Prospective clinical study of EUS-guided choledochoduodenostomy for malignant lower biliary tract obstruction

OBJECTIVES

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has recently been reported as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction, when endoscopic biliary drainage (EBD) is unsuccessful. However, prospective studies of EUS-CDS have not yet been performed. We conducted a prospective study to evaluate the safety, feasibility, and efficacy of EUS-CDS in patients with malignant lower biliary tract obstruction.

METHODS

A prospective study to confirm the safety of EUS-CDS was carried out in 6 patients, followed by a trial to evaluate the feasibility and efficacy of EUS-CDS in 12 additional patients. We placed a plastic stent from the duodenal bulb into the extrahepatic bile duct under EUS guidance using an oblique viewing echoendoscope, needle knife, guidewire, and biliary dilators.

RESULTS

The site of extrahepatic bile duct puncture was the common hepatic duct in 15 patients and the common bile duct in 3 patients. Mean diameter of the punctured extrahepatic bile ducts was 10 mm (range: 6-20 mm). Technical and functional success rates were 94% (17/18) and 100% (17/17), respectively. Median procedure time was 30 min (range: 10-52 min). Median duration to first oral intake after the procedure was 1 day (range: 1-3 days). Early complications were encountered in three (17%) patients, including focal peritonitis in two patients and hemobilia in one patient. During the follow-up period (median: 163 days; range: 46-484 days), 12 stent occlusion events were observed in nine patients. Re-intervention with exchange of the occluded stent was successful in 8 of 12 (66%) times. Severe early and late complications were not encountered in any patients in this study. Median duration of stent patency by Kaplan-Meier analysis was 272 days.

CONCLUSIONS

EUS-CDS is safe, feasible, and effective as an alternative to PTBD and EBD in cases of malignant distal biliary tract obstruction. Prospective randomized studies are needed to compare the safety and efficacy of various kinds of endoscopic devices used in EUS-CDS and to compare EUS-CDS with PTBD or EBD.

ABO genotype and the risk of gastric cancer, atrophic gastritis, and Helicobacter pylori infection

BACKGROUND

Although several studies have investigated the association between ABO blood type and risk of gastric cancer (GC), atrophic gastritis (AG), and Helicobacter pylori (HP) infection, no study has investigated these associations by using ABO genotype.

METHODS

We conducted a case-control study in 703 patients with GC and 1,465 noncancer patients. We also conducted a cross-sectional study by using 1,406 of these 1,465 controls, who were examined for pepsinogens and anti-HP IgG antibody levels in serum. ABO genotype was determined from single nucleotide polymorphisms in ABO gene. We used rs8176719 to mark the O allele, and rs8176746 and rs8176747 to mark the B allele. ORs and 95% CIs were calculated by a multivariate logistic model.

RESULTS

We observed significant associations between ABO genotype and GC, AG, and HP infection. ORs (95% CIs) of GC were 0.70 (0.50-0.99) for OO and 0.53 (0.36-0.77) for BO relative to AA genotype. An increased risk of GC was observed with addition of the A allele (P(trend) < 0.001), and a decreased risk with that of the B allele (P(trend) = 0.023). An OR of AG was 0.73 (95% CI, 0.53-0.99) for blood type B relative to blood type A, and an OR of HP infection was 0.39 (95% CI, 0.17-0.87) for BB relative to AA genotype.

CONCLUSION

This study identified a statistically significant association between ABO genotype and GC risk. In addition, ABO gene locus may influence AG prevalence and HP infection.

IMPACT

Further studies are necessary to confirm these findings.

Association of fluoropyrimidines, platinum agents, taxanes, and irinotecan in any line of chemotherapy with survival in patients with advanced gastric cancer

BACKGROUND

Although fluoropyrimidines, platinum agents, taxanes, and irinotecan are used in the treatment of advanced gastric cancer (AGC), it remains unclear whether these agents in any line of chemotherapy are associated with overall survival (OS) in these patients.

METHODS

We retrospectively analyzed 704 patients with AGC. To avoid possible lead-time bias, we applied time-varying covariate analysis for chemotherapy with four agents in any line.

RESULTS

Median OS was 12.3 months. The frequency of exposure to each agent class during all lines of treatment was 92.6% for FU (5-fluorouracil or oral fluoropyrimidine), 48.2% for platinum agents, 65.1% for taxanes, and 39.1% for irinotecan. According to a multivariate Cox model with exposure to each agent class as a time-varying covariate, the hazard ratios (HRs) of death were 0.41 (95% confidence interval [CI], 0.27-0.57; p < 0.001) for FU, 0.71 (95% CI, 0.58-0.84; p < 0.001) for platinum agents, 0.51 (95% CI, 0.41-0.63; p < 0.001) for taxanes, and 0.53 (95% CI, 0.43-0.65; p < 0.001) for irinotecan. Although other agents were used in 18.6% of the patients, they did not affect survival.

CONCLUSIONS

Each of the four agent classes (FU, platinum agents, taxanes, and irinotecan) appears to be independently associated with improved OS in patients with AGC regardless of timing. This result suggests the importance of developing strategies which make these active agents available to all patients with AGC to prolong OS.

[Metastasis of uterine leiomyosarcoma to the pancreas--usefulness and limitations of EUS-FNA]

A woman in her 60's presented with a tumor of the pancreatic body. Pan-hysterectomy had been performed under a diagnosis of uterine leiomyoma 11 years previously. A sample obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) revealed the histopathological proliferation of spindle-shaped bundles of atypical cells, and immunohistochemical staining demonstrated that these cells were positive for KIT. Therefore, distal pancreatectomy was performed under a diagnosis of pancreatic gastrointestinal stromal tumor (GIST). Immunohistochemical staining of surgical specimens demonstrated that the tumor cells were positive for desmin and negative for KIT and CD34. The low-grade leiomyosarcoma in pathological specimens of the uterine myoma obtained 11 years previously histologically resembled the pathological findings of the pancreatic specimens except for atypical nuclei and mitotic cells. Therefore, the final diagnosis was extremely rare metastatic leiomyosarcoma of the pancreas. Herein, we report metastasis of uterine leiomyosarcoma to the pancreas and discuss the usefulness and limitations of EUS-FNA.

Impact of alcohol consumption with polymorphisms in alcohol-metabolizing enzymes on pancreatic cancer risk in Japanese

The putative impact of alcohol on pancreatic cancer (PC) risk remains controversial. Here, we conducted a case-control study in Japanese to assess the impact of alcohol in conjunction with polymorphisms in alcohol-metabolizing enzymes. Cases were 160 patients with pancreatic cancer at Aichi Cancer Center, Nagoya, Japan. Two control groups of 800 age- and sex-matched non-cancer subjects each were independently selected. The impact of alcohol and polymorphisms in aldehyde dehydrogenase 2 (ALDH2) Glu504Lys, alcohol dehydrogenase (ADH) 1B His48Arg, and ADH1C Arg272Gln on PC risk was examined with multivariate analysis adjusted for potential confounders to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results showed no independent impact of alcohol or genotype on PC risk except former drinking. To avoid reverse causation, former drinkers were excluded in further analyses. In the analysis of the combined effects of alcohol consumption and genotype, significant impact of alcohol was seen for those subjects with ALDH2 Lys+ allele, ADH1B His/His, or ADH1C Arg/Arg (trend P = 0.077, 0.003, or 0.020, respectively), each of which is associated with a high concentration or rapid production of acetaldehyde. Analysis of genotype combinations showed that ‘ever drinking’ with both ADH1B His/His and ALDH2 Lys + was the most potent risk factor for PC relative to ‘never drinkers’ with both ADH1B His/His and ALDH2 Glu/Glu [OR (95% CI); 4.09 (1.30–12.85)]. These results indicate that alcohol has an impact on PC risk when the effects of alcohol consumption and metabolism are combined. Acetaldehyde may be involved in the mechanisms underlying PC development.

