Open Access

ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX‑based neoadjuvant concurrent chemoradiation

  • Authors:
    • Ming-Yii Huang
    • Hsin-Hua Lee
    • Ching-Wen Huang
    • Chun-Ming  Huang
    • Cheng-Jen Ma
    • Tzu-Chieh Yin
    • Hsiang-Lin Tsai
    • Chee-Yin  Chai
    • Yi-Ting Chen
    • Jaw-Yuan Wang
  • View Affiliations

  • Published online on: September 8, 2020
  • Article Number: 212
  • Copyright: © Huang et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

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Colorectal cancer (CRC) of the clinical tumor stage T4b (cT4b) refers to advanced tumors with direct invasion of adjacent structures and the tumors are considered unresectable. Despite advancements in aggressive surgery and combination chemotherapy, the prognosis of cT4b CRC remains poor. Optimizing the therapeutic sequence administered to patients with cT4b CRC to improve clinical outcomes is crucial. In the present study, patients with unresectable cT4b and nodal stage N1‑2 CRC were investigated at a single institution. A total of 20 consecutive patients were treated with pre‑operative concurrent chemoradiation by using 5‑fluorouracil/leucovorin/oxaliplatin (FOLFOX) since February 2015 and were regularly followed up until March 2020. Due to their poor response to concurrent chemoradiation (CCRT) with FOLFOX, the chemotherapy regimen was changed to irinotecan plus 5‑fluorouracil/leucovorin (FOLFIRI) as the second‑line neoadjuvant treatment. Genetic alterations, such as microsatellite instability (MSI), were documented, and the expression levels of excision repair cross‑complementing group 1 (ERCC1) and ERCC2 were examined. Of the 20 patients, the tumors of 14 patients (70%) became resectable after FOLFIRI administration. The median duration between the last date of radiotherapy and surgery was 32.7 weeks (range, 10.1‑59.3 weeks). Of note, 4 of the 14 patients with resectable tumors (28.6%) achieved a pathologic complete response. The median overall survival and progression‑free survival were 27.5 months (range, 12‑39 months) and 27.5 months (range, 8‑39 months), respectively. The cancerous specimens of all of the patients (100%) exhibited ERCC2 overexpression and 18 specimens (90%) had ERCC1 overexpression. Only one tumor (5%) exhibited high MSI. The present study indicated that ERCC overexpression associated with the poor response of FOLFOX‑based CCRT and FOLFIRI after FOLFOX‑based CCRT failure may have a potential role in conversion to resectable tumors by neoadjuvant treatment in cT4b CRC. However, a further prospective study with more patients is required to improve the precision of the conclusions.


The highest incidence of colorectal cancer (CRC) is observed in certain European countries, Australia, New Zealand, Northern America and East Asia (1). The global burden of CRC is expected to persist at least until the year 2035 (2,3). The highest number of cancer-associated deaths are caused by cancers of the lungs, prostate gland, and colon/rectum in males and cancers of the lungs, breasts and colon/rectum in females (4). CRC is the most commonly diagnosed cancer type in Taiwan (5). Despite significant improvements achieved with multidisciplinary treatment, CRC remains one of the major causes of cancer-associated mortality. Of note, the death rate for CRC decreased by 53% from 1970 to 2016 (4).

A growing body of evidence supports the concept of perioperative treatment for CRC. Concurrent chemoradiation (CCRT) followed by surgery and adjuvant chemotherapy has become the standard treatment for locally advanced rectal cancer (6). An analysis of the National Cancer Database (NCDb) revealed that neoadjuvant radiotherapy (RT) for clinical T4 stage (cT4) disease may be associated with superior R0 resection rates and improved overall survival (OS) (7). The clinical T4b classification refers to advanced tumors with direct invasion of adjacent structures and those tumors are unresectable (8).

