The relationship between clinicopathological factors and the reduction of pyrimidine nucleoside phosphorylase activity after preoperative administration of 5'-deoxy-5-fluorouridine

AIM

The response to fluoropyrimidine chemotherapeutic drugs is different in individual tumors. Predictive biomarkers of antitumor effects by these drugs are unknown. 5'-Deoxy-5-fluorouridine (5'-DFUR), a fluoro-pyrimidine chemotherapeutic drug, is converted to 5-fluorouracil (5-FU) by pyrimidine nucleoside phosphorylase (PyNPase). It is suggested that 5'-DFUR will efficiently exert antitumor effects via PyNPase in tumor tissues. The change of PyNPase activity in tumor tissues following 5'-DFUR administration may reflect antitumor effects, and may be useful for detecting predictive factors of antitumor effects. The aim of this study was to search for predictive factors of antitumor effects by analyzing the relationship between clinicopathological factors and the change of PyNPase activity in colorectal tumor tissues after preoperative 5'-DFUR administration.

PATIENTS AND METHODS

PyNPase activity in colorectal tissues from 45 patients with colorectal tumors was measured using an ELISA method.

RESULTS

The reduction rate of PyNPase activity in colorectal tumor tissues after preoperative 5'-DFUR administration was correlated with significant differences in lymphatic invasion, stage, and histologic classification. It is suggested that lymphatic invasion, stage (distant metastasis), and histologic classification may be predictive factors for evaluating antitumor effects and selecting 5-FU-based chemotherapeutic drugs for patients with colorectal tumors.

Hepatic arterial infusion with oxaliplatin, irinotecan and doxifluridine for unresectable liver metastases of colorectal cancer

AIM

To evaluate the therapeutic efficacy and safety of combination chemotherapy with oxaliplatin, irinotecan and doxifluridine through hepatic arterial infusion (HAI) in patients with unresectable liver metastases of colorectal cancer.

PATIENTS AND METHODS

Individual patients were treated through the tumour-blood supplying arteries with oxaliplatin, irinotecan and doxifluridine and chemoembolised with irinotecan and lipiodol for the detected hypervascular lesions.

RESULTS

A total of 173 cumulative cycles of chemotherapy were performed for the 32 patients, with a median of 5.0 cycles, including 96 chemoembolisations. Fifteen patients reached partial remission, 14 patients had stable disease and only 3 patients had progressive disease. The overall response rate was 46.9%. Of the 32 patients, 18 patients received first-line treatment with an overall response rate of 61.1%. The remaining 14 patients received second-line treatment, with an overall response rate of 28.6%.

CONCLUSION

Combination chemotherapy through HAI is well tolerated and highly effective in patients with unresectable liver metastases of colorectal cancer.

Phase I study of irinotecan and doxifluridine for metastatic colorectal cancer focusing on the UGT1A1*28 polymorphism

Although individuals carrying the UGT1A1 allele *28 have an increased risk of severe toxicities associated with irinotecan, no phase I study has been conducted based on the polymorphism. This report presents the recommended doses of irinotecan for patients with the respective genotypes. Twenty-seven patients with advanced colorectal cancer were enrolled in this study, and the UGT1A1*28 polymorphism was genotyped before chemotherapy. One course of chemotherapy consisted of irinotecan infused once every 2 weeks at 70, 100, 120, and 150 mg/m(2) at dose levels 1, 2, 3, and 4, respectively, and doxifluridine was administered orally. This treatment continued for at least 12 weeks. The dose-limiting toxicity was determined as grade 3 hematological and non-hematological toxicities for the TA(6)/TA(6) (6/6) and TA(6)/TA(7) (6/7) genotypes. The pharmacokinetics of irinotecan, SN-38, and SN-38 glucuronide, was assessed at dose level 2. Eighteen and nine patients had the 6/6 and 6/7 genotypes, respectively. The maximum tolerated dose (MTD) was not observed up to dose level 4 in patients with the 6/6 genotype. In contrast, MTD was observed at dose level 2 (100 mg/m(2)) in patients with the 6/7 genotype. Patients with the 6/7 genotype had a significantly higher area under the plasma time-concentration curve (0-infinity) SN-38 (P = 0.022) and biliary index (P = 0.030) than those with 6/6. The recommended starting doses of biweekly irinotecan for phase II/III were 150 mg/m(2) for patients with the UGT1A1 6/6 genotype and 70 mg/m(2) for those with the 6/7 genotype, respectively. The gene polymorphism should be considered when determining the precise recommended doses to be administered in phase I studies.

