Different Effects of KRAS Gene on Recurrence for Right- and Left-sided Colorectal Liver Metastases Undergoing Radiofrequency Ablation

doi:10.21203/rs.3.rs-5286032/v1

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Different Effects of KRAS Gene on Recurrence for Right- and Left-sided Colorectal Liver Metastases Undergoing Radiofrequency Ablation

https://doi.org/10.21203/rs.3.rs-5286032/v1

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Objective: To investigate the association of KRAS mutations with recurrence in patients with colorectal liver metastases (CLM) undergoing radiofrequency ablation (RFA) according to the primary tumor location.

Methods: CLM patients with a known KRAS gene status who underwent RFA were enrolled from January 1, 2012 to December 31, 2018. Clinicopathological data, recurrence, and survival dates were evaluated retrospectively.

Results: 164 patients (mean age: 58.0+9.8 years, range: 34–83) who underwent percutaneous RFA of 325 CLM (mean sizes: 2.2+1.0 cm, range: 0.7–5.0) were included in the study; Patients (30.7%) in the KRAS mutation group had LTP, which was significantly higher than in patients with KRAS wild-type (14.6%) (p = 0.013). Of the 126 (76.8%) patients with recurrence after RFA, 101 (61.6%) had intrahepatic recurrence, while 88 (53.7%) had extrahepatic recurrence. Among patients with left-sided colorectal cancer (CRC), intrahepatic recurrence rates were higher among patients with KRAS mutation than among patients with the wild type KRAS (77.2% vs 52.5%, p=0.003); the median intrahepatic recurrence-free survival (RFS) was worse in KRAS mutation patients (25 vs 15 months, P=0.007). In patients with right-sided CRC, there was no significant difference in intrahepatic recurrence between the KRAS wild-type and KRAS mutation groups (P＞0.05).

Conclusions: KRAS status is associated with recurrence of CLM after RFA depending on primary tumor location.

Advances in knowledge: KRAS mutation had worse intrahepatic recurrence-free survival after RFA of CLM among patients with left-sided CRC, but was not significantly different in recurrence among patients with right-sided CRC.

KRAS

Recurrence

Primary tumor location

Radiofrequency ablation

Colorectal cancer

Radiofrequency ablation (RFA) is recommended as a critical local treatment for colorectal liver metastases (CLM) [1, 2], especially in the management of multiple, bilobar, and recurrent liver metastases [3–5]. It can help to preserve enough liver volume and avoid hepatic failure. RFA is minimally invasive; therefore, it is a suitable therapeutic option for CLM patients with an advanced age or associated co-morbidity [6]. Many prior studies have shown RFA to be safe and effective for CLM [7, 8]. A recent randomized prospective phase II trial [9] showed that RFA as a local treatment can improve overall survival (OS) for patients with unresectable CLM.

However, a high recurrence rate following RFA is the main challenge faced with RFA in CLM [10, 11]. Studies have suggested that KRAS is associated with recurrence for colorectal cancer (CRC)[12, 13]. In addition, the KRAS gene impacted recurrence after CLM metastases resection had been reported, but their findings were controversial [14–17]. There were several studies investigated the coloration KRAS gene and recurrence after RFA for CLM[18, 19]. A recent report showed that recurrence after RFA could influence the treatment and survival of CLM patients [20].Therefore, A better comprehension of correlation may improve decision-making about pre-, intra-, and post-RFA.

Several studies [21, 22] have shown that primary location could influence the outcome of CLM patients undergoing RFA. However, the prevalence of KRAS mutations was found to vary with the primary tumor location; KRAS mutation was more prevalent in right-sided tumors than in left-sided tumors [23]. Thus, collinearity may occur when primary location and KRAS gene is not only associated with prognosis, but also with each other, leading to biased estimations [24]. A recent study [25] reported that for patients who underwent hepatic resection for CLM, the KRAS status had a variable prognostic impact depending on the primary colorectal cancer (CRC) location. In addition, the KRAS wild-type according to different primary locations had different treatment responses [26, 27]. Therefore, the primary tumor site can be considered in future studies investigating the impact of KRAS gene on recurrence and survival.

Thus, we investigated the association of KRAS mutations with recurrence in patients with CLM undergoing RFA according to the primary tumor location. A better understanding of recurrence may change the therapeutic strategy and improve outcomes.