Excision repair cross-complementing (ERCC) genes encode proteins involved in a complex DNA repair mechanism that is responsible for the removal of DNA lesions and the maintenance of chromosome stability. ERCC1 gene polymorphisms have been investigated as a potential predictive biomarkers of the efficacy of oxaliplatin and platinum treatment in various cancer types (9). Increased ERCC1 expression is associated with clinical resistance to platinum-based chemotherapy. In a previous study by our group, ERCC1 overexpression was indicated to be an independent predictor of poor disease-free survival (DFS) and OS in patients with stage III CRC who received adjuvant 5-fluorouracil/leucovorin/oxaliplatin (FOLFOX) (10). Despite advancements in aggressive surgery and combination chemotherapy, the prognosis of cT4b CRC remains poor, with a 5-year survival rate of 15.7–38.5% (1114). Therefore, identifying potential prognostic biomarkers and optimizing the therapeutic sequence administered to patients with cT4b CRC to improve clinical outcomes are crucial. Whether neoadjuvant treatment for cT4b CRC improves the resectability of tumors and patient survival has remained to be fully determined. A previous study by our group demonstrated that neoadjuvant chemoradiotherapy is feasible and safe with a prominent pathologic complete response in locally advanced colon cancer (15). In the present study, its capacity to convert the tumor into a resectable tumor was comprehensively studied for patients with cT4b CRC after neoadjuvant CCRT.

Materials and methods


The present study assessed patients with unresectable cT4b and clinical nodal stage N1-2 (cN1-2) CRC between February 2015 and March 2019 at Kaohsiung medical university hospital. A total of 20 consecutive patients were treated with preoperative CCRT by using the FOLFOX regimen (15). The resectability of their tumors was assessed through imaging techniques such as CT, after 6 to 12 cycles of FOLFOX with duration of 12 to 24 weeks. Only patients who did not respond to this first-line CCRT regimen were included in the present study. This poor response was not expected. However, all patients exhibited a poor response to CCRT and all tumors were still unresectable after CCRT with FOLFOX. Therefore, the chemotherapy regimen was changed to irinotecan plus fluorouracil/leucovorin (FOLFIRI) after FOLFOX-based CCRT (16). The clinical course of the patients was followed up from the time of cancer diagnosis through to their last available clinical record. Genetic alterations, such as microsatellite instability (MSI) and ERCC1 and ERCC2 expression, were examined. Clinicopathological variables, treatment outcomes and adverse events were also analyzed. Patients were included in this study if they had pathologically proven colorectal adenocarcinoma and a clinical diagnosis of cT4b with cN1 or cN2. Patients were excluded if they had a history of prior pelvic irradiation or malignancies other than CRC. A total of two patients were excluded because one underwent prior pelvic irradiation for cervical cancer and the other one underwent the same for prostate cancer. Furthermore, patients with distant metastasis were also not included in this study. Patient follow-ups were performed by visits to the clinic until the end of March 2020.

All of the patients underwent pretreatment workups comprising a physical examination, a history review, chest radiography, bronchoscopy with tumor biopsy, contrast-enhanced CT or MRI and routine laboratory tests. The tumor stage was classified according to the seventh edition of the Cancer Staging Manual and Handbook of the American Joint Committee on Cancer (8). The Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1) guidelines, which are also routinely used in clinical practice, were used to evaluate the CRC tumor response (17,18). Side effects were graded according to the Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE) ( The following variables (patient characteristics) were recorded: Age, sex, tumor location, initial clinical tumor and nodal classification, tumor size, ERCC1 and ERCC2 overexpression levels and MSI status in the cancerous specimen by diagnostic biopsy, best objective response according to the RECIST criteria and adverse events.

Ethics approval statement

The present study was approved by the ethical and research committee of Kaohsiung Medical University Hospital [approval no. KMUHIRB-E(I)-20190182]. This study was conducted in compliance with institutional review board regulations in accordance with the Helsinki Declaration of 1975 as revised in 1983. All patients provided written informed consent for the addition of their sample to the collection, use for scientific research and added to a specimen bank; patient information was anonymized prior to the analysis.

