- Email: [email protected]
gemcitabine-treated non-small-cell lung cancer patients
original article
Annals of Oncology 17: 668–675, 2006 doi:10.1093/annonc/mdj135 Published online 11 January 2006
Polymorphisms in DNA repair genes modulate survival in cisplatin/gemcitabine-treated non-small-cell lung cancer patients
1
Hospital Provincial de Castello´n, Castello´n; 2Universidad Auto´noma de Madrid, Madrid; 3Hospital Arnau de Vilanova, Valencia; 4Institut Catala d’Oncologia, Badalona, Barcelona; 5Hospital General Universitario de Valencia, Valencia; 6Hospital Severo Ochoa, Madrid; 7Hospital General de Alicante, Alicante; 8Hospital Universitario Gregorio Maran˜on, Madrid; 9Hospital Clı´nico Universitario Lozano Blesa, Zaragoza; 10Hospital Carlos Haya, Malaga, Spain; 11University of Messina, Messina; 12 Regina Elena Institute for Cancer Research, Rome, Italy
Received 19 October 2005; revised 30 November 2005; accepted 5 December 2005
original article
Background: Impaired DNA repair capacity may favorably affect survival in cisplatin/gemcitabine-treated nonsmall-cell lung cancer (NSCLC) patients. We investigated the association of survival with genetic polymorphisms in X-ray repair cross-complementing group 1 and group 3 (XRCC3), xeroderma pigmentosum group D (XPD), excision repair cross-complementing group 1, ligase IV, ribonucleotide reductase, TP53, cyclooxygenase-2, interleukin-6, peroxisome proliferator-activated receptor c, epidermal growth factor, methylene-tetra-hydrofolate reductase and methionine synthase. Patients and methods: One hundred and thirty-five stage IV or IIIB (with malignant pleural effusion) NSCLC patients treated with cisplatin/gemcitabine from different hospitals of the Spanish Lung Cancer Group were genotyped for 14 different polymorphisms in 13 genes. Polymorphisms were detected by the TaqMan method, using genomic DNA extracted from baseline blood samples. Results: Median survival was significantly increased in patients harboring XRCC3 241 MetMet: 16 months versus 10 months for patients with ThrMet and 14 months for those with ThrThr (P = 0.01). The risk of death ratio was significantly lower for MetMet than for ThrMet patients (hazard ratio, 0.43; P = 0.01). In the multivariate Cox model, XRCC3 241 remained an independent prognostic factor (hazard ratio: XRCC3 241 MetMet, 0.44; P = 0.01), and XPD 751 and XRCC1 399 also emerged as significant prognostic factors (hazard ratios: XPD 751 LysGln, 0.46, P = 0.03; XRCC1 399 ArgGln, 0.61, P = 0.04). No other association was observed between genotype and survival. Conclusion: XRCC3 241 MetMet is an independent determinant of favorable survival in NSCLC patients treated with cisplatin/gemcitabine. A simple molecular assay to determine the XRCC3 241 genotype can be useful for customizing chemotherapy. Key words: cisplatin, DNA repair genes, gemcitabine, non-small-cell lung cancer, polymorphisms, XRCC3
introduction Polymorphic variants in DNA repair genes can explain inter-individual differences in survival in cisplatin-treated non-small-cell lung cancer (NSCLC) patients independently of performance status, the primary clinical prognostic factor [1, 2]. Single nucleotide polymorphisms can impair the DNA repair mechanisms involved in removing DNA adducts [3, 4] through DNA double-strand break/recombination repair, *Correspondence to: Dr R. Rosell, Chief, Medical Oncology Service, Scientific Director of Oncology Research, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Ctra Canyet, s/n, 08916 Badalona, Barcelona, Spain. Tel: +34-93–497–89–25; Fax: +34-93–497–89–50; E-mail: [email protected]
ª 2006 European Society for Medical Oncology
nucleotide excision repair, base excision repair and non-homologous end joining. Understanding the correlation between DNA repair genotypes and survival in NSCLC can help to elucidate how certain polymorphic variants can adversely or favorably influence chemotherapy outcome. The X-ray repair cross-complementing group 3 (XRCC3) gene is integral to DNA double-strand break recombination repair, and the polymorphism in codon 241 (Thr to Met) of XRCC3 has been associated with the level of bulky DNA adducts in leukocytes of healthy subjects [3]. Carriers of XRCC3 241 MetMet had higher levels of DNA adducts regardless of smoking status [3], leading us to hypothesize that an inefficient DNA repair mechanism in these patients could make them more
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R. de las Pen˜as1, M. Sanchez-Ronco2, V. Alberola3, M. Taron4, C. Camps5, R. Garcia-Carbonero6, B. Massuti7, C. Queralt4, M. Botia4, R. Garcia-Gomez8, D. Isla9, M. Cobo10, M. Santarpia4,11, F. Cecere4,12, P. Mendez4, J. J. Sanchez2 & R. Rosell4* On behalf of the Spanish Lung Cancer Group
original article
Annals of Oncology
Volume 17 | No. 4 | April 2006
of the subunit M1 (RRM1), located 37 base-pairs upstream of the start codon, has been linked to RRM1 expression levels, with high levels in patients with the variant allele [19]. TP53 plays a central role in DNA synthesis and repair and apoptosis; a polymorphism at codon 72 (Arg to Pro) [20] has been associated with survival in head and neck cancer patients receiving cisplatin-based chemoradiotherapy, with patients harboring the Arg allele having longer survival than those with the Pro allele [21]. Human NSCLC cell lines with TP53 mutations at codons 273 and 282 were resistant to cisplatin/ gemcitabine in the presence of the 72 Arg allele but not in that of the 72 Pro allele [22]. These findings indicate that TP53 mutations in the presence of the 72 Arg genotype can result in drug- and mutation-specific resistance to some chemotherapy combinations. Single nucleotide polymorphisms in key genes related to inflammation have been related to the risk of lung cancer. A polymorphism in the 39-untranslated region (T to C) of cyclooxygenase-2 (COX2) stabilizes COX2 mRNA, resulting in a larger amount of protein and increased pro-inflammatory and angiogenic stimulus. A polymorphism in the promoter region ÿ174 (G to C) of interleukin-6 (IL6) is associated with risk of lung cancer. In addition, a polymorphism in codon 12 (Pro to Ala) of peroxisome proliferator-activated receptor c (PPARc) diminishes PPARc activity, which negatively regulates the production of pro-inflammatory molecules such as IL6 and COX2 [23]. An epidermal growth factor (EGF) polymorphism at position 61 of the 59-untranslated region (A to G) was assessed in brain tumor patients. Patients with the GA or GG genotype had higher tumor levels of EGF and shorter progression-free survival than patients with the AA genotype [24]. Functional single nucleotide polymorphisms in genes encoding folate metabolizing enzymes – methylene-tetra-hydrofolate reductase (MTHFR) and methionine synthase (MTR) – are involved in DNA methylation and synthesis. A polymorphism at codon 222 (Ala to Val) of MTHFR alters enzyme activity [25], and carriers of the MTHFR 222 Val genotype showed global genomic hypermethylation in their tumors [26]. Patients harboring MTR 919 Gly displayed a lower frequency of hypermethylation of multiple tumor suppressor genes [26]. A complete listing of these 14 polymorphisms is given in Table 1. To clarify the impact of these 14 polymorphisms in these 13 genes, we examined the relationship between the different genotypes and survival in stage IV and IIIB (with pleural effusion) NSCLC patients receiving cisplatin/gemcitabine.
patients and methods This multicenter prospective study assessed polymorphisms in the peripheral blood of NSCLC patients and correlated genotypes with survival. The study was approved by the independent ethics committees of all participating centers, and all patients gave their signed informed consent.
