Med Oncol (2014) 31:58 DOI 10.1007/s12032-014-0058-9
ORIGINAL PAPER
Prognostic and predictive role of ERCC1 protein expression in locally advanced stage III non-small cell lung cancer Lamiss Mohamed Sad • Samar Galal Younis Mohamed Mosad Elity
•
Received: 9 May 2014 / Accepted: 29 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Systemic therapy improves the survival and quality of life of patients with advanced stage non-small cell lung cancer (NSCLC). Several new therapeutic options have emerged for advanced NSCLC, incorporating novel cytotoxicity agents (taxanes, gemcitabine, pemetrexed) and molecular-targeted agents (erlotinib, bevacizumab) and the optimal prognostic marker for survival remains unclear. The aim of the present study was to assess the prognostic value of the clinicopathologic features and excision repair cross-complementation group-1 (ERCC1) in locally advanced NSCLC patients that received cisplatin-based chemotherapy. Clinical data concerning 80 patients with histopathologically confirmed non-small cell lung cancer who are planned to receive cisplatin-based adjuvant chemotherapy were collected. The protein expression levels for ERCC1 are immunohistochemical examined in 80 patients. The relationship between the ERCC1 protein expression level and the clinical outcomes of the patients is then observed. The 3-year survival rate and median survival time of stage III NSCLC received chemotherapy with/without concurrent chemoradiotherapy were 20 % and 10 months, respectively. Survival of patients with ERCC1-negative tumors was significantly longer than those with ERCC1-positive tumors (p = 0.0001). Prognostic factors with overall survival were performance status, cigarette smoking, stage, weight loss and ERCC1. While as regard progression-free survival prognostic factors were stage, weight loss, ERCC1 and degree of positivity of ERCC1 progression. It was found that ERCC1 protein expression might play an important role in the
L. M. Sad (&) S. G. Younis M. M. Elity Tanta University, Tanta, Egypt e-mail: [email protected]
prognosis of locally advanced NSCLC patients treated with cisplatin-based adjuvant chemotherapy. Keywords
ERCC1 Stage III NSCLC
Introduction Lung cancer is the commonest cause of cancer death globally, accounting for around 1.3 million deaths per year [1]. Despite advances in therapeutics, survival from both major subtypes [non-small cell lung cancer (NSCLC) and SCLC] remains poor, with only around 5 % of all patients reaching 5 years. Standard of care for both advanced NSCLC and SCLC is platinum-based doublet chemotherapy, with nonplatinum doublets inferior [2], [3]. In NSCLC, platinum doublets are associated with response rates of 25–30 % [4]. A number of tumor biomarkers have been investigated for prognostic and predictive utility when considering systemic therapy, and prominent among these is excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is the rate-limiting member of the nucleotide excision repair pathway (NER), one of at least five overlapping biochemical pathways by which altered DNA sequences can be restored to baseline. Abrogation of these pathways has been both associated with carcinogenesis [5] and targeted as a therapeutic mechanism [6]. The NER pathway functions to remove bulky DNA lesions [5], including tobacco-associated adducts formed by carcinogen exposure [7]. Mechanisms of platinum cytotoxicity include forming bulky DNA adducts leading to both inter-and intra-strand cross-link generation, which results in apoptosis unless repaired. The critical role of ERCC1 in carcinogen and platinum adduct removal by NER has led to a number of studies reporting the relationship between ERCC1 status and
123
58
Page 2 of 9
survival in lung cancer patients, predominantly in NSCLC. ERCC1 has been investigated both as a prognostic biomarker, and for a predictive influence in determining benefit from platinum-directed therapy, with estimates between studies differing considerably. The aim of our study was to investigate the prognostic and predictive utility of ERCC1 status in locally advanced non-small cell lung cancer.
Patients and methods The patients were treated between January 2008 and June 2013 at clinical oncology and nuclear medicine department, Tanta university hospitals. Patients received gemcitabine 1,250 mg/m2 on days 1 and 8 plus CDDP 100 mg/m2 on day 1 every 3 weeks or cisplatin at a dose of 75 mg/m2 on day 1 plus paclitaxel at a dose of 175 mg/m2 on day 1 every 3 weeks (TP) for 6 cycles followed by concurrent chemoradiotherapy (65 patients only). Eligibility criteria for IIIA, IIIB [8] NSCLC. Other eligibility criteria included: Eastern Cooperative Oncology Group performance status (PS) (ECOG PS) of 0–2; aged over 18 years; adequate hematologic function (hemoglobin [9 g/dl, neutrophil count [1,500/mm3 and platelet count [100,000/mm3); adequate renal function (creatine clearance rate [50 ml/s); adequate liver function (bilirubin \1.5 times the normal upper limit, aspartate aminotransferase and alanine aminotransferase \2 times the normal upper limit); and measurable disease. The concurrent chemoradiotherapy regimens consisted of weekly paclitaxel [50 mg/m2 per week intravenously (iv)] or/plus cisplatin (25 mg/m2 per week iv) or carboplatin (AUC 1.5/week iv) for 5 weeks The radiation dose was 6,840 cent grays (cGy) over 7 weeks (1.8 Gy/fraction per day, 5 fractions/week) using 6-MV X-ray. All patients had chest X-ray and a computed tomography scan of the chest and upper abdomen before entry into the study and underwent repeat evaluations at least every 6 weeks. The efficacy of chemotherapy was evaluated with a computed tomography scan after three cycles of chemotherapy and 1 month after the end of treatment and recorded in accordance with the RECIST version as follows: complete remission (CR); partial remission (PR); stable disease (SD); and progression (PD) [9, 10]. Immunohistochemical preparation of tissue samples Four-micrometer thick, formalin-fixed paraffin-embedded (FFPE) sections were cut and mounted on coated slide glass. From each tissue specimen, sections stained with hematoxylin–eosin were histologically evaluated for verification of diagnosis and eligibility for IHC analysis.
123
Med Oncol (2014) 31:58
For ERCC1 immunostainings, tissue sections were deparaffinized and incubated in Tris/ethylene glycol tetraacetic acid buffer (pH 9.0) for 20 min at 97_C for antigen retrieval using a DAKO (DAKO North America, Inc, Carpinteria, CA) Pt. link machine according to manufacturer’s instructions. The tissue sections were then processed with the Envision Flex ? kit (DAKO K 8002; DAKO, Glostrup, Denmark) blocking endogenous peroxidase activity for 5 min and then incubating for 20 min with the mouse monoclonal antibody ERCC1 Ab-2 (Clone 8F1; Thermo Fisher Scientific, Fremont, CA, USA) (diluted 1: 200) against full-length human. ERCC1. The reaction was visualized by incubation with Envision Linker (Mouse) for 15 min, followed by Envision Flex ? horseradish peroxidase for 20 min and finally diaminobenzidine for 10 min. The sections were counterstained with Mayer’s hematoxylin for 1 min. Immunohistochemical evaluation for ERCC1 status ERCC1 immunostaining of the eligible tissue samples under a light microscope at a magnification of 400. ERCC1 nuclear expression was classified into four categories: score 0, no staining at all \10 % of tumor cells; score 1?, faint/barely perceptible partial nuclear expression in[10 % of tumor cells; score 2?, weak to moderate staining of the entire nucleus in [10 % of tumor cells; and score 3?, strong staining of the entire nucleus in[10 % of tumor cells. A semiquantitative H score for each tissue sample was calculated multiplying the staining intensity of tumor cells (0: no expression, 1: weak expression, 2: moderate expression, 3: strong expression) [11]. Statistical analysis Statistical analyses were conducted using SPSS for Windows, version 12.0 (SPSS Inc., Chicago, IL, USA). PFS was calculated from the date of initiation of platinum-based chemotherapy until the date of disease progression. OS was defined as the period from the date of initiation of platinum-based chemotherapy until the date of death. The Kaplan–Meier method was used to calculate survival. Overall survival and progression-free survival were expressed in terms of months from the beginning of platinum treatments and were expressed as the median with a 95 % confidence interval. Univariate analyses of survival according to response and genotype were conducted using a two-sided log-rank test.