Immunohistochemical (IHC) staining of ERCC1 and ERCC2

All incubations were performed at room temperature unless otherwise specified. Formalin-fixed and paraffin-embedded tissue blocks of samples from each patient were used to obtain 4-µm-thick sections, and the sections were deparaffinized in xylene (10,19). They were then rehydrated in a graded alcohol series (100, 95 and 75%). Each rehydration step was performed for 1 min at room temperature. Next, the sections were washed with tap water for 5 min at room temperature. Antigen retrieval was performed using target retrieval solution (pH 9.0; DAKO) in an autoclave (121°C, 1.2 kg/cm2) for 10 min, and endogenous peroxidase was blocked in the sections by incubating them in 3% hydrogen peroxide for 5 min. Finally, for antigen retrieval, the sections were immersed in citrate buffer (ERCC1: pH 9.0, ERCC2: pH 9.0) prior to immunostaining at room temperature. The sections were incubated for 15 min at room temperature with antibodies against ERCC1 (dilution, 1/25; cat. no. #ab2356; Abcam) and ERCC2 (dilution, 1/250; #ab111596; Abcam). Next, the samples were treated with the DAKO REAL EnVision Detection System-HRP (DAKO) for 30 min. Finally, the sections were incubated in 3′,3-diaminobenzidine for 5 min, followed by Mayer's hematoxylin counterstaining, and dehydration was then performed through 2 changes of 95% ethanol and 2 changes of 100% ethanol. Subsequently, the samples were cleared in 3 changes of xylene and then mounted on slides for observation by using a microscope. Negative controls were prepared by replacing the primary antibody with distilled water.

To improve the accuracy and reduce interobserver differences, the immunostaining of ERCC1 and ERCC2 was scored by two independent pathologists (CYC and YTC). They evaluated slides and scored the extent of immunostaining through light microscopy. They analyzed gene expression based on the intensity of IHC staining and the percentage of positive cancerous cells. Samples with nuclear ERCC1 and cytoplasmic ERCC2 immunostaining were considered positive. ERCC1 and ERCC2 overexpression was defined as a score of 2 (positive staining in >50% of cells), whereas absence of overexpression was defined as a score of 0 or 1.

Pre-operative CCRT and post-operative chemotherapy or RT regimen

All of the patients received CCRT once the diagnosis of stage IIIC CRC was confirmed. For pelvic RT, each patient was placed in a customized thermoplastic immobilization cast. The primary and boost beams were combined in a single integrated treatment plan. A total of 19 patients received intensity-modulated RT. The fractionation scheme was 45 Gy in 25 fractions to the pelvic lymphatic drainage area with a simultaneous boost of 50 Gy delivered to primary tumors and also to metastatic lymph nodes for 18 patients. Furthermore, one patient received 49.5 Gy in 27 fractions to the pelvic lymphatic drainage area with a simultaneous boost of 54 Gy delivered to primary tumors and metastatic lymph nodes. Three-dimensional conventional RT was delivered to one patient with a 44 Gy/22 fraction to the pelvis with a boost of 6 Gy/3 fractions to the tumor. RT was delivered without interruption.

The FOLFOX regimen followed a biweekly schedule concurrent with RT. Each cycle of FOLFOX consisted of oxaliplatin (85 mg/m2) through a 2-h infusion concurrently with folinic acid (400 mg/m2) through a 2-h infusion on day 1 and 5-FU (2,800 mg/m2) through a 46-h infusion repeated every 2 weeks. The FOLFIRI regimen after CCRT consisted of leucovorin calcium (calcium folinate), 5-fluorouracil and irinotecan. Each cycle of FOLFIRI consisted of irinotecan (180 mg/m2) through a 2-h infusion concurrently with folinic acid (400 mg/m2) through a 2-h infusion on day 1 and 5-FU (2,800 mg/m2) through a 46-h infusion repeated every 2 weeks. Furthermore, seven patients received bevacizumab (Avastin; Roche) 5 mg/kg repeated every 2 weeks combined with FOLFIRI.