Phase 2 study of nilotinib as third-line therapy for patients with gastrointestinal stromal tumor

BACKGROUND

Patients with gastrointestinal stromal tumors (GISTs) resistant to both imatinib and sunitinib have a poor prognosis and few therapeutic options. In this study, the efficacy and safety of nilotinib (AMN107) as a third-line therapy for patients with GISTs was evaluated.

METHODS

A single-arm, open-label trial was conducted in 8 Japanese hospitals. The key eligibility criteria included resistance or intolerance to both imatinib and sunitinib treatment. The primary endpoint was disease control rate, defined as the percentage of patients with complete response, partial response (PR), or stable disease (SD) lasting 24 weeks or longer.

RESULTS

Thirty-five patients were enrolled and treated with nilotinib 400 mg twice daily, which generally was well tolerated. Disease control rate at Week 24 was 29% (90% confidence interval, 16.4%-43.6%). The median progression-free survival was 113 days, and the median overall survival was 310 days. The objective response rate was 3%, comprising 1 PR in a patient with a GIST possessing both a KIT exon 11 mutation, and an imatinib-resistant and sunitinib-resistant KIT exon 17 mutation. Twenty-three (66%) patients had SD (≥6 weeks) as the best response.

CONCLUSIONS

These results suggest that nilotinib is generally well tolerated and has encouraging antitumor activity in patients with GIST who failed both imatinib and sunitinib.

Distinct profiles of epigenetic evolution between colorectal cancers with and without metastasis

Liver metastasis is a fatal step in the progression of colorectal cancer (CRC); however, the epigenetic evolution of this process is largely unknown. To decipher the epigenetic alterations during the development of liver metastasis, the DNA methylation status of 12 genes, including 5 classical CpG island methylator phenotype (CIMP) markers, was analyzed in 62 liver metastases and in 78 primary CRCs (53 stage I-III; 25 stage IV). Genome-wide methylation analysis was also performed in stage I-III CRCs and in paired primary and liver metastatic cancers. Methylation frequencies of MGMT and TIMP3 increased progressively from stage I-III CRCs to liver metastasis (P = 0.043 and P = 0.028, respectively). The CIMP-positive cases showed significantly earlier recurrence of disease than did CIMP-negative cases with liver metastasis (P = 0.030), whereas no such difference was found in stage I-III CRCs. Genome-wide analysis revealed that more genes were methylated in stage I-III CRCs than in paired stage IV samples (P = 0.008). Hierarchical cluster analysis showed that stage I-III CRCs and stage IV CRCs were clustered into two distinct subgroups, whereas most paired primary and metastatic cancers showed similar methylation profiles. This analysis revealed distinct methylation profiles between stage I-III CRCs and stage IV CRCs, which may reflect differences in epigenetic evolution during progression of the disease. In addition, most methylation status in stage IV CRCs seems to be established before metastasis.

Improvement of oral intake following chemotherapy in gastric cancer patients with an inability to eat

BACKGROUND

Based on several phase III studies, oral S-1-based chemotherapy has become the standard for treatment of advanced gastric cancer in Japan. However, these studies included patients able to maintain sufficient oral intake, and the effectiveness of chemotherapy for patients unable to eat remained unclear.

METHODS

We retrospectively analyzed the effect of chemotherapy on patients with advanced gastric cancer who presented with inability to eat. We defined 'inability to eat' as requirement for daily intravenous fluids or hyperalimentation and 'improvement of oral intake' as no such requirement >1 week.

RESULTS

Among the 777 patients who received first-line chemotherapy, 100 patients (12.8%) were considered unable to eat and required daily intravenous fluids or hyperalimentation. Performance status was 0-1 in 26 patients and ≥ 2 in the other 74 patients. Seventy-eight patients (78%) had peritoneal metastasis and 62 patients (62%) had ascites. First-line chemotherapy with 5-fluorouracil-based regimens was used in 46 patients, taxane-based chemotherapy in 34 patients, oral fluoropyrimidine-based therapy in 19 patients, and irinotecan-cisplatin combination treatment in 2 patients. Median survival time was 5.0 months (95% confidence interval, CI, 3.9-6.6). Improvement in oral intake with duration for >1 week was achieved in 40 patients (40%) with the median duration of nutritional-support-free time of 3.1 months (95% CI 2.5-4.6).

CONCLUSION

Chemotherapy is moderately effective in improving oral intake in patients with advanced gastric cancer with inability to eat. Further study is required to improve its prognosis.

Interventional endoscopic ultrasonography for pancreatic cancer

Endoscopic ultrasonography (EUS) represents the combination of endoscopy and intraluminal ultrasonography. This allows use of a high-frequency transducer (5-20 MHz) that, due to the short distance to the target lesion, provides ultrasonographic images of higher resolution than those obtained from other imaging modalities, including multiple-detector-row-computed tomography, magnetic resonance imaging, and positron emission tomography. EUS is now a widely accepted modality for diagnosing pancreatic diseases. However, the most important limitation of EUS has been the lack of specificity in differentiating between benign and malignant changes. In 1992, EUS-guided fine needle aspiration (FNA) of lesions in the pancreas head was introduced into clinical practice, using a curved linear-array echoendoscope. Since then, EUS has evolved from EUS imaging to EUS-FNA and wider applications. Interventional EUS for pancreatic cancer includes EUS-FNA, EUS-guided fine needle injection, EUS-guided biliary drainage and anastomosis, EUS-guided celiac neurolysis, radiofrequency ablation, brachytherapy, and delivery of a growing number of anti-tumor agents. This review focuses on interventional EUS, including EUS-FNA and therapeutic EUS for pancreatic cancer.

The use of trastuzumab in Japanese patients with HER2-positive advanced or metastatic gastric cancer

102

Background: The Trastuzumab for Gastric Cancer (ToGA) study showed the efficacy of trastuzumab for HER2-positive gastric cancer (HGA). The aim of this study is to evaluate the benefit of trastuzumab for Japanese HGA patients.

Methods: ToGA was an open-label, international, phase III, randomized controlled trial undertaken in 122 centers in 24 countries. Median overall survival (OS) was 13.8 months in those assigned to trastuzumab plus chemotherapy (C+T) compared with 11.1 months in those assigned to chemotherapy alone (C) with hazard (HR) ratio of 0.74. Subgroup analyses of patients enrolled from Japan were undertaken to estimate the hazard ratio (HR) for OS in the Japanese population. Based upon the prescribed protocol for Japan, we calculated HR using multiple Cox regression model with prespecified covariates in the ToGA study in order to make up for the small number of Japanese patients and reduce the bias in the baseline characteristics between two groups.

