Tumor Biol. (2014) 35:5637–5645 DOI 10.1007/s13277-014-1746-y

RESEARCH ARTICLE

XRCC1 and XPD genetic polymorphisms and clinical outcomes of gastric cancer patients treated with oxaliplatin-based chemotherapy: a meta-analysis Xin Zhang & Li-Peng Jiang & Yu Yin & Ya-Di Wang

Received: 29 November 2013 / Accepted: 12 February 2014 / Published online: 4 March 2014 # International Society of Oncology and BioMarkers (ISOBM) 2014

Abstract This meta-analysis aimed to obtain a comprehensive and reliable assessment of the relationships between XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and the clinical outcomes of gastric cancer (GC) patients treated with oxaliplatin-based chemotherapy. The PubMed, CINAHL, Web of Science, CISCOM, EBSCO, Google Scholar, Cochrane Library, and CBM databases were searched for relevant articles published before September 1, 2013 without language restrictions. Crude odd ratios (ORs) or hazard risk (HR) [95 % confidence intervals (CI)] were calculated. Twelve clinical cohort studies were assessed with a total 1,024 GC patients treated with oxaliplatin-based chemotherapy. Our meta-analysis findings revealed that GC patients with the GA+AA (A carrier) genotypes of XRCC1 Arg399Gln showed a lower effective clinical response (CR+PR) than those with the GG (A non-carrier) genotype (OR = 0.41, 95 % CI 0.20∼0.82, P=0.012). However, there was no statistically significant difference in effective clinical response between those with XPD AC+CC (C carrier) genotypes and CC (C non-carrier) genotype (OR=0.55, 95 % CI 0.28∼1.07, P= 0.076). Furthermore, the GA+AA genotypes of XRCC1 X. Zhang Department of Oncology, The First Affiliated Hospital of Liaoning Medical University, Jinzhou, People’s Republic of China L.C) are considered to be significantly linked to the low efficacy of platinum drugs and to have an impact on the clinical outcome of GC patients [26, 27]. However, there have also been some contradictory conclusions with regard to the relationship of XRCC1 Arg399Gln and XPD Lys751Gln with the efficacy of oxaliplatin in the platinum-based chemotherapy for GC. Therefore, this meta-analysis was performed to evaluate the relationships between XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and the clinical outcomes of GC patients treated with oxaliplatin-based chemotherapy.

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Methods Search strategy The PubMed, CINAHL, Web of Science, CISCOM, EBSCO, Google Scholar, Cochrane Library, and CBM databases were searched for relevant articles published before September 1, 2013 with no language restrictions. The following keywords and MeSH terms were “stomach neoplasms” or “gastric cancer” or “gastric neoplasms” or “stomach carcinomas”, and “genetic polymorphism” or “single nucleotide polymorphism” or “polymorphism” or “SNP” or “mutation” or “variation” or “variant”, and (“oxaliplatin” or “oxolatoplatinuma” or “L-OHP”, and “X-ray repair cross-complementing protein 1” or “XRCC1” or “L-OHP” or “XPD”. And we also performed a manual search of the reference lists of relevant articles to find further potential articles. Selection criteria The included studies meet all four of the following criteria: (1) must be a cohort study, nested case–control study, or case–control study focusing on the relationships of XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and clinical outcomes of GC patients treated with oxaliplatin-based chemotherapy; (2) all patients with the diagnosis of GC must have been confirmed through histopathologic examinations; (3) the minimum number of cases in the included studies must be greater than 30; and (4) the study must provide sufficient information on clinical response, overall survival (OS), and progressionfree survival (PFS). According to the Response Evaluation Criteria in Solid Tumors (RECIST) guidelines [28], clinical response evaluation was categorized into complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). Studies were excluded if they did not meet all of these inclusion criteria. The most recent or largest sample size publication was included when authors published several studies using the same subjects. Data extraction Relevant data were systematically extracted from all included studies by two independent researchers using a standardized form. The researchers collected the following data: language of publication, publication year, the first author’s surname, geographical location, design of study, genotyping method of SNP, sample size, population ethnicity, treatment method, CR, PR, SD, PD, OS, and PFS. Conflicting evaluations or inconsistent data from the eligible studies were resolved through discussion and careful reexaminations of the full texts.

