Evaluation Of Neoadjuvant Chemotherapy And The Correlation With DNA Repair Genes For Locally Advanced Cervical Carcinoma

BackgroundCervical carcer is the second most frequently diagnosed malignancy in womenworldwide,and also one of the most common cnacer among women in china.Recently,its incidence increased rapidly,more and more younger women suffered from it.Cervical cancer continues to be a leading cause of death in women.The major treatment for cervical carer is surgery and radiotherapy.One sort ofhigh risk cervical carcer,which is called locally advanced cervical cancer(LACC)and is defined as an early stage cervical career with diameter larger than 4cm,LACC has apoor prognosis,the avaliable treatment for LACC contain concurrent chemoradiation,surgery,and neoadjuvant chemotherapy(NACT)+ surgery or radiotherapy.There aretheoretical advantages for the use of NACT,including decrease the loading of thetumor,reduce micro-metastatic disease,and improve the quality of life.NACT hasbeen the first considered therapy choice for young women with LACC.Although NACT in LACC is still the subject of much controvery,manyinvestigates have reported that NACT is highly effective for patients with LACC,butthe clinical and pathological parameters which influence the effect are still unknown.Where the NACT have the survival benefit remains the focus of controvery.Chemotherapy is the mainly therapy method for tumor,there are still differentoutcomes in different individuals as both tumors and their hosts have heterogeneity.Therefore,to search avaliable predit criterions to evaluate the response ofchemotherapy is the basic task for individual use.The regimen of NACT used for LACC is platinum-based chemotherapy,there are many mechanisms leading to theplatinum-resistance.The change of DNA repair ability is one of the most importmentmechanisms.X-ray repair cross complementing gene 1(XRCC1)and Xeroderma pigmentosum pomplementary group D(XPD)are the major DNA repairing genes.They repair the DNA damages by base excision repair(BER)and nucleotide excision repair(NER).The expression of these two genes may be related closely to the platinum resistance.But the relationship between the expression of those two protein and the response ofNACT in LACC have not reported yet.The pharmacological and genetic studies in resent years confirmed that the genetic polymorphism,especially the single nucleotide polymorphism(SNP),is theimportant reasons to cause the differences of individual cnacer susceptibility and therapy outcomes.There are three polymorphism sites in XRCC1,which isrespectively located on genetic codon 194(Arg-Trp),280(Arg-His)and 399(Arg-Gln).Some studies indicated that the SNP of XRCC1 related to many tumors,and alsoassociated with response to platinum-based chemotherapy in of NSCLC and carcinoma of colon.Whereas,the studies of the relationship between SNP of XRCC1and LACC is rare.The aim of our study were to evaluate the efficacy of NACT in LACC,toanalysis the possible clinical and pathological parameters which could influence theeffect,and to assess relationship between the effect and the survival rate.Furthermore,we try to disclose the association of the expression of XRCC1 and XPD protein withthe chemotherapy response,and also the association of SNP in XRCC1 with theeffect of NACT for LACC.From these,we try to find a possible criterion to predictthe response of NACT in LACC,which can provide us with evidences to individualchemotherapy. Part 1Evaluation of the value of neoadjuvant chemotherapy for locallyadvanced cervical carcinomaObjective:To evaluate the efficacy of neoadjuvant chemotherapy for locallyadvanced cervical cancer,the related clinical parameters affecting the outcome ofchemotherapy,and also the the survival.Methods:A total of 109 patients with stageⅠb—Ⅱa of locally advanced cervicalcancers treated with neoadjuvant chemotherapy between June 1999 and June 2007 inWomen s Hospital,School of Medicine,Zhejiang University,were retrospectivelyanalysed the response of neoadjuvant chemotherapy,selected age,clinical stage,grade of differentiation,histology type,initial tumor size,chemotherapy regimens,number of courses and pre-treatment hemoglobin lever as the clinical parameters toanalysis the assosiation of the chemotherapy response and the clinical parameters,andalso analysis the difference of survival rate according to the response of NACT.Results:1.In 109 patients,85 cases were effective(3 complete response and 82 partialresponse),Overall response rate of neoadjuvant chemotherapy was 77.9%.2.The clinical response was associated with histology type.The patients withsquamous cell cancer had significantly higher response rate than those withadenocarcinoma(82.3% vs 46.2%,X~2=9.342,P=0.002).the response ofneoadjuvant chemotherapy has no assosiation with age,clinical stage,grade ofdifferentiation,initial tumor size,chemotherapy regimens,number of coursesand pre-treatment hemoglobin lever.3.The rates of positive pelvic lymph node metastasis were significantly lower incomplete or partial response patients than those in stable patients(4.70% vs23.53%,X~2=6.85,P=0.008).and also the rate of stroma invasion=outer1/3 weresignificantly lower than those<1/3(15.29% VS 52.94%,X~2=11.87,P= 0.012),while parametrial invasion has no difference(X~2=2.06,P=0.153).4.In the 109 