Patient Selection

The need for informed consent was waived because of the retrospective study design, and the study was approved by the Hospital Medical Ethics Committee. Between January 2012 and December 2018, 164 consecutive patients with surgical resection of primary tumor and known KRAS gene status who underwent percutaneous RFA of 325 CLMs were included in our study. The inclusion criteria for this study were as follows: (1) Surgical resection of a primary tumor; (2) patients with known KRAS gene status; (3) metastases diameter ≤ 5 cm; (4) extrahepatic metastases with stable control before RFA; (5) ultrasound or contrast-enhanced ultrasonography (CEUS) showing hepatic metastases; (6) liver function classification of Child-Pugh A/B; and (7) normal coagulation function. However, patients suffering from serious diseases, such as congestive heart failure, myocardial infarction, and cerebrovascular accident, in the past 6 months were excluded.

RFA Treatment techniques

Before RFA, all patients were examined using an ultrasound (US) and contrast computed tomography (CT)/magnetic resonance imaging (MRI) to obtain baseline data. Treatments were planned according to the size, shape, and border of the tumor. Local anesthesia and general anesthesia were performed by the anesthesiologist. Local infiltration anesthesia was induced with 5–15 ml of 1% lidocaine (Liduokayin; Yimin, Beijing, China) after which the RFA electrode was placed when the patient was conscious. General intravenous anesthesia was then induced with 2.5–5.0 mg of midazolam (Roche; Basel, Switzerland) and 50–100 ug of fentanyl (Fentaini; Renfu, Yichang, China). During the procedure, the vital signs of the patients were continuously monitored.

RFA procedures were performed by two of four radiologists (CMH, YK, WW, and YW), with ˃10 years of experience in ultrasound-guided interventional procedures. Real-time US and enhanced US if necessary were used to target, monitor, and modify the ablation. If tumors were ˃ 3 cm, overlapping ablations were used to ensure a sufficient ablation zone [28]. Ablative margins covering > 0.5 cm beyond the original tumor with the exception of tumors close to important structures such as the diaphragm, gastrointestinal tract, or gallbladder did not have a sufficient ablative margin around the lesion. Therefore, an individualized protocol was needed [29] for patients with CLM.

The ablation electrodes used included multi-polar electrodes (Celon Lab Power, Germany), multitoned RITA electrodes (RITA Medical Systems, Martinez, CA), and Valleylab system (Tyco Healthcare, North Haven, CT). Real-time US systems Aloka SSD-4000, SSD-5500, a-10 (Tokyo, Japan) and GE Logic-9 (CT) US systems were used for scanning and guidance with 3.5–5.0 MHz convex probes with needle guide devices.

After RFA, CEUS was immediately performed to evaluate the ablated tumor size and whether the target lesion was completely covered.

KRAS gene analysis

KRAS mutations were measured using polymerase chain reaction (PCR) amplification fluorescence technique. The pathologist analyzed hematoxylin and eosin stained (H & E) sections and extracted DNA from surgically resected primary tumor samples. The main reason is KRAS mutational status between primary and metastatic lesions has a high concordance rate [30]. After specific primers and probes are combined with DNA, Taq DNA polymerase uses deoxynucleotide (dNTP) as a substrate to amplify the internal reference gene and mutant genes in specific regions of codons 12, 13, and 61 of the KRAS gene in vitro. The pathologist who performed the KRAS gene analyses had no knowledge of the clinical outcome.

Follow-up

To evaluate technical effectiveness, a contrast-enhanced CT was performed at 1 month after RFA. The patients were then followed up using an abdominal CEUS and enhanced CT/MRI every 2–3 months in the first 2 years, and every 4–6 months in the following years. Radiologists were blinded to the clinical to ensure the evaluation of the treatment effect.

OS[31] was from the date of RFA to the date of death or last follow-up. The local tumor progression (LTP) [31] was measured from the date of RFA to the date when new lesions occurred around the prior ablation site or last follow-up. Intrahepatic recurrence was measured from the date of ablation to the date of detection of new hepatic lesions without contact with the prior ablation zone in the liver or to the last follow-up data. Extrahepatic recurrence was measured from the date of ablation to the date of detection of new extrahepatic lesions or to the last follow-up date. Recurrence-free survival (RFS) was calculated from the time of ablation to the time intra- or extrahepatic recurrence appeared or to the last follow-up date. The right-sided colon was from the cecum to the transverse colon, while the left-sided colon was from the splenic flexure to the rectum.