Results: Sixteen institutes participated and 102 patients were enrolled, of which 101 patients were evaluable for this research. The median OS was 15.9 months in C+T arm versus 17.7 months in C arm. The HR for OS was 1.00 [95% CI: 0.59-1.69]. However, the HR for OS adjusted for the above covariates was estimated to be 0.68 [95% CI: 0.36-1.27]. There were differences between C+T arm and C arm in some baseline characteristics. Higher frequencies were seen in C arm as follow: intestinal type, prior gastrectomy, and smaller number of metastatic sites. For HER2 status, the percentage of patients with IHC0/FISH+ was lower in C+T arm (5.9%) than in C arm (18.0%), while that of patients with HER2 status IHC2+/FISH+ was higher in C+T arm (35.3%) than in C arm (26.0%).

Conclusions: Although ToGA's overall OS HR = 0.74 (p = 0.0046), in the Japan patient subgroup, the unadjusted hazard ratio was 1.00. However, there was an imbalance of the baseline characteristics between the treatment arms in Japanese population. When adjusted for these characteristics, the HR was 0.68 which is similar to those in the ToGA study. Adding trastuzumab to chemotherapy in Japanese population appears to confer a similar magnitude of benefit compared to the whole population enrolled in the ToGA study.

[Table: see text]

Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings in adrenal metastasis from renal cell carcinoma

Solitary adrenal metastasis is often difficult to distinguish from benign adrenal tumor using only plain computed tomography (CT) scanning. We describe a solitary left adrenal gland mass in a patient who had undergone simultaneous gastrectomy and right nephrectomy for advanced gastric cancer and renal cell carcinoma (RCC), respectively. Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings indicated a hypervascular adrenal mass, and EUS-guided fine needle aspiration (EUS-FNA) revealed clear cell carcinoma. Adrenalectomy confirmed metastatic clear cell carcinoma of the kidney.

Development of pancreatic cancers during long-term follow-up of side-branch intraductal papillary mucinous neoplasms

BACKGROUND AND STUDY AIMS

Side-branch intraductal papillary mucinous neoplasms (SB-IPMNs), and associated synchronous and metachronous pancreatic cancers are increasingly detected as imaging modalities become more sensitive. We investigated the natural history of SB-IPMN, and the incidence and characteristics of pancreatic cancers among patients undergoing long-term follow-up.

PATIENTS AND METHODS

We reviewed the clinical, imaging, and pathological features in 103 patients, diagnosed at the Aichi Cancer Center between September 1988 and September 2006 as having SB-IPMN, and conservatively followed up for ≥ 2 years (median 59 months) based on an endoscopic ultrasonography (EUS) database.

RESULTS

74 (71.8 %) patients had nonprogressive lesions. Overall, six patients (5.8 %) developed pancreatic cancers during follow-up, with intraductal papillary mucinous (IPM) carcinoma in four, and ductal carcinoma of pancreas that was not IPMN in two patients. Of the six pancreatic cancers, five were diagnosed at a resectable stage. The 5-year and 10-year actuarial rates of development of pancreatic cancer were 2.4 % and 20.0 %, respectively. Although, at the last follow-up, cyst size, main pancreatic duct (MPD) diameter, mural nodule size, and frequency of metachronous and/or synchronous cancers of other organs were significantly higher in patients who developed IPM carcinoma, resected SB-IPMNs without mural nodules and dilated MPDs had no IPM carcinomas.

CONCLUSIONS

The frequency of pancreatic cancers is high on long-term follow-up of SB-IPMN. Although conservative management is appropriate for selected patients, regular and long-term imaging, especially by EUS is essential, even if SB-IPMN remains unchanged for 2 years. Presence of mural nodule and dilated MPD seem to be more appropriate indicators for resection than cyst size alone for SB-IPMNs.

Serum tumor antigen REG4 as a useful diagnostic biomarker in gastric cancer

BACKGROUND/AIM

Serum biomarkers for the detection of gastric cancer are needed even now in order to find a larger number of candidates for suspected gastric cancer. We evaluated the usefulness of a novel serum marker, REG4, as compared to that of CA19-9, CEA, and pepsinogen.

METHODOLOGY

Pre-therapeutic sera were collected from 74 patients with gastric cancer and 106 healthy controls without any cancers. REG4, CEA, CA19-9, and pepsinogen serum levels were measured in each group. The cut-off value of REG4 was defined, and then the usefulness of REG4 was evaluated with a validation study that included sera collected from 37 patients with gastric cancer and 44 healthy controls without any cancers.

RESULTS

REG4 levels were significantly higher in early gastric cancer patients (median 8.42 ng/ml) than in controls (median 5.01 ng/ml) (p < 0.001), and in advanced gastric cancer patients (median 13.12 ng/ml) than in early gastric cancer patients (p < 0.02). A cut-off value of 6.67 ng/ml was defined using the receiver operating characteristics curve. The sensitivity for gastric cancer was 73.0%, the specificity was 70.8%, and the accuracy was 71.8%. Diagnostic accuracy of REG4 was superior to that of the other tests. In the validation study, the sensitivity for gastric cancer was 94.5%, the specificity was 31.8%, and the accuracy was 60.5%.

CONCLUSIONS

Serum REG4 level can be a useful indicator to distinguish between patients with gastric cancer and healthy subjects. This has the potential to be used as a screening serum marker for gastric cancers, including cancers in the early stages.

Pre-operative diagnosis of synchronous solid-pseudopapillary neoplasms of the pancreas

We report the case of a 37-year-old woman with two synchronous solid-pseudopapillary neoplasms (SPNs) of the pancreas. The patient underwent abdominal echography as part of the screening for hepatitis C virus antibody positivity, and a pancreatic tail tumor was detected. She was referred to our hospital for further examination of the pancreatic tail tumor. There were two masses measuring 37 and 20 mm, in the pancreatic body and tail, respectively, which were slightly enhanced on abdominal computed tomography. On endoscopic ultrasonography (EUS), their surfaces were smooth, their margins were clear, anechoic spots were seen in the hypoechoic mass, and there were no lateral shadows. Magnetic resonance imaging showed a low- and high-intensity mass of the body and a low- and low-intensity mass of the tail on T1- and T2-weighted images, respectively. EUS-guided fine needle aspiration biopsy (EUS-FNA) suggested SPNs because the tumor cells showed an aberrant nuclear expression of β-catenin and loss of membranous staining of E-cadherin on immunohistochemical analysis. With a diagnosis of SPNs based on the EUS-FNA findings, a distal pancreatectomy was performed. On histopathologic examination of the resected specimen, the SPNs were arising synchronously.

Characteristic methylation profile in CpG island methylator phenotype-negative distal colorectal cancers

Aberrant DNA methylation is involved in colon carcinogenesis. Although the CpG island methylator phenotype (CIMP) is defined as a subset of colorectal cancers (CRCs) with remarkably high levels of DNA methylation, it is not known whether epigenetic processes are also involved in CIMP-negative tumors. We analyzed the DNA methylation profiles of 94 CRCs and their corresponding normal-appearing colonic mucosa with 11 different markers, including the five classical CIMP markers. The CIMP markers were frequently methylated in proximal CRCs (p < 0.01); however, RASSF1A methylation levels were significantly higher in distal CRCs, the majority of which are CIMP-negative (p < 0.05). Similarly, methylation levels of RASSF1A and SFRP1 in the normal-appearing mucosae of distal CRC cases were significantly higher than those in the proximal CRC cases (p < 0.05). They were also positively correlated with age (RASSF1A, p < 0.01; SFRP1, p < 0.01). Microarray-based genome-wide DNA methylation analysis of 18 CRCs revealed that 168 genes and 720 genes were preferentially methylated in CIMP-negative distal CRCs and CIMP-positive CRCs, respectively. Interestingly, more than half of the hypermethylated genes in CIMP-negative distal CRCs were also methylated in the normal-appearing mucosae, indicating that hypermethylation in CIMP-negative distal CRCs is more closely associated with age-related methylation. By contrast, more than 60% of the hypermethylated genes in CIMP-positive proximal CRCs were cancer specific (p < 0.01). These data altogether suggest that CpG island promoters appear to be methylated in different ways depending on location, a finding which may imply the presence of different mechanisms for the acquisition of epigenetic changes during colon tumorigenesis.