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Quality assessment

Clinical response

Methodological quality was assessed by two independent researchers according to the Newcastle-Ottawa Scale (NOS) criteria [29]. The NOS criteria is scored according to three aspects: (1) subject selection, 0∼4; (2) comparability of subject, 0∼2; and (3) clinical outcome, 0∼3. Total NOS scores range from 0 to 9 with a score ≥7 indicating good methodological quality.

Seven studies focused on the relationships between XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and the clinical response of GC patients treated with oxaliplatinbased chemotherapy. We detected no heterogeneity in the results (XRCC1 P=0.102, I2 =48.2 %; XPD P=0.600, I2 = 0.0 %, respectively) so the fixed-effects model was conducted. The meta-analysis results reveal that GC patients with the GA+AA (A carrier) genotypes of XRCC1 Arg399Gln showed a lower effective clinical response (CR+PR) than those with the GG (A non-carrier) genotype (OR = 0.41, 95 % CI 0.20∼0.82, P=0.012). However, there was no statistically significant difference in effective clinical response between carriers of the XPD AC+CC (C carrier) genotypes and the CC (C non-carrier) genotype (OR=0.55, 95 % CI 0.28∼1.07, P= 0.076) (Fig. 3).

Statistical analysis Crude odd ratios (ORs) or hazard risk (HR) with 95 % confidence intervals (CIs) were calculated under a fixed or randomeffect model. The statistical significance of pooled ORs was assessed by the Z test. The Cochran’s Q statistic and I2 test were used to evaluate potential heterogeneity between studies [30, 31]. If Q test shows a P50 %, which indicate significant heterogeneity, the random-effect model was conducted. Otherwise, the fixed-effects model was used. We also performed subgroup and meta-regression analyses to investigate potential sources of heterogeneity. In order to evaluate the influence of single studies on the overall estimate, a sensitivity analysis was performed. We conducted Begger’s funnel plots and Egger’s test to investigate publication bias [32]. All analyses were calculated using the STATA software, version 12.0 (Stata Corp, College Station, TX, USA).

Results

Prognosis Nine studies examined the relationships between the XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and the clinical prognosis of GC patients treated with oxaliplatinbased chemotherapy. Since significant heterogeneity was observed, the random-effects model was used. Meta-analysis results showed that the GA + AA genotypes of XRCC1 Arg399Gln were associated with a worse PFS and OS compared with the CC genotype (PFS, HR= 1.90, 95 % CI 1.12∼2.69, P0.05).

Discussion XRCC1 and XPD participate in the NER pathway, which is able to remove a broad range of DNA lesions, including benzo[a]pyrene-guanine adducts caused by smoking, guanine-cisplatin adducts resulting from chemotherapy, and photoproducts generated by ultraviolet light [14, 43]. Recent

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Fig. 1 Flow chart of study selection process. Twelve cohort studies were included in this meta-analysis

INITIAL SEARCH (September 1st, 2013)

TITLE & ABSTRACT REVIEW (n = 101) Studies were excluded, due to: (n = 9) Letters, reviews, meta-analysis (n = 15) Not human studies (n = 21) Obviously irrelevant studies

FULL-TEXT REVIEW (n = 56) Studies were excluded, due to: (n = 8) Not relevant to XRCC1 (n = 15) Not relevant to XPD (n = 16) Not relevant to oxaliplatin

DATA INTEGRITY REVIEW (n = 17) Studies were excluded, due to: (n = 2) Duplicate publication (n = 3) Not provide sufficient data

FINAL SELECTION (n = 12)

studies have also found relationships between genetic polymorphisms of XRCC1 and XPD and the clinical outcomes of GC patients treated with platinum-based chemotherapy [44–46]. Fluorouracil coupled with cisplatin has been commonly used in GC patients for many years [47]. Recently, oxaliplatin was introduced into the chemotherapy regimens for treating GC with promising results and manageable toxicity [48]. Generally, oxaliplatin-DNA adducts are capable of blocking DNA replication and lead to cancer cell death. Pubmed database