subjects Patients were included in a Spanish Lung Cancer Group multicenter clinical trial. Patients were considered eligible if they had stage IV or stage IIIB (with malignant pleural effusion) histologically confirmed NSCLC. Other
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chemosensitive. In a recent study, individuals with XRCC3 241 MetMet showed a higher risk of developing lung cancer [5]. Intriguingly, Matullo et al. [3] found that a polymorphism in codon 751 (Lys to Gln) of xeroderma pigmentosum group D (XPD), which is essential for transcription during nucleotide excision repair, was also associated with differences in the levels of bulky DNA adducts. Among XPD 751 GlnGln carriers, extremely low levels of DNA adducts were detected in smokers, while non-smokers had high levels. Experimental evidence indicates that XPD overexpression leads to cisplatin resistance [6]. In contrast, it has also been reported that XPD variant alleles (Gln751 or Asn312) were associated with reduced DNA repair capacity as measured by host cell reactivation assay [7]. A non-significant tendency towards an increased frequency of TP 53 mutations has also been observed in lung cancer patients carrying XPD variant alleles (Gln751 and Asn312) [8]. However, gene-smoking interaction for these XPD polymorphisms has been documented; Gln751 and Asn312 variants were risk factors of lung cancer in non-smokers but protective factors in heavy smokers, when compared with the Lys751 and Asp312 homozygous wild-types [9]. XRCC1 encodes a protein that complexes with DNA ligase to repair DNA gaps resulting from base excision repair; a polymorphism at codon 399 (Arg to Gln) of XRCC1 has been associated with risk of lung cancer, with a significant interaction between XRCC1 399 GlnGln and age. The adjusted odds ratio of the GlnGln versus the ArgArg genotype was 2.4 for younger subjects (<55 years) and 1 for older subjects [10]. In addition, the GlnGln genotype was a risk factor for lung cancer in non-smokers and light smokers but a protective factor in heavy smokers [10]. Indeed, it has been shown that heavy smokers among both lung cancer patients and control subjects tended to have more efficient DNA repair capacity in lymphocytes than lighter smokers [11]. Moreover, a high host DNA repair capacity was associated with poor survival in NSCLC patients receiving cisplatin-based chemotherapy [12]. These studies highlight the fact that differences in DNA repair capacity related to certain genotypes are dramatically more striking in heavy smokers and older patients. For example, cisplatin-treated NSCLC patients harboring XPD 312 AsnAsn or XRCC3 399 GlnGln had significantly shorter survival than patients carrying the wild-type alleles [13]. A single nucleotide polymorphism at codon 118 (C to T) of the excision repair cross-complementing group 1 (ERCC1), belonging to the nucleotide excision repair pathway, is associated with diminished mRNA and protein levels, with functional consequences in the repair of cisplatin DNA lesions [14, 15]. Significantly prolonged survival was observed in NSCLC patients treated with cisplatin-based chemotherapy harboring ERCC1 118 CC in comparison with patients carrying TT [15, 16]. Similar results were detected in another study of colorectal cancer patients treated with oxaliplatin [17]. A polymorphism at codon 501 (T to C) of ligase IV can compromise the function of the non-homologous end joining pathway and has been associated with increased breast cancer risk in cases with first-degree family history of breast cancer [18]. Ribonucleotide reductase, a key enzyme for DNA synthesis, is involved in DNA repair and in gemcitabine metabolism. A C to A substitution in the 59 non-coding region
original article
Annals of Oncology
Table 1. Polymorphic variants of the genes analyzed dbSNPa
NCBI Ref Seqb
Chromosome
XRCC3 T241M
rs861539
NM_005432
14q32.3
7
XPD K751Q
rs13181
NM_000400
19q13.3
23
XPD D312N
rs1799793
NM_000400
19q13.3
10
XRCC1 R399Q
rs25487
NM_006297
19q13.2
10
ERCC1 N118N
rs11615
NM_001983
19q13.2-q13.3
4
LIG4 D501D
rs1805386
NM_206937
13q33-q34
2
RRM1 37
rs12806698
NM_001033
11p15.5
TP53 R72P
rs1042522
NM_000546
17p13.1
COX2 C8473T
rs5275
NM_000963
1q25.2-q25.3
39UTR
IL6 –174
rs1800795
NM_000600
7p21
Promoter
EGF A61G
rs4444903
NM_001963
4q25
59UTR
PPARc P12A
rs1801282
NM_015869
3p25
1
MTHFR C677T
rs1801133
NM_005957
1p36.3
4
MTR D919G
rs1805087
NM_000254
1q43
Exon
Promoter 4
26
Genotype
Amino acid substitution
T C C A A G G A C T C T A C G C C T G C A G G C C T G A
Met [M] Thr [T] Gln [Q] Lys [K] Asn [N] Asp [D] Arg [R] Gln [Q] Asn [N] Asn [N] Asp [D] Asp [D] –
Amino acid position 241 751 312 399 118 568 –
Arg [R] Pro [P] –
–
–
–
–
–
72
Ala [A] Pro [P] Ala [A] Val [V] Gly [G] Asp [D]
12 222 919
a
Available at http://www.ncbi.nlm.nih.gov/projects/SNP/ Available at http://www.ncbi.nlm.nih.gov/entrez UTR, Untranslated Region.
b
eligibility criteria included an Eastern Cooperative Oncology Group performance status of 0 (asymptomatic and fully active) or 1 (symptomatic, fully ambulatory, restricted in physically strenuous activity); age of at least 18 years; adequate hematologic function (hemoglobin at least 9 g/dl [5.6 mmol/l], neutrophil count at least 1500/mm3, and platelet count at least 100 000/mm3); adequate renal function (serum creatinine less than 1.5 times the upper limit of normal); and adequate liver function (bilirubin not more than 1.5 times the upper limit of normal, aspartate aminotransferase and alanine aminotransferase not more than 5 times the upper limit of normal). Patients with clinically overt brain metastases and those who had received previous chemotherapy were excluded. Patients with a performance status of 2 (symptomatic, ambulatory, capable of self-care, more than 50% of waking hours spent out of bed) were also excluded, based on results of previous studies where these patients had a high rate of serious adverse events and poor survival [1].
treatment Patients received cisplatin at a dose of 75 mg per square meter of body-surface area on day 1 plus gemcitabine at a dose of 1250 mg/m2 on days 1 and 8. The cycle was repeated every 3 weeks for a maximum of six cycles. All patients underwent staging procedures at baseline, including a physical examination, a two-view chest X-ray, and a computed tomography of the thorax and abdomen. Bone scans or computed tomographic scans of the brain were required only if bone or brain metastases were suspected.
670 | de las Pen˜as et al.
Before each chemotherapy cycle, patients underwent a physical examination with routine biochemistry workup and blood counts. Survival was calculated from the date of enrollment to the date of death or last clinical follow-up.
sample collection and genotyping Venous blood (10 ml) was collected from each subject into tubes containing 50 mmol of EDTA per liter, and genomic DNA was isolated with the QIAmp DNA blood Mini kit (Qiagen, Germany), according to manufacturer’s instructions. Polymorphisms were assessed using the 59 nuclease allelic discrimination assay. In this method, the region flanking the polymorphism is amplified by PCR in the presence of two probes, each specific for one or the other allele. Each oligonucleotide probe is 59 labeled with a different fluorescent reporter dye (FAM or VIC) to differentiate the amplification of each allele, and with a quencher dye. During PCR, each probe anneals specifically to complementary sequences between the forward and reverse primer sites. DNA polymerase can cleave only probes that fully hybridize to the allele. Cleavage separates the reporter dye from the quencher dye, which results in increased fluorescence by the reporter dye. The PCR-generated fluorescent signal(s) indicate(s) the alleles that are present in the sample. (Primer and probe sequences are shown in Table 1 of the Supplementary Appendix.) Each reaction mixture (12.5 ll) of polymerase chain reaction contained 50 ng of DNA, 900 nM of each forward and reverse primer, 300 nM of each allele specific probe, and 6.25 ll of TaqMan Universal PCR Master Mix (Applied Biosystems,
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Polymorphism
Annals of Oncology
Foster City, CA). Amplification was done under the following conditions: 50C for 2 min, 95C for 10 min followed by 40 cycles of 92C for 15 s and 60C for 1 minute. Fluorescence in each sample well was measured before and after PCR using ABI Prism 7900HT Sequence Detection System (Applied Biosystems). Data were analyzed using Allelic Discrimination Program (Applied Biosystems). For each polymorphism, a minimum of 20 randomly selected DNA samples were genotyped at least twice to confirm the results.
statistical analyses
results A total of 135 patients were enrolled in this study between August 1, 2001 and June 30, 2002. The median follow-up for all patients was 9.7 months (range, 0.4–30.7). Patient characteristics are shown in Table 2. Seventeen percent had stage IIIB disease with pleural effusion, and 83% had stage IV disease. Median age was 62 years (range, 31–81); 92% were male; 28% had performance status 0; 83% were smokers; and 47% had adenocarcinoma. No patient had received thoracic radiotherapy. (Information on response and time to progression is included in the Supplementary Appendix.) The distribution of all genotypes (wild-type, heterozygous and homozygous polymorphic variants) and allelic frequencies are shown in Table 3. Genotype frequencies were consistent with previously reported studies and were in agreement with those expected according to the Hardy-Weinberg equilibrium model (Table 2 of the Supplementary Appendix). TP53 72 ArgArg was found more frequently in adenocarcinomas (72%), and TP53 72 ProArg in squamous cell carcinomas (52%) (P = 0.01). There was no other significant correlation between genotype and age, performance status, smoking status, gender or histology.
survival Median survival for all 135 patients was 11 months (95% CI, 8.82 to 13). Median survival was 16 months for patients with
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Table 2. Baseline characteristics of the patients n (%) Age, years (median, range) Number of cycles (median, range) Sex Male Female Smoking status Smokers (current or ex-smokers) Never smokers Performance status 0 1 Disease stage IIIB (with pleural effusion) IV Histological type Adenocarcinoma Squamous cell carcinoma Large cell carcinoma
62 (31–81) 6 (1–7) 125 (92.6) 10 (7.4) 113 (83.7) 22 (16.3) 38 (28.1) 97 (71.9) 23 (17) 112 (83) 63 (47) 46 (34.3) 25 (18.7)
performance status 0 and 10 for those with performance status 1 (hazard ratio, 0.46; 95% CI, 0.28 to 0.77; P = 0.003). Median survival was 11 months for smokers while it was not reached for non-smokers (hazard ratio, 0.51; 95% CI, 0.26 to 1.02, P = 0.06). No significant differences in survival were observed between patients with stage IIIB and IV disease (data not shown). No other correlation between survival and clinical or demographic characteristics was observed.
polymorphisms and survival Table 4 shows the survival analysis according to the 14 polymorphisms examined. Median survival was 16 months for carriers of XRCC3 241 MetMet, 14 months for those with ThrThr and 10 months for those with ThrMet (log-rank test, P = 0.01) (Table 4, Figure 1). No other significant differences in survival were observed according to genotype (Table 4), although the small sample size of some genotype variants may have been inadequate to detect moderate differences (TP53 72 ProPro; MTR 919 GlyGly; ligase IV 1977 C/C; PPARc 12 AlaAla). The univariate Cox regression model showed that XRCC3 241 MetMet significantly correlated with prolonged survival (hazard ratio: XRCC3 241 MetMet, 0.43; 95% CI, 0.22 to 0.82; P = 0.01 when compared to XRCC3 241 ThrMet). Carriers of XPD 751 GlnGln had a higher risk of death than carriers of LysGln (hazard ratio, 2.02; 95% CI, 0.99 to 4.09; P = 0.05) (Table 4). The stepwise multivariate Cox regression model including performance status, smoking status, XRCC3 241 and XPD 751 identified only XRCC3 241 and performance status as independent prognostic factors for survival. survival adjusted for performance status Based on striking differences observed in survival according to performance status 0 versus 1, a Cox proportional hazards model adjusted for performance status was carried out.