Cellular pharmacology of multi- and duplex drugs consisting of ethynylcytidine and 5-fluoro-2'-deoxyuridine

Prodrugs can have the advantage over parent drugs in increased activation and cellular uptake. The multidrug ETC-L-FdUrd and the duplex drug ETC-FdUrd are composed of two different monophosphate-nucleosides, 5-fluoro-2′deoxyuridine (FdUrd) and ethynylcytidine (ETC), coupled via a glycerolipid or phosphodiester, respectively. The aim of the study was to determine cytotoxicity levels and mode of drug cleavage. Moreover, we determined whether a liposomal formulation of ETC-L-FdUrd would improve cytotoxic activity and/or cleavage. Drug effects/cleavage were studied with standard radioactivity assays, HPLC and LC-MS/MS in FM3A/0 mammary cancer cells and their FdUrd resistant variants FM3A/TK⁻. ETC-FdUrd was active (IC₅₀ of 2.2 and 79 nM) in FM3A/0 and TK⁻ cells, respectively. ETC-L-FdUrd was less active (IC₅₀: 7 nM in FM3A/0 vs 4500 nM in FM3A/TK⁻). Although the liposomal formulation was less active than ETC-L-FdUrd in FM3A/0 cells (IC₅₀:19.3 nM), resistance due to thymidine kinase (TK) deficiency was greatly reduced. The prodrugs inhibited thymidylate synthase (TS) in FM3A/0 cells (80–90%), but to a lower extent in FM3A/TK⁻ (10–50%). FdUMP was hardly detected in FM3A/TK⁻ cells. Inhibition of the transporters and nucleotidases/phosphatases resulted in a reduction of cytotoxicity of ETC-FdUrd, indicating that this drug was cleaved outside the cells to the monophosphates, which was verified by the presence of FdUrd and ETC in the medium. ETC-L-FdUrd and the liposomal formulation were neither affected by transporter nor nucleotidase/phosphatase inhibition, indicating circumvention of active transporters. In vivo, ETC-FdUrd and ETC-L-FdURd were orally active. ETC nucleotides accumulated in both tumor and liver tissues. These formulations seem to be effective when a lipophilic linker is used combined with a liposomal formulation.

[A long term survivor of advanced gastric cancer treated with multi-drug combination chemotherapy]

We report a case of 70-year-old man who was admitted to our hospital due to hematemesis in June 2004. He was diagnosed by gastroscopy as having a type III moderately-poorly differentiated adenocarcinoma. A computed tomography (CT) scan revealed multiple lymph nodes swelling (#13, #16), finally he was diagnosed with gastric cancer stage IV (cT3, cN3, cM1). He was treated with S-1, but lymph nodes swelling increased in size, and then in March 2005, the treatment was changed to a second-line chemotherapy consisting of CPT-11 and CDDP. Abdominal CT scan showed a remarkable reduction of #16b1 lymph node, and the second-line chemotherapy was continued until 23 courses. But in April 2007, gastroscopy revealed the enlargement of gastric lesion. He was treated by third-line chemotherapy consisting of paclitaxel and doxifluoridine. This therapy was effective and continued until 7 courses. However, the treatment gradually became resistant and he died in May 2008, which was 4 years since the initial diagnosis.

Hepatic arterial infusion for unresectable colorectal liver metastases combined or not with systemic chemotherapy

BACKGROUND

The hypothesis was tested that systemic chemotherapy might contribute to improving overall survival (OS) of patients with unresectable colorectal liver metastases treated with hepatic arterial infusion (HAI).

PATIENTS AND METHODS

We considered 153 consecutive patients retrospectively divided into group A (n=72) treated with HAI alone (floxuridine [FUDR] + leucovorin [LV]), and group B (n=81) treated with HAI combined with systemic chemotherapy (5-fluorouracil [5FU] + LV).

RESULTS

No significant difference in OS was observed between the two groups. Median OS was better in patients with <50% of liver involvement (21.3 vs. 13.2 months; p<0.0001) and in responders vs. non-responders (24.4 vs. 13.4 months; p<0.0001). The combination of low tumor load with good tumor response to HAI was the only variable retained on multivariate survival analysis, associated with a better clinical outcome (median OS: 34.2 months).

CONCLUSION

Our study does not support the use of FUDR-based HAI combined or not with 5FU-based systemic chemotherapy as the first-line therapeutic approach to unresectable colorectal cancer liver metastases. The identification of responsive patients would improve the therapeutic index of this HAI regimen.

