Dynamic monitoring of circulating tumor DNA to predict prognosis and efficacy of adjuvant chemotherapy after resection of colorectal liver metastases

Abstract

Rationale: Hepatectomy and adjuvant chemotherapy after resection of colorectal liver metastases (CRLM) may improve survival, however, patients which may benefit cannot currently be identified. Postoperative circulating tumor DNA (ctDNA) analysis can detect minimal residual disease (MRD) and predict the prognosis and efficacy of adjuvant chemotherapy. Our study aims to determine the impact of serial ctDNA analysis to predict the outcome among patients undergoing resection of CRLM. Methods: Between May 2018 and October 2019, 91 CRLM patients were prospectively enrolled. Whole exome sequencing was performed in 50 primary and 48 metastatic liver tissues. Targeted sequencing of 451 cancer relevant genes was performed in 50 baseline plasma to determine plasma-tissue concordance. We prospectively investigated changes in the amount and constitution of ctDNA in 271 serial plasma samples taken at different time points (baseline, pre-operation, post-operation, post-operative adjuvant chemotherapy (post-ACT) and recurrence) during the treatment of CRLM. Results: Detected molecular alterations were highly consistent among baseline ctDNA, primary and liver metastases tissue. Patients with a higher variant allele frequency (VAF) level at baseline ctDNA represent a higher tumor burden, and decreased ctDNA during pre-operative chemotherapy predicted better tumor response. Patients with detectable post-operative and post-ACT ctDNA were associated with significantly shorter recurrence-free survival (RFS). ROC analysis showed that post-ACT ctDNA status was superior to post-operative ctDNA status in predicting RFS with an AUROC of 0.79. A significant difference in overall recurrence rate was observed in patients with detectable vs undetectable levels of ctDNA after resection of CRLM (79.4% vs 41.7%) and after completion of adjuvant chemotherapy (77.3% vs 40.7%). During adjuvant chemotherapy, patients with decreased ctDNA VAF after adjuvant chemotherapy had a recurrence rate of 63.6%, compared to 92.3% in patients with increased ctDNA VAF. Conclusions: We envision that dynamic ctDNA analysis, especially in a post-ACT setting, might be used to not only reflect MRD but also to determine rational personalized adjuvant therapy after the resection of CRLM.

Keywords: adjuvant chemotherapy; colorectal liver metastases; ctDNA; next-generation sequencing; prognosis.

Figure 1

The landscape and consistency of tumor tissue and baseline blood in 50 patients. (A) Genomic alterations detected from baseline ctDNA, primary tumor (PT), and liver metastases (LM). The different colors represent different mutant types. The black dot represents the lack of two colorectal liver metastases cases. Each column represents a patient, and each row represents a gene. The sidebars represent the mutation rate of the 50 patients in our study. The lowest pillars represent the clinical characteristics of synchronous or metachronous liver metastases. (B) The mutation consistency (shared mutated and shared unmutated) of 50 matched primary tissues and baseline blood.

Figure 2

The dynamic changes of the ctDNA level during treatment. (A) The ctDNA VAF in baseline, pre-operation, post-operation, and post-ACT. P-value was calculated using the Wilcoxon rank-sum test. (B) Association between decreased ctDNA VAF during the pre-operative chemotherapy and the tumor response. The decreased group represents a decrease of more than 10-fold, and the not decreased group represents an increase or a decrease of less than 10-fold. PR partial response, SD stable disease.

Figure 3

Prognostic value of serial ctDNA in patients with CRLM. Kaplan-Meier survival analysis shows the probability of recurrence-free survival (RFS) stratified by ctDNA status of baseline (A), pre-operation (B), post-operation (C), and post-ACT (D). (E) Dichotomized association between disease recurrence and ctDNA status in the post-operative and post-ACT setting. (F) Time-dependent ROC curves of survival prediction between the CRS and VAF of ctDNA at four-time points.

Figure 4

The association of dynamic changes of ctDNA during adjuvant chemotherapy with RFS. (A) ctDNA dynamic changes from post-operation to post-ACT. (B) Kaplan-Meier survival analysis of RFS for 46 patients stratified by a combination of post-operative and post-ACT ctDNA status. P = 0.031 for statistical comparison between the four groups.