Statistical Analysis

The two KRAS gene groups were compared for patients and clinicopathologic characteristics, LTP, intrahepatic and extrahepatic recurrence, RFS and survival. Categorical outcomes were analyzed using the chi-square test or Fisher’s exact test. Continuous variables were analyzed using the Wilcoxon rank sum test or independent t-test. RFS and OS analyses were done using Cox regression models in univariate and multivariate analyses. All data was analyzed using SPSS software (SPSS Inc., Chicago, IL). P ≤ 0.05 was considered significant.

Demographics and Clinicopathologic Characteristics

Of the 164 patients (98 men and 66 women; mean age: 58.0 ± 9.8 years, range: 34–83 years) with colorectal adenocarcinoma liver metastases (CLM), 89 (54.3%) cases had KRAS wild-type and 75 (45.7%) cases had a KRAS mutation. The baseline characteristics of the KRAS wild-type and KRAS mutation groups were compared before RFA and are shown in Table 1. The prevalence of KRAS mutations in right-sided CRC was higher than in left-sided CRC (66.7% vs 41.6%, P = 0.017) (Additional Fig. 1). No other difference in clinical factors was observed between the two groups.

Table 1

Demographic and clinicopathologic characteristics
Characteristics	No. of Patients(n = 164)	KRAS
Characteristics	No. of Patients(n = 164)	Wild(n = 89)	Mutation(n = 75)	P
Age (y), mean	58.0 ± 9.8	57.0 ± 9.5	59.1 ± 10.0	0.167
≤ 60	90(54.9)	51(56.7)	39(43.3)	0.497
>60	74(45.1)	38(51.4)	36(48.6)
Sex				0.794
Male	98(59.8)	54(55.1)	44(44.9)
Female	66(40.2)	35(53.0)	31(47.0)
Primary tumor site				0.017
Right colon	27(16.5)	9(33.3)	18(66.7)
Left colon	137(83.5)	80(58.4)	57(41.6)
Primary tumor invasion				0.203
T1-2	11(6.7)	8(72.7)	3(27.3)
T3-4	153(93.3)	81(52.9)	72(47.1)
Nodal status of primary tumor				0.561
Positive	128(78.0)	71(55.5)	57(44.5)
Negative	36(22.0)	18(50.0)	18(50.0)
Time of CLM				0.504
Synchronous	85(51.8)	44(51.8)	41(48.2)
Heterochronous	79(48.2)	45(57.0)	34(43.0)
Extrahepatic metastases				0.139
Yes	75(45.7)	36(48.0)	39(52.0)
No	89(54.3)	53(59.6)	36(40.4)
Tumor size (cm)
Median diameter, cm (quartile)	2.2(1.7–2.9)	2.0(1.7–2.7)	2.2(1.6–3.3)	0.236
≤ 3	123(75.0)	71(57.8)	52(42.2)	0.124
>3	41(25.0)	18(43.9)	23(56.1)
DFI (months)				0.485
<12	137(83.5)	76(55.5)	61(44.5)
≥ 12	27(16.5)	13(48.1)	14(51.9)
CEA level (ng/ml)				0.914
≤ 30	135(82.3)	73(54.1)	62(45.9)
>30	29(17.7)	16(55.2)	13(44.8)
CRS				0.313
0–2	77(47.0)	45(58.4)	32(41.6)
3–5	87(53.0)	44(50.6)	43(49.4)
Liver metastases resection pre-RFA				0.485
Yes	66(40.2)	38(57.6)	28(42.4)
No	98(59.8)	51(52.0)	47(48.0)
Preoperative chemotherapy				0.221
Yes	148(90.2)	78(52.7)	70(47.3)
No	16(9.8)	11(68.8)	5(31.2)
Ablative margin (mm)				0.156
<5	17(10.4)	7(41.2)	10(58.8)
5–10	101(61.6)	52(51.5)	49(48.5)
>10	46(28.0)	30(65.2)	16(34.8)
DFI, disease-free interval from primary resection to the diagnosis of liver metastasis; CRS, Node-positive primary tumor, DFI < 12 months, more than one liver tumor, size of largest tumor > 3 cm, carcinoembryonic antigen (CEA) level > 30 ng/mL (mg/L); RFA: radiofrequency ablation; CLM, colorectal liver metastases.