Metastasis of gestational trophoblastic neoplasia to the spinal canal: a case report

BACKGROUND

Spinal canal metastasis secondary to gestational trophoblastic neoplasia (GTN) is a rare condition.

CASE

A 21-year-old female presented with symptoms of cauda equina compression by an extradural metastasis from GTN. The patient received multiagent chemotherapy combined with intrathecal methotrexate administration. Her neurologic symptoms improved remarkably after the cessation of chemotherapy. During the 21-month follow-up period, she was asymptomatic and has shown overall improvement in well-being.

CONCLUSION

Spinal canal metastasis of GTN is a possibility that must be considered in young women with a history of hydatidiform mole who have neurologic symptoms or signs, which were improved completely by chemotherapy alone in this case.

Fluoropyrimidine-HAI (hepatic arterial infusion) versus systemic chemotherapy (SCT) for unresectable liver metastases from colorectal cancer

BACKGROUND

Although locoregional treatments such as hepatic arterial infusion (HAI) claim the advantage of delivering higher doses of anticancer agents directly into the metastatic organ as compared to systemic chemotherapy (SCT), the benefit in terms of overall survival (OS) is unclear. We quantitatively summarized the results of randomised controlled trials (RCT) comparing HAI to SCT for the treatment of unresectable liver metastatic disease from colorectal cancer (CRC).

OBJECTIVES

The aim of this work is to quantitatively summarize the results of RCT comparing HAI to SCT for the treatment of unresectable hepatic metastases from CRC.

SEARCH STRATEGY

A systematic review of reports published until September 2008 on the findings of RCT that compared HAI to SCT for the treatment of unresectable CRC liver metastases was performed by searching the MEDLINE, Embase, Cancerlit, Cochrane and GoogleScholar electronic databases as well as other databanks collecting information on clinical trials.

SELECTION CRITERIA

Inclusion criteria were patients with unresectable CRC liver metastases enrolled in RCT comparing HAI to SCT. The outcome measures were tumor response rate and overall survival.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out study selection and assessment of methodological quality. A third author performed a concordance analysis in order to unravel potential systematic biases.

MAIN RESULTS

Ten RCT were identified that met the eligibility criteria. HAI regimens were based on floxuridine (FUDR), 5-fluorouracil or either one of these two fluoropyrimidines in eight and one RCT, respectively. SCT consisted of FUDR or 5-fluorouracil in three and seven RCT, respectively. By pooling the summary data, tumor response rate resulted 42.9% and 18.4% for HAI and SCT, respectively (RR = 2.26; 95% CI, 1.80 to 2.84; P < 0.0001). Mean weighted median OS times were 15.9 and 12.4 months for HAI and SCT, respectively: the meta-risk of death was not statistically different between the two treatment groups (HR = 0.90; 95% CI, 0.76 to 1.07; P = 0.24).

AUTHORS' CONCLUSIONS

Currently available evidence does not support the clinical or investigational use of fluoropyrimidine-based HAI alone for the treatment of patients with unresectable CRC liver metastases: in fact, the greater tumor response rate obtained with this HAI regimen does not translate into a survival advantage over fluoropyrimidine alone SCT.

[Preparation and liver targeting of floxuridinyl dibutyrate solid lipid nanoparticles]

This paper described the preparation and liver targeting traits of new solid lipid nanoparticles (SLN) containing floxuridinyl dibutyrate (FUDRB) modified with beta-D-galactosides (G2). FUDRB-SLN and FUDRB-G2SLN were prepared by thin layer ultrasonic technique. Transmission electron microscopy micrograph analysis demonstrated that the particle sizes of FUDRB-SLN and FUDRB-G2SLN were (137.5 +/- 11.1) nm and (95.0 +/- 10.7) nm. Drug loading were 9.64% and 8.56%, and entrapment efficiency were 99.81% and 96.23%, respectively. The concentrations of floxuridine (FUDR) in serum and some organs (liver, kidney and lung) were determined by RP-HPLC after iv administration of SLN. FUDR release was confirmed, and a significant enrichment of SLN modified with G2 was observed in liver with G2 complex (targeting rates of SLN-G2 was 8.28 for liver) in comparison with FUDR-sol (targeting rate was 2.56). FUDR could be detected in liver in mice at 480 min after iv administration of FUDRB-G2SLN. These results suggested that incorporation of G2 (4%-5%, g/g) into SLN enhanced the liver targeting-ability of FUDRB. SLN containing G2 could be a useful drug carrier system for liver targeting.

