Trial Information

Thymidylate Synthase Polymorphisms as a Predictor of Toxicity to 5-Fluorouracil Based Chemotherapy in Stage III Colon Cancer

Hypothesis:

Recently, the thymidylate synthase gene's promoter has been found to be polymorphic, with
variable numbers of tandem repeats of 28 base pairs in length. These polymorphisms have been
associated with tumor response to treatment with fluoropyrimidines. The researchers
hypothesize that polymorphisms in thymidylate synthase (TS) gene's promoter region are
associated with toxicity from 5-fluorouracil (5FU)/leucovorin (LV) treatment specifically
development of myelosuppression and diarrhea. The researchers hypothesize that a
polymorphism in methylene tetrahydrofolate reductase (MTHFR) is also associated with
toxicity and efficacy of 5FU/LV treatment. The researchers speculate that the MTHFR
polymorphism only becomes clinically significant by stratifying patients by TS promoter
polymorphisms.

Objectives:

1. To determine if polymorphisms in thymidylate synthase's promoter region are associated
with development of overall toxicity, diarrhea, neutropenia, or mucositis in patients
treated with 5FU/LV.

2. To determine if a polymorphism in methylene tetrahydrofolate reductase (MTHFR) is
associated with development of overall toxicity, diarrhea, neutropenia, or mucositis in
patients treated with 5FU/LV

Background and Significance:

5-fluorouracil (5FU) is a potent antimetabolite that is the currently accepted adjuvant
treatment for colorectal cancer. As well, 5FU is used to treat head and neck cancers, breast
cancer and gastric cancer. In 1985, Takeishi et al demonstrated that thymidylate synthase's
gene had a satellite in the 5' untranslated region, which consisted of 3 tandem repeats of a
28 base pair sequence. Horie et al demonstrated that these satellites were polymorphic in
length due to different numbers of tandem repeats, with 2 length polymorphism existing 2
tandem repeats of 28 base pairs (2R) and 3 tandem repeats of 28 base pairs (3R). Subsequent
authors have demonstrated 4 repeats (4R), five repeats (5R) and nine repeats (9R). Kawakami
et al demonstrated that the number of tandem repeats affected TS gene translation. They
showed those patients homozygous for 3R alleles had higher TS protein levels than 2R/3R
heterozygotes. Using in vitro expression of 2R and 3R genes they demonstrated that the
increased protein levels were due to increased translational efficiency of the 3R RNA and
not due to increased 3R mRNA expression. These tandem repeats are predictive of response
rates of various cancers to fluoropyrimidine cancer chemotherapy. Park et al showed in
metastatic colorectal cancer patients treated with capecitabine, the response rate was 14%
in patients homozygous for 3R repeats, and 80% in the patients homozygous for 2R repeats. No
prospective study has examined if a patient's TS genotype predicts for 5-FU toxicity.

A polymorphism in methylene tetrahydrofolate reductase's (MTHFR) gene may also determine a
patient's risk for capecitabine toxicity. A polymorphism in MTHFR exists at position 677, C
to T producing a thermolabile and rapidly degraded enzyme. TT homozygotes have increased
levels of methylene tetrahydrofolate. Methylene tetrahydrofolate stabilizes binding of 5FU
to thymidylate synthase and the complex of TS, 5FU, and methylene tetrahydrofolate is
referred to as the ternary complex. The researcher hypothesizes that increased stabilization
of TS and 5FU due to increased amounts of methylene tetrahydrofolate would lead to increased
capecitabine toxicity and efficacy. No study has examined if TT homozygotes have an
increased response rate to fluoropyrimidines or increased toxicity. Dihydropyrimidine
dehydrogenase (DPD) deficiency has been identified as the cause of rare severe life
threatening reactions to fluoropyrimidines. The first case was reported by Tuchman et al in
a 27 year old woman who had undergone adjuvant chemotherapy with cyclophosphamide,
methotrexate, and 5-fluoruracil and developed severe neurological complications. Diasio et
al reported the second case again in a women being treated with 5-fluoruracil for breast
cancer.

A study by Etienne et al has raised questions regarding the utility of DPD activity alone to
predict patients at risk for fluoropyrimidine toxicity. They prospectively studied 185
patients treated with 5FU containing chemotherapy regimens. They found a normal distribution
of DPD activity with a mean value of 0.222 nmol/min/mg protein. They did not find any
correlation between DPD activity and 5FU toxicity. The researchers propose to study the
effect of these two polymorphic enzymes on 5FU/LV's toxicity in adjuvant colon cancer
patients. The researchers anticipate that patients homozygous for 2R/2R will have higher
rates of overall toxicity, diarrhea, neutropenia and mucositis than 3R/3R homozygotes. For
MTHFR, the researchers anticipate that TT homozygotes will have higher rates of overall
toxicity, diarrhea, neutropenia, and mucositis than CC homozygotes. The effect of MTHFR
polymorphism on 5FU/LV's toxicity will be examined controlling for thymidylate synthase
genotype.

Methods:

Patients who have been advised to have adjuvant chemotherapy for colorectal cancer will be
enrolled. Patients will be treated with standard doses of 5FU/LV according to the Mayo
regimen. Toxicities during cycle one will be graded according to National Cancer Institute
Common Toxicity Criteria Version 2. Dose reductions during cycle one will be recorded.

Investigations:

Prior to starting treatments patients will provide a 10 ml sample of blood which will be
used to obtain DNA from white bloods. Patients will be genotyped according to TS and MTHFR
genotypes. Plasma will be banked to determined DPD phenotype.

Sample Size Calculation:

The allele frequency of 3R tandem repeats is 0.6 and 2R tandem repeats is 0.417. In 100
patients therefore, one would expect 16 patients with 2R/2R genotypes, 48 with 2R/3R
genotypes and 36 with 3R/3R genotypes. It is interesting to note that the incidence of grade
3/4 palmar plantar erythrodysesthesia and diarrhea is on the order of 14 to 16 percent. A
sample of 104 patients would have a power of 0.8 to show a statistically significant
difference of 40% between 2R/2R (60 %) and 3R/3R (20 %).

Statistical Analysis:

Associations between TS genotype and development of grade1/2 and 3/4 overall toxicity will
be examined using the chi square test, with a level of significance of 0.05. Other
toxicities of interest, diarrhea, mucositis and neutropenia, will be examined for
association with TS genotype chi square test. Similar exploratory analysis will be done for
MTHFR phenotypes