After a median post-RT follow-up of 24.3 months (range, 7.8–37 months), radical protectomy or colectomy was performed. A total of five patients with negative pathological margins were treated using capecitabine (Xeloda; Roche) at a dose of 850 mg/m2 every 12 h between days 1 and 14. This protocol was applied every 21 days in 6 to 8 cycles and capecitabine was prescribed for up to 6 months. The other five patients with negative pathological margins and were treated using oral tegafur 100 mg-uracil 224 mg (UFUR; TTY Biopharm Co., Ltd.) at a dose of one capsule three times a day for up to 6 months. Adjuvant FOLFIRI was administered to four patients (three with positive circumferential radial margin involvement and one with 0.5 cm circumferential radial margin).

Statistical analysis

Primary endpoints were OS and progression-free survival (PFS). OS was defined as the period from the date of the start of treatment to the date of death from any cause or until the date of the last follow-up. PFS was measured from the start date of treatment to the date of any type of progression or the final follow-up. OS and PFS rates were assessed using the Kaplan-Meier method. Statistical analyses were performed using the SPSS software package, version 19.0 for Windows (IBM Corp.).


Patient and treatment characteristics

A total of 20 patients were retrospectively enrolled after applying the inclusion and exclusion criteria. The median age was 60.5 years (range, 34–75 years). Table I summarizes the clinical characteristics of the 20 patients. All of the patients had overexpression of ERCC2, which was detected using IHC staining. Furthermore, 18 patients exhibited ERCC1 overexpression, whereas 2 patients did not exhibit ERCC1 overexpression. Only one patient exhibited high MSI, two patients exhibited low MSI and 17 patients (85%) exhibited microsatellite stability. According to the RECIST criteria (16,17), 12 patients (60%) were categorized as exhibiting partial response (PR), 2 patients (10%) achieved stable disease and 4 patients had a complete response (CR) (20%). Only two patients exhibited progressive disease (PD). Adverse events noted during treatment were mostly CTCAE grade 1–2 toxicity. None of the patients exhibited any grade 4 toxicity. When the patients experienced CTCAE grade 3 neutropenia, dermatitis, diarrhea, stomatitis, liver toxicity or painful paresthesia for up to 7 days, the oxaliplatin dose was reduced by 25%. The median duration between the last date of radiotherapy and surgery was 32.7 weeks (range, 10.1–59.3 weeks). The median follow-up time in all patients was 24.3 months (range, 7.8–37 months).

Table I.

Demographic and clinicopathological characteristics of 20 patients with cT4b colorectal cancer.

Table I.

Demographic and clinicopathological characteristics of 20 patients with cT4b colorectal cancer.

Age, years60.5 (34–75)
  Male14 (70)
  Female6 (30)
Tumor location
  Cecum1 (5)
  Ascending colon4 (20)
  Descending colon2 (10)
  Sigmoid colon4 (20)
  Rectosigmoid colon3 (15)
  Rectum6 (30)
Clinical T classification
  cT4b20 (100)
Clinical N classification
  cN17 (35)
  cN213 (65)
Tumor size (cm)
  ≤52 (10)
  >518 (90)
ERCC1 overexpression
  Yes18 (90)
  No2 (10)
ERCC2 overexpression
  Yes20 (100)
  No0 (0)
  High1 (5)
  Low2 (10)
  MSS17 (85)
Best objective response (RECIST)
  Complete response4 (20)
  Partial response12 (60)
  Stable disease2 (10)
  Progressive disease2 (10)
Grade 1/2 adverse events
  Nausea/vomiting20 (100)
  Diarrhea8 (40)
  Skin itchy rash1 (5)
  Leukopenia16 (80)
  Anemia17 (85)
  Thrombocytopenia6 (30)
  Liver toxicities7 (35)
  Oral mucositis2 (10)
  Peripheral neuropathy5 (25)
Grade 3 adverse events
  Skin itchy rash1 (5)
  Leukopenia3 (15)
  Liver toxicity1 (5)

[i] Values are expressed as n (%) or the median (range). ERCC1, excision repair cross-complementing 1; MSI, microsatellite instability; MSS, microsatellite stable; RECIST, Response Evaluation Criteria in Solid Tumors.