Technical effectiveness and Local tumor progression

A total of 325 CLM lesions (mean size ± standard deviation: 2.2 ± 1.0 cm, range: 0.7–5.0) were analyzed in this study. The technical effectiveness was 98.8% (321/325). Of the patients, 22.0% (36 of 164) had LTP; 23 of 75 patients (30.7%) in the KRAS mutation group had LTP, which was significantly higher than in the patients with KRAS wild-type (13 of 89 (14.6%)) (P = 0.013). The cumulative incidences of LTP at 3 years were also higher in the KRAS mutation group (40.5% vs. 17.0%, P = 0.008). The major complications included liver abscess (n = 1) and acute biliary infection (n = 2). All patients who underwent active treatment improved. There was no treatment-related death.

Correlation of KRAS gene and Recurrence site according to according to the primary tumor location

In the study, the 126 (76.8%) patients had recurrence after RFA; 101 (61.6% of all patients) had intrahepatic recurrence, and 88 (53.7% of all patients) had extrahepatic recurrence.

A total of 47 (46.5%) of the 101 patients with intrahepatic recurrence were the KRAS wild-type, while 54 (53.5%) had KRAS mutations. There was significant difference between the two groups (P = 0.012). In the left-sided CRC group, patients with KRAS mutation had a higher intrahepatic recurrence than the KRAS wild-type (77.2% vs 52.5%, P = 0.003). In the right-sided CRC, there were no clear differences in the proportion of intrahepatic recurrence (P>0.05) (Table 2).

Table 2

Recurrence after colorectal liver metastases underwent RFA
Characteristic	All patients n = 164	Right colon			Left colon
Characteristic	All patients n = 164	Wild n = 9	Mutation n = 18	P	Wild n = 80	Mutation n = 57	P
Intrahepatic recurrence	101(61.6)	5(55.6)	10(55.6)	1.000	42(52.5)	44(77.2)	0.003
Extrahepatic recurrence	88(53.7)	5(55.6)	7(38.9)	0.448	43(53.7)	33(57.9)	0.630
				1.000			0.460
Single	79(89.8)	4(80.0)	6(85.7)		40(93.0)	29(87.9)
Multiple	9(10.2)	1(20.0)	1(14.3)		3(7.0)	4(12.1)
Site of single extrahepatic recurrence
Lung	38(48.1)	2(50.0)	2(33.3)	0.582	20(50.0)	14(48.3)	1.000
Bone	11(13.9)	0	2(33.3)	0.538	5(10.0)	4(13.8)	1.000
Peritoneal	8(10.1)	0	0	-	4(8.0)	4(13.8)	0.719
Ovary	4(5.1)	1(25.0)	0	0.333	2(4.0)	1(3.4)	1.000
Adrenal	2(2.5)	0	0	-	0	2(6.9)	0.171
Lymph node	15(19.0)	1(25.0)	2(33.3)	1.000	8(16.0)	4(13.8)	0.761
Other	1(1.3)	0	0	-	1(2.0)	0	1.000
RFS interval*	10(0–57)	11(1–35)	14(1–45)	0.944	11(0–57)	9(0–44)	0.012
Intrahepatic RFS interval *	19(0–86)	13(1–35)	15(1–49)	0.950	25(0–86)	15(0–63)	0.007
Extrahepatic RFS interval *	23(0–95)	22(2–35)	37(1–47)	0.515	27(0–57)	22(0–95)	0.467
Note. — Unless indicated otherwise, data indicate the number of patients, with percentages in parentheses. *Data are medians, with ranges in parentheses; RFS, recurrence-free survival

A total of 48 of 88 patients with extrahepatic recurrence were the KRAS wild-type, 40 of 88 patients had KRAS mutations (53.9% vs 53.3%, P = 0.939). There were no clear differences in the proportion of extrahepatic recurrence regardless of the primary site (P>0.05). the initial single and multiple location of extrahepatic recurrence were 89.8% (79/88) and 10.2% (9/88), respectively. The initial single locations of the extrahepatic recurrence after RFA were as follows: the lungs (n = 38, 48.1%), bone (n = 11, 13.9%), peritoneal dissemination (n = 8, 10.1%), ovary (n = 4, 5.1%), adrenal glands (n = 2, 2.5%), and lymph nodes (n = 15, 19.0%) and other (n = 1, 1.3%) (Table 2). There were no clear differences in the proportion of initial recurrence sites between the KRAS wild-type and mutation groups irrespective of the primary sites (P>0.05) (Table 2).

