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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 193-197

Prediction of response to combination chemotherapy with irinotecan in Greek patients with metastatic colorectal cancer


Departments of Medical Oncology, “Agii Anargiri” Cancer Hospital, Athens, Basic Medical Science, Laboratory of Biology, Pathology, and Propaedeutic Surgery, School of Medicine, University of Athens, Athens, Greece

Date of Web Publication13-Apr-2016

Correspondence Address:
Maria Gazouli
Assistant Professor of Molecular Biology, Michalakopoulou 176, 11527 Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.148654

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 > Abstract 


Background: The aim of our study was to analyze the possible relationships between treatment efficacy, and germinal gene polymorphisms linked to the irinotecan in combination with bevasizumab or panitumumab and capecitabine or 5-FU that has been routinely used in our practice, in the management of metastatic colorectal cancer (CRC).
Materials and Methods: Ninety-four Greek with histologically proven metastatic CRC were included in the study. Treatment was administered until disease progression or unacceptable toxicity, for a maximum of eight cycles. Patients were stratified into stable disease. (SD) and progressive disease. (PD). Associations between clinical data, KRAS, UGT1A1. (UGT1A1*28) and DPD (IVS14+1 G. > A) polymorphisms, and toxicity were analyzed.
Results: Fifty-eight (61.70%) patients were characterized with SD disease and 36 (38.30%) with PD. There were not statistical significant differences between carriers of KRAS mutated alleles between SD and PD groups. No significant difference was found between response rates and toxicity and DPD or UGT1A1 genotypes. Our results suggested that determination of DPD or UGT1A1 genotypes could not be useful for predicting severe toxicity of irinotecan in our population.
Conclusions: The clinical significance of the findings requires replication in larger populations. Furthermore, as 5.FU and irinotecan metabolism is complex, numerous genes in addition to DPD and UGT1A1 should be investigated.

Keywords: DPD, irinotecan, KRAS, metastatic colorectal cancer, toxicity, UGT1A1


How to cite this article:
Isaakidou A, Gazouli M, Aravantinos G, Pectasides D, Theodoropoulos GE. Prediction of response to combination chemotherapy with irinotecan in Greek patients with metastatic colorectal cancer. J Can Res Ther 2016;12:193-7

How to cite this URL:
Isaakidou A, Gazouli M, Aravantinos G, Pectasides D, Theodoropoulos GE. Prediction of response to combination chemotherapy with irinotecan in Greek patients with metastatic colorectal cancer. J Can Res Ther [serial online] 2016 [cited 2021 Jan 24];12:193-7. Available from: https://www.cancerjournal.net/text.asp?2016/12/1/193/148654




 > Introduction Top


Colorectal cancer (CRC) is the second highest cause of cancer death in Western countries. It is well accepted that surgery is potentially curative, however, a significant proportion of patients have distant metastasis and are not candidates for curative surgery.[1] Chemotherapy is an effective method for improving overall survival and quality of life of metastatic CRC patients. Standard chemotherapeutic agents currently used include 5-fluorouracil/leucovorin, capecitabine, oxaliplatin, irinotecan, and new biological agents that target vascular endothelial growth factor (VEGF) or epidermal growth factor receptor (EGFR). At present, several studies have recommended oxaliplatin- or irinotecan-based therapeutic procedures.[1],[2],[3] Widely accepted and well-established guidelines have recommended five mainly regimens: FOLFOX (combination of oxaliplatin, 5-fluorouracil, and leucovorin); FOLFIRI (combination of irinotecan, 5-fluorouracil, and leucovorin); CapeOX (combination of capecitabine and oxaliplatin); infusional 5-FU/LV (5-fluorouracil/leucovorin) or capecitabine; and FOLFOXIRI (infusional 5-FU/LV, oxaliplatin, and irinotecan) (http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf).[4] The combination of 5-fluorouracil (5-FU) i.v. or Capecitabine p.o. and irinotecan remains a cornerstone for the first-line treatment of patients with metastatic CRC. However, the use of irinotecan could be burdened by unpredictable severe toxicity that may result in dose reduction or discontinuation of treatment.[5],[6],[7]

