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10.1245/ASO.2006.05.052
Annals of Surgical Oncology 13:823-835 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Prognostic Significance of Epidermal Growth Factor Receptor Expression in Colon Cancer Patients Undergoing Curative Surgery

Gennaro Galizia, MD1, Eva Lieto, MD1, Francesca Ferraraccio, MD2, Ferdinando De Vita, MD3, Paolo Castellano, MD1, Michele Orditura, MD3, Vincenzo Imperatore, MD1, Anna La Mura, MD2, Giovanni La Manna, MD1, Margherita Pinto, MD1, Giuseppe Catalano, MD3, Carlo Pignatelli, MD1 and Fortunato Ciardiello, MD3

1 Division of Surgical Oncology, "F. Magrassi and A. Lanzara" Department of Clinical and Experimental Medicine and Surgery, Second University of Naples School of Medicine, c/o II Policlinico, Edificio 17, Via Pansini, 5, 80131 Naples, Italy
2 Division of Pathology, "F. Magrassi and A. Lanzara" Department of Clinical and Experimental Medicine and Surgery, Second University of Naples School of Medicine, 80131 Naples, Italy
3 Division of Medical Oncology, "F. Magrassi and A. Lanzara" Department of Clinical and Experimental Medicine and Surgery, Second University of Naples School of Medicine, 80131 Naples, Italy

Correspondence: Address correspondence and reprint requests to: Gennaro Galizia, MD; E-mail: gennaro.galiza{at}unina2.it.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: To investigate the role of epidermal growth factor receptor (EGFR) expression as a prognostic marker for prediction of cancer behavior and clinical outcomes in colon cancer patients undergoing potentially curative surgery.

Methods: EGFR determination using a commercially available immunohistochemistry kit was performed in tissues from 149 colon cancer patients receiving primary surgical treatment and in 25 normal colon mucosa specimens from noncancer patients. EGFR positivity was correlated in univariate and multivariate analyses with disease recurrence and survival. In addition, p27, p53, and vascular endothelial growth factor expression were assessed by immunohistochemistry in 104 patients and correlated with EGFR tumor expression and clinical outcome.

Results: EGFR expression was detected in approximately one third of colon cancer patients (53 of 149; 35.6%). In 126 curatively treated patients, EGFR expression was correlated with disease recurrence and worse survival in both univariate and multivariate analyses. In a multivariate model for predicting recurrence and survival, Dukes’ staging, p27, and EGFR expression were the only independent covariates. In particular, in Dukes’ A and B patients the 5-year survival probability was 96% for EGFR-negative and high p27 expression cases and was 30.7% for EGFR-positive and low p27 expression cases.

Conclusions: EGFR expression was an independent prognostic indicator of disease recurrence and poor survival in colon cancer patients undergoing curative surgery. In the context of novel therapeutic options such as molecularly targeted therapies, these findings suggest that anti-EGFR drugs could be evaluated in the adjuvant treatment of EGFR-positive colon cancer patients.

Key Words: Epidermal growth factor receptor • p27 protein • Colon cancer • Adjuvant chemotherapy • Targeted therapy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Colorectal cancer is the second leading cause of cancer-related deaths in Western countries.1 Approximately four fifths of colorectal cancers are found in the large bowel (colon cancer). In apparently localized colon cancers, radical surgery with appropriate lymphadenectomy is the mainstay of therapy.2 The tumor-node-metastasis and Dukes’ staging systems are widely used for the selection of patients who are candidates for postoperative adjuvant medical treatment.3 Node-negative (Dukes’ A and B) colon cancer patients are considered to have generally a low risk for systemic disease recurrence, and, therefore, adjuvant therapy is not indicated in these patients.4,5 Indeed, a postoperative systemic therapy based on intravenous 5-fluorouracil plus folinic acid (5-FU/FA) with the eventual addition of oxaliplatin is currently indicated only in node-positive colon cancer patients.4,5 However, a nonnegligible number of curatively treated colon cancer patients ultimately develop disease recurrence, and this suggests that both these classifications may be unable to precisely predict cancer prognosis and that currently available chemotherapy regimens for node-positive patients, although effective, are not completely satisfactory.6,7 Therefore, a relevant clinical issue is the identification of independent prognostic factors capable of selecting high-risk categories of patients that can then used as predictive factors for tailored therapies.8,9

