Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease

Clinical evidence for three distinct gastric cancer subtypes: time for a new approach

BACKGROUND

Recently, a new classification for gastric cancer (GC) has been proposed, based on Lauren's histology and on anatomic tumour location, identifying three subtypes of disease: type 1 (proximal non diffuse GC), type 2 (diffuse GC) and type 3 (distal non diffuse GC). Aim of our analysis was to compare clinical outcome according to different GC subtypes (1,2,3) in metastatic GC patients receiving first-line chemotherapy.

PATIENTS AND METHODS

Advanced GC pts treated with a first-line combination chemotherapy were included in our analysis. Pts were divided in three subgroups (type 1, type 2 and type 3) as previously defined.

RESULTS

A total of 248 advanced GC pts were included: 45.2% belonged to type 2, 43.6% to type 3 and 11.2% to type 1. Patients received a fluoropyrimidine-based chemotherapy doublet or three drugs regimens including a platinum derivate and a fluoropyrimidine with the addition of an anthracycline, a taxane or mytomicin C. RR was higher in type 1 pts (RR = 46.1%) and type 3 (34,3%) compared to type 2 (20,4%), (p = 0.015). Type 2 presented a shorter PFS, median PFS = 4.2 months, compared to type 1, mPFS = 7.2 months, and type 3, mPFS = 5.9 months (p = 0.011) and also a shorter OS (p = 0.022).

CONCLUSIONS

Our analysis suggests that GC subtypes may be important predictors of benefit from chemotherapy in advanced GC patients. Future clinical trials should take in account these differences for a better stratification of patients.

Can we resect EGC with Signet ring cells in Europe?

PURPOSE

The proposed guideline for performing endoscopic resection of early gastric carcinoma (EGC) in Paris classification is a well-differentiated carcinoma with maximum involvement Sm1. Signet ring cell carcinomas (SRC) are excluded from this recommendation. Authors from Eastern countries have proposed extending this resection to include selected undifferentiated EGC. Via an analysis of a series of cases of signet ring carcinoma, we will discuss whether it is possible to resect EGC with signet ring cells in Europe.

METHODS

We retrospectively included patients with histological classification pT1 of EGC showing SRC. Data was extracted from the hospital gastrectomy register. Lymphadenomectomy D1.5 was performed on all patients. Histology results were retrospectively obtained from the electronic patient file.

RESULTS

Twelve patients (mean age = 55.4, four women, eight men) underwent surgery, without previous chemotherapy, between 2000 and 2012, for EGC with SRC. Mean size of the lesions was 20.2 mm (5-35 mm). Seven lesions were located in the antrum, five in the fundus. In the case of nine patients, histology showed no lymphovascular involvement. None of these nine patients presented lymph node metastases (LNM). Five patients had intramucosal carcinoma, four were classified as Sm1, one patient was Sm2, and one patient was Sm3. On surgery, the three patients with lymphovascular invasion showed LNM.

CONCLUSION

Endoscopic resection of EGC with SRC does not systematically imply complementary treatment by surgery, although criteria for endoscopic resection are difficult to determine because of the lack of data in Europe.

Combination of cisplatin/S-1 in the treatment of patients with advanced gastric or gastroesophageal adenocarcinoma: Results of noninferiority and safety analyses compared with cisplatin/5-fluorouracil in the First-Line Advanced Gastric Cancer Study

BACKGROUND

The aim of developing oral fluorouracil (5-FU) is to provide a more convenient administration route with similar efficacy and the best achievable tolerance. S-1, a novel oral fluoropyrimidine, was specifically designed to overcome the limitations of intravenous fluoropyrimidine therapies.

PATIENTS AND METHODS

A multicentre, randomised phase 3 trial was undertaken to compare S-1/cisplatin (CS) with infusional 5-FU/cisplatin (CF) in 1053 patients with untreated, advanced gastric/gastroesophageal adenocarcinoma. This report discusses a post-hoc noninferiority overall survival (OS) and safety analyses.

RESULTS

Results (1029 treated; CS = 521/CF = 508) revealed OS in CS (8.6 months) was statistically noninferior to CF (7.9 months) [hazard ratio (HR) = 0.92 (two-sided 95% confidence interval (CI), 0.80-1.05)] for any margin equal to or greater than 1.05. Statistically significant safety advantages for the CS arm were observed [G3/4 neutropenia (CS, 18.6%; CF, 40.0%), febrile neutropenia (CS, 1.7%; CF, 6.9%), G3/4 stomatitis (CS, 1.3%; CF, 13.6%), diarrhoea (all grades: CS, 29.2%; CF, 38.4%) and renal adverse events (all grades: CS, 18.8%; CF, 33.5%)]. Hand-foot syndrome, infrequently reported, was mainly grade 1/2 in both arms. Treatment-related deaths were significantly lower in the CS arm than the CF arm (2.5% and 4.9%, respectively; P<0.047).

CONCLUSION

CS is noninferior to CF with a better safety profile and provides a new treatment option for patients with advanced gastric carcinoma.

The successful endoscopic hemostasis factors in bleeding from advanced gastric cancer

BACKGROUND

When patients with advanced gastric cancer experience active bleeding, gastroenterologists normally choose between two treatment modalities, endoscopic hemostasis and transarterial embolization (TAE). In patients with advanced gastric cancer with bleeding, the predictive factors for endoscopic hemostatic failure are still unknown. Thus, the purpose of this study was to evaluate predictive factors for endoscopic hemostasis failure and to differentiate which hemostasis procedure is more effective for advanced gastric cancer with bleeding.

METHODS

We reviewed the medical records of patients who were diagnosed with advanced gastric cancer and acute non-variceal gastric bleeding from January 2006 to August 2011. Forty-five patients were enrolled in this study and they were divided into a group of 14 patients who had experienced successful endoscopic hemostasis and a group of 31 patients who had had unsuccessful hemostasis with the first endoscopy and then underwent TAE.

RESULTS

Lesion size and bleeding condition of Forrest class 1a or 1b were statistically significant predictive factors for endoscopic hemostatic failure (P = 0.023 and P = 0.017, respectively). On multivariate logistic regression analysis, size (lesion >2 cm) was a significant predictive factor for endoscopic hemostatic failure [adjusted odds ratio (aOR) 8.056; 95% confidence interval (CI) 1.329-48.846].

CONCLUSIONS

We determined that small bleeding lesions (<2 cm) and exposed vessels in the bleeding site with gastric cancer indicated that endoscopic hemostasis would be an effective hemostatic modality to choose. Particularly, in the opposite condition, the presence of large bleeding lesions (>2 cm) and non-exposed vessel bleeding with a tumor, endoscopic hemostasis failure is predicted and TAE could be recommended.

