Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine

Better 5-year survival rate following curative gastrectomy in overweight patients

BACKGROUND

Westernization of lifestyle and diet has resulted in an increase in overweight patients in Japan. Although the adverse effects of higher body mass index (BMI) on early surgical outcomes are known, the relationship between BMI and long-term outcome is unclear.

MATERIALS AND METHODS

Clinicopathological characteristics and 5-year survival rate of overweight (BMI >or= 25 kg/m2; H-BMI; n = 1126) and nonoverweight (BMI < 25 kg/m2; N-BMI; n = 6799) patients who underwent gastrectomy with curative intent at the Cancer Institute Hospital between 1970 and 2004 were compared.

RESULTS

Patients in the H-BMI group tended to have earlier-stage disease. The 5-year survival rate was significantly better in the H-BMI than N-BMI group (81.5% vs 74.1%, respectively; P < .001). Postoperative mortality was 1% in both groups (P = .482), whereas postoperative morbidity was 22% and 19% in the H-BMI and N-BMI groups, respectively (P = .007). Multivariate analysis indicated overweight, age, gender, surgical procedure, histology, operation year, pT, and pN as independent prognostic factors. Subset analyses of pT and pN stages revealed overweight as an independent prognostic factor in patients with pT1 and pN0.

CONCLUSION

The 5-year survival rate following curative gastrectomy is better in overweight than nonoverweight Japanese patients, especially for early-stage gastric cancer. Further studies are needed to determine whether these results apply to other countries where morbidity and mortality for gastric cancer are higher than in Asian countries.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Establishment and identification of a rabbit model of peritoneal carcinomatosis from gastric cancer

BACKGROUND

Gastric cancer peritoneal carcinomatosis is a common clinical problem, but there are no suitable large animal models to study this problem. This study was to establish a stable rabbit peritoneal carcinomatosis model of gastric cancer using VX2 tumor, and analyze the clinico-pathological features.

METHODS

VX2 tumor was implanted into 36 New Zealand rabbits by 3 methods: laparotomic orthotopic injection of cancer cells into the submucosal layer of the stomach (Group A), laparotomic implantation of tumor tissue into the greater omentum immediately beneath the gastric antrum (Group B), and percutaneous injection of tumor cells directly into the peritoneal cavity (Group C), 12 rabbits in each group. The animals were closely observed and detailed clinico-pathological studies were conducted.

RESULTS

The success rates of peritoneal carcinomatosis formation were 100% (12/12), 91.7% (11/12) and 58.3% (7/12), respectively, for Groups A, B and C (P = 0.019, A versus C; P = 0.077, B versus C; P = 0.500, A versus B, Fisher's exact test). Two weeks after submucosal cancer cells injection in Group A, ulcerative gastric cancer with peritoneal carcinomatosis showed typical VX2 tumor pathology, with widespread intraperitoneal metastatic nodules, bloody ascites and perspicuous pulmonary metastases. The clinico-pathological progression pattern was very similar to patients of advanced gastric cancer with peritoneal carcinomatosis. Groups B and C showed similar pattern of cancer progression, but less aggressive.

CONCLUSIONS

First large animal model of peritoneal carcinomatosis from gastric cancer has been established by laparotomic orthotopic injection of VX2 cancer cells into the submucosal layer of the stomach, providing a more suitable model for surgical interventional studies. The clinico-pathological features of this model resemble human peritoneal carcinomatosis.

A case of esophageal adenocarcinoma arising from the ectopic gastric mucosa in the thoracic esophagus

A 75-year old man was detected with a pediculate tumor in the upper esophagus. A biopsy determined that it was an adenocarcinoma. A subtotal esophagectomy with dissection of three-fields of lymph nodes was selected. The pathological study revealed it to be an esophageal adenocarcinoma arising from ectopic gastric mucosa of the fundus of the stomach. His post-operative course was uneventful and without sign of recurrence for 3.5 years.

