Possible predictors of histopathological response to neoadjuvant chemoradiotherapy for rectal cancer

  • Robert Farkas
  • Eva Pozsgai
  • Andrew V. Schally
  • Andras Szigeti
  • Edit Szigeti
  • Zoltan Laszlo
  • Andras Papp
  • Eva Gomori
  • Laszlo Mangel
  • Peter O. Horvath
  • Szabolcs Bellyei
Original Paper



The response to neoadjuvant chemoradiotherapy (CRT) varies greatly in patients suffering from locally advanced rectal cancer. Our aim was to correlate the response to CRT with the pre-treatment expression of heat shock protein 90 (Hsp90), small heat shock protein 16.2 (sHsp 16.2), phospho-Akt (p-Akt), growth hormone–releasing hormone receptor (GHRH-R) and heme-binding protein 2 (SOUL) in order to try to identify one or more as a predictive marker.

Materials and methods

Sixty-nine patients receiving combined CRT for locally advanced rectal cancer were examined retrospectively. Surgical resection was carried out 6–9 weeks following CRT. The histopathological response to neoadjuvant treatment was determined according to the modified Mandard score. Using immunohistochemistry, we investigated the relationship between the expression of the five cited proteins in the pre-operative samples as well as various clinical parameters and the histopathological regression of the tumors.


Thirty-one patients (48%) were good responders, and 33 patients (52%) were found to respond poorly to neoadjuvant therapy. Among patients undergoing surgery 7 weeks following CRT, there were significantly more good responders than among patients who underwent surgery sooner (63% vs. 37%). High levels of expression of GHRH-R and Hsp90 were shown to be significantly correlated with minor or absent histological regression.


GHRH-R and Hsp90 were found to be independent predictive factors of histopathological response to neoadjuvant RCT. Since GHRH-R antagonists and Hsp90 inhibitors are currently being tested as potential anticancer agents, our study implies the possible elaboration of an effective and individualized treatment of poor responders.


Neoadjuvant chemoradiotherapy Rectal cancer Hsp90 GHRH-R Predictive marker of tumor regression Prediction of response 



This work was supported by a grant from the Hungarian Science Foundation 68469, by Research Grants from the Ministry of Health (2006–2008; 01/270) and by the Janos Bolyai Research Scholarship of the Hungarian Academy of Sciences and Research Grants from AOKKA-34039-1004/2010.


  1. Aoyama A, Steiger RH, Frohli E, Schafer R, von Deimling A, Wiestler OD, Klemenz R (1993) Expression of alpha B-crystallin in human brain tumors. Int J Cancer 55(5):760–764PubMedCrossRefGoogle Scholar
  2. Baba Y, Nosho K, Shima K, Hayashi M, Meyerhardt JA, Chan AT, Giovannucci E, Fuchs CS, Ogino S (2010) Phosphorylated AKT expression is associated with PIK3CA mutation, low stage, and favorable outcome in 717 colorectal cancers. Cancer. doi: 10.1002/cncr.25630
  3. Barabutis N, Schally AV (2008) Knocking down gene expression for growth hormone-releasing hormone inhibits proliferation of human cancer cell lines. Br J Cancer 98(11):1790–1796. doi: 10.1038/sj.bjc.6604386 PubMedCrossRefGoogle Scholar