Changes of gene expression of thymidine phosphorylase, thymidylate synthase, dihydropyrimidine dehydrogenase after the administration of 5'-deoxy-5-fluorouridine, paclitaxel and its combination in human gastric cancer xenografts

BACKGROUND

Although a variety of combination chemotherapies has been tested in gastric carcinoma, the most effective chemotherapeutic regimen and the precise mechanisms underlying anticancer agent combination have not yet been sufficiently elucidated.

MATERIALS AND METHODS

Experimental chemotherapy was performed using human gastric carcinoma xenografts, MKN-45 and TMK-1, to examine the anticancer effects and gene expressions of the enzymes involved in 5-fluorouracil metabolism, thymidine phosphorylase (dThdPase), thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD). Nude mice were treated with 5'-deoxy-5-fluorouridine (5'-dFUrd), or paclitaxel alone or in combination. The in vivo antitumor effects on gene expressions of the enzymes were examined using the quantitative real-time RT-PCR method.

RESULTS

The combined use of 5'-dFUrd and paclitaxel showed additive to synergistic antitumor effects on both gastric cancer xenografts. There were significant differences of the gene expressions of dThdPase, TS, and DPD between the xenografts. The expression of dThdPase mRNA was consistently up-regulated by the administration of paclitaxel, while no constant direction of TS mRNA and DPD mRNA change was found in the xenografts.

CONCLUSION

A synergistic antitumor effect of the combined administration of 5'-dFUrd and paclitaxel was found in gastric cancer xenografts and up-regulation of dThdPase mRNA may be an important underlying mechanism especially in tumors with high gene expression of this enzyme.

[Current therapeutic options for liver metastasis]

The liver is a common site of hematogenous metastasis, especially from gastrointestinal malignancies. Liver metastasis are generally classified as stage IV disease. Previously treatment in such patients was met with great skeptiscism. However, advances in surgical and medical therapies during the last two decades have provided effective therapeutic options for selected patients. Since major hepatic resections are now performed with acceptable morbidity and a mortality rate <3%, colorectal cancer metastasis to the liver are associated with 5-year survival rates of 30% or more. Meanwhile, a variety of new therapies have been developed, including hepatic artery infusion of chemotherapy; alcoholic, crio and radiofrequency ablation and novel strategies of systemic chemotherapy with the development of molecular targeted new products. These new therapeutic armamentarium have been used mostly in liver metastasis from colorectal cancer patients. However, liver metastasis of neuroendocrine tumors and selected cases of non colorectal cancer liver metastasis are benefited from the same strategies. This report summarizes the different therapeutic tools, their advantages and results mainly on colorectal cancer liver metastasis. These results are expected to improve even further with multimodality approaches.

Fixed dose rate infusion of gemcitabine with oral doxifluridine and leucovorin for advanced unresectable pancreatic cancer: a phase II study

The standard beneficial chemotherapy proven for patients with advanced pancreatic cancer is a regimen containing gemcitabine. In the pregemcitabine era, 5-fluorouracil (5-FU) was the standard agent. Oral 5-FU can be added to gemcitabine to improve the efficacy of chemotherapy and to provide better patient convenience. The possibility to improve efficacy of gemcitabine by fixed dose rate infusion (FDRI) was proposed in addition to combining it with 5-FU. We tried a new chemotherapy combining FDRI of gemcitabine with doxifluridine and leucovorin. Eligibility criteria were pathologically proven, chemotherapy-naïve, and metastatic or nonoperable advanced pancreatic cancer. Gemcitabine 1,000 mg/m(2) was infused over 100 min (days 1, 8 and 15). Doxifluridine 200 mg/m(2) t.i.d. and leucovorin 15 mg b.i.d. were given orally (days 1-21). Chemotherapy was repeated every 28 days until a patient had received 6 cycles or progression was found. Twenty-nine patients were enrolled from October 2002 to December 2004. A total of 78 cycles were given at a mean of 2.7 cycles per patient. Response could be evaluated in 26 patients. Responses were partial remission in 4/26 patients (15.4%), stable disease in 8/26 (30.8%) and progression in 14/26 (53.8%). All patients progressed except for 2 in partial remission and 2 in stable disease. Toxicities could be assessed in 23 patients. Maximal hematological toxicities greater than grade 2 were leucopenia in 3 patients (11.5%), neutropenia in 2 (7.7%), anemia in 2 (7.7%), thrombocytopenia in 1 (3.8%) and febrile neutropenia in 3 (11.5%). Maximal nonhematological grade 3 or 4 toxicities were asthenia in 1 patient (3.8%), anorexia in 1 (3.8%), vomiting in 1 (3.8%), diarrhea in 2 (7.7%), allergic reaction in 1 (3.8%), hand-foot syndrome in 1 (3.8%) and hyperbilirubinemia in 1 (3.8%). All 29 patients were dead on last follow-up. Median progression-free survival was 3.91 months in 26 evaluable patients and median overall survival was 5.59 months in all patients. Combination chemotherapy including FDRI of gemcitabine seems minimally active for patients with advanced, nonoperable pancreatic cancer. Further research to improve effectiveness of chemotherapy for advanced pancreatic cancer is mandatory.