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The endpoint of the study was overall survival, calculated from the start of treatment to the date of last follow-up or death. Demographic and clinical variables were compared across genotype, using Fisher’s exact test or the Pearson chi square test for categorical variables and the one-way analysis of variance for continuous and normally distributed variables or the Kruskall-Wallis test for non-normal variables. Normality was checked by the Kolmogorov-Smirnov test. To verify the agreement of the observed genotype frequencies with those expected according to the Hardy-Weinberg equilibrium model, the likelihood-ratio test G was used. Both univariate and multivariate logistic regression models were used to calculate either crude or adjusted odds ratios of response to treatment. Survival curves were plotted using the Kaplan and Meier method and compared with the log-rank test. Median follow-up time was computed for all patients alive at the time of analysis. The association between each genotype and survival was estimated by computing the hazard ratios and their 95% CIs from both univariate and multivariate Cox regression models, where the most frequent allele was assumed to be the reference. Only those genotypes and clinical or demographic characteristics showing significance in the univariate setting were included in forward and backward stepwise multivariate Cox regression models in order to identify prognostic factors for survival. Statistical significance was set at 5%. All tests were two-sided and analyses were carried out with SPSS software, version 11.5 (Chicago, IL).
original article
original article
Annals of Oncology
Table 3. Genotypic and allelic frequencies Genotypic frequencies (%)
XRCC3 T241M
ThrThr 39.2 LysLys 48.4 AspAsp 47.0 ArgArg 37.6 TT 30.2 TT 71.2 CC 53.0 ArgArg 60.2 TT 43.2 GG 36.3 AA 31.8 ProPro 89.3 AlaAla 33.3 AspAsp 68.2
XPD K751Q XPD D312N XRCC1 R399Q ERCC1 N118N LIG4 D501D RRM1 37 TP53 R72P COX2 C8473T IL6 –174 EGF A61G PPARc P12A MTHFR C677T MTR D919G
ThrMet 42.3 LysGln 42.4 AspAsn 41.0 ArgGln 48.4 CT 54.2 TC 26.5 CA 37.8 ArgPro 34.3 CT 48.4 GC 49.2 AG 53.0 ProAla 9.9 AlaVal 55.0 AspGly 28.0
Significant differences in survival were observed for the variant genotypes of XRCC3 241, XPD 751 and XRCC1 399. Compared to carriers of XRCC3 241 ThrMet, the adjusted hazard ratio was significantly lower for patients with MetMet (hazard ratio, 0.44; 95% CI, 0.23 to 0.84; P = 0.01) and nearly significantly lower for those with ThrThr (hazard ratio, 0.64; 95% CI, 0.40 to 1.02; P = 0.06) (Table 3 of the Supplementary Appendix). In the multivariate model including performance status and smoking status, the hazard ratios for XRCC3 241 MetMet and ThrThr remained the same as in the univariate model, indicating that XRCC3 is an independent prognostic factor for survival. Compared to carriers of XPD 751 LysGln, the adjusted hazard ratio was significantly higher for patients with GlnGln (hazard ratio, 2.19; 95% CI, 1.08 to 4.46; P = 0.03), but not for patients with LysLys (hazard ratio, 1.34; 95% CI, 0.84 to 2.11; P = 0.22) (Table 3 of the Supplementary Appendix). Compared to carriers of XRCC1 399 ArgGln, the adjusted hazard ratio was significantly higher for patients with ArgArg (hazard ratio, 1.63; 95% CI, 1.03 to 2.59; P = 0.04) but not for those with GlnGln (hazard ratio, 1.49; 95% CI, 0.75 to 2.94; P = 0.25) (Table 3 of the Supplementary Appendix). The Kaplan and Meier analysis showed an association between XRCC1 399 genotype and survival in patients with performance status 1 (log-rank test, P = 0.05) but not in those with performance status 0. Among patients with performance status 1, the hazard ratio was significantly higher
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Allelic frequencies MetMet 18.4 GlnGln 9.1 AsnAsn 12.0 GlnGln 14.0 CC 15.5 CC 2.2 AA 9.1 ProPro 5.4 CC 8.3 CC 14.4 GG 15.1 AlaAla 0.7 ValVal 11.6 GlyGly 3.8
Thr 0.60 Lys 0.70 Asp 0.67 Arg 0.62 T 0.57 T 0.84 C 0.72 Arg 0.77 T 0.67 G 0.61 A 0.58 Pro 0.94 Ala 0.61 Asp 0.82
Met 0.40 Gln 0.30 Asn 0.33 Gln 0.38 C 0.42 C 0.15 A 0.28 Pro 0.22 C 0.32 C 0.39 G 0.41 Ala 0.05 Val 0.39 Gly 0.18
for patients with ArgArg than for those with ArgGln (hazard ratio, 1.87; 95% CI, 1.10 to 3.16; P = 0.02). Although no significant association between RRM1 37 genotype and survival was observed in the Cox proportional hazard model adjusted for performance status, the Kaplan and Meier analysis showed an association between RRM1 37 genotype and survival in patients with performance status 0 (log-rank test, P < 0.001) but not in those with performance status 1. Among patients with performance status 0, the hazard ratio was significantly higher for patients with CA than for those with CC (hazard ratio, 9.06; 95% CI, 2.52 to 32.66; P = 0.001). Despite the small sample size, the hazard ratio was also significantly higher for the three patients with AA than for those with CC (hazard ratio, 22.94; 95% CI, 4.38–120.16; P < 0.001). In addition to evaluating the 14 polymorphisms separately, we analyzed the association between the total number of variant alleles and survival. No significant association was found either overall or according to histological subtype.
discussion There is increasing evidence that reduced DNA repair capacity resulting from genetic polymorphisms of various DNA repair genes is associated with improved survival with platinum-based chemotherapy [13, 15–17, 27]. Reduced efficacy of the XRCC3 protein, a consequence of the polymorphic variant, may result in impaired ability to repair cisplatin DNA damage [3].
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Polymorphism
original article
Annals of Oncology
Table 4. Polymorphisms and median survival in NSCLC patients treated with cisplatin/gemcitabine: univariate survival analyses Gene
Genotype
No. of patients
Median (95%CI)
Logrank P Value
Univariate hazard ratio (95%CI)
P value
XRCC3 241
ThrThr ThrMet MetMet LysLys LysGln GlnGln AspAsp AspAsn AsnAsn ArgArg ArgGln GlnGln CC CT TT TT CT CC CC CA AA ArgArg ArgPro ProPro TT CT CC GG GC CC AA GA GG ProPro ProAla AlaAla AlaAla AlaVal ValVal AspAsp AspGly GlyGly
51 55 24 64 56 12 62 54 16 49 63 18 20 70 39 94 35 3 70 50 12 77 44 7 57 64 11 48 65 19 42 70 20 117 13 1 43 71 15 90 37 5
13.95 9.61 15.56 11.32 12.30 7.53 11.22 12.30 7.53 10.86 13.95 10.56 8.22 11.32 13.26 10.13 13.68 NR 13.62 9.74 7.96 10.86 11.22 15.56 11.64 10.92 13.95 12.34 11.64 6.97 11.32 10.56 12.93 11.41 9.87 14.18 10.86 12.30 8.22 10.56 13.52 6.97
(9.89–18.01) (7.33–11.88) (ÿ) (8.30–14.33) (9.16–15.45) (1.95–13.12) (8.57–13.86) (8.85–15.75) (5.70–9.76) (7.40–14.31) (10.92–16.97) (5.03–16.09) (6.71–9.74) (7.57–15.06) (9.70–16.82) (8.19–12.07) (12.13–15.24)
0.012
0.03 0.01
(10.70–16.54) (6.87–12.60) (0–17.89) (7.38–14.33) (8.32–14.11) (ÿ) (7.47–15.82) (9.42–12.42) (7.45–20.44) (9.12–15.55) (8.91–14.38) (4.44–9.50) (7.02–15.61) (7.68–13.44) (6.72–19.14) (9.11–13.72) (5.19–14.54) (ÿ) (8.74–12.97) (8.95–15.66) (4.58–11.86) (8.66–12.46) (9.65–17.38) (6.90–7.04)
0.18
0.60 (0.37–0.95) 1.0 (Reference) 0.43 (0.22–0.82) 1.13 (0.73–1.78) 1.0 (Reference) 2.02 (0.99–4.09) 1.0 (Reference) 0.86 (0.54–1.36) 1.47 (0.78–2.79) 1.51 (1.03–2.40) 1.0 (Reference) 1.59 (0.81–3.10) 1.38 (0.76–2.53) 1.0 (Reference) 0.88 (0.54–1.43) 1.0 (Reference) 0.76 (0.50–1.25) 0.36 (0.10–2.59) 1.0 (Reference) 1.50 (0.96–2.34) 1.40 (0.66–2.97) 1.0 (Reference) 0.99 (0.62–1.56) 0.42 (0.13–1.35) 0.78 (0.35–1.74) 1.0 (Reference) 0.96 (0.62–1.49) 0.98 (0.62–1.57) 1.0 (Reference) 1.20 (0.65–2.24) 1.04 (0.66–1.65) 1.0 (Reference) 0.70 (0.36–1.39) 1.0 (Reference) 1.10 (0.60–2.14) 1.10 (0.15–7.54) 1.15 (0.72–1.82) 1.0 (Reference) 1.19 (0.60–2.37) 1.0 (Reference) 0.80 (0.50–1.31) 1.24 (0.50–3.40)
XPD 751
XPD 312
XRCC1 399
Ligase IV 1977
RRM1 37
TP53 72
COX2 8473
IL6 –174
EGF 61
PPARc 12
MTHFR 222
MTR 919
Cisplatin cytotoxicity results from the formation of cisplatin DNA adducts, and survival is longer in patients with higher levels of cisplatin DNA adducts [28]. Individuals vary considerably in their capacity to remove DNA adducts [29], and cisplatin-resistant human NSCLC cell lines rapidly clear cisplatin DNA adducts [30]. A functional assay of DNA repair capacity in NSCLC patients treated with cisplatin-based chemotherapy found that median survival was significantly shorter for patients in the top quartile than for those in the bottom quartile (9 versus 16 months; P = 0.04) [12]. XRCC3 belongs to the homologous recombination pathway, which actively repairs the DNA double-strand breaks induced by chemotherapy. BRCA1 is also involved in the homologous recombination pathway, functioning as a differential
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0.28
0.15
0.40
0.34
0.32
0.83
0.82
0.54
0.96
0.80
0.60
0.58 0.05
0.54 0.24 0.08 0.18 0.29 0.61
0.28 0.31 0.08 0.39 0.95 0.15 0.84 0.55 0.95 0.56 0.86 0.31
0.77 0.97 0.57 0.62
0.38 0.68
modulator of survival with cisplatin and antimicrotubule drugs. Low levels of BRCA1 enhance cisplatin sensitivity but lead to resistance to paclitaxel and vinorelbine, while the opposite phenomenon is observed in the presence of normal or high levels of BRCA1 [31, 32]. In contrast, BRCA1 levels do not influence the effect of gemcitabine [31]. Intriguingly, Matullo et al. [3] reported significantly higher levels of bulky DNA adducts in carriers of XRCC3 241 MetMet than in carriers of other genotypes (mean levels: MetMet 11.44, ThrMet 7.69, ThrThr 6.94; P = 0.04). Our results show that XRCC3 is strongly associated with survival in cisplatin/gemcitabine-treated NSCLC patients. No other polymorphism in any of the genes included in the present study was significantly related to survival. Shorter
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ERCC1 118
0.14
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Annals of Oncology
1,0
significantly longer survival in cisplatin/gemcitabine-treated NSCLC patients, independently of performance status. Due to the multiple exploratory analyses carried out, this finding merits further validation as a simple tool for individualizing chemotherapy.
