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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 1  |  Page : 42-48

Gene expression of excision repair cross-complementation group 1 enzyme as a novel predictive marker in patients receiving platinum-based chemotherapy in advanced bladder cancer


1 Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
2 Department of Pathology, Urology and Nephrology Centre, Mansoura University Hospital, Mansoura, Egypt

Date of Submission15-Sep-2017
Date of Acceptance15-Oct-2017
Date of Web Publication28-Feb-2018

Correspondence Address:
Wesal M Eldehna
Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University Hospital, Mansoura, 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_184_17

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  Abstract 


Background Excision repair cross-complementation group 1 enzyme (ERCC1) expression is most probably associated with cisplatin resistance in different tumors, including bladder tumors. Predictive role of ERCC1 expression in the neoadjuvant setting in bladder cancer had been studied as this genetic testing could personalize the chemotherapy by selecting the patients who would benefit from platinum-based chemotherapy.
Participants and methods This is a descriptive study that was conducted on 80 patients with muscle invasive bladder cancer who received platinum-based chemotherapy. Clinical and histopathologic parameters along with immunohistochemical ERCC1 staining were examined and correlated with response rates and survival.
Results The study showed a significant relationship between treatment response and ERCC1 expression of tumor tissue samples (P=0.013), indicating an association between negative immunoexpression and more favorable outcome. analysis of variance test revealed no significant difference neither between mean progression-free survival in different immunoexpression levels (P=0.794) nor mean overall survival in different immunoexpression levels (P=0.499).
Conclusion Our study showed that there was a significant relationship between treatment response and ERCC1 expression of tumor tissue samples, although it did not show a significant difference between ERCC1 expression and mean overall survival or progression-free survival in different immunoexpression levels in patients with bladder cancer who received neoadjuvant platinum-based chemotherapy. ERCC1 may represent a potential predictive, but not prognostic, marker for platinum-based treatment in bladder cancer.

Keywords: bladder cancer, excision repair cross-complementation group 1 enzyme, platinum-based chemotherapy, predictive, prognostic


How to cite this article:
Eldehna WM, Fouda MM, Eteba SM, Abdelrahim M, Elashry MS. Gene expression of excision repair cross-complementation group 1 enzyme as a novel predictive marker in patients receiving platinum-based chemotherapy in advanced bladder cancer. Benha Med J 2018;35:42-8

How to cite this URL:
Eldehna WM, Fouda MM, Eteba SM, Abdelrahim M, Elashry MS. Gene expression of excision repair cross-complementation group 1 enzyme as a novel predictive marker in patients receiving platinum-based chemotherapy in advanced bladder cancer. Benha Med J [serial online] 2018 [cited 2018 May 21];35:42-8. Available from: http://www.bmfj.eg.net/text.asp?2018/35/1/42/226413




  Introduction Top


The standard treatment for muscle invasive organ confined bladder carcinoma is radical cystectomy followed by urinary diversion; however, this procedure affects the quality of life of those patients. The use of combined trimodality treatment including transurethral resection, radiation therapy, and platinum-based chemotherapy has promising results [1]. Currently, neoadjuvant cisplatin-based chemotherapy is the standard of care in muscle invasive bladder cancer regarding level I evidence from randomized trials and meta-analyses. Downstaging of the tumors by the use of 4−6 cycles of chemotherapy in locally advanced nonmetastatic disease makes the disease amenable to local treatment [2]. Chemotherapy in advanced bladder cancer has reached a plateau with no evidence of survival benefits with the use of combined and new agents. Better understanding of the genetic basis of chemotherapy response may offer a promise in optimizing treatment through the development of new treatment strategies [3].

Excision repair cross-complementation group 1 enzyme (ERCC1) has a predictive role for cisplatin response, as high ERCC1 expression is associated with platinum-based chemotherapy resistance [4]. The selection of therapy should be based on individual genetic profile. Patients with tumors having platinum resistance would be the ideal candidates for new agents testing. On the other hand, patients with a platinum sensitivity would benefit from most of the standard platinum-based regimens [5].


  Aim Top


This study evaluated the outcomes of patients with muscle invasive nonoperable, nonmetastatic bladder cancer at the diagnosis receiving platinum-based chemotherapy. Primary endpoint was to assess patients’ response to chemotherapy in relation to expression of ERCC1. Secondary endpoint was to evaluate the prognostic values of ERCC1 through evaluation of the overall survival (OS) and progression-free survival (PFS).