Oral fluoropyrimidines may not reduce the risk of postoperative recurrence in colorectal cancer associated with mesenteric lymph node metastasis

To clarify the efficacy and problems of postoperative adjuvant chemotherapy using oral fluoropyrimidines, the clinicopathological data of 307 colorectal cancer patients treated with or without postoperative chemotherapy were analyzed retrospectively. Patients in the chemotherapy group (n=188) who underwent curative resection were followed by administration of oral fluoropyrimidine. The other 119 patients underwent surgery alone. The disease-free survival rates were compared between the two groups. The disease-free survival rate in the chemotherapy group was significantly higher than that in the surgery alone. However, no significant difference in disease-free survival rate was found for those with tumors that were associated with mesenteric lymph node involvement and tumors with a high grade of lymphatic invasion or high grade of venous invasion. Postoperative adjuvant chemotherapy using oral fluoropyrimidines such as UFT (litegafur +4:uracil) and 5'-DFUR (doxifluridine) might not reduce the risk of recurrence in colorectal cancer with mesenteric lymph nodes involvement.

Efficacy of the FAEV regimen in the treatment of high-risk, drug-resistant gestational trophoblastic tumor

OBJECTIVE

To evaluate the efficacy of the FAEV regimen (floxuridine, actinomycin D, etoposide, vincristine) in the treatment of high-risk, drug-resistant gestational trophoblastic tumor (GTT).

STUDY DESIGN

From October 2001 to May 2004, 11 cases of high-risk, drug-resistant GTT were treated with the FAEV regimen. All cases were referred to Peking Union Medical College Hospital because of previous failure of chemotherapy. The patients' ages ranged from 21 to 60 (median, 32) years. The International Federation of Gynecologists and Obstetricians score was 7-13 (median, 9). All cases were followed for 15-42 months after FAEV treatment.

RESULTS

Seven cases (63.6%, 7 of 11) were cured by the FAEV regimen. The median course number for serum human chorionic gonadotropin reaching a normal level was 3. Four cases (36%, 4 of 11) showed drug resistance to the FAEV regimen. The major side effect of FAEV regimen is myelosuppression. Granulocyte colony-stimulating factor support was needed after 98.4% (63 of 64) of the courses.

CONCLUSION

For high-risk, drug-resistant GTT cases, FAEV regimen could be an effective treatment.

A clinical study of docetaxel with or without 5'DFUR as a second-line chemotherapy for advanced gastric cancer

We conducted a clinical pilot study to evaluate the efficacy and safety of the combination of docetaxel and 5'DFUR as a second-line chemotherapy for gastric cancer. Twenty-four patients were divided into two groups by simple randomization: group A (60 mg/m2 of docetaxel, every 3 wk) and group B (regimen A + 600 mg/body of 5'DFUR). The response rate was 17% and 42% in group A and B, respectively (p < 0.05). The MST from the start of the first-line was 17 mo in group B. The major adverse event was leukopenia in both groups.

Bladder tumor associated with phenacetin abuse: a case report and a review of the literature

We herein report the case of a bladder tumor in an 85-year-old man who had been engaged in phenacetin abuse. He had been taking phenacetin owing to migraine headaches since he was 45 year of age. His total intake of phenacetin was approximately 7.3 to 11.5 kg over a period of years. He visited the Department of Urology in our hospital due to gross hematuria and pain on urination. IVP and a pelvic CT scan revealed a tumor mass on the right lateral wall of the urinary bladder. TUR-BT was performed. A histopathological examination of the resected specimen was diagnosed as urotherial carcinoma, grade 2∼3, pT2N0M0. To our acknowledge, only 24 cases of urotherial tumors owing to phenacetin abuse have been previously reported in the Japanese literature, making this the 25 th such case to be reported in Japan.

Saphenous vein graft conduits for insertion of hepatic arterial infusion pumps in patients with abnormal hepatic arterial anatomy

BACKGROUND AND OBJECTIVES

Hepatic arterial infusion (HAI) chemotherapy offers improved hepatic control for liver metastases from colon cancer. Optimal catheter insertion requires an adequate gastroduodenal artery (GDA). Limited data exists on using saphenous vein grafts (SVG) as conduits when native vasculature is inadequate.

