Association of ERCC1 gene expression with outcome in stage II-III esophageal adenocarcinoma patients...
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Association of ERCC1 gene expression with outcome in stage II-III esophageal adenocarcinoma patients treated with
preoperative platinum-based chemoradiation in a phase II cooperative
group study (SWOG S0356).
P. Bohanes1, B. H. Goldman2, J. K. Benedetti2, C. Blanke3, L. P. Leichman4, S. Iqbal1, C. R. Thomas5, C. L. Corless5, K. G. Billingsley5, K. D. Danenberg6, P. J. Gold7, and H.J. Lenz1
1University of Southern California, Los Angeles, CA; 2SWOG Statistical Center, Seattle WA; 3University of British Columbia Vancouver, BC, Canada; 4Desert Regional Medical Center,
Palm Springs, CA; 5Oregon Health and Science University, Portland, OR; 6Response Genetics, Inc, Los Angeles, CA; 7Swedish Cancer Institute, Seattle, WA
Author’s Disclosures
P. Bohanes: NoneB.H. Goldman: NoneL. Leichman: NoneC. Blanke: Sanofi-AventisS. Iqbal: Sanofi-AventisC.R. Thomas: NoneC.L. Corless: NoneJ.K. Benedetti: NoneK.G. Billingsley: NoneK.D. Danenberg: Response Genetics P. Gold: NoneH.J. Lenz: Sanofi-Aventis, Response Genetics
Background There is no worldwide accepted standard treatment for
locally advanced esophageal adenocarcinoma.◦ Neoadjuvant chemo-radiation prior to surgery is one of the
accepted treatment strategies
◦ Platinum agents are often used as the chemotherapy backbone for patients treated with trimodality therapy
In contrast to the growing number of predictive biomarkers for anti-cancer agents, there are no established biomarkers to select patients who will benefit most from chemo-radiation.
Utilization of predictive biomarkers to select therapy should lead to higher cure rates.
Background – ERCC1
ERCC1 has been shown to be a critical gene in DNA repair◦ NER pathway - recognizes and removes platinum-induced DNA adducts
◦ DSBR pathway- repairs radiation-induced damage (Bohanes et al. Clin Colorectal Cancer. In Press; Ahmad et al. Moll Cell Biol 2008)
A prospective clinical trial demonstrated in advanced NSCLC that customized therapy based on ERCC1 mRNA levels increased the response rate to cisplatin-based chemotherapy administered to patients with low ERCC1 mRNA levels (Cobo et al. J Clin Oncol 2007)
Cisplatin (4 uM) Oxaliplatin (2 uM) Carboplatin (20 uM)
0
10
20
30
40
50
60
70
80
90
controlsiRNA
Cell
via
bili
ty
(%)
ERCC1 down-regulation sensitizes cells to all platinum compounds
Youn et al. Cancer Res 2004
Tumor ERCC1 mRNA Levels
Type of Cancer NSCLC Colorectal Esophageal
Median Value 1.65 1.15 1.92
Range 0.14-13.4 0.34-4.66 0.33-5.29
% with low expression 57% 78% 42%
References Cobo et al. JCO.2007
Lenz et al. ASCO. 2008 Current study
Author Tumor Setting Patients Cutoff Results
Shirota et al. J Clin Oncol 2001
Colorectal
FOLFOX 50> 1.7 x
10-3 OS
Lenz et al.ASCO 2008
Colorectal
FOLFOX 191> 1.7 x
10-3
RR, OS
Uchida et al. BMC Cancer 2006
Colorectal
