UGT1A1 predicts outcome in colorectal cancer treated with irinotecan and fluorouracil

Abstract

Aim: To evaluate effects of UDP-glucuronosyltransferase1A1 (UGT1A1) and thymidylate synthetase (TS) gene polymorphisms on irinotecan in metastatic colorectal cancer (mCRC).

Methods: Two irinotecan- and fluorouracil-based regimens, FOLFIRI and IFL, were selected as second-line therapy for 138 Chinese mCRC patients. Genomic DNA was extracted from peripheral blood samples before treatment. UGT1A1 and TS gene polymorphisms were determined by direct sequencing and restriction fragment length polymorphism, respectively. Gene polymorphisms of UGT1A1*28, UGT1A1*6 and promoter enhancer region of TS were analyzed. The relationship between genetic polymorphisms and clinical outcome, that is, response, toxicity and survival were assessed. Pharmacokinetic analyses were performed in a subgroup patients based on different UGT1A1 genotypes. Plasma concentration of irinotecan and its active metabolite SN-38 and inactive metabolite SN-38G were determined by high performance liquid chromatography. Differences in irinotecan and its metabolites between UGT1A1 gene variants were compared.

Results: One hundred and eight patients received the FOLFIRI regimen, 29 the IFL regimen, and one irinotecan monotherapy. One hundred and thirty patients were eligible for toxicity and 111 for efficacy evaluation. One hundred and thirty-six patients were tested for UGT1A1*28 and *6 genotypes and 125 for promoter enhancer region of TS. Patients showed a higher frequency of wild-type UGT1A1*28 (TA6/6) compared with a Caucasian population (69.9% vs 45.2%). No significant difference was found between response rates and UGT1A1 genotype, although wild-type showed lower response rates compared with other variants (17.9% vs 24.2% for UGT1A1*28, 15.7% vs 26.8% for UGT1A1*6). When TS was considered, the subgroup with homozygous UGT1A1*28 (TA7/7) and non-3RG genotypes showed the highest response rate (33.3%), while wild-type UGT1A1*28 (TA6/6) with non-3RG only had a 13.6% response rate, but no significant difference was found. Logistic regression showed treatment duration was closely linked to clinical response. In toxicity comparison, UGT1A1*28 TA6/6 was associated with lower incidence of grade 2-4 diarrhea (27.8% vs 100%), and significantly reduced the risk of grade 4 neutropenia compared with TA7/7 (7.8% vs 37.5%). Wild-type UGT1A1*6 (G/G) tended to have a lower incidence of grade 3/4 diarrhea vs homozygous mutant (A/A) genotype (13.0% vs 40.0%). Taking UGT1A1 and TS genotypes together, lower incidence of grade 2-4 diarrhea was found in patients with non-3RG TS genotypes, when TA6/6 was compared with TA7/7 (35.3% vs 100.0%). No significant association with time to progression (TTP) and overall survival (OS) was observed with either UGT1A1 or TS gene polymorphisms, although slightly longer TTP and OS were found with UGT1A1*28 (TA6/6). Irinotecan PK was investigated in 34 patients, which showed high area under concentration curve (AUC) of irinotecan and SN-38, but low AUC ratio (SN-38G / SN-38) in those patients with UGT1A1*28 TA7/7.

Conclusion: A distinct distribution pattern of UGT1A1 genotypes in Chinese patients might contribute to relatively low toxicity associated with irinotecan and 5-fluorouracil in mCRC patients.

Keywords: Fluorouracil; Irinotecan; Metastatic colorectal cancer; Pharmacokinetics; Polymorphisms; Thymidylate synthetase; Toxicity; Treatment outcome; UDP-glucuronosyltransferase1A1.

Figure 1

Schematic diagram of UDP-glucuronosyltransferase1A1 and thymidylate synthetase. A: UDP-glucuronosyltransferase1A1 (UGT1A1) is the main enzyme involved in the glucuronidation of SN-38 (SN-38G). Single-nucleotide polymorphisms (SNPs) of UGT1A1 are the key factor in irinotecan metabolism; B: Thymidylate synthetase (TS) is the main target of 5-fluorouracil (5-FU). The ternary complex of TS, active metabolite of 5-FU (FdUMP) and methyl-tetra-hydrofolic acid (MTHF) inhibits DNA synthesis. SNP of TS affects the expression of enzyme and 5-FU efficacy. CES: Carboxylesterases; TOP1: Topoisomerase-1.

Figure 2

Analysis of UDP-glucuronosyltransferase1A1*28 and *6 by DNA sequencing and thymidylate synthetase by restriction fragment length polymorphism. A: 211G>A of UDP-glucuronosyltransferase1A1 (UGT1A1)*6; B: (TA) nTAA variant of UGT1A1*28; C: Polymerase chain reaction-based restriction fragment length polymorphism for 2R or 3R and G>C single-nucleotide polymorphism in 3R located in the 5’-UTR region of the thymidylate synthetase gene.

Figure 3

Time to progression and overall survival according to UDP-glucuronosyltransferase1A1*28 genotypes. A: Time to progression (TTP): Patients with TA6/6 were 5.97 (95%CI: 3.85-8.09), patients with TA6/7 and TA7/7 were 4.00 (95%CI: 1.15-6.85), P = 0.154; B: Overall survival (OS): Patients with TA6/6 were 18.00 (95%CI: 10.77-25.23), patients with TA6/7 and TA7/7 were 14.90 (95%CI: 7.58-22.22), P = 0.444. No significant difference was found between TA6/6 (wild type) and mutated genotypes. UGT1A1: UDP-glucuronosyltransferase1A1.

Figure 4

Area under concentration curve ratios of SN-38G/SN-38 comparison according to UDP-glucuronosyltransferase1A1*28 genotypes and UDP-glucuronosyltransferase1A1*28 + *6 group. A: Area under concentration curve (AUC) ratios comparison by UDP-glucuronosyltransferase1A1 (UGT1A1)*28: The AUC ratio of TA7/7 was less than half of the TA6/6 ratio (1.488 vs 3.178, P = 0.158); B: AUC ratios comparison by UGT1A1*28 + *6 group: Lower AUC ratio was found in the double mutation group (TA6/7 + G/A and TA7/7 + G/G), compared with the other two groups [wild type or single mutation group (1.488 vs 3.177, P = 0.078)].