Published OnlineFirst January 24, 2019; DOI: 10.1158/0008-5472.
CAN-18-2991
Controversy and Consensus
Is Adjuvant Chemotherapy Efficient in Colon
Cancer with High Microsatellite Instability? A Look
Towards the Future
Guido V. Schiappacasse Cocio1,2,3 and Enrico D. Schiappacasse4
Abstract
The high microsatellite instability (MSI-H) is frequently
observed in localized colorectal adenocarcinoma. MSI-H is
a good prognostic factor in nonmetastatic colon adenocarci-
noma. However, MSI-H is not a predictive factor because it is
not related with better survival in patients with colon cancer
with adjuvant chemotherapy. MSI-H should be a predictive
Introduction
The standard care in stage II and III of colorectal adenocarci-
noma after surgery is based on adjuvant chemotherapy (fluor-
opyridines and oxaliplatin).
Microsatellites or short tandem repeats correspond to short
sequences of bases (from 1 to 6 bases), which are repeated
throughout coding and noncoding regions of the genome. In
these regions, the DNA polymerase tends to make more mis-
takes during the DNA synthesis by inserting additional bases.
Microsatellite instability (MSI) increases mutation rates com-
ing from defects in the DNA mismatch repair by 100–1,000
times (1).
Approximately 15% of colorectal adenocarcinomas are asso-
ciated with MSI: 2.5% coming from a genetic inheritance and
12.5% being a sporadic one. Sporadic MSI is caused by epigenetic
silencing of the MLH1 promoter by methylation, which is asso-
ciated with a somatic BRAF V600E mutation. Hereditary MSI
commonly happens due to autosomal dominant mutations in
mismatch repair (Lynch syndrome; ref. 1).
High microsatellite instability (MSI-H) is a good prognostic
factor for nonmetastatic colon adenocarcinoma. However, MSI-
H is not a predictive factor because it is not related with better
survival in patients with stage II and III colon cancer with
adjuvant chemotherapy. Indeed, MSI-H should be a predictive
factor because it is associated with higher expression of thy-
midylate synthase (2) and topoisomerase 1. While fluoropyr-
imidines inhibit the thymidylate synthase, the irinotecan inhi-
1
~a del Mar, Vin
Department of Medical Oncology, Clinic Hospital of Vin ~a del Mar,
~aca Clinic, Vin
Chile. 2Department of Medical Oncology, Bupa Ren ~a del Mar, Chile.
3
Department of Medical Oncology, Ciudad del Mar Clinic, Vin ~a del Mar, Chile.
4
Graduate School of Arts and Sciences, Tufts University, Medford,
Massachusetts.
Corresponding Author: Guido Virgilio Schiappacasse Cocio, Clinic Hospital of
~a del Mar, #1741 Limache Street, Vin
Vin ~a del Mar 2520612, Valparaíso, Chile.
Phone: 56-32-2323823; E-mail: medicooncologo@hospitalclinico.cl
doi: 10.1158/0008-5472.CAN-18-2991

2019 American Association for Cancer Research.
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Cancer
Research
factor because it is associated with a higher expression of
enzymes, which are inhibited by cytotoxic agents. Here, we
analyze this controversy. We conclude MSI-H is not a predic-
tive factor because the adjuvant therapy based on traditional
cytotoxic agents does not act on either immune signaling
pathways or BRAF mutation.
bits the topoisomerase 1. In this short paper, we analyze this
controversy and propose adjuvant therapeutic lines that would
increase overall survival at stage II and III of adenocarcinoma
with MIS-H. In these therapies MSI-H would become a predic-
tive factor.
Is MSI-H a prognostic factor in stage II and III colon cancer?
MSI-H is described in 22% and 12% of cases of stage II and III of
colon cancer, respectively (2). Critical analysis of the best available
evidence in the literature allows us to conclude that stage II and III
colon cancer with MSI-H is associated with a statistically significant
better disease-free survival (DFS) and overall survival (OS) com-
pared with stage II and III colon cancer with low microsatellite
instability (MSI-L) or microsatellite stability (MSS; refs. 2–5).
