Elsevier

European Journal of Cancer

Volume 159, December 2021, Pages 24-33
European Journal of Cancer

Original Research
Circulating tumor DNA is a prognostic marker of tumor recurrence in stage II and III colorectal cancer: multicentric, prospective cohort study (ALGECOLS)

https://doi.org/10.1016/j.ejca.2021.09.004Get rights and content

Highlights

  • Longitudinal ctDNA evaluation is a prognostic marker of recurrence in a prospective series.

  • The rate of ctDNA detection was 27.5% before surgery and 10.5% after surgery.

  • Patients with preoperative ctDNA detection recurred in 32.7% of the cases.

  • Patients with postoperative ctDNA detection recurred in 44.4% of the cases.

  • Patients with preoperative and postoperative negative ctDNA recurred in 10.4% of the cases.

Abstract

Background

In non-metastatic colorectal cancer (CRC), we evaluated prospectively the pertinence of longitudinal detection and quantification of circulating tumor DNA (ctDNA) as a prognostic marker of recurrence.

Method

The presence of ctDNA was assessed from plasma collected before and after surgery for 184 patients classified as stage II or III and at each visit during 3–4 years of follow-up. The ctDNA analysis was performed by droplet-based digital polymerase chain reaction, targeting mutation and methylation markers, blindly from the clinical outcomes. Multivariate analyses were adjusted on age, gender, stage, and adjuvant chemotherapy.

Results

Before surgery, 27.5% of patients were positive for ctDNA detection. The rate of recurrence was 32.7% and 11.6% in patients with or without detectable ctDNA respectively (P = 0.001). Time to recurrence (TTR) was significantly shorter in patients with detectable ctDNA before (adjusted hazard ratio [HR] = 3.58, 95% confidence interval [CI] 1.71–7.47) or immediately after surgery (adjusted HR = 3.22, 95% CI 1.32–7.89). The TTR was significantly shorter in patients with detectable ctDNA during the early postoperative follow-up (1–6 months) (adjusted HR = 5, 95% CI 1.9–12.9). Beyond this period, ctDNA remained a prognostic marker with a median anticipated diagnosis of recurrence of 13.1 weeks (interquartile range 28 weeks) when compared to imaging follow-up. The rate of ctDNA+ might be underestimated knowing that consensus pre-analytical conditions were not described at initiation of the study.

Conclusion

This prospective study confirms the relevance of ctDNA as a recurrence risk factor in stage II and III CRC before surgery and as a marker of minimal residual disease after surgery that may predict recurrence several months before imaging techniques.

Introduction

Colorectal cancer (CRC) is the third most frequent cancer worldwide [1]. Most non-metastatic patients will achieve remission but 20–40% of them will recur, the risk depending on initial tumor staging [2]. In patients with ‘histological high-risk’ stage II and III, surgery is followed by adjuvant chemotherapy (ACT) that decreases the risk of recurrence. However, the survival is largely contrasted. In stage II, the overall survival (OS) is 80% but decreases up to 58% in case of invasion of the nearby structures (stage IIc). Likewise, the 3-year disease-free survival (DFS) is superior to 80% for patients with early stage III tumors but inferior to 66% for T4/N2 patients [2]. Such heterogeneity suggests that other factors should be taken into consideration to sharpen algorithms for CRC prognostication.

In metastatic CRC (mCRC), the longitudinal detection of circulating tumor DNA (ctDNA) is strongly correlated with the course of disease. At diagnosis, ctDNA is detectable (ctDNA+) in 80–90% of the patients [3,4]. High ctDNA concentration has been associated with tumor burden [5], liver metastasis [6], shorter progression-free survival [7], and shorter OS [3,8]. During chemotherapy, variations in ctDNA detection could provide early indication of recurrence [3,[9], [10], [11]] and clonal resistance [12,13]. In operable patients with liver metastasis, ctDNA+ before surgery is associated with an increased risk of recurrence [4,14].

Some questions remain in the landscape of non-mCRC. Before treatment, the reported frequency of ctDNA+ patients comprises between 50% and 90% [[15], [16], [17], [18], [19]]. The ctDNA clearance during treatment has rarely been evaluated. Within patients with preoperative ctDNA+ about 80% present no detectable DNA after surgery. Within patients with postoperative ctDNA+, 50% are cleared by ACT [16,21]. In locally advanced rectal cancer, Tie et al. [22] reported that 80% of ctDNA+ patients at baseline are cleared by radio-chemotherapy and surgery. After resection of the primary tumor, ctDNA+ could be associated with local and distant recurrence [16,20,23,24]. At the end of the ACT, ctDNA+ patients have shown an increased risk of relapse [16]. Finally, this marker may provide months’ lead-time on the detection of recurrence compared to conventional imaging [16]. Overall, patients with early stages of CRC should be cured and ctDNA tracking is essential to understand the crossroad between non-metastatic and micro-metastatic disease.