Amongst other factors, such as organ dysfunction or medical co-morbidity, genetic variability may contribute to the chemotherapy toxicity. Many of the genes that encode proteins, which interact with drugs are subject to common polymorphic variation affecting their regulation or function. The latter may be related to the variation of the toxicity patterns amongst patients. The aim of our study was to analyze the possible relationships between treatment efficacy and germinal gene polymorphisms linked to the administered drugs. Irinotecan in combination with bevasizumab or panitumumab and capecitabine or 5-FU in the management of metastatic CRC has been routinely used in our practice. As a first step, we tested the functional polymorphism of the UDP-glycosyltransferase1-polypeptide A1 (UGT1A1) gene, the variant UGT1A1*28. This variant is known to affect the glucuronidation capacity of SN38, the active metabolite of irinotecan.[7] Then we tested the IVS14 + 1 G > A variant of the dihydropyrimidine dehydrogenase gene (DPD) since that encodes for dihydropyrimidine dehydrogenase, which is the key enzyme of the 5-FU catabolic pathway.[8]


 > Materials and Methods Top


Patients and treatment

During 2005-2013, consecutive incident cases of CRC were recruited. Inclusion criteria included patient age 18 years or more, histologically confirmed. Bidimensionally measured metastatic, unresectable CRC, no prior chemotherapy, and adequate bone marrow and renal and hepatic function. The study was carried out with ethics committee approval. Treatment was administered until disease progression or unacceptable toxicity, for a maximum of eight cycles. All patients received irinotecan in combination with bevasizumab or panitumumab and capecitabine or 5-FU. Specifically, 55 patients received bevasizumab, irinotecan, and capecitabine; 13 patients received panitumumab, irinotecan, and capecitabine; 17 patients received bevasizumab, irinotecan, and 5-FU, and 9 patients received panitumumab, irinotecan, and 5-FU. A description of the analyzed patients is given in [Table 1].
Table 1: Patient characteristics and first-line therapeutic approaches

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Efficacy evaluation

The clinical response was assessed according to Response Evaluation Criteria In Solid Tumors (RECIST).[9] Only patients with measurable disease at baseline were included in study. CT and MRI are the best currently available and reproducible methods to measure target lesions selected for response assessment. All measurable lesions up to a maximum of five lesions per organ and 10 lesions in total, representative of all involved organs should be identified as target lesions and recorded and measured at baseline. A sum of the longest diameter (LD) for all target lesions were calculated and reported as the baseline sum LD. The baseline sum LD was used as reference for characterizing the objective tumor response. Evaluation of target lesions

was stratified as follows:

  • Complete Response (CR): Disappearance of all target lesions;
  • Partial Response (PR): At least a 30% decrease in the sum of the LD of target lesions, taking the baseline sum LD as reference;
  • Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum LD since the treatment started;
  • Progressive Disease (PD): At least a 20% increase in the sum of the LD of target lesions, taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions.


The evaluation of non-target lesions was as follows:

  • Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker level;
  • Incomplete Response/Stable Disease (SD): Persistence of one or more non-target lesion (s) or/and maintenance of tumor marker level above the normal limits;
  • Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions.


In order for a status of PD or CR to be assigned, changes in tumor measurements must be confirmed by repeat assessments that should be performed no less than 4 weeks after the criteria for response were first met. Longer intervals as determined by the study protocol may also be appropriate.

In the case of SD, follow-up measurements must have met the SD criteria at least once after study entry at a minimum interval (in general, not less than 6-8 weeks) that is defined in the study protocol. Patients were stratified into stable disease (SD) and progressive disease (PD). Time to progression and survival were calculated from day 1 of treatment.

