Epidermal Growth Factor Receptor, P53 Mutation, and Pathological

Vol. 9, 6461–6468, December 15, 2003 Clinical Cancer Research 6461

Epidermal Growth Factor Receptor, p53 Mutation, and Pathological Response Predict Survival in Patients with Locally Advanced Esophageal Cancer Treated with Preoperative Chemoradiotherapy log rank) correlated with 0.051 ؍ Michael K. Gibson,1 Susan C. Abraham,2 and p53 mutation (P Tsung-Teh Wu,3 Barbara Burtness,4 increased OS, whereas increased EGF-R expression pre- ؍ Richard F. Heitmiller,5 Elisabeth Heath,1 and dicted poor OS (P 0.009 log rank). EGF-R remained 1 significant when adjusted for clinical covariates. There was Arlene Forastiere a trend toward increased OS related to better tumor differ- 1Division of Medical Oncology, The Sidney Kimmel Comprehensive 2 entiation and decreased bcl-2. Cancer Center at Johns Hopkins, Baltimore, Maryland; Department Conclusions: These data suggest that EGF-R and p53 of Pathology, Mayo Clinic, Rochester, Minnesota; 3Department of Pathology, The University of Texas M. D. Anderson Cancer Center, mutation may be used as both outcome predictors and tar- Houston, Texas; 4Department of Internal Medicine, Yale University gets for molecular therapy for esophageal cancer. School of Medicine, New Haven, Connecticut; and 5Department of Surgery, Union Memorial Hospital, Baltimore, Maryland INTRODUCTION Esophageal cancer comprises a small percentage (1.5%) ABSTRACT and low incidence (12,300 cases/year) of total cancer cases in Purpose: Despite the availability of cellular markers the United States; however, the mortality rate remains high (1, associated with cell cycle, apoptosis, and DNA repair, pre- 2). In our experience and the experience of others, locally dictive factors for pathological complete response (CR) and advanced, nonmetastatic disease is curable in up to 40% of overall survival (OS) are few in patients with locally ad- patients (3–5). Overall survival with surgery alone ranges be- vanced esophageal cancer. This study evaluates the role of tween 15% and 25% (6). These rates likely reflect both late clinical and cellular markers in predicting CR and OS in stage of disease at diagnosis as well as inadequacy of therapy. patients with esophageal cancer. Although survival results in phase II trials using preoper- Experimental Design: Patients were treated with infu- ative chemoradiotherapy are promising, randomized trials dem- sional cisplatin and 5-fluorouracil combined with daily ra- onstrate mixed results (7–10). Therefore, the role of this treat- diotherapy followed by esophagectomy. Pretreatment tu- ment approach remains controversial. Overall, standard were analyzed for epidermal growth factor preoperative chemoradiotherapy using cisplatin/5-fluorouracil (54 ؍ mors (n receptor (EGF-R), bax, and bcl-2 expression by immunohis- (5-FU)-based regimens results in a pathological complete re- tochemistry and for p53 mutations by direct DNA sequenc- sponse (CR) rate of approximately 25%. There is often an ing of exons 5–8. Clinical covariates included patients’ age apparent improvement in survival and local control compared at enrollment; gender; Barrett’s metaplasia; and tumor lo- with results expected with historical controls of surgery alone. cation, histology, and differentiation. Logistic regression Over the past 10 years, we conducted two phase II trials at and survival analyses were used to evaluate the predictors. Johns Hopkins and Yale that provided intensive regimens of Results: Age ranged from 32 to 75 years; most patients cisplatin and 5-FU chemotherapy combined with radiotherapy were male (45 male; 9 female); and tumors were distal (47 before surgical resection (3–5, 11). The second trial also incor- distal; 7 mid), adenocarcinoma (41 adenocarcinomas; 13 porated postoperative chemotherapy with paclitaxel and cispla- squamous cell carcinomas), and moderately differentiated tin. Combined trial results demonstrated that 93% percent of 92 (33 moderate; 6 well; 15 poor). Female gender predicted CR patients underwent surgery and 87% were completely resected (odds ratio 7.5; 95% confidence interval, 1.4–41). The OS with negative margins. The pathological CR rate was 33%. At was 43% at 5 years. Presence of CR (P < 0.001 log rank) median follow-up of 63.5 months, median survival of all enrolled patients was 35 months, and 5-year survival was 40%. Patients with a pathological CR did better (67% survival at 5 years, median not reached), whereas the remainder of the patients had 5-year survival of 27% (median survival at 21 Received 3/17/03; revised 8/28/03; accepted 8/28/03. months; P Ͻ 0.001). Survival is promising, but toxicity during The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked therapy and limited tolerance of adjuvant chemotherapy suggest advertisement in accordance with 18 U.S.C. Section 1734 solely to that both novel therapies and better selection of patients for indicate this fact. aggressive treatment are warranted. Requests for reprints: Michael K. Gibson, The Sidney Kimmel Com- One strategy to improve the outcome of patients treated prehensive Cancer Center at Johns Hopkins, Bunting-Blaustein Clinical Research Building, Room 186, 1650 Orleans Street, Baltimore, Mary- with chemoradiotherapy is to select treatment responders for land 21231-1000. Phone: (410)955-8838; Fax: (410)955-8587; E-mail: directed therapy. Current knowledge about the molecular mech- [email protected]. anisms of cancer-related pathways is facilitating numerous stud-