Noncurative gastrectomy for gastric adenocarcinoma should only be performed in highly selected patients

BACKGROUND

The benefit of surgical resection in patients with incurable gastric adenocarcinoma is controversial.

METHODS

A total of 289 patients who presented with advanced or metastatic gastric cancer from 1995 to 2010 were retrospectively reviewed.

RESULTS

Ten patients (3.5 %) required emergent surgery at presentation and were excluded from further analyses. Patients who underwent nonemergent surgery at presentation (n = 110, 38.1 %) received either gastric resection (group A, n = 46, 42 %) or surgery without resection (group B, n = 64, 58 %). Procedures in group A included distal gastrectomy (n = 25, 54 %), total gastrectomy (n = 17, 37 %), and proximal/esophagogastrectomy (n = 4, 9 %). Procedures in group B included laparoscopy (n = 17, 27 %), open exploration (n = 25, 39 %), gastrostomy and/or jejunostomy tube (n = 12, 19 %), and gastrojejunostomy (n = 10, 16 %). Group A required a stay in the intensive care unit or additional invasive procedure significantly more often than group B (15 vs. 2 %, p = 0.009). Four patients in group A (8.7 %) and three patients in group B (4.7 %) died within 30 days of surgery (p = 0.45). When the 110 patients who underwent nonemergent surgery (groups A and B) were compared to nonoperatively managed patients (group C, n = 169, 58 %), median overall survival did not significantly differ (8.6 vs. 9.2 vs. 7.7 months; p > 0.05). Three patients in group B (4.7 %) and three in group C (1.8 %) ultimately required an operation for their primary tumor.

CONCLUSIONS

Patients with gastric adenocarcinoma who present with advanced or metastatic disease not amenable to curative resection infrequently require emergent surgery. Noncurative resection is associated with significant perioperative morbidity and mortality as well as limited overall survival, and should therefore be performed judiciously.

Gastric cancer in young people under 30 years of age: worse prognosis, or delay in diagnosis?

Background

Gastric cancer is an aggressive disease with nonspecific early symptoms. Its incidence and prognosis in young patients has shown considerable variability.

Purpose of the study

Our objective was to retrospectively study patients from our institution aged <30 years with gastric carcinoma. The study was undertaken to describe the experience of gastric cancer in this population, and to demonstrate its specific clinical and pathological characteristics.

Materials and methods

We reviewed the cases of histologically confirmed gastric cancer between 1985 and 2006 at the Instituto Nacional de Cancerología of Mexico (INCan); emphasis in our review was placed on clinical presentation, diagnostic and therapeutic intervention, pathology, and the results.

Results

Thirty cases of gastric carcinoma were reviewed. The patients’ median age was 27 years (range, 18–30 years) and the male:female ratio was 1:1.

Conclusion

Gastric cancer exhibits different behavior in patients aged, 30 years, but delay in diagnosis and the tumor’s behavior appear to be the most important factors in prognosis of the disease.

Gastric cancer epidemiology and risk factors

Gastric cancer is a prevalent yet heterogeneous disease. From diet and lifestyle to genetics and ethnicity, our appreciation of the complexity of gastric cancer has evolved. This review will discuss the epidemiology of gastric cancer focusing on trends across various risk categories. We realize that gastric cancer is not merely a single disease, but rather individual diseases within a single organ-a distinction that will aid our understanding of disease heterogeneity and its significance.

Anti-VEGF therapies in the clinic

The development and use of antiangiogenesis agents, particularly those targeting vascular endothelial growth factor (VEGF), has become an integral component of anticancer regimens for many tumor types. This review is intended to highlight some of the most important clinical successes and failures of anti-VEGF therapies, and where possible, to suggest important lessons that have been learned. This review emphasizes data from agents that have been FDA approved and/or have completed phase III studies.

Combined evaluation of centromere protein H and Ki-67 as prognostic biomarker for patients with gastric carcinoma

AIM

Centromere protein H (CENP-H) is one of the essential components of the human active kinetochore which close links with carcinogenesis. Its expression and clinical value of prognostic prediction for gastric cancer (GC) is unclear.

METHODS

CENP-H and Ki-67 expressions in specimens from 166 patients with GC were determined by tissue microarrays and immunostaining. Their correlations between patients' clinicopathologic features and prognosis were explored. For mechanisms, quantitative CENP-H examination on gastric cancer tissue and cell lines was performed via real-time quantitative PCR and Western Blot. Its effect on Survivin expression and cell function was evaluated via CENP-H knocking down (SiRNA) or overexpression.

RESULTS

Highly expression of CENP-H was found in 85 of 166 GC, showing a significant correlation with tumour size, depth of infiltration, lymph node metastasis, distant metastasis and UICC staging of gastric carcinoma (P < 0.05), as well as clinical prognosis (coefficient = 0.550, P < 0.001). Multivariate analysis revealed that combined CENP-H and Ki67 expression was a more valuable independent prognostic predictor for patients' survival (hazard ratio, 2.18; P = 0.0109). Furthermore, total mRNA and protein expression of CENP-H in GC tissue and cell lines were noticeably increased. Survivin expression and cell function including growth, proliferation and clonogenic ability could be inhibited by CENP-H siRNA or enhanced by overexpressing CENP-H.

CONCLUSION

High expression of CENP-H in GC indicates poor prognosis and Survivin may mediate its procancer role. Combined evaluation of CENP-H and Ki-67 aids in predicting the clinical prognosis.

Advances in the management of HER2-positive advanced gastric and gastroesophageal junction cancer

In the past, patients with advanced or metastatic gastric or gastroesophageal junction cancer have had few treatment options and generally poor survival rates. The human epidermal growth factor receptor 2 (HER2) has been identified as a potential therapeutic target because of its overexpression or gene amplification in 6% to 35% of gastric or gastroesophageal junction cancers, although the methods of assessment and prognostic value of HER2 have been subject to debate. The phase III Trastuzumab for Gastric Cancer (ToGA) trial showed that adding the HER2-targeted humanized monoclonal antibody trastuzumab to chemotherapy significantly improves survival without negatively impacting quality of life in patients with advanced gastric or gastroesophageal junction cancer. As a result, trastuzumab is now the sole HER2-targeted therapy approved in several countries for this indication. The ToGA trial also demonstrated that patients who expressed higher levels of HER2 (determined by immunohistochemical screening) received the greatest benefit from trastuzumab therapy. This finding underlines the importance of accurate HER2 testing. Because of the unique characteristics of gastric cancer, a new gastric cancer-specific scoring system for HER2 expression was proposed during the ToGA trial. The aim of this review is to inform the gastroenterologist of the potential role of HER2-targeted therapy, to discuss the importance of accurate and reliable HER2 testing, and to discuss ongoing studies with HER2-targeted therapies that may have an impact on the future treatment of HER2-positive gastric cancer.

