mutations in KRAS, BRAF, cKIT, EGFR, or PI3K; protein expression of c-KIT or COX-2; or microsatellite instability (MSI) status by immunohistochemistry. Kaplan-Meier product limit method and log-rank test were used to estimate overall survival (OS) and to determine associations among OS, COX-2 expression, KRAS mutations, and other characteristics.

Results.

Age, grade, stage, signet ring cells, mucinous histology, and completeness of cytoreduction score correlated with survival outcomes. COX-2 expression, KRAS, PI3K, and BRAF mutations were seen in 61%, 55%, 17%, and 4% of patients, respectively. High MSI was seen in 6% of patients. KRAS mutation was strongly associated with well differentiated or moderately differentiated AA (p < .01). COX-2 expression (p = .33) and the presence of KRAS mutation (p = .91) had no impact on OS. The use of celecoxib in patients whose tumors expressed COX-2 (p = .84) and the use of cetuximab or panitumumab in patients with KRAS wild-type tumors (p = .83) also had no impact on OS.

Conclusion.

In this cohort, we demonstrated that COX-2 expression and KRAS mutations were frequently seen in AA, although neither exhibited any prognostic significance. MSI was infrequent in AA. Targeted therapy against COX-2 and EGFR appeared to provide no clinical benefit. Well and moderately differentiated AA were molecularly distinct from poorly differentiated AA.

Implications for Practice:

Appendiceal adenocarcinomas (AAs) are rare, and current understanding of their molecular biology is poor. Surgical resection is the mainstay of therapy. Limited data exists to guide medical management, and the role of targeted therapy in AAs has not been studied. This study endeavors to define molecular alterations in AAs. Activating KRAS mutations represent the most common alteration, occurring in 55% cases. Interestingly, well and moderately differentiated tumors demonstrate similar high rates of KRAS mutation, contrary to the low rates seen in poorly differentiated tumors. These data link clinical behavior with molecular biology and suggest that moderately differentiated tumors resemble well-differentiated tumors and should be treated similarly. Further prospective trials are needed to evaluate the efficacy of targeted therapies such as antiepidermal growth factor receptor therapy in AAs, prior to their implementation in clinical practice. Constructing a molecular sketch of AAs is a necessary first step toward recognizing molecular pathways involved in their carcinogenesis and advancing the role of targeted therapies in AAs.

Introduction

Appendix tumors are rare malignancies. Appendiceal neoplasms are incidentally found in about 0.9% of all appendectomy specimens [1]. The age-adjusted incidence of appendiceal malignancies appears to be increasing from 0.12 cases per 1,000,000 per year in 1973 to 5–6 cases per 1,000,000 per year in 2006–2007 [2, 3]. Primary appendiceal adenocarcinomas (AA) are the most common subtype of appendiceal tumors and constitute 50% to 70% of all appendiceal neoplasms and 0.5% of all neoplasms of gastrointestinal origin [3, 4].

Classification of appendiceal epithelial neoplasms is controversial and is based on architectural and cytologic features [5, 6]. The clinical course is complicated and can vary from being relatively indolent to highly aggressive, depending on histologic subtype [2–4]. A review of the literature reveals scattered reports illustrating histologic subtype, age at diagnosis, grade, stage, presence of signet ring cell features, and extent of surgery as being significantly associated with survival outcomes [2–4, 7–9]. To date, only limited studies with small numbers of patients have evaluated the molecular profile of AA. Although there are anatomic associations between AA and colorectal cancer (CRC), AA are distinct entities with a unique biologic behavior. AA are commonly mucinous and tend to spread intraperitoneally, with limited incidence of nodal or distant metastases [9, 10].

Cyclooxygenase-2 (COX-2) expression and KRAS mutations have been implicated in colorectal carcinogenesis and have been shown to adversely affect the survival of patients with CRC [11–13]. Epidermal growth factor receptor (EGFR) inhibition using anti-EGFR antibodies has been demonstrated to improve survival in KRAS wild-type CRC [14–16]. Furthermore, COX-2 inhibition with celecoxib has been shown to reduce the occurrence of colorectal adenomas [17]. Selective COX-2 inhibition has also shown to inhibit tumor growth in nude mice implanted with COX-2-expressing CRC cell lines [18]. Extrapolating from these studies in CRC, COX-2 inhibition (celecoxib) and anti-EGFR therapy (cetuximab and panitumumab) have been used in the clinic, but at present no publications describe the results of such a therapeutic approach [19, 20].