30

All database

Number of articles

25 20 15 10 5 0

2000~2001

2002~2003

2004~2005

2006~2007

2008~2009

2010~2011

2012~2013

Publication year

Fig. 2 The distribution of the number of topic-related literature in electronic databases over the last decade

However, DNA damage cause by oxaliplatin-DNA adducts is recognized and repaired by the NER pathway [49]. XPD and XRCC1, as major proteins of NER, act as the rate-limiting enzymes in the NER pathway and thus are considered to have some effect on the efficacy of oxaliplatin-based chemotherapy and clinical outcomes of GC patients [50]. This is the first meta-analysis evaluating the relationships between XRCC1 and XPD genetic polymorphisms and clinical outcomes of GC patients treated with oxaliplatin-based chemotherapy. This meta-analysis included 12 studies with a total 1,024 GC patients who were treated with oxaliplatinbased adjuvant chemotherapy. Our findings revealed that the XRCC1 Arg399Gln polymorphism was significantly associated with a low effective clinical response (CR+PR) and a poor outcome in terms of OS and PFS in GC patients who were treated with oxaliplatin-based chemotherapy, suggesting that the XRCC1 Arg399Gln polymorphism may play a main role in affecting the efficacy of oxaliplatin-based chemotherapy for GC patients. Although the exact function of the XRCC1 Arg399Gln polymorphism in influencing the efficacy of oxaliplatin is still not clear, a possible explanation is that XRCC1 gene mutations decrease the level and functions of oxaliplatin, which directly contribute to drug sensitivity phenotypes by modifying the functions of related genes and

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Table 1 Characteristics and methodological quality of the included studies in this meta-analysis First author [Ref] Year Country Number Gender (M/F) Age (years) Genotype method Gene

SNP

Clinical index

NOS score

Arg399Gln Lys751Gln Lys751Gln Lys751Gln Arg399Gln

OS

6

OS, PFS Clinical response Clinical response, PFS Clinical response OS, PFS Clinical response, PFS Clinical response Clinical response, PFS OS Clinical response, OS, PFS

7 7 8

Liu YP [38]

2013 China

126

90/36



Li X [42] Gao CM [34] Wu XM [40]

2011 China 2011 China 2010 China

90 91 48

60/30 67/24 33/15

50 (34–70) TaqMan 58 (21–75) PCR-RFLP 58 (38–81) PCR-RFLP

XRCC1 XPD XPD XPD XRCC1

Sun YY [41] Liang J [43] Jiang J [37]

2010 China 2010 China 2010 China

128 85 60

76/52 62/23 –

59 (31–37) TaqMan 55 (32–75) TaqMan 55 (32–77) TaqMan

XPD Lys751Gln XRCC1 Arg399Gln XRCC1 Arg399Gln

Gao CM [33] Qiu DM [39]

2010 China 2009 China

91 68

67/24 42/26

58 (21–75) PCR-RFLP 55 (38–77) PCR-RFLP

XRCC1 Arg399Gln XRCC1 Arg399Gln

Huang ZH [6] Keam B [36]

2009 China 2008 Korea

102 73

73/29 48/25

58 (34–76) PCR-LDR 59 (24–77) PCR-RFLP

XRCC1 Arg399Gln XRCC1 Arg399Gln

Liu B [27]

2007 China

62

45/17

55 (23–75) TaqMan

XPD Lys751Gln XRCC1 Arg399Gln OS XPD Lys751Gln

TaqMan

7 8 7 7 8 7 8

7

M male, F female, SNP single nucleotide polymorphism, NOS Newcastle-Ottawa quality assessment scale, PCR-RFLP polymerase chain reactionrestriction fragment length polymorphism, PCR-LDR polymerase chain reaction-ligase detection reaction, OS overall survival, PFS progression-free survival

reflecting platinum sensitivity as an inborn trait [51]. Huang et al. have observed significant relationships between the XRCC1 Arg399Gln polymorphism and resistance to oxaliplatin-based chemotherapy for GC [6]. Furthermore, Liu et al. have concluded that the XRCC1 Arg399Gln polymorphism may help predict the outcomes of GC patients receiving oxaliplatin-based chemotherapy [27]. However, no statistically significant differences in effective clinical response were found between the AC+CC (C carrier) genotypes Fig. 3 Forest plots for the association between the XRCC1 Arg399Gln and the XPD Lys751Gln polymorphisms and effective clinical response of GC patients treated with oxaliplatinbased chemotherapy