Toxicity evaluation

Toxicity was evaluated in every cycle as previously described.[10]

KRAS mutation analysis

KRAS mutation analysis was performed in formalin-fixed paraffin-embedded tumor material from each patient. The percentage of tumor cells in analyzed samples was 30% or more. DNA was extracted using a commercial kit (Nucleospin Tissue, Macherey-Nagel, Germany). The presence of a mutation at codon 12 and codon 13 of KRAS was determined by an enriched polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) as previously described.[11]

Pharmacogenetic analyses

On completion of patient recruitment, frozen blood samples (5 ml) were used for DNA extraction. DNA was extracted using a commercial kit (Nucleospin Blood, Macherey-Nagel, Germany). Germline polymorphisms of UGT1A1 and DPD genes were analyzed. The DPD IVS14 + 1G > A (rs3918290) polymorphism was examined using PCR-RFLP as previously described.[12] The TA tandem repeat polymorphism in the UGT1A1 gene promoter was analyzed by PCR using the primers: Forward 5′-GCCAGTTCAACTGTTGTTGCC-3′ and reverse 5′-CCACTGGGATCAACAGTATCT-3′. The UGT1A1*28 polymorphism (rs8175347) corresponds to the [A (TA)7 TAA] sequence, while UGT1A1 * 1 the wild-type allele corresponds to the [A (TA)6 TAA] sequence. The PCR fragments were subjected to direct sequencing analysis.

Statistic analysis

Frequency and susceptibilities of mutations were compared using the χ2 test. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with the corresponding χ2 distribution test. The P values obtained were two-tailed and determined to be significant at P < 0.05. Hardy–Weinberg equilibrium was verified by calculating the expected frequencies and numbers and was tested separately in patients and in controls using the goodness-of-fit χ2 test. All the comparisons were performed using GraphPad version 3.00 (GraphPad Software Inc., San Diego, CA, USA).


 > Results Top


Of all 94 patients enrolled, 57 (60.64%) patients were male and 37 (39.36%) were female, with a median age of 67.42 years (range 39-86 years) [Table 1]. Radical resection of the primary tumor had been performed in 86.17% of the patients (n = 81). Relapse occurred in 7 patients. Until March 31, 2014, 58 (61.70%) patients were characterized with SD disease whereas 36 (38.30%) with PD. Concerning KRAS mutation status, 27 of all patients tested were carriers of codon 12 mutated allele (28.72%) and 5 were carriers of the codon 13 mutated allele (5.32%). There was not statistical significant differences between carriers of KRAS mutated alleles between SD and PD patients group (P = 0.28). When the patients stratified according to chemotherapy combination used, 22 patients received panitumumab. Among them, 4 were carriers of codon 12 mutated allele, and there was not statistical significant differences between carriers of KRAS mutated alleles between SD and PD patients received panitumumab group (P = 0.15).

[Table 2] illustrates the distributions of genotypes for the DPD IVS14 + 1G > A (rs3918290), and UGT1A1*28 (rs8175347) polymorphisms, which were in Hardy-Weinberg equilibrium. As indicated in [Table 3], no significant difference was found between response rates and DPD or UGT1A1 genotypes. Regarding the DPD IVS14 + 1G > A (rs3918290), when patients stratified according to 5-FU use, there was also no statistical significant difference between SD and PD patients (P = 1.00).
Table 2: The DPD IVS14+1G>A (rs3918290) and UGT1A1*28 (rs8175347) genotypes distributions

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Table 3: The relationship between the DPD IVS14+1G>A (rs3918290), and UGT1A1*28 (rs8175347) polymorphisms, and the patients response status

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The most frequent major toxicities observed were nausea (33 patients), neutropenia (20 patients), and diarrhea (1 patient). As illustrated in [Table 4], no significant difference was observed between toxicity and DPD and UGT1A1 genotypes.
Table 4: The relationship between the DPD IVS14+1G>A (rs3918290), and UGT1A1*28 (rs8175347) polymorphisms, and the toxicity status

Click here to view



 > Discussion Top


Predictive biomarkers correlate with the impact of specific treatments on outcome and may be of substantial clinical usefulness. The aim of this study, conducted among 94 patients with metastatic CRC, was to perform a pharmacogenetic analysis in patients receiving irrinotecan in combination with bevasizumab or panitumumab and capecitabine or 5-FU.