As both the molecular profile and the role of molecularly targeted therapy remains uncharted in AAs, we sought to investigate the frequency of molecular alterations in these rare tumors and to ascertain the potential prognostic and therapeutic significance of targeting the COX-2 and EGFR pathways.

Patients and Methods

Population

We performed a retrospective review of 607 patients with AA evaluated at The University of Texas MD Anderson Cancer Center (MDACC) between January 2002 and December 2010. Data were collected by reviewing electronic medical records under a protocol approved by the MDACC institutional review board. The inclusion criteria for the study required a histopathologic diagnosis of AA and the presence of a tested molecular alteration. Clinical and pathologic variables of interest reviewed included demographics (age at diagnosis, race, gender), tumor characteristics (grade; tumor, node, metastasis [TNM] stage; presence/absence of signet-ring cells) and treatment history (surgery, completeness of cytoreduction score [CCS]). A total of 149 (24%) patients were identified as having been tested for at least one of the following: activating DNA mutations in KRAS, BRAF, PI3K, EGFR, or c-KIT using polymerase chain reaction-based DNA sequencing; COX-2, cKIT, EGFR, or microsatellite instability (MSI) status (MLH-1, MSH-2, MSH-6, and PMS-2) expression analysis by immunohistochemistry. All testing was performed at a Clinical Laboratory Improvements Amendments-certified MDACC laboratory and reviewed by a referenced pathologist.

TNM staging was detailed according to the 2010 edition of the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) TNM staging system for appendiceal carcinomas [21]. The tumor grade was also classified according to 2010 AJCC/UICC TNM staging system as grade 1 (G1), grade 2 (G2) and grade 3 (G3) for well differentiated, moderately differentiated, and poorly differentiated histology, respectively [21]. The CCS was recorded as CCS 0 (no visible disease), CCS 1 (<2.5 mm visible disease), CCS 2 (between 2.5 and 25 mm visible disease), and CCS 3 (>25 mm visible disease) [9]. Mucinous adenocarcinomas were defined as tumors with >50% mucin present on pathologic review.

To assess the impact of molecularly targeted therapy for COX-2 and EGFR, patients treated with either anti-EGFR (cetuximab or panitumumab) or anti-COX-2 (celecoxib) therapy were reviewed for tumor markers (carcinoembryonic antigen, cancer antigen 125, cancer antigen 19–9, chemotherapy, radiologic restaging, and treating physician evaluation. Response to therapy was categorized as stable disease, progressive disease, or responding disease according to the treating physician's assessment.

Statistical Analysis

Kaplan-Meier product limit estimation was used to calculate the survival functions. The primary clinical endpoint was overall survival (OS) and was defined as the time from diagnosis to death. In the cohort of patients treated with targeted therapy, time to progression (TTP) was defined as the time from initiation of therapy to its discontinuation for toxicity, disease progression, or treating physician's discretion. Log-rank tests were used to test the survival differences for categoric variables. Fisher exact tests and chi-square tests were used to determine association between OS and other characteristics. For multivariate survival analysis, included covariates were age, grade, TNM stage, CCS, COX-2 expression, and KRAS mutation status. The multiple imputation technique was used to impute the missing data and then a proportional hazards Cox model was used to assess effects of the covariates on OS. The results were combined using Rubin methodology [22]. A p value <.05 was considered significant. All computations were carried out in SAS 9.2 and S-plus 8.0 or R 2.12.0 (SPSS software, IBM Corp., Armonk, NY, http://www-01.ibm.com/software/analytics/spss/.

Results

Baseline Characteristics

A total of 149 patients underwent testing for at least one molecular alteration. The clinical and pathologic characteristics and treatment variables of the study population are summarized in Table 1. The median age at diagnosis was 50 years (range: 29.5–78.9 years). The majority of patients had stage IV disease (77%). The most common histologic grade was low grade or well differentiated histology (43%), and 61% of all cases were mucinous adenocarcinomas.

Table 1.

Summary of baseline characteristics for patients with appendiceal adenocarcinomas

^aGrade: 1–well-differentiated; 2–moderately differentiated; 3–poorly differentiated.

^bStage: I/II/III–nonmetastatic disease; IVA–well-differentiated intraperitoneal metastatic disease; IVB/IVC–moderate to poorly differentiated metastatic disease.

^cCCS: 0/1–disease <2.5 mm; 2/3–disease >2.5 mm.

