title: Microsatellite instability predicts improved response to adjuvant therapy with irinotecan, fluorouracil, and leucovorin in stage III colon cancer: Cancer and Leukemia Group B Protocol 89803.
abstract: OBJECTIVE
  Colon cancers exhibiting DNA mismatch repair (MMR) defects demonstrate distinct clinical and pathologic features, including better prognosis and reduced response to fluorouracil (FU) -based chemotherapy. This prospective study investigated adjuvant chemotherapy containing FU and irinotecan in patients with MMR deficient (MMR-D) colon cancers.
  
  
  METHODS
  Cancer and Leukemia Group B 89803 randomly assigned 1,264 patients with stage III colon cancer to postoperative weekly bolus FU/leucovorin (LV) or weekly bolus irinotecan, FU, and LV (IFL). The primary end point was overall survival; disease-free survival (DFS) was a secondary end point. Tumor expression of the MMR proteins, MLH1 and MSH2, was determined by immunohistochemistry (IHC). DNA microsatellite instability was also assessed using a panel of mono- and dinucleotide markers. Tumors with MMR defects were those demonstrating loss of MMR protein expression (MMR-D) and/or microsatellite instability high (MSI-H) genotype.
  
  
  RESULTS
  Of 723 tumor cases examined by genotyping and IHC, 96 (13.3%) were MMR-D/MSI-H. Genotyping results were consistent with IHC in 702 cases (97.1%). IFL-treated patients with MMR-D/MSI-H tumors showed improved 5-year DFS as compared with those with mismatch repair intact tumors (0.76; 95% CI, 0.64 to 0.88 v 0.59; 95% CI, 0.53 to 0.64; P = .03). This relationship was not observed among patients treated with FU/LV. A trend toward longer DFS was observed in IFL-treated patients with MMR-D/MSI-H tumors as compared with those receiving FU/LV (0.57; 95% CI, 0.42 to 0.71 v 0.76; 95% CI, 0.64 to 0.88; P = .07; hazard ratio interaction between tumor status and treatment, 0.51; likelihood ratio P = .117).
  
  
  CONCLUSIONS
  Loss of tumor MMR function may predict improved outcome in patients treated with the IFL regimen as compared with those receiving FU/LV.
authors.affiliation: Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA 02115, USA. mbertagnolli@partners.org
authors.forename: Monica M
authors.initials: MM
authors.lastname: Bertagnolli
authors.forename: Donna
authors.initials: D
authors.lastname: Niedzwiecki
authors.forename: Carolyn C
authors.initials: CC
authors.lastname: Compton
authors.forename: Hejin P
authors.initials: HP
authors.lastname: Hahn
authors.forename: Margaret
authors.initials: M
authors.lastname: Hall
authors.forename: Beatrice
authors.initials: B
authors.lastname: Damas
authors.forename: Scott D
authors.initials: SD
authors.lastname: Jewell
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Mayer
authors.forename: Richard M
authors.initials: RM
authors.lastname: Goldberg
authors.forename: Leonard B
authors.initials: LB
authors.lastname: Saltz
authors.forename: Robert S
authors.initials: RS
authors.lastname: Warren
authors.forename: Mark
authors.initials: M
authors.lastname: Redston
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002166:Camptothecin / Q000008:administration & dosage / Q000031:analogs & derivatives; D017024:Chemotherapy, Adjuvant; D003110:Colonic Neoplasms / Q000188:drug therapy* / Q000235:genetics*; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D006801:Humans; D000077146:Irinotecan; D002955:Leucovorin / Q000008:administration & dosage; D008297:Male; D053842:Microsatellite Instability; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D016019:Survival Analysis; D055815:Young Adult
chemical_list: D000077146:Irinotecan; D002955:Leucovorin; D005472:Fluorouracil; D002166:Camptothecin