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Circulating tumor DNA analysis detects minimal residual disease and predicts recurrence in patients with stage II colon cancer

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Science Translational Medicine  06 Jul 2016:
Vol. 8, Issue 346, pp. 346ra92
DOI: 10.1126/scitranslmed.aaf6219
  • Fig. 1. Patient enrolment and sample collection.
  • Fig. 2. RFS in patients not treated with adjuvant chemotherapy.

    (A) Kaplan-Meier estimates of RFS for all patients not treated with adjuvant chemotherapy, stratified by postoperative ctDNA status. (B) Kaplan-Meier estimates of RFS in the same patients, stratified by clinicopathologic characteristics. (C) Kaplan-Meier estimates of RFS stratified by postoperative ctDNA status in patients with low-risk clinicopathologic characteristics. (D) Kaplan-Meier estimates of RFS stratified by postoperative ctDNA status in patients with high-risk clinicopathologic characteristics. The high-risk group is defined as those having mismatch repair–proficient (pMMR) tumors with at least one of the following poor prognostic features: T4, LN yield <12, LVI, and poor tumor differentiation. The low-risk group is defined as those with no poor prognostic features.

  • Fig. 3. ctDNA status before, during, and after adjuvant chemotherapy.

    (A to F) ctDNA concentrations (% mutant alleles) for the six patients with positive postoperative ctDNA who subsequently received adjuvant chemotherapy. The blue shaded box indicates the period during which adjuvant chemotherapy was administered. The dotted line indicates the time of radiologic recurrence or last follow-up (if recurrence-free). The ctDNA status of patients represented in (A) and (B) initially became negative, then became positive again at the completion of adjuvant chemotherapy; both patients subsequently suffered a radiologic recurrence. Note that CEAs were not elevated in either patient at any time point. (C to F) Four patients whose ctDNA became negative after completion of chemotherapy. Three of these patients (patients C, D, and F) remained radiologic recurrence-free at their last follow-up visit. (G) Kaplan-Meier estimates of RFS according to post-chemotherapy ctDNA status in patients treated with adjuvant chemotherapy. ND, not detected; NE, not elevated.

  • Fig. 4. Serial ctDNA status up to radiological recurrence.

    (A) Serial ctDNA measurements up to the time of radiological recurrence for the nine patients who were not treated with adjuvant chemotherapy and who were ctDNA-positive postoperatively. (B) Scatter plot of the lead time to radiological recurrence for ctDNA detection and CEA elevation, with the error bars representing the median and IQR.

  • Table 1. Mutations and mutant allele fractions detected in postoperative ctDNA-positive cases.
    MutationsMAF (%)
    TP53 p.R342X1.631
    TP53 p.G245D0.123
    APC p.L878fs0.11
    TP53 p.R248Q0.01
    TP53 p.R248Q0.006
    TP53 p.R248Q0.017
    APC p.Q1406fs0.059
    APC p.E1379X0.235
    KRAS p.G13D0.066
    TP53 p.R248Q0.678
    APC p.C1578fs0.140
    KRAS p.G12D0.027
    KRAS p.G12V0.008
    TP53 p.P151fs0.003
    APC p.S1436fs0.046
    TP53 p.R282W1.774
    APC p.D1178fs0.007
    APC p.E1408fs0.046
    TP53 p.I254fs0.05
    APC p.S1010fs0.006
  • Table 2. Patient and tumor characteristics according to postoperative ctDNA status.
    Characteristics*All patients
    (n = 230)
    Postoperative
    ctDNA-positive
    (n = 20)
    Postoperative
    ctDNA-negative
    (n = 210)
    Age (years)
      Median
    [interquartile
    range (IQR)]
    65 (59–73)64 (54–68)66 (59–74)
      Range23–8743–8623–87
    Sex, no. (%)
      Male131 (57)10 (50)121 (58)
      Female99 (43)10 (50)89 (42)
    Tumor site, no. (%)
      Right colon103 (45)5 (25)98 (47)
      Left colon127 (55)15 (75)112 (53)
    Differentiation, no. (%)
      Well/moderate193 (84)18 (90)175 (83)
      Poor37 (16)2 (10)35 (17)
    T stage, no. (%)
      T3192 (83)17 (85)175 (83)
      T438 (17)3 (15)35 (17)
    Lymph node yield, no. (%)
      <1229 (13)5 (25)24 (11)
      ≥12201 (87)15 (75)186 (89)
    Lymphovascular invasion, no./total no. (%)
      Yes41/221 (19)6/20 (30)35/201 (17)
      No180/221 (81)14/20 (70)166/201 (83)
    MMR status, no. (%)
      Proficient189 (82)19 (95)170 (81)
      Deficient41 (18)1 (5)40 (19)
    Clinicopathologic risk group, no. (%)
      Low140/224 (63)10 (50)130/204 (64)
      High84/224 (37)10 (50)74/204 (36)
    Adjuvant chemotherapy, no. (%)
      Yes52 (23)6 (30)46 (22)
      No178 (77)14 (70)164 (78)

    *There were no significant differences between the groups in any of the characteristics listed in this table.