The systematic review and meta-analysis from Guetz and
colleagues (2009) analyzed 7 studies for treated [5-fluorouracil
(5-FU)-based chemotherapy] and untreated patients with stage II
or III colorectal adenocarcinoma with MSI. The survival in
untreated patients with stage II or III colorectal adenocarcinoma
and MSI-H was better than that in untreated patients with stage II
or III colorectal adenocarcinoma and MSS (6). On the other hand,
the systematic review and meta-analysis from Romiti and collea-
gues (2016) analyzed two studies. In one study patients were
randomly assigned to either 5-FU and leucovorin alone or with
irinotecan, whereas in the second study patients were randomly
assigned to either 5-FU plus folinic acid or observation. The DFS
resulted to be better in untreated patients with stage II colorectal
adenocarcinoma with MSI-H in comparison with that in untreat-
ed patients with stage II colorectal adenocarcinoma with MSI-L/
MSS (7). As a result, in patients with stage II and III colorectal
adenocarcinoma, MSI-H (as independent variable) is a good
prognostic factor compared with MSI-L/MSS.
MSI-H versus MSI-L/MSS has a significant association with
nonmetastatic colon with high status T, less histologic differentia-
tion (2), and mucinous histologic expression. In other words, we
are talking about more aggressive phenotypes associated with
higher infiltration of the colonic wall, higher risk of lymphovas-
cular invasion, higher risk of lymph node and distant metastases,
and worse survival. Indeed, pT4 has been associated with
OF1
 Published OnlineFirst January 24, 2019; DOI: 10.1158/0008-5472.CAN-18-2991
Schiappacasse Cocio and Schiappacasse
significant reduction of both DFS (P < 0.0001) and OS (P ¼ 0.002;
ref. 5). However, MSI-H is a good prognostic factor. Plausible
reasons that would explain this fact are the following:
i. MSI-H is related to histology with a higher lymphocyte rate
of tumor infiltration mediated by CD8 T and Th 1 lympho-
cytes (1). This relation is caused by a higher activation of
cellular defenses of the immune system. The higher activa-
tion of the immune system is associated with better response
of the host against cancer, less ganglia involvement, lower
possibility of metastasis, and better survival.
ii. In patients with nonmetastatic colon cancer, MSI-H is sig-
nificantly associated with less ganglion status N compared
with MSI-L/MSS (2). In colon cancer, pathologic stage N2
(pN2) is significantly associated with reduced survival (5).
In addition, in nonadvanced colon cancer with pN2, MSI-H
is associated with a better survival compared with MSI-L/
MSS. Survival in patients with MSI-H/pN2 is comparable
with that in patients with pathologic stage N1 (pN1) (5).
iii. In patients with stage II and III colon cancer aged below
65 years, MSI-H is more often than MSI-L (2). In some
studies, age is a factor of good prognosis in colon cancer.
Probably, this is because younger patients tend to have
better organic conditions than older ones.
iv. MSI-H is more frequently reported in right colon than in left
colon (2). In addition, the right colon cancer has better
prognosis than the left colon cancer. Indeed, the DFS in
patients with right colon cancer with MSI-H is better than
that in patients with left colon cancer with MSI-H (2).
Probably neoplasms of the right and left colon have different
genotypes, which determine their different prognosis and
aggressiveness.
Is MSI-H a predictive factor in stage II and III colon cancer?
A predictive factor corresponds to the variable that shows the
best response, namely, survival in the presence of a therapeutic
intervention.
The study of Ribic and colleagues (2003) analyzed relation
between patients with stage II and III colon cancer treated with
5-FU and microsatellite status (N ¼ 570). Their results did not
show a correlation between survival and MSI-H in patients treated
with 5-FU (HR, 1.07 with P ¼ 0.8). Indeed, patients with 5-FU-
based adjuvant therapy with MSI-L/MSS showed a better OS,
decreasing risk of death of 28% and HR 0.72 with P ¼ 0.04, than
those with 5-FU-based adjuvant therapy with MSI-H (3).