Treatment outcomes and failure patterns

Of the 20 inoperable patients, the tumors of 14 patients became resectable after the administration of FOLFIRI. Of the seven patients who received bevacizumab combined with FOLFIRI, three displayed neoplasms that were converted to resectable tumors, while the remaining four patients who received bevacizumab combined with FOLFIRI were still unresectable. A total of six patients underwent radical proctectomy, 5 patients were treated using laparoscopic hemicolectomy and 3 patients received laparoscopy anterior resection. The median OS and PFS were 27.5 months (95% CI: 20.58–28.48) and 27.5 months (95% CI: 19.73–28.37), respectively (Fig. 1). A total of two patients developed distant metastases, but no local recurrence was noted. Furthermore, 18 patients (90%) survived until the end of the present study. The treatment sequence, OS and PFS are listed in Table II. All patients received upfront CCRT with FOLFOX. As a poor response was noted on imaging (Fig. 2), FOLFIRI was added after CCRT.

Table II.

Pathological and treatment evaluation of 20 patients with cT4b colorectal cancer.

Table II.

Pathological and treatment evaluation of 20 patients with cT4b colorectal cancer.

Case no.Age, years/sexTumor locationPrimary tumor resection, yes vs. noTime intervals between RT completion date to surgery date, weeksPFS, monthsOS, monthsGene overexpressionSurvival, yes/no
148/MSigmoidNoND812ERCC1 (+)/ERCC2 (+)No (died of cancer)
267/MRectumYes473939ERCC1 (+)/ERCC2 (+)Yes
363/MRectumYes27.13535ERCC1 (+)/ERCC2 (+)Yes
465/MRectumNoND3434ERCC1 (+)/ERCC2 (+)Yes
561/MCecumYes13.13232ERCC1 (+)/ERCC2 (+)Yes
641/MAscendingYes59.33232ERCC1 (+)/ERCC2 (+)Yes
760/MRectumYes52.93030ERCC1 (−)/ERCC2 (+)Yes
861/MDescendingNoND814ERCC1 (+)/ERCC2 (+)No (died of cancer)
956/MSigmoidNoND2929ERCC1 (+)/ERCC2 (+)Yes
1061/FDescendingYes35.12828ERCC1 (+)/ERCC2 (+)Yes
1156/FAscendingYes13.42828ERCC1 (−)/ERCC2 (+)Yes
1275/MRectumYes392727ERCC1 (+)/ERCC2 (+)Yes
1339/MRectosigmoidNoND2828ERCC1 (+)/ERCC2 (+)Yes
1453/MSigmoidYes25.32727ERCC1 (+)/ERCC2 (+)Yes
1570/FAscendingYes10.11818ERCC1 (+)/ERCC2 (+)Yes
1664/FSigmoidYes34.41717ERCC1 (+)/ERCC2 (+)Yes
1760/FRectosigmoidNoND1717ERCC1 (+)/ERCC2 (+)Yes
1834/FRectumYes30.91616ERCC1 (+)/ERCC2 (+)Yes
1968/MRectosigmoidYes35.91616ERCC1 (+)/ERCC2 (+)Yes
2034/MAscendingYes29.31212ERCC1 (+)/ERCC2 (+)Yes

[i] ERCC1, excision repair cross-complementing 1; RT, radiotherapy; PFS, progression-free survival; OS, overall survival; ND, not determined; M, male; F, female.