  4. Bardeesy N, DePinho RA (2002) Pancreatic cancer biology and genetics. Nat Rev Cancer 2(12):897–909. doi: 10.1038/nrc949nrc949 PubMedCrossRefGoogle Scholar
  5. Bellyei S, Szigeti A, Boronkai A, Pozsgai E, Gomori E, Melegh B, Janaky T, Bognar Z, Hocsak E, Sumegi B, Gallyas F Jr (2007a) Inhibition of cell death by a novel 16.2 kD heat shock protein predominantly via Hsp90 mediated lipid rafts stabilization and Akt activation pathway. Apoptosis 12(1):97–112. doi: 10.1007/s10495-006-0486-x PubMedCrossRefGoogle Scholar
  6. Bellyei S, Szigeti A, Pozsgai E, Boronkai A, Gomori E, Hocsak E, Farkas R, Sumegi B, Gallyas F Jr (2007b) Preventing apoptotic cell death by a novel small heat shock protein. Eur J Cell Biol 86(3):161–171. doi: 10.1016/j.ejcb.2006.12.004 PubMedCrossRefGoogle Scholar
  7. Berger C, de Muret A, Garaud P, Chapet S, Bourlier P, Reynaud-Bougnoux A, Dorval E, de Calan L, Huten N, le Folch O, Calais G (1997) Preoperative radiotherapy (RT) for rectal cancer: predictive factors of tumor downstaging and residual tumor cell density (RTCD): prognostic implications. Int J Radiat Oncol Biol Phys 37(3):619–627. doi: S0360301696005779 PubMedCrossRefGoogle Scholar
  8. Bohonowych JE, Gopal U, Isaacs JS (2010) Hsp90 as a gatekeeper of tumor angiogenesis: clinical promise and potential pitfalls. J Oncol 2010:412985. doi: 10.1155/2010/412985 PubMedGoogle Scholar
  9. Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, Daban A, Bardet E, Beny A, Ollier JC (2006) Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 355(11):1114–1123. doi: 10.1056/NEJMoa060829 PubMedCrossRefGoogle Scholar
  10. Bouzourene H, Bosman FT, Seelentag W, Matter M, Coucke P (2002) Importance of tumor regression assessment in predicting the outcome in patients with locally advanced rectal carcinoma who are treated with preoperative radiotherapy. Cancer 94(4):1121–1130. doi: 10.1002/cncr.10327 PubMedCrossRefGoogle Scholar
  11. Braczkowski R, Schally AV, Plonowski A, Varga JL, Groot K, Krupa M, Armatis P (2002) Inhibition of proliferation in human MNNG/HOS osteosarcoma and SK-ES-1 Ewing sarcoma cell lines in vitro and in vivo by antagonists of growth hormone-releasing hormone: effects on insulin-like growth factor II. Cancer 95(8):1735–1745. doi: 10.1002/cncr.10865 PubMedCrossRefGoogle Scholar
  12. Busto R, Schally AV, Varga JL, Garcia-Fernandez MO, Groot K, Armatis P, Szepeshazi K (2002) The expression of growth hormone-releasing hormone (GHRH) and splice variants of its receptor in human gastroenteropancreatic carcinomas. Proc Natl Acad Sci USA 99(18):11866–11871. doi: 10.1073/pnas.182433099182433099 PubMedCrossRefGoogle Scholar
  13. Carlomagno C, Farella A, Bucci L, D’Armiento FP, Pesce G, Pepe S, Cannella L, Pacelli R, De Stefano A, Solla R, D’Armiento MR, De Placido S (2009) Neo-adjuvant treatment of rectal cancer with capecitabine and oxaliplatin in combination with radiotherapy: a phase II study. Ann Oncol 20(5):906–912. doi: 10.1093/annonc/mdn719 PubMedCrossRefGoogle Scholar
  14. Chang HJ, Jung KH, Kim DY, Jeong SY, Choi HS, Kim YH, Sohn DK, Yoo BC, Lim SB, Kim DH, Ahn JB, Kim IJ, Kim JM, Yoon WH, Park JG (2005) Bax, a predictive marker for therapeutic response to preoperative chemoradiotherapy in patients with rectal carcinoma. Hum Pathol 36(4):364–371. doi: 10.1016/j.humpath.2005.01.018 PubMedCrossRefGoogle Scholar
