Tumor Biology

, Volume 36, Issue 6, pp 4301–4308 | Cite as

TIMP-1 and CEA as biomarkers in third-line treatment with irinotecan and cetuximab for metastatic colorectal cancer

  • Karen-Lise Garm Spindler
  • Ib Jarle Christensen
  • Hans Jørgen Nielsen
  • Anders Jakobsen
  • Nils Brünner
Research Article


KRAS wild-type (wt) status determines indication for treatment with combination therapy, including epidermal growth factor receptor (EGFR) inhibitors, but still, the overall response rate in KRAS wt patients is less than 40 %. Consequently, the majority of patients will suffer from substantial side effects and no apparent benefit. Tissue inhibitor of metalloproteinases-1 is a glycoprotein, which regulates metalloproteinases and may consequently imply a central role in tumour progression. Furthermore, it is closely related to the EGFR regulation and has shown promising potential as a biomarker in colorectal cancer (CRC). The aim of the present study was to investigate the clinical value of TIMP-1 in patients with metastatic colorectal cancer (mCRC) treated with cetuximab and irinotecan. Patients with chemotherapy-resistant mCRC referred to third-line treatment with cetuximab (initial 400 mg/m2 followed by weekly 250 mg/m2)/irinotecan (350 mg/m2 q3w) were prospectively included in the biomarker study, as previously published. Pre-treatment blood samples were collected, and plasma TIMP-1 was measured by a validated in-house ELISA assay. In addition, carcinoembryonic antigen (CEA) measurement was performed with a standardised method. A total of 107 patients were included in the biomarker study. The median baseline plasma TIMP-1 level was 271.1 ng/ml (range 65.9–1432 ng/ml) with no significant associations with baseline clinical characteristics. Median baseline plasma TIMP-1 levels were significantly higher in patients with early progression compared to patients who achieved disease control, 349 ng/ml (233–398 95 % confidence interval (CI)) and 215 ng/ml (155–289 95 % CI), respectively, p = 0.03, suggesting some association with treatment efficacy. When dividing patients according to TIMP-1 tertiles, the median progression-free survival (PFS) in patients with a high level of TIMP-1 was 2.4 months (95 % CI 2.1–4.1) compared to 3.3 months (95 % CI 2.1–6.2) and 4.7 months (95 % 3.2–7.6) in patients with intermediate or low levels, respectively. Analysis of TIMP-1 as a continuous variable revealed a shorter PFS associated with increasing levels of TIMP-1 (hazard ratio (HR) 1.36). These results translated into a significantly lower overall survival (OS) in patients with a high baseline TIMP-1 level (4.5 months (95 % CI 3.4–5.4)), compared to those with intermediate or low TIMP-1 levels (7.8 months (95 % CI 4.4–13.7) and 12.0 months (95 % CI 10.1–14.3), respectively, p < 0.0001). An 83 % higher hazard for death was revealed (HR = 1.83) with each twofold increase in the TIMP-1 level. Pre-treatment levels of CEA were not associated with any of the baseline characteristics (except primary tumour localisation) or to differences in PFS or OS. The rank correlation between CEA and TIMP-1 was r = 0.50, and a test for interaction between TIMP-1 and CEA (dichotomised at 5 ng/ml) in survival analysis was not significant (p = 0.18). A multivariate analysis for PFS and OS resulted in a model with significant contributions from TIMP-1, KRAS, and the number of metastatic sites. We have confirmed the potential prognostic value of TIMP-1 measurement prior to palliative chemotherapy for mCRC. However, validation in randomised trials will be essential with the perspective of establishing a potential predictive role of plasma TIMP-1 in this setting.


Metastatic colorectal cancer TIMP-1 Cetuximab Irinotecan 



The Strategic Research Council, Danish Cancer Society, Kathrine og Vigo Skovgaards Foundation, Simon Fougner Hartmanns Family Foundation, IMK Almene Foundation, Fabrikant Einar Willumsens Memorial Trust, Director Ib Henriksens Foundation and Sawmill owner Jeppe Juhl and Wife Ovita Juhl Foundation are acknowledged.