EUS-Guided Biliary Drainage

Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography, and allows imaging with a high-frequency transducer over a short distance to generate high-resolution ultrasonographic images. EUS is now a widely accepted modality for diagnosing pancreatobiliary diseases. EUS-guided fine-needle aspiration (EUS-FNA) using a curved linear-array echoendoscope was initially described more than 20 years ago, and since then many researchers have expanded its indications to sample diverse lesions and have also used it for various therapeutic purposes. EUS-guided biliary drainage (EUS-BD) is one of the therapeutic procedures that has been developed using a curved linear-array echoendoscope. Technically, EUS-BD includes rendezvous techniques via transesophageal, transgastric, and transduodenal routes, EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS). Published data have demonstrated a high success rate, albeit with a comparatively high rate of nonfatal complications for EUS-CDS and EUS-HGS, and a comparatively low success rate with a low complication rate for the rendezvous technique. At present, these procedures represent an alternative to surgery or percutaneous transhepatic biliary drainage (PTBD) for patients with obstructive jaundice when endoscopic biliary drainage (EBD) has failed. However, these procedures should be performed in centers with extensive experience in linear EUS and therapeutic biliary ERCP. Large prospective studies are needed in the near future to establish standardized EUS-BD procedures as well as to perform controlled comparative trials between EUS-BD and PTBD, between rendezvous techniques and direct-access techniques (EUS-CDS and EUS-HGS), and between EBD and EUS-BD.

Can EUS-guided FNA distinguish between gallbladder cancer and xanthogranulomatous cholecystitis?

BACKGROUND

EUS-guided FNA (EUS-FNA) is a useful modality for sampling various targets, but its applicability to gallbladder (GB) mass lesions is limited.

OBJECTIVE

To determine the usefulness of EUS-FNA for diagnosing GB mass lesions.

DESIGN

Single-center, retrospective, case-series study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 15 consecutive patients who underwent EUS-FNA of GB mass lesions. We punctured GB masses in patients with suspected xanthogranulomatous cholecystitis to distinguish them from malignancy, and in patients with unresectable GB carcinoma for pathological confirmation. The final diagnosis was based on surgical histopathological results or follow-up outcome.

INTERVENTIONS

EUS-FNA.

MAIN OUTCOME MEASUREMENTS

Evaluation of EUS-FNA sampling adequacy rate and diagnostic yield.

RESULTS

Xanthogranulomatous cholecystitis was suspected in 6 of the 15 patients. EUS-FNA revealed foam cells (n = 3), inflammatory cells (n = 1, proven by cholecystectomy), and GB carcinoma (n = 1), and the amount of the aspirate was insufficient in one case (xanthogranulomatous cholecystitis was later proven by extended hepatectomy). The mean follow-up period of the patients with xanthogranulomatous cholecystitis was 1177 days. Adenocarcinoma was confirmed by EUS-FNA in 8 of the 9 patients with suspected unresectable GB carcinoma, and the FNA was inconclusive in one. All 10 patients with GB carcinoma underwent chemotherapy. The overall sampling adequacy was 86.6%. The accuracy of EUS-FNA for detecting malignancy and for the final diagnosis was 93.3% (95% CI, 62.4%-99.9%) and 80% (95% CI, 54%-93.7%), respectively.

LIMITATIONS

A small patient cohort and a retrospective design with potential selection bias.

CONCLUSIONS

Malignant GB mass lesions can be safely and accurately differentiated by EUS-FNA. Thus, patients with xanthogranulomatous cholecystitis can avoid undue extensive surgery.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial

BACKGROUND

Trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), was investigated in combination with chemotherapy for first-line treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer.

METHODS

ToGA (Trastuzumab for Gastric Cancer) was an open-label, international, phase 3, randomised controlled trial undertaken in 122 centres in 24 countries. Patients with gastric or gastro-oesophageal junction cancer were eligible for inclusion if their tumours showed overexpression of HER2 protein by immunohistochemistry or gene amplification by fluorescence in-situ hybridisation. Participants were randomly assigned in a 1:1 ratio to receive a chemotherapy regimen consisting of capecitabine plus cisplatin or fluorouracil plus cisplatin given every 3 weeks for six cycles or chemotherapy in combination with intravenous trastuzumab. Allocation was by block randomisation stratified by Eastern Cooperative Oncology Group performance status, chemotherapy regimen, extent of disease, primary cancer site, and measurability of disease, implemented with a central interactive voice recognition system. The primary endpoint was overall survival in all randomised patients who received study medication at least once. This trial is registered with ClinicalTrials.gov, number NCT01041404.

FINDINGS

594 patients were randomly assigned to study treatment (trastuzumab plus chemotherapy, n=298; chemotherapy alone, n=296), of whom 584 were included in the primary analysis (n=294; n=290). Median follow-up was 18.6 months (IQR 11-25) in the trastuzumab plus chemotherapy group and 17.1 months (9-25) in the chemotherapy alone group. Median overall survival was 13.8 months (95% CI 12-16) in those assigned to trastuzumab plus chemotherapy compared with 11.1 months (10-13) in those assigned to chemotherapy alone (hazard ratio 0.74; 95% CI 0.60-0.91; p=0.0046). The most common adverse events in both groups were nausea (trastuzumab plus chemotherapy, 197 [67%] vs chemotherapy alone, 184 [63%]), vomiting (147 [50%] vs 134 [46%]), and neutropenia (157 [53%] vs 165 [57%]). Rates of overall grade 3 or 4 adverse events (201 [68%] vs 198 [68%]) and cardiac adverse events (17 [6%] vs 18 [6%]) did not differ between groups.

INTERPRETATION

Trastuzumab in combination with chemotherapy can be considered as a new standard option for patients with HER2-positive advanced gastric or gastro-oesophageal junction cancer.

FUNDING

F Hoffmann-La Roche.

Folate intake along with genetic polymorphisms in methylenetetrahydrofolate reductase and thymidylate synthase in patients with advanced gastric cancer

BACKGROUND

A relationship between dietary folate intake and efficacy of fluorouracil (FU) is supported by preclinical data. Furthermore, there are several reports that evaluated genetic polymorphisms of MTHFR (methylenetetrahydrofolate reductase) or TYMS (thymidylate synthase) and efficacy of FU. However, to our knowledge, there are no reports that evaluate simultaneously the effects of folate intake and genetic polymorphisms on clinical outcome of gastric cancer patients.

METHODS

We retrospectively analyzed the survival impact of estimated folate intake by a food frequency questionnaire and MTHFR and TYMS polymorphisms in 132 patients with advanced gastric cancer who were treated with first-line FU-based chemotherapy.