  15. Chatzistamou I, Schally AV, Varga JL, Groot K, Armatis P, Busto R, Halmos G (2001a) Antagonists of growth hormone-releasing hormone and somatostatin analog RC-160 inhibit the growth of the OV-1063 human epithelial ovarian cancer cell line xenografted into nude mice. J Clin Endocrinol Metab 86(5):2144–2152PubMedCrossRefGoogle Scholar
  16. Chatzistamou I, Schally AV, Varga JL, Groot K, Busto R, Armatis P, Halmos G (2001b) Inhibition of growth and metastases of MDA-MB-435 human estrogen-independent breast cancers by an antagonist of growth hormone-releasing hormone. Anticancer Drugs 12(9):761–768PubMedCrossRefGoogle Scholar
  17. Chung H, Seo S, Moon M, Park S (2008) Phosphatidylinositol-3-kinase/Akt/glycogen synthase kinase-3 beta and ERK1/2 pathways mediate protective effects of acylated and unacylated ghrelin against oxygen-glucose deprivation-induced apoptosis in primary rat cortical neuronal cells. J Endocrinol 198(3):511–521. doi: 10.1677/JOE-08-0160 PubMedCrossRefGoogle Scholar
  18. Crane CH, Eng C, Feig BW, Das P, Skibber JM, Chang GJ, Wolff RA, Krishnan S, Hamilton S, Janjan NA, Maru DM, Ellis LM, Rodriguez-Bigas MA (2010) Phase II trial of neoadjuvant bevacizumab, capecitabine, and radiotherapy for locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 76(3):824–830. doi: 10.1016/j.ijrobp.2009.02.037 PubMedCrossRefGoogle Scholar
  19. Das P, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Wolff RA, Eng C, Krishnan S, Janjan NA, Crane CH (2007) Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer 109(9):1750–1755. doi: 10.1002/cncr.22625 PubMedCrossRefGoogle Scholar
  20. Dhadda AS, Dickinson P, Zaitoun AM, Gandhi N, Bessell EM (2011) Prognostic importance of Mandard tumour regression grade following pre-operative chemo/radiotherapy for locally advanced rectal cancer. Eur J Cancer. doi: 10.1016/j.ejca.2010.12.006
  21. Engel JB, Keller G, Schally AV, Toller GL, Groot K, Havt A, Armatis P, Zarandi M, Varga JL, Halmos G (2005) Inhibition of growth of experimental human endometrial cancer by an antagonist of growth hormone-releasing hormone. J Clin Endocrinol Metab 90(6):3614–3621. doi: 10.1210/jc.2004-2179 PubMedCrossRefGoogle Scholar
  22. Gerard JP, Conroy T, Bonnetain F, Bouche O, Chapet O, Closon-Dejardin MT, Untereiner M, Leduc B, Francois E, Maurel J, Seitz JF, Buecher B, Mackiewicz R, Ducreux M, Bedenne L (2006) Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3–4 rectal cancers: results of FFCD 9203. J Clin Oncol 24(28):4620–4625. doi: 10.1200/JCO.2006.06.7629 PubMedCrossRefGoogle Scholar
  23. Gunther K, Dimmler A, Rodel F, Reulbach U, Merkel S, Bittorf BR, Matzel KE, Papadopoulos T, Hohenberger W, Sauer R, Rodel C (2003) P27 does not predict histopathological response to radiochemotherapy in rectal cancer. J Surg Res 113(2):179–188.PubMedCrossRefGoogle Scholar
  24. Havt A, Schally AV, Halmos G, Varga JL, Toller GL, Horvath JE, Szepeshazi K, Koster F, Kovitz K, Groot K, Zarandi M, Kanashiro CA (2005) The expression of the pituitary growth hormone-releasing hormone receptor and its splice variants in normal and neoplastic human tissues. Proc Natl Acad Sci USA 102(48):17424–17429. doi: 10.1073/pnas.0506844102 PubMedCrossRefGoogle Scholar