patients,88 patients finished the follow-up,The overall 2-year survivalrate was 98.4%,The 5-year survival rate was 86.5%;The survival rate(until thefollow-up finished)in complete or partial response group was 100%,1-yearsurvival rate and 2-year survival rate in stable disease group was 92.9% and 59.7%(chi-square=7.299,P=0.007).The disease-free survival rate in complete orpartial response group was 100%(until the follow-up finished),while 1-yeardisease-free survival rate and 2-year disease-free survival rate in stable diseasegroup was 88.9% and 57.3% respectively(chi-square=6.814,P=0.009).Conclusions1.NACT could decrease the rate of pelvic lymph node metastasis,the stroma invasion≥outer 1/3 and adjuvant therapy after surgery.indicated that NACT could decrease and inhibite the micro-metastasis,improve the locally control for locallyadvanced cervical carcinoma.2.The patients who have good response to NACT should select surgery.It could beimprove the long-term survival rate.Part 2The Association of XRCC1 and XPD Protein Expression With the Responses toNeoadjuvant Chemotherapy in Locally Advanced Cervical CarcinomaObjective:To asses the association between the expression of XRCC1,XPD proteinand clinical responses to neoadjuvant chemotherapy in locally advanced cervicalcancinoma.Methods:A total of 99 patients with stageⅠb2—Ⅱa of locally advanced cervicalcancers treated with neoadjuvant chemotherapy between June 1999 and June 2007 inWomen s Hospital,School of Medicine,Zhejiang University were retrospectivelyanalysed.Immunohistochemistry method was adopted to detected the expression of XRCC1,XPD protein in pretreatment cancer tissue,the protein expression ofXRCC1,XPD and the response of NACT were analysised.and also analysised theassociation of protein expression and the clinical-pathology parameters in locallyadvanced cervical carcinomaResults:1.The expression of XRCC1 protein were significantly lower in effectivepatients than those in stable patients(2.99±0.38 vs 1.94±0.28,t=13.64,P=0.008).2.The expression of XPD protein were significantly lower in effective patientsthan those in stable patients(2.93±0.29 vs 1.78±0.39,t=11.89,P=0.007).3.The expression of XRCC1 protein in adenocarcinoma and in patients withpositive pelvic lymph node were significantly higher than those in squamous cellcancer and negative pelvic lymph node(2.23±0.61 vs 1.92±0.57,t=-2.46,P=0.02;2.52±0.77vs2.07±0.44,t=-3.00,P=0.01)).the stroma invasion≥outer 1/3 weresignificantly higher than those 0.05).4.The expression of XPD protein in tissures of less than 35 years old patientsand in adenocarcinoma weres significantly higher than those more than 35 years andin squamous cell cancer.(2.23±0.61 VS 1.92±0.57,t=2.27,P=0.03;2.44±0.72VS1.93±-0.54,t=-3.01,P=0.01).patients with positive pelvic lymph node weresignificantly higher than those with negative pelvic lymph node(2.42±0.71 VS1.93±0.55,t=-2.83,P=0.01);the stroma invasion≥outer 1/3 were significantlyhigher than thos0.05).Conclusions1.The expression of XRCC1 and XPD protein were significantly lower in effectivepatients than those in stable patients,which implies the abnormal expression ofXRCC1,XPD protein may be associated with the drug-resistance ofplatinum-based neoadjuvant chemotherapy for locally advanced cervical carcinoma.2.The expression of XRCC1,XPD protein can be considered as the index topredict the response of neoadjuvant chemotherapy in locally advanced cervicalcarcinoma.Part 3The Association of Single Nucleotide Polymorphism in DNA Repair GeneXRCC1 With the Effect of Neoadjuvant Chemotherapy for Locally AdvancedCervical CarcinomaObjective:To investigate the possible associations between the effect of neoadjuvantchemotherapy for locally advanced cervical cancer and Single nucleotidepolymorphism of DNA repair gene XRCC1.Methods:A total of 70 patients with locally advanced cervical cancers treated withneoadjuvant chemotherapy between June 1999 and June 2007 in Women s Hospital,School of Medicine,Zhejiang University were analysed.SNP of XRCC1 at codon194,399 were detected by MAMA-PCR.The contributions of different genotypesto the effect of neoadjuvant chemotherapy and XRCC1 protein expression level werecompared and analyzed.Results:1.Genotypes(Arg/Arg,Arg/TrP,Trp/TrP)of XRCC1 at codon 194 were notassociation with the effect of neoadjuvant chemotherapy(X~2=1.243,P=0.07);The XRCC1 protein expression level between different genotypes at codon 194 hadno siginificantly difference.(F=1.186,P=0.103).2. Genotypes(Arg/Arg,Arg/Gln,Gln/Gln)of XRCC1 at codon 399 weresignificantly association with the effect of neoadjuvant chemotherapy(X~2=2.283,P=0.030),the risk of faliure to chemotherapy with Gln allele(Arg/Gln+Gln/Gln) were significantly higher than Arg/Arg(0R=3.254,95%CI 0.708～14.951);TheXRCC1 protein expression level between different genotypes had significantlydifference.(F=15.915,P<0.001).the expression of XRCC1 protein with Glnallele(Arg/Gln+Gln/Gln)were significantly higher than Arg/Arg(F=2.699,p=0.009).Conclusions1.The risk of failure to neoadjuvant chemotherapy and the expression of XRCC1protein were siginificantly increase in patients with Gln allele at codon 399 SNP,indicated that the SNP of XRCC1 gene at codon 399 can be considered as theindex to predict the response of neoadjuvant chemotherapy in locally advancedcervical carcinoma.