Conflict of interest



  1. 1.
    Cunningham D, Humblet Y, Siena S, Khayat D, Bleiberg H, Santoro A, et al. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med. 2004;351(4):337.CrossRefPubMedGoogle Scholar
  2. 2.
    Peeters M, Balfour J, Arnold D. Panitumumab—a fully human anti-EGFR monoclonal antibody for treatment of metastatic colorectal cancer. Aliment Pharmacol Ther. 2008;28(3):269–81. Review.CrossRefPubMedGoogle Scholar
  3. 3.
    De Roock W, Claes B, Bernasconi D, De Schutter J, Biesmans B, Fountzilas G, et al. Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of cetuximab plus chemotherapy in chemotherapy-refractory metastatic colorectal cancer: a retrospective consortium analysis. Lancet Oncol. 2010;11(8):753–62. doi: 10.1016/S1470-2045(10)70130-3. Epub 2010 Jul 8.CrossRefPubMedGoogle Scholar
  4. 4.
    Linardou H, Briasoulis E, Dahabreh IJ, Mountzios G, Papadimitriou C, Papadopoulos S, et al. All about KRAS for clinical oncology practice: gene profile, clinical implications and laboratory recommendations for somatic mutational testing in colorectal cancer. Cancer Treat Rev. 2011;37(3):221–33. doi: 10.1016/j.ctrv.2010.07.008. Epub 2010 Sep 29. Review.CrossRefPubMedGoogle Scholar
  5. 5.
    Amado RG, Wolf M, Peeters M, Van Cutsem E, Siena S, Freeman DJ, et al. Wild-type KRAS is required for panitumumab efficacy in patients with metastatic colorectal cancer. J Clin Oncol. 2008;26(10):1626–34. doi: 10.1200/JCO.2007.14.7116. Epub 2008 Mar 3.CrossRefPubMedGoogle Scholar
  6. 6.
    Bjerre C, Knoop A, Bjerre K, Larsen MS, Henriksen KL, Lyng MB, et al. Association of tissue inhibitor of metalloproteinases-1 and Ki67 in estrogen receptor positive breast cancer. Acta Oncol. 2013;52(1):82–90.CrossRefPubMedGoogle Scholar
  7. 7.
    Guedez L, Stetler-Stevenson WG, Wolff L, Wang J, Fukushima P, Mansoor A, et al. In vitro suppression of programmed cell death of B cells by tissue inhibitor of metalloproteinases-1. J Clin Invest. 1998;102(11):2002–10.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Murphy FR, Issa R, Zhou X, Ratnarajah S, Nagase H, Arthur MJ, et al. Inhibition of apoptosis of activated hepatic stellate cells by tissue inhibitor of metalloproteinase-1 is mediated via effects on matrix metalloproteinase inhibition: implications for reversibility of liver fibrosis. J Biol Chem. 2002;277(13):11069–76.CrossRefPubMedGoogle Scholar
  9. 9.
    Liu XW, Bernardo MM, Fridman R, Kim HR. Tissue inhibitor of metalloproteinase-1 protects human breast epithelial cells against intrinsic apoptotic cell death via the focal adhesion kinase/phosphatidylinositol 3-kinase and MAPK signaling pathway. J Biol Chem. 2003;278:40364–72.CrossRefPubMedGoogle Scholar
  10. 10.
    Fu ZY, Lv JH, Ma CY, Yang DP, Wang T. Tissue inhibitor of metalloproteinase-1 decreased chemosensitivity of MDA-435 breast cancer cells to chemotherapeutic drugs through the PI3K/AKT/NF-small ka, CyrillicB pathway. Biomed Pharmacother. 2011;65:163–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Holten-Andersen MN, Christensen IJ, Nielsen HJ, Lilja H, Murphy G, Jensen V, et al. Measurement of the noncomplexed free fraction of tissue inhibitor of metalloproteinases 1 in plasma by immunoassay. Clin Chem. 2002;48(8):130.Google Scholar
  12. 12.
    Holten-Andersen MN, Stephens RW, Nielsen HJ, Murphy G, Christensen IJ, Stetler-Stevenson W, et al. High preoperative plasma tissue inhibitor of metalloproteinase-1 levels are associated with short survival of patients with colorectal cancer. Clin Cancer Res. 2000;6(11):4292–9.PubMedGoogle Scholar
  13. 13.
    Zeng ZS, Cohen AM, Zhang ZF, Stetler-Stevenson W, Guillem JG. Elevated tissue inhibitor of metalloproteinase 1 RNA in colorectal cancer stroma correlates with lymph node and distant metastases. Clin Cancer Res. 1995;1(8):899–906.PubMedGoogle Scholar
  14. 14.
    Holten-Andersen MN, Nielsen HJ, Sørensen S, Jensen V, Brünner N, Christensen IJ. Tissue inhibitor of metalloproteinases-1 in the postoperative monitoring of colorectal cancer. Eur J Cancer. 2006;42(12):1889–96.CrossRefPubMedGoogle Scholar
  15. 15.
    Yukawa N, Yoshikawa T, Akaike M, Sugimasa Y, Takemiya S, Yanoma S, et al. Prognostic impact of tissue inhibitor of matrix metalloproteinase-1 in plasma of patients with colorectal cancer. Anticancer Res. 2004;24(3b):2101–5.PubMedGoogle Scholar
  16. 16.
