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Comparison of Mismatch Repair Status Between Primary and Matched Metastatic Sites in Patients with Colorectal Cancer

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Comparison of Mismatch Repair Status Between Primary and Matched Metastatic Sites in Patients with Colorectal Cancer ORIGINAL RESEARCH Comparison of Mismatch Repair Status Between Primary and Matched Metastatic Sites in Patients With Colorectal Cancer Wen-Zhuo He, MDa,*; Wan-Ming Hu, MDb,c,d,*; Fang Wang, MDe,*; Yu-Ming Rong, MDa; Lin Yang, MDa; Qian-Kun Xie, MDa; Yuan-Zhong Yang, MDb; Chang Jiang, MDa; Hui-Juan Qiu, MDa; Jia-Bin Lu, MDb; Bei Zhang, MDa; Pei-Rong Ding, MDf; Xiao-Jun Xia, PhDg; Jian-Yong Shao, MDe; and Liang-Ping Xia, MDa Background ABSTRACT Colorectal cancer (CRC) is among the most common cancers worldwide,1 and distant metastasis is ex- Background: Differences between the features of primary cancer and tremely common in CRC.2 Recently, different profiles matched metastatic cancer have recently drawn attention in research. between the primary CRC and corresponding meta- This study investigated the concordance in microsatellite instability (MSI) and mismatch repair (MMR) status between primary and corre- static cancers have been found, particularly genetic sponding metastatic colorectal cancer (CRC). Methods: Consecutive discordances between the primary and the metastatic patients with metastatic CRC who had both primary and meta- sites.3–6 Moreover, oxidative DNA damage and some static tumors diagnosed at our institution in January 2008 through chemokines were significantly higher in metastases fi December 2016 were identi ed. Immunohistochemistry was used to than in primary tumors,7,8 andtheleveloftumor- test the MMR status of both primary and matched metastatic tumors, fi and PCR analysis was performed to test MSI in patients with deficient in ltrating lymphocytes and expression of PD-L1 dif- 9,10 MMR (dMMR) status. Results: A total of 369 patients were included. fered between primary and metastatic tumors, with Of the 46 patients with MSI-high primary tumors, 37 (80.4%) also had the discrepancy being site-specificinsomecases.11 MSI-high metastatic tumors, whereas 9 (19.6%) had microsatellite These differences indicate that metastases may pro- stable (MSS) metastatic tumors. A high concordance was found in vide a better “predictive window” for targeted therapy patients with liver, lung, or distant lymph node metastases. Inter- 3 estingly, the discrepancy was more likely to be limited to peritoneal than the primary cancer alone. (5/20) or ovarian (4/4) metastasis (chi-square test, P,.001). These The mismatch repair (MMR)/microsatellite in- organ-specific features were also found in the pooled analysis. Along stability (MSI) pathway significantly contributes to CRC with the change of MSI-high in primary cancer to MSS in metastatic development12,13 and is associated with the immune fi fi P5 cancer, lymphocyte in ltration decreased signi cantly ( .008). microenvironment.14,15 However, although the dis- However, the change did not influence survival; the median overall survival of MSI-high and MSS metastatic tumors was 21.3 and tinct features of MSI-high (MSI-H) tumors have been 16 21.6 months, respectively (P5.774). The discrepancy rate was 1.6% identified, MSI status of the primary CRC versus its for patients with proficient MMR primary tumors. Conclusions: For metastatic lesions has not been fully explored. Change patients with dMMR primary tumors, the concordance of MSI and in MSI status is important because studies have shown MMR status in primary CRC and corresponding metastatic cancer is that only patients with deficient MMR (dMMR) or potentially organ-specific. High concordance is found in liver, lung, fi – 17,18 and distant lymph node metastases, whereas discrepancy is more MSI-high tumors bene tfromantiPD-1 therapy. 19 likely to occur in peritoneal or ovarian metastasis. Rebiopsy to Haraldsdottir et al reported a 100% concordance evaluate MSI-high/dMMR status might be needed during the course of anti–PD-1 therapy in cases of peritoneal or ovarian metastasis. J Natl Compr Canc Netw 2019;17(10):1174–1183 a b doi: 10.6004/jnccn.2019.7308 VIP Region and Department of Pathology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong, P. R. China; cDepartment of Pathology, School of Basic Medical Sciences, and dDepartment of Pathology, Nanfang Hospital, Southern Medical University, Guangzhou, P. R. China; and eDepartment of Molecular Diagnostics, fDepartment of Colorectal Surgery, and gDepartment of Experimental Research, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China. *These authors contributed equally. See JNCCN.org for supplemental online content. See page 1263 for related commentary. 