^dCOX-2: COX-2 expression was assessed using immunohistochemistry.

^eKRAS: KRAS mutation was assessed using polymerase chain reaction-based DNA sequencing.

Abbreviations: CCS, completeness of cytoreduction score; COX-2, cyclooxygenase-2 expression.

Molecular Profile

Results of the analysis for molecular alterations with their respective frequency of occurrence are summarized in Table 2. In AA, the mutation rates for BRAF and PI3K were 4% (2/50) and 17% (2/12), respectively. Both mutations in the BRAF gene involved codon 600 (GTG to GAG), resulting in a valine to glutamate substitution (V600E). Mutations in the PI3K gene were found in codon 545 and codon 1047, resulting in a charge change from negative to highly positive (E545K) and in a histidine to arginine substitution (H1047R), respectively. No EGFR mutations (0/7) or c-KIT mutations (0/5) were seen in the tested cohort. Furthermore, we also identified 35 patients who were tested for MSI and 94% (33/35) of these were MSI stable. The two patients in whom MSI was high had loss of MLH1 (MLH1 gene promoter hypermethylation testing negative) and MSH2; however, the complete germline mutational testing on both of these patients was negative.

Table 2.

Molecular alterations in appendiceal adenocarcinomas

Abbreviations: COX-2, cyclooxygenase-2 expression; EGFR, epidermal growth factor receptor; IHC, immunohistochemistry; MSI, microsatellite instability; PCR, polymerase chain reaction.

Survival Analysis

The median follow-up for the whole group was 60.3 months (95% confidence interval [CI]: 43.8–84.6). The median OS for all patients was 53.9 months (95% CI: 46.1–79.7). In subgroup analysis, median OS for the groups tested for COX-2 and KRAS were 55.7 months (95% CI: 39.2–not applicable [NA]) and 58.7 months (95% CI: 44.8–90.9), respectively. These results were not statistically different from those of patients without available COX-2 expression or KRAS mutation information (supplemental online Fig. 1).

Results of univariate survival estimates are shown in Table 3. Among the evaluated clinical and pathologic factors, age >60 years at diagnosis, poorly differentiated histology, advanced TNM stage, presence of signet cells, nonmucinous histology, and CCS ≥2 correlated with poor OS (Fig. 1). Grade was an important prognostic determinant of survival in metastatic AA. In patients presenting with metastatic AA, the median OS decreased significantly with poorer differentiation (G1: 87.3 months; G2: 33.1 months; and G3: 27.6 months; p < .001) (supplemental online Fig. 2).

Table 3.

Univariate overall survival analysis for patients with appendiceal adenocarcinoma

^aGrade: 1–well differentiated; 2–moderately differentiated); 3–poorly differentiated.

^bStage: I/II/III–nonmetastatic disease; IVA–well-differentiated intraperitoneal metastatic disease; IVB/IVC–moderate to poorly differentiated metastatic disease.

^cCCS: 0/1 (disease <2.5 mm); 2/3 (disease >2.5 mm).

^dCOX-2: COX-2 expression was assessed using immunohistochemistry.

^eKRAS: KRAS mutation was assessed using polymerase chain reaction-based DNA sequencing.

Abbreviations: CI, confidence intervals; CCS, completeness of cytoreduction score; COX-2, cyclooxygenase-2 expression; NA, not applicable; OS, overall survival.

Figure 1.

Kaplan-Meier estimates and plots of overall survival probabilities by age (A), CCS (B), grade (C), tumor, node, metastasis stage (D), signet ring cells (E), and mucinous histology (F). Tumor grade is classified as G1 (well differentiated), G2 (moderately differentiated), or G3 (poorly differentiated). TNM stage is grouped as I/II/III (nonmetastatic disease), IVA (well differentiated intraperitoneal metastatic disease), and IVB/IVC (moderate poorly differentiated metastatic disease). CCS is defined as CCS 0/1 (disease <2.5 mm) and CSS 2/3 (disease >2.5 mm).

Abbreviations: CCS, completeness of cytoreduction score; MAA, mucinous adenocarcinoma; NMAA, nonmucinous appendiceal adenocarcinoma.