ies that attempt to identify molecular markers of both response Gy. Esophagogastrectomy was carried out approximately 4 to preoperative therapy and overall survival. Markers of interest weeks after completion of chemoradiotherapy in those patients include those associated with apoptosis (p53, bax, and bcl-2), without disease progression. Study J9528 differed from study cell cycle control (p16, p21, and cyclin D1), growth regulation J8908 in that patients were subsequently treated i.v. with adju- [epidermal growth factor receptor (EGF-R), transforming vant chemotherapy consisting of 135 mg/m2 paclitaxel for 24 h growth factor-␣, HER-2neu, Ki-67], and DNA repair (ERCC1), on day 1 and 75 mg/m2 cisplatin on day 2 repeated every 3 metastatic potential (tissue inhibitor of metalloproteinase, E- weeks for three cycles. cadherin), angiogenesis (vascular endothelial growth factor), The NIH CTC criteria were used to measure toxicity, and 6 and sensitivity to chemotherapy (P-glycoprotein, thymidylate appropriate dose adjustments and delays were made. All pa- synthase, glutathione S-transferase, and metallothionine; tients provided written informed consent, and the Institutional Ref. 12). Review Boards at Yale and Johns Hopkins approved both pro- Despite extensive study, there remain no clear candidate tocols. markers that predict pathological response, and there are only Follow-up after treatment involved medical oncology visits equivocal data for a limited number of markers that might at 4-month intervals for the first year and at 6-month intervals predict survival for patients treated with preoperative multimo- for the 2nd through 5th years. After 5 years, patients were dality therapy (13–17). Although the study by Harpole et al. evaluated annually. (14) contained mostly adenocarcinomas, many of the studies The primary outcome was pathological response in the involved only squamous cell histologies, despite the marked resected specimen. A CR was defined as the histological ab- increase in the incidence of adenocarcinoma (18, 19). The need sence of residual tumor in the resected esophageal specimen and for additional information about these mechanisms is becoming nodal tissue. A partial response was defined as residual malig- more pressing with the recent and ongoing development of nant cells in the resected specimen. Progressive disease was drugs that target these markers and pathways. defined as the presence of metastatic or unresectable disease Given the need for both better predictors of outcome and before surgery. The secondary outcome, survival, was defined identification of targets for directed therapy, we examined the as any patient remaining alive within 6 months of the time of role of clinical and cellular markers in predicting pathological final follow-up (October, 2002), regardless of the cause of response and overall survival in patients with locally advanced death. esophageal cancer who were treated with combined modality Tissue Samples and Immunohistochemistry (IHC). therapy at Johns Hopkins and Yale. Paraffin embedded, pretreatment tumor tissue was available for 54 of the 92 patients treated on protocols J8908 (n ϭ 34) and J9528 (n ϭ 20) at Johns Hopkins and Yale. All tissue was MATERIALS AND METHODS obtained by endoscopic biopsy of the primary esophageal tumor. Study Design. A total of 92 patients with histologically Unstained histopathological sections on ChemMate (Bio- confirmed invasive squamous cell carcinoma or adenocarci- Tek Solutions) slides were stained with an automated stainer in noma of the esophagus, gastroesophageal junction, or gastric the Johns Hopkins Immunopathology Laboratory per methods cardia were enrolled in two phase II clinical trials (3, 4). All used in studies of colorectal cancer described previously (20, patients were newly diagnosed and had received no prior treat- 21). Tissue was stained with antibodies to the following mark- ment. Each patient was older than 18 years of age, had a ers: EGF-R, bax, and bcl-2. Citrate buffer or Pronase (for Karnofsky performance status of Ͼ60%, and had adequate EGF-R) was used for antigen enhancement, and final detection hepatic, renal, and bone marrow reserve. The disease was lim- involved standard avidin-biotin staining methods. The mono- ited to the primary and regional nodes, although celiac nodal clonal antibodies Oncoprotein 124 (DakoCytomation) at a dilu- involvement (M1a) was permitted for primary tumors in the tion of 1:25 and 31G7 (Zymed, South San Francisco, CA) at a mid, distal, or gastroesophageal junction/cardia. Patients were dilution of 1:50 were used for detection of bcl-2 and EGF-R, required to be surgical candidates with disease that could be respectively. Biotinylated rabbit antimouse (DakoCytomation) encompassed in a single radiation port. In study J8908, patients was used as the secondary antibody. The bax marker was were staged with barium esophagogram and computed tomog- detected using the polyclonal rabbit IgG p19 (Santa Cruz Bio- raphy scans of the chest, abdomen, and pelvis. In study J9528, technology, Inc., Santa Cruz, CA) at a dilution of 1:100 with staging also included endoscopic ultrasound and exploratory biotinylated swine antirabbit (DakoCytomation) as a secondary laparoscopy. antibody. Primary antibodies were replaced with PBS in nega- Although patients in both trials received preoperative che- tive control slides. The positive controls used were lymph node moradiotherapy with cisplatin, 5-FU, and radiation, the regi- (bcl-2), Paneth cells in small intestine (bax), and basal epithe- mens differed slightly. In both studies, chemotherapy and ra- lium (EGF-R). diotherapy were administered over 30 calendar days. For study Slides were reviewed by a single pathologist who had no J8908, cisplatin at a dose of 26 mg/m2/day was administered on knowledge of the status of the response to chemoradiation. days 1–5 and 26–30, and 5-FU at a dose of 300 mg/m2/day was Grading of immunolabeling for bax, bcl-2, and EGF-R was given on days 1–30 by continuous i.v. infusion. For study J9528, performed using the immunoreactive score (IRS). The IRS takes cisplatin at a dose of 20 mg/m2/day was administered on days 1–5 and 26–30, and 5-FU at a dose of 225 mg/m2/day was given on days 1–30 by continuous i.v. infusion. In each study, radiotherapy was given at a daily dose of 2 Gy to a total dose of 44 6 http://ctep.info.nih.gov/reporting/ctc.html.