Results Eighty patients (51 male, 29 female, mean age 53.2 years) fulfilled the inclusion criteria of this randomized conducted
Med Oncol (2014) 31:58
Page 3 of 9 58
Table 1 Main characteristics of the studied patients with inoperable non-small cell lung cancer treated with platinum-based chemotherapy (n = 80)
Table 2 Treatment response of the studied patients with inoperable non-small cell lung cancer treated with platinum-based chemotherapy (n = 80)
Variables
Response to chemotherapy treatment
The studied patients with inoperable non-small cell lung cancer/(n = 80) n
The studied patients with inoperable non-small cell lung cancer (n = 80)
% Total (n = 80)
Age (years) \53 C53 Range Mean ± SD Sex Males Females History of smoking Current smoker Ex smoker Non-smoker Body weight loss No weight loss Weight loss Performance -P0 -P1 -P2 Stage of disease IIIa IIIb Pathological diagnosis Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Tumor size T2 T3 Number of lymph nodes N0 N1 N2 ERCC1 findings Negative Positive Weak positive Moderate positive Strong positive Type of chemotherapy Cisplatin/taxane Cisplatin/gemcitabine Radiotherapy treatment Yes No
36 44 31–69 53.22 ± 9.65
45.0 55.0
51 29
63.8 36.2
23 23 34
28.8 28.8 42.4
14 66
17.5 82.5
21 41 18
26.3 51.3 22.4
30 50
37.5 62.5
37 35 8
46.3 43.7 10.0
35 45
43.8 56.2
14 41 25
17.4 51.3 31.3
33 47 14 20 13
41.3 58.7 29.8 42.6 27.6
9 71
11.3 88.7
65 15
81.2 18.8
Bold values indicate statistical significance (p \ 0.05)
n Complete response (CR)
% 1
1.3
Partial response (PR) Stable disease (SD)
17 34
21.2 42.5
Disease progress (DP)
28
35.0
Overall response (OAR)
18
22.5
Non-responsive
62
77.5
at Clinical Oncology and Nuclear Medicine Department in Tanta University Hospital These were as follows: stage IIIA or IIIB NSCLC patients; treated with platinum doublet chemotherapy as a first-line treatment from January 2008 to June 2013; and had sufficient histological material to allow for ERCC1 testing by immunohistochemistry (IHC). The characteristics of the subjects are summarized in Table 1. The histological types of NSCLC according to the WHO classifications were as follows: adenocarcinoma was the most frequent histological type (n = 37), followed by squamous cell carcinoma (n = 35), and large cell carcinoma (n = 8). According to TNM classifications of anatomical stages, 30 cases were stage IIIA and 50 cases were stage IIIB. Clinical information about each case was obtained from the medical records; the parameters included gender, age, Eastern Cooperative Oncology Group (ECOG) PS, tumor histology, stage and smoking status. Responses to treatment were as follows: CR in one patients (1.3 %); PR in 17 patients (21.2 %); SD n 34 patients (42.5 %); and PD in 28 patients (15 %). Thus, there were 18 subjects (22.5 %) in the responder group (PR and CR) and 62 (77.5 %) subjects in the non-responder group (SD and PD) Table 2. Parameters including age, sex, histological type, stage and combination chemotherapeutic agents did not differ significantly between responders and non-responders (Table 3). In the ERCC1-negative group, one patient (3 %) maintained a complete response, 11 patients (33.3 %) maintained a partial response (PR), 19 (57.6 %) maintained stable disease (SD), and 2(6.1 %) maintained progressive disease (PD), whereas in ERCC1-positive group, six patients (12.8 %) maintained a PR, 15(31.9 %) maintained SD, and 26(55.3 %) maintained PD. Response in ERCC1 negative was higher than ERCCC1 positive which was statistically significant, whereas other characteristics (Table 4).
123
58
Page 4 of 9
Med Oncol (2014) 31:58 Overall survival of all patients
Table 3 overall response with different prognostic factors Patient characteristics
OAR
Non-responsive
1.0
p value .8
\53
12
24
[53
6
38
0.037*
Sex Male
7
44
11
18
0
8
13
1
6
35
2
4
14
Female
0.013*
Cum Survival
Age
Performance status
.6
Confidence interval(9.1010.90)
.4
.2 Survival Function
0.112
Censored
0.0 0
12
24
36
48
60
follow up time (months)
Smoking history Non-smoking
9
25
Ex smoker
5
18
Current smoker
4
19
No weight loss
1
3
Wight loss
7
59
Adenocarcinoma
9
28
Squamous cell carcinoma
9
26
Large cell carcinoma
0
8
T2
11
24
T3
7
38
N0
4
10
N1 N2
11 3
30 22
IIIa
10
20
IIIb
8
42
Negative
12
21
Positive
6
41
0.719
Fig. 1 Overall survival of all patients
Weight loss 0.001*
Progression free survival 1.0
Pathology
.8
T stage 0.092
Cum Survival
0.272 Confidence interval (8.0811.92)
.6
.4
.2
N stage
Survival Function
0.314
Censored
0.0 0
6
12 18
24 30 36 42 48 54
60
follow up time (months)
Stage 0.072
Fig. 2 Progression-free survival
0.013*
0.409
median overall survival was 11 month. P value 0.0001. Median progression-free survival was 20 % Fig. 2. It was 40 months in ERCC1-negative tumors and 2 months in ERCCC1-negative tumors, p value, 0.001. Prognostic factors with overall survival were PS, cigarette smoking, stage, weight loss and ERCC1 Fig. 3. While as regard progression-free survival were stage, weight loss, ERCC1 and degree of positivity of ERCC1 Table 5 and Fig. 4.
0.797
Discussion
ERCC1
ERCC1 Weak positive
5
9
Moderate positivity
1
19
Highly positive
0
13
0.008*
Type of chemotherapy received Cisplatin-taxane
3
6
Cisplatin-gemcitabine
15
56
Radiotherapy No radiotherapy
15
50
3
12
Radiotherapy * p \ 0.05
Three year OAS is 20 % Fig. 1, and median overall survival is 10 month. Median overall survival in negative ERCC1 was 14 months, and in ERCC1-positive tumors,
123
Lung cancer is the commonest cause of cancer death globally, accounting for around 1.3 million deaths per year [1, 12]. Despite advances in therapeutics, survival from both major subtypes (NSCLC and SCLC) remain poor, with only around 5 % of all patients reaching 5 years.
Med Oncol (2014) 31:58
Page 5 of 9 58
Fig. 3 Prognostic factors with overall survival
Overall survival in relation to ERCC1 Overall survival in relation to cigeratte
1.0
smoking
0.049
1.0 .8
0.0001
cigeratte smoking current smokng
.6
Cum Survival
Cum Survival
.8
ERCC1
.4 +ve
current smokng
.6
-censored exsmoker
.4
exsmoker-censored
+ve-censored
.2
.2
-ve -ve-censored
0.0 0
12
24
36
48
no smoking no smoking-censored
0.0
60
0
follow up time (months)
12
24
36
48
60
follow up time (months)
Overall survival in relation to weight loss 1.0
Overall survival in relation to PS 1.0
0.004
0.003
.8
performance status
Cum Survival
Cum Survival
.8
.6 weight loss weight loss
.4
.6
2 2-censored
.4 1
weight loss-censored
1-censored
no weight loss
.2
.2 0
no weight loss -censored
0.0 0
12
24
36
48
0-censored
0.0
60
0
follow up time (months)
12
24
36
48
60
follow up time (months)
Overall survival in relation to stage 1.0
0.007
Cum Survival
.8
.6
stage
.4 IIIB IIIB-censored
.2 IIIA IIIA-censored
0.0 0
10
20
30
40
50
60
follow up time (months)
Standard of care for both advanced NSCLC and SCLC is platinum-based doublet chemotherapy, with non-platinum doublets inferior [2, 13]. In NSCLC, platinum doublets are associated with response rates of 25–30 % [4]. But the
resistance to these drugs causes unsatisfactory of overall survival rate. Therefore, it is very important to understand the molecular markers of resistance to chemotherapeutic drugs.