    †Right-sided colon cancer was defined as tumors arising from the cecum, ascending, hepatic flexure, or transverse colon; left-sided colon cancer was defined as tumors arising from the splenic flexure, descending, sigmoid, or rectosigmoid colon.

    ‡Except for two cases where oxaliplatin-based chemotherapy was used, all other adjuvant treatment was fluorouracil-based chemotherapy.

    • Table 3. Recurrence-free survival analysis by clinicopathological variables and postoperative ctDNA status.
      VariableUnivariate analysisMultivariate analysis
      HR95% CIPHR95% CIP
      Patients not treated with chemotherapy (n = 178)
      Age, <70 versus ≥700.920.43–2.00.8
      Sex, male versus female1.30.62–2.80.5
      Tumor site, right versus left1.50.69–3.30.3
      Tumor differentiation, well/moderate versus poor0.390.09–1.70.2
      T stage, T3 versus T44.01.7–9.50.0028.13.1–21<0.001
      Lymph node yield, ≥12 versus <123.11.3–7.40.009
      Lymphovascular invasion, no versus yes2.41.1–5.40.03
      MMR status, deficient versus proficient3.60.86–150.08
      Clinicopathologic risk group, low versus high3.21.5–6.90.002
      Postoperative CEA, normal versus elevated1.60.37–6.80.5
      Postoperative ctDNA status, negative versus positive187.9–40<0.0012811–68<0.001
      All patients (n = 230)
      Age, <70 versus ≥701.00.50–2.01.0
      Sex, male versus female1.10.57–2.20.7
      Tumor site, right versus left1.10.55–2.10.8
      Tumor differentiation, well/moderate versus poor0.320.08–1.30.1
      T stage, T3 versus T42.41.2–5.10.022.61.2–5.50.01
      Lymph node yield, ≥12 versus <122.20.97–4.80.06
      Lymphovascular invasion, no versus yes1.90.92–4.10.08
      MMR status, deficient versus proficient3.50.83–14.50.09
      Clinicopathologic risk group, low versus high2.11.06–4.20.03
      Adjuvant chemotherapy, no versus yes0.790.34–1.80.6
      Postoperative CEA, normal versus elevated2.80.98–7.90.06
      Postoperative ctDNA status, negative versus positive136.6–27<0.001146.8–28<0.001

    Supplementary Materials

    • www.sciencetranslationalmedicine.org/cgi/content/full/8/346/346ra92/DC1

      Fig. S1. Recurrence-free survival in patients not treated with adjuvant chemotherapy stratified by postoperative CEA status.

      Table S1. Relationship between postoperative ctDNA, postoperative CEA, and recurrence status for patients not treated with chemotherapy.

      Table S2. Time-dependent predictive accuracy of postoperative ctDNA for recurrence at 5, 6, 12, 18, 24, 36, and 40 months.

      Table S3. Serial circulating biomarker status and clinical characteristics of patients not treated with adjuvant chemotherapy who experienced recurrence.

      Table S4. Serial circulating biomarker status and clinical characteristics of chemotherapy-treated patients who experienced recurrence.

      Table S5. Genomic and clinical summary for all patients included in the final evaluable population.

      Table S6. Panel of 15 genes used for identification of somatic mutations in tumor tissue.

    • Supplementary Material for:

      Circulating tumor DNA analysis detects minimal residual disease and predicts recurrence in patients with stage II colon cancer

      Jeanne Tie,* Yuxuan Wang, Cristian Tomasetti, Lu Li, Simeon Springer, Isaac Kinde, Natalie Silliman, Mark Tacey, Hui-Li Wong, Michael Christie, Suzanne Kosmider, Iain Skinner, Rachel Wong, Malcolm Steel, Ben Tran, Jayesh Desai, Ian Jones, Andrew Haydon, Theresa Hayes, Tim J. Price, Robert L. Strausberg, Luis A. Diaz Jr., Nickolas Papadopoulos, Kenneth W. Kinzler, Bert Vogelstein,* Peter Gibbs*

      *Corresponding author. Email: jeanne.tie{at}mh.org.au (J.T.); vogelbe{at}jhmi.edu (B.V.); peter.gibbs{at}mh.org.au (P.G.)

      Published 06 July 2016, Sci. Transl. Med. 8, 346ra92 (2016)
      DOI: 10.1126/scitranslmed.aaf6219

      This PDF file includes:

      • Fig. S1. Recurrence-free survival in patients not treated with adjuvant chemotherapy stratified by postoperative CEA status.
      • Table S1. Relationship between postoperative ctDNA, postoperative CEA, and recurrence status for patients not treated with chemotherapy.
      • Table S2. Time-dependent predictive accuracy of postoperative ctDNA for recurrence at 5, 6, 12, 18, 24, 36, and 40 months.
      • Table S3. Serial circulating biomarker status and clinical characteristics of patients not treated with adjuvant chemotherapy who experienced recurrence.
      • Table S4. Serial circulating biomarker status and clinical characteristics of chemotherapy-treated patients who experienced recurrence.
      • Table S5. Genomic and clinical summary for all patients included in the final evaluable population.
      • Table S6. Panel of 15 genes used for identification of somatic mutations in tumor tissue.

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