To this end, we selected the DPD IVS14 + 1G > A (rs3918290) and the UGT1A1 * 28 (rs8175347) polymorphisms that have previously been shown to influence the pharmacodynamics of these drugs.[7],[8]KRAS analysis was also performed before the initiation of the therapy. In accordance with data in the literature, no significant difference was observed in response rate in patients with a wild-type compared with patients carried a mutated KRAS tumor.[13]

Concerning the DPD IVS14 + 1G > A (rs3918290) polymorphism, it has been documented that it is associated with toxicity of capecitabine in patients with metastatic colorectal cancer treated with capecitabine-based chemotherapy plus targeted agents.[14] Nevertheless, in the present study, we did not find any significant difference in the response and the toxicity status among the patients tested. The existence of other genetic polymorphisms, the role of non-genetic factors such disease status, comorbidity, and age, the drug dose intensity, and the concomitant chemotherapy may partially explain for the discordance between our study and the previous report. One should also take into account that studies in nonrandomized populations are unlikely to detect predictive markers reliably, since they cannot distinguish whether differing outcomes are due to underlying tumor behavior or to the impact of treatment.

It has been reported that UGT1A1*28 polymorphism may identify patients with lower SN-38 glucuronidation rates and greater susceptibility to irinotecan-induced gastrointestinal and bone marrow toxicity.[15] However, the role of routine testing for the presence of germline isoforms of UGT1A1 remains unsettled. Evidence indicates that at relatively high irinotecan dose levels (> mg/m 2), patients who are homozygous for the UGT1A1 * 28 variant experience a greater risk of clinically important neutropenia.[16] Our results did not indicate any implication of UGT1A1*28 polymorphism in irrinotecan toxicity or therapy response prediction. Results from similar studies conducted to date have been conflicting and often have generated opposite conclusions.[7] This is most likely a consequence of the relatively low number of patients included in these studies, the different schedules of irinotecan treatment used the patient type, or the use of retrospective analyses. Our findings are in accordance with the study by Braun et al. study that did not support the clinical use of molecular markers, such as UGT1A1, to predict the toxicity of irinotecan.[17] Liu et al.[18] in a homogeneous patient population and single treatment regimen, though, Braun et al. suggested that UGT1A1*28 polymorphism may be important in the development of hematologic toxicity at the beginning of therapy but becomes less important during subsequent cycles.[17] This association seemed to have marginal clinical implications, given that the observed toxicities could be managed during the course of chemotherapy. Therefore, the possibility of a dose reduction for irinotecan in patients with a UGT1A1*28 polymorphism was not supported by the result of their analysis. Furthermore, Liu et al.[18] in a recent meta-analysis supported that UGT1A1 * 28 polymorphism cannot be considered as a reliable predictor of therapeutic response in CRC patients treated with irinotecan-based chemotherapy. It is our firm belief that studies on populations of distinct ethnic backgrounds are worthwhile in drawing definite conclusions, since the role of specific polymorphisms may well vary from one patient population to the other.

In conclusion, the clinical significance of the findings requires replication and additional research, in larger populations. In particular, as 5-FU and irinotecan metabolism is complex, numerous genes in addition to DPD and UGT1A1 should be investigated.


 > Acknowledgments and Disclosures Top


This study was supported by a non-profit organization of Greek Society of Cancer Biomarkers and Targeted Therapy. The authors have no conflicts of interest that are directly relevant to the content of this article.