Among the 14 patients who underwent surgery, 12 patients (85.7%) achieved a pathologic N0 status and 4 patients achieved a pT0 status. Overall, 4 (28.6%) of the 14 cases that became resectable after neoadjuvant treatment achieved pathologic CR (pCR). A total of 12 patients (60%) exhibited an initial CEA level of >5 ng/ml prior to treatment, but only 5 patients (25%) exhibited a CEA level of >5 ng/ml at the last follow-up. Among the 20 patients, after FOLFOX-based CCRT and the FOLFIRI regimen, only one PD patient exhibited an increase of 21.2% in tumor size (longest diameter × widest length) (Table III). The remaining 19 patients had 2.3–73.9% reduction in tumor size compared with the size prior to FOLFIRI administration (Table III).

Table III.

Treatment outcomes in 20 patients with cT4b colorectal cancer.

Table III.

Treatment outcomes in 20 patients with cT4b colorectal cancer.

Case no.SexAge, yearsPre-CCRT tumor size, cmPre-FOLFIRI therapy tumor size, cmPost-FOLFIRI therapy tumor size, cmTumor size reduction, % (post-FOLFIRI minus pre-FOLFIRI)Post-resection tumor riskBest overall response (RECIST)
2Male676.0×3.76.5×3.62.5×1.5−61.5Tumor margin negativePR
3Male636.7×3.44.6×2.81.2×1.0−73.9Pathological CRCR
5Male617.2×5.36.3×5.14.6×2.7−27.0Tumor margin negativePR
6Male416.3×3.24.4×2.54.3×2.3−2.3Tumor margin positive (CRM involved)PR
7Male6010.9×9.66.8×5.53.7×3.2−45.6Tumor margin negativePR
8Male616.0×5.25.3×3.53.7×3.1−30.2Unresectable (due to peritoneal carcinomatosis)PD
9Male5615.4×10.39.8×6.86.8×3.1−30.6Unresectable (due to tumor invasion to urinary bladder and cecum persisting)PR
10Female618.9×4.87.5×2.73.0×1.3−60.0Tumor margin positive (CRM involved)PR
11Female565.1×3.25.6×3.63.6×2.5−35.7Tumor margin negativePR
12Male755.6×2.73.5×2.51.0×1.0−71.4Pathological CRCR
14Male538.6×4.76.7×3.42.7×1.2−59.7Pathological CRCR
15Female707.9×3.06.0×4.04.5×2.4−25.0Tumor margin negativePR
16Female645.5×5.54.9×2.11.5×1.0−69.4Tumor margin positive (CRM involved)PR
18Female345.5×3.54.8×1.93.2×1.2−33.0Tumor margin negative (CRM 0.5 cm)PR
19Male684.0×3.55.4×3.03.0×0.9−44.0Pathological CRCR
20Male343.9×1.24.9×3.02.5×1.2−49.0Tumor margin negativePR

[i] CCRT, concurrent chemoradiation; FOLFIRI, irinotecan plus fluorouracil/leucovorin; RECIST, Response Evaluation Criteria in Solid Tumors, the best overall response is evaluated using version 1.1 of the criteria; PD, progressive disease; PR, partial response; CR, complete response; SD, stable disease; CRM, circumferential radial margin. Tumor size, longest length × widest length.