123
58
Page 6 of 9
Med Oncol (2014) 31:58
Table 4 Relation between expression of ERCC1 and patient characteristics Patient characteristics
No. of patients
No. of patients according to ERCC1 Negative
p value
Positive
n
%
n
%
n
%
\53
36
45
14
42.4
22
46.8
[ or equal 53 Sex
44
55
19
57.6
25
53.2
Male
33
41.3
20
60.6
31
66
Female
47
58.7
13
39.4
16
34
0
21
26.25
10
30.3
11
23.4
1
41
51.25
19
57.6
22
46.8
2
18
22.5
4
12.1
14
29.8
Age 0.437
0.399
Performance status 0.176
Smoking No smoking
34
42.5
18
54.5
16
34
Current smoking
23
28.75
6
18.2
17
36.2
Ex smoker
23
28.75
9
27.3
14
29.8
0.126
Weight loss No weight loss
15
18.7
9
27.3
6
12.8
Weight loss [10 %
65
81.3
24
72.7
41
87.2
Pathology Adenocarcinoma
36
45
19
57.6
17
36.2
Squamous cell carcinoma
36
45
11
33.3
25
53.2
8
10
3
9.1
5
10.6
Large cell carcinoma
0.09
0.156
T stage T2
35
43.7
16
48.5
19
40.4
T3
45
56.3
17
51.5
28
59.6
N0
14
17.5
6
18.2
8
N1
41
51.25
17
51.5
24
51.1
N2
25
31.25
10
30.3
15
93.9
IIIa
30
37.5
13
39.4
17
36.2
IIIb
50
62.5
20
60.6
30
63.8
0.313
N stage 17
0.984
Stage 0.475
Type of chemotherapy Cisplatin-gemcitabine
71
88.7
30
90.9
41
87.2
Cisplatin-taxane Type of radiotherapy
9
11.3
3
8.1
6
12.8
No
65
81.3
30
90.9
35
74.5
Yes
15
18.7
3
8.1
12
25.5
CR
1
1.25
1
3
PR
17
21.25
11
SD
34
42.5
19
DP
28
35
2
6.1
0.446
0.056
Response
* p \ 0.05
123
0
0
33.3
6
12.8
57.6
15
31.9
26
55.3
0.001*
Med Oncol (2014) 31:58
Page 7 of 9 58
Table 5 Multivariate analysis of progression-free survival Factor
Comparison
p value
Performance status
0–1;2
0.05*
Weight loss
No-yes
0.05*
ERCC1
Negative; positive
0.001*
Degree of positivity
Mild, moderate, strong
0.027*
* p \ 0.05
A number of tumor biomarkers have been investigated for prognostic and predictive utility when considering systemic therapy, and prominent among these is excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is the limiting factor in nucleotide excision repair, which removes platinum–DNA adducts. ERCC1 may also be involved in the repair of DNA double-strand breaks, especially those induced by interstrand cross-links. It is possible that the presence of ERCC1 reflects an inherent biologic characteristic of the tumor. The ERCC1 expression level has recently been reported to be a prognostic factor in the survival of patients with early stage NSCLC [14, 15]. Recent studies have investigated a number of tumor biomarkers for prognostic and predictive utility when considering systemic therapy and the most prominent among these is the excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is one of the key enzymes of the nucleotide excision repair pathway, which is essential for the removal of platinum–DNA adducts. Recent studies have demonstrated that the expression levels of ERCC1 are related to a survival benefit from cisplatin-based chemotherapy among patients with advanced NSCLC [16–18]. Our study evaluated the effect of intratumoral ERCC1 expression on the survival of patients locally advanced stage III NSCLC. The survival for patients with ERCC1-negative
tumors was significantly longer than those for patients with ERCC1-positive tumors. This suggested that chemotherapy with cisplatin-based agents may be beneficial for ERCC1negative patients. Olaussen et al. [19] also reported that ERCC1 protein expression status was associated with favorable prognosis in patients treated with cisplatin-base adjuvant chemotherapy, similar to data reported in another study [20]. Furthermore, in the multivariate analysis, ERCC1 was identified as an independent predictor of survival. Further validation of these findings may help us to choose molecularbased personalized multimodality therapy. Responses to treatment were as follows: CR (1.3 %); PR (21.2 %); SD (42.5 %); and PD (15 %). Thus, there were 18 subjects (22.5 %) in the responder group (PR and CR) and 62 (77.5 %) subjects in the non-responder group (SD and PD). The 3-year overall survival and progression-free survival was 20 and 20 %, respectively. This was nearly constant with Vokes et al. [21] who reported overall response 40, 31, 35 %, three overall survival was 23, 19, 28 % in navelabine, paclitaxel, gemcitabine-based chemotherapy, respectively. This was constant with Belani et al. [22] in which a total of 369 patients were enrolled, 179 on arm A (cisplatin 75 mg/m2 and etoposide 100 mg/m2) and 190 on arm B (carboplatin AUC = 6 mg/ml min and paclitaxel 225 mg/m2), with cycles repeated every 3 weeks. The objective response rate (ORR) was 15 % on arm A compared with 23 % on arm B (p = 0.061). The overall response was lower than that reported by Huber et al. [23], in which chemotherapy with two cycles of carboplatin and paclitaxel, combined chemoradiotherapy with weekly paclitaxel was superior to radiotherapy alone. The OAR was 45.4 %. But the 3-year survival was the same 20 %. As regard overall response, our results showed high statistically significant between age, it was better in
Progression free survival in relation to
Progression free survival in relation to
degree of positivity of erccc1 ercc1 1.0
1.0
ERCC1
strong positive strong positive -censored
0.027* .6
moderate positive moderate positive
.4
-censored
.8
Cum Survival
Cum Survival
.8
.6
0.001* ERCC1 +ve
.4
+ve-censored
weak positive
.2
.2
-ve
weak positive -censored
0.0 60
12
18
24
30
36
follow up time (months)
-ve-censored
0.0 60 12 18 24 30 36 42 48 54 60
follow up time (months)
Fig. 4 ERCC1 with progression-free survival
123
58
Page 8 of 9
patients aged \53 than [53, (33.3 and 13.6 %, respectively, p value = 0.036) (Asmis et al. [24]), sex, OAR in females was better than males (37.9 and 13.7 %, respectively, p value = 0.013) this was constant with Cappuzzo et al. [25]. Body weight loss was better in patients without body weight loss than in patients with body weight loss (80 vs. 9.2 %, p value = 0.0001) this was constant with Asmis et al. [24]. Prognostic factors with overall survival were PS, cigarette smoking, stage, weight loss and ERCC1. While as regard progression-free survival, prognostic factors were stage, weight loss, ERCC1 and degree of positivity of ERCC1 progression and this in agreement with Rozensztain et al. [26]. Our results showed high ERCC1 levels were associated with shorter 3 year survival and lower response to chemotherapy in advanced NSCLC patients (0 vs. 61.6 %, p value 0.0001; RR 12.8 vs. 36.3 %, p value 0.001). Median overall survival (OS) in the ERCC1-negative population and ERCC1-positive population was 14 and 11 months, and this was statistically significant (p = 0001). This was lower than that reported by Leng et al. [20] in which 74 patients treated with the regimen of cisplatin/carboplatin, patients after surgery negative for ERCC1 expression had a significantly longer median progression-free survival (more than 42.6 vs. 13.0 months, p = 0.001) and overall (more than 42.6 vs. 19.7 months, p = 0.001) survival, compared with those positive for ERCC1 expression. This was also constant with Jiang et al. [14] who reported the same results in patients with locally advanced NSCLC who received palliative chemotherapy (HR 1.75; 95 % CI 1.39–2.22; p = 0.000; RR 0.77; 95 % CI 0.64–0.93; p = 0.007; respectively). This was also constant with that reported with that reported by Li et al. [17]; Simon et al. [18] in which patients who received neoadjuvant chemotherapy in locally advanced NSCLC with ERCC1 low expression had a significantly longer overall survival (p = 0.007), than those with ERCC1 high expression. This was different from that reported by Wang et al. [17]; Friboulet et al. [27] between ERCC1 polymorphism and locally advanced NSCLC and response. The limitations of this study were as follows: (1) it was retrospective and many factors could have influenced survival; and (2) the sample size was limited, so the prognostic significant of skip metastasis with regard to OS was not confirmed.