RESULTS

Median overall survival was 11.3 months (95% confidence interval, 9.4-13.4 mo) and median progression-free survival was 5.2 months (95% confidence interval, 4.1-6.3 mo). Patients with folate intake of >260 microg/day (n=88) showed longer overall survival compared with low folate intake (n=44; overall survival, 12.2 versus 8.4 mo). In a multivariate Cox model, patients who had folate intake of >260 microg/day, MTHFR 677 TT polymorphism, and TYMS-3' untranslated region 6-bp insertion were associated with better survival. Similar tendency was observed in progression-free survival. No interaction was observed between folate intake and favorable genotypes.

CONCLUSION

Folate intake and genetic polymorphisms of MTHFR and TYMS were associated with better clinical outcome by FU-based chemotherapy in advanced gastric cancer.

IMPACT

Our results suggested folate intake and folate-related genetic polymorphisms may play an important role in efficacy of FU-based chemotherapy in advanced gastric cancer.

AVAGAST: A randomized, double-blind, placebo-controlled, phase III study of first-line capecitabine and cisplatin plus bevacizumab or placebo in patients with advanced gastric cancer (AGC)

LBA4007

Background: The median survival for patients (pts) with AGC in most phase III studies is less than 1 year. The addition of bevacizumab (bev) to chemotherapy (chemo) is supported by a strong preclinical rationale and by phase II evaluation. AVAGAST is the first randomized study to compare the efficacy and safety of bev + chemo vs placebo + chemo.

Methods: Pts with inoperable, locally advanced or metastatic stomach/gastroesophageal junction adenocarcinoma with no prior therapy were randomized 1:1 to capecitabine (cape, or 5-FU) + cisplatin (cis) and either bev (7.5 mg/kg iv) or placebo q3w. Stratification variables: geographical region, fluoropyrimidine treatment, disease status. Cis was given for 6 cycles; bev/placebo + cape/5-FU were given until disease progression or unmanageable toxicity. Primary objective: compare overall survival (OS); secondary objectives: compare progression-free survival (PFS), overall response rate (ORR), and safety (as overseen by an independent DSMB).

Results: From Sep 2007 to Dec 2008, 774 pts were enrolled. Treatment arms were balanced. Approx 95% of pts were metastatic. Two-thirds of pts were male, 49% of pts were from Asia/Pacific, 32% from Europe and 19% from the Americas. Median OS was 10.1 months with chemo + placebo and 12.1 months with chemo + bev in the intent-to-treat population (HR 0.87; p=0.1002). Median OS according to geographical region was 6.8 vs. 11.5 months (HR 0.63) in the Americas, 8.6 vs. 11.1 months (HR 0.85) in Europe and 12.1 vs. 13.9 months in Asia-Pacific (HR 0.97). Secondary endpoints and AEs of special interest for Bev are summarized below ( Table ).

Conclusions: While the primary endpoint was not met (median OS HR 0.87; p=0.1002), there was a significant improvement in PFS and ORR and an acceptable safety profile for bev + chemo in patients with AGC.

[Table: see text]

[Table: see text]

Neutropenia as a prognostic factor in advanced gastric cancer patients undergoing second-line chemotherapy with weekly paclitaxel

BACKGROUND

Neutropenia during chemotherapy has been reported to be a predictor of better survival in patients with several types of cancers, although there are no reports in pretreated patients.

METHODS

We retrospectively analyzed 242 patients with advanced gastric cancer (AGC) who received weekly paclitaxel (Taxol) as second-line chemotherapy. Background characteristics and neutropenia as time-varying covariates (TVCs) were analyzed as prognostic factors.

RESULTS

Of the 242 patients, mild neutropenia (grades 1-2) occurred in 101 patients (41.7%) and severe neutropenia (grades 3-4) occurred in 63 patients (26.0%). The other 78 patients (32.2%) did not experience neutropenia. According to a multivariate Cox model with neutropenia as a TVC, hazard ratios of death were 0.61 [95% confidence interval (CI) 0.43-0.85; P = 0.004] for patients with mild neutropenia and 0.61 (95% CI 0.41-0.88; P = 0.009) for those with severe neutropenia. Among the patients in landmark analysis (landmark of 2.5 months; median time to treatment failure of paclitaxel), mild and severe neutropenia remained significant prognostic factors.

CONCLUSIONS

Our results indicate that neutropenia during chemotherapy is associated with improved survival in patients with AGC who received weekly paclitaxel as second-line chemotherapy. Prospective trials are required to assess whether dosing adjustments based on neutropenia may improve chemotherapy efficacy.

Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors

BACKGROUND

Submucosal tumors (SMTs) comprise both benign and malignant lesions, and most of the gastric lesions tend to be malignant. The addition of EUS-guided FNA (EUS-FNA) has the potential to improve this distinction, but published series are limited.

OBJECTIVE

To evaluate the yield of EUS-FNA in gastric SMTs with referral to a criterion standard final diagnosis.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 141 consecutive patients with gastric SMTs, who underwent EUS-FNA from January 2000 to December 2008. Immunohistochemical staining with c-kit, CD34, actin, and S-100 antibodies was done if a spindle cell tumor was found. Based on FNA sample adequacy, and whether a specific diagnosis could be established, EUS-FNA results were categorized as diagnostic, suggestive, or nondiagnostic. The criterion standards for final diagnosis were the surgical histopathological results or the follow-up course for malignant, inoperable cases.

INTERVENTION

EUS-FNA.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of EUS-FNA and factors related to sampling adequacy for cytological and immunohistochemical evaluation.

RESULTS

A total of 141 patients (52% female, mean age 56.7 years) underwent EUS-FNA (range 1-5 passes). The overall results of EUS-FNA were diagnostic, suggestive, and nondiagnostic in 43.3%, 39%, and 17.7% of cases, respectively. Adequate specimens were obtained in 83% of cases, and 69 cases (48.9%) had a definitive final diagnosis. The most common gastric SMT was GI stromal tumor (59.5%). EUS-FNA results were 95.6% accurate (95% confidence interval [CI], 87.5%-99%) for the final diagnosis and 94.2% (95% CI, 85.6%-98.1%) accurate for differentiating potentially malignant lesions. A heterogeneous echo pattern was the only independent predictor for sampling adequacy (adjusted odds ratio 6.15; P = .002). There were no procedure-related complications.

LIMITATIONS

Possibility of selection bias.

CONCLUSION

EUS-FNA is an accurate method for diagnosis of gastric SMTs and for differentiating malignant lesions.

Phase II study of S-1 plus leucovorin in patients with metastatic colorectal cancer

BACKGROUND

S-1, a novel oral fluoropyrimidine, is well tolerated in patients with metastatic colorectal cancer (mCRC). The response rate of S-1 for colorectal cancer is high, ranging from 35% to 40%. This study aimed to evaluate the safety and efficacy of S-1 combined with oral leucovorin (LV) to enhance antitumor activity in chemotherapy-naive patients with mCRC.

PATIENTS AND METHODS

S-1 was given orally twice daily for two consecutive weeks at a daily dose of 80-120 mg, followed by a 2-week rest period, within a 4-week cycle. LV was given orally twice a day at a daily dose of 50 mg, simultaneously with S-1.

RESULTS

Of the 56 patients with previously untreated mCRC, 32 (57%) had partial responses. The median follow-up period was 27.2 months. The median time to progression was 6.7 months (95% confidence interval 5.4-7.9). The median survival time was 24.3 months. There was no treatment-related death or grade 4 toxicity. The most common grade 3 toxic effects were diarrhea (32%), anorexia (21%), stomatitis (20%), and neutropenia (14%).