Table 1 Patient characteristics Protocol no. (patient no.) J8908 J9528 Variable Result (34) (20) Pa Age at enrollment mean (SD) 56 (11) 60 (7.5) 0.13 Age category Յ65 years 24 16 Ͼ65 years 10 4 0.44 Gender Male 28 17 Female 6 3 0.8 Pathologic response Progressive disease 1 3 Partial response 20 10 Complete response 13 7 0.26 Location Mid esophagus 7 0 Distal esophagus 27 20 0.03 Survival Alive 13 10 Dead 21 10 0.4 Barrett’s histology Present 13 10 Absent 21 10 0.4 Differentiation Well differentiated 4 2 Moderately differentiated 18 15 Poorly differentiated 12 3 0.23 Histology Adenocarcinoma 22 19 Squamous cell 12 1 0.01 a t test of proportions or ␹2 test.

into account both the intensity of staining (graded on a scale of (squamous cell carcinoma/adenocarcinoma); and differentiation 0to3;0ϭ no staining, 1 ϭ faint staining, 2 ϭ moderate (categorical; well, moderate, poor). Stage was not included as a staining, 3 ϭ strong staining) and the percentage of positive covariate because the staging methods differed between the two tumor cells (graded on a scale of 0 to 4; 0 ϭ none, 1 ϭϽ10%, studies. Histological IRSs were coded as either continuous 2 ϭ 10–50%, 3 ϭϾ50–80%, 4 ϭϾ80%). The final score (scale 0–12) or categorical (Յ1, 2–5, 6–9, Ͼ9). Middle strati- ranges from 0 to 12 and was obtained by multiplying the two fication at an IRS of 5 was chosen based on the median EGF-R parameters. IRS of 5. Mutation in p53 was coded as a binary variable p53 Gene Mutation Analysis. Four sets of oligonucleo- (present/absent). Ј Ј Ј tide primers (5 -GACTTTCAACTCTGTCTCC-3 and 5 - Survival was determined by the Kaplan-Meier method GAGCAATCAGTGAGGAATC-3Ј for exon 5; 5Ј-TCCCCAG- (22). Survival curves were compared using the log-rank test. GCTCTGATTCC-3Ј and 5Ј-TGACAACCACCCTTAACCC-3Ј Univariate and multivariate Cox proportional hazard models for exon 6; 5Ј-CAAGGCGCACTGGCCTCATC-3Ј and 5Ј-CA- were used to investigate the role of clinical and histological CAGCAGGCCAGTGTGCAG-3Ј for exon 7; and 5Ј-GATTTC- covariates. Hazard ratios are expressed as mean with 95% CTTACTGCCTCTTGC-3Ј and 5Ј-GTGAATCTGAGGCATA- ACTGC-3Ј for exon 8) were used to amplify exons 5–8ofthe confidence intervals. To investigate for interactions and cova- p53 gene. PCR was performed under standard conditions in a rations, multivariate and stratified models were checked. EGF-R 50-␮l volume using PCR Master (Boehringer Mannheim) and 1 and p53 were sequentially stratified against each other, and ␮M of both 5Ј and 3Ј oligonucleotides with 40 cycles (94°C for these variables were adjusted for the clinical covariates. 1 min, 58°C for 1 min, and 72°C for 2 min). PCR products were All statistical analyses were done using Intercooled Stata purified using shrimp alkaline phosphatase and exonuclease I version 7.0 (Stata Corp., College Station, TX). (Amersham, Buckinghamshire, United Kingdom). Purified PCR products were sequenced directly with SequiTherm Excel II DNA Sequencing kit (Epicenter, Madison, WI) with the same RESULTS primers used for DNA amplification. Oligonucleotides were Clinical Characteristics. Clinical characteristics of the end-labeled with [␥-32P]ATP (DuPont-New England Nuclear 54 patients who underwent tissue marker analysis are presented Research Products, Boston, MA) using T4 polynucleotide ki- in Table 1. Most patients were male and had adenocarcinoma. nase (New England Biolabs, Beverly, MA). All mutations were As expected given the preponderance of adenocarcinomas, the verified in both the sense and antisense directions. majority of cases (85%) occurred in the distal esophagus. Of the Data and Statistical Analysis. Follow-up data regarding distal adenocarcinomas (n ϭ 39), 21 were distal esophageal, and survival were extracted from oncology medical records main- 18 were gastroesophageal junction lesions. Significant differ- tained at Johns Hopkins. All living patients had at least 5 years ences in distribution between protocols were seen for tumor of follow-up. Clinical covariates were also extracted from the location and histology; i.e. patients on protocol J9528 had medical record and coded as follows: age at enrollment (con- essentially only distal adenocarcinomas. The age range was tinuous and binary; Յ65/Ͼ65); gender (M/F); Barrett’s meta- broad (32–75 years), although most patients (74%) were plasia (present/absent); tumor location (mid/distal); histology younger than 65 years old. Barrett’s histology was identified in