Conclusions In conclusion, the survival of patients with stage III NSCLC depends on numerous factors and accurately determining
123
Med Oncol (2014) 31:58
the prognosis of disease in these patients is unclear. Therefore, valuable biomarker fitting to determine the subgroup of patients who have a relatively poor prognosis is needed. Our study revealed that DNA repair genes may play an important role in the prognosis of locally advanced NSCLC patients. Therefore, ERCC1 protein expression might be a useful biological indicator in patients with locally advanced NSCLC when planning clinical studies by testing the hypothesis of customized chemotherapy. Conflict of interest
None.
References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49. 2. Smit EF, van Meerbeeck JP, Lianes P, et al. Three-arm randomized study of two cisplatin-based regimens and paclitaxel plus gemcitabine in advanced non-small-cell lung cancer: a phase III trial of the European organization for research and treatment of cancer lung cancer group–EORTC 08975. J Clin Oncol. 2003;21:3909–17. 3. Yau T, Ashley S, Popat S, et al. Time and chemotherapy treatment trends in the treatment of elderly patients (age [/=70 years) with small cell lung cancer. Br J Cancer. 2006;94:18–21. 4. Ardizzoni A, Boni L, Tiseo M, et al. Cisplatin- versus carboplatin-based chemotherapy in first-line treatment of advanced non-small-cell lung cancer: an individual patient data meta-analysis. J Natl Cancer Inst. 2007;99:847–57. 5. Friedberg EC. DNA damage and repair. Nature. 2003;421: 436–40. 6. Helleday T, Petermann E, Lundin C, Hodgson B, Sharma RA. DNA repair pathways as targets for cancer therapy. Nat Rev Cancer. 2008;8:193–204. 7. Phillips DH. Smoking-related DNA and protein adducts in human tissues. Carcinogenesis. 2002;23:1979–2004. 8. Lababede O, Meziane M, Rice T. Seventh edition of the cancer staging manual and stage grouping of lung cancer: quick reference chart and diagrams. Chest. 2011;139(1):183–9. 9. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228–47. 10. Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. European organization for research and treatment of cancer, national cancer institute of the United States, national cancer institute of Canada. J Natl Cancer Inst. 2000;92:205–16. 11. Seyhan EC, Altın S, Cetinkaya E, et al. Prognostic significance of ERCC1 expression in resected non-small cell lung carcinoma. Ann Thorac Cardiovasc Surg. 2011;17:110–7. 12. American cancer society: Cancer facts and figures 2014. Atlanta, Ga: American Cancer Society, 2014. 13. Yau T, Ashley S, Popat S, et al. Time and chemotherapy treatment trends in the treatment of elderly patients (age [/= 70 years) with small cell lung cancer. Br J Cancer. 2009;94: 18–21. 14. Jiang J, Liang X, Zhou X, et al. ERCC1 expression as a prognostic and predictive factor in patients with non-small cell lung cancer: a meta-analysis. Mol Biol Rep. 2012;39(6):6933–42. 15. Li J, Li ZN, Yu LC, et al. Association of expression of MRP1, BCRP, LRP and ERCC1 with outcome of patients with locally
Med Oncol (2014) 31:58
16.
17.
18.
19.
20.
21.
advanced non-small cell lung cancer who received neoadjuvant chemotherapy. Lung Cancer. 2010;69(1):116–22. Fujii T, Toyooka S, Ichimura K, et al. ERCC1 protein expression predicts the response of cisplatin-based neoadjuvant chemotherapy in non-small-cell lung cancer. Lung Cancer. 2008;59:377–84. Wang J, Zhang Q, Zhang H, et al. Association between polymorphisms of ERCC1 and response in patients with advanced non-small cell lung cancer receiving cisplatin-based chemotherapy. Zhongguo Fei Ai Za Zhi. 2010;13(4):337–41. Simon GR, Schell MJ, Begum M. Early indication of survival benefit from ERCC1 and RRM1 tailored chemotherapy in patients with advanced Non-Small Cell Lung Cancer (NSCLC). Evidence from an individual patient analysis. Cancer. 2012; 118(9):2525–31. Olaussen KA, Dunant A, Fouret P, IALT Bio Investigators, et al. DNA repair by ERCC1 in non-small-cell lung cancer and cisplatin-based adjuvant chemotherapy. N Engl J Med. 2006;355: 983–91. Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res. 2012;31(1):25. Vokes EE, Herndon JE 2nd, Crawford J, et al. Randomized phase II study of cisplatin with gemcitabine or paclitaxel or vinorelbine as induction chemotherapy followed by concomitant chemoradiotherapy
Page 9 of 9 58
22.
23.
24.
25.
26.
27.
for stage IIIB non-small-cell lung cancer: cancer and leukemia group B study 9431. J Clin Oncol. 2002;20:4191–8. Belani CP, Lee JS, Socinski MA, et al. Randomized phase III trial comparing cisplatin-etoposide to carboplatin-paclitaxel in advanced or metastatic non-small cell lung cancer. Ann Oncol. 2005;16:1069–75. Huber RM, Flentje M, Bronchial Carcinoma Therapy Group, et al. Simultaneous chemoradiotherapy compared with radiotherapy alone after induction chemotherapy in inoperable stage IIIA or IIIB non-small-cell lung cancer: study CTRT99/97 by the bronchial carcinoma therapy group. J Clin Oncol. 2006;24(27):4397–404. Asmis TR, Ding K, Seymour L, et al. Age and comorbidity as independent prognostic factors in the treatment of non small-cell lung cancer: a review of National Cancer institute of Canada clinical trials group trials. J Clin Oncol. 2008;26(1):54–9. Cappuzzo F, Hirsch FR, Rossi E, et al. Epidermal growth factor receptor gene and protein and gefitinib sensitivity in non-smallcell lung cancer. J Natl Cancer Inst. 2005;97(9):643–55. Rozensztajn N, Ruppert AM, Lavole A, et al. Factors associated with early progression of non-small-cell lung cancer treated by epidermal growth factor receptor tyrosine-kinase inhibitors. Cancer Med. 2014;3(1):61–9. Friboulet L, Friboulet KA, Pignon JP, et al. ERCC1 isoform expression and DNA repair in non–small-cell lung cancer. N Engl J Med. 2013;368:1101–10.