  Participants and methods Top


This is a descriptive study that was conducted on 80 patients with muscle invasive nonoperable, nonmetastatic bladder cancer patients who received platinum-based chemotherapy and had sufficient histopathological material allowed for ERCC1 testing by immunohistochemistry (IHC) during the period of September 2015 to February 2017. This study was carried out after obtaining approval from the Ethics Research Committee.

Patients included in the study had stages of T2–T4a N negative or positive M0. None of the patients was pretreated with any other chemotherapy or radiotherapy. Patients signed study-specific informed consent before study entry.

Patients received 4–6 cycles of platinum-based chemotherapy regimen (4–6 cycles) as follows: gemcitabine: 1000 mg/m2 (30–60 min intravenous infusion) days 1 and 8 plus cisplatin: 75 mg/m2 (over 60 min intravenous infusion) day 1, to be repeated every 21 days, or gemcitabine: 1000 mg/m2 (30–60 min intravenous infusion) days 1 and 8 plus carboplatin: Appropriate Use Criteria (AUC) of 4 (over 120 min intravenous infusion) day 1, to be repeated every 21 days.

Formalin-fixed paraffin-embedded tissue sections were stained using the mouse monoclonal antihuman ERCC1 antibody (catalog number sc-17809; Santa Cruz Biotechnology Inc., Heidelberg, Germany) through immunoperoxidase. Four-micron-thick paraffin slides were placed on plus slides dried for 1 h in a 60°C oven and placed on a manual immunostainer where they were deparaffinized and heat-induced epitope retrieval was performed with citrate buffer solution, pH of 6, for 30 min at 95–100°C. Primary antibody, mouse monoclonal antihuman ERCC1 antibody (1 : 50 dilution), was applied to sections at 37°C for 60 min. Immunoreactivity was visualized by using the Genemed power staint 1.0 poly HRB kit for mouse+rabbit (South San Francisco, California, USA). Slides were counterstained with hematoxylin, dehydrated, cleared, and mounted with permanent mounting medium. The staining intensity was evaluated in a semiquantitative way representing the average intensity of the stained tumor cells (0=no staining, 1=weak staining, 2=moderate staining, and 3=strong staining).

Statistical method

Data entry and analyses were performed using SPSS statistical package version 16 (SPSS Inc., Chicago, Illinois, USA). The quantitative data were presented as mean, standard deviation, median, and range. The qualitative data were presented as number and percentage. Kaplan–Meier survival analysis was used to find out OS and PFS. Relative risk and 95% confidence intervals were calculated for factors affecting response. The P value of 0.05 or less indicates significant results at confidence interval 95%.


  Results Top


A total of 80 patients of muscle invasive nonoperable, nonmetastatic pathologically confirmed bladder cancer were enrolled in this study. ERCC1 IHC was performed on paraffin-embedded tissue blocks from cystoscopic biopsies and staining was evaluated semiquantitatively. Patients received chemotherapy regimen with 4–6 cycles of platinum-based chemotherapy.

Patient characteristics

The age of the patients ranged between 44 and 79 years, with a mean age of 64.7 years. The majority of the patients were male (77.5%) and 22.5% were female. The male to female ratio was 3.4 : 1; other patient characteristics are shown in [Table 1].
Table 1 Basic characteristics of the studied patients

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ERCC1 expression was found to be positive in 35 (43.75%) and negative in 45 (56.25%) patients’ tumor tissues. The tumor’s expression of ERCC1 scored as strong positive in 12 (15%), moderate positive in 13 (16.2%), and weak positive in 10 (12.5%) studied patients ([Table 2]).
Table 2 Excision repair cross-complementation group 1 enzyme expression of the studied patients

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It was found that there is no significant relationship between patients’ basic, pathological, or clinical characteristics and ERCC1 expression of tumor tissue samples. There was no significant relationship between histopathological type, tumor size, or tumor, node and metastasis staging and ERCC1 expression of tumor tissue samples. However, levels of ERCC1 expression significantly varied in different tumor grades and in association with lymph node status (P=0.013). Weak expression was associated with grade I tumor in four (57.1%) cases. Moreover, N3 tumors were associated with strong immunoexpression (two cases=50%).