In this regard, it has been suggested that the epidermal growth factor receptor (EGFR) could be a suitable target for molecularly directed therapy.10–12 EGFR is a cell membrane tyrosine kinase receptor that belongs to the ErbB family. When activated by its natural ligands (i.e., epidermal growth factor or transforming growth factor {alpha}), EGFR initiates a complex intracellular signal transduction cascade that promotes cancer cell division and migration, angiogenesis, and apoptosis inhibition.10–12 EGFR plays a major role in human carcinogenesis, and its overexpression has been generally associated with a more aggressive disease, thus representing both a potential prognostic indicator and a possible target for anticancer drugs.10–12 In colon cancer, EGFR expression has been extensively studied, although a great variability of results has been observed. This could be due to different methods for detecting EGFR protein expression and different cutoff values used for defining expression.7,13–15 Therefore, the prognostic role of EGFR expression in colon cancer remains a controversial clinical issue. Furthermore, only a few studies have focused on the relationship between EGFR expression and other clinicopathologic features and on the effect of EGFR expression on disease recurrence and patient survival.16–20 Thus, further analyses are warranted. In addition, potential correlations between EGFR expression and other molecular markers critically involved in cell-cycle regulation (p27), apoptosis (p53), and neoangiogenesis (vascular endothelial growth factor [VEGF]), all of which are potentially relevant in affecting the prognosis in colon cancer patients, are also lacking.6,21

A large body of preclinical data has shown that selective anti-EGFR targeted therapies, such as the anti-EGFR blocking chimeric human-mouse mono-clonal antibody cetuximab, have a potent antitumor activity alone and in combination with certain cytotoxic treatments.21,22 On the basis of a large, randomized phase II clinical trial, cetuximab has been approved for the treatment of metastatic colorectal cancer patients after failure of irinotecan-containing chemotherapy.22,23 Cetuximab is currently being evaluated in association with chemotherapy in first-and second-line treatment of advanced colorectal cancer according to the preliminary results of phase II studies demonstrating an interesting activity of cetuximab in combination with 5-FU/FA and irinotecan or oxaliplatin.22,24 However, it is not yet clear whether the clinical benefit of EGFR-targeted therapies can be related to the immunohistochemical (IHC) demonstration of EGFR protein expression in cancer cells and/or its expression levels.22,23,25,26

In this study, we report on the prognostic role of EGFR protein expression in a consecutive series of 149 colon cancer patients who received potentially curative surgery. EGFR expression was analyzed in correlation with other relevant molecular markers, with clinicopathologic features, and with disease recurrence and survival, with the aim of identifying colon cancer patients with different prognosis who could benefit from tailored and EGFR-targeted treatments.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
The study population consisted of 154 consecutive colon cancer patients (99 men and 55 women; age range, 28–84 years; mean, 64 ± 12 years) observed between January 1995 and December 2003 in a single-institution unit of surgical oncology. Patients suspected of having hereditary nonpolyposis colorectal cancer, carcinoma associated with inflammatory bowel diseases, or rectal cancer were excluded from this analysis because their molecular features and recurrence and survival rates could differ from those of sporadic large-bowel carcinomas, thus possibly causing misinterpretation of the results.18,27 Twenty-five samples of normal-appearing colon mucosa from noncancer patients served as controls. All patients gave their informed consent, and the study was approved by the Department of Clinical and Experimental Medicine and Surgery of the Second University of Naples. All patients underwent surgical exploration with intraoperative hepatic ultrasonography and tumor removal. One hundred twenty-six patients underwent a potentially curative operation, defined as the removal of all of the macroscopic tumoral masses, absence of microscopic residual tumor, histology-negative resection margins, and lymphadenectomy extended beyond the involved nodes at the postoperative pathologic examination. In the remaining 28 patients, the operation was judged as noncurative, or palliative. No major complications were observed, and all patients could be discharged from the hospital. All Dukes’ C and D patients were treated for 6 months with either 5-FU/FA–based or, more recently, 5-FU/ FA plus oxaliplatin (FOLFOX-4) adjuvant chemotherapy. No patient was lost to follow-up, which was updated to March 31, 2005.