123
ORIGINAL PAPER
Prognostic and predictive role of ERCC1 protein expression in locally advanced stage III non-small cell lung cancer Lamiss Mohamed Sad • Samar Galal Younis Mohamed Mosad Elity
•
Received: 9 May 2014 / Accepted: 29 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Systemic therapy improves the survival and quality of life of patients with advanced stage non-small cell lung cancer (NSCLC). Several new therapeutic options have emerged for advanced NSCLC, incorporating novel cytotoxicity agents (taxanes, gemcitabine, pemetrexed) and molecular-targeted agents (erlotinib, bevacizumab) and the optimal prognostic marker for survival remains unclear. The aim of the present study was to assess the prognostic value of the clinicopathologic features and excision repair cross-complementation group-1 (ERCC1) in locally advanced NSCLC patients that received cisplatin-based chemotherapy. Clinical data concerning 80 patients with histopathologically confirmed non-small cell lung cancer who are planned to receive cisplatin-based adjuvant chemotherapy were collected. The protein expression levels for ERCC1 are immunohistochemical examined in 80 patients. The relationship between the ERCC1 protein expression level and the clinical outcomes of the patients is then observed. The 3-year survival rate and median survival time of stage III NSCLC received chemotherapy with/without concurrent chemoradiotherapy were 20 % and 10 months, respectively. Survival of patients with ERCC1-negative tumors was significantly longer than those with ERCC1-positive tumors (p = 0.0001). Prognostic factors with overall survival were performance status, cigarette smoking, stage, weight loss and ERCC1. While as regard progression-free survival prognostic factors were stage, weight loss, ERCC1 and degree of positivity of ERCC1 progression. It was found that ERCC1 protein expression might play an important role in the
L. M. Sad (&) S. G. Younis M. M. Elity Tanta University, Tanta, Egypt e-mail: [email protected]
prognosis of locally advanced NSCLC patients treated with cisplatin-based adjuvant chemotherapy. Keywords
ERCC1 Stage III NSCLC
Introduction Lung cancer is the commonest cause of cancer death globally, accounting for around 1.3 million deaths per year [1]. Despite advances in therapeutics, survival from both major subtypes [non-small cell lung cancer (NSCLC) and SCLC] remains poor, with only around 5 % of all patients reaching 5 years. Standard of care for both advanced NSCLC and SCLC is platinum-based doublet chemotherapy, with nonplatinum doublets inferior [2], [3]. In NSCLC, platinum doublets are associated with response rates of 25–30 % [4]. A number of tumor biomarkers have been investigated for prognostic and predictive utility when considering systemic therapy, and prominent among these is excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is the rate-limiting member of the nucleotide excision repair pathway (NER), one of at least five overlapping biochemical pathways by which altered DNA sequences can be restored to baseline. Abrogation of these pathways has been both associated with carcinogenesis [5] and targeted as a therapeutic mechanism [6]. The NER pathway functions to remove bulky DNA lesions [5], including tobacco-associated adducts formed by carcinogen exposure [7]. Mechanisms of platinum cytotoxicity include forming bulky DNA adducts leading to both inter-and intra-strand cross-link generation, which results in apoptosis unless repaired. The critical role of ERCC1 in carcinogen and platinum adduct removal by NER has led to a number of studies reporting the relationship between ERCC1 status and
123
58
Page 2 of 9
survival in lung cancer patients, predominantly in NSCLC. ERCC1 has been investigated both as a prognostic biomarker, and for a predictive influence in determining benefit from platinum-directed therapy, with estimates between studies differing considerably. The aim of our study was to investigate the prognostic and predictive utility of ERCC1 status in locally advanced non-small cell lung cancer.
Patients and methods The patients were treated between January 2008 and June 2013 at clinical oncology and nuclear medicine department, Tanta university hospitals. Patients received gemcitabine 1,250 mg/m2 on days 1 and 8 plus CDDP 100 mg/m2 on day 1 every 3 weeks or cisplatin at a dose of 75 mg/m2 on day 1 plus paclitaxel at a dose of 175 mg/m2 on day 1 every 3 weeks (TP) for 6 cycles followed by concurrent chemoradiotherapy (65 patients only). Eligibility criteria for IIIA, IIIB [8] NSCLC. Other eligibility criteria included: Eastern Cooperative Oncology Group performance status (PS) (ECOG PS) of 0–2; aged over 18 years; adequate hematologic function (hemoglobin [9 g/dl, neutrophil count [1,500/mm3 and platelet count [100,000/mm3); adequate renal function (creatine clearance rate [50 ml/s); adequate liver function (bilirubin \1.5 times the normal upper limit, aspartate aminotransferase and alanine aminotransferase \2 times the normal upper limit); and measurable disease. The concurrent chemoradiotherapy regimens consisted of weekly paclitaxel [50 mg/m2 per week intravenously (iv)] or/plus cisplatin (25 mg/m2 per week iv) or carboplatin (AUC 1.5/week iv) for 5 weeks The radiation dose was 6,840 cent grays (cGy) over 7 weeks (1.8 Gy/fraction per day, 5 fractions/week) using 6-MV X-ray. All patients had chest X-ray and a computed tomography scan of the chest and upper abdomen before entry into the study and underwent repeat evaluations at least every 6 weeks. The efficacy of chemotherapy was evaluated with a computed tomography scan after three cycles of chemotherapy and 1 month after the end of treatment and recorded in accordance with the RECIST version as follows: complete remission (CR); partial remission (PR); stable disease (SD); and progression (PD) [9, 10]. Immunohistochemical preparation of tissue samples Four-micrometer thick, formalin-fixed paraffin-embedded (FFPE) sections were cut and mounted on coated slide glass. From each tissue specimen, sections stained with hematoxylin–eosin were histologically evaluated for verification of diagnosis and eligibility for IHC analysis.
123
Med Oncol (2014) 31:58
For ERCC1 immunostainings, tissue sections were deparaffinized and incubated in Tris/ethylene glycol tetraacetic acid buffer (pH 9.0) for 20 min at 97_C for antigen retrieval using a DAKO (DAKO North America, Inc, Carpinteria, CA) Pt. link machine according to manufacturer’s instructions. The tissue sections were then processed with the Envision Flex ? kit (DAKO K 8002; DAKO, Glostrup, Denmark) blocking endogenous peroxidase activity for 5 min and then incubating for 20 min with the mouse monoclonal antibody ERCC1 Ab-2 (Clone 8F1; Thermo Fisher Scientific, Fremont, CA, USA) (diluted 1: 200) against full-length human. ERCC1. The reaction was visualized by incubation with Envision Linker (Mouse) for 15 min, followed by Envision Flex ? horseradish peroxidase for 20 min and finally diaminobenzidine for 10 min. The sections were counterstained with Mayer’s hematoxylin for 1 min. Immunohistochemical evaluation for ERCC1 status ERCC1 immunostaining of the eligible tissue samples under a light microscope at a magnification of 400. ERCC1 nuclear expression was classified into four categories: score 0, no staining at all \10 % of tumor cells; score 1?, faint/barely perceptible partial nuclear expression in[10 % of tumor cells; score 2?, weak to moderate staining of the entire nucleus in [10 % of tumor cells; and score 3?, strong staining of the entire nucleus in[10 % of tumor cells. A semiquantitative H score for each tissue sample was calculated multiplying the staining intensity of tumor cells (0: no expression, 1: weak expression, 2: moderate expression, 3: strong expression) [11]. Statistical analysis Statistical analyses were conducted using SPSS for Windows, version 12.0 (SPSS Inc., Chicago, IL, USA). PFS was calculated from the date of initiation of platinum-based chemotherapy until the date of disease progression. OS was defined as the period from the date of initiation of platinum-based chemotherapy until the date of death. The Kaplan–Meier method was used to calculate survival. Overall survival and progression-free survival were expressed in terms of months from the beginning of platinum treatments and were expressed as the median with a 95 % confidence interval. Univariate analyses of survival according to response and genotype were conducted using a two-sided log-rank test.