Epstein-barr virus infected gastric adenocarcinoma expresses latent and lytic viral transcripts and has a distinct human gene expression profile

BACKGROUND

EBV DNA is found within the malignant cells of 10% of gastric cancers. Modern molecular technology facilitates identification of virus-related biochemical effects that could assist in early diagnosis and disease management.

METHODS

In this study, RNA expression profiling was performed on 326 macrodissected paraffin-embedded tissues including 204 cancers and, when available, adjacent non-malignant mucosa. Nanostring nCounter probes targeted 96 RNAs (20 viral, 73 human, and 3 spiked RNAs).

RESULTS

In 182 tissues with adequate housekeeper RNAs, distinct profiles were found in infected versus uninfected cancers, and in malignant versus adjacent benign mucosa. EBV-infected gastric cancers expressed nearly all of the 18 latent and lytic EBV RNAs in the test panel. Levels of EBER1 and EBER2 RNA were highest and were proportional to the quantity of EBV genomes as measured by Q-PCR. Among protein coding EBV RNAs, EBNA1 from the Q promoter and BRLF1 were highly expressed while EBNA2 levels were low positive in only 6/14 infected cancers. Concomitant upregulation of cellular factors implies that virus is not an innocent bystander but rather is linked to NFKB signaling (FCER2, TRAF1) and immune response (TNFSF9, CXCL11, IFITM1, FCRL3, MS4A1 and PLUNC), with PPARG expression implicating altered cellular metabolism. Compared to adjacent non-malignant mucosa, gastric cancers consistently expressed INHBA, SPP1, THY1, SERPINH1, CXCL1, FSCN1, PTGS2 (COX2), BBC3, ICAM1, TNFSF9, SULF1, SLC2A1, TYMS, three collagens, the cell proliferation markers MYC and PCNA, and EBV BLLF1 while they lacked CDH1 (E-cadherin), CLDN18, PTEN, SDC1 (CD138), GAST (gastrin) and its downstream effector CHGA (chromogranin). Compared to lymphoepithelioma-like carcinoma of the uterine cervix, gastric cancers expressed CLDN18, EPCAM, REG4, BBC3, OLFM4, PPARG, and CDH17 while they had diminished levels of IFITM1 and HIF1A. The druggable targets ERBB2 (Her2), MET, and the HIF pathway, as well as several other potential pharmacogenetic indicators (including EBV infection itself, as well as SPARC, TYMS, FCGR2B and REG4) were identified in some tumor specimens.

CONCLUSION

This study shows how modern molecular technology applied to archival fixed tissues yields novel insights into viral oncogenesis that could be useful in managing affected patients.

Intestinal metaplasia and the risk of gastric cancer in an immigrant asian population

The development of intestinal metaplasia (IM) has been purported to be a critical step in the pathogenesis of gastric cancer. However, the natural history of IM in migrant human populations has not been well elucidated. The purpose of this study was to determine the risk of gastric cancer posed by IM in Asian immigrants undergoing gastric cancer screening. A retrospective review of Asian immigrants found to have IM during screening was conducted over an 18-month period. In total, 222 patients were found to have IM. Altogether, 24% had a history of smoking, 48% had a family history of gastric cancer, and 52% had a history of Helicobacter pylori (H. pylori) infection with a 96% eradication rate. Patients with stable IM (SIM) were then compared with those who developed high risk pathology (HRP), specifically dysplasia and/or adenocarcinoma. Thirty-five patients (16%) were included in the HRP group, 31 with dysplasia (14%) and 4 with adenocarcinoma (2%). Of those with dysplasia, 55% demonstrated regression to IM over the course of follow-up. Patients in the SIM group were more likely to be female (60% vs. 31%, P = 0.002) and more likely to have had a normal biopsy during follow-up (32% vs. 9%, P = 0.005). Odds ratios for IM stability were 3.3 (95% CI 1.5-7.0) and 5.0 (95% CI 1.5-17.1) for female gender and presence of a normal biopsy, respectively. Intestinal metaplasia in immigrant Asian populations is predominantly a stable histologic finding associated with a low rate of persistent dysplasia and adenocarcinoma.

Geographic difference in safety and efficacy of systemicchemotherapy for advanced gastric or gastroesophagealcarcinoma: a meta-analysis and meta-regression

BACKGROUND

The standard of chemotherapy regimens for advanced or metastatic gastric cancer and the clinical outcome were heterogeneous in Asian versus non-Asian countries. This study aimed to explore predictors of safety and efficacy of chemotherapy for patients with advanced or metastatic gastric cancer.

METHODS

Treatment group-based meta-analysis and met a regression were performed to analyze results of randomized trials published since 2005 for advanced or metastatic gastric cancer patients who received systemic chemotherapy as first-line treatment. Data were extracted and synthesized according to the Cochrane guidelines.

RESULTS

Twenty-five trials (8 Asian, 17 Western or international) with 56 treatment groups were analyzed. Asian trials reported a lower percentage of gastroesophageal junctional carcinoma, higher percentage of diffuse type histology, and more frequent use of second-line chemotherapy. Meta-analysis revealed significant heterogeneity both in treatment safety (grade 3–4 neutropenia and diarrhea) and efficacy [6-month progression-free survival(PFS) and 1-year overall survival (OS)]. Meta-regression analyses indicate that Asian trials are associated with an 8.2% lower incidence of grade 3–4 neutropenia and 2.1%lower incidence of grade 3–4 diarrhea. A lower percentage of patients with gastroesophageal junction carcinoma and the use of combination regimens predicted better PFS. The use of second-line chemotherapy predicts better 1-year OS,which will increase by 10% for every 10% increase inpatients who received second-line chemotherapy.

CONCLUSION

Geographic region (Asian vs. non-Asian) is an independent predictor of safety in systemic therapy for gastric cancer.

Non-curative gastric resection for patients with stage 4 gastric cancer--a single center experience and current review of literature

PURPOSE

The majority of patients with gastric cancer present with an advanced stage and, therefore, may not be eligible for curative treatment. The role of non-curative gastric resection in situations other than emergency treatment for life threatening tumor-related complications is still under discussion.

METHODS

Data from 290 consecutive patients with advanced gastric cancer who were treated in our hospital were analyzed. A total of 48 patients underwent primary non-curative gastric resection.