METHODS

All HAI pump insertions from 7/99 to 7/03 requiring SVG conduits (N = 10) were analyzed for arterial anatomy, operative conduct, and outcome.

RESULTS

From 1988 through 2005, 124 HAI pumps were placed of which 10 received SVG conduits to optimize placement. Mean operative time was 251 +/- 50 min and mean blood loss was 230 +/- 30 cm(3). All were placed with palliative intent. Three patients (30%) had type 1 anatomy with inadequate GDA. Five (50%) had type 3 anatomy with replaced right hepatic artery, one (10%) had a small GDA originating off the right hepatic artery, and one patient (10%) had a trifurcation. Two (20%) pump-related complications were identified, and only one (10%) was related to vasculature (catheter thrombosis as a result of hepatic arterial stenosis distal to the SVG insertion site).

CONCLUSIONS

Complication rates related to SVG conduits for hepatic arterial infusion pump placement are low. Saphenous vein grafts are acceptable conduits for patients with abnormal hepatic arterial anatomy.

A phase II study of irinotecan, high-dose 24-h continuous intravenous infusion of floxuridine and leucovorin (IFLUX) for advanced, previously untreated colorectal cancer

Our objectives were to determine response rate, time to progression, overall survival and tolerability of novel combination chemotherapy, consisting of irinotecan, high-dose 24-h continuous intravenous infusion of floxuridine and leucovorin in advanced previously untreated colorectal cancer. Thirty-eight patients with advanced colorectal cancer were treated at Sylvester Comprehensive Cancer Center, University of Miami, from 2000 to 2004, and received weekly intravenous infusion of irinotecan at 110 mg/m with a combination of 120 mg/kg floxuridine and 500 mg/m leucovorin administered as a 24-h continuous intravenous infusion. The treatment cycle consisted of 4 weeks of consecutive therapy followed by 2 weeks of rest. Five (13%) patients achieved complete response, 10 (26%) patients achieved partial response, 17 (45%) patients attained stable disease and six (16%) patients progressed. The overall response rate was 39% in this study. This chemotherapy regiment was well tolerated; the most common grade 3 toxicities were neutropenia (16%), anemia (16%), vomiting (24%), diarrhea (16%), and hand-and-foot syndrome (26%). The median time to progression was 11.5 months (347.5 days) with 95% confidence intervals of 6.8-12.9 months (206-389 days). The time to progression ranged from 1.8 to 34 months. The median survival of the patients in this trial was 31.28 months (952 days) with a confidence interval of 20.9-38.0 months (629-1141 days). Intravenous infusion of floxuridine and leucovorin is beneficial as first-line therapy in advanced colorectal cancer, demonstrating a prolonged time to progression and overall survival with acceptable tolerability and manageable toxicity profile.

Neoadjuvant, surgery and adjuvant chemotherapy without radiation for esophageal cancer

BACKGROUND

A phase II trial to evaluate neoadjuvant (NAD), surgery and adjuvant (AD) combination chemotherapy without radiation therapy (RT) for patients with esophageal adenocarcinoma staged with endoscopic ultrasound and CT as T3N1 was carried out.

METHODS

Thirty-three eligible patients were enrolled. NAD therapy was administered in two 49-day cycles and included cisplatin, floxuridine, paclitaxel and leucovorin. Esophageal resection was performed followed by AD therapy.

RESULTS

Thirty-three patients initiated NAD therapy; 10 experienced grade 3 and 4 toxicities, which included leucopenia, fatigue, nausea, diarrhea and stomatitis. Additionally, 16 patients experienced grade 1 and 2 hematologic and non-hematologic toxicities. Fifteen patients were down-staged, of whom five were T2, seven were T1, and three had nodal disease with no evidence of residual cancer in the esophageal bed. Fifteen patients remained T3, and two showed progressive disease. Thirty-two patients proceeded to surgery and 30 were resected. Although all resected patients were eligible for AD therapy, 15 did not receive it either because of patient refusal or surgeon recommendation. Fifteen patients received AD therapy: nine who had remained T3 and six who had down-staged. Three patients experienced grade 3 and 4 toxicities similar to those in NAD therapy. Six patients had grade 1 and 2 toxicities. Kaplan-Meier estimates of overall survival at 1, 3 and 5 years were 73% (95% CI: 58-88%), 52% (95% CI: 34-69%) and 29% (95% CI: 13-45%), respectively. Median survival was 42 months.