Results Eighty patients (51 male, 29 female, mean age 53.2 years) fulfilled the inclusion criteria of this randomized conducted
Med Oncol (2014) 31:58
Page 3 of 9 58
Table 1 Main characteristics of the studied patients with inoperable non-small cell lung cancer treated with platinum-based chemotherapy (n = 80)
Table 2 Treatment response of the studied patients with inoperable non-small cell lung cancer treated with platinum-based chemotherapy (n = 80)
Variables
Response to chemotherapy treatment
The studied patients with inoperable non-small cell lung cancer/(n = 80) n
The studied patients with inoperable non-small cell lung cancer (n = 80)
% Total (n = 80)
Age (years) \53 C53 Range Mean ± SD Sex Males Females History of smoking Current smoker Ex smoker Non-smoker Body weight loss No weight loss Weight loss Performance -P0 -P1 -P2 Stage of disease IIIa IIIb Pathological diagnosis Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Tumor size T2 T3 Number of lymph nodes N0 N1 N2 ERCC1 findings Negative Positive Weak positive Moderate positive Strong positive Type of chemotherapy Cisplatin/taxane Cisplatin/gemcitabine Radiotherapy treatment Yes No
36 44 31–69 53.22 ± 9.65
45.0 55.0
51 29
63.8 36.2
23 23 34
28.8 28.8 42.4
14 66
17.5 82.5
21 41 18
26.3 51.3 22.4
30 50
37.5 62.5
37 35 8
46.3 43.7 10.0
35 45
43.8 56.2
14 41 25
17.4 51.3 31.3
33 47 14 20 13
41.3 58.7 29.8 42.6 27.6
9 71
11.3 88.7
65 15
81.2 18.8
Bold values indicate statistical significance (p \ 0.05)
n Complete response (CR)
% 1
1.3
Partial response (PR) Stable disease (SD)
17 34
21.2 42.5
Disease progress (DP)
28
35.0
Overall response (OAR)
18
22.5
Non-responsive
62
77.5
at Clinical Oncology and Nuclear Medicine Department in Tanta University Hospital These were as follows: stage IIIA or IIIB NSCLC patients; treated with platinum doublet chemotherapy as a first-line treatment from January 2008 to June 2013; and had sufficient histological material to allow for ERCC1 testing by immunohistochemistry (IHC). The characteristics of the subjects are summarized in Table 1. The histological types of NSCLC according to the WHO classifications were as follows: adenocarcinoma was the most frequent histological type (n = 37), followed by squamous cell carcinoma (n = 35), and large cell carcinoma (n = 8). According to TNM classifications of anatomical stages, 30 cases were stage IIIA and 50 cases were stage IIIB. Clinical information about each case was obtained from the medical records; the parameters included gender, age, Eastern Cooperative Oncology Group (ECOG) PS, tumor histology, stage and smoking status. Responses to treatment were as follows: CR in one patients (1.3 %); PR in 17 patients (21.2 %); SD n 34 patients (42.5 %); and PD in 28 patients (15 %). Thus, there were 18 subjects (22.5 %) in the responder group (PR and CR) and 62 (77.5 %) subjects in the non-responder group (SD and PD) Table 2. Parameters including age, sex, histological type, stage and combination chemotherapeutic agents did not differ significantly between responders and non-responders (Table 3). In the ERCC1-negative group, one patient (3 %) maintained a complete response, 11 patients (33.3 %) maintained a partial response (PR), 19 (57.6 %) maintained stable disease (SD), and 2(6.1 %) maintained progressive disease (PD), whereas in ERCC1-positive group, six patients (12.8 %) maintained a PR, 15(31.9 %) maintained SD, and 26(55.3 %) maintained PD. Response in ERCC1 negative was higher than ERCCC1 positive which was statistically significant, whereas other characteristics (Table 4).
123
58
Page 4 of 9
Med Oncol (2014) 31:58 Overall survival of all patients
Table 3 overall response with different prognostic factors Patient characteristics
OAR
Non-responsive
1.0
p value .8
\53
12
24
[53
6
38
0.037*
Sex Male
7
44
11
18
0
8
13
1
6
35
2
4
14
Female
0.013*
Cum Survival
Age
Performance status
.6
Confidence interval(9.1010.90)
.4
.2 Survival Function
0.112
Censored
0.0 0
12
24
36
48
60
follow up time (months)
Smoking history Non-smoking
9
25
Ex smoker
5
18
Current smoker
4
19
No weight loss
1
3
Wight loss
7
59
Adenocarcinoma
9
28
Squamous cell carcinoma
9
26
Large cell carcinoma
0
8
T2
11
24
T3
7
38
N0
4
10
N1 N2
11 3
30 22
IIIa
10
20
IIIb
8
42
Negative
12
21
Positive
6
41
0.719
Fig. 1 Overall survival of all patients
Weight loss 0.001*
Progression free survival 1.0
Pathology
.8
T stage 0.092
Cum Survival
0.272 Confidence interval (8.0811.92)
.6
.4
.2
N stage
Survival Function
0.314
Censored
0.0 0
6
12 18
24 30 36 42 48 54
60
follow up time (months)
Stage 0.072
Fig. 2 Progression-free survival
0.013*
0.409
median overall survival was 11 month. P value 0.0001. Median progression-free survival was 20 % Fig. 2. It was 40 months in ERCC1-negative tumors and 2 months in ERCCC1-negative tumors, p value, 0.001. Prognostic factors with overall survival were PS, cigarette smoking, stage, weight loss and ERCC1 Fig. 3. While as regard progression-free survival were stage, weight loss, ERCC1 and degree of positivity of ERCC1 Table 5 and Fig. 4.
0.797
Discussion
ERCC1
ERCC1 Weak positive
5
9
Moderate positivity
1
19
Highly positive
0
13
0.008*
Type of chemotherapy received Cisplatin-taxane
3
6
Cisplatin-gemcitabine
15
56
Radiotherapy No radiotherapy
15
50
3
12
Radiotherapy * p \ 0.05
Three year OAS is 20 % Fig. 1, and median overall survival is 10 month. Median overall survival in negative ERCC1 was 14 months, and in ERCC1-positive tumors,
123
Lung cancer is the commonest cause of cancer death globally, accounting for around 1.3 million deaths per year [1, 12]. Despite advances in therapeutics, survival from both major subtypes (NSCLC and SCLC) remain poor, with only around 5 % of all patients reaching 5 years.
Med Oncol (2014) 31:58
Page 5 of 9 58
Fig. 3 Prognostic factors with overall survival
Overall survival in relation to ERCC1 Overall survival in relation to cigeratte
1.0
smoking
0.049
1.0 .8
0.0001
cigeratte smoking current smokng
.6
Cum Survival
Cum Survival
.8
ERCC1
.4 +ve
current smokng
.6
-censored exsmoker
.4
exsmoker-censored
+ve-censored
.2
.2
-ve -ve-censored
0.0 0
12
24
36
48
no smoking no smoking-censored
0.0
60
0
follow up time (months)
12
24
36
48
60
follow up time (months)
Overall survival in relation to weight loss 1.0
Overall survival in relation to PS 1.0
0.004
0.003
.8
performance status
Cum Survival
Cum Survival
.8
.6 weight loss weight loss
.4
.6
2 2-censored
.4 1
weight loss-censored
1-censored
no weight loss
.2
.2 0
no weight loss -censored
0.0 0
12
24
36
48
0-censored
0.0
60
0
follow up time (months)
12
24
36
48
60
follow up time (months)
Overall survival in relation to stage 1.0
0.007
Cum Survival
.8
.6
stage
.4 IIIB IIIB-censored
.2 IIIA IIIA-censored
0.0 0
10
20
30
40
50
60
follow up time (months)
Standard of care for both advanced NSCLC and SCLC is platinum-based doublet chemotherapy, with non-platinum doublets inferior [2, 13]. In NSCLC, platinum doublets are associated with response rates of 25–30 % [4]. But the
resistance to these drugs causes unsatisfactory of overall survival rate. Therefore, it is very important to understand the molecular markers of resistance to chemotherapeutic drugs.