CONCLUSION

S-1 combined with LV therapy demonstrated promising efficacy and acceptable safety in chemotherapy-naive patients with mCRC without the concurrent use of irinotecan, oxaliplatin, or molecular-targeted drugs.

Clinical impact of radiotherapy for locally advanced pancreatic cancer

BACKGROUND

Although a randomized controlled trial for locally advanced pancreatic cancer (PC) has demonstrated a survival advantage for treatment with gemcitabine alone, chemoradiotherapy remains the treatment of choice for locally advanced disease in Japan. The aim of this study was to compare the survival benefits associated with gemcitabine and concurrent chemoradiotherapy in locally advanced unresectable PC.

PATIENTS

Seventy-seven patients with locally advanced unresectable PC were retrospectively enrolled from April 2001 to December 2006. All cases were histologically proven, and patients received gemcitabine chemotherapy (n = 30) or concurrent chemoradiotherapy (based on 5-fluorouracil, n = 28, or gemcitabine, n = 19, as a radiosensitizer) at Aichi Cancer Center Hospital.

RESULTS

Patients who received chemoradiotherapy had significantly better performance status than those who had chemotherapy. Tumor response was 0% for chemotherapy and 13% chemoradiotherapy, but survival benefit was similar among patients in the chemotherapy group (overall response (OS) 12 months; progression-free survival (PFS), 3 months) and those in the chemoradiotherapy group (OS, 13 months; PFS, 5 months). Two-year survival was 21% for chemotherapy patients and 19% for chemoradiotherapy patients. Severe toxicities (Grade 3-4 National Cancer Institute-Common Toxicity Criteria, version 3.0) were significantly more frequent for chemoradiotherapy than for chemotherapy.

CONCLUSIONS

Gemcitabine chemotherapy showed similar survival benefit compared to 5-fluorouracil- and gemcitabine-based chemoradiotherapy.

Effects of genetic polymorphisms in the ABCB1 gene on clinical outcomes in patients with gastric cancer treated by second-line chemotherapy

OBJECTIVE

Tumor cells that overexpress P-glycoprotein (Pgp) may be resistant to several anticancer agents due to altered pharmacokinetics and reduced intracellular concentrations of the anticancer agents. Pgp is encoded by the ATP binding cassette gene B1 (ABCB1). To our knowledge, only one previous report has evaluated the effect of ABCB1 gene polymorphisms on clinical outcomes of gastric cancer. The purpose of this analysis was to evaluate the impact of genetic polymorphisms of the ABCB1 gene on clinical outcomes in patients with advanced gastric cancer (AGC) treated with second-line chemotherapy.

METHODS

We retrospectively analyzed the impact of ABCB1 gene polymorphisms (ABCB1 3435C>T) on clinical outcomes in 100 patients with AGC who received second-line chemotherapy.

RESULTS

Median overall survival (OS) since the initiation of second-line chemotherapy was 6.0 months (95% confidence interval [CI], 4.8 to 8.0 months), and median progression-free survival (PFS) was 2.7 months (95% CI, 2.1 to 3.4 months). In a multivariate analysis of PFS, a 3435 CC polymorphism (n=45) was significantly associated with longer PFS compared with the CT/TT type polymorphism (n=55), with borderline significance (PFS of 3.2 months vs. 2.2 months, respectively; HR 1.50; 95% CI, 0.98-2.30; P = 0.061). ABCB1 3435 C>T polymorphisms were not associated with OS. No interaction was seen between ABCB1 polymorphisms and treatment regimens.

CONCLUSION

Genetic polymorphisms of ABCB1 3435C>T might have a possible impact on clinical outcomes of second-line chemotherapy in AGC. Further prospective evaluation using a larger sample size is required.

Chemotherapy for patients with advanced gastric cancer with performance status 2

METHODS

We retrospectively analyzed 657 patients with advanced gastric cancer who received first-line chemotherapy. Baseline patient characteristics and treatment results were compared between Eastern Cooperative Oncology Group performance status (PS) 0-1 and PS 2 patients.

RESULTS

Prior to beginning first-line chemotherapy, 513, 112, and 32 patients were PS 0-1, PS 2, and PS 3-4, respectively. Patients with massive ascites (42% vs. 3%; P < .001) or inability to eat (39% vs. 4%; P < .001) were more likely to be PS 2 than PS 0-1. Significantly fewer PS 2 patients received first-line chemotherapy regimens containing oral agents (40% vs. 77%; P < .001) or combination chemotherapy (19% vs. 40%; P < .001) compared to PS 0-1 patients. Median survival time was significantly shorter in PS 2 patients (5.8 vs. 13.9 months; P < .001). Multivariate survival analysis revealed that use of oral agents was associated with a better prognosis in PS 0-1 patients (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.59-0.97, P = .03), while it was associated with poorer survival in PS 2 patients (HR 1.52, 95% CI 1.0-2.3, P = .046).

CONCLUSION

Advanced gastric cancer patients with PS 2 not only had a poorer prognosis but also differed in several baseline characteristics compared to PS 0-1 patients. These results indicate that additional clinical trials that specifically target gastric cancer patients with PS 2 may be required to evaluate optimal treatment regimens for this patient population.

Fluorouracil versus combination of irinotecan plus cisplatin versus S-1 in metastatic gastric cancer: a randomised phase 3 study

BACKGROUND

The best chemotherapy regimen for metastatic gastric cancer is uncertain, but promising findings have been reported with irinotecan plus cisplatin and S-1 (tegafur, 5-chloro-2,4-dihydropyrimidine, and potassium oxonate). We aimed to investigate the superiority of irinotecan plus cisplatin and non-inferiority of S-1 compared with fluorouracil, with respect to overall survival, in patients with metastatic gastric cancer.

METHODS

We undertook a phase 3 open label randomised trial in 34 institutions in Japan. We enrolled patients aged 20-75 years or younger, who had histologically proven gastric adenocarcinoma, and randomly assigned them by minimisation to receive either: a continuous infusion of fluorouracil (800 mg/m(2) per day, on days 1-5) every 4 weeks (n=234); intravenous irinotecan (70 mg/m(2), on days 1 and 15) and cisplatin (80 mg/m(2), on day 1) every 4 weeks (n=236); or oral S-1 (40 mg/m(2), twice a day, on days 1-28) every 6 weeks (n=234). The primary endpoint was overall survival. Analyses were done by intention to treat. This study is registered with Clinicaltrials.gov, number NCT00142350, and with UMIN-CTR, number C000000062.

FINDINGS

All randomised patients were included in the primary analysis. Median overall survival was 10.8 months (IQR 5.7-17.8) for individuals assigned fluorouracil, 12.3 months (8.1-19.5) for those allocated irinotecan plus cisplatin (hazard ratio 0.85 [95% CI 0.70-1.04]; p=0.0552), and 11.4 months (6.4-21.3) for those assigned S-1 (0.83 [0.68-1.01]; p=0.0005 for non-inferiority). Three treatment-related deaths occurred in the irinotecan plus cisplatin group and one was recorded in the S-1 group.

INTERPRETATION

S-1 is non-inferior to fluorouracil and, in view of the convenience of an oral administration, could replace intravenous fluorouracil for treatment of unresectable or recurrent gastric cancer, at least in Asia. Irinotecan plus cisplatin is not superior to fluorouracil in this setting.