,8
Probability
acknowledgements ,6
This study was partially supported by the Spanish Ministry of Health grants provided through Red Tematica de Investigacion Cooperativa de Centros de Cancer (CO-010) and Red de Centros de Epidemiologia y Salud Publica (RCESP), and by funding from La Fundacio Badalona Contra el Cancer and from La Fundacion Carvajal.
MetMet ,4 ThrThr
0,0
references
ThrMet
0
6
12
18
24
30
36
Months Figure 1. Kaplan-Meier curves for survival according to XRCC3 241 genotype.
survival in cisplatin-treated stage III-IV NSCLC patients has been associated with XPD 312 AsnAsn and with XRCC1 399 GlnGln, but this correlation was no longer significant in the subset of stage IV patients [13]. In addition, several studies have reported longer survival in patients with ERCC1 118 CC [15–17]. However, in a recent study [27], no differences in survival were found according to the ERCC1 118 genotype. Although differences were observed according to the ERCC1 8092 genotype in a mixed group of stage III-IV NSCLC patients, these differences were not significant in the subset of stage IV patients [27]. In the present study, survival was longer in patients carrying ERCC1 118 TT, although the difference was not significant (Table 4). In contrast, in our previous study of stage IV NSCLC patients treated with cisplatin/docetaxel, median survival was significantly prolonged in patients harboring the ERCC1 118 TT genotype [15]. Previous therapeutic studies of advanced NSCLC patients have not prospectively considered the influence of polymorphic variants on survival. However, polymorphisms could well be useful surrogates of DNA repair machinery, and patients with polymorphisms indicating low DNA repair capacity could be more sensitive to cisplatin/gemcitabine, while others could obtain greater benefit from antimicrotubule combinations. Our landmark finding that XRCC3 241 MetMet predicts prolonged survival with cisplatin/gemcitabine can stimulate the development of polymorphism assays for selection of chemotherapy.
conclusion The present study based on the analysis of 14 polymorphisms in 13 genes shows that XRCC3 241 MetMet is associated with
674 | de las Pen˜as et al.
1. Schiller JH, Harrington D, Belani CP et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med 2002; 346: 92–98. 2. Hoang T, Xu R, Schiller JH et al. Clinical model to predict survival in chemonaive patients with advanced non-small-cell lung cancer treated with third-generation chemotherapy regimens based on eastern cooperative oncology group data. J Clin Oncol 2005; 23: 175–183. 3. Matullo G, Palli D, Peluso M et al. XRCC1, XRCC3, XPD gene polymorphisms, smoking and (32)P-DNA adducts in a sample of healthy subjects. Carcinogenesis 2001; 22: 1437–1445. 4. Qiao Y, Spitz MR, Shen H et al. Modulation of repair of ultraviolet damage in the host-cell reactivation assay by polymorphic XPC and XPD/ERCC2 genotypes. Carcinogenesis 2002; 23: 295–299. 5. Popanda O, Schattenberg T, Phong CT et al. Specific combinations of DNA repair gene variants and increased risk for non-small cell lung cancer. Carcinogenesis 2004; 25: 2433–2441. 6. Aloyz R, Xu ZY, Bello V et al. Regulation of cisplatin resistance and homologous recombinational repair by the TFIIH subunit XPD. Cancer Res 2002; 62: 5457–5462. 7. Spitz MR, Wu X, Wang Y et al. Modulation of nucleotide excision repair capacity by XPD polymorphisms in lung cancer patients. Cancer Res 2001; 61: 1354–1357. 8. Mechanic LE, Marrogi AJ, Welsh JA et al. Polymorphisms in XPD and TP53 and mutation in human lung cancer. Carcinogenesis 2005; 26: 597–604. 9. Zhou W, Liu G, Miller DP et al. Gene-environment interaction for the ERCC2 polymorphisms and cumulative cigarette smoking exposure in lung cancer. Cancer Res 2002; 62: 1377–1381. 10. Zhou W, Liu G, Miller DP et al. Polymorphisms in the DNA repair genes XRCC1 and ERCC2, smoking, and lung cancer risk. Cancer Epidemiol Biomarkers Prev 2003; 12: 359–365. 11. Wei Q, Cheng L, Amos CI et al. Repair of tobacco carcinogen-induced DNA adducts and lung cancer risk: a molecular epidemiologic study. J Natl Cancer Inst 2000; 92: 1764–1772. 12. Bosken CH, Wei Q, Amos CI, Spitz MR. An analysis of DNA repair as a determinant of survival in patients with non-small-cell lung cancer. J Natl Cancer Inst 2002; 94: 1091–1099. 13. Gurubhagavatula S, Liu G, Park S et al. XPD and XRCC1 genetic polymorphisms are prognostic factors in advanced non-small-cell lung cancer patients treated with platinum chemotherapy. J Clin Oncol 2004; 22: 2594–2601. 14. Ford BN, Ruttan CC, Kyle VL et al. Identification of single nucleotide polymorphisms in human DNA repair genes. Carcinogenesis 2000; 21: 1977–1981. 15. Isla D, Sarries C, Rosell R et al. Single nucleotide polymorphisms and outcome in docetaxel-cisplatin-treated advanced non-small-cell lung cancer. Ann Oncol 2004; 15: 1194–1203.
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,2
original article
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25.
26.
27.
28.
29. 30.
31.
32.
patients and is associated with more aggressive disease. Cancer Res 2004; 64: 1220–1223. Shen H, Spitz MR, Wang LE et al. Polymorphisms of methylene-tetrahydrofolate reductase and risk of lung cancer: a case-control study. Cancer Epidemiol Biomarkers Prev 2001; 10: 397–401. Paz MF, Avila S, Fraga MF et al. Germ-line variants in methyl-group metabolism genes and susceptibility to DNA methylation in normal tissues and human primary tumors. Cancer Res 2002; 62: 4519–4524. Zhou W, Gurubhagavatula S, Liu G et al. Excision repair cross-complementation group 1 polymorphism predicts overall survival in advanced non-small cell lung cancer patients treated with platinum-based chemotherapy. Clin Cancer Res 2004; 10: 4939–4943. van de Vaart PJ, Belderbos J, de Jong D et al. DNA-adduct levels as a predictor of outcome for NSCLC patients receiving daily cisplatin and radiotherapy. Int J Cancer 2000; 89: 160–166. Wei Q, Cheng L, Hong WK, Spitz MR. Reduced DNA repair capacity in lung cancer patients. Cancer Res 1996; 56: 4103–4107. Zeng-Rong N, Paterson J, Alpert L et al. Elevated DNA repair capacity is associated with intrinsic resistance of lung cancer to chemotherapy. Cancer Res 1995; 55: 4760–4764. Quinn JE, Kennedy RD, Mullan PB et al. BRCA1 functions as a differential modulator of chemotherapy-induced apoptosis. Cancer Res 2003; 63: 6221–6228. Taron M, Rosell R, Felip E et al. BRCA1 mRNA expression levels as an indicator of chemoresistance in lung cancer. Hum Mol Genet 2004; 13: 2443–2449.