123
58
Page 6 of 9
Med Oncol (2014) 31:58
Table 4 Relation between expression of ERCC1 and patient characteristics Patient characteristics
No. of patients
No. of patients according to ERCC1 Negative
p value
Positive
n
%
n
%
n
%
\53
36
45
14
42.4
22
46.8
[ or equal 53 Sex
44
55
19
57.6
25
53.2
Male
33
41.3
20
60.6
31
66
Female
47
58.7
13
39.4
16
34
0
21
26.25
10
30.3
11
23.4
1
41
51.25
19
57.6
22
46.8
2
18
22.5
4
12.1
14
29.8
Age 0.437
0.399
Performance status 0.176
Smoking No smoking
34
42.5
18
54.5
16
34
Current smoking
23
28.75
6
18.2
17
36.2
Ex smoker
23
28.75
9
27.3
14
29.8
0.126
Weight loss No weight loss
15
18.7
9
27.3
6
12.8
Weight loss [10 %
65
81.3
24
72.7
41
87.2
Pathology Adenocarcinoma
36
45
19
57.6
17
36.2
Squamous cell carcinoma
36
45
11
33.3
25
53.2
8
10
3
9.1
5
10.6
Large cell carcinoma
0.09
0.156
T stage T2
35
43.7
16
48.5
19
40.4
T3
45
56.3
17
51.5
28
59.6
N0
14
17.5
6
18.2
8
N1
41
51.25
17
51.5
24
51.1
N2
25
31.25
10
30.3
15
93.9
IIIa
30
37.5
13
39.4
17
36.2
IIIb
50
62.5
20
60.6
30
63.8
0.313
N stage 17
0.984
Stage 0.475
Type of chemotherapy Cisplatin-gemcitabine
71
88.7
30
90.9
41
87.2
Cisplatin-taxane Type of radiotherapy
9
11.3
3
8.1
6
12.8
No
65
81.3
30
90.9
35
74.5
Yes
15
18.7
3
8.1
12
25.5
CR
1
1.25
1
3
PR
17
21.25
11
SD
34
42.5
19
DP
28
35
2
6.1
0.446
0.056
Response
* p \ 0.05
123
0
0
33.3
6
12.8
57.6
15
31.9
26
55.3
0.001*
Med Oncol (2014) 31:58
Page 7 of 9 58
Table 5 Multivariate analysis of progression-free survival Factor
Comparison
p value
Performance status
0–1;2
0.05*
Weight loss
No-yes
0.05*
ERCC1
Negative; positive
0.001*
Degree of positivity
Mild, moderate, strong
0.027*
* p \ 0.05
A number of tumor biomarkers have been investigated for prognostic and predictive utility when considering systemic therapy, and prominent among these is excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is the limiting factor in nucleotide excision repair, which removes platinum–DNA adducts. ERCC1 may also be involved in the repair of DNA double-strand breaks, especially those induced by interstrand cross-links. It is possible that the presence of ERCC1 reflects an inherent biologic characteristic of the tumor. The ERCC1 expression level has recently been reported to be a prognostic factor in the survival of patients with early stage NSCLC [14, 15]. Recent studies have investigated a number of tumor biomarkers for prognostic and predictive utility when considering systemic therapy and the most prominent among these is the excision repair cross-complementation group 1 (ERCC1) protein. ERCC1 is one of the key enzymes of the nucleotide excision repair pathway, which is essential for the removal of platinum–DNA adducts. Recent studies have demonstrated that the expression levels of ERCC1 are related to a survival benefit from cisplatin-based chemotherapy among patients with advanced NSCLC [16–18]. Our study evaluated the effect of intratumoral ERCC1 expression on the survival of patients locally advanced stage III NSCLC. The survival for patients with ERCC1-negative
tumors was significantly longer than those for patients with ERCC1-positive tumors. This suggested that chemotherapy with cisplatin-based agents may be beneficial for ERCC1negative patients. Olaussen et al. [19] also reported that ERCC1 protein expression status was associated with favorable prognosis in patients treated with cisplatin-base adjuvant chemotherapy, similar to data reported in another study [20]. Furthermore, in the multivariate analysis, ERCC1 was identified as an independent predictor of survival. Further validation of these findings may help us to choose molecularbased personalized multimodality therapy. Responses to treatment were as follows: CR (1.3 %); PR (21.2 %); SD (42.5 %); and PD (15 %). Thus, there were 18 subjects (22.5 %) in the responder group (PR and CR) and 62 (77.5 %) subjects in the non-responder group (SD and PD). The 3-year overall survival and progression-free survival was 20 and 20 %, respectively. This was nearly constant with Vokes et al. [21] who reported overall response 40, 31, 35 %, three overall survival was 23, 19, 28 % in navelabine, paclitaxel, gemcitabine-based chemotherapy, respectively. This was constant with Belani et al. [22] in which a total of 369 patients were enrolled, 179 on arm A (cisplatin 75 mg/m2 and etoposide 100 mg/m2) and 190 on arm B (carboplatin AUC = 6 mg/ml min and paclitaxel 225 mg/m2), with cycles repeated every 3 weeks. The objective response rate (ORR) was 15 % on arm A compared with 23 % on arm B (p = 0.061). The overall response was lower than that reported by Huber et al. [23], in which chemotherapy with two cycles of carboplatin and paclitaxel, combined chemoradiotherapy with weekly paclitaxel was superior to radiotherapy alone. The OAR was 45.4 %. But the 3-year survival was the same 20 %. As regard overall response, our results showed high statistically significant between age, it was better in
Progression free survival in relation to
Progression free survival in relation to
degree of positivity of erccc1 ercc1 1.0
1.0
ERCC1
strong positive strong positive -censored
0.027* .6
moderate positive moderate positive
.4
-censored
.8
Cum Survival
Cum Survival
.8
.6
0.001* ERCC1 +ve
.4
+ve-censored
weak positive
.2
.2
-ve
weak positive -censored
0.0 60
12
18
24
30
36
follow up time (months)
-ve-censored
0.0 60 12 18 24 30 36 42 48 54 60
follow up time (months)
Fig. 4 ERCC1 with progression-free survival
123
58
Page 8 of 9
patients aged \53 than [53, (33.3 and 13.6 %, respectively, p value = 0.036) (Asmis et al. [24]), sex, OAR in females was better than males (37.9 and 13.7 %, respectively, p value = 0.013) this was constant with Cappuzzo et al. [25]. Body weight loss was better in patients without body weight loss than in patients with body weight loss (80 vs. 9.2 %, p value = 0.0001) this was constant with Asmis et al. [24]. Prognostic factors with overall survival were PS, cigarette smoking, stage, weight loss and ERCC1. While as regard progression-free survival, prognostic factors were stage, weight loss, ERCC1 and degree of positivity of ERCC1 progression and this in agreement with Rozensztain et al. [26]. Our results showed high ERCC1 levels were associated with shorter 3 year survival and lower response to chemotherapy in advanced NSCLC patients (0 vs. 61.6 %, p value 0.0001; RR 12.8 vs. 36.3 %, p value 0.001). Median overall survival (OS) in the ERCC1-negative population and ERCC1-positive population was 14 and 11 months, and this was statistically significant (p = 0001). This was lower than that reported by Leng et al. [20] in which 74 patients treated with the regimen of cisplatin/carboplatin, patients after surgery negative for ERCC1 expression had a significantly longer median progression-free survival (more than 42.6 vs. 13.0 months, p = 0.001) and overall (more than 42.6 vs. 19.7 months, p = 0.001) survival, compared with those positive for ERCC1 expression. This was also constant with Jiang et al. [14] who reported the same results in patients with locally advanced NSCLC who received palliative chemotherapy (HR 1.75; 95 % CI 1.39–2.22; p = 0.000; RR 0.77; 95 % CI 0.64–0.93; p = 0.007; respectively). This was also constant with that reported with that reported by Li et al. [17]; Simon et al. [18] in which patients who received neoadjuvant chemotherapy in locally advanced NSCLC with ERCC1 low expression had a significantly longer overall survival (p = 0.007), than those with ERCC1 high expression. This was different from that reported by Wang et al. [17]; Friboulet et al. [27] between ERCC1 polymorphism and locally advanced NSCLC and response. The limitations of this study were as follows: (1) it was retrospective and many factors could have influenced survival; and (2) the sample size was limited, so the prognostic significant of skip metastasis with regard to OS was not confirmed.