  25. Hermisson M, Strik H, Rieger J, Dichgans J, Meyermann R, Weller M (2000) Expression and functional activity of heat shock proteins in human glioblastoma multiforme. Neurology 54(6):1357–1365PubMedGoogle Scholar
  26. Hohla F, Buchholz S, Schally AV, Seitz S, Rick FG, Szalontay L, Varga JL, Zarandi M, Halmos G, Vidaurre I, Krishan A, Kurtoglu M, Chandna S, Aigner E, Datz C (2009) GHRH antagonist causes DNA damage leading to p21 mediated cell cycle arrest and apoptosis in human colon cancer cells. Cell Cycle 8(19):3149–3156.PubMedCrossRefGoogle Scholar
  27. Holzbeierlein JM, Windsperger A, Vielhauer G (2010) Hsp90: a drug target? Curr Oncol Rep 12(2):95–101. doi: 10.1007/s11912-010-0086-3 PubMedCrossRefGoogle Scholar
  28. Hwang M, Moretti L, Lu B (2009) HSP90 inhibitors: multi-targeted antitumor effects and novel combinatorial therapeutic approaches in cancer therapy. Curr Med Chem 16(24):3081–3092PubMedCrossRefGoogle Scholar
  29. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61(2):69–90. doi: 10.3322/caac.20107 PubMedCrossRefGoogle Scholar
  30. Kabakov AE, Kudryavtsev VA, Gabai VL (2010) Hsp90 inhibitors as promising agents for radiotherapy. J Mol Med 88(3):241–247. doi: 10.1007/s00109-009-0562-0 PubMedCrossRefGoogle Scholar
  31. Kahan Z, Varga JL, Schally AV, Rekasi Z, Armatis P, Chatzistamou L, Czompoly T, Halmos G (2000) Antagonists of growth hormone-releasing hormone arrest the growth of MDA-MB-468 estrogen-independent human breast cancers in nude mice. Breast Cancer Res Treat 60(1):71–79PubMedCrossRefGoogle Scholar
  32. Kalady MF, de Campos-Lobato LF, Stocchi L, Geisler DP, Dietz D, Lavery IC, Fazio VW (2009) Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal Cancer Ann Surg. doi: 10.1097/SLA.0b013e3181b91e63
  33. Kiaris H, Schally AV, Varga JL, Groot K, Armatis P (1999) Growth hormone-releasing hormone: an autocrine growth factor for small cell lung carcinoma. Proc Natl Acad Sci USA 96(26):14894–14898PubMedCrossRefGoogle Scholar
  34. Kiaris H, Schally AV, Varga JL (2000) Antagonists of growth hormone-releasing hormone inhibit the growth of U-87MG human glioblastoma in nude mice. Neoplasia 2(3):242–250PubMedCrossRefGoogle Scholar
  35. Kiaris H, Koutsilieris M, Kalofoutis A, Schally AV (2003) Growth hormone-releasing hormone and extra-pituitary tumorigenesis: therapeutic and diagnostic applications of growth hormone-releasing hormone antagonists. Expert Opin Investig Drugs 12(8):1385–1394. doi: 10.1517/13543784.12.8.1385 PubMedCrossRefGoogle Scholar
  36. Klemenz R, Frohli E, Aoyama A, Hoffmann S, Simpson RJ, Moritz RL, Schafer R (1991) Alpha B crystallin accumulation is a specific response to Ha-ras and v-mos oncogene expression in mouse NIH 3T3 fibroblasts. Mol Cell Biol 11(2):803–812PubMedGoogle Scholar
  37. Lin LC, Lee HH, Hwang WS, Li CF, Huang CT, Que J, Lin KL, Lin FC, Lu CL (2006) p53 and p27 as predictors of clinical outcome for rectal-cancer patients receiving neoadjuvant therapy. Surg Oncol 15(4):211–216. doi: 10.1016/j.suronc.2007.01.001 PubMedCrossRefGoogle Scholar
  38. Losi L, Ponti G, Gregorio CD, Marino M, Rossi G, Pedroni M, Benatti P, Roncucci L, de Leon MP (2006) Prognostic significance of histological features and biological parameters in stage I (pT1 and pT2) colorectal adenocarcinoma. Pathol Res Pract 202(9):663–670. doi: 10.1016/j.prp.2006.05.003 PubMedCrossRefGoogle Scholar