Oxaliplatin + capecitabine
91> 3.4 x
10-3 TTR
Metzger et al. J Clin Oncol 1998
GastricCisplatin +
5-FU38
> 1.46 x 10-3 OS
Wei et al.Br J Cancer 2008
Gastric FOLFOX 76> 2.2 x
10-3OS
Langer et al.Clin Cancer Res
2008
Esophageal
Cisplatin + 5-FU
± Paclitaxel38 -- NS for RR
Warnecke-Eberz et al. Clin Cancer
Res 2004
Esophageal
Oxaliplatin + 5FU + EBRT
36 > 1.1 x
10-3 RR
Joshi et al. Clin Cancer Res
2005
Esophageal
Cisplatin + 5-FU
+ EBRT99
> 3.0 x 10-3
OS
ERCC1 in Gastrointestinal Malignancies
Author Tumor Setting Patients Cutoff Results
Shirota et al. J Clin Oncol 2001
Colorectal
FOLFOX 50> 1.7 x
10-3 OS
Lenz et al.ASCO 2008
Colorectal
FOLFOX 191> 1.7 x
10-3
RR, OS
Uchida et al. BMC Cancer 2006
Colorectal
Oxaliplatin + capecitabine
91> 3.4 x
10-3 TTR
Metzger et al. J Clin Oncol 1998
GastricCisplatin +
5-FU38
> 1.46 x 10-3 OS
Wei et al.Br J Cancer 2008
Gastric FOLFOX 76> 2.2 x
10-3OS
Langer et al.Clin Cancer Res
2008
Esophageal
Cisplatin + 5-FU
± Paclitaxel38 -- NS for RR
Warnecke-Eberz et al. Clin Cancer
Res 2004
Esophageal
Oxaliplatin + 5FU + EBRT
36 > 1.1 x
10-3 RR
Joshi et al. Clin Cancer Res
2005
Esophageal
Cisplatin + 5-FU
+ EBRT99
> 3.0 x 10-3
OS
ERCC1 in Gastrointestinal Malignancies
Author Tumor Setting Patients Cutoff Results
Shirota et al. J Clin Oncol 2001
Colorectal
FOLFOX 50> 1.7 x
10-3 OS
Lenz et al.ASCO 2008
Colorectal
FOLFOX 191> 1.7 x
10-3
RR, OS
Uchida et al. BMC Cancer 2006
Colorectal
Oxaliplatin + capecitabine
91> 3.4 x
10-3 TTR
Metzger et al. J Clin Oncol 1998
GastricCisplatin +
5-FU38
> 1.46 x 10-3 OS
Wei et al.Br J Cancer 2008
Gastric FOLFOX 76> 2.2 x
10-3OS
Langer et al.Clin Cancer Res
2008
Esophageal
Cisplatin + 5-FU
± Paclitaxel38 -- NS for RR
Warnecke-Eberz et al. Clin Cancer
Res 2004
Esophageal
Oxaliplatin + 5FU + EBRT
36 > 1.1 x
10-3 RR
Joshi et al. Clin Cancer Res
2005
Esophageal
Cisplatin + 5-FU
+ EBRT99
> 3.0 x 10-3
OS
ERCC1 in Gastrointestinal Malignancies
Author Tumor Setting Patients Cutoff Results
Shirota et al. J Clin Oncol 2001
Colorectal
FOLFOX 50> 1.7 x
10-3 OS
Lenz et al.ASCO 2008
Colorectal
FOLFOX 191> 1.7 x
10-3
RR, OS
Uchida et al. BMC Cancer 2006
Colorectal
Oxaliplatin + capecitabine
91> 3.4 x
10-3 TTR
Metzger et al. J Clin Oncol 1998
GastricCisplatin +
5-FU38
> 1.46 x 10-3 OS
Wei et al.Br J Cancer 2008
Gastric FOLFOX 76> 2.2 x
10-3OS
Langer et al.Clin Cancer Res
2008
Esophageal
Cisplatin + 5-FU
± Paclitaxel38 -- NS for RR
Warnecke-Eberz et al. Clin Cancer
Res 2004
Esophageal
Oxaliplatin + 5FU + EBRT
36 > 1.1 x
10-3 RR
Joshi et al. Clin Cancer Res
2005
Esophageal
Cisplatin + 5-FU
+ EBRT99
> 3.0 x 10-3
OS
ERCC1 in Gastrointestinal Malignancies
Author Tumor Setting Patients Cutoff Results
Shirota et al. J Clin Oncol 2001
Colorectal
FOLFOX 50> 1.7 x
10-3 OS
Lenz et al.ASCO 2008
Colorectal
FOLFOX 191> 1.7 x
10-3
RR, OS
Uchida et al. BMC Cancer 2006
Colorectal
Oxaliplatin + capecitabine
91> 3.4 x
10-3 TTR
Metzger et al. J Clin Oncol 1998
GastricCisplatin +
5-FU38