43% of biopsy specimens before initiation of treatment. Histo- Table 3 Multivariate Cox proportional hazard model: hazard ratio logical differentiation was mostly moderate (61%). for not surviving, univariate predictors adjusted for clinical a Of the 54 studied patients, 50 underwent complete surgical co-variates resection of tumor. Of the four patients with progressive disease, Hazard b three progressed during neoadjuvant therapy (two with liver Variable ratio 95% CI P lesions, one with bone lesions), and one was found to have liver Presence of p53 mutation 0.453 0.187 to 1.1 0.079 metastases intraoperatively at time of planned resection. Of the (8 values missing) remaining 50 patients who underwent potentially curative sur- EGF-R IRS Յ1 1 Baseline hazardBaseline hazard gical resection, 20 had no remaining viable tumor for a patho- 2 to 5 1.29 0.274 to 6.08 0.747 logical CR rate of 40%. Using intention-to-treat analysis and 6 to 9 3.55 0.944 to 13.4 0.061 including all 54 patients, pathological CR rate was 37%. Ͼ9 8 1.83 to 35 0.006 Five year follow-up survival data are available for all a Age, gender, protocol, Barrett’s metaplasia, tumor location, tu- surviving patients. Death was defined as all-cause (not cancer- mor histology, tumor differentiation. b specific) mortality. The longest survival follow-up was 11.75 CI, confidence interval; EGF-R, epidermal growth factor receptor; IRS, immunoreactive score. years, and the median survival follow-up was 7.3 years. In nonsurvivors, death occurred anywhere from 4 months to 4.25 years after initial diagnosis. Median survival time of dying patients equaled 1.3 years. The overall survival of approxi- experience, squamous cell histology tends to be more responsive mately 43% did not differ significantly between protocols (P ϭ to chemoradiotherapy. 0.45 by log-rank test for Kaplan-Meier survival curves). Survival analysis (Table 3; Figs. 1–3) revealed several IHC and p53 Mutation Analysis. IHC data and p53 significant predictors of better survival outcome. Patients who mutation analysis results are shown in Table 2. The IHC IRSs attained a pathological CR after preoperative chemoradio- are listed in categorical form. In general, EGF-R and bax scores therapy did better than those who did not. Presence of p53 are evenly distributed, whereas the bcl-2 score is skewed toward mutation (P ϭ 0.051 by log-rank test) and lower EGFR-IRS the low categories. The mutation analysis results for p53 exons (P ϭ 0.009 by log-rank test) predicted better survival. In addi- 5–8 show that a mutation is present in 29 of 46 tumors (mutation, the survival curves were suggestive of better survival in tion analysis could not be completed in eight patients because patients with well-differentiated tumors and low bcl-2 scores, the tumor DNA failed to amplify). but neither reached significance. In the univariate analysis with Correlation of Clinical and Molecular Markers with EGFR-IRS coded as a continuous variable, each one-unit in- Patient Outcome. We next used ␹2 and regression analysis to crease in EGFR-IRS resulted in a 14% decrease in survival determine whether any of the clinical covariates or marker data (hazard ratio of 1.14; 95% confidence interval, 1.04–1.25). predicted the presence of pathological CR. Only female gender When adjusted for all other clinical covariates using multivari- correlated, but the small number of female patients resulted in a ate modeling, only the lower EGFR-IRS remained a significant wide confidence interval (1.37–41.4). Furthermore, when ad- predictor of survival (Table 3). When stratified by tumor