    Frederiksen C, Lomholt AF, Davis GJ, Dowell BL, Blankenstein MA, Christensen IJ, et al. Changes in plasma TIMP-1 levels after resection for primary colorectal cancer. Anticancer Res. 2009;29(1):75–81.PubMedGoogle Scholar
  17. 17.
    Schrohl AS, Meijer-van Gelder ME, Holten-Andersen MN, Christensen IJ, Look MP, Mouridsen HT, et al. Primary tumor levels of tissue inhibitor of metalloproteinases-1 are predictive of resistance to chemotherapy in patients with metastatic breast cancer. Clin Cancer Res. 2006;12(23):7054–8. Epub 2006 Nov 17.CrossRefPubMedGoogle Scholar
  18. 18.
    Willemoe GL, Hertel PB, Bartels A, Jensen MB, Balslev E, Rasmussen BB, et al. Lack of TIMP-1 tumour cell immunoreactivity predicts effect of adjuvant anthracycline-based chemotherapy in patients (n=647) with primary breast cancer. A Danish Breast Cancer Cooperative Group Study. Eur J Cancer. 2009;45(14):2528–36.CrossRefPubMedGoogle Scholar
  19. 19.
    Glimelius B, Sørbye H, Balteskard L, Byström P, Pfeiffer P, Tveit K, et al. A randomized phase III multicenter trial comparing irinotecan in combination with the Nordic bolus 5-FU and folinic acid schedule or the bolus/infused de Gramont schedule (Lv5FU2) in patients with metastatic colorectal cancer. Ann Oncol. 2008;19(5):909–14.CrossRefPubMedGoogle Scholar
  20. 20.
    Sørensen NM, Byström P, Christensen IJ, Berglund A, Nielsen HJ, Brünner N, et al. TIMP-1 is significantly associated with objective response and survival in metastatic colorectal cancer patients receiving combination of irinotecan, 5-fluorouracil, and folinic acid. Clin Cancer Res. 2007;13(14):4117–22.CrossRefPubMedGoogle Scholar
  21. 21.
    Aldulaymi B, Byström P, Berglund A, Christensen IJ, Brünner N, Nielsen HJ, et al. High plasma TIMP-1 and serum CEA levels during combination chemotherapy for metastatic colorectal cancer are significantly associated with poor outcome. Oncology. 2010;79(1–2):144–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Frederiksen C, Qvortrup C, Christensen IJ, Glimelius B, Berglund A, Jensen BV, et al. Plasma TIMP-1 levels and treatment outcome in patients treated with XELOX for metastatic colorectal cancer. Ann Oncol. 2011;22(2):369–75.CrossRefPubMedGoogle Scholar
  23. 23.
    Hekmat O, Munk S, Fogh L, Yadav R, Francavilla C, Horn H, et al. TIMP-1 increases expression and phosphorylation of proteins associated with drug resistance in breast cancer cells. J Proteome Res. 2013;12(9):4136–51.CrossRefPubMedGoogle Scholar
  24. 24.
    Garm Spindler KL, Pallisgaard N, Rasmussen AA, Lindebjerg J, Andersen RF, Crüger D, et al. The importance of KRAS mutations and EGF61A>G polymorphism to the effect of cetuximab and irinotecan in metastatic colorectal cancer. Ann Oncol. 2009;20(5):879–84.CrossRefPubMedGoogle Scholar
  25. 25.
    Holten-Andersen MN, Murphy G, Nielsen HJ, Pedersen AN, Christensen IJ, Høyer-Hansen G, et al. Quantitation of TIMP-1 in plasma of healthy blood donors and patients with advanced cancer. Br J Cancer. 1999;80(3–4):495–503.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Altman DG, McShane LM, Sauerbrei W, Taube SE. Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK): explanation and elaboration. PLoS Med. 2012;9(5):e1001216.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Holten-Andersen MN, Fenger C, Nielsen HJ, Rasmussen AS, Christensen IJ, Brünner N, et al. Plasma TIMP-1 in patients with colorectal adenomas: a prospective study. Eur J Cancer. 2004;40(14):2159–64.CrossRefPubMedGoogle Scholar
  28. 28.
    Sørensen NM, Schrohl AS, Jensen V, Christensen IJ, Nielsen HJ, Brünner N. Comparative studies of tissue inhibitor of metalloproteinases-1 in plasma, serum and tumour tissue extracts from patients with primary colorectal cancer. Scand J Gastroenterol. 2008;43(2):186–911.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Oncology and BioMarkers (ISOBM) 2015

Authors and Affiliations

  • Karen-Lise Garm Spindler
    • 1
    • 5
  • Ib Jarle Christensen
    • 2
  • Hans Jørgen Nielsen
    • 3
  • Anders Jakobsen
    • 1
  • Nils Brünner
    • 4
  1. 1.Department of OncologyVejle HospitalVejleDenmark
  2. 2.The Finsen Laboratory Rigshospitalet and Biotech Research and Innovation Center (BRIC)University of CopenhagenCopenhagenDenmark
  3. 3.Department of Surgical GastroenterologyCopenhagen University HospitalHvidovreDenmark
  4. 4.Faculty of Health and Medical Sciences, Institute of Veterinary PathobiologyUniversity of CopenhagenCopenhagenDenmark
  5. 5.Department of OncologyAarhus University HospitalAarhus CDenmark

Personalised recommendations