Results of multivariate analysis are shown in supplemental online Table 1. In multivariate analysis, stage IV disease (hazard ratio [HR] = 2.76; 95% CI: 1.29–5.87; p = .008), CCS ≥2 (HR = 2.10; 95% CI: 1.10–3.99; p = .023), and age >60 years at diagnosis (HR = 2.84; 95% CI: 1.25–6.43; p = .011) were independently associated with worse OS. COX-2 expression (HR = 0.67; 95% CI: 0.19–2.39; p = .524) and KRAS (HR = 1.96; 95% CI: 0.84–4.57; p = .116) mutation had no significant impact on OS.

COX-2 Expression and COX-2 Inhibition

Among the 49 patients with tested COX-2 expression, immunohistochemistry showed COX-2 expression in 30 (61%) and revealed no expression of COX-2 in 19 (39%) patients. Results of COX-2 expression and association with clinical–pathologic variables are shown in supplemental online Table 2. COX-2 expression was significantly associated with age (p = .025) and gender (p = .019), being more commonly expressed in older individuals and in men. The difference in median OS of patients with tumors that expressed COX-2 (57.6 months; 95% CI: 42.3–NA) was not statistically significant (p = .328) compared with OS of patients with tumors that did not express COX-2 (42.2 months; 95% CI: 27.7–NA) (Fig. 2A).

Figure 2.

Kaplan-Meier estimates and plots of overall survival probabilities by COX expression (A), celecoxib treatment in COX-2-expressing tumors (B), KRAS mutation status (C), and cetuximab/panitumumab treatment in KRAS wild-type tumors (D). COX-2 was assessed using immunohistochemistry. KRAS mutation was assessed using polymerase chain reaction–based DNA sequencing. KRAS negative and positive represent wild-type and mutant tumors, respectively.

Abbreviations: COX, cyclooxygenase; EGFR, epidermal growth factor receptor; Neg, negative; Pos, positive; Rx, prescription.

Additionally, we identified 9/30 (30%) patients with COX-2-expressing tumors who received selective COX-2 inhibition, all with celecoxib. The median OS for patients with and without celecoxib treatment was 57.6 and 55.7 months, respectively (p = .843) (Fig. 2B).

In all but one case, celecoxib was used in conjunction with standard cytotoxic therapy at a dose of 200 mg twice daily (supplemental online Table 3). No radiographic responses were seen, and the best response of stable disease was seen in 44% of patients. The median TTP on celecoxib was 2.9 months (95% CI: 1.8–6.5 months) and there was no difference between mean TTP on celecoxib and TTP for prior systemic therapy (p = .44) (Fig. 3).

Figure 3.

Scatter plots showing TTP on prior systemic therapies and study therapy. The study therapies are celecoxib (COX) (A) and EGFR inhibitors cetuximab and panitumumab (B). TTP was defined as duration from time of initiation of therapy to its discontinuation for any reason.

Abbreviations: EGFR, epidermal growth factor receptor; TTP, time to progression.

KRAS Mutations and EGFR Inhibition

Among the 108 patients with KRAS mutation analysis, 59 (55%) were found to have mutations; 49 (45%) were wild type. Results of KRAS mutation and association with clinical–pathologic variables are shown in supplemental online Table 4. Among the KRAS mutation subtypes, 86% (51/59) involved codon 12, and 14% (8/59) involved codon 13. The presence of KRAS mutations inversely correlated with the use of anti-EGFR antibody treatment (p < .001), presence of signet ring cells (p < .001), poorly differentiated histology (p < .001), and advanced TNM stage (p = .003). The difference in KRAS mutation rate by histologic grade was dramatic, with a rate of 21% in poorly differentiated cases but 74% in well or moderately differentiated cases (p < .001) (Fig. 4). In a subset of mucinous adenocarcinomas, KRAS mutations were seen in 18% of poorly differentiated tumors compared with 70% of well or moderately differentiated tumors (p = .002) (Fig. 4). The difference in median OS of patients with tumors that harbored KRAS mutations (57.6 months; 95% CI: 41.0–109.9) was not statistically significant (p = .906) compared with median OS of patients with tumors that were KRAS wild type (62.7 months; 95% CI: 41.3–99.8) (Fig. 2C).

Figure 4.

Stacked bar graph showing distribution of KRAS mutations in well differentiated (grade 1), moderately differentiated (grade 2), and poorly differentiated (grade 3) appendiceal adenocarcinomas. (A): All tumors. (B): Mucinous adenocarcinomas.

Abbreviations: Mut, mutation; WT, wild type.