his- justed for other covariates, the relation did not persist. Stratifi- tology, however, EGFR-IRS was predictive only in patients cation of tumor histology by gender provides a likely explana- with adenocarcinoma. tion. Most males had adenocarcinoma (39 versus 6), whereas Clinical stage was not included as a clinical covariate, most females had squamous cell carcinoma (7 versus 2). In our although it is historically the most important predictor of survival. As a result, the impact on survival and on marker expression of potential differences in stage distribution between the two protocols was not assessed. Protocol J8908 used barium Table 2 Immunohistochemistry and mutation analysis esophagogram and computed tomography to determine the local extent of tumor. These techniques are unable to determine T and Marker Characteristic No. of patients N stage accurately. In contrast, use of endoscopic ultrasound in a p53 Mutation Present 29 protocol J9528 enabled a more precise determination of T and N Absent 17 EGF-Rb IRS (0–12)c Յ18stage. 2–519 Because of inherent limitations, staging with esophago- 6–915gram and computed tomography only may lead to incorrect Ͼ911inclusion of T1 and exclusion of M1a lesions from the treatment Յ Bax IRS 12group. However, if these staging errors resulted in marked 2–518 6–926differences in the stage distribution, one would expect to see a Ͼ98difference in survival between the two protocols. Because a Bcl-2 IRS Յ146difference does not exist, it is unlikely that the stage, and thus 2–57the expression of molecular markers, differs between the two 6–91 Ͼ90groups. To determine the relative contribution of each marker to a Eight missing values. b EGF-R, epidermal growth factor receptor; IRS, immunoreactive survival, we also carried out a multivariate analysis that in- score. cluded p53 mutation and EGFR-IRS in the model simulta- c One missing value. neously. When adjusted for each other and all other clinical

Fig. 1 Survival analysis stratified by pathological response plotted as the proportion of patients surviving from the date of surgery versus time in days using the Kaplan-Meier method (P Ͻ 0.001 by log-rank test, one missing value, three patients who progressed before surgery not included).

covariates using multivariate modeling; again, only lower thought to be involved in tumorigenesis and response to therapy EGF-R score remained a significant predictor of better survival are evaluated for their correlation with surgically determined (hazard ratio of 1.26; 95% confidence interval, 1.09–1.45). response to induction therapy and overall 5-year survival. The clinical outcomes of pathological response and sur- DISCUSSION vival in these patients compare favorably with those seen in This study reviews the clinical outcomes of pathological previous studies both at Johns Hopkins and elsewhere that used response and overall survival in a subset of patients with locally induction regimens containing 5-FU and cisplatin (23, 24). In advanced esophageal cancer treated with preoperative chemo- study J8908, 40% of patients had a pathological CR, 58% of radiotherapy in two trials conducted in the 1990s at Johns patients had 2-year survival, and pathological CR predicted a Hopkins and Yale. In addition, a group of molecular markers more favorable outcome. In study J9528, 28% of patients had a

Fig. 2 Survival analysis stratified by the presence or absence of p53 mutation plotted as the proportion of patients surviving from the date of diagnosis versus time in days using the Kaplan-Meier method (P ϭ 0.051 by log-rank test, eight missing values).