Recent advances in chemotherapy for advanced gastric cancer in Japan

In the early 1990s, a combination of 5-fluorouracil (5-FU) and cisplatin was widely adopted to treat advanced gastric cancer; however, no survival advantage over single-agent 5-FU was confirmed by the results of randomized trials conducted over a long period. Recently developed agents such as irinotecan, taxanes (docetaxel), and new oral fluorouracil (S-1) have yielded more promising results, with a response rate of over 50% and a median survival time of over 10 months in combination studies. These newer combination regimens were investigated in various randomized phase III studies to clarify if the newer-generation regimens provided a survival advantage over the older-generation regimens. Based on the findings of a large randomized study, S-1 has become standard in the adjuvant setting after D2 dissection curatively resected stage II and III gastric cancer. This article reviews the recent advances in gastric cancer chemotherapy, especially in Japan.

Association of CYP2A6 polymorphisms with S-1 plus docetaxel therapy outcomes in metastatic gastric cancer

AIMS

S-1, an oral fluoropyrimidine, contains tegafur, which is converted to 5-fluorouracil mainly by CYP2A6. We evaluated the association between CYP2A6 polymorphisms and treatment outcome in metastatic gastric cancer patients treated with S-1 plus docetaxel.

MATERIALS & METHODS

Chemonaive patients received S-1 40 mg/m(2) twice daily on days 1-14 and docetaxel 35 mg/m(2) on days 1 and 8 of a 3-week cycle. We analyzed the wild-type (W) allele (CYP2A6*1) and four variant (V) alleles that abolish or reduce enzyme activity (CYP2A6*4, *7, *9 and *10). A total of 50 patients were enrolled.

RESULTS

The genotype frequencies were as follows: W/W (n=14, 28%), W/V (n=26, 52%) and V/V (n=0, 20%). Patients having fewer variant alleles had significantly better response rates (W/W vs W/V vs V/V=79 vs 65 vs 30%; p=0.04) and median progression-free survival (W/W vs W/V vs V/V=8.1 vs 6.9 vs 3.1 months; p=0.0009).

CONCLUSION

Our findings showed that the CYP2A6 genotype correlated with the treatment efficacy of S-1-based chemotherapy in previously untreated metastatic gastric cancer patients.

Recent advances in gastrointestinal oncology--updates and insights from the 2009 annual meeting of the American society of clinical oncology

We have reviewed the pivotal presentations related to gastrointestinal malignancies from 2009 annual meeting of the American Society of Clinical Oncology with the theme of "personalizing cancer care". We have discussed the scientific findings and the impact on practice guidelines and ongoing clinical trials. Adding trastuzumab to chemotherapy improved the survival of patients with advanced gastric cancer overexpressing human epidermal growth factor receptor 2. Gemcitabine plus cisplatin has become a new standard for first-line treatment of advanced biliary cancer. Octreotide LAR significantly lengthened median time to tumor progression compared with placebo in patients with metastatic neuroendocrine tumors of the midgut. Addition of oxaliplatin to fluoropyrimidines for preoperative chemoradiotherapy in patients with stage II or III rectal cancer did not improve local tumor response but increased toxicities. Bevacizumab did not provide additional benefit to chemotherapy in adjuvant chemotherapy for stage II or III colon cancer. In patients with resected stage II colon cancer, recurrence score estimated by multigene RT-PCR assay has been shown to provide additional risk stratification. In stage IV colorectal cancer, data have supported the routine use of prophylactic skin treatment in patients receiving antibody against epidermal growth factor receptor, and the use of upfront chemotherapy as initial management in patients with synchronous metastasis without obstruction or bleeding from the primary site.

Chemotherapy for advanced gastric cancer

BACKGROUND

Gastric cancer currently ranks second in global cancer mortality. Most patients are either diagnosed at an advanced stage, or develop a relapse after surgery with curative intent. Apart from supportive care and palliative radiation to localized (e.g. bone) metastasis, systemic chemotherapy is the only treatment option available in this situation.

OBJECTIVES

To assess the efficacy of chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapy regimens in advanced gastric cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE up to March 2009, reference lists of studies, and contacted pharmaceutical companies and national and international experts.