The following clinicopathologic parameters were recorded: age, sex, cancer site, performance status according to the Eastern Cooperative Oncology Group scale, basal carcinoembryonic antigen serum level, type of surgical resection (curative or noncurative), tumor-node-metastasis and Dukes’ stage, degree of histological differentiation (well, moderate, or poor), tumor growth pattern (expanding or infiltrating),28 DNA microsatellite stability status (stable or unstable, as assessed by analysis of BAT26 mononucleotide repeats),29 number of resected nodes, number of metastatic nodes, tumor size, postoperative complications, and disease recurrences after potentially curative resections.

Immunohistochemistry
Fresh tissues were fixed in neutral buffered formalin for 24 hours, followed by infiltration with melted Istowax (Carlo Erba, Milan, Italy). Consecutive 4-µm sections were cut from the paraffin blocks of 154 colon carcinoma and 25 normal colon mucosa specimens. After histological evaluation to individuate blocks without necrotic and hemorrhagic areas, 4-µm tissue sections were cut from these defined blocks and used for IHC with the commercially available EGFR pharmDx kit (DakoCytomation, Carpinteria, CA), which includes the EGFR pharmDx mouse monoclonal antibody (clone 2-18C9), a negative control reagent (a mouse monoclonal antibody to an enzyme that is not expressed in mammalian tissue), and positive and negative control cancer cell preparations (the EGFR-positive CAMA-1 breast cancer cell line and the EGFR-negative HT29 colon cancer cell line). IHC was performed according to the manufacturer’s instructions. In addition, information on p27, p53, and VEGF expression was available for 104 of 154 colon cancer specimens subjected to the IHC procedure previously described.30

Interpretation of IHC Staining
Slides were examined at x200 magnification; all cells present in the slides were counted, and randomization was avoided. For each case, at least 4 sections and 25,000 cells were observed. All the slides were reviewed twice by two independent pathologists (F.F. and A.L.M.), who were both blinded and had no prior knowledge of the clinicopathologic parameters. Discrepancies between investigators (<5% of the cases) required a third joint observation with conclusive agreement. The staining score was expressed as the percentage ratio of membrane-stained cells to the total number of cells evaluated. To unequivocally categorize cases in two groups, each sample was defined as EGFR-negative or EGFR-positive when none or <1% or ≥1% of the tumor cells showed an EGFR immunospecific membranous brown staining. In addition, in EGFR-positive colon cancers, the staining intensity was scored as 1+ (weak), 2+ (moderate), and 3+ (strong) according to a recently proposed three-tier system.15 As previously reported, colon cancer samples were defined as p27 positive when >20% of tumor cells stained and as p53 and VEGF positive when >10% of tumor cells stained.6