On the other hand, the MOSAIC (Multicenter International
Study of Oxaliplatin/Fluorouracil/Leucovorin in the Adjuvant
Treatment of Colon Cancer) study after 10-year follow-up (N ¼
2,246) showed that OS in patients with stage III colon cancer
treated with FOLFOX (oxaliplatin/fluorouracil/leucovorin)-4
was better than that in patients with stage III colon cancer
treated with LV5FU2 (fluorouracil/leucovorin; HR, 0.8 with P ¼
0.016). The same tendency was found in patients with stage II
colon cancer with respect to DFS but not to OS. The only
exception to that was a subgroup of patients with stage II
colon cancer of high risk (T4, perforated tumor and less than
10 regional nodes examined) that showed a better OS at the
limit of statistical significance (P ¼ 0.058; ref. 8).
In addition, FOLFOX-4 in the MOSAIC study was associated
with a better survival in cases of mismatch repair deficiency
(HR, 0.41) and BRAF mutation (HR, 0.66) compared with
LV5FU2 (8). However, a definitive conclusion cannot be drawn
OF2 Cancer Res; 79(3) February 1, 2019
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Research.
from this last statistical analysis because the mismatch repair
deficiency study was a retrospective study performed after
histologic sampling. In addition, mentioned analysis is based
only on a subgroup and is not part of original end points of the
study. All these issues decrease the statistical weight of the
discussed conclusion.
In other studies, which were focused on determining the
effect of FOLFOX in patients with nonmetastatic colon adeno-
carcinoma with MSI-H, the condition of MSI-H was not a
predictive factor with respect to the survival (4, 5).
In the follow-up of the PETACC-3 trial (N ¼ 1,254) 10
different loci were analyzed, and patients with stage II and III
colon cancer were classified by microsatellite status (MSI-H,
three or more unstable loci, and MSI-L/MSS). The study focused
on patients with colon cancer treated with 5-FU/leucovorin
versus FOLFIRI (irinotecan/5-FU/leucovorin). MSI-H was not
a predictive factor of survival after adding irinotecan to the
adjuvant chemotherapy (2).
In a systematic review and meta-analysis from Guetz and
colleagues (2009), the adjuvant therapy, under the presence of
MSI-H, was not found to be related to either DFS (HR, 0.96
with P ¼ 0.86) or OS (HR, 0.70 with P ¼ 0.12). Because the
survival in treated patients with MSI-H and untreated patients
with MSI-H was similar, authors concluded that MSI-H was not
a predictive factor. Indeed, treated patients with MSS were
associated with better survival compared with untreated pati-
ents with MSS (6).
In a systematic review and meta-analysis from Romiti and
colleagues (2016), authors concluded that MSI-H was not a
predictive factor. In the context of stage II colon cancer with the
presence of MSI-H, the survival in treated patients was compara-
ble with that in untreated patients (P ¼ 0.20; ref. 7).
As a result, the best available evidence leads us to conclude
that MSI-H is a good prognostic factor. On the other hand, in
patients with nonmetastatic colon cancer, MSI-H has been
associated with higher expression of thymidylate synthase (2)
and topoisomerase 1 compared with MSI-L/MSS. We know that
the enzyme thymidylate synthase is inhibited by the cytotoxic
actions of fluoropyrimidines (such as the 5-FU) and that irino-
tecan acts over the topoisomerase 1. Then we could anticipate
that MSI-H should be a predictive factor of tumor response for
treated patients with adjuvant cytotoxic chemotherapy based
on 5-FU or irinotecan plus 5-FU/leucovorin. However, the best
available evidence leads us to a conclusion that MSI-H is not a
predictive factor of tumor response for treated patients with
adjuvant cytotoxic chemotherapy. To explain this apparent
contradiction, we must focus on hidden variables, immune
signaling pathways, and mutations, which are associated with
MIS-H in colon cancer. These variables have not been consid-
ered in therapeutics.
Signaling pathways in the immune response and MSI-H in
colon cancer
Among studies on immunotherapy and colon cancer, we
highlight the Keynote 164 and the CheckMate 142 trials:
i. The Keynote 164 trial (phase II study with N ¼ 63) for
patients with metastatic colon cancer with MSI-H and at least
one previous line of treatment (fluoropyrimidine, oxalipla-
tin, irinotecan, or anti-VEGF/EGFR) evaluated pembrolizu-
mab administration. In this study, the objective response
rate was 32%, the median duration of response was 6
Cancer Research
 Published OnlineFirst January 24, 2019; DOI: 10.1158/0008-5472.CAN-18-2991
months or more in 75% of cases, the median DFS was 4.1
months with a 12-month DFS rate of 41%, and the median
OS was not reached with a 12-month OS rate of 76% (9).
ii. The CheckMate 142 trial (open label, multicenter, phase II
study with N ¼ 74) for patients with metastatic or recurrent
colorectal cancer with MSI-H and at least one previous line
of treatment (including fluoropyrimidine and oxaliplatin
or irinotecan) evaluated nivolumab administration. In this
study, the response rate was 69% with a duration of 12 weeks
or longer (10).