SELECTION CRITERIA

Randomised controlled trials on systemic intravenous chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapies in advanced gastric cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. A third investigator was consulted in case of disagreements. We contacted study authors to obtain missing information.

MAIN RESULTS

Thirty five trials, with a total of 5726 patients, have been included in the meta-analysis of overall survival. The comparison of chemotherapy versus best supportive care consistently demonstrated a significant benefit in overall survival in favour of the group receiving chemotherapy (hazard ratios (HR) 0.37; 95% confidence intervals (CI) 0.24 to 0.55, 184 participants). The comparison of combination versus single-agent chemotherapy provides evidence for a survival benefit in favour of combination chemotherapy (HR 0.82; 95% CI 0.74 to 0.90, 1914 participants). The price of this benefit is increased toxicity as a result of combination chemotherapy. When comparing 5-FU/cisplatin-containing combination therapy regimens with versus without anthracyclines (HR 0.77; 95% CI 0.62 to 0.95, 501 participants) and 5-FU/anthracycline-containing combinations with versus without cisplatin (HR 0.82; 95% CI 0.73 to 0.92, 1147 participants) there was a significant survival benefit for regimens including 5-FU, anthracyclines and cisplatin. Both the comparison of irinotecan versus non-irinotecan (HR 0.86; 95% CI 0.73 to 1.02, 639 participants) and docetaxel versus non-docetaxel containing regimens (HR 0.93; 95% CI 0.75 to 1.15, 805 participants) show non-significant overall survival benefits in favour of the irinotecan and docetaxel-containing regimens.

AUTHORS' CONCLUSIONS

Chemotherapy significantly improves survival in comparison to best supportive care. In addition, combination chemotherapy improves survival compared to single-agent 5-FU. All patients should be tested for their HER-2 status and trastuzumab should be added to a standard fluoropyrimidine/cisplatin regimen in patients with HER-2 positive tumours. Two and three-drug regimens including 5-FU, cisplatin, with or without an anthracycline, as well as irinotecan or docetaxel-containing regimens are reasonable treatment options for HER-2 negative patients.

Potential utility of HOP homeobox gene promoter methylation as a marker of tumor aggressiveness in gastric cancer

HOP homeobox (HOPX) is an unusual homeobox gene encoding three spliced transcript variants, among which the only HOPX-beta promoter harbors CpG islands. The characteristics of its promoter methylation was analyzed using bisulfite sequencing and quantitative-methylation-specific polymerase chain reaction (Q-MSP), and the effects of HOPX expression were also examined. HOPX-beta expression was silenced in all gastric cancer cell lines tested; its expression could be restored by treatment with demethylating agent. On Q-MSP, HOPX-beta hypermethylation (cut-off value of 3.55) was found in 84% (67 out of 80) of primary tumor tissues and 10% (8 out of 80) of the corresponding normal tissues and could discriminate normal from tumor tissues (P<0.0001). The prognosis of the advanced cases with HOPX-beta hypermethylation was as poor as those with stage IV disease when cut-off value was set at 11.28. This finding was validated in an independent cohort of 90 advanced gastric cancers. The HOPX-beta hypermethylation was also an independent prognostic factor (P=0.029) on multivariate analysis. Exogenous HOPX expression significantly inhibited cell proliferation, colony formation and invasion as well as enhanced apoptosis. Taken together, HOPX-beta promoter methylation is a frequent and cancer-specific event in gastric cancer. Quantitative assessment of HOPX-beta methylation has great clinical potential as a marker of tumor aggressiveness.

Comparison of combination chemotherapy with irinotecan and cisplatin regimen administered every 2 or 4 weeks in pretreated patients with unresectable or recurrent gastric cancer: retrospective analysis

BACKGROUND

Efficacy and safety of irinotecan and cisplatin administration every 2 weeks (biweekly regimen) or 4 weeks (4-weekly regimen) in patients with pretreated unresectable or recurrent gastric cancer was retrospectively evaluated.