Statistical Analysis
Statistical analysis was performed by using the BMDP statistical package (BMDP Statistical Software Inc., Los Angeles, CA). In all analyses, the significance level was specified as P < .05. The equality of group means and comparisons between proportions were analyzed by using unpaired Student’s t-tests and {chi}2 tests, respectively. Stepwise multiple regression analyzed correlations of different molecular markers with each other, clinicopathologic features, and curative and noncurative surgery. The patients who died of causes other than colon cancer without evidence of disease were regarded as censored events for cancer-related mortality rate or disease-specific survival (DSS). The analyses related to DSS and disease-free survival (DFS) were restricted to 126 patients undergoing curative surgery. Univariate statistical analysis was determined by log-rank test (Mantel-Cox). The curves were plotted by using the product-limit method (Kaplan-Meier) and analyzed with the generalized Savage test or the Mantel-Cox test (BMDP1L). The independent significance of prognostic variables related to DSS and DFS was determined by multivariate analysis by using the Cox proportional hazards model. The level of significance was obtained by score test (BMDP2L). A stepwise multivariate analysis was performed to generate a model of the best linear combination of variables able to predict DSS and DFS. Finally, a Cox model stratified by the different covariates was constructed according to Kalbfleisch and Prentice31 to estimate the 5-year probability of death and cumulative hazard functions for different combinations of the major variables.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
EGFR Expression in Colon Cancer
The clinicopathologic characteristics of the 154 patients are listed in Table 1Go. None of the normal-appearing colon mucosa samples stained positive for EGFR. IHC staining results were available in 149 cases for EGFR and in 104 cases for p27, p53, and VEGF (Table 2Go). EGFR was not detectable in 96 samples (64.4%) and was expressed in 53 cases (35.6%). The EGFR score intensity was weak in 24, moderate in 23, and strong in 6 cases. The tissue sample mean storage time was 58 ± 29 months (range, 12–120 months; median, 56 months) and 56 ± 35 months (range, 13–120 months; median, 52 months) for EGFR-negative and EGFR-positive cases, respectively (P = .743). EGFR expression was significantly correlated with other molecular markers, tumor-node-metastasis parameters (tumor: r = .244, P = .003; nodal status: r = .184, P = .025; presence of distant metastases: r = .237, P = .004), and Dukes’ stage (r = .303, P = .001). The percentages of EGFR-positive cases in Dukes’ A, B, C, and D colon cancers were 15%, 30%, 44%, and 59%, respectively. To summarize, EGFR expression was significantly associated with p27 downregulation, p53 overexpression, VEGF positive staining, and tumor progression.


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  		TABLE 1. Clinicopathologic characteristics
 

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  		TABLE 2. Immunohistochemical staining results
 
DSS in the 126 Patients Subjected to Curative Surgery
The mean follow-up time was 44 ± 25 months (range, 13–108 months; median, 48 months). During this time period, 21 (17%) patients died of disease. The 5-year DSS and cumulative risk of cancer death were 79.5% and 22.9%, respectively. IHC data regarding EGFR and other molecular markers (p27, p53, and VEGF) were available in 122 and 86 cases, respectively. The presence of metastatic nodes and/or distant metastases, Dukes’ stage, absence of microsatellite instability, number of resected and metastatic nodes ≤14 and >2, p27 downregulation, and p53 and VEGF overexpression were all significantly associated with a worse cancer-related death rate on univariate analysis (Table 3Go). DSS also strongly correlated with EGFR expression status. The 5-year DSS and cumulative risk of cancer death in EGFR-negative and -positive colon cancer patients were 93% and 7%, and 37% and 78%, respectively. Thus, colon cancer patients undergoing potentially curative surgery, if EGFR-positive, had a >10-fold risk of cancer-related death when compared with EGFR-negative colon cancer patients (Fig. 1Go). However, among EGFR-positive tumors, no significant correlation with survival was found when taking into account the different staining intensity. On multivariate analysis, Dukes’ stage, p27 downregulation, high p53 expression, VEGF overexpression, and positive membrane staining for EGFR were the only covariates independently associated with DSS. A stepwise multivariate analysis removed p53 and VEGF from the model, thus selecting Dukes’ stage, p27, and EGFR as the best combination of independent variables for DSS prediction (Tables 4Go and 5Go). Significant differences were found within the same Dukes’ stage according to EGFR expression. The 5-year survival rates of Dukes’ A and B colon cancer patients undergoing potentially curative surgery were significantly different between EGFR-negative (94.1%) and EGFR-positive (33.3%) tumors (P < 0.001; Fig. 2AGo). Among the 27 Dukes’ A patients, the 5-year survival rates were 95% and 66% in EGFR-negative and EGFR-positive colon cancer patients, respectively. EGFR-negative and EGFR-positive Dukes’ B patients (61 cases) had 93% and 31% 5-year survival rates, respectively. In Dukes’ C and D colon cancer patients, the difference was even stronger, with 5-year survival rates of 92.6% and 22.3% in EGFR-negative and EGFR-positive tumors (P < 0.001), respectively (Fig. 2BGo). On the basis of the model generated by the stepwise process, further prognostic insights in defining high-risk patients were obtained by adding p27 status. The 5-year survival rate of EGFR-positive and p27-downregulated colon cancers was significantly poorer than that recorded in EGFR-negative and p27-upregulated tumors. In particular, in Dukes’ A and B stages, the 5-year survival probability declined progressively from 96% in tumors with EGFR negativity and high levels of p27 expression to 30.7% in the 13 patients with EGFR expression and p27 downregulation (Fig. 3AGo). In Dukes’ C and D stages, the 5-year survival probability was only 20.3% in the eight patients with EGFR-positive and p27-downregulated tumors (Fig. 3BGo).