> 1.46 x 10-3 OS
Wei et al.Br J Cancer 2008
Gastric FOLFOX 76> 2.2 x
10-3OS
Langer et al.Clin Cancer Res
2008
Esophageal
Cisplatin + 5-FU
± Paclitaxel38 -- NS for RR
Warnecke-Eberz et al. Clin Cancer
Res 2004
Esophageal
Oxaliplatin + 5FU + EBRT
36 > 1.1 x
10-3 RR
Joshi et al. Clin Cancer Res
2005
Esophageal
Cisplatin + 5-FU
+ EBRT99
> 3.0 x 10-3
OS
ERCC1 in Gastrointestinal Malignancies
Main Objective
To validate prospectively ERCC1 gene expression (predefined cutoff of 1.7) as a biomarker predicting outcome in patients treated with oxaliplatin-based chemotherapy in combination with radiation in the SWOG S0356 trial.
To explore the association between outcome and :◦ Other baseline mRNA levels of genes involved in
DNA repair (XPD, RRM1) and 5-FU metabolism (TS, TP, DPD and GSTP1)
◦ Functional polymorphisms in genes involved in DNA repair (ERCC1, XPD, RAD51, XRCC1, XRCC3) and 5-FU metabolism (TS, MTHFR, GSTP1)
Secondary Objectives
SWOG S0356 Treatment Design
Tumor biopsy
Surgery
CTX + EBRT
CTX
D1 D8 D15 D22 D29 D36 D43
D1 D8 D15 D22 D29 D36 D43
OHP 85 mg/m2PI 5FU 180 mg/m2/dayEBRT 180 cGy/day
Inclusion Criteria
Esophageal or gastroesophageal junction adenocarcinoma◦ Patients > 18 years◦ Clinical stage II or III; Zubrod PS ≤ 2◦ Endoscopic ultrasound only for tumors that do not
form a clear mass on CT scan◦ Pre-tx PET scans mandatory ◦ Thoracic esophagus or gastroesophageal junction ◦ Tumors < 2 cm into the gastric cardia (Siewert I-II)◦ Standard hematologic/non-hematologic parameters
Patient Characteristics
N=92
Median Age (range)
62.0 (41.6-83.1)
Gender Male Female
86 (93%)6 (7%)
Race White Other Missing
85 (96%)
4 (4%)3
Performance Status 0/1 Missing
54/37
(59%/41%)1
Primary Site Esophagus GE Junction Missing
54 (60%)36 (40%)
2
February 2005 to August 2008
98 patients registered
92 eligible for clinical outcome evaluation and this study
6 ineligible patients*
*2 squamous tumors, 2 met disease, 2 with biopsy/scans performed >28 days from protocol entry
Pathologic Response
26 (28.2%) patients = pCR (centrally confirmed)
10 patients had either Tin situ N0M0 or T1N0M0
Leichman et al. Annual Meeting of the ASTRO, San Diego, 2010
Overall Survival (OS)
0%
20%
40%
60%
80%
100%
0 2 4 6Years After Registration
N92
Events47
Median in Months33.7
Progression-Free Survival (PFS)
0%
20%
40%
60%
80%
100%
0 2 4 6Years After Registration
92
N Events
55
Median in Months20.8
2-year PFS
45.6%
2-year OS
55.4%
Median follow-up of 36.8 months
Leichman et al. Annual Meeting of the ASTRO, San Diego, 2010
Gene Expression
RNA Extracted
Reverse Transcription
PCR with TaqMan®
Data Analysis
RNA
cDNA
Laser Capture Micro-dissection
Statistical ConsiderationsCox regression used for univariate analyses of
biomarker association with outcome◦ Adjustment for baseline factors did not affect any
results
Recursive partitioning used to look for optimal cut points for continuous markers◦ Also used for building “regression trees”◦ P values adjusted for the multiple comparisons