RESULTS

The overall survival in the non-curatively resected group was 15 months and 6 months for non-resected patients, respectively (p < 0.001). The incidence of tumor-related complications which required intervention was 63% in non-resected patients as compared to 12% in patients who underwent primary non-curative resection. Younger age, less than three tumor locations, and chemotherapy have been identified as prognostic factors for improved survival by univariate analysis. D3 lymph node involvement and chemotherapy were independent prognostic factors in the multivariate analysis. Peritoneal carcinosis did not significantly influence survival in resected patients. Non-curative resection in combination with chemotherapy resulted in longer overall survival than resection alone.

CONCLUSIONS

Primary non-curative gastric resection can reduce the incidence of severe tumor-related complications and can prolong overall survival in selected subgroups. In particular, younger patients with no more than two tumor locations should be considered for this procedure.

Euphol from Euphorbia tirucalli selectively inhibits human gastric cancer cell growth through the induction of ERK1/2-mediated apoptosis

Gastric cancer is one of the most common malignancies worldwide, and the main cause of cancer-related death in Asia. The present study assessed the anticancer effects of euphol, a triterpene alcohol with anti-inflammatory and antiviral activities on human gastric cancer cells. Euphol showed higher cytotoxicity activity against human gastric CS12 cancer cells than against noncancer CSN cells. In addition, it up-regulated the pro-apoptotic protein BAX and down-regulated the prosurvival protein Bcl-2, causing mitochondrial dysfunction, possibly by caspase-3 activation. The anti-proliferative effects of euphol were associated with the increased p27(kip1) levels and decreased cyclin B1 levels. Inhibition of ERK1/2 activation by PD98059 reversed euphol-induced pro-apoptotic protein expression and cell death. Taken together, these findings suggest that euphol selectively induced gastric cancer cells apoptosis by modulation of ERK signaling, and could thus be of value for cancer therapy.

Resection of liver metastases is beneficial in patients with gastric cancer: report on 15 cases and review of literature

BACKGROUND

Although up to 9% of patients with gastric cancer develop liver metastases, liver resection is rarely performed because of co-existing non-curative factors. Furthermore, the benefit of liver resection is still controversially discussed. Our goal was to investigate the outcome of patients who underwent liver resection or radiofrequency ablation (RFA) for hepatic metastasized gastric cancer.

METHODS

Retrospectively collected data from a prospectively maintained database were analyzed from 15 patients who underwent liver resection or RFA for liver metastases from gastric cancer.

RESULTS

Overall 5-year survival and median survival were 27% and 48 months for resected/RFA patients. The peri-operative complication rate was low. One patient has been tumor-free for 90 months now.

CONCLUSIONS

Liver resection in patients with hepatic metastasized gastric cancer is beneficial and safe if an R0 situation can be achieved. RFA might be a useful alternative in those patients where surgery is not feasible.

HER-2/neu overexpression is an independent prognostic factor for intestinal-type and early-stage gastric cancer patients

GOALS

To evaluate the HER-2/neu protein level by immunohistochemistry (IHC) and its gene amplification by fluorescence in situ hybridization (FISH) in gastric cancer samples, and the relevance to the prognosis of gastric cancer patients.

STUDY

HER-2/neu overexpression and gene amplification were examined with semiquantitative standardized IHC in 775 formalin-fixed paraffin-embedded gastric cancer samples, and 252 of these cases were analyzed with FISH.

RESULTS

Of the 775 gastric cancer samples examined by IHC, a total of 88 (11%) cases were positive for HER-2/neu overexpression at a score of 3+; another 44 (6%) cases were equivocal with a score of 2+; and the rest 643 (83%) cases were negative scored as 0/1+. Intestinal-type and early-stage cancers exhibited higher rate of HER-2/neu overexpression than those of diffuse/mixed-type and advanced cancers (P<0.05). Intestinal-type and early-stage cancers with HER-2/neu overexpression also exhibited short 5 year survival rates (21% vs. 47%, P=0.027; 29% vs. 60%, P=0.037) than HER-2/neu-negative cases, but not in the diffuse/mixed-type and advanced stage cancers. By FISH analysis, it was shown that 70% (60/86) of IHC 3+ had HER-2/neu gene amplication. In contrast, only 14% (6/43) of IHC 2+ cases, and 2.5% (3) of the 120 cases with IHC 0/1+ randomly selected showed HER-2/neu gene amplification.

CONCLUSIONS

HER-2/neu overexpression may be used as an independent prognostic factor for intestinal-type and early-stage gastric cancer patients. IHC 3+ and 2+ cases should be further detected by FISH to assess HER-2/neu gene status. Patients with HER-2/neu amplification also might constitute potential candidates for targeted therapy with trastuzumab.

Impact of clinical and pathohistological characteristics on the incidence of recurrence and survival in elderly patients with gastric cancer

BACKGROUND

Gastric cancer is one of the most frequent malignant tumors worldwide. Despite improvements in diagnostic procedures, as well as the introduction of multimodal treatment strategies, the overall prognosis remains poor. The role of gastric resection in elderly patients with gastric cancer has not been clearly defined as yet. The goal of the present study was to assess whether specific pathohistological features result in different outcomes for younger patients and elderly patients.

METHODS

A total of 272 patients with advanced gastric cancer treated surgically in our hospital between 1998 and 2009 were included in the study. Data were analyzed from a prospectively maintained database.

RESULTS

Median overall survival was 84 months in the younger subgroup and 37 months in the elderly subgroup (P = 0.038), whereas local recurrence occurred more frequently in younger patients (33% vs. 23%). We identified positive lymph nodes at the contralateral curvature, perilymphonodular tumor cells, and positive lymph node conglomerates as strong negative prognostic factors. There were few pathohistological characteristics that affected survival and the incidence of tumor recurrence differently in elderly and younger patients. Although only a few elderly patients underwent chemotherapy plus gastric resection (7% vs. 28% of the younger patients), there was a trend toward longer survival for those who received multimodal treatment.

CONCLUSIONS

Our results suggest that there is no tumor-related prognostic difference between young and elderly patients that would preclude radical surgery in elderly patients, as long as they are generally fit for surgery.

The association of statins and taxanes: an efficient combination trigger of cancer cell apoptosis

Background:

Cancer cell killing might be achieved by the combined use of available drugs. Statins are major anti-hypercholesterolemia drugs, which also trigger apoptosis of many cancer cell types, while docetaxel is a potent microtubule-stabilising agent.

Methods:

Here, we looked at the combined effects of lovastatin and docetaxel in cancer cells.