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  		TABLE 3. Univariate analysis related to disease-specific survival in 126 colon cancer patients undergoing curative surgery
 

Figure 1
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  		FIG. 1. Five-year disease-specific survival according to epidermal growth factor receptor (EGFR) expression in colon cancer patients undergoing curative surgery. Closed squares depict EGFR-negative cancers (n = 84); open squares depict EGFR-positive cancers (n = 38); open circles depict all cancers (n = 126).

 

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  		TABLE 4. Multivariate analysis related to disease-specific survival in 126 colon cancer patients undergoing curative surgery
 

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  		TABLE 5. Stepwise multivariate analysis
 

Figure 2
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  		FIG. 2. Five-year disease-specific survival according to epidermal growth factor receptor (EGFR) status and Dukes’ stage in 122 colon cancer patients undergoing curative surgery. (A) Dukes’ A and B colon cancers. Closed squares depict EGFR-negative cancers (n = 66); open squares depict EGFR-positive cancers (n = 22). (B) Dukes’ C and D colon cancers. Closed squares depict EGFR-negative cancers (n = 18); open squares depict EGFR-positive cancers (n = 16).

 

Figure 3
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  		FIG. 3. Estimated 5-year disease-specific survival (DSS) function stratified for Dukes’ stage and different combinations of two molecular markers (epidermal growth factor receptor [EGFR] and p27) in colon cancer patients undergoing curative surgery. (A) Dukes’ A and B colon cancers. Closed squares depict cancers (n = 36) not expressing EGFR and with a high p27 protein accumulation; open squares depict cancers (n = 13) with EGFR positivity and p27 down-regulation. (B) Dukes’ C and D colon cancers. Closed squares depict cancers (n = 8) not expressing EGFR and with high p27 protein accumulation; open squares depict cancers (n = 8) with EGFR positivity and p27 down-regulation.

