Prospective Multicenter Study on the Prognostic and Predictive Impact of Tumor Budding in Stage II Colon Cancer: Results From the SACURA Trial

Abstract

Purpose: The International Union Against Cancer highlighted tumor budding as a tumor-related prognostic factor. International assessment criteria for tumor budding were recently defined by the 2016 International Tumor Budding Consensus Conference (ITBCC2016). This study aimed to clarify the prognostic and predictive values of tumor budding in a randomized controlled trial evaluating the superiority of adjuvant chemotherapy with oral tegafur-uracil over surgery alone for stage II colon cancer (SACURA trial; ClinicalTrials.gov identifier: NCT00392899).

Patients and methods: Between 2006 and 2010, we enrolled 991 patients from 123 institutions with stage II colon cancer. Tumor budding was diagnosed by central review on the basis of the criteria adopted in the ITBCC2016. We prospectively recorded all clinical and pathologic data, including the budding grade, and performed prognostic analyses after 5 years of completing the patients' registration.

Results: Of 991 tumors, 376, 331, and 284 were classified as BD1, BD2, and BD3, respectively; the 5-year relapse-free survival (RFS) rate was 90.9%, 85.1%, and 74.4%, respectively (P < .001), and ranged widely in T4 tumors (86.6% to 53.3%). The budding grade significantly correlated with recurrence in the liver, lungs, lymph nodes, and peritoneum (P < .001 to .01). Multivariable analysis revealed that budding and T stage exerted an independent impact on RFS, and on the basis of the Harrell concordance index, these two factors substantially contributed to the improvement of the Cox model for predicting RFS. Both the BD2 and BD3 groups demonstrated greater improvement in the 5-year recurrence rate in the adjuvant chemotherapy group than the surgery-alone group by approximately 5%, but the difference was statistically nonsignificant.

Conclusion: Tumor budding grade on the basis of the ITBCC2016 criteria should be routinely evaluated in pathologic practice and could improve the benefit of adjuvant chemotherapy for stage II colon cancer.

FIG 1.

Kaplan-Meier estimates of the relapse-free survival (RFS) rate in patients with colon cancer according to grade of tumor budding.

FIG 2.

Comparison of time to recurrence between the surgery-alone group and the chemotherapy group in patients with (A) BD1, (B) BD2, and (C) BD3 tumors. The 5-year recurrence rates (95% CI) for the surgery-alone and tegafur-uracil (UFT) group were 6.8% (4.0% to 11.4%) and 6.5% (3.6% to 11.5%) in BD1, 10.3% (6.5% to 16.0%) and 14.8% (10.1% to 21.5%) in BD2, and 21.0% (15.0% to 29.0%) and 26.4% (20.1% to 34.4%) in BD3, respectively. Log-rank test: BD1, P = .8124; BD2, P = .1889; BD3, P = .2954.

FIG A1.

CONSORT diagram. Numbers in brackets indicate the number of patients in the translational study for new histopathologic factors. UFT, tegafur-uracil.