CONCLUSION

Deletion of RT may safely allow for more aggressive chemotherapy and increase chances of survival. The results need to be confirmed in a randomized phase II or larger phase III trial.

[Efficacy of transcatheter arterial chemoembolization combined thalidomide on hepatocellular carcinoma: a controlled randomized trial]

BACKGROUND & OBJECTIVE

Transcatheter arterial chemoembolization (TACE) is an important therapy for hepatocellular carcinoma (HCC), but the recurrence rate is still high and the long-term survival is unsatisfactory. This study was to evaluate the efficacy of TACE combined thalidomide on HCC.

METHODS

From Aug. 2004 to Aug. 2006, 108 patients with unresectable primary HCC were randomized into combination (TACE plus thalidomide) group and TACE group. Combination group received oral administration of thalidomide (200 mg/d) for 1-6 months. Both groups were treated with 0.4-1.6 g gemcitabine, 100-200 mg oxaliplatin, and 0.5-1.0 g floxuridine as chemotherapeutic drugs, ethanol, glutin, and iodolipol as ambolic agent in TACE. The side effects of thalidomide and survival of the patients were observed.

RESULTS

The median survival period was 18 months [95% confidence interval (CI), 12-24 months] in combination group and 13 months (95% CI, 10-16 months) in TACE group. The 6-month, 1-year, and 2-year survival rates were 92.9%, 82.7%, and 58.4% respectively in combination group, and 85.6%, 57.2%, and 32.3% respectively in TACE group. The median time to progression was significantly longer in combination group than in TACE group [181 days (95% CI, 91-271 days) vs. 97 days (95% CI, 33-161 days), P<0.05]. Excluding the patients who took thalidomide for less than 1 month, the median survival period was significantly longer in combination group than in TACE group [18 months (95% CI, 12-24 months) vs. 13 months (95% CI, 10-16 months), P<0.05]û the 6-month, 1-year, and 2-year survival rates were 96.6%, 70.8%, and 44.3% respectively in combination group, and 84.7%, 54.4%, and 14.9% respectively in TACE group. The occurrence rate of serious rashes was 11.1% and that of serious somnolency was 6.7%. Multivariate Cox analysis showed that the times of TACE was an independent prognostic factor of HCC.

CONCLUSIONS

Compared with TACE alone, the combination of TACE and thalidomide can obviously postpone disease progression and prolong survival of HCC patients. The times of TACE is a prognostic factor of HCC after TACE.

Significance of thymidine phosphorylase in metronomic chemotherapy using CPT-11 and doxifluridine for advanced colorectal carcinoma

BACKGROUND

A phase II study was designed to evaluate the efficacy, safety and predictors for response of metronomic chemotherapy using weekly low-dosage CPT-11 and doxifluridine (5'-DFUR) in 45 patients with metastatic colorectal cancer.

PATIENTS AND METHODS

Forty mg/m2 of CPT-11 was administered for 3 consecutive weeks in a 4-week treatment cycle, with 5'-DFUR (800 mg/day) given orally.

RESULTS

One or more adverse effects were seen in 42 patients. However, most of these were mild at grade 1 or 2, including only leucopenia in 2, neutropenia in 1, diarrhea in 1 and nausea in 1 as grade 3. The objective response rate was 36% with a median overall survival of 452 days. The response rate in patients with a high expression of thymidine phosphorylase (dThdPase) in tumor cells (47%) was higher (p=0.092) than that (19%) in patients with a low expression.

CONCLUSION

The efficacy of metronomic chemotherapy using low-dosage weekly CPT-1 and 5'-DFUR is worthy of further clinical study, especially in patients with a high expression of dThdPase in primary tumor cells.

[Evaluation of combination therapy of high-dose toremifene and oral chemotherapy]

High-dose toremifene therapy (120 mg/day) is useful for the recurrence of receptor-positive breast cancer. However, some reports show that combination therapy of high-dose toremifene and chemotherapy exhibits additive effects. Twelve patients were given oral chemotherapy (capecitabine, 5'-DFUR+CPA, S-1) with high-dose toremifene. The overall response rate was 41.7%, in addition to 58.3% with no change beyond three months. Adverse events were restricted to headache, stomatitis and nausea. Average time to progressive (TTP) was 5.8 months. It was shown that high-dose toremifene and oral chemotherapy were useful for breast cancer recurrence without severe side effects.

Chemosensitivity-related genes of breast cancer detected by DNA microarray

BACKGROUND

The feasibility of a preoperative docetaxel/5'-deoxy-5-fluorouridine (5'-DFUR) regimen for breast cancer patients was examined and the genes related to the response to it was investigated.