The use of pembrolizumab and nivolumab in these studies
(anti-PD-1 mAbs) in patients with metastatic colon cancer with
MSI-H in second and third lines suggests that MSI-H is a bio-
marker for PD-1 blockade and the effectiveness of these anti-
bodies (1). PD-1 is a transmembrane protein of T cells. This
protein interacts with its ligand PD-L1 expressed by the cancer
cell, leading to a T-cell anergy. The use of mABs that release PD-1
from its union with PD-L1 leads to activation of T cells and
anticancer immune response (1).
From all the information given above, we anticipate future
studies about the use of these antibodies in the first line in
patients with metastatic colorectal adenocarcinoma with MSI-H
versus the use of a traditional cytotoxic chemotherapy. Regret-
tably, because MSI-H is described in advanced colorectal cancer
only in 4% of cases (2), the epidemiologic impact of this
research line would be reduced. In contrast, we propose future
research lines based on the use of these antibodies in patients
with stage II and III colon adenocarcinoma with MSI-H versus
the use of the traditional cytotoxic chemotherapy. In patients
with stage II and III colon adenocarcinoma with MSI-H, we
expect that patients treated with anti-PD-1 mABs show a better
DFS and OS in comparison with those treated with traditional
cytotoxic chemotherapy based on 5-FU plus oxaliplatin or
irinotecan.
Other mutations and MSI-H in colon cancer
BRAF is a gene that encodes the serine/threonine protein
kinase. This protein is involved in the intracellular signaling of
MAP kinases regulated by the KRAS protein. The most frequent
BRAF mutation is the substitution of a valine by a glutamine at
the position 600 of its chain of amino acids (BRAF V600E). In
stage II and III colon cancer, BRAF mutation in MSI-H is four
times more often than BRAF wild-type in MSI-H. In contrast, in
nonmetastatic colon cancer, KRAS mutation in MSI-H is 1.5
times less often than KRAS wild-type in MSI-H (2). In the
context of stage II and III colon cancer, Gavin and colleagues
(2012) reported that mutations in KRAS, NRAS, MET, and
PIK3CA were not associated with tumor recurrence, survival
after recurrence, and OS. On the contrary, BRAF mutation was
associated with defects in the DNA repair system (P < 0.0001),
poor OS (HR, 1.46 with P  0.0002), and poor survival
after recurrence (HR, 2.31 with P < 0.0001; ref. 4). In the
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Conclusions
Colon cancer is not a homogeneous disease. Indeed, this
disease shows diverse genotypes with different both clinical
manifestations, and prognoses. In the nonmetastatic colon can-
cer, the patients' subgroup with MSI-H is very important. MSI-H,
as independent variable, is a good prognostic factor. However, it is
not a predictive factor under the presence of adjuvant chemo-
therapy based on traditional cytotoxic agents (fluoropyrimidine,
oxaliplatin, or irinotecan). MSI-H should be a predictive factor
because it is related to a higher expression of thymidylate synthase
and topoisomerase 1. In this paper, we analyze this controversy
and conclude that MSI-H is not a predictive factor because
adjuvant therapy does not act on either immune signaling path-
ways or BRAF mutation (both related with MSI-H). We propose
new research lines pointing out these targets in patients with stage
II and III colon adenocarcinoma with MIS-H.
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Cancer Research
 Published OnlineFirst January 24, 2019; DOI: 10.1158/0008-5472.CAN-18-2991

Is Adjuvant Chemotherapy Efficient in Colon Cancer with

High Microsatellite Instability? A Look Towards the Future
Guido V. Schiappacasse Cocio and Enrico D. Schiappacasse

Cancer Res Published OnlineFirst January 24, 2019.

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