[Table 3] shows that there was a significant relationship between treatment response and ERCC1 expression of tumor tissue samples (P=0.013). Among the cases showing complete response (CR), 24 (64.9%) showed negative immunostaining. Similarly, 15 (68.2%) partial response (PR) patients showed negative immunostaining. However, two (40%) progressive disease (PD) patients and four (25%) stable disease (SD) patients showed negative immunostaining, indicating an association between negative immunoexpression and more favorable outcome.
Table 3 Correlation between excision repair cross-complementation group 1 enzyme expression and treatment response

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The lowest mean PFS was 3.5±0.71 months and was recorded for patients having moderate ERCC1-positive staining. However, analysis of variance (ANOVA) test revealed no significant difference between mean PFS in different immunoexpression levels (P=0.794). Tests of equality of PFS distributions for the different levels of ERCC1 using Kaplan–Meir analysis also revealed a nonsignificant difference ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).
Figure 1 High grade TCC infiltrating the muscle layer showing negative nuclear staining for ERCC1; immunoperoxidase ×200.

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Figure 2 High-grade TCC showing weak diffuse nuclear staining for ERCC1; immunoperxoidase ×200.

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Figure 3 High-grade TCC showing moderate focal nuclear staining for ERCC1; immunoperxoidase ×200.

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Figure 4 High-grade TCC showing strong focal nuclear staining for ERCC1; immunoperxoidase ×200.

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Figure 5 High-grade TCC showing strong diffuse nuclear staining for ERCC1; immunoperxoidase ×200.

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Figure 6 The Kaplan–Meier curve for progression free survival (PFS).

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The lowest mean OS was 5±0 months and was recorded for patients having weak ERCC1-positive staining. However, ANOVA test revealed no significant difference between mean OS in different immunoexpression levels (P=0.499). Tests of equality of OS survival distributions for the different levels of ERCC1 using Kaplan–Meir analysis also revealed a nonsignificant difference ([Figure 7]).
Figure 7 The Kaplan–Meier curve for overall survival (OAS).

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  Discussion Top


Cisplatin is the most important chemotherapy agent for bladder cancer and is usually administered with gemcitabine. The cytotoxic effect of platinum-based chemotherapy can be attributed to the formation of bulky platinum DNA adducts. Cisplatin resistance appears to be due to removal of these adducts ERCC1, which plays a major part in cisplatin resistance [6].

ERCC1 is an important predictive marker. It was found that an increase in ERCC1 expression is most probably associated with cisplatin resistance in cancer patients who were treated with platinum-based regimens [7].

Chemotherapy in advanced bladder cancer had reached a plateau. Better understanding of the genetic basis of chemotherapy response might offer promise in optimizing the treatment strategy [3].

ERCC1 was assessed in the present study by IHC; it was found to be positive in 43.75% of the patients’ tumor tissues and negative in 56.25%. The tumor’s expression of ERCC1 scored as strong positive in 15%, moderate positive in 16.2%, and weak positive in 12.5%. These results were compatible with those reported by Sakano et al., in which ERCC1 was positive in 52.1% and negative in 47.9% [9]; however, they showed ERCC1 positivity in nearly 70% of cases [9].

In our study, the overall response rate (CR+PR) was 73.75%. Complete remission was detected in 46.2% of the patients; 27.5% showed PR, 20% showed SD, and 6.2% showed disease progression (PD). This was nearly in agreement with the studies of Lee et al. [2], which reported CR in 78.1%.

This current study showed that there is a significant relationship between treatment response and ERCC1 expression of tumor tissue samples (P=0.013). Among the cases showing CR, 64.9% showed negative immunostaining. Similarly, 68.2% of PR patients showed negative immunostaining. However, 40% of PD patients and 25% of SD patients showed negative immunostaining, indicating an association between negative immunoexpression and more favorable outcome, which is in agreement with that reported by Bellmunt et al. [8], who stated that CR rates were lower in patients with high ERCC1 expression than those with lower ERCC1 expression. Therefore, patients with high ERCC1 levels can benefit from new agents testing, whereas those with low ERCC1 levels may have a better outcome with standard cisplatin-based chemotherapy regimens [8].