METHODS

Study patients comprised two cohorts: cohort 1, consisting of 31 patients received chemotherapy on a 4-weekly regimen; and cohort 2, consisting of 32 patients received chemotherapy on a biweekly regimen. In cohort 1, patients received irinotecan (70 mg/m(2)) on days 1 and 15 and cisplatin (80 mg/m(2)) on day 1 every 4 weeks; in cohort 2, patients received irinotecan (60 mg/m(2)) on day 1 and cisplatin (30 mg/m(2)) on day 1 every 2 weeks.

RESULTS

Response rates were for cohorts 1 and 2 were 26% (7/27) and 28% (7/25) in patients with measurable lesions, median progression-free survivals were 3.5 and 4.3 months, and median survival times after irinotecan and cisplatin initiation were 9.5 and 10.1 months, respectively. The incidence of grades 3 and 4 hematological toxicities in cohorts 1 and 2 were 74% and 44% for leukopenia, 81% and 53% for neutropenia, and 45% and 28% for anemia, respectively. Incidences of grades 3 and 4 nonhematological toxicities were 23% and 12% for nausea, 23% and 9% for vomiting, 19% and 12% for anorexia, and 6% and 6% for febrile neutropenia, respectively.

CONCLUSION

Irinotecan plus cisplatin chemotherapy administered on a biweekly regimen was comparable in efficacy to a 4-weekly regimen and might be more feasible than the 4-weekly regimen.

Variations in gastric cancer care: a trend beyond racial disparities

BACKGROUND

Race is associated with patterns of presentation and survival outcomes of gastric cancer in the United States. However, the impact of race on the receipt of guideline-recommended care is not well characterized. By using current recommendations, the authors examined the association between race and guideline-recommended treatments and identified factors that are predictive of variations in gastric cancer care.

METHODS

By using the National Cancer Database for 1998 through 2005, 106,002 patients with gastric adenocarcinoma were identified. Multivariate analysis techniques were used to examine the association between race, the receipt of guideline-recommended care, and survival after adjusting for covariates.

RESULTS

Although African-American and Hispanic patients were more likely to undergo adequate lymphadenectomy (> or =15 lymph nodes) and to receive care at comprehensive cancer centers and high-volume facilities (for all, P < or = .001), they were less likely to receive adjuvant multimodality therapy for American Joint Committee on Cancer stage IB through IV, lymph node-negative (M0) disease. Up to 60% of all patients who underwent gastrectomy failed to receive adequate lymphadenectomy and adjuvant multimodality therapy. The delivery of multimodality therapy varied significantly by stage and lymph node evaluation (P < or = .001). These findings persisted on our multivariate analyses, indicating that African-American and Hispanic patients received adequate lymph node evaluation (P < or = .001), whereas they were associated with receiving no adjuvant multimodality therapy (P < or = .025).

CONCLUSIONS

There were significant variations in treatment for gastric cancer among ethnic groups in the United States. It was noteworthy that, although nonwhite race was associated with improved surgical care, gastric cancer care remained suboptimal overall. Cancer programs need to identify procedures to maximize the delivery of adequate gastric cancer care to all patients.

Population-based differences in treatment outcome following anticancer drug therapies

Population-based differences in toxicity and clinical outcome following treatment with anticancer drugs have an important effect on oncology practice and drug development. These differences arise from complex interactions between biological and environmental factors, which include genetic diversity affecting drug metabolism and the expression of drug targets, variations in tumour biology and host physiology, socioeconomic disparities, and regional preferences in treatment standards. Some well-known examples include the high prevalence of activating epidermal growth factor receptor (EGFR) mutations in pulmonary adenocarcinoma among northeast (China, Japan, Korea) and parts of southeast Asia (excluding India) non-smokers, which predict sensitivity to EGFR kinase inhibitors, and the sharp contrast between Japan and the west in the management and survival outcome of gastric cancer. This review is a critical overview of population-based differences in the four most prevalent cancers in the world: lung, breast, colorectal, and stomach cancer. Particular attention is given to the clinical relevance of such knowledge in terms of the individualisation of drug therapy and in the design of clinical trials.