  39. Mandard AM, Dalibard F, Mandard JC, Marnay J, Henry-Amar M, Petiot JF, Roussel A, Jacob JH, Segol P, Samama G et al (1994) Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations. Cancer 73(11):2680–2686PubMedCrossRefGoogle Scholar
  40. Mistafa O, Stenius U (2009) Statins inhibit Akt/PKB signaling via P2X7 receptor in pancreatic cancer cells. Biochem Pharmacol 78(9):1115–1126. doi: 10.1016/j.bcp.2009.06.016 PubMedCrossRefGoogle Scholar
  41. Pollheimer MJ, Kornprat P, Lindtner RA, Harbaum L, Schlemmer A, Rehak P, Langner C (2010) Tumor necrosis is a new promising prognostic factor in colorectal cancer. Hum Pathol 41(12):1749–1757. doi: 10.1016/j.humpath.2010.04.018 PubMedCrossRefGoogle Scholar
  42. Pozsgai E, Gomori E, Szigeti A, Boronkai A, Gallyas F Jr, Sumegi B, Bellyei S (2007) Correlation between the progressive cytoplasmic expression of a novel small heat shock protein (Hsp16.2) and malignancy in brain tumors. BMC Cancer 7:233. doi: 10.1186/1471-2407-7-233 PubMedCrossRefGoogle Scholar
  43. Rebischung C, Gerard JP, Gayet J, Thomas G, Hamelin R, Laurent-Puig P (2002) Prognostic value of P53 mutations in rectal carcinoma. Int J Cancer 100(2):131–135. doi: 10.1002/ijc.10480 PubMedCrossRefGoogle Scholar
  44. Rekasi Z, Czompoly T, Schally AV, Halmos G (2000) Isolation and sequencing of cDNAs for splice variants of growth hormone-releasing hormone receptors from human cancers. Proc Natl Acad Sci USA 97(19):10561–10566. doi: 10.1073/pnas.180313297180313297 PubMedCrossRefGoogle Scholar
  45. Rekasi Z, Czompoly T, Schally AV, Boldizsar F, Varga JL, Zarandi M, Berki T, Horvath RA, Nemeth P (2005) Antagonist of growth hormone-releasing hormone induces apoptosis in LNCaP human prostate cancer cells through a Ca2+ -dependent pathway. Proc Natl Acad Sci USA 102(9):3435–3440. doi: 10.1073/pnas.0410006102 PubMedCrossRefGoogle Scholar
  46. Rodel C, Martus P, Papadoupolos T, Fuzesi L, Klimpfinger M, Fietkau R, Liersch T, Hohenberger W, Raab R, Sauer R, Wittekind C (2005) Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol 23(34):8688–8696. doi: 10.1200/JCO.2005.02.1329 PubMedCrossRefGoogle Scholar
  47. Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351(17):1731–1740. doi: 10.1056/NEJMoa040694 PubMedCrossRefGoogle Scholar
  48. Schally AV, Varga JL (1999) Antagonistic analogs of growth hormone-releasing hormone: new potential antitumor agents. Trends Endocrinol Metab 10(10):383–391.PubMedCrossRefGoogle Scholar
  49. Schally AV, Comaru-Schally AM, Plonowski A, Nagy A, Halmos G, Rekasi Z (2000) Peptide analogs in the therapy of prostate cancer. Prostate 45(2):158–166. doi: 10.1002/1097-0045(20001001)45:2<158::AID-PROS10>3.0.CO;2-K PubMedCrossRefGoogle Scholar
  50. Schally AV, Comaru-Schally AM, Nagy A, Kovacs M, Szepeshazi K, Plonowski A, Varga JL, Halmos G (2001) Hypothalamic hormones and cancer. Front Neuroendocrinol 22(4):248–291. doi: 10.1006/frne.2001.0217 PubMedCrossRefGoogle Scholar
  51. Schally AV, Szepeshazi K, Nagy A, Comaru-Schally AM, Halmos G (2004) New approaches to therapy of cancers of the stomach, colon and pancreas based on peptide analogs. Cell Mol Life Sci 61(9):1042–1068. doi: 10.1007/s00018-004-3434-3 PubMedCrossRefGoogle Scholar