Hoffmann et al. [10], also reported that high ERCC1 mRNA expression was associated with poor outcomes following cisplatin-based chemotherapy in 108 patients with locally advanced bladder cancer.

Our results were incompatible with the study of Kawashima et al. [11], which reported CR of 75% in ERCC1-negative tissues, whereas CR was 25% with ERCC1-positive tumors, with P value of 0.008 done for all patients.

Muhammet et al. [12], failed to demonstrate a relationship between ERCC1 expression levels and chemotherapy response in patients with locally advanced bladder cancer who received neoadjuvant platinum-based chemotherapy.

Our study showed that there is no significant relationship between histopathological type, tumor size, or tumor, node and metastasis staging and ERCC1 expression of tumor tissue samples. This contradicts the study which reported CR of 95.7% in T2 tumors versus 80% CR regarding T3–T4a (P=0.04), and the study which reported significant P value of 0.02 regarding tumor stage, and that of Sabaa et al. [13], who showed significant P value of 0.031 for T stage.

However, levels of ERCC1 expression significantly varied in different tumor grades and in association with lymph node status (P=0.013). Weak expression was associated with grade I tumor (57.1%). This was compatible with the study of Sabaa et al. [13], with significant P value of 0.004. Moreover, our study showed that N3 tumors were associated with strong immunoexpression of ERCC1.

In this study, the lowest mean PFS was 3.5±0.71 months and was recorded for patients having moderate ERCC1-positive staining. However, ANOVA test revealed no significant difference between mean PFS in different immunoexpression levels (P=0.794). Tests of equality of PFS distributions for the different levels of ERCC1 using Kaplan–Meir analysis also revealed a nonsignificant difference.

In the present study, the lowest mean OS was 5±0 months and was recorded for patients having weak ERCC1-positive staining. However, ANOVA test revealed no significant difference between mean OS in different immunoexpression levels (P=0.499). Tests of equality of OS distributions for the different levels of ERCC1 using Kaplan–Meir analysis also revealed a nonsignificant difference.

Our results are not matched with those reported by Bellmunt et al. [8], who revealed a significantly longer median survival (25.4 vs. 15.4 months, P=0.03) and longer time to progression in advanced bladder cancer patients with low ERCC1 levels compared with those with high levels. Their study was a retrospective one that was conducted on 57 patients who received gemcitabine/cisplatin paclitaxel. However, they found no correlation between ERCC1 levels and response rates to chemotherapy, which contradict our study that showed positive correlation between ERCC1 levels and response rates [8].

Guix et al. [14], also found that the median disease-specific survival was significantly higher in patients having negative ERCC1 expression by IHC (12.6 vs. 8.6 months; P 0.032) compared with positive ones in patients with advanced bladder cancer.

Hoffmann et al. [10], indicated that high ERCC1 mRNA expression was associated with poor outcomes following cisplatin-based chemotherapy in 108 patients with locally advanced bladder cancer in the adjuvant setting. Muhammet et al. [12], also reported that tumors with high ERCC1 expression had inferior outcomes as regards disease-free and OS compared with those with low ERCC1 expression in the patients receiving neoadjuvant platinum-based chemotherapy in advanced bladder cancer.

Genetic testing of ERCC1 mRNA expression levels could personalize the chemotherapy by selecting the patients who would benefit from platinum-based chemotherapy. Those patients with high ERCC1 levels would be the ideal target for testing of new agents and those with low levels may have a better outcome with standard cisplatin-based chemotherapy regimens [8].


  Conclusion Top


By analyzing the previous studies, there is in agreement that the predicting and prognostic role of ERCC1 in the treatment of advanced bladder cancer was controversial. Although many studies have shown that high tumor ERCC1 expression was associated with less outcomes in terms of response rates, PFS, or OS in patients with bladder cancer who received platinum-based chemotherapy. Our study demonstrated a correlation between ERCC1 expression and treatment response, which is our primary endpoint that has been achieved through this study; however, we failed to demonstrate a correlation between ERCC1 expression levels and neither OS nor PFS, which is our secondary endpoint.