Alternate-day treatment with S-1 in patients with gastric cancer: a retrospective study of strategies for reducing toxicity

BACKGROUND

In patients with adverse events of S-1, the dose is generally reduced or the treatment cycle is shortened. Whether the therapeutic effectiveness of modified regimens is similar to that of the standard dosage remains unclear.

METHODS

We retrospectively studied patients with gastric cancer who received S-1 on alternate days.

RESULTS

A total of 266 patients received S-1 on alternate days. In 116 patients, S-1 was initially given at the standard dosage but was switched to alternate-day treatment because of toxicity within 28 days on average. The other 150 patients initially received alternate-day treatment because of poor general condition. In the adjuvant chemotherapy group (n = 96), the 3-year survival rate was 88% in patients with stage II, 73% in stage IIIA, and 67% in stage IIIB who underwent D2 lymph-node dissection. In the palliative surgery group (n = 96), the response rate was 13%, with a median survival time (MST) of 624 days. In patients with unresectable/recurrent disease (n = 74), the response rate was 25%, with an MST of 338 days. Among the 116 patients who initially received treatment on consecutive days, 100% had grade 1, 53% had grade 2, and 5.2% had grade 3 adverse events. When S-1 was switched to alternate-day treatment, toxicity decreased in all patients. In the 266 patients who received alternate-day treatment, 8% had grade 1, 6% had grade 2, and 0% had grade 3 adverse events.

CONCLUSION

Alternate-day treatment with S-1 may have milder adverse events without compromising therapeutic effectiveness.

Health-related quality of life and survival in the 2 years after surgery for gastric cancer

BACKGROUND

This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer.

METHODS

Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for 2 years afterwards. Changes of 10 or more points on a 0-100 scale were considered clinically significant.

RESULTS

Some 30 patients were alive after 2 years (52%). In the first 3 months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by 6 months in patients who subsequently were alive at 2 years, although at least a third of patients experienced specific symptoms, even 6 months after surgery, especially diarrhoea. For those dying within 2 years, some postoperative functional HRQL recovery occurred, but many symptoms were common.

CONCLUSIONS

Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some 2 years. Patients who die within 2 years may experience limited postoperative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

Can superextended lymph node dissection be justified for gastric cancer with pathologically positive para-aortic lymph nodes?

BACKGROUND

The prognosis of patients with gastric cancer and para-aortic lymph node (PALN) metastasis is poor. Recent Japanese randomized trials concluded that prophylactic PALN dissection is not effective for curable advanced gastric cancer. However, the value of curative resection in patients with pathologically positive PALN is not determined yet.

METHODS

We retrospectively identified 178 patients with pathologically positive PALN who underwent curative resection at the Cancer Institute Hospital from 1980 to 2004. Patient characteristics were analyzed and independent prognostic factors for death were identified by Cox proportional hazard model.

RESULTS

Partial gastrectomy was the most frequently performed procedure (142 of 178). Postoperative morbidity and mortality rates were 30 and 2%, respectively, with a 5-year survival rate of 13.0%. Multivariate analysis revealed the total number of positive nodes (hazard ratio, 1.804; 95% confidence interval, 1.221-2.665) and macroscopic type (hazard ratio, 1.697; 95% confidence interval, 1.138-2.530) as independent prognostic factors, while age, sex, histology, pathological tumor depth, and degree of PALN dissection were not statistically significant. The 5-year survival rate increased to 28.6% in patients with < or =15 positive nodes and macroscopic type other than type 4.

CONCLUSIONS

Prophylactic PALN dissection can not be justified in curable advanced gastric cancer. However, R0 resection including PALN retrieval might be beneficial in patients with pathologically positive PALN, providing patients are carefully selected and operations are performed safely.