T4b CRC is associated with a poor prognosis due to the direct local extension or infiltration into surrounding structures or organs, thus causing unresectability or a high incidence of nodal and distant metastases (12,20,21). As it involves adhesion to the adjacent organs, complete resection of cT4b CRC is difficult, as the organs may be damaged during resection. A growing body of clinical evidence suggests that the combination of neoadjuvant chemotherapy, specifically pre-operative CCRT, curative surgery and adjuvant chemotherapy, has a favorable prognostic effect on patients with locally advanced CRC (22). In the present study, unresectable tumors in 14 of the 20 patients with CRC (70%), who exhibited a poor response toward CCRT with FOLFOX, were converted to resectable tumors after undergoing FOLFIRI. Gao et al (13) analyzed the Surveillance, Epidemiology and End Results (SEER) dataset between 1973 and 2008 in their study. They determined an incidence of 4.4% for pathological T4b CRC. Rectal cancers (21.3%) were reported to have a lower risk of developing a real pathological invasion (pathological T4) than colon cancers (48.8%) (23). The principle of ‘en bloc’ resection is to resect all invaded organs along with the colon tumor, which may be performed in 65–91.1% of cases (23,24). For unresectable locally advanced disease, pre-operative chemotherapy is delivered to reduce the size of primary tumors and convert them to resectable tumors. The randomized phase III FOxTROT trial of locally advanced, operable colon cancer demonstrated that 3 cycles of pre-operative FOLFOX resulted in significant downstaging compared with post-operative chemotherapy (25). The patients with cT4b colon cancer treated with neoadjuvant chemotherapy had a 23% lower risk of death at 3 years than the patients who received post-operative chemotherapy (26). As up to 45% of patients with T4 CRC develop distant metastases, chemotherapy not only results in size regression but also eradicates micrometastatic disease (27). Furthermore, up to 65% of patients with T4 CRC develop nodal dissemination (28), and pre-operative CCRT enhances local RT sensitization and eradication of micrometastases. For locally advanced rectal cancer, pre-operative CCRT also has the potential to increase the rate of sphincter preservation. In the present study, 14 (70%) and 4 patients (20%) with both ERCC1 and ERCC2 overexpression reached PR and pCR after receiving FOLFIRI as a second-line therapy, respectively. In the present study, the conversion to resectability rate (70%) was higher than that observed in previous studies. Population-based data from the SEER dataset from January 1992 to December 2004 on 109,953 patients with colon cancer were compared with NCDb data of 134,206 patients; the 5-year OS rate in the T4bN1-2 patients was 15.8–27.9% (14). Other studies have reported that the 5-year relative survival rate in T4b with nodal involvement was 15.7–38.5% (1113). A negative resection margin (R0) resulted in a 5-year local control rate for primary locally advanced CRC of up to 89% and 5-year OS of up to 66% (29). In the present study, 11 out of 14 patients had R0 after conversion to resectability and only 3 had positive resection margins.

The use of peri-operative pelvic RT in the treatment of patients with stage III unresectable CRC continues to develop. Well-established neoadjuvant RT protocols for treating T4 colon tumors are not available (22). At present, several cohorts of patients do not respond to pre-operative therapies, resulting in inoperable status and poor survival. The present study aimed to incorporate the detection of ERCC expression for prescribing precision medicine. Pre-clinical and clinical trials involving ERCC have demonstrated the importance of understanding the pharmacogenetics prior to treatment (3032).

Protein products of ERCC genes are responsible for nucleotide excision repair (NER) of damaged DNA. Oxaliplatin induces adducts, which are not processed by the mismatch repair mechanism. They are predominantly repaired by components of the NER and base excision repair pathways (33). NER removes a DNA segment with adducts, followed by restoration of that DNA segment (34). ERCC1 is an excision nuclease in the NER pathway that is involved in oxaliplatin metabolism (35). High ERCC1 expression levels are associated with increased platinum drug resistance (36). Shirota et al (37) first reported that a high level of intratumoral ERCC1 mRNA was associated with poor prognosis in CRC patients who received oxaliplatin-based chemotherapy. A marked increase in ERCC1 protein expression levels was also noted in patients with C/T or T/T genotypes (70% vs. 20%; P<0.01), which was associated with a significantly lower response to FOLFOX-4 (36.4% vs. 57.5%; P=0.01), shorter PFS (7 vs. 13 months; P<0.01) and shorter OS (16 months vs. 25 months; P<0.01) (38). The ERCC1 rs11615 polymorphism with the T allele was indicated to be associated with a significant increase in the risk of shorter PFS and OS in patients with CRC treated with oxaliplatin-based chemotherapy in a recent meta-analysis (9). However, certain studies have not determined any correlation between ERCC1 mRNA expression and FOLFOX activity (39,40). An increase in ERCC protein expression was noted in the patients of the present study, which may account for a poor response to FOLFOX-based CCRT treatment; this result is compatible with the findings of most previous studies (10,19,36). However, 6 patients (30%) had unresectable tumors that were not conversion to resectable tumors by neoadjuvant treatment. Further validation of the ERCC1 for the FOLFIRI regimen in patients with resistance to CCRT and FOLFOX is mandatory.