doi:10.1093/annonc/mdj135 | 675
Downloaded from http://annonc.oxfordjournals.org/ at Fresno Pacific University on December 24, 2014
16. Ryu JS, Hong YC, Han HS et al. Association between polymorphisms of ERCC1 and XPD and survival in non-small-cell lung cancer patients treated with cisplatin combination chemotherapy. Lung Cancer 2004; 44: 311–316. 17. Stoehlmacher J, Park DJ, Zhang W et al. A multivariate analysis of genomic polymorphisms: prediction of clinical outcome to 5-FU/oxaliplatin combination chemotherapy in refractory colorectal cancer. Br J Cancer 2004; 91: 344–354. 18. Han J, Hankinson SE, Ranu H et al. Polymorphisms in DNA double-strand break repair genes and breast cancer risk in the Nurses’ Health Study. Carcinogenesis 2004; 25: 189–195. 19. Bepler G, Zheng Z, Gautam A et al. Ribonucleotide reductase M1 gene promoter activity, polymorphisms, population frequencies, and clinical relevance. Lung Cancer 2005; 47: 183–192. 20. Matakidou A, Eisen T, Houlston RS. TP53 polymorphisms and lung cancer risk: a systematic review and meta-analysis. Mutagenesis 2003; 18: 377–385. 21. Sullivan A, Syed N, Gasco M et al. Polymorphism in wild-type p53 modulates response to chemotherapy in vitro and in vivo. Oncogene 2004; 23: 3328–3337. 22. Vikhanskaya F, Siddique MM, Kei Lee M et al. Evaluation of the combined effect of p53 codon 72 polymorphism and hotspot mutations in response to anticancer drugs. Clin Cancer Res 2005; 11: 4348–4356. 23. Campa D, Zienolddiny S, Maggini V et al. Association of a common polymorphism in the cyclooxygenase 2 gene with risk of non-small cell lung cancer. Carcinogenesis 2004; 25: 229–235. 24. Bhowmick DA, Zhuang Z, Wait SD, Weil RJ. A functional polymorphism in the EGF gene is found with increased frequency in glioblastoma multiforme
Annals of Oncology 17: 668–675, 2006 doi:10.1093/annonc/mdj135 Published online 11 January 2006
Polymorphisms in DNA repair genes modulate survival in cisplatin/gemcitabine-treated non-small-cell lung cancer patients
1
Hospital Provincial de Castello´n, Castello´n; 2Universidad Auto´noma de Madrid, Madrid; 3Hospital Arnau de Vilanova, Valencia; 4Institut Catala d’Oncologia, Badalona, Barcelona; 5Hospital General Universitario de Valencia, Valencia; 6Hospital Severo Ochoa, Madrid; 7Hospital General de Alicante, Alicante; 8Hospital Universitario Gregorio Maran˜on, Madrid; 9Hospital Clı´nico Universitario Lozano Blesa, Zaragoza; 10Hospital Carlos Haya, Malaga, Spain; 11University of Messina, Messina; 12 Regina Elena Institute for Cancer Research, Rome, Italy
Received 19 October 2005; revised 30 November 2005; accepted 5 December 2005
original article
Background: Impaired DNA repair capacity may favorably affect survival in cisplatin/gemcitabine-treated nonsmall-cell lung cancer (NSCLC) patients. We investigated the association of survival with genetic polymorphisms in X-ray repair cross-complementing group 1 and group 3 (XRCC3), xeroderma pigmentosum group D (XPD), excision repair cross-complementing group 1, ligase IV, ribonucleotide reductase, TP53, cyclooxygenase-2, interleukin-6, peroxisome proliferator-activated receptor c, epidermal growth factor, methylene-tetra-hydrofolate reductase and methionine synthase. Patients and methods: One hundred and thirty-five stage IV or IIIB (with malignant pleural effusion) NSCLC patients treated with cisplatin/gemcitabine from different hospitals of the Spanish Lung Cancer Group were genotyped for 14 different polymorphisms in 13 genes. Polymorphisms were detected by the TaqMan method, using genomic DNA extracted from baseline blood samples. Results: Median survival was significantly increased in patients harboring XRCC3 241 MetMet: 16 months versus 10 months for patients with ThrMet and 14 months for those with ThrThr (P = 0.01). The risk of death ratio was significantly lower for MetMet than for ThrMet patients (hazard ratio, 0.43; P = 0.01). In the multivariate Cox model, XRCC3 241 remained an independent prognostic factor (hazard ratio: XRCC3 241 MetMet, 0.44; P = 0.01), and XPD 751 and XRCC1 399 also emerged as significant prognostic factors (hazard ratios: XPD 751 LysGln, 0.46, P = 0.03; XRCC1 399 ArgGln, 0.61, P = 0.04). No other association was observed between genotype and survival. Conclusion: XRCC3 241 MetMet is an independent determinant of favorable survival in NSCLC patients treated with cisplatin/gemcitabine. A simple molecular assay to determine the XRCC3 241 genotype can be useful for customizing chemotherapy. Key words: cisplatin, DNA repair genes, gemcitabine, non-small-cell lung cancer, polymorphisms, XRCC3
introduction Polymorphic variants in DNA repair genes can explain inter-individual differences in survival in cisplatin-treated non-small-cell lung cancer (NSCLC) patients independently of performance status, the primary clinical prognostic factor [1, 2]. Single nucleotide polymorphisms can impair the DNA repair mechanisms involved in removing DNA adducts [3, 4] through DNA double-strand break/recombination repair, *Correspondence to: Dr R. Rosell, Chief, Medical Oncology Service, Scientific Director of Oncology Research, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Ctra Canyet, s/n, 08916 Badalona, Barcelona, Spain. Tel: +34-93–497–89–25; Fax: +34-93–497–89–50; E-mail: [email protected]
ª 2006 European Society for Medical Oncology
nucleotide excision repair, base excision repair and non-homologous end joining. Understanding the correlation between DNA repair genotypes and survival in NSCLC can help to elucidate how certain polymorphic variants can adversely or favorably influence chemotherapy outcome. The X-ray repair cross-complementing group 3 (XRCC3) gene is integral to DNA double-strand break recombination repair, and the polymorphism in codon 241 (Thr to Met) of XRCC3 has been associated with the level of bulky DNA adducts in leukocytes of healthy subjects [3]. Carriers of XRCC3 241 MetMet had higher levels of DNA adducts regardless of smoking status [3], leading us to hypothesize that an inefficient DNA repair mechanism in these patients could make them more
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R. de las Pen˜as1, M. Sanchez-Ronco2, V. Alberola3, M. Taron4, C. Camps5, R. Garcia-Carbonero6, B. Massuti7, C. Queralt4, M. Botia4, R. Garcia-Gomez8, D. Isla9, M. Cobo10, M. Santarpia4,11, F. Cecere4,12, P. Mendez4, J. J. Sanchez2 & R. Rosell4* On behalf of the Spanish Lung Cancer Group
original article
Annals of Oncology
Volume 17 | No. 4 | April 2006
of the subunit M1 (RRM1), located 37 base-pairs upstream of the start codon, has been linked to RRM1 expression levels, with high levels in patients with the variant allele [19]. TP53 plays a central role in DNA synthesis and repair and apoptosis; a polymorphism at codon 72 (Arg to Pro) [20] has been associated with survival in head and neck cancer patients receiving cisplatin-based chemoradiotherapy, with patients harboring the Arg allele having longer survival than those with the Pro allele [21]. Human NSCLC cell lines with TP53 mutations at codons 273 and 282 were resistant to cisplatin/ gemcitabine in the presence of the 72 Arg allele but not in that of the 72 Pro allele [22]. These findings indicate that TP53 mutations in the presence of the 72 Arg genotype can result in drug- and mutation-specific resistance to some chemotherapy combinations. Single nucleotide polymorphisms in key genes related to inflammation have been related to the risk of lung cancer. A polymorphism in the 39-untranslated region (T to C) of cyclooxygenase-2 (COX2) stabilizes COX2 mRNA, resulting in a larger amount of protein and increased pro-inflammatory and angiogenic stimulus. A polymorphism in the promoter region ÿ174 (G to C) of interleukin-6 (IL6) is associated with risk of lung cancer. In addition, a polymorphism in codon 12 (Pro to Ala) of peroxisome proliferator-activated receptor c (PPARc) diminishes PPARc activity, which negatively regulates the production of pro-inflammatory molecules such as IL6 and COX2 [23]. An epidermal growth factor (EGF) polymorphism at position 61 of the 59-untranslated region (A to G) was assessed in brain tumor patients. Patients with the GA or GG genotype had higher tumor levels of EGF and shorter progression-free survival than patients with the AA genotype [24]. Functional single nucleotide polymorphisms in genes encoding folate metabolizing enzymes – methylene-tetra-hydrofolate reductase (MTHFR) and methionine synthase (MTR) – are involved in DNA methylation and synthesis. A polymorphism at codon 222 (Ala to Val) of MTHFR alters enzyme activity [25], and carriers of the MTHFR 222 Val genotype showed global genomic hypermethylation in their tumors [26]. Patients harboring MTR 919 Gly displayed a lower frequency of hypermethylation of multiple tumor suppressor genes [26]. A complete listing of these 14 polymorphisms is given in Table 1. To clarify the impact of these 14 polymorphisms in these 13 genes, we examined the relationship between the different genotypes and survival in stage IV and IIIB (with pleural effusion) NSCLC patients receiving cisplatin/gemcitabine.
patients and methods This multicenter prospective study assessed polymorphisms in the peripheral blood of NSCLC patients and correlated genotypes with survival. The study was approved by the independent ethics committees of all participating centers, and all patients gave their signed informed consent.