 
 > References Top

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Casado-Saenz E, Feliu J, Gomez-España MA, Sanchez-Gastaldo A, Garcia-Carbonero R. SEOM. SEOM clinical guidelines for the treatment of advanced colorectal cancer 2013. Clin Transl Oncol 2013;15:996-1003.  Back to cited text no. 1
    
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Tournigand C, André T, Achille E, Lledo G, Flesh M, Mery-Mignard D, et al. FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: A randomized GERCOR study. J Clin Oncol 2004;22:229-37.  Back to cited text no. 2
    
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Douillard JY, Cunningham D, Roth AD, Navarro M, James RD, Karasek P, et al. Irinotecan combined with fluorouracil compared with fluorouracil alone as first-line treatment for metastatic colorectal cancer: A multicentre randomised trial. Lancet 2000;355:1041-7.  Back to cited text no. 3
    
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Toffoli G, Cecchin E, Corona G, Russo A, Buonadonna A, D'Andrea M, et al. The role of UGT1A1 * 28 polymorphism in the pharmacodynamics and pharmacokinetics of irinotecan in patients with metastatic colorectal cancer. J Clin Oncol 2006;24:3061-8.  Back to cited text no. 7
    
8.
Kristensen MH, Pedersen PL, Melsen GV, Ellehauge J, Mejer J. Variants in the dihydropyrimidine dehydrogenase, methylenetetrahydrofolate reductase and thymidylate synthase genes predict early toxicity of 5-fluorouracil in colorectal cancer patients. J Int Med Res 2010;38:870-83.  Back to cited text no. 8
    
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Eisenhauera EA, Therasseb P, Bogaertsc J, Schwartz LH, Sargent D, Ford R, et al. New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J Cancer 2009;45:228-47.  Back to cited text no. 9
    
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Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 1995;31:1341-6.  Back to cited text no. 10
    
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Hatzaki A, Razi E, Anagnostopoulou K, Iliadis K, Kodaxis A, Papaioannou D, et al. A modified mutagenic PCR-RFLP method for K-ras codon 12 and 13 mutations detection in NSCLC patients. Mol Cell Probes 2001;15:243-7.  Back to cited text no. 11
    
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Largillier R, Etienne-Grimaldi MC, Formento JL, Ciccolini J, Nebbia JF, Ginot A, et al. Pharmacogenetics of capecitabine in advanced breast cancer patients. Clin Cancer Res 2006;12:5496-502.  Back to cited text no. 12
    
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Etienne-Grimaldi MC, Bennouna J, Formento JL, Douillard JY, Francoual M, Hennebelle I, et al. Multifactorial pharmacogenetic analysis in colorectal cancer patients receiving 5-fluorouracil-based therapy together with cetuximab-irinotecan. Br J Clin Pharmacol 2012;73:776-85.  Back to cited text no. 13
    
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Deenen MJ, Tol J, Burylo AM, Doodeman VD, de Boer A, Vincent A, et al. Relationship between single nucleotide polymorphisms and haplotypes in DPYD and toxicity and efficacy of capecitabine in advanced colorectal cancer. Clin Cancer Res 2011;17:3455-68.  Back to cited text no. 14
    
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Iyer L, Das S, Janisch L, Wen M, Ramírez J, Karrison T, et al. UGT1A1*28 polymorphism as a determinant of irinotecan disposition and toxicity. Pharmacogenomics J 2002;2:43-7.  Back to cited text no. 15
    
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Swen JJ, Nijenhuis M, de Boer A, Grandia L, Maitland-van der Zee AH, Mulder H, et al. Pharmacogenetics: From bench to byte--an update of guidelines. Clin Pharmacol Ther 2011;89:662-73.  Back to cited text no. 16
    
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Braun MS, Richman SD, Quirke P, Daly C, Adlard JW, Elliott F, et al. Predictive biomarkers of chemotherapy efficacy in colorectal cancer: Results from the UK MRC FOCUS trial. J Clin Oncol 2008;26:2690-8.  Back to cited text no. 17
    
18.
Liu X, Cheng D, Kuang Q, Liu G, Xu W. Association between UGT1A1 * 28 polymorphisms and clinical outcomes of irinotecan-based chemotherapies in colorectal cancer: A meta-analysis in Caucasians. PLoS One 2013;8:e58489.  Back to cited text no. 18
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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