Results:

Whole transcriptome microarrays in HGT-1 gastric cancer cells demonstrated that lovastatin strongly suppressed expression of genes involved in cell division, while docetaxel had very little transcriptional effects. Both drugs triggered apoptosis, and their combination was more than additive. A marked rise in the cell-cycle inhibitor p21, together with reduction of aurora kinases A and B, cyclins B1 and D1 proteins was induced by lovastatin alone or in combination with docetaxel. The drug treatments induced the proteolytic cleavage of procaspase-3, a drop of the anti-apoptotic Mcl-1 protein, Poly-ADP-Ribose Polymerase and Bax. Strikingly, docetaxel-resistant HGT-1 cell derivatives overexpressing the MDR-1 gene were much more sensitive to lovastatin than docetaxel-sensitive cells.

Conclusion:

These results suggest that the association of lovastatin and docetaxel, or lovastatin alone, shows promise as plausible anticancer strategies, either as a direct therapeutic approach or following acquired P-glycoprotein-dependent resistance.

Strong YB-1 expression is associated with liver metastasis progression and predicts shorter disease-free survival in advanced gastric cancer

BACKGROUND

The most significant cause of gastric cancer (GC) death is metastasis, although the underlying mechanisms remain obscure. Y-box binding protein-1 (YB-1) is associated with tumor aggressiveness and poor prognosis in various cancers. In this study we investigated the relationship between YB-1 expression and the clinicopathologic features and metastasis-associated epithelial-mesenchymal transition (EMT) phenotype in advanced GC patients.

PATIENTS AND METHODS

Immunohistochemistry (IHC) was used to analyze YB-1, E-cadherin, and vimentin expression in 98 advanced GC cases.

RESULTS

Twenty-nine (29.6%) cases of GC exhibited strong YB-1 immunoreactivity. Strong YB-1 staining occurred more often in patients with intestinal or non-scirrhous cancer, and demonstrated a significant correlation with vascular invasion (VI), liver metastasis, and shorter disease-free survival (DFS). However, we observed no relationship between YB-1 expression and EMT phenotype or overall survival. Logistic regression analysis revealed that strong staining for YB-1 was the only predictive factor for liver metastasis.

CONCLUSIONS

Our results indicate that YB-1 plays a role in the process of GC metastasis, and that the immunohistochemical detection of this protein potentially delivers valuable insight regarding the prediction of liver metastasis and shorter DFS in patients undergoing curative resection for advanced GC.

Aberrant expression of intelectin-1 in gastric cancer: its relationship with clinicopathological features and prognosis

PURPOSES

Human intelectin-1 (ITLN-1) is a novel identified galactose-binding lectin that is expressed in the colonic goblet cells. Since gastric adenocarcinomas can arise through a process of intestinalization, we speculate that ITLN-1 may be aberrantly expressed in gastric cancer. This study was undertaken to examine the ITLN-1 expression in gastric cancer and correlate it with clinical outcomes.

METHODS

One hundred and ninety-six gastric cancer patients were evaluated for the ITLN-1 expression by immunohistochemistry. The ITLN-1 transcripts were measured by real-time quantitative PCR.

RESULTS

ITLN-1 expression was absent in normal gastric mucosa, whereas areas of intestinal metaplasia revealed ITLN-1 immunoreactivity. One hundred and forty-two gastric cancer patients (72.4%) were positive for ITLN-1 expression. In a subtotal of 20 patients, ITLN-1 transcripts were significantly enhanced in gastric cancer tissues than in normal gastric mucosa (P < 0.001). The expression rate of ITLN-1 was higher in intestinal-type carcinomas than in diffuse-type carcinomas (P = 0.003). ITLN-1 positivity in gastric cancer was positively correlated with tumor differentiation (P = 0.001) and CDX2 expression (P < 0.001), and inversely correlated with depth of invasion (P = 0.007), lymph node metastasis (P = 0.001), distant metastasis (P = 0.014), clinical stage (P = 0.006), Ki-67 expression (P = 0.001), and heparanase expression (P < 0.001), without correlation with age, gender, tumor location, or tumor size. In univariate and multivariate analyses, ITLN-1 was an independent prognostic factor for longer survival of gastric cancer patients (P = 0.001).

CONCLUSION

The aberrant ITLN-1 expression in gastric cancer is correlated with clinicopathological features and may be a useful prognostic factor for predicting the outcomes of gastric cancer patients.

Will disease heterogeneity help define treatment paradigms for gastroesophageal adenocarcinoma? A global perspective

Cancers of the upper gastrointestinal (GI) tract form a heterogeneous group of diseases for which treatment paradigms for localized disease continue to emerge. Recently, several phase III studies in esophagus and gastric cancer that have attempted to define new standards of care have been reported. However, controversy still persists and treatment algorithms often depend on individual preference, patient referral patterns, and treatment biases. In the current era of improving quality control and standardization of care, such variations in practice present a substantial challenge for both patients and physicians. In this article, I will highlight differences in disease biology for upper GI diseases, and in particular, gastric cancer.

Human epidermal growth factor receptor 2 testing in gastroesophageal cancer: correlation between immunohistochemistry and fluorescence in situ hybridization

CONTEXT

Patients with advanced gastroesophageal cancer have poor survival with current therapy. Human epidermal growth factor receptor 2 (HER2) represents a promising therapeutic target, but the optimal HER2 testing strategy is not yet defined.

OBJECTIVES

To evaluate the concordance between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) and to determine if the American Society of Clinical Oncology/College of American Pathologists HER2 scoring system is applicable to gastroesophageal carcinomas.

DESIGN

Formalin-fixed paraffin-embedded tumor samples from patients with advanced stage gastroesophageal cancer were tested by IHC and FISH and scored according to the American Society of Clinical Oncology/College of American Pathologists criteria for breast cancer. Concordance between IHC and FISH was evaluated. A subset of cases was subjected to array comparative genomic hybridization to verify the positive and negative HER2 results.

RESULTS

A total of 135 cases with paired IHC and FISH results were evaluated. The majority of samples (84%) were biopsies. HER2 amplification was detected in 20 tumors (15%). Using the American Society of Clinical Oncology/College of American Pathologists scoring system, IHC-FISH concordance was 97% for IHC 0, 93% for IHC 1+, and 100% for IHC 3+. Human epidermal growth factor receptor 2 positivity was strongly associated with tumor grade (moderately differentiated > poorly differentiated, P < .001) and histologic subtype (intestinal > diffuse, P  =  .007). Array comparative genomic hybridization analysis was successful in 31 tumors (14 FISH+ and 17 FISH-). Fluorescence in situ hybridization and array comparative genomic hybridization results were highly concordant in both HER2-positive and HER2-negative groups (93% and 100% concordance, respectively).