In addition to the limited number of studies at early cancer stages, the absence of standardization and the multiple detection technics might explain the discrepancies. The quantitative detection of ctDNA at early stages requires highly sensitive tools such as droplet-based digital polymerase chain reaction (ddPCR) and/or optimized next generation sequencing (NGS) [3,16]. The ctDNA monitoring by ddPCR targeting tumor-specific genetic and/or epigenetic alterations has been recently described as cost-effective and time-efficient [3,6,9].

In this study, we investigated the prognostic impact of the longitudinal ctDNA detection of patients with stage II or III CRC.

Section snippets

Study design and patients

The prospective multicenter ALGECOLS (Presence of Circulating Tumor DNA in Colorectal Cancer) study (NCT01198743) received the ethical approval from ‘the committee Ile-de-France II’ and all patients provided written informed consent. Patients were eligible if they had a resectable CRC above the Douglas reflection (colon and high rectum) without previous history of cancer. In per-protocol, the inclusions were restricted to stage II and III cancer (see workflow in Supplementary Fig. S1).

Plasma

Patients’ characteristics

Overall, 250 patients were included. Among them, 187 presented a stage II or III (per protocol) and were thus further studied (Supplementary Fig. S1). The mean age was 66.7 11.3 [30.1–86.1] and the gender ratio 1.37. The TNM classification showed 54.5% and 45.5% of stage II and III respectively and 52.4% received ACT (Table 1). Three patients were without plasma samples leading to 184 patients with both tumor tissues and serial plasma sample collected (Supplementary Fig. S1). Plasma samples

Discussion

Beyond histopathology, the molecular assessment of microsatellite status is the only prognostic factor used in daily practice for the decision of ACT.

In this work, ctDNA was detectable before surgery in 25% of stage II and 30% of stage III CRC. This rate is lower to what was observed in many other series [[15], [16], [17], [18], [19]]. Using multiplex assay PCR directed toward methylated genes, Symonds et al. [5] detected ctDNA+ preoperatively in 64% of stage II and 74% of stage III. The

Conclusion

Using a cost-effective and financially affordable method for a routine practice, this prospective study confirms the relevance of ctDNA as a recurrence risk factor in stage II and III CRC before surgery and as a marker of minimal residual disease after surgery that may predict recurrence several months before imaging techniques. It confirms the likelihood of ctDNA longitudinal sampling to become part of the decision process. More than a one-shot picture, it appears fundamental to determine

Fundings

This work was supported by the Ministère de l’Enseignement Supérieur et de la Recherche, the Université Paris-Descartes, the Centre National de la Recherche Scientifique (CNRS), the Institut National de la Santé et de la Recherche Médicale (INSERM), the Institut National du Cancer (INCA, n° 2009-1-RT-03-US-1 and 2009-RT-03-UP5-1), the Association pour la recherche contre le cancer (ARC, no. SL220100601375), the Agence Nationale de la Recherche (ANR Nanobiotechnologies; no. ANR-10-NANO-0002-09),

Conflict of interest statement

The authors of this work have conflicts of interest to declare:

Valerie Taly: Honoraria from Raindance Technologies and Boerhinger Ingehleim; cofounder Emulseo; board Emulseo.

Pierre Laurent-Puig: honoraria and board: Amgen, Merck-Serono, Boehringer Ingelheim, Sanofi, Roche, Lilly.

Julien Taieb: Honoraria from Merck, Amgen, Roche, Pierre Fabre, MSD, Sanofi, Lilly, Servier, Astra-Zeneca.

AZ: consulting and/or advisory boards: Roche, Merck Serono, Amgen, Sanofi, and Lilly.

Olivier Bouché: honoraria

Acknowledgments

This work was supported by the Ministère de l’Enseignement Supérieur et de la Recherche, the Université Paris-Descartes, the Centre National de la Recherche Scientifique (CNRS), the Institut National de la Santé et de la Recherche Médicale (INSERM), the Institut National du Cancer (INCA, n° 2009-1-RT-03-US-1 and 2009-RT-03-UP5-1), the Association pour la recherche contre le cancer (ARC, no. SL220100601375), the Agence Nationale de la Recherche (ANR Nanobiotechnologies; no. ANR-10-NANO-0002-09),

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