Association Between KRAS gene and recurrence-free Survival

The median 1-,3-and 5-year intrahepatic RFS rates of the patients at 19 months were 59.6%, 31.0%, and 20.9%, respectively. Intrahepatic RFS in the KRAS wild-type group (median: 25 months, 3-year intrahepatic RFS: 44.2%) were longer than in the KRAS mutation group (median: 19 months, 3-year intrahepatic RFS: 22.5%, P = 0.014). Among patients with right-sided CRC, intrahepatic RFS in the KRAS mutation group seemed consistent with the effects observed in patients with the KRAS wild-type (median: 13 vs 15 months, 2-year intrahepatic RFS: 44.4% vs 38.4%, P = 0.950). However, in the left-sided CRC group, intrahepatic RFS differed between KRAS wild-type patients (median, 25 months and 3-year intrahepatic RFS 44.1%) and KRAS mutation patients (median, 15 months and 3-year intrahepatic RFS, 12.7%, P = 0.007) (Fig. 1).

Extrahepatic RFS between the KRAS wild-type and mutation groups were not significantly different (median: 26 months vs 22 months, 3-year extrahepatic RFS: 42.7% vs 32.8%, P = 0.663). In addition, there were similar conclusions about extrahepatic RFS between the two groups irrespective of the primary lesion location (left-sided CRC: median: 27 vs 23 months, P = 0.467; right-sided CRC, median: 22 vs 37 months, P = 0.515) (Additional Fig. 1).

The RFS in the KRAS wild-type group was longer than that in the KRAS mutation group (median: 11 vs 9 months, 3-year RFS: 28.0% vs 2.7%, P = 0.012) for left-sided CRC. However, the two groups had similar RFS in right-sided CRC (P>0.05) (Fig. 2). Univariable and multivariable analyses revealed that KRAS mutation and positive lymph nodes were independent factors associated with worse RFS (HR: 1.526, 95% CI: 1.056–2.207, P = 0.025; HR: 1.602, 95% CI: 1.008–2.54, P = 0.046) (Table 3).

Table 3

Univariable and Multivariable Analyses of Prognostic Factors for recurrence-free survival for CLMs
Prognostic factor	Univariate analysis		Multivariate analysis
Prognostic factor	HR (95% CI)	p	HR (95% CI)	p
Age (yr)	0.890(0.622–1.273)	0.523
Tumor size>3cm	1.070(0.715–1.602)	0.743
Sex	1.112(0.776–1.593)	0.563
Right colon	1.072(0.657–1.748)	0.781
Pathological differentiation /Poorly	0.766(0.430–1.364)	0.366
KRAS mutation	1.507(1.058–2.148)	0.023	1.526(1.056–2.207)	0.025
T stage	0.910(0.461–1.796)	0.786
Lymph node metastasis	1.674(1.064–2.635)	0.026	1.602(1.008–2.545)	0.046
Synchronous liver metastasis	0.824(0.580–1.169)	0.278
No. of liver metastases	1.414(0.992–2.014)	0.055	1.241(0.857–1.797)	0.253
Liver metastasis resection pre-RFA	1.414(0.990–2.019)	0.057	1.418(0.988–2.034)	0.058
Extrahepatic metastases	1.066(0.745–1.524)	0.727
CRS	1.238(0.869–1.762)	0.236
CEA	0.893(0.563–1.417)	0.631
DFI	1.043(0.645–1.686)	0.863
Preoperative chemotherapy	1.111(0.611–2.017)	0.731
DFI, disease-free interval from primary resection to the diagnosis of liver metastasis; CRS, clinical risk score, including node-positive primary tumor, DFI < 12 months, more than one liver tumor, size of largest tumor > 3 cm, carcinoembryonic antigen (CEA) level > 30 ng/mL (mg/L); RFA: radiofrequency ablation; CLM, colorectal liver metastases.