subjects Patients were included in a Spanish Lung Cancer Group multicenter clinical trial. Patients were considered eligible if they had stage IV or stage IIIB (with malignant pleural effusion) histologically confirmed NSCLC. Other
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chemosensitive. In a recent study, individuals with XRCC3 241 MetMet showed a higher risk of developing lung cancer [5]. Intriguingly, Matullo et al. [3] found that a polymorphism in codon 751 (Lys to Gln) of xeroderma pigmentosum group D (XPD), which is essential for transcription during nucleotide excision repair, was also associated with differences in the levels of bulky DNA adducts. Among XPD 751 GlnGln carriers, extremely low levels of DNA adducts were detected in smokers, while non-smokers had high levels. Experimental evidence indicates that XPD overexpression leads to cisplatin resistance [6]. In contrast, it has also been reported that XPD variant alleles (Gln751 or Asn312) were associated with reduced DNA repair capacity as measured by host cell reactivation assay [7]. A non-significant tendency towards an increased frequency of TP 53 mutations has also been observed in lung cancer patients carrying XPD variant alleles (Gln751 and Asn312) [8]. However, gene-smoking interaction for these XPD polymorphisms has been documented; Gln751 and Asn312 variants were risk factors of lung cancer in non-smokers but protective factors in heavy smokers, when compared with the Lys751 and Asp312 homozygous wild-types [9]. XRCC1 encodes a protein that complexes with DNA ligase to repair DNA gaps resulting from base excision repair; a polymorphism at codon 399 (Arg to Gln) of XRCC1 has been associated with risk of lung cancer, with a significant interaction between XRCC1 399 GlnGln and age. The adjusted odds ratio of the GlnGln versus the ArgArg genotype was 2.4 for younger subjects (<55 years) and 1 for older subjects [10]. In addition, the GlnGln genotype was a risk factor for lung cancer in non-smokers and light smokers but a protective factor in heavy smokers [10]. Indeed, it has been shown that heavy smokers among both lung cancer patients and control subjects tended to have more efficient DNA repair capacity in lymphocytes than lighter smokers [11]. Moreover, a high host DNA repair capacity was associated with poor survival in NSCLC patients receiving cisplatin-based chemotherapy [12]. These studies highlight the fact that differences in DNA repair capacity related to certain genotypes are dramatically more striking in heavy smokers and older patients. For example, cisplatin-treated NSCLC patients harboring XPD 312 AsnAsn or XRCC3 399 GlnGln had significantly shorter survival than patients carrying the wild-type alleles [13]. A single nucleotide polymorphism at codon 118 (C to T) of the excision repair cross-complementing group 1 (ERCC1), belonging to the nucleotide excision repair pathway, is associated with diminished mRNA and protein levels, with functional consequences in the repair of cisplatin DNA lesions [14, 15]. Significantly prolonged survival was observed in NSCLC patients treated with cisplatin-based chemotherapy harboring ERCC1 118 CC in comparison with patients carrying TT [15, 16]. Similar results were detected in another study of colorectal cancer patients treated with oxaliplatin [17]. A polymorphism at codon 501 (T to C) of ligase IV can compromise the function of the non-homologous end joining pathway and has been associated with increased breast cancer risk in cases with first-degree family history of breast cancer [18]. Ribonucleotide reductase, a key enzyme for DNA synthesis, is involved in DNA repair and in gemcitabine metabolism. A C to A substitution in the 59 non-coding region
original article
Annals of Oncology
Table 1. Polymorphic variants of the genes analyzed dbSNPa
NCBI Ref Seqb
Chromosome
XRCC3 T241M
rs861539
NM_005432
14q32.3
7
XPD K751Q
rs13181
NM_000400
19q13.3
23
XPD D312N
rs1799793
NM_000400
19q13.3
10
XRCC1 R399Q
rs25487
NM_006297
19q13.2
10
ERCC1 N118N
rs11615
NM_001983
19q13.2-q13.3
4
LIG4 D501D
rs1805386
NM_206937
13q33-q34
2
RRM1 37
rs12806698
NM_001033
11p15.5
TP53 R72P
rs1042522
NM_000546
17p13.1
COX2 C8473T
rs5275
NM_000963
1q25.2-q25.3
39UTR
IL6 –174
rs1800795
NM_000600
7p21
Promoter
EGF A61G
rs4444903
NM_001963
4q25
59UTR
PPARc P12A
rs1801282
NM_015869
3p25
1
MTHFR C677T
rs1801133
NM_005957
1p36.3
4
MTR D919G
rs1805087
NM_000254
1q43
Exon
Promoter 4
26
Genotype
Amino acid substitution
T C C A A G G A C T C T A C G C C T G C A G G C C T G A
Met [M] Thr [T] Gln [Q] Lys [K] Asn [N] Asp [D] Arg [R] Gln [Q] Asn [N] Asn [N] Asp [D] Asp [D] –
Amino acid position 241 751 312 399 118 568 –
Arg [R] Pro [P] –
–
–
–
–
–
72
Ala [A] Pro [P] Ala [A] Val [V] Gly [G] Asp [D]
12 222 919
a
Available at http://www.ncbi.nlm.nih.gov/projects/SNP/ Available at http://www.ncbi.nlm.nih.gov/entrez UTR, Untranslated Region.
b
eligibility criteria included an Eastern Cooperative Oncology Group performance status of 0 (asymptomatic and fully active) or 1 (symptomatic, fully ambulatory, restricted in physically strenuous activity); age of at least 18 years; adequate hematologic function (hemoglobin at least 9 g/dl [5.6 mmol/l], neutrophil count at least 1500/mm3, and platelet count at least 100 000/mm3); adequate renal function (serum creatinine less than 1.5 times the upper limit of normal); and adequate liver function (bilirubin not more than 1.5 times the upper limit of normal, aspartate aminotransferase and alanine aminotransferase not more than 5 times the upper limit of normal). Patients with clinically overt brain metastases and those who had received previous chemotherapy were excluded. Patients with a performance status of 2 (symptomatic, ambulatory, capable of self-care, more than 50% of waking hours spent out of bed) were also excluded, based on results of previous studies where these patients had a high rate of serious adverse events and poor survival [1].
treatment Patients received cisplatin at a dose of 75 mg per square meter of body-surface area on day 1 plus gemcitabine at a dose of 1250 mg/m2 on days 1 and 8. The cycle was repeated every 3 weeks for a maximum of six cycles. All patients underwent staging procedures at baseline, including a physical examination, a two-view chest X-ray, and a computed tomography of the thorax and abdomen. Bone scans or computed tomographic scans of the brain were required only if bone or brain metastases were suspected.
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Before each chemotherapy cycle, patients underwent a physical examination with routine biochemistry workup and blood counts. Survival was calculated from the date of enrollment to the date of death or last clinical follow-up.
sample collection and genotyping Venous blood (10 ml) was collected from each subject into tubes containing 50 mmol of EDTA per liter, and genomic DNA was isolated with the QIAmp DNA blood Mini kit (Qiagen, Germany), according to manufacturer’s instructions. Polymorphisms were assessed using the 59 nuclease allelic discrimination assay. In this method, the region flanking the polymorphism is amplified by PCR in the presence of two probes, each specific for one or the other allele. Each oligonucleotide probe is 59 labeled with a different fluorescent reporter dye (FAM or VIC) to differentiate the amplification of each allele, and with a quencher dye. During PCR, each probe anneals specifically to complementary sequences between the forward and reverse primer sites. DNA polymerase can cleave only probes that fully hybridize to the allele. Cleavage separates the reporter dye from the quencher dye, which results in increased fluorescence by the reporter dye. The PCR-generated fluorescent signal(s) indicate(s) the alleles that are present in the sample. (Primer and probe sequences are shown in Table 1 of the Supplementary Appendix.) Each reaction mixture (12.5 ll) of polymerase chain reaction contained 50 ng of DNA, 900 nM of each forward and reverse primer, 300 nM of each allele specific probe, and 6.25 ll of TaqMan Universal PCR Master Mix (Applied Biosystems,
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Polymorphism
Annals of Oncology
Foster City, CA). Amplification was done under the following conditions: 50C for 2 min, 95C for 10 min followed by 40 cycles of 92C for 15 s and 60C for 1 minute. Fluorescence in each sample well was measured before and after PCR using ABI Prism 7900HT Sequence Detection System (Applied Biosystems). Data were analyzed using Allelic Discrimination Program (Applied Biosystems). For each polymorphism, a minimum of 20 randomly selected DNA samples were genotyped at least twice to confirm the results.
statistical analyses
results A total of 135 patients were enrolled in this study between August 1, 2001 and June 30, 2002. The median follow-up for all patients was 9.7 months (range, 0.4–30.7). Patient characteristics are shown in Table 2. Seventeen percent had stage IIIB disease with pleural effusion, and 83% had stage IV disease. Median age was 62 years (range, 31–81); 92% were male; 28% had performance status 0; 83% were smokers; and 47% had adenocarcinoma. No patient had received thoracic radiotherapy. (Information on response and time to progression is included in the Supplementary Appendix.) The distribution of all genotypes (wild-type, heterozygous and homozygous polymorphic variants) and allelic frequencies are shown in Table 3. Genotype frequencies were consistent with previously reported studies and were in agreement with those expected according to the Hardy-Weinberg equilibrium model (Table 2 of the Supplementary Appendix). TP53 72 ArgArg was found more frequently in adenocarcinomas (72%), and TP53 72 ProArg in squamous cell carcinomas (52%) (P = 0.01). There was no other significant correlation between genotype and age, performance status, smoking status, gender or histology.
survival Median survival for all 135 patients was 11 months (95% CI, 8.82 to 13). Median survival was 16 months for patients with
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Table 2. Baseline characteristics of the patients n (%) Age, years (median, range) Number of cycles (median, range) Sex Male Female Smoking status Smokers (current or ex-smokers) Never smokers Performance status 0 1 Disease stage IIIB (with pleural effusion) IV Histological type Adenocarcinoma Squamous cell carcinoma Large cell carcinoma
62 (31–81) 6 (1–7) 125 (92.6) 10 (7.4) 113 (83.7) 22 (16.3) 38 (28.1) 97 (71.9) 23 (17) 112 (83) 63 (47) 46 (34.3) 25 (18.7)
performance status 0 and 10 for those with performance status 1 (hazard ratio, 0.46; 95% CI, 0.28 to 0.77; P = 0.003). Median survival was 11 months for smokers while it was not reached for non-smokers (hazard ratio, 0.51; 95% CI, 0.26 to 1.02, P = 0.06). No significant differences in survival were observed between patients with stage IIIB and IV disease (data not shown). No other correlation between survival and clinical or demographic characteristics was observed.
polymorphisms and survival Table 4 shows the survival analysis according to the 14 polymorphisms examined. Median survival was 16 months for carriers of XRCC3 241 MetMet, 14 months for those with ThrThr and 10 months for those with ThrMet (log-rank test, P = 0.01) (Table 4, Figure 1). No other significant differences in survival were observed according to genotype (Table 4), although the small sample size of some genotype variants may have been inadequate to detect moderate differences (TP53 72 ProPro; MTR 919 GlyGly; ligase IV 1977 C/C; PPARc 12 AlaAla). The univariate Cox regression model showed that XRCC3 241 MetMet significantly correlated with prolonged survival (hazard ratio: XRCC3 241 MetMet, 0.43; 95% CI, 0.22 to 0.82; P = 0.01 when compared to XRCC3 241 ThrMet). Carriers of XPD 751 GlnGln had a higher risk of death than carriers of LysGln (hazard ratio, 2.02; 95% CI, 0.99 to 4.09; P = 0.05) (Table 4). The stepwise multivariate Cox regression model including performance status, smoking status, XRCC3 241 and XPD 751 identified only XRCC3 241 and performance status as independent prognostic factors for survival. survival adjusted for performance status Based on striking differences observed in survival according to performance status 0 versus 1, a Cox proportional hazards model adjusted for performance status was carried out.