Association of prostate stem cell antigen gene polymorphisms with the risk of stomach cancer in Japanese

A recent whole-genome association study identified a strong association between polymorphisms in the prostate stem cell antigen (PSCA) gene and stomach cancer risk. In this case-control study, we aimed to validate this association, and further to explore environmental factors possibly interacting with PSCA polymorphisms in 708 incident stomach cancer cases and 708 age-sex matched controls. The association between PSCA polymorphisms and Helicobacter pylori infection was also examined. We found that rs2294008 and rs2976392, which were strongly linked to each other (D' = 1.00), were significantly associated with stomach cancer risk. Per allele odds ratio for rs2994008 was 1.40 (95% confidence interval: 1.19-1.65; p = 3.7 x 10(-5)). We found significant interaction with a family history of stomach cancer in first-degree relatives (p-heterogeneity = 0.009). Similar to originally reported association, we found significant heterogeneity between diffuse and intestinal type (p-heterogeneity = 0.007). No association was seen between PSCA polymorphisms and H. pylori infection. In conclusion, PSCA polymorphisms are associated with stomach cancer risk in Japanese. A possible interaction with family history warrants further evaluation.

Is (18)F-fluorodeoxyglucose positron emission tomography meaningful for estimating the efficacy of corticosteroid therapy in patients with autoimmune pancreatitis?

BACKGROUND

Autoimmune pancreatitis (AIP) is often misdiagnosed as pancreatic cancer (PC). Both conditions accumulate (18)F-fluorodeoxyglucose (FDG), so FDG positron emission tomography (FDG-PET) is not discriminatory. This study aimed to evaluate the pattern of FDG accumulation, and the change in FDG uptake after steroid treatment in AIP and PC.

METHODS

We compared FDG-PET patterns between 18 patients with AIP and 20 patients with PC, and also evaluated the short-term changes in FDG uptake after steroid therapy.

RESULTS

FDG uptake was observed in 88.9% in AIP and 90.0% in PC. FDG uptake in extra-abdominal lymph nodes was seen more frequently in AIP, and uptake in salivary glands, eyes and biliary ducts was seen only in AIP. Follow-up PET was performed in 6 AIP patients and in 3 PC patients. Changes in SUV(max) after steroid therapy were estimated within 1 week in 5 AIP patients and in all 3 PC patients, retrospectively. In 4 AIP patients, the change in SUV(max) was more than 10%. On the other hand, in PC, SUV(max) increased or remained almost unchanged (within 10%).

CONCLUSIONS

FDG-PET pattern at baseline, and a decrease in FDG uptake after a short steroid trial can be useful for discriminating AIP from PC.

Histological diagnosis of autoimmune pancreatitis using EUS-guided trucut biopsy: a comparison study with EUS-FNA

PURPOSE

The aim of this study was to evaluate the feasibility and safety of endoscopic ultrasonography (EUS)-guided trucut biopsy (TCB) for diagnosis of autoimmune pancreatitis (AIP).

METHODS

Fourteen patients with suspected AIP based on imaging studies underwent both EUS-guided fine-needle aspiration (FNA) and EUS-TCB for diagnosis of AIP and exclusion of pancreatic cancer (PC). According to the revised Japanese clinical diagnostic criteria, AIP was diagnosed in eight while the remaining six patients had pancreatitis of other etiologies. Pathologically, AIP was defined as lymphoplasmacytic sclerosing pancreatitis (LPSP), and sub-divided into two types: definite LPSP (d-LPSP) showing fulspectrum of LPSP and probable LPSP (p-LPSP) without obliterative phlebitis or abundant (>10 cells/hpf) IgG4-positive plasmacytes infiltration.

RESULTS

PC was excluded in all patients. EUS-FNA resulted in three of eight patients with AIP were reported as p-LPSP, one was reported as normal, and 4 were inconclusive. One of six with non-autoimmune pancreatitis was diagnosed as p-LPSP on EUS-FNA, one as idiopathic chronic pancreatitis (ICP) and four were inconclusive. By using EUS-TCB, all AIP patients were diagnosed as LPSP (4 d-LPSP and 4 p-LPSP). Of the six patients with non-autoimmune pancreatitis, three were diagnosed as LPSP (1 d-LPSP and 2 p-LPSP) and three showed ICP on TCB. No complications were identified in any patient with either EUS-FNA or TCB.

CONCLUSION

EUS-TCB is a safe and accurate procedure for obtaining a histological diagnosis in patients with suspected AIP. EUS-TCB can serve as a rescue technique in cases of AIP lacking typical findings.

Phase II study of motesanib in Japanese patients with advanced gastrointestinal stromal tumors with prior exposure to imatinib mesylate

Purpose

Motesanib (AMG 706) is a multitargeted anticancer agent with an inhibitory action on the human vascular endothelial growth factor receptor, the platelet-derived growth factor receptor, and the cellular stem-cell factor receptor (KIT). The aim of this single-arm phase II clinical study was to assess the efficacy and safety of single-agent motesanib in Japanese patients with advanced gastrointestinal stromal tumors with prior exposure to imatinib mesylate.

Methods

All patients had experienced progression or relapse while undergoing with imatinib as 400 mg/day or higher. The patients were administered 125 mg of motesanib once daily. The primary endpoint was overall response. Efficacy was evaluated according to the Response Evaluation Criteria in Solid Tumor, and safety was assessed according to the Common Terminology Criteria for Adverse Events (version 3).

Results

Of 35 enrolled and treated patients, no patient showed a complete response, and one patient showed a partial response (PR). Seven had stable disease (SD) for at least 24 months, two of whom continued to have SD for more than 2 years. The median progression-free survival time was 16.1 weeks. Motesanib was well tolerated; commonly reported treatment-related adverse events were hypertension, diarrhea, and fatigue. Anemia was the only hematological toxicity that was reported.

Conclusions

One patient showed PR, and seven patients showed SD more than 24 weeks. Motesanib was found to be safe and well tolerated. The observed toxicities were consistent with Phase I study findings.

Usefulness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for undiagnosed intra-abdominal lymphadenopathy

BACKGROUND

The differentiation between benign and malignant abdominal lymph nodes is difficult, especially if no primary site is evident or if cancer resection was remote in time. The aim of this study was to evaluate the yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in patients with undiagnosed intra-abdominal lymphadenopathy.

METHODS

Fifty-seven consecutive patients with undiagnosed abdominal lymphadenopathy who were registered in our EUS-FNA database from January 1997 to December 2007 were reviewed. EUS-FNA was carried out using a 22-G needle. The final pathological diagnosis was based on the cytopathological, histological, and immunohistochemical (IHC) findings.

RESULTS

Adequate specimens were obtained in 93% cases. The final diagnoses included local recurrence of malignancy after resection (n = 16), lymphoma (n = 12), and benign/reactive changes (n = 17). The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of EUS-FNA were 94, 100, 100, 90 and 96%, respectively. In addition, it was also possible to classify lymphoma subtypes in 83% of cases. No complications occurred during the procedures.

CONCLUSIONS

EUS-FNA is clinically very useful for establishing the diagnosis of abdominal lymphadenopathy of unknown cause and can provide sufficient tissue for IHC and subtyping of lymphomas.