We identified 49 patients with KRAS wild-type tumors, 20 (40.8%) of whom received anti-EGFR antibody therapy with either cetuximab (n = 16) or panitumumab (n = 4) (supplemental online Table 5). The median OS for patients with and without cetuximab/panitumumab treatment was 68.4 and 51.7 months, respectively (p = .832) (Fig. 2D).

Cetuximab or panitumumab were used as monotherapy in 25% of cases (supplemental online Table 5). EGFR inhibition was most often used as either the second or third line of therapy. The best radiologic response with EGFR inhibition was responding disease and stable disease in 15% (3/20) and 35% (7/20) of patients, respectively. The median TTP on EGFR inhibition was 2.67 months (95% CI: 2.1 months–4.1 months), and the mean TTP on anti-EGFR therapy was significantly lower than TTP on immediate prior systemic therapy (p = .01) (Fig. 3).

In a further exploratory analysis, the entire cohort of patient who were treated with anti-EGFR antibody therapy was investigated. A total of 29 patients were treated with either cetuximab or panitumumab, 20 (69%) of whom had KRAS wild-type tumors and 9 (31%) of whom had tumors that were either mutants or did not undergo KRAS mutation testing. The median OS for patients with KRAS-mutated or unknown status tumors was significantly inferior to those with KRAS wild-type tumors (p = .012) (supplemental online Fig. 3).

Discussion

Our study results suggest that COX-2 expression and KRAS mutations occur in about 61% and 55% of AA, respectively, but do not have any significant prognostic impact on survival. Furthermore, there is no evidence of benefit from the use of targeted therapies such as celecoxib, cetuximab, or panitumumab in AA. The molecular profile of AA reveals that mutations of c-KIT, EGFR, and BRAF pathways are seen uncommonly in AA. Notably, KRAS mutations were seen more commonly in well or moderately differentiated tumors compared with those of poorly differentiated histology. Additionally, clinical–pathologic variables such as age, histologic grade, TNM stage, signet ring cells, and CCS are significant prognostic factors for AA.

This is the first study documenting a comprehensive molecular profile of AA in a large cohort of patients. Our analysis shows that the molecular profile of AA differs from that of CRC as assessed by The Cancer Genomic Atlas data [23]. Mutations involving BRAF (4% vs. 9.7%), EGFR (0% vs. 3.6%), and c-KIT (0% vs. 3.1%) are less frequent in AA. Whereas PI3K mutations occur at a rate similar to the rate in CRC (16% vs. 23%), KRAS mutations are seen at a higher rate in AA (55% vs. 41%). The rate of KRAS mutations found in our study was similar to that seen in a prior report in patients with pseudomyxoma peritonei [24]. This molecular profile lends supports to the assumption that, despite their anatomic congruity, AA and CRC are two molecularly distinct tumor types.

Of greater interest is the marked variation in the KRAS mutation rate depending on histology, with a threefold higher rate in well or moderately differentiated AA compared with poorly differentiated AA (74% vs. 21%; p < .001). This finding is consistent with previously published studies [24, 25]. KRAS mutation was strongly associated with moderately differentiated histology compared with poorly differentiated tumors (odds ratio [OR] 24.5, p < .001) (Fig. 4). Even within the subset of mucinous adenocarcinomas, KRAS mutations were strongly associated with well and moderately differentiated tumors (OR 10.69; p = .002). As has been shown in prior studies [2, 3], we demonstrated that histologic grade is the single most important prognostic factor affecting survival in AA; however, the biologic significance of the relative abundance of KRAS mutation in the well or moderately differentiated tumors requires further study. This finding indicates that well and moderately differentiated tumors may be related closely from a molecular perspective and are distinct from poorly differentiated AA, which argues reconsidering the combination of these two histologic grades in the recent seventh edition of the AJCC guidelines [21, 26, 27].

Our study also revealed that AA have a low prevalence of MSI (approximately 5%) compared with colon adenocarcinomas, where high levels of MSI are seen in approximately 15%–20% of cases [28]. MSI results from defective DNA mismatch repair. It is associated with increased mutations of several critical genes and plays a key role in carcinogenesis and progression of CRC [23]. MSI-high tumors in CRC are commonly hypermutated and have distinct rates of mutations compared with MSI-stable tumors [23]. Hypermutated tumors frequently have BRAF (V600E) mutations and the lack of MSI-high tumors could explain the lower incidence of BRAF mutations in AA. Similarly, MSI-high tumors have fewer KRAS mutations than MSI-stable tumors, which may explain the frequent KRAS mutations seen in this cohort of AA [28]. Furthermore, because nonhypermutated cancers have higher TP53 and APC mutations, it is likely that these mutations may play a more important role in AA [23]. Additional studies are needed to assess the biologic role of these checkpoints and molecular pathways in AA [29]. This difference of MSI status further strengthens the argument that AA and CRC are distinct tumor types at a molecular level and indicates that AA may progress through a different sequence of genetic events than CRC.