Acknowledgements

Wesal M. Eldehna, Mona M. Fouda, Soumaya M. Eteba, and Mohamed S. Elashry were responsible for application of the treatment protocol and follow-up of the patients. Mona Abdelrahim was responsible for histopathological examination of the specimens of the studied patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rödel C, Grabenbauer GG, Kühn R, Papadopoulos T, Dunst J, Meyer M et al. Combined-modality treatment and selective organ preservation in invasive bladder cancer: long-term results. J Clin Oncol 2002; 20:3061–3071.  Back to cited text no. 1
    
2.
Lee CY, Yang KL, Ko HL, Huang RY, Tsai PP, Chen MT et al. Tri-modality bladder sparing approach without neo-adjuvant chemotherapy for node negative localized muscle invasive urinary bladder cancer resulted in comparable cystectomy free survival. Radiat Oncol 2014; 9:213.  Back to cited text no. 2
    
3.
Bellmunt J, Albanell J, Paz-Ares L, Climent MA, González-Larriba JL, Carles J et al. Pretreatment prognostic factors for survival in patients with advanced urothelial tumors treated in a phase I/II trial with paclitaxel, cisplatin, and gemcitabine. Cancer 2002; 95:751–757.  Back to cited text no. 3
    
4.
Simon GR, Sharma S, Cantor A, Smith P, Bepler G. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest 2005; 127:978–983.  Back to cited text no. 4
    
5.
Sun J-M., Ahn M-J., Park MJ, Lee H-Y., Ahn JS, Lee S et al. Expression of excision repair cross-complementation group 1 as predictive marker for nasopharyngeal cancer treated with concurrent chemoradiotherapy. Int J Radiat Oncol Biol Phys 2011; 80:655–660.  Back to cited text no. 5
    
6.
Hwang I, Ahn M, Park B, Ahn YC, Han J, Lee S et al. ERCC1 expression as a prognostic marker in N2 (+) non-small-cell lung cancer patients treated with platinum-based neo-adjuvant concurrent chemo-radiotherapy. Cancer 2008; 113:1379–1386.  Back to cited text no. 6
    
7.
Maithel SK, Coban I, Kneuertz PJ, Kooby DA, El-Rayes BF, Kauh JS et al. Differential expression of ERCC1 in pancreas adenocarcinoma: high tumor expression is associated with earlier recurrence and shortened survival after resection. Ann Surg Oncol 2011; 18:2699–2705.  Back to cited text no. 7
    
8.
Bellmunt J, Paz-Ares L, Cuello M, Cecere FL, Albiol S, Guillem V et al. Gene expression of ERCC1 as a novel prognostic marker in advanced bladder cancer patients receiving cisplatin-based chemotherapy. Ann Oncol 2007; 18:522–528.  Back to cited text no. 8
    
9.
Sakano S, Ogawa S, Yamamoto Y, Nishijima J, Miyachika Y, Matsumoto H et al. ERCC1 and XRCC1 expression predicts survival in bladder cancer patients receiving combined trimodality therapy. Clin Mol Oncol 2013; 1:403–410.  Back to cited text no. 9
    
10.
Hoffmann A, Wild P, Leicht C, Bertz S, Danenberg KD, Danenberget PV et al. MDR1 and ERCC1 expression predict outcome of patients with locally advanced bladder cancer receiving adjuvant chemotherapy. Neoplasia 2010; 12:628–636.  Back to cited text no. 10
    
11.
Kawashima A, Takayama H, Tsujimura A, Excision Repair Cross-Complementing Group 1 may predict the efficacy of chemoradiation therapy for muscle-invasive bladder cancer. Clin Cancer Res 2010; 10:1078–1158.  Back to cited text no. 11
    
12.
Muhammet F, Omer D, Nazmiye D, Serdar B, Gulnur G, Bahri G et al. Low ERCC1 expression is associated with prolonged survival in patients with bladder cancer receiving platinum-based neoadjuvant chemotherapy. Urol Oncol 2013; 31:1709–1715.  Back to cited text no. 12
    
13.
Sabaa MA, El-Gamal OM, Abo-Elenen M, Khanam A. Combined modality treatment with bladder preservation for muscle invasive bladder cancer. Urol Oncol 2010; 28:14–20.  Back to cited text no. 13
    
14.
Guix M, Lema L, Lloreta J, Rojo F, Suárez C, Carles J et al. Excision repair cross-complementing 1 (ERCC1) and survival in advanced bladder cancer: confirmatory results using immunohistochemistry. J Clin Oncol 2009; 27. 5025.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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