The present study has certain limitations. Given its nonrandomized retrospective design, a selection bias that may have affected the present results is likely. In addition, only 20 patients from a single institution were analyzed in the present small-sample study. Despite these drawbacks, the conclusions may provide a path for conversion to resectable tumor by using FOLFIRI in patients with cT4b CRC that did not sufficiently respond to FOLFOX-based CCRT. The underlying mechanisms of action require further investigation.

In conclusion, the present retrospective study suggested that overexpression of ERCC is an indicator of poor response to FOLFOX-based CCRT and indicated the potential advantage of FOLFORI as a second-line neoadjuvant treatment in cT4b CRC that do not respond to FOLFOX-based CCRT. FOLFIRI may potentiate the antitumor response and thereby improve the efficacy of peri-operative treatment for patients with cT4b CRC. The underlying mechanisms of action of FOLFIRI in conversion to resectable tumors by neoadjuvant treatment require additional prospective clinical trials to confirm its validity.


Not applicable.


This work was supported by grants received as funds from the Ministry of Science and Technology (grant nos. MOST 109-2314-B-037-035, MOST 109-2314-B-037-040, MOST 109-2314-B-037-046-MY3, MOST108- 2314-B-037-021-MY3), the Ministry of Health and Welfare (grant nos. MOHW107-TDU-B-212-123006, MOHW107-TDU-B-212-114026B, MOHW108-TDU-B- 212-133006 and MOHW109-TDU-B-212-124026), the Health and Welfare Surcharge of Tobacco Products, and Kaohsiung Medical University Hospital (grant nos. KMUH108-8R66, KMUH108-8R34, KMUH108-8R35, KMUH108-8M33, KMUH108-8M35, KMUH108-8M36, KMUHS10801, KMUHSA10804, KMUHS10807, KMUH-DK109001-3 and KMUH-DK109005-3), as well as the Center for Cancer Research (grant no. KMU-TC108A04) and the Research Center Grant (grant no. KMU-TC108B07) of Kaohsiung Medical University (Kaohsiung, Taiwan). In addition, this study was supported by the Grant of Taiwan Precision Medicine Initiative, Academia Sinica, Taiwan, R.O.C.

Availability of data and materials

The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Authors' contributions

JYW designed the study. MYH performed the statistical analysis, participated in the interpretation of data, and wrote and revised the manuscript. HHL drafted the manuscript. JYW, CWH, CJM, HLT and TCY recruited patients for the study and treated them. MYH, HHL and CMH are radiation oncologists who contributed to the provision of RT. CYC and YTC were the pathologists who scored the IHC staining. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This present study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital [Kaohsiung, Taiwan; no. KMUHIRB-E(I)-20190182].

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.



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Huang M, Lee H, Huang C, Huang C, Ma C, Yin T, Tsai H, Chai C, Chen Y, Wang J, Wang J, et al: ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX‑based neoadjuvant concurrent chemoradiation. Oncol Lett 20: 212, 2020
Huang, M., Lee, H., Huang, C., Huang, C., Ma, C., Yin, T. ... Wang, J. (2020). ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX‑based neoadjuvant concurrent chemoradiation. Oncology Letters, 20, 212.
Huang, M., Lee, H., Huang, C., Huang, C., Ma, C., Yin, T., Tsai, H., Chai, C., Chen, Y., Wang, J."ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX‑based neoadjuvant concurrent chemoradiation". Oncology Letters 20.5 (2020): 212.
Huang, M., Lee, H., Huang, C., Huang, C., Ma, C., Yin, T., Tsai, H., Chai, C., Chen, Y., Wang, J."ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX‑based neoadjuvant concurrent chemoradiation". Oncology Letters 20, no. 5 (2020): 212.