We also demonstrated that COX-2 expression and KRAS mutations are not prognostic. The subset analysis showed that COX-2 inhibition in COX-2-expressing tumors showed no clear benefit. Similarly, there was no clear benefit from EGFR inhibition in KRAS wild-type tumors. This is the largest case series investigating the role of these targeted therapies in AA. This exploratory finding, even within a small cohort, is of potential clinical significance for patients and should be investigated further.

Our study has limitations inherent to all retrospective analyses. Molecular testing was conducted at variable time points during the treatment course based on treating physician's discretion, and the reasons for ordering molecular tests could not be discerned. However, it should be noted that clinically the study does reflect standard appendix cancer in terms of classic clinical and pathologic prognostic factors such as age, tumor grade, stage, signet ring cells, and extent of surgery, as shown in prior publications [2–5]. In addition, the demographic distribution (median age at diagnosis, race, and gender) of our cohort is similar to that of AA subgroups in prior studies [3, 4]. Despite these similarities, clinical heterogeneity of patient and treatment selection can confound survival results of the study. Moreover, although records were reviewed extensively and patient and treatment characteristics were recorded accurately, it is conceivable that some deficiencies and missing data may have biased the results. A variety of concurrent therapies were used with study drugs, and therefore the true independent treatment effect of celecoxib, cetuximab, and panitumumab could not be assessed. Interpretation of molecular analyses of PI3K, EGFR, and cKIT was limited by the small numbers. Therefore, our conclusions should be considered hypothesis-generating rather than definitive. Despite the modest size of this study, it is still the largest study of its kind in this rare tumor type.

Conclusion

This is the first study in a large cohort of patients with AA characterizing its molecular profile. AA demonstrates the frequent presence of PI3K and KRAS mutations along with a predominant microsatellite-stable phenotype. COX-2 expression and KRAS mutations, although seen frequently in AA, are not prognostic. Furthermore, although limited by small sample size, these data do not support a benefit from targeted therapies—namely, COX-2 inhibition and EGFR inhibition in AA—and suggests that further investigation is needed prior to routine clinical use. We also propose that moderately differentiated AA is molecularly distinct from poorly differentiated AA and should be regarded as such for staging and therapy.

Delineating the molecular landscape of AA is critical to understanding the true biology of this disease and is the necessary first step to developing effective therapeutic strategies that can translate into improved patient outcomes in this malignancy.

See www.TheOncologist.com for supplemental material available online.

Author Contributions

Conception/Design: Kanwal P.S. Raghav, Nianxiang Zhang, Keith Fournier, Richard Royal, Paul Mansfield, Cathy Eng, Michael J. Overman

Provision of study material or patients: Michael J. Overman

Collection and/or assembly of data: Kanwal P.S. Raghav, Aditya V. Shetty, Syed M.A. Kazmi, Michael J. Overman

Data analysis and interpretation: Kanwal P.S. Raghav, Aditya V. Shetty, Syed M.A. Kazmi, Nianxiang Zhang, Jeffrey Morris, Melissa Taggart, Keith Fournier, Richard Royal, Paul Mansfield, Cathy Eng, Michael J. Overman

Manuscript writing: Kanwal P.S. Raghav, Aditya V. Shetty, Syed M.A. Kazmi, Nianxiang Zhang, Jeffrey Morris, Melissa Taggart, Keith Fournier, Richard Royal, Paul Mansfield, Cathy Eng, Robert A. Wolff, Michael J. Overman

Final approval of manuscript: Kanwal P.S. Raghav, Aditya V. Shetty, Syed M.A. Kazmi, Nianxiang Zhang, Jeffrey Morris, Melissa Taggart, Keith Fournier, Richard Royal, Paul Mansfield, Cathy Eng, Robert A. Wolff, Michael J. Overman

Disclosures

Cathy Eng: Eli Lilly (H); Genentech/Roche (H); Amgen (RF); Arqule (RF); Keryx (RF). The other authors indicated no financial relationships.

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board