  52. Schally AV, Varga JL, Engel JB (2008) Antagonists of growth-hormone-releasing hormone: an emerging new therapy for cancer. Nat Clin Pract Endocrinol Metab 4(1):33–43. doi: 10.1038/ncpendmet0677 PubMedCrossRefGoogle Scholar
  53. Somji S, Sens MA, Lamm DL, Garrett SH, Sens DA (2001) Metallothionein isoform 1 and 2 gene expression in the human bladder: evidence for upregulation of MT-1X mRNA in bladder cancer. Cancer Detect Prev 25(1):62–75PubMedGoogle Scholar
  54. Suarez J, Vera R, Balen E, Gomez M, Arias F, Lera JM, Herrera J, Zazpe C (2008) Pathologic response assessed by Mandard grade is a better prognostic factor than down staging for disease-free survival after preoperative radiochemotherapy for advanced rectal cancer. Colorectal Dis 10(6):563–568. doi: 10.1111/j.1463-1318.2007.01424.x PubMedCrossRefGoogle Scholar
  55. Sun Y, Mansour M, Crack JA, Gass GL, MacRae TH (2004) Oligomerization, chaperone activity, and nuclear localization of p26, a small heat shock protein from Artemia franciscana. J Biol Chem 279(38):39999–40006. doi: 10.1074/jbc.M406999200M406999200 PubMedCrossRefGoogle Scholar
  56. Szigeti A, Bellyei S, Gasz B, Boronkai A, Hocsak E, Minik O, Bognar Z, Varbiro G, Sumegi B, Gallyas F Jr (2006) Induction of necrotic cell death and mitochondrial permeabilization by heme binding protein 2/SOUL. FEBS Lett 580(27):6447–6454. doi: 10.1016/j.febslet.2006.10.067 PubMedCrossRefGoogle Scholar
  57. Szigeti A, Hocsak E, Rapolti E, Racz B, Boronkai A, Pozsgai E, Debreceni B, Bognar Z, Bellyei S, Sumegi B, Gallyas F Jr (2010) Facilitation of mitochondrial outer and inner membrane permeabilization and cell death in oxidative stress by a novel Bcl-2 homology 3 domain protein. J Biol Chem 285(3):2140–2151. doi: 10.1074/jbc.M109.015222 PubMedCrossRefGoogle Scholar
  58. Vecchio FM, Valentini V, Minsky BD, Padula GD, Venkatraman ES, Balducci M, Micciche F, Ricci R, Morganti AG, Gambacorta MA, Maurizi F, Coco C (2005) The relationship of pathologic tumor regression grade (TRG) and outcomes after preoperative therapy in rectal cancer. Int J Radiat Oncol Biol Phys 62(3):752–760. doi: 10.1016/j.ijrobp.2004.11.017 PubMedCrossRefGoogle Scholar
  59. Zeitler P, Siriwardana G (2002) Antagonism of endogenous growth hormone-releasing hormone (GHRH) leads to reduced proliferation and apoptosis in MDA231 breast cancer cells. Endocrine 18(1):85–90. doi: 10.1385/ENDO:18:1:85 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Robert Farkas
    • 1
  • Eva Pozsgai
    • 2
  • Andrew V. Schally
    • 3
  • Andras Szigeti
    • 1
  • Edit Szigeti
    • 2
  • Zoltan Laszlo
    • 1
  • Andras Papp
    • 4
  • Eva Gomori
    • 5
  • Laszlo Mangel
    • 1
  • Peter O. Horvath
    • 4
  • Szabolcs Bellyei
    • 1
  1. 1.Department of OncologyUniversity of PécsPecsHungary
  2. 2.Department of Biochemistry and Medical ChemistryUniversity of PécsPecsHungary
  3. 3.Veterans Affairs Medical Center and South Florida Veterans Affairs Foundation for Research and EducationMiamiUSA
  4. 4.Department of SurgeryUniversity of PécsPecsHungary
  5. 5.Department of PathologyUniversity of PécsPecsHungary

Personalised recommendations