Prognostic factors for Overall Survival (OS)

The overall median follow-up period was 42 months. The median follow-up for patients with KRAS wild-type and KRAS mutation were 40 months and 51 months, respectively (P = 0.099). The 1-, 3-, 5-, and 7-year OS rates were 86%, 44.3%, 13.5%, and 10.1%, respectively for the CLM patients. The 1-, 3-, 5-, and 7-year OS rates were 89.9%, 52.0%, 16.0%, and 16.0%, respectively in the KRAS wild-type group and 81.3%, 35.2%, 10.3%, and 5.2%, respectively in the KRAS mutation group (P = 0.012). KRAS gene had no impact on OS irrespective of the primary tumor site. (P>0.05) (Additional Fig. 2). Multivariate analysis revealed that the right colon (hazard ratio [HR]: 2.234, 95% confidence interval [CI]: 1.298–3.845, P = 0.004), tumor size ≥ 3cm (HR: 1.829, 95% CI: 1.124–2.972, P = 0.015), and extrahepatic metastases pre-RFA (HR: 1.700, 95% CI: 1.113–2.598, P = 0.014) were independent risk factors for OS in patients with CLM (Table 4).

Table 4

Univariable and Multivariable Analyses of Prognostic Factors for OS for CLMs
Prognostic factor	Univariate analysis		Multivariate analysis
Prognostic factor	HR (95% CI)	P	HR (95% CI)	p
Age (yr)	1.057(0.707–1.579)	0.787
Tumor size>3cm	1.598(1.037–2.464)	0.034	1.829(1.124–2.972)	0.015
Sex	0.898(0.599–1.347)	0.604
Right colon	2.098(1.258–3.498)	0.005	2.234(1.298–3.845)	0.004
Pathological differentiation /Poorly	1.465(0.813–2.638)	0.203
KRAS mutation	1.681(1.123–2.515)	0.012	1.325(0.865–2.031)	0.196
T stage	1.338(0.583–3.070)	0.492
Lymph node metastases	1.317(0.787–2.201)	0.294
Synchronous liver metastasis	1.267(0.846–1.898)	0.252
No. of liver metastases	1.708(1.124–2.594)	0.012	1.469(0.839–2.570)	0.178
Liver metastasis resection pre-RFA	0.803(0.526–1.226)	0.310
Extrahepatic metastases	1.849(1.229–2.782)	0.003	1.700(1.113–2.598)	0.014
CRS	1.690(1.115–2.561)	0.013	1.174(0.658–2.095)	0.587
CEA	1.069(0.636–1.797)	0.802
DFI	1.279(0.755–2.167)	0.360
Margin	1.216(0.843–1.755)	0.295
Preoperative chemotherapy	1.623(0.751–3.508)	0.218
DFI, disease-free interval from primary resection to the diagnosis of liver metastasis; CRS, clinical risk score, including node-positive primary tumor, DFI < 12 months, more than one liver tumor, size of largest tumor > 3 cm, carcinoembryonic antigen (CEA) level > 30 ng/mL (mg/L); RFA: radiofrequency ablation; CLM, colorectal liver metastases.

In this study, the impact of KRAS gene on recurrence differed in CLM after RFA according to the primary tumor location. In left-sided CRC, the recurrence in the KRAS wild-type and KRAS mutation patients was significantly different. However, there was a similar outcome in right-sided CRC patients. This may be explained by the varying embryological origins of the right-sided colon (originated from the midgut) and the left-sided colon (originated from the hindgut) [32]. These could develop on two different molecular carcinogenic pathways and as distal metastases [33, 34]. A Meta-analysis made up of 66 studies revealed that primary right-sided CRC was associated with a significantly worse outcome, which was considered a stratification factor in future studies [35].

KRAS gene is a small G protein. Its mutations can activate the RAS/MAPK signaling pathway that permits the cell to evade apoptosis, promotes growth and proliferation [36, 37], Approximately 40% of CRCs harbor KRAS mutations [38]. Large phase II trials [12, 13] comprised of 2721 and 4268 patients reported that KRAS mutations were associated with an increased risk of recurrence and death of CRC patients. Meanwhile, some studies suggest otherwise [39, 40]. Similarly, the conclusion whether KRAS gene affects the prognosis of CLM patients who undergo RFA is also inconsistent [41, 42], Therefore, further discussion is necessary.