PATIENTS AND METHODS

Women with advanced breast cancer were treated with docetaxel (60 mg/m2, day 1) and 5'-DFUR (800 mg/day, on days 1-14) q3 weeks by 4 cycles. Microarray analysis was carried out using preoperative core biopsy samples. Based on the mRNA expression levels, genes related to clinical and pathological responses were selected.

RESULTS

The docetaxel/5'-DFUR regimen showed a 86% clinical response rate including 42% complete response, one pathological complete response and one ductal carcinoma in situ component. In microarray analysis, we identified 6 genes, including IGF-1, and derived a predictive formula with 67% accuracy. In addition, x2 analysis revealed a tendency for good response in ER-negative and Her2/neu-positive cases.

CONCLUSION

Microarray analysis enabled us to predict the pathological response to docetaxel/5'-DFUR chemotherapy.

Preoperative hepatic and regional arterial chemotherapy in the prevention of liver metastasis after colorectal cancer surgery

OBJECTIVE

To investigate whether preoperative hepatic and regional arterial chemotherapy is able to prevent liver metastasis and improve overall survival in patients receiving curative colorectal cancer resection.

METHODS

Patients with stage II or stage III colorectal cancer (CRC) were randomly assigned to receive preoperative hepatic and regional arterial chemotherapy (PHRAC group, n = 110) or surgery alone (control group, n = 112). The primary endpoint was disease-free survival, whereas the secondary endpoints included liver metastasis-free survival and overall survival.

RESULTS

There were no significant differences in overall morbidity between PHRAC and Control groups. During the follow-up period (median, 36 months), the median liver metastasis time for patients with stage III CRC was significantly longer in the PHRAC group (16 +/- 3 months vs. 8 +/- 1 months, P = 0.01). In stage III patients, there was also significant difference between the 2 groups with regard to the incidence of liver metastasis (20.6% vs. 28.3%, P = 0.03), 3-year disease-free survival (74.6% vs. 58.1%, P = 0.0096), 3-year overall survival (87.7% vs. 75.7%, P = 0.020), and the median survival time (40.1 +/- 4.6 months vs. 36.3 +/- 3.2 months, P = 0.03). In the PHRAC arm, the risk ratio of recurrence was 0.61 (95% CI, 0.51-0.79, P = 0.0002), of death was 0.51 (95% CI, 0.32-0.67; P = 0.009), and of liver metastasis was 0.73 (95% CI, 0.52-0.86; P = 0.02). In contrast, PHRAC seemed to be no benefit for stage II patients. Toxicities, such as hepatic toxicity and leukocyte decreasing, were mild and could be cured with medicine.

CONCLUSIONS

Preoperative hepatic and regional arterial chemotherapy, in combination with surgical resection, could be able to reduce and delay the occurrence of liver metastasis and therefore improve survival rate in patients with stage III colorectal cancer.

Doxifluridine combined with weekly paclitaxel for second-line treatment in patients with gastric cancer resistant to TS-1

BACKGROUND

Many patients with gastric cancer respond to TS-1, but some fail to respond or have recurrence. Second-line therapy is needed.

METHODS

We performed a pilot study in patients with advanced gastric cancer who did not respond to TS-1 or who had disease recurrence. The patients received oral doxifluridine (600 mg/day) on days 1 to 21 and an intravenous infusion of paclitaxel (70 mg/m(2)) on days 7, 14, and 21 of a 28-day cycle. The treatment was repeated until disease progression or prohibitive toxicity. Response rate, duration of response, median survival time (MST), effects on pleural effusion, ascites, and other signs, and toxicity were evaluated.

RESULTS

The study group comprised 52 patients. The response rate was 28%. The duration of response was 103 days. The MST after the start of second-line treatment was 175 days (95% confidence interval, 135 to 224 days). Pleural effusion or ascites resolved or decreased in 73% of the patients. Hair loss occurred in 32 patients (62%), and leukopenia developed in 28 (54%, grade 3 in 1 patient and grade 2 or lower in the others). The MST after the start of treatment with TS-1 was about 16 months.

CONCLUSION

A combination of doxifluridine and weekly paclitaxel is expected to be an effective second-line treatment for gastric cancer not responding to TS-1, especially in patients with malignant ascites or pleural effusion. However, it remains unclear whether paclitaxel plus doxifluridine results in a better response and survival benefit than paclitaxel alone in this subgroup of patients. Further studies are therefore necessary.