 
DFS and Recurrence Rate in the 126 Patients Who Underwent Curative Surgery
Thirty patients (24%) experienced a tumor recurrence; nine of them are still alive, and five have no evidence of tumor after a second surgical procedure. All recurrences were distant metastases in the liver and, less frequently, in the lung and/or skeleton. The mean recurrence time was 19 ± 8 months (range, 10–38 months; median, 18 months). In 22 (73%) of 30 patients, disease recurred within 2 years. The 5-year DFS and cumulative risk of recurrence were 72.4% and 32.3%, respectively. The univariate and multivariate analyses related to DFS are shown in Tables 6Go and 7Go. In the 84 EGFR-negative and 38 EGFR-positive colon cancer patients, the 5-year DFS was 82.5% and 41.8%, respectively. Cox and stepwise analyses selected Dukes’ stage, p27, and EGFR as the only independent variables related to DFS. The probability of the 48-month risk of tumor recurrence analyzed for each covariate was <20% in Dukes’ A or B stages, EGFR-negative cancers, or cancers with high p27 protein levels and was 74%, 87%, and 92% in Dukes’ C and D, EGFR-positive, and p27-downregulated colon cancers, respectively (Fig. 4AGo). When stratifying for Dukes’ stages, the association of EGFR and p27 status significantly predicted tumor relapse. In particular, the cumulative risk of tumor recurrence for Dukes’ A and B stages was 100% at 48 months in patients with EGFR-positive and p27-downregulated cancers and was only 3% in patients with EGFR-negative and p27-upregulated tumors (Fig. 4BGo).


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  		TABLE 6. Univariate and multivariate analysis related to disease-free survival in 126 colon cancer patients undergoing curative surgery
 

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  		TABLE 7. Stepwise multivariate analysis
 

Figure 4
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  		FIG. 4. Multivariate cumulative hazard rate of tumor recurrence according to Dukes’ stage and different molecular markers (epidermal growth factor receptor [EGFR] and p27) in colon cancer patients undergoing curative surgery. (A) Open and closed circles depict cancers with high (n = 48) and low (n = 38) p27 protein expression; open and closed squares depict negative (n = 84) and positive (n = 38) EGFR cancers; open and closed triangles depict Dukes’ A/B (n = 92) and C/D (n = 34) cancers. (B) Closed circles depict EGFR-negative and p27-upregulated Dukes’ A and B cancers; open circles depict EGFR-positive and p27-downregulated Dukes’ A and B cancers; closed squares depict EGFR-negative and p27-upregulated Dukes’ C and D cancers; open squares depict EGFR-positive and p27-downregulated Dukes’ C and D cancers.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
A substantial subset of colon cancer patients undergoing potentially curative surgery have recurrent disease.2,4,6,7 Recently, many studies have suggested that the knowledge of molecular features underlying the behavior of individual colon tumors may be a fundamental step in identifying patients with a high risk of recurrence.8,30 In this respect, it has been postulated that determination of EGFR expression could be crucial for two reasons: first, to determine patient prognosis, and second, to identify patients who could be treated with EGFR-targeted therapies.9,21,22 In fact, cetuximab, an anti-EGFR monoclonal antibody, has been successfully added to conventional chemotherapy in metastatic EGFR-positive colon cancer patients.22–24 However, the prognostic value of EGFR expression in colon cancer is still debated.7,16–20

In this study, by IHC, we evaluated EGFR expression in 149 colon cancer patients in relationship to other clinicopathological factors, including 3 other molecular markers (namely, p27, p53, and VEGF) and investigated the prognostic role of EGFR expression in 126 colon cancer patients undergoing potentially curative surgery. Recently, the lack of correlation between EGFR expression, determined by IHC, and clinical responses to EGFR-targeted therapies raised doubts about the accuracy of this technique. This could be due to differences in tumor collection in different hospitals, the type of fixative used, storage time, arbitrary cutoff values, and interobserver discrepancies.15,26,32–35 In this study, we tried to minimize these problems; all patients were followed up by a single multidisciplinary oncology team, and fresh samples were fixed in neutral buffered formalin, thus avoiding alcohol-based fixatives. In our hands, the possibility of EGFR detection was not affected by the storage time before IHC (median of 58 and 56 months in EGFR-negative and EGFR-positive cases, respectively). All samples were examined by two pathologists, and interob-server discrepancies were resolved with a third observation. For each case, at least four sections were observed and scored, and, according to previous reports, the 1% value was set as the cutoff, thus avoiding combined scores.15,34,36