implied by this technique
Genes Analyzed for mRNA Levels
Genes Number of patients
Median expression level (Range)
GSTP1 55 1.61 (0.52-8.73)
ERCC1 53 1.92 (0.33-5.29)
TP 52 8.93 (1.36-38.45)
TS 50 3.32 (0.92-8.62)
DPD 39 0.57 (0-2.22)
RRM1 26 1.75 (0.35-5.81)
XPD 19 1.88 (0.76-3.60)
92 patients -> 90 pre-treatment samples -> 55 with sufficient tumor tissue
Overall (N=92)
Gene Expression Dataset (N=55)
Median age (range)
62.0 (41.6-83.1) 63.9 (43.6-83.1)
Gender Male Female
86 (93%)6 (7%)
51 (93%)4 (7%)
Race White Other Missing
85 (96%)
4 (4%)3
51 (94%)
3 (6%)1
Performance status 0/1 Missing
54/37 (59%/41%)
1
34/21 (62%/38%)
0
Primary Site Esophagus GE Junction Missing
54 (60%)36 (40%)
2
34 (62%)21 (38%)
0
pCR 26 (28%) 14 (25%)
PFS by ERCC1 mRNA Levels
0%
20%
40%
60%
80%
100%
0 1 2 3 4 5Years After Registration
>1.7≤1.7
N
3122
Median
14.8 mosNR
2-year PFS
17%67%
HR (95% CI)
2.97 (1.37-6.45)1.0 (ref)
p*
0.0058
Median follow-up of 36.8 months
OS by ERCC1 mRNA Levels
0%
20%
40%
60%
80%
100%
0 1 2 3 4 5Years After Registration
> 1.7
≤ 1.7
N
31
22
Median
22.4 mos
NR
2-year OS
37%
72%
HR (95% CI)
2.32 (1.01-5.31)
1.0 (ref)
p*
0.047
Median follow-up of 36.8 months
Other ResultsAn analysis of PFS using a recursive partitioning
model found the optimal split for ERCC1 gene expression to be 1.66 (adjusted p=0.04).
ERCC1 mRNA levels were not associated with pCR
None of the other accessed mRNA levels were associated with outcome (either univariate or in recursive partitioning)◦ DNA-repair: XPD, RRM1
◦ Platinum detoxification: GSTP1
◦ 5-FU metabolism: TS, TP, DPD
Genotyping DNA was extracted from blood (Qiagen, CA, USA).
Genotyping was performed by using PCR-RFLP technique.
Performed in 91 patients (out of 92 eligible)
ERCC1 118C>T ERCC1 8092C>A GSTP1 Ile105Val RAD51 135G>C XPD 156A>C XPD Lys751Gln XRCC1 Arg391Gln XRCC3 Thr241Met
MTHFR 677C>T MTHFR 1298A>C TS 3’UTR 6bp+/6bp- TS 5’UTR VNTR TS 5’UTR G/C SNP
None are significant after adjusting for multiple comparisons
Summary In this trial, using oxaliplatin and protracted-infusion 5FU
with radiation, low intratumoral ERCC1 from the primary esophageal cancer predicted for PFS and OS.
Pre-established ERCC1 mRNA cutoff of 1.7 was confirmed in this trial.
This pre-specified cutoff was further validated by using recursive partitioning (optimal cutoff of 1.66).
Genomic polymorphisms analyzed were not associated with outcome in this study.
Study Limitations
Small sample size.
Lack of sufficient tumor tissue collection.
No differentiation between clinical stage II and clinical stage III patients
Conclusions
ERCC1 mRNA level is a very promising pre-treatment biomarker in patients with localized esophageal and gastroesophageal adenocarcinoma treated with trimodality treatment.
Biomarker studies are feasible within cooperative groups.
Based on these and published data, the SWOG is planning a prospective biomarker-driven clinical trial.