This study showed that KRAS mutations were more prevalent in right-sided CRC than in left‐sided CRC before RFA, which is consistent with findings of a prior study [23]. Thus, the primary tumor site may interact with KRAS gene, which reflects a more aggressive tumor biology. Although the association between primary location and gene expression is not well reported, some investigators proposed possible reasons. The KRAS-mutation’s aggressive behavior is associated with methylation [43]. Concurrent methylation of more CpG islands was more common in right-sided CRC than in left-sided CRC [44]. Therefore, right-sided CRC with KRAS mutation may have an aggressive biological behavior. We used the primary site for hierarchical analysis to show the relationship between KRAS and recurrence better.

Recurrence after RFA could influence treatment and survival for CLM [20]. Thus, a better understanding of recurrence was necessary. As we know, the liver is a common target for CRC metastases because cancer cells are arrested there primarily and cellular interactions within the mutation is a significant predictor of intrahepatic recurrence after RFA in CLM patients. However, in our prior study [18], we concluded that the intrahepatic recurrence between the two groups was not significantly different, which is consistent with the outcome of right-sided CRC patients with CLM. The possible reason was that the prior study paid mainly attention to LTP and made no further analysis of intrahepatic recurrence after RFA by stratification. Thus, frequent follow-up to detect early recurrence might be reasonable for CLM patients with different KRAS statuses according to the primary tumor site.

Extrahepatic recurrence among patients with CLM did not differ between tumors with a KRAS mutation and that with KRAS wild-type, regardless of the primary site. This was different from findings of another study in which CLM patients with KRAS mutation had more peritoneal metastases after RFA of CLM [19]. There are fewer studies on recurrence after RFA. However, there are also controversial conclusions on the relationship between KRAS gene and extrahepatic recurrence after surgical resection of CLM. Some studies showed that the cumulative incidence of extrahepatic recurrence, such as bone, brain, or lung metastases, was significantly higher for patients with KRAS mutation than for those with KRAS wild-type [5, 14, 17, 45]. Meanwhile, another study reported that KRAS mutation was not linked to recurrence specifically after surgery [46]. Therefore, the association between extrahepatic recurrence and KRAS gene in CLM patients who underwent RFA requires evaluation in further studies.

This study had several limitations. First, the study was retrospective and subject to inherent bias. Second, we considered the primary location and KRAS gene, which may occur in collinearity, the tumors were stratified according to the primary site, but the proportion of patients with right-sided CRC was small (16.5%), A possible reason for this is that the incidence of right colon cancer is lower than that of left colon cancer, right-sided CRC may have an aggressive biological behavior and have no chance of RFA. In addition, it is consistent with the recent study on the incidence of right colon cancer(18.1%)[47]. Prospective and large sample studies are needed to verify the conclusion. Next, other gene mutations, such as BRAF and NRAS, were not considered. However, these mutations do not commonly occur and may not affect the generalizability of our study.

KRAS gene has an impact on recurrence after RFA for CLM depending on the site of the primary CRC. Specifically, KRAS mutation had worse intrahepatic RFS after RFA of CLM among patients with left-sided CRC. In contrast, KRAS mutation was not significantly different in recurrence after RFA of CLM among patients with right-sided CRC.

Competing interests

The authors declare that they have no competing interests

Funding

This research was supported by Beijing Municipal Science & Technology Commission (grant no. Z151100004015186) and Capital Health Development Research Project (grant no. 2020-2-2152)

Authors' contributions

BB. Jiang and JC.Wang have made equal contribution. BB.J., JC.Wang., K.Y., W.W., W.Y., MH.C. designed the study; BB.J., JC.Wang., K.Y. and ZY.Z. wrote the main manuscript text and BB.J. H.W. prepared figures. All authors reviewed the manuscript.

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No competing interests reported.

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Different Effects of KRAS Gene on Recurrence for Right- and Left-sided Colorectal Liver Metastases Undergoing Radiofrequency Ablation

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Abstract

Figures

Introduction

Material and methods

Patient Selection

RFA Treatment techniques

KRAS gene analysis

Follow-up

Statistical Analysis

Results

Demographics and Clinicopathologic Characteristics

Technical effectiveness and Local tumor progression

Correlation of KRAS gene and Recurrence site according to according to the primary tumor location

Association Between KRAS gene and recurrence-free Survival

Prognostic factors for Overall Survival (OS)

Discussion

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1