Conclusions In conclusion, the survival of patients with stage III NSCLC depends on numerous factors and accurately determining
123
Med Oncol (2014) 31:58
the prognosis of disease in these patients is unclear. Therefore, valuable biomarker fitting to determine the subgroup of patients who have a relatively poor prognosis is needed. Our study revealed that DNA repair genes may play an important role in the prognosis of locally advanced NSCLC patients. Therefore, ERCC1 protein expression might be a useful biological indicator in patients with locally advanced NSCLC when planning clinical studies by testing the hypothesis of customized chemotherapy. Conflict of interest
None.
References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49. 2. Smit EF, van Meerbeeck JP, Lianes P, et al. Three-arm randomized study of two cisplatin-based regimens and paclitaxel plus gemcitabine in advanced non-small-cell lung cancer: a phase III trial of the European organization for research and treatment of cancer lung cancer group–EORTC 08975. J Clin Oncol. 2003;21:3909–17. 3. Yau T, Ashley S, Popat S, et al. Time and chemotherapy treatment trends in the treatment of elderly patients (age [/=70 years) with small cell lung cancer. Br J Cancer. 2006;94:18–21. 4. Ardizzoni A, Boni L, Tiseo M, et al. Cisplatin- versus carboplatin-based chemotherapy in first-line treatment of advanced non-small-cell lung cancer: an individual patient data meta-analysis. J Natl Cancer Inst. 2007;99:847–57. 5. Friedberg EC. DNA damage and repair. Nature. 2003;421: 436–40. 6. Helleday T, Petermann E, Lundin C, Hodgson B, Sharma RA. DNA repair pathways as targets for cancer therapy. Nat Rev Cancer. 2008;8:193–204. 7. Phillips DH. Smoking-related DNA and protein adducts in human tissues. Carcinogenesis. 2002;23:1979–2004. 8. Lababede O, Meziane M, Rice T. Seventh edition of the cancer staging manual and stage grouping of lung cancer: quick reference chart and diagrams. Chest. 2011;139(1):183–9. 9. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228–47. 10. Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. European organization for research and treatment of cancer, national cancer institute of the United States, national cancer institute of Canada. J Natl Cancer Inst. 2000;92:205–16. 11. Seyhan EC, Altın S, Cetinkaya E, et al. Prognostic significance of ERCC1 expression in resected non-small cell lung carcinoma. Ann Thorac Cardiovasc Surg. 2011;17:110–7. 12. American cancer society: Cancer facts and figures 2014. Atlanta, Ga: American Cancer Society, 2014. 13. Yau T, Ashley S, Popat S, et al. Time and chemotherapy treatment trends in the treatment of elderly patients (age [/= 70 years) with small cell lung cancer. Br J Cancer. 2009;94: 18–21. 14. Jiang J, Liang X, Zhou X, et al. ERCC1 expression as a prognostic and predictive factor in patients with non-small cell lung cancer: a meta-analysis. Mol Biol Rep. 2012;39(6):6933–42. 15. Li J, Li ZN, Yu LC, et al. Association of expression of MRP1, BCRP, LRP and ERCC1 with outcome of patients with locally
Med Oncol (2014) 31:58
16.
17.
18.
19.
20.
21.
advanced non-small cell lung cancer who received neoadjuvant chemotherapy. Lung Cancer. 2010;69(1):116–22. Fujii T, Toyooka S, Ichimura K, et al. ERCC1 protein expression predicts the response of cisplatin-based neoadjuvant chemotherapy in non-small-cell lung cancer. Lung Cancer. 2008;59:377–84. Wang J, Zhang Q, Zhang H, et al. Association between polymorphisms of ERCC1 and response in patients with advanced non-small cell lung cancer receiving cisplatin-based chemotherapy. Zhongguo Fei Ai Za Zhi. 2010;13(4):337–41. Simon GR, Schell MJ, Begum M. Early indication of survival benefit from ERCC1 and RRM1 tailored chemotherapy in patients with advanced Non-Small Cell Lung Cancer (NSCLC). Evidence from an individual patient analysis. Cancer. 2012; 118(9):2525–31. Olaussen KA, Dunant A, Fouret P, IALT Bio Investigators, et al. DNA repair by ERCC1 in non-small-cell lung cancer and cisplatin-based adjuvant chemotherapy. N Engl J Med. 2006;355: 983–91. Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res. 2012;31(1):25. Vokes EE, Herndon JE 2nd, Crawford J, et al. Randomized phase II study of cisplatin with gemcitabine or paclitaxel or vinorelbine as induction chemotherapy followed by concomitant chemoradiotherapy
Page 9 of 9 58
22.
23.
24.
25.
26.
27.
for stage IIIB non-small-cell lung cancer: cancer and leukemia group B study 9431. J Clin Oncol. 2002;20:4191–8. Belani CP, Lee JS, Socinski MA, et al. Randomized phase III trial comparing cisplatin-etoposide to carboplatin-paclitaxel in advanced or metastatic non-small cell lung cancer. Ann Oncol. 2005;16:1069–75. Huber RM, Flentje M, Bronchial Carcinoma Therapy Group, et al. Simultaneous chemoradiotherapy compared with radiotherapy alone after induction chemotherapy in inoperable stage IIIA or IIIB non-small-cell lung cancer: study CTRT99/97 by the bronchial carcinoma therapy group. J Clin Oncol. 2006;24(27):4397–404. Asmis TR, Ding K, Seymour L, et al. Age and comorbidity as independent prognostic factors in the treatment of non small-cell lung cancer: a review of National Cancer institute of Canada clinical trials group trials. J Clin Oncol. 2008;26(1):54–9. Cappuzzo F, Hirsch FR, Rossi E, et al. Epidermal growth factor receptor gene and protein and gefitinib sensitivity in non-smallcell lung cancer. J Natl Cancer Inst. 2005;97(9):643–55. Rozensztajn N, Ruppert AM, Lavole A, et al. Factors associated with early progression of non-small-cell lung cancer treated by epidermal growth factor receptor tyrosine-kinase inhibitors. Cancer Med. 2014;3(1):61–9. Friboulet L, Friboulet KA, Pignon JP, et al. ERCC1 isoform expression and DNA repair in non–small-cell lung cancer. N Engl J Med. 2013;368:1101–10.
123