and the CC (C non-carrier) genotype of the XPD Lys751Gln polymorphism. We also observed no relationship between the XPD Lys751Gln polymorphism and either PFS or OS. These results reveal that the efficacy of adjuvant chemotherapy with oxaliplatin is related to the XRCC1 and XPD gene polymorphisms, which is consistent with previous studies. Our findings are also consistent with the previous studies that suggest that the XRCC1 Arg399Gln polymorphism may be associated with poor prognosis in GC patients treated with oxaliplatin-

CR+PR

Included studies

OR (95% CI)

Weight%

(WM+MM vs WW) XRCC1 Wu XM (2010)

0.06 (0.01, 0.63)

3.36

Jiang J (2010)

0.21 (0.06, 0.72)

11.27

Gao CM (2010)

0.59 (0.25, 1.39)

18.76

13 Qiu DM (2009)

0.33 (0.12, 0.89)

15.13

Keam B (2008)

1.01 (0.38, 2.68)

15.72

0.41 (0.20, 0.82)

64.22

Gao CM (2011)

0.82 (0.23, 2.95)

10.22

Sun YY (2010)

0.38 (0.15, 1.01)

15.87

Keam B (2008)

0.69 (0.18, 2.61)

9.68

0.55 (0.28, 1.07)

35.78

Heterogeneity test (I2 = 48.2%,P = 0.102 ) Z test (Z = 2.50, P = 0.012)

XPD

Heterogeneity test (I2 = 0.0%, P = 0.600) Z test (Z = 1.78, P = 0.076) 0.00521

1

192

5642 Fig. 4 Forest plots for the association between the XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and progressionfree survival of GC patients treated with oxaliplatin-based chemotherapy

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PFS

Included studies

OR (95% CI)

Weight%

(WM+MM vs WW) XRCC1 Wu XM (2010)

1.97 (0.99, 3.95)

12.27

Liang J (2010)

2.00 (1.21, 3.29)

18.04

Jiang J (2010)

3.40 (1.74, 6.64)

5.72

Qiu DM (2009)

2.97 (1.71, 5.52)

8.57

Keam B (2008)

1.09 (0.65, 1.83)

27.45

1.90 (1.12, 2.69)

72.41

Li X (2011)

4.48 (1.57, 12.78)

1.26

Keam B (2008)

0.87 (0.44, 1.73)

26.33

Heterogeneity test (I2 = 36.4%, P = 0.210) Z test (Z = 1.10, P = 0.271)

1.56 (−1.22, 4.34)

27.59

Heterogeneity test (I2 == 48.7%, P = 0.069) Z test (Z = 5.04, P < 0.001)

1.64 (1.00, 2.28)

100.00

Heterogeneity test (I2 = 47.9%, P = 0.104) Z test (Z = 4.73, P < 0.001) XPD

NOTE: random effects analysis −12.8

based chemotherapy and may be a useful biomarker in predicting the efficacy of oxaliplatin-based chemotherapy and the prognosis of GC patients. Our meta-analysis has several limitations that should be acknowledged. Our results lacked sufficient statistical power Fig. 5 Forest plots for the association between the XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and overall survival of GC patients treated with oxaliplatin-based chemotherapy

0

12.8

to assess correlations between the XRCC1 and XPD genetic polymorphisms in GC patients who were treated with oxaliplatin-based adjuvant chemotherapy. Therefore, more studies with larger sample sizes are still needed to determine these relationships. In addition, as a type of a retrospective

os

Included studies

OR (95% CI)

Weight%

(WM+MM vs WW) XRCC1 Liu YP (2013) Liang J (2010)

0.62 (0.35, 1.09) 2.76 (1.59, 4.77)

17.08 11.25

Huang ZH (2009)

1.90 (1.08, 3.34)

13.71

Keam B (2008)

1.58 (0.83, 2.97)

14.02

Liu BR (2007)

4.09 (3.12, 5.36)

13.74

2.13 (0.79, 3.47)

