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 en- rolled 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 pa- tients 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- Downloaded from clincancerres.aacrjournals.org on September 26, 2021. © 2003 American Association for Cancer Research. 6462 Epidermal Growth Factor Receptor and Esophageal Cancer 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).