1174 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 17 Issue 10 | October 2019 MMR Status of Primary/Metastatic Tumors ORIGINAL RESEARCH rate in MMR status between the primary tumor and Assessment of Lymphocyte Infiltration corresponding metastatic tissue in 25 patients with CRC, Tumor microenvironment parameters were assessed as whereas Fujiyoshi et al20 found a discordance in 3 patients previously reported.22,23 Briefly, absent and weak in- and Jung et al21 found a concordance rate of only 77%. creases in lymphocytes were considered low-grade in- Our study evaluated concordance in MSI and MMR filtration, whereas moderate to severe increases were status between primary and corresponding metastatic considered high-grade (see eAppendix 1). tumors in CRC. Because prior studies examining this were small, we also performed a pooled analysis. DNA Isolation and Assessment of Tumor MSI Genomic DNA was extracted using a QIAamp DNA FFPE Methods Tissue Kit (QIAGEN). PCR analyses were performed to test for MSI when tumors were classified as dMMR. MSI Patients and Ethical Concerns analysis was performed using 5 microsatellite markers This study evaluated consecutive patients with meta- (BAT-25, BAT-26, D2S123, D5S346, and D17S250) rec- static CRC diagnosed with both primary and meta- ommended by NCI. static tumors at Sun Yat-sen University Cancer Center in January 2008 through December 2016. Those with in- sufficient primary tumor tissue, frozen metastatic tumor Germline MMR Mutational Analysis tissue, and a history of receiving neoadjuvant chemo- Patients with MSI-high tumors underwent germline radiation before surgery were excluded (Figure 1). This genetic testing of the MMR genes. The genetic sus- MLH1 MSH2 study was approved by the ethics review board at Sun ceptibility panel targeting all exons of , , MSH6 PMS2 EPCAM Yat-sen University Cancer Center, and informed consent , ,and , and proximal intronic fl 6 was obtained from all patients. anking sequences ( 10 base pairs [bp]) were analyzed for screening of single-nucleotide variation, including in- Assessment of MMR Status sertion and deletions shorter than 20 bp (see eAppendix 1). Formalin-fixed, paraffin-embedded (FFPE) tumor tissue was selected per case, and immunostaining was per- BRAF V600E Mutation Analysis formed using standard protocols. The 4 most com- In patients with MSI-high tumors, a BRAF V600E mu- mon MMR proteins, namely, MLH1, MSH2, MSH6, tation analysis was performed with quantitative real- and PMS2, were analyzed using the anti-MLH1, anti- time PCR using the minor groove binder probes (see MSH2, anti-MSH6, and anti-PMS2 antibodies, re- eAppendix 1). spectively (1:50; Beijing Zhongshan Golden Bridge Biotechnology Co, Ltd). Methods are described in Tumor Mutational Burden Analysis detail in eAppendix 1, available with this article at Tumor mutational burden (TMB) was measured by JNCCN.org. counting all nonsynonymous missense mutations that Patients with both primary and metastatic tumor tissue (n=407) Excluded (n=38) • Insufficient primary tumor tissue (n=17) • Frozen metastatic tumor tissue (n=11) • History of receiving neoadjuvant chemoradiation (n=10) Patients meeting inclusion criteria (n=369) dMMR primary tumor pMMR primary tumor (n=48; 13.0%) (n=321; 87.0%) dMMR metastatic pMMR metastatic dMMR metastatic pMMR metastatic tumor (n=39; 81.2%) tumor (n=9; 18.8%) tumor (n=5; 1.6%) tumor (n=316; 98.4%) Figure 1. Flowchart of patient selection. Abbreviations: dMMR, deficient mismatch repair; pMMR, proficient mismatch repair. JNCCN.org | Volume 17 Issue 10 | October 2019 1175 ORIGINAL RESEARCH He et al had not been previously reported as germline alterations. interval was 15.6 months (range, 4.0–96.7 months). A total The workflow of TMB analysis according to HaploX of 112 (30.4%), 147 (39.8%), and 110 patients (29.8%) were Biotechnology’s laboratory standardization24 is available diagnosed with right-sided colon cancer, left-sided in eAppendix 1. colon cancer, and rectal cancer, respectively. Patient and tumor characteristics are shown in Table 1. MLH1 Promoter Methylation Analysis Methylation in the region near the start codon of MLH1 Patients With dMMR Primary Tumors was assessed using bisulfite-treated DNA. The PCR A total of 48 patients had dMMR primary tumors, in conditions were first set at 98°C for 4 minutes; following whom PCR analyses were performed to test for MSI; this, 20 cycles were completed at 94°C for 45 seconds, 66°C 2 patients had MSI-low tumors, and their corresponding for45seconds,and72°Cfor1minute.Then20cycleswere metastatic tumors were also MSI-low. The remaining completed at 94°C for 45 seconds, 56°C for 45 seconds, and 46 patients had MSI-high primary tumors. Among these, 72°C for 1 minute, and a final extension was completed at 37 (80.4%) had MSI-high and 9 (19.6%) had micro- 72°C for 8 minutes. The PCR reaction was performed with satellite stable (MSS) metastatic tumors. The site of the following primers: M254-3F (59-GTT TTG GTT TTA metastasis was the perineum in 20 patients (43.5%), the GTT TAG GAG TAT TGG-39)andM254-3R(59-CCR AAT liver in 10 (21.7%), distant lymph nodes in 9 (19.6%), the TCA AAA ACT TAC TAT AAA CCT AC-39). ovaries in 4 (8.7%), and the lungs in 3 (6.5%). No dis- crepancy regarding MSI status was observed in patients Identification of Studies and Eligibility Criteria with liver, lung, or distant lymph node metastasis.
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