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The endpoint of the study was overall survival, calculated from the start of treatment to the date of last follow-up or death. Demographic and clinical variables were compared across genotype, using Fisher’s exact test or the Pearson chi square test for categorical variables and the one-way analysis of variance for continuous and normally distributed variables or the Kruskall-Wallis test for non-normal variables. Normality was checked by the Kolmogorov-Smirnov test. To verify the agreement of the observed genotype frequencies with those expected according to the Hardy-Weinberg equilibrium model, the likelihood-ratio test G was used. Both univariate and multivariate logistic regression models were used to calculate either crude or adjusted odds ratios of response to treatment. Survival curves were plotted using the Kaplan and Meier method and compared with the log-rank test. Median follow-up time was computed for all patients alive at the time of analysis. The association between each genotype and survival was estimated by computing the hazard ratios and their 95% CIs from both univariate and multivariate Cox regression models, where the most frequent allele was assumed to be the reference. Only those genotypes and clinical or demographic characteristics showing significance in the univariate setting were included in forward and backward stepwise multivariate Cox regression models in order to identify prognostic factors for survival. Statistical significance was set at 5%. All tests were two-sided and analyses were carried out with SPSS software, version 11.5 (Chicago, IL).
original article
original article
Annals of Oncology
Table 3. Genotypic and allelic frequencies Genotypic frequencies (%)
XRCC3 T241M
ThrThr 39.2 LysLys 48.4 AspAsp 47.0 ArgArg 37.6 TT 30.2 TT 71.2 CC 53.0 ArgArg 60.2 TT 43.2 GG 36.3 AA 31.8 ProPro 89.3 AlaAla 33.3 AspAsp 68.2
XPD K751Q XPD D312N XRCC1 R399Q ERCC1 N118N LIG4 D501D RRM1 37 TP53 R72P COX2 C8473T IL6 –174 EGF A61G PPARc P12A MTHFR C677T MTR D919G
ThrMet 42.3 LysGln 42.4 AspAsn 41.0 ArgGln 48.4 CT 54.2 TC 26.5 CA 37.8 ArgPro 34.3 CT 48.4 GC 49.2 AG 53.0 ProAla 9.9 AlaVal 55.0 AspGly 28.0
Significant differences in survival were observed for the variant genotypes of XRCC3 241, XPD 751 and XRCC1 399. Compared to carriers of XRCC3 241 ThrMet, the adjusted hazard ratio was significantly lower for patients with MetMet (hazard ratio, 0.44; 95% CI, 0.23 to 0.84; P = 0.01) and nearly significantly lower for those with ThrThr (hazard ratio, 0.64; 95% CI, 0.40 to 1.02; P = 0.06) (Table 3 of the Supplementary Appendix). In the multivariate model including performance status and smoking status, the hazard ratios for XRCC3 241 MetMet and ThrThr remained the same as in the univariate model, indicating that XRCC3 is an independent prognostic factor for survival. Compared to carriers of XPD 751 LysGln, the adjusted hazard ratio was significantly higher for patients with GlnGln (hazard ratio, 2.19; 95% CI, 1.08 to 4.46; P = 0.03), but not for patients with LysLys (hazard ratio, 1.34; 95% CI, 0.84 to 2.11; P = 0.22) (Table 3 of the Supplementary Appendix). Compared to carriers of XRCC1 399 ArgGln, the adjusted hazard ratio was significantly higher for patients with ArgArg (hazard ratio, 1.63; 95% CI, 1.03 to 2.59; P = 0.04) but not for those with GlnGln (hazard ratio, 1.49; 95% CI, 0.75 to 2.94; P = 0.25) (Table 3 of the Supplementary Appendix). The Kaplan and Meier analysis showed an association between XRCC1 399 genotype and survival in patients with performance status 1 (log-rank test, P = 0.05) but not in those with performance status 0. Among patients with performance status 1, the hazard ratio was significantly higher
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Allelic frequencies MetMet 18.4 GlnGln 9.1 AsnAsn 12.0 GlnGln 14.0 CC 15.5 CC 2.2 AA 9.1 ProPro 5.4 CC 8.3 CC 14.4 GG 15.1 AlaAla 0.7 ValVal 11.6 GlyGly 3.8
Thr 0.60 Lys 0.70 Asp 0.67 Arg 0.62 T 0.57 T 0.84 C 0.72 Arg 0.77 T 0.67 G 0.61 A 0.58 Pro 0.94 Ala 0.61 Asp 0.82
Met 0.40 Gln 0.30 Asn 0.33 Gln 0.38 C 0.42 C 0.15 A 0.28 Pro 0.22 C 0.32 C 0.39 G 0.41 Ala 0.05 Val 0.39 Gly 0.18
for patients with ArgArg than for those with ArgGln (hazard ratio, 1.87; 95% CI, 1.10 to 3.16; P = 0.02). Although no significant association between RRM1 37 genotype and survival was observed in the Cox proportional hazard model adjusted for performance status, the Kaplan and Meier analysis showed an association between RRM1 37 genotype and survival in patients with performance status 0 (log-rank test, P < 0.001) but not in those with performance status 1. Among patients with performance status 0, the hazard ratio was significantly higher for patients with CA than for those with CC (hazard ratio, 9.06; 95% CI, 2.52 to 32.66; P = 0.001). Despite the small sample size, the hazard ratio was also significantly higher for the three patients with AA than for those with CC (hazard ratio, 22.94; 95% CI, 4.38–120.16; P < 0.001). In addition to evaluating the 14 polymorphisms separately, we analyzed the association between the total number of variant alleles and survival. No significant association was found either overall or according to histological subtype.
discussion There is increasing evidence that reduced DNA repair capacity resulting from genetic polymorphisms of various DNA repair genes is associated with improved survival with platinum-based chemotherapy [13, 15–17, 27]. Reduced efficacy of the XRCC3 protein, a consequence of the polymorphic variant, may result in impaired ability to repair cisplatin DNA damage [3].
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Polymorphism
original article
Annals of Oncology
Table 4. Polymorphisms and median survival in NSCLC patients treated with cisplatin/gemcitabine: univariate survival analyses Gene
Genotype
No. of patients
Median (95%CI)
Logrank P Value
Univariate hazard ratio (95%CI)
P value
XRCC3 241
ThrThr ThrMet MetMet LysLys LysGln GlnGln AspAsp AspAsn AsnAsn ArgArg ArgGln GlnGln CC CT TT TT CT CC CC CA AA ArgArg ArgPro ProPro TT CT CC GG GC CC AA GA GG ProPro ProAla AlaAla AlaAla AlaVal ValVal AspAsp AspGly GlyGly
51 55 24 64 56 12 62 54 16 49 63 18 20 70 39 94 35 3 70 50 12 77 44 7 57 64 11 48 65 19 42 70 20 117 13 1 43 71 15 90 37 5
13.95 9.61 15.56 11.32 12.30 7.53 11.22 12.30 7.53 10.86 13.95 10.56 8.22 11.32 13.26 10.13 13.68 NR 13.62 9.74 7.96 10.86 11.22 15.56 11.64 10.92 13.95 12.34 11.64 6.97 11.32 10.56 12.93 11.41 9.87 14.18 10.86 12.30 8.22 10.56 13.52 6.97
(9.89–18.01) (7.33–11.88) (ÿ) (8.30–14.33) (9.16–15.45) (1.95–13.12) (8.57–13.86) (8.85–15.75) (5.70–9.76) (7.40–14.31) (10.92–16.97) (5.03–16.09) (6.71–9.74) (7.57–15.06) (9.70–16.82) (8.19–12.07) (12.13–15.24)
0.012
0.03 0.01
(10.70–16.54) (6.87–12.60) (0–17.89) (7.38–14.33) (8.32–14.11) (ÿ) (7.47–15.82) (9.42–12.42) (7.45–20.44) (9.12–15.55) (8.91–14.38) (4.44–9.50) (7.02–15.61) (7.68–13.44) (6.72–19.14) (9.11–13.72) (5.19–14.54) (ÿ) (8.74–12.97) (8.95–15.66) (4.58–11.86) (8.66–12.46) (9.65–17.38) (6.90–7.04)
0.18
0.60 (0.37–0.95) 1.0 (Reference) 0.43 (0.22–0.82) 1.13 (0.73–1.78) 1.0 (Reference) 2.02 (0.99–4.09) 1.0 (Reference) 0.86 (0.54–1.36) 1.47 (0.78–2.79) 1.51 (1.03–2.40) 1.0 (Reference) 1.59 (0.81–3.10) 1.38 (0.76–2.53) 1.0 (Reference) 0.88 (0.54–1.43) 1.0 (Reference) 0.76 (0.50–1.25) 0.36 (0.10–2.59) 1.0 (Reference) 1.50 (0.96–2.34) 1.40 (0.66–2.97) 1.0 (Reference) 0.99 (0.62–1.56) 0.42 (0.13–1.35) 0.78 (0.35–1.74) 1.0 (Reference) 0.96 (0.62–1.49) 0.98 (0.62–1.57) 1.0 (Reference) 1.20 (0.65–2.24) 1.04 (0.66–1.65) 1.0 (Reference) 0.70 (0.36–1.39) 1.0 (Reference) 1.10 (0.60–2.14) 1.10 (0.15–7.54) 1.15 (0.72–1.82) 1.0 (Reference) 1.19 (0.60–2.37) 1.0 (Reference) 0.80 (0.50–1.31) 1.24 (0.50–3.40)
XPD 751
XPD 312
XRCC1 399
Ligase IV 1977
RRM1 37
TP53 72
COX2 8473
IL6 –174
EGF 61
PPARc 12
MTHFR 222
MTR 919
Cisplatin cytotoxicity results from the formation of cisplatin DNA adducts, and survival is longer in patients with higher levels of cisplatin DNA adducts [28]. Individuals vary considerably in their capacity to remove DNA adducts [29], and cisplatin-resistant human NSCLC cell lines rapidly clear cisplatin DNA adducts [30]. A functional assay of DNA repair capacity in NSCLC patients treated with cisplatin-based chemotherapy found that median survival was significantly shorter for patients in the top quartile than for those in the bottom quartile (9 versus 16 months; P = 0.04) [12]. XRCC3 belongs to the homologous recombination pathway, which actively repairs the DNA double-strand breaks induced by chemotherapy. BRCA1 is also involved in the homologous recombination pathway, functioning as a differential
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0.28
0.15
0.40
0.34
0.32
0.83
0.82
0.54
0.96
0.80
0.60
0.58 0.05
0.54 0.24 0.08 0.18 0.29 0.61
0.28 0.31 0.08 0.39 0.95 0.15 0.84 0.55 0.95 0.56 0.86 0.31
0.77 0.97 0.57 0.62
0.38 0.68
modulator of survival with cisplatin and antimicrotubule drugs. Low levels of BRCA1 enhance cisplatin sensitivity but lead to resistance to paclitaxel and vinorelbine, while the opposite phenomenon is observed in the presence of normal or high levels of BRCA1 [31, 32]. In contrast, BRCA1 levels do not influence the effect of gemcitabine [31]. Intriguingly, Matullo et al. [3] reported significantly higher levels of bulky DNA adducts in carriers of XRCC3 241 MetMet than in carriers of other genotypes (mean levels: MetMet 11.44, ThrMet 7.69, ThrThr 6.94; P = 0.04). Our results show that XRCC3 is strongly associated with survival in cisplatin/gemcitabine-treated NSCLC patients. No other polymorphism in any of the genes included in the present study was significantly related to survival. Shorter
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ERCC1 118
0.14
original article
Annals of Oncology
1,0
significantly longer survival in cisplatin/gemcitabine-treated NSCLC patients, independently of performance status. Due to the multiple exploratory analyses carried out, this finding merits further validation as a simple tool for individualizing chemotherapy.