69.8

11.43

Heterogeneity test (I2 = 90.2%, P < 0.001) Z test (Z = 3.11, P = 0.002) XPD Liu YP (2013)

1.07 (0.33, 3.44)

Li X (2011)

4.30 (1.54, 11.99)

2.48

Keam B (2008)

0.49 (0.17, 1.37)

16.29

Heterogeneity test (I2 = 17.2%, P = 0.299) Z test (Z = 1.71, P = 0.088)

0.71 (−0.10, 1.53)

30.20

Heterogeneity test (I2 = 84.8%, P < 0.001) Z test (Z = 3.90, P < 0.001)

1.77 (0.88, 2.66)

100.00

NOTE: random effects analysis −12

0

12

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Fig. 6 Sensitivity analysis of the relationships between the XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and effective clinical response of GC patients treated with oxaliplatin-based chemotherapy. Results were computed by omitting each study in turn. Meta-analysis randomeffects estimates (exponential form) were used. The two ends of the dotted lines represent the 95 % CI

CR+PR (WM+MM vs WW) Lower CI Limit

Estimate

Upper CI Limit

Liu YP (2013)

Wu XM (2010)

Liang J (2010)

Jiang J (2010)

Gao CM (2010)

Qiu DM (2009)

Huang ZH (2009)

Keam B (2008)

Liu BR (2007) 0.46

0.53

0.67

0.91

PFS

CR+PR

(WM+MM vs WW)

(WM+MM vs WW) 0.5

0.85

Begg’s funnel plot with pseudo 95% confidence limits

2

(Egger’s test: t = -0.01, P = 0.994)

Begg’s funnel plot with pseudo 95% confidence limits (Egger’s test: t = 0.94, P = 0.392)

1

In[HR]

Log[OR]

0

−0.5

0 −1

−1.5

−1 0

0.2

0

0.4

0.2

SE Log[OR]

2

0.6

0.4

SE (In[HR])

OS

RFS

(WM+MM vs WW)

(WM+MM vs WW) 1

Begg’s funnel plot with pseudo 95% confidence limits (Egger’s test: t = -2.03, P = 0.089)

Begg’s funnel plot with pseudo 95% confidence limits (Egger’s test: t = 0.20, P = 0.876)

In[HR]

In[HR]

0.5 1

0

0 −0.5

−1

−1 0

0.2

0.4

0.6

SE (In[HR]) Fig. 7 Begger’s funnel plots of the relationships between the XRCC1 Arg399Gln and XPD Lys751Gln polymorphisms and clinical outcomes of GC patients treated with oxaliplatin-based chemotherapy. Each point

0

0.2

0.4

SE (In[HR]) represents a separate study for the indicated association. Log [OR] represents natural logarithm of OR. Horizontal line mean magnitude of the effect

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study, a meta-analysis of summary data from previously published studies may encounter recall or selection bias, which thus may have influenced the reliability of our results. Most importantly, the lack of access to all data from the original studies limited further evaluations of the potential values of XRCC1 and XPD polymorphisms. In conclusion, our meta-analysis indicates that the XRCC1 Arg399Gln polymorphism may be associated with poor clinical outcomes in GC patients who were treated with oxaliplatin-based chemotherapy. Thus, detection of the XRCC1 Arg399Gln polymorphism may be a useful biomarker in predicting the efficacy of oxaliplatin-based chemotherapy and the prognosis of GC patients. Considering the limitations mentioned above, detailed studies are needed to confirm our findings.

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12.

13.

14.

15.

16. Acknowledgments We would like to acknowledge the reviewers for their helpful comments on this paper. We would also like to thank our colleagues at the Department of Oncology, the First Affiliated Hospital of Liaoning Medical University. This work is funded by Liaoning Medical University Youth Foundation (Y2012Z017).

17.

Conflicts of interest None

18.

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XRCC1 and XPD genetic polymorphisms and clinical outcomes of gastric cancer patients treated with oxaliplatin-based chemotherapy: a meta-analysis.

This meta-analysis aimed to obtain a comprehensive and reliable assessment of the relationships between XRCC1 Arg399Gln and XPD Lys751Gln polymorphism...
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