Fig. 3 Survival analysis stratified by categorical epidermal growth factor receptor-immunoreactive score (EGFR-IRS) plotted as the proportion of patients surviving from the date of diagnosis versus time in days using the Kaplan-Meier method (P ϭ 0.009 by log-rank test, 1 missing value).

CR, 62% of patients had 2-year survival, and again CR pre- ageal cancer remains unclear, recent work with the p53 codon dicted better outcome. Median survival follow-up was 43 72 polymorphism may provide some insight. The Arg72 variant months in the earlier trial and 30 months in the later trial. of this codon, located in exon 4 of the p53 gene, seems to This study extends the results seen in each of these indi- enhance the apoptotic ability of the protein (28). Perhaps the vidual trials by adding longer follow-up using the combined patients in this study sustained this or a similar activating data. After 4 years and 3 months, the survival curve reached a mutation. Other effectors of the intrinsic apoptosis pathway, bax plateau of 43%, with no additional deaths seen at a median of and bcl-2, were also analyzed. Although the effect of neither 7.3 years and a maximum follow-up of 11 years and 9 months. reached statistical significance, it is intriguing that the absence Overall survival in this combined group is lower than the 2-year of the antiapoptotic bcl-2 suggested better survival. survival in either single study, because a number of deaths An additional strong predictor of poor outcome was in- occurred after 2 years of follow-up. This suggests that patients creased EGF-R expression. This transmembrane protein tyro- remaining alive after approximately 4 years are cured and that at sine kinase growth factor receptor is abnormal or overexpressed least 4 years of follow-up is required for accurate survival data in many human tumors of epithelial origin, including head and in this patient population. neck, colorectal, pancreatic, lung, and esophageal cancers (29– Although we were unable to identify any variables that 32). In these tumors, overexpression is associated with more predicted response to therapy, we did confirm that patients who aggressive behavior and poor prognosis (33). attain a pathological CR do better. Several molecular markers The findings in this study are consistent with the EGF-R that correlate with survival were also found. Patients whose expression of approximately 30–70% in esophageal cancers tumors possess a p53 mutation had better survival. Many studies documented previously. Our data are also in agreement with have evaluated the role of p53 in the prediction of both patho- numerous prior studies, mostly in the squamous cell cancer, that logical CR and survival in patients treated with chemoradio- demonstrate that EGF-R expression is associated with poor therapy, but the results are mixed. Ribeiro et al. (15) showed by prognosis (17, 34–40). sequence analysis that the presence of a p53 mutation in either Our findings expand on these prior studies by evaluating a squamous or adenocarcinoma correlated with worse survival. A greater number of patients, of whom a significant number have study by Eto et al. (25), however, demonstrated no predictive adenocarcinoma (41 versus 13). Interestingly, differing from role of p53 mutation in squamous cell cancers. earlier studies involving squamous cell carcinomas, our data Consideration of the role of p53 in tumorigenesis and suggest that the predictive effect of EGF-R is limited to patients response to treatment could support any of the above results. with adenocarcinoma. These findings are intriguing in that they Given that p53 mutation is so frequent in human tumors, loss of suggest that adenocarcinoma, the histological type that is most normal functioning for DNA damage sensing, cell cycle arrest, rapidly increasing, is also a target for EGF-R directed therapies and apoptosis is thought to be a hallmark of cancer (12, 26). (18, 19). Recently available drugs include the small molecules Despite its clear contribution to the molecular pathogenesis of ZD1839 (Iressa) and OSI-774 (Tarceva) as well as the mono- tumors, however, the roles of p53 in the response of tumors to clonal antibody C225 (Erbitux). therapy and survival are variable (27). This demonstration of a measurable tumor marker to which Although the impact of p53 mutations on survival in esoph- a selective therapy is directed creates the possibility of individ-

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Michael K. Gibson, Susan C. Abraham, Tsung-Teh Wu, et al.

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