CONCLUSIONS

Human epidermal growth factor receptor 2 testing in gastroesophageal cancer can be performed using standard breast cancer procedures and the American Society of Clinical Oncology/College of American Pathologists scoring criteria. Although IHC 0 and IHC 3+ provide clear stratification, reliable separation of IHC 1+ and IHC 2+ may be difficult, especially in biopsy samples. The latter 2 groups are best referred to FISH for definitive classification.

Biomarker analysis of cetuximab plus oxaliplatin/leucovorin/5-fluorouracil in first-line metastatic gastric and oesophago-gastric junction cancer: results from a phase II trial of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

Background

The activity of the epidermal growth factor receptor (EGFR)-directed monoclonal antibody cetuximab combined with oxaliplatin/leucovorin/5-fluorouracil (FUFOX) was assessed in first-line metastatic gastric and oesophago-gastric junction (OGJ) cancer in a prospective phase II study showing a promising objective tumour response rate of 65% and a low mutation frequency of KRAS (3%). The aim of the correlative tumour tissue studies was to investigate the relationship between EGFR gene copy numbers, activation of the EGFR pathway, expression and mutation of E-cadherin, V600E BRAF mutation and clinical outcome of patients with gastric and OGJ cancer treated with cetuximab combined with FUFOX.

Methods

Patients included in this correlative study (n = 39) were a subset of patients from the clinical phase II study. The association between EGFR gene copy number, activation of the EGFR pathway, abundance and mutation of E-cadherin which plays an important role in these disorders, BRAF mutation and clinical outcome of patients was studied. EGFR gene copy number was assessed by FISH. Expression of the phosphorylated forms of EGFR and its downstream effectors Akt and MAPK, in addition to E-cadherin was analysed by immunohistochemistry. The frequency of mutant V600E BRAF was evaluated by allele-specific PCR and the mutation profile of the E-cadherin gene CDH1 was examined by DHPLC followed by direct sequence analysis. Correlations with overall survival (OS), time to progression (TTP) and overall response rate (ORR) were assessed.

Results

Our study showed a significant association between increased EGFR gene copy number (≥ 4.0) and OS in gastric and OGJ cancer, indicating the possibility that patients may be selected for treatment on a genetic basis. Furthermore, a significant correlation was shown between activated EGFR and shorter TTP and ORR, but not between activated EGFR and OS. No V600E BRAF mutations were identified. On the other hand, an interesting trend between high E-cadherin expression levels and better OS was observed and two CDH1 exon 9 missense mutations (A408V and D402H) were detected.

Conclusion

Our finding that increased EGFR gene copy numbers, activated EGFR and the E-cadherin status are potentially interesting biomarkers needs to be confirmed in larger randomized clinical trials.

Trial registration

Multicentre clinical study with the European Clinical Trials Database number 2004-004024-12.

Adaptation to statins restricts human tumour growth in Nude mice

BACKGROUND

Statins have long been used as anti-hypercholesterolemia drugs, but numerous lines of evidence suggest that they may also bear anti-tumour potential. We have recently demonstrated that it was possible to isolate cancer cells adapted to growth in the continuous presence of lovastatin. These cells grew more slowly than the statin-sensitive cells of origin. In the present study, we compared the ability of both statin-sensitive and statin-resistant cells to give rise to tumours in Nude mice.

METHODS

HGT-1 human gastric cancer cells and L50 statin-resistant derivatives were injected subcutaneously into Nude mice and tumour growth was recorded. At the end of the experiment, tumours were recovered and marker proteins were analyzed by western blotting, RT-PCR and immunohistochemistry.

RESULTS

L50 tumours grew more slowly, showed a strong decrease in cyclin B1, over-expressed collagen IV, and had reduced laminin 332, VEGF and CD34 levels, which, collectively, may have restricted cell division, cell adhesion and neoangiogenesis.

CONCLUSIONS

Taken together, these results showed that statin-resistant cells developed into smaller tumours than statin-sensitive cells. This may be reflective of the cancer restricting activity of statins in humans, as suggested from several retrospective studies with subjects undergoing statin therapy for several years.

Bevacizumab in Combination With Chemotherapy As First-Line Therapy in Advanced Gastric Cancer: A Randomized, Double-Blind, Placebo-Controlled Phase III Study

Purpose

The Avastin in Gastric Cancer (AVAGAST) trial was a multinational, randomized, placebo-controlled trial designed to evaluate the efficacy of adding bevacizumab to capecitabine-cisplatin in the first-line treatment of advanced gastric cancer.

Patients and Methods

Patients received bevacizumab 7.5 mg/kg or placebo followed by cisplatin 80 mg/m2 on day 1 plus capecitabine 1,000 mg/m2 twice daily for 14 days every 3 weeks. Fluorouracil was permitted in patients unable to take oral medications. Cisplatin was given for six cycles; capecitabine and bevacizumab were administered until disease progression or unacceptable toxicity. The primary end point was overall survival (OS). Log-rank test was used to test the OS difference.

Results

In all, 774 patients were enrolled; 387 were assigned to each treatment group (intention-to-treat population), and 517 deaths were observed. Median OS was 12.1 months with bevacizumab plus fluoropyrimidine-cisplatin and 10.1 months with placebo plus fluoropyrimidine-cisplatin (hazard ratio 0.87; 95% CI, 0.73 to 1.03; P = .1002). Both median progression-free survival (6.7 v 5.3 months; hazard ratio, 0.80; 95% CI, 0.68 to 0.93; P = .0037) and overall response rate (46.0% v 37.4%; P = .0315) were significantly improved with bevacizumab versus placebo. Preplanned subgroup analyses revealed regional differences in efficacy outcomes. The most common grade 3 to 5 adverse events were neutropenia (35%, bevacizumab plus fluoropyrimidine-cisplatin; 37%, placebo plus fluoropyrimidine-cisplatin), anemia (10% v 14%), and decreased appetite (8% v 11%). No new bevacizumab-related safety signals were identified.

Conclusion

Although AVAGAST did not reach its primary objective, adding bevacizumab to chemotherapy was associated with significant increases in progression-free survival and overall response rate in the first-line treatment of advanced gastric cancer.

Update on HER2 testing for breast and upper gastrointestinal tract cancers

With the regulatory approvals in Europe and the USA of trastuzumab-based anti-HER2 targeted therapy for upper gastrointestinal cancers in 2010, HER2 testing has now become universal for newly diagnosed cases of both breast cancer and adenocarcinomas of esophagus, stomach and gastroesophageal origin. In the 12 years or more since the approval of trastuzumab for breast cancer, general refinements in approaches to HER2 testing, including a greater understanding of the implications of preanalytic factors impacting the test results and the application of standardization of reporting of HER2 test results, have taken place. There has also been continuing development in breast cancer with the introduction of new HER2 tests, including non-FISH tests, dimerization assays, phosphorylated HER2 receptor tests, mRNA-based tests, HER2 gene sequencing tests and the application of HER2 testing to circulating tumor cells. Most recently, the introduction of HER2 testing for upper gastrointentinal malignancies has emphasized the need for performing and interpreting slide-based assays in a manner unique to these specimens and not to apply the breast cancer testing protocols to esophageal and gastric adenocarcinomas.