Efficacy results from the ToGA trial: A phase III study of trastuzumab added to standard chemotherapy (CT) in first-line human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (GC)

LBA4509

Background: Advanced GC is an incurable disease; new and less toxic treatments are needed. HER2 overexpression has been reported in 6–35% of stomach and gastroesophageal tumors. Trastuzumab (H; Herceptin), a monoclonal antibody against HER2, has shown survival benefits when given with CT in patients (pts) with HER2-positive early and metastatic breast cancer. The ToGA study is the first randomized, prospective, multicenter, phase III trial to study the efficacy and safety of H in HER2- positive GC. Methods: Pts with HER2-positive gastroesophageal and gastric adenocarcinoma (locally advanced, recurrent, or metastatic) were randomized to receive H+CT (5-fluorouracil or capecitabine and cisplatin) q3w for 6 cycles or CT alone. H was given until disease progression. The primary end point was overall survival (OS); secondary end points included overall response rate (ORR), progression-free survival, time to progression, duration of response, and safety. An interim analysis was planned at 75% of deaths and the Independent Data Monitoring Committee recommended releasing the data as the pre-specified boundary was exceeded and median follow-up of pts was 17.1 months. Results: Tumors from 3,807 pts were centrally tested for HER2 status: 22.1% were HER2 positive (abstract #4556). 594 pts were randomized 1:1 at sites in Europe, Latin America, and Asia. Baseline characteristics were well balanced across arms. Median OS was significantly improved with H+CT compared to CT alone: 13.5 vs. 11.1 months, respectively (p=0.0048; HR 0.74; 95% CI 0.60, 0.91). ORR was 47.3% in the H+CT arm and 34.5% in the CT arm (p=0.0017). Safety profiles were similar with no unexpected adverse events in the H+CT arm. There was no difference in symptomatic congestive heart failure between arms. Asymptomatic left ventricular ejection fraction decreases were reported in 4.6% of pts in the H+CT arm and 1.1% in the CT arm. Conclusions: This first randomized trial investigating anti-HER2 therapy in advanced GC showed that H+CT is superior to CT alone. The OS benefit indicates that H is a new, effective, and well-tolerated treatment for HER2-positive GC.

[Table: see text]

Gemcitabine sensitivity-related mRNA expression in endoscopic ultrasound-guided fine-needle aspiration biopsy of unresectable pancreatic cancer

Background

The aim of this study was to determine a predictive indicator of gemcitabine (GEM) efficacy in unresectable pancreatic cancer using tissue obtained by endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA).

Methods

mRNAs extracted from 35 pancreatic tubular adenocarcinoma tissues obtained by EUS-FNA before GEM-treatment were studied. mRNAs were amplified and applied to a Focused DNA Array, which was restricted to well-known genes, including GEM sensitivity-related genes, deoxycytidine kinase (dCK), human equilibrative nucleoside transporter 1 (hENT1), hENT2, dCMP deaminase, cytidine deaminase, 5'-nucleotidase, ribonucleotide reductase 1 (RRM1) and RRM2. mRNA levels were classified into high and low expression based on a cut-off value defined as the average expression of 35 samples. These 35 patients were divided into the following two groups. Patients with partial response and those with stable disease whose tumor markers decreased by 50% or more were classified as the effective group. The rest of patients were classified as the non-effective group. The relationship between GEM efficacy and mRNA expression was then examined by chi-squared test.

Results

Among these GEM sensitivity-related genes, dCK alone showed a significant correlation with GEM efficacy. Eight of 12 patients in the effective group had high dCK expression, whereas 16 of 23 patients in non-effective group had low dCK expressions (P = 0.0398).

Conclusion

dCK mRNA expression is a candidate indicator for GEM efficacy in unresectable pancreatic cancer. Quantitative mRNA measurements of dCK using EUS-FNA samples are necessary for definitive conclusions.

Gastric submucosal tumors: Lessons learned from 10-year follow-up

e15631

Background: Gastric Submucosal tumors (SMTs) were incidentally discovered esophagogastroduodenoscopy (EGD). However, they have not been studied in detail of epidemiology. Furthermore, no treatment strategy for SMTs has been established with few studies looking into long-term outcomes. The aim of this study is to clarify the clinical features and long-term outcomes of gastric SMT at a single institute for 10-year period. Methods: We performed a total of 5307 EGDs and detected 188 gastric SMTs during 1998. All clinical data including incidence, size and location in stomach were analyzed for the medical records. A retrospective review was conducted for 10-year period for 109 patients and 79 patients were excluded because of simultaneous surgery (3), disappear in follow- up EGD (27), lost of follow-up (49). Results: Gastric SMTs were detected 188 (81 males, 107 females) of 5307 patients (3.5%). Majority size of SMTs was less than 1cm (64%) and SMTs<2cm were 91%. 56% of SMTs located middle one third of stomach, and half (22%) of the remaining SMTs were detected at upper and lower one third, respectively. In 10-year follow-up, 83 of 109 patients were alive at December 2008. One patient was dead of SMT and the remaining 25 patients were dead of other disease till December 2008. Enlargement of SMT was observed in 2 of 109 SMTs (1.8%). Both of them underwent surgical resection and diagnosed as gastrointestinal stromal tumors (GIST). One patient was annually monitored by endoscopy, from 0.6cm to 1.5cm during 4 years, without recurrence for 6 years after surgical intervention. Another didn't undergo regular endoscopy, from 1.8cm to 8cm during 2 years, with recurrence, and consequently died of SMT. Conclusions: The incidence of SMTs is 3.5%, majority (91%) is small (<2cm), and frequent location is middle one third of stomach. Most of SMTs might be managed conservatively, but regular endoscopy is required.

No significant financial relationships to disclose.

Efficacy results from the ToGA trial: A phase III study of trastuzumab added to standard chemotherapy (CT) in first-line human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (GC)

LBA4509

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]

Updated results of randomized phase III study of 5-fluorouracil (5-FU) alone versus combination of irinotecan and cisplatin (CP) versus S-1 alone in advanced gastric cancer (JCOG 9912)

4514

Background: We reported the primary results of JCOG9912 in ASCO 2007. In the planning, this study with 230 patients (pts) per arm had 80% power to demonstrate 10% superiority of CP and non-inferiority with 5% margin (HR=1.16) of S-1 at 6 months in overall survival (OS) and 0.05 study-wise 1-sided alpha. Primary analysis was conducted in Feb 2007, one year after the last patient accrual with 601 deaths (85%) of all randomized 704 pts. S-1 showed statistically significant non-inferiority to 5-FU (p<0.001), but after adjusting for multiplicity either S-1 or CP failed to show statistically significant superiority to 5-FU (CP, hazard ratio (HR)=0.85 (95% CI, 0.70–1.04), p=0.055 and S-1, HR=0.83 (0.68–1.01), p=0.034). Methods: The survival information of all surviving 103 pts at the primary analysis was updated in Apr 2008 when 660 pts (94%) were dead. An updated analysis and multivariate analyses with Cox proportional hazard model were conducted. The multivariate analysis model included arms, sex, age, tumor status (unresectable/recurrent), PS, the number of metastatic sites, target lesion (TL), macroscopic type, histological type and peritoneal dissemination. Results: The updated results are shown in Table . OS curves and HRs remained almost identical to the previous report. Multivariate analyses showed that number of metastatic sites (≥2), PS (≥1), presence of TL were associated with worse survival, and that the adjusted HRs of CP and S-1 were 0.79 (0.65–0.95, p=0.014) and 0.80 (0.66–0.96, p=0.017), respectively. There was no significant interaction among baseline factors and treatment arms. Conclusions: The updated results reconfirmed the primary conclusion that S-1 monotherapy can be a new standard regimen for advanced gastric cancer, and suggest that CP is still worthy for further clinical investigation.

[Table: see text]

[Table: see text]