The percentage of EGFR positivity in colon cancer patients has been reported with great variability, ranging from 25% to 82%.7,15–17,20,37 In our series, EGFR expression was recorded in approximately 36% of the tumor samples; it did not correlate with poorly differentiated histology (tumor grade, growth pattern, and microsatellite status), but it did correlate with Dukes’ stages, thus suggesting that cancer progression is associated with an increased EGFR expression. It is interesting to note that EGFR positivity was significantly correlated with low p27 protein levels and high p53 and VEGF expression. It has been suggested that the activation of EGFR-dependent intracellular signaling pathways could promote cell proliferation, inhibition of apoptosis, and neo-angiogenesis by downregulating p27 expression and inducing VEGF production.10,11,38

The results of this study showed EGFR, p27, and VEGF, along with the Dukes’ stage, to be the only independent prognostic indicators of clinical outcome in colon cancer patients undergoing potentially curative surgery; this suggests that the knowledge of the molecular pathways that determine the behavior of individual colon tumors may be a crucial step in identifying high-risk patients. Furthermore, although different score intensities in EGFR-positive colon cancer cells did not show any prognostic effect, EGFR determination added a significant prognostic relevance to the conventional staging system based on the Dukes’ classification. In early-stage colon cancers (Dukes’ A and B) that were not treated with adjuvant chemotherapy, patients with EGFR-positive tumors showed a nearly halved 5-year survival probability when compared with patients with EGFR-negative colon cancers. In Dukes’ C and D stage patients, who received postoperative chemotherapy, this difference was even more evident. These data confirm previous results indicating that IHC determination of EGFR could allow identification of high-risk colon cancer patients, particularly Dukes’ A and B stages.7,16,17,19 By adding p27 determination, as selected by a multivariate stepwise analysis, significant differences in clinical outcome were further evident. Twenty percent of Dukes’ A and B and 38% of Dukes’ C and D colon cancer patients undergoing curative surgery showed EGFR expression and low p27 expression. The 5-year survival functions in these patients were significantly different from those observed in EGFR-negative and high-p27 colon cancers. Regardless of the Dukes’ stage, virtually all patients with EGFR-positive and low-p27 tumors had a 100% risk of tumor recurrence at 48 months after surgery.

In conclusion, EGFR IHC detection in ≥1% of cancer cells correlated with clinical cancer progression and several molecular alterations. EGFR expression was an independent prognostic indicator of poor survival and a higher recurrence risk in colon cancer patients undergoing potentially curative surgery. Together with the determination of the p27 protein level and the Dukes’ classification, EGFR detection allowed construction of a multivariate prognostic model for such patients. Furthermore, our results suggest that in Dukes’ A and B stages, high-risk colon cancer patients might be identified by EGFR positivity and low p27 expression. These patients may be candidates for adjuvant systemic chemotherapy after potentially curative surgery. Finally, in Dukes’ C stage colon cancer patients, clinical trials with anti-EGFR–directed drugs could be considered in combination with chemotherapy for the adjuvant treatment of EGFR-positive patients.

While we await larger trials verifying these findings, the strong effect of molecular alterations on the prediction of overall and DFS prompted our oncology team to schedule a prospective trial that provides the use of adjuvant chemotherapy in Dukes’ A and B colon cancer patients undergoing potentially curative surgery identified by molecular staging as high-risk patients. On the other hand, cetuximab will be associated to conventional chemotherapy in EGFR-positive Dukes’ C stage patients. Because almost 80% of cancer recurrences occur in the first 3 years after curative surgery, substantial results are expected in the next 36 months.


   ACKNOWLEDGMENTS
 
The authors thank Bert Vogelsteinm MD, of the Howard Hughes Medical Institute and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, for his invaluable collaboration and very constructive discussions and criticisms.

Received for publication June 17, 2005. Accepted for publication November 21, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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