Trastuzumab: a new treatment option for HER2-positive metastatic gastric and gastroesophageal junction cancer

In patients with metastatic gastric cancer, median overall survival with standard chemotherapy remains under 1 year. As such, effective new treatments with acceptable tolerability are urgently needed. Amplification/overexpression of HER2 is reported in approximately 20% of gastric tumors, providing a rationale to investigate trastuzumab, a monoclonal antibody against HER2, in this setting. In the Phase III international Trastuzumab for Gastric Cancer (ToGA) study, the addition of trastuzumab to chemotherapy significantly improved overall survival without compromising safety in patients with HER2-positive metastatic gastric or gastroesophageal junction cancer. The purpose of this review is to discuss clinical data supporting the role of trastuzumab in metastatic gastric cancer, and consider the optimization of gastric cancer-specific HER2 testing and analysis.

Gastric adenocarcinoma in children and adolescents

Gastric adenocarcinoma (GAC) is an extremely rare cancer in children with very limited information on the clinical presentation and outcome. We report five pediatric patients with GAC-treated between 1990 and 2008 at our institution. Median age at diagnosis was 17 years (range: 8-17). Our case series suggests that pediatric GAC patients present with diffuse metastatic disease (four patients) and with patterns of spread similar to adult GAC. Initial chemotherapy was mainly platinum-based. Median time to progression was 4 months. The only long-term survivor was a patient with localized disease who had complete surgical removal of primary tumor.

Chemotherapy in the treatment of metastatic gastric cancer: is there a global standard?

Gastric cancer remains one of the leading causes of cancer mortality worldwide even though its incidence has been decreasing in recent years. Despite remarkable advancements in chemotherapy, advanced gastric cancer has remained a therapeutic challenge for physicians as well as for patients. While early chemotherapeutic regimens succeeded in showing a modest but definite improvement over best supportive care, no single regimen stood out as superior. Most early trials failed to show survival benefit of combination regimens over single agent fluorouracil, but combination regimens were shown to have better response rates. Based on these data, the Japanese adopted single agent fluorouracil as a reference standard for further investigations, while the rest of the world used a doublet containing fluorouracil and platinum. As more clinical trials were conducted, the Japanese standard evolved into a doublet, while the Western countries adopted triplet combinations. There is no established global standard as yet, but with the introduction of newer targeted agents based on molecular assays and personalized approaches combined with conventional chemotherapy, multiple regimens are likely to emerge as global standards rather than one standard treatment for all.

HER2 Testing in Gastric/Gastroesophageal Junction Adenocarcinomas: Unique Features of a Familiar Test

Using the standard slide-based techniques of immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), it has been firmly established that human epidermal growth factor receptor 2 (HER2) is overexpressed in adenocarcinoma of the upper gastrointestinal tract. In the ToGA trial, the addition of the monoclonal antibody trastuzumab to a standard regimen of cisplatin and fluoropyrimidine resulted in a clinically and statistically significant benefit in terms of response rate, median progression-free survival, and median overall survival in HER2-positive patients. Major differences exist, however, between HER2 testing in gastric/gastroesophageal junction (GEJ) cancer versus breast cancer, and the ToGA trial employed a significant modification of the breast cancer scoring criteria. As trastuzumab approaches regulatory approval in the United States for gastric/GEJ cancer, it is critical that pathologists and diagnostic laboratories learn and apply the unique criteria for assessing gastric/GEJ tumors for their HER2 status defined by the ToGA investigators, as they ready themselves for the approximately 50,000 new specimens that will be tested for HER2 status by both IHC and FISH each year.

EUS for the staging of gastric cancer: a meta-analysis

BACKGROUND

The role of EUS in the locoregional staging of gastric carcinoma is undefined.

OBJECTIVE

We aimed to comprehensively review and quantitatively summarize the available evidence on the staging performance of EUS.

DESIGN

We systematically searched the MEDLINE, Cochrane, CANCERLIT, and EMBASE databases for relevant studies published until July 2010.

SETTING

Formal meta-analysis of diagnostic accuracy parameters was performed by using a bivariate random-effects model.

PATIENTS

Fifty-four studies enrolling 5601 patients with gastric cancer undergoing disease staging with EUS were eligible for the meta-analysis.

MAIN OUTCOME MEASUREMENTS

EUS staging accuracy across eligible studies was measured by computing overall sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR).

RESULTS

EUS can differentiate T1-2 from T3-4 gastric cancer with high accuracy, with overall sensitivity, specificity, PLR, NLR, and DOR of 0.86 (95% CI, 0.81-0.90), 0.91 (95% CI, 0.89-0.93), 9.8 (95% CI, 7.5-12.8), 0.15 (95% CI, 0.11-0.21), and 65 (95% CI, 41-105), respectively. In contrast, the diagnostic performance of EUS for lymph node status is less reliable, with overall sensitivity, specificity, PLR, NLR, and DOR of 0.69 (95% CI, 0.63-0.74), 0.84 (95% CI, 0.81-0.88), 4.4 (95% CI, 3.6-5.4), 0.37 (95% CI, 0.32-0.44), and 12 (95% CI, 9-16), respectively. Results regarding single T categories (including T1 substages) and Bayesian nomograms to calculate posttest probabilities for any target condition prevalence are also provided.

LIMITATIONS

Statistical heterogeneity was generally high; unfortunately, subgroup analysis did not identify a consistent source of the heterogeneity.

CONCLUSIONS

Our results support the use of EUS for the locoregional staging of gastric cancer, which can affect the therapeutic management of these patients. However, clinicians must be aware of the performance limits of this staging tool.

β-Elemene-induced autophagy protects human gastric cancer cells from undergoing apoptosis

Background

β-Elemene, a compound found in an herb used in traditional Chinese medicine, has shown promising anti-cancer effects against a broad spectrum of tumors. The mechanism by which β-elemene kills cells remains unclear. The aim of the present study is to investigate the anti-tumor effect of β-elemene on human gastric cancer cells and the molecular mechanism involved.