,8
Probability
acknowledgements ,6
This study was partially supported by the Spanish Ministry of Health grants provided through Red Tematica de Investigacion Cooperativa de Centros de Cancer (CO-010) and Red de Centros de Epidemiologia y Salud Publica (RCESP), and by funding from La Fundacio Badalona Contra el Cancer and from La Fundacion Carvajal.
MetMet ,4 ThrThr
0,0
references
ThrMet
0
6
12
18
24
30
36
Months Figure 1. Kaplan-Meier curves for survival according to XRCC3 241 genotype.
survival in cisplatin-treated stage III-IV NSCLC patients has been associated with XPD 312 AsnAsn and with XRCC1 399 GlnGln, but this correlation was no longer significant in the subset of stage IV patients [13]. In addition, several studies have reported longer survival in patients with ERCC1 118 CC [15–17]. However, in a recent study [27], no differences in survival were found according to the ERCC1 118 genotype. Although differences were observed according to the ERCC1 8092 genotype in a mixed group of stage III-IV NSCLC patients, these differences were not significant in the subset of stage IV patients [27]. In the present study, survival was longer in patients carrying ERCC1 118 TT, although the difference was not significant (Table 4). In contrast, in our previous study of stage IV NSCLC patients treated with cisplatin/docetaxel, median survival was significantly prolonged in patients harboring the ERCC1 118 TT genotype [15]. Previous therapeutic studies of advanced NSCLC patients have not prospectively considered the influence of polymorphic variants on survival. However, polymorphisms could well be useful surrogates of DNA repair machinery, and patients with polymorphisms indicating low DNA repair capacity could be more sensitive to cisplatin/gemcitabine, while others could obtain greater benefit from antimicrotubule combinations. Our landmark finding that XRCC3 241 MetMet predicts prolonged survival with cisplatin/gemcitabine can stimulate the development of polymorphism assays for selection of chemotherapy.
conclusion The present study based on the analysis of 14 polymorphisms in 13 genes shows that XRCC3 241 MetMet is associated with
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1. Schiller JH, Harrington D, Belani CP et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med 2002; 346: 92–98. 2. Hoang T, Xu R, Schiller JH et al. Clinical model to predict survival in chemonaive patients with advanced non-small-cell lung cancer treated with third-generation chemotherapy regimens based on eastern cooperative oncology group data. J Clin Oncol 2005; 23: 175–183. 3. Matullo G, Palli D, Peluso M et al. XRCC1, XRCC3, XPD gene polymorphisms, smoking and (32)P-DNA adducts in a sample of healthy subjects. Carcinogenesis 2001; 22: 1437–1445. 4. Qiao Y, Spitz MR, Shen H et al. Modulation of repair of ultraviolet damage in the host-cell reactivation assay by polymorphic XPC and XPD/ERCC2 genotypes. Carcinogenesis 2002; 23: 295–299. 5. Popanda O, Schattenberg T, Phong CT et al. Specific combinations of DNA repair gene variants and increased risk for non-small cell lung cancer. Carcinogenesis 2004; 25: 2433–2441. 6. Aloyz R, Xu ZY, Bello V et al. Regulation of cisplatin resistance and homologous recombinational repair by the TFIIH subunit XPD. Cancer Res 2002; 62: 5457–5462. 7. Spitz MR, Wu X, Wang Y et al. Modulation of nucleotide excision repair capacity by XPD polymorphisms in lung cancer patients. Cancer Res 2001; 61: 1354–1357. 8. Mechanic LE, Marrogi AJ, Welsh JA et al. Polymorphisms in XPD and TP53 and mutation in human lung cancer. Carcinogenesis 2005; 26: 597–604. 9. Zhou W, Liu G, Miller DP et al. Gene-environment interaction for the ERCC2 polymorphisms and cumulative cigarette smoking exposure in lung cancer. Cancer Res 2002; 62: 1377–1381. 10. Zhou W, Liu G, Miller DP et al. Polymorphisms in the DNA repair genes XRCC1 and ERCC2, smoking, and lung cancer risk. Cancer Epidemiol Biomarkers Prev 2003; 12: 359–365. 11. Wei Q, Cheng L, Amos CI et al. Repair of tobacco carcinogen-induced DNA adducts and lung cancer risk: a molecular epidemiologic study. J Natl Cancer Inst 2000; 92: 1764–1772. 12. Bosken CH, Wei Q, Amos CI, Spitz MR. An analysis of DNA repair as a determinant of survival in patients with non-small-cell lung cancer. J Natl Cancer Inst 2002; 94: 1091–1099. 13. Gurubhagavatula S, Liu G, Park S et al. XPD and XRCC1 genetic polymorphisms are prognostic factors in advanced non-small-cell lung cancer patients treated with platinum chemotherapy. J Clin Oncol 2004; 22: 2594–2601. 14. Ford BN, Ruttan CC, Kyle VL et al. Identification of single nucleotide polymorphisms in human DNA repair genes. Carcinogenesis 2000; 21: 1977–1981. 15. Isla D, Sarries C, Rosell R et al. Single nucleotide polymorphisms and outcome in docetaxel-cisplatin-treated advanced non-small-cell lung cancer. Ann Oncol 2004; 15: 1194–1203.
Volume 17 | No. 4 | April 2006
Downloaded from http://annonc.oxfordjournals.org/ at Fresno Pacific University on December 24, 2014
,2
original article
Annals of Oncology
Volume 17 | No. 4 | April 2006
25.
26.
27.
28.
29. 30.
31.
32.
patients and is associated with more aggressive disease. Cancer Res 2004; 64: 1220–1223. Shen H, Spitz MR, Wang LE et al. Polymorphisms of methylene-tetrahydrofolate reductase and risk of lung cancer: a case-control study. Cancer Epidemiol Biomarkers Prev 2001; 10: 397–401. Paz MF, Avila S, Fraga MF et al. Germ-line variants in methyl-group metabolism genes and susceptibility to DNA methylation in normal tissues and human primary tumors. Cancer Res 2002; 62: 4519–4524. Zhou W, Gurubhagavatula S, Liu G et al. Excision repair cross-complementation group 1 polymorphism predicts overall survival in advanced non-small cell lung cancer patients treated with platinum-based chemotherapy. Clin Cancer Res 2004; 10: 4939–4943. van de Vaart PJ, Belderbos J, de Jong D et al. DNA-adduct levels as a predictor of outcome for NSCLC patients receiving daily cisplatin and radiotherapy. Int J Cancer 2000; 89: 160–166. Wei Q, Cheng L, Hong WK, Spitz MR. Reduced DNA repair capacity in lung cancer patients. Cancer Res 1996; 56: 4103–4107. Zeng-Rong N, Paterson J, Alpert L et al. Elevated DNA repair capacity is associated with intrinsic resistance of lung cancer to chemotherapy. Cancer Res 1995; 55: 4760–4764. Quinn JE, Kennedy RD, Mullan PB et al. BRCA1 functions as a differential modulator of chemotherapy-induced apoptosis. Cancer Res 2003; 63: 6221–6228. Taron M, Rosell R, Felip E et al. BRCA1 mRNA expression levels as an indicator of chemoresistance in lung cancer. Hum Mol Genet 2004; 13: 2443–2449.
doi:10.1093/annonc/mdj135 | 675
Downloaded from http://annonc.oxfordjournals.org/ at Fresno Pacific University on December 24, 2014
16. Ryu JS, Hong YC, Han HS et al. Association between polymorphisms of ERCC1 and XPD and survival in non-small-cell lung cancer patients treated with cisplatin combination chemotherapy. Lung Cancer 2004; 44: 311–316. 17. Stoehlmacher J, Park DJ, Zhang W et al. A multivariate analysis of genomic polymorphisms: prediction of clinical outcome to 5-FU/oxaliplatin combination chemotherapy in refractory colorectal cancer. Br J Cancer 2004; 91: 344–354. 18. Han J, Hankinson SE, Ranu H et al. Polymorphisms in DNA double-strand break repair genes and breast cancer risk in the Nurses’ Health Study. Carcinogenesis 2004; 25: 189–195. 19. Bepler G, Zheng Z, Gautam A et al. Ribonucleotide reductase M1 gene promoter activity, polymorphisms, population frequencies, and clinical relevance. Lung Cancer 2005; 47: 183–192. 20. Matakidou A, Eisen T, Houlston RS. TP53 polymorphisms and lung cancer risk: a systematic review and meta-analysis. Mutagenesis 2003; 18: 377–385. 21. Sullivan A, Syed N, Gasco M et al. Polymorphism in wild-type p53 modulates response to chemotherapy in vitro and in vivo. Oncogene 2004; 23: 3328–3337. 22. Vikhanskaya F, Siddique MM, Kei Lee M et al. Evaluation of the combined effect of p53 codon 72 polymorphism and hotspot mutations in response to anticancer drugs. Clin Cancer Res 2005; 11: 4348–4356. 23. Campa D, Zienolddiny S, Maggini V et al. Association of a common polymorphism in the cyclooxygenase 2 gene with risk of non-small cell lung cancer. Carcinogenesis 2004; 25: 229–235. 24. Bhowmick DA, Zhuang Z, Wait SD, Weil RJ. A functional polymorphism in the EGF gene is found with increased frequency in glioblastoma multiforme