Results

β-Elemene inhibited the viability of human gastric cancer MGC803 and SGC7901 cells in a dose-dependent manner. The suppression of cell viability was due to the induction of apoptosis. A robust autophagy was observed in the cells treated with β-elemene; it was characterized by the increase of punctate LC3 dots, the cellular morphology, and the increased levels of LC3-II protein. Further study showed that β-elemene treatment up-regulated Atg5-Atg12 conjugated protein but had little effect on other autophagy-related proteins. PI3K/Akt/mTOR/p70S6K1 activity was inhibited by β-elemene. Knockdown of Beclin 1 with small interfering RNA, or co-treatment with the autophagy inhibitor, 3-methyladenine or chlorochine enhanced significantly the antitumor effects of β-elemene.

Conclusions

Our data provides the first evidence that β-elemene induces protective autophagy and prevents human gastric cancer cells from undergoing apoptosis. A combination of β-elemene with autophagy inhibitor might thus be a useful therapeutic option for advanced gastric cancer.

Molecular classification of gastric cancer: a new paradigm

PURPOSE

Gastric cancer may be subdivided into 3 distinct subtypes--proximal, diffuse, and distal gastric cancer--based on histopathologic and anatomic criteria. Each subtype is associated with unique epidemiology. Our aim is to test the hypothesis that these distinct gastric cancer subtypes may also be distinguished by gene expression analysis.

EXPERIMENTAL DESIGN

Patients with localized gastric adenocarcinoma being screened for a phase II preoperative clinical trial (National Cancer Institute, NCI #5917) underwent endoscopic biopsy for fresh tumor procurement. Four to 6 targeted biopsies of the primary tumor were obtained. Macrodissection was carried out to ensure more than 80% carcinoma in the sample. HG-U133A GeneChip (Affymetrix) was used for cDNA expression analysis, and all arrays were processed and analyzed using the Bioconductor R-package.

RESULTS

Between November 2003 and January 2006, 57 patients were screened to identify 36 patients with localized gastric cancer who had adequate RNA for expression analysis. Using supervised analysis, we built a classifier to distinguish the 3 gastric cancer subtypes, successfully classifying each into tightly grouped clusters. Leave-one-out cross-validation error was 0.14, suggesting that more than 85% of samples were classified correctly. Gene set analysis with the false discovery rate set at 0.25 identified several pathways that were differentially regulated when comparing each gastric cancer subtype to adjacent normal stomach.

CONCLUSIONS

Subtypes of gastric cancer that have epidemiologic and histologic distinctions are also distinguished by gene expression data. These preliminary data suggest a new classification of gastric cancer with implications for improving our understanding of disease biology and identification of unique molecular drivers for each gastric cancer subtype.

miR-449 inhibits cell proliferation and is down-regulated in gastric cancer

BACKGROUND

Gastric cancer is the fourth most common cancer in the world and the second most prevalent cause of cancer related death. The development of gastric cancer is mainly associated with H. Pylori infection leading to a focus in pathology studies on bacterial and environmental factors, and to a lesser extent on the mechanistic development of the tumour. MicroRNAs are small non-coding RNA molecules involved in post-transcriptional gene regulation. They are found to regulate genes involved in diverse biological functions and alterations in microRNA expression have been linked to the pathogenesis of many malignancies. The current study is focused on identifying microRNAs involved in gastric carcinogenesis and to explore their mechanistic relevance by characterizing their targets.

RESULTS

Invitrogen NCode miRNA microarrays identified miR-449 to be decreased in 1-year-old Gastrin KO mice and in H. Pylori infected gastric tissues compared to tissues from wild type animals. Growth rate of gastric cell lines over-expressing miR-449 was inhibited by 60% compared to controls. FACS cell cycle analysis of miR-449 over-expressing cells showed a significant increase in the sub-G1 fraction indicative of apoptosis. ß-Gal assays indicated a senescent phenotype of gastric cell lines over-expressing miR-449. Affymetrix 133v2 arrays identified GMNN, MET, CCNE2, SIRT1 and CDK6 as miR-449 targets. Luciferase assays were used to confirm GMNN, MET, CCNE2 and SIRT1 as direct targets. We also show that miR-449 over-expression activated p53 and its downstream target p21 as well as the apoptosis markers cleaved CASP3 and PARP. Importantly, qPCR analyses showed a loss of miR-449 expression in human clinical gastric tumours compared to normal tissues.

CONCLUSIONS

In this study, we document a diminished expression of miR-449 in Gastrin KO mice and further confirmed its loss in human gastric tumours. We investigated the function of miR-449 by identifying its direct targets. Furthermore we show that miR-449 induces senescence and apoptosis by activating the p53 pathway.

Phase II study of modified docetaxel, cisplatin, and fluorouracil with bevacizumab in patients with metastatic gastroesophageal adenocarcinoma

PURPOSE

To evaluate the safety and efficacy of a modified administration schedule of docetaxel, cisplatin, and fluorouracil (mDCF) with bevacizumab in patients with advanced gastroesophageal malignancies.

PATIENTS AND METHODS

Previously untreated patients with metastatic gastroesophageal adenocarcinoma received bevacizumab 10 mg/kg, docetaxel 40 mg/m², fluorouracil 400 mg/m², leucovorin 400 mg/m² on day 1, fluorouracil 1,000 mg/m²/d × 2 days intravenous continuous infusion beginning on day 1, and cisplatin 40 mg/m² on day 3. The primary objective was to improve 6-month progression-free survival (PFS) from 43% (historical DCF control) to 63% with the addition of bevacizumab. The target accrual was 44 patients to have 10% type I and II error rates.

RESULTS

In total, 44 eligible patients with cancer were enrolled from October 2006 to October 2008: 22 gastric, 20 gastroesophageal junction (GEJ), and two esophagus. In 39 patients with measurable disease, the confirmed response rate was 67% (95% CI, 50% to 81%). Six-month PFS was 79% (95% CI, 63% to 88%), and median PFS was 12 months (95% CI, 8.8 to 18.2 months). With 26-month follow-up, median overall survival (OS) was 16.8 months (95% CI, 12.1 to 26.1 months), and 2-year survival was 37%. Treatment-related grade 3 to 4 toxicity was as follows: neutropenia without fever (50%), fatigue (25%), venous thromboembolism (39%), and nausea, vomiting, mucositis, neuropathy, and febrile neutropenia less than 10% each. In subset analysis, diffuse gastric cancer had significantly worse PFS and OS, and the response rate in proximal/GEJ tumors was 85% (95% CI, 62% to 97%).

CONCLUSION

mDCF with bevacizumab appears tolerable and has notable patient outcomes in patients with advanced gastroesophageal adenocarcinoma. Six-month PFS was 79%, surpassing our predefined efficacy end point, and median and 2-year OS were 16.8 months and 37%, respectively.