ML17032 trial: capecitabine/cisplatin versus 5-fluorouracil/cisplatin as first-line therapy in advanced gastric cancer

The combination of infusional 5-fluorouracil (5-FU) and cisplatin is commonly used for the treatment of advanced gastric cancer. Capecitabine is an oral fluoropyrimidine designed to mimic a continuous infusion of 5-FU, and its use can prevent the need for cumbersome intravenous catheters and hospitalization of patients. Capecitabine has another pharmacologic advantage over intravenous 5-FU as it is preferentially activated by 5-FU in tumor tissue, which has higher activity of thymidine phosphorylase than normal tissue, resulting in selective accumulation of 5-FU within tumor tissue. The final analysis of a large, international, multicenter Phase III trial (ML17032) comparing capecitabine/cisplatin versus 5-FU/cisplatin as first-line therapy in patients with advanced gastric cancer was recently published in Annals of Oncology. The purpose of this review is to summarize the ML17032 study, and to discuss the impact and implications of the results.

Optimal surgery for advanced gastric cancer

Locoregional control remains a major problem after surgery, although a curative resection is still the only treatment to offer a cure for patients with gastric cancer. Despite the results of major randomized trials, the extent of nodal dissection continues to be debated. If there is a survival benefit to be gained by extended lymphadenectomy, added operative mortality should be eliminated. A pancreas and spleen-preserving D2 lymphadenectomy provides superior staging information and may provide a survival benefit while avoiding its excess morbidity. Splenectomy during gastric resection for tumors not adjacent to or invading the spleen increases morbidity and mortality without improving survival. Therefore, splenectomy should not be performed unless there is direct tumor extension. The Maruyama Index and nomograms that predict disease-specific survival may help to discriminate between patients with a high risk of relapse and select those patients who will be most likely to benefit from tailored multimodality treatment. There is growing evidence that gastric cancer surgery should be performed in high-volume centers with experienced specialists to reduce morbidity and operative mortality and to achieve better survival results.

Surgical outcome after docetaxel-based neoadjuvant chemotherapy in locally-advanced gastric cancer

AIM: To investigate feasibility, morbidity and surgical mortality of a docetaxel-based chemotherapy regimen randomly administered before or after gastrectomy in patients suffering from locally-advanced resectable gastric cancer.

METHODS: Patients suffering from locally-advanced (T3-4 any N M0 or any T N1-3 M0) gastric carcinoma, staged with endoscopic ultrasound, bone scan, computed tomography, and laparoscopy, were assigned to receive four 21 d/cycles of TCF (docetaxel 75 mg/m² day 1, cisplatin 75 mg/m² day 1, and fluorouracil 300 mg/m² per day for days 1-14), either before (Arm A) or after (Arm B) gastrectomy. Operative morbidity, overall mortality, and severe adverse events were compared by intention-to-treat analysis.

RESULTS: From November 1999 to November 2005, 70 patients were treated. After preoperative TCF (Arm A), thirty-two (94%) resections were performed, 85% of which were R0. Pathological response was complete in 4 patients (11.7%), and partial in 18 (55%). No surgical mortality and 28.5% morbidity rate were observed, similar to those of immediate surgery arm (P = 0.86). Serious chemotherapy adverse events tended to be more frequent in arm B (23% vs 11%, P = 0.07), with a single death per arm.

CONCLUSION: Surgery following docetaxel-based chemotherapy was safe and with similar morbidity to immediate surgery in patients with locally-advanced resectable gastric carcinoma.

Multicenter phase III comparison of cisplatin/S-1 with cisplatin/infusional fluorouracil in advanced gastric or gastroesophageal adenocarcinoma study: the FLAGS trial

PURPOSE

Patients with advanced gastric or gastroesophageal adenocarcinoma need more efficacious and safer treatments than established today. S-1, a contemporary oral fluoropyrimidine, can provide that advantage.

PATIENTS AND METHODS

This study was conducted in 24 countries and 146 centers. One thousand fifty-three patients were stratified (center, number of metastatic sites, prior adjuvant therapy, and measurable cancer) and randomly assigned. Patients received either S-1 at 50 mg/m(2) divided in two daily doses for 21 days and cisplatin at 75 mg/m(2) intravenously on day 1, repeated every 28 days (527 patients) or infusional fluorouracil at 1,000 mg/m(2)/24 hours for 120 hours and cisplatin at 100 mg/m(2) intravenously on day 1, repeated every 28 days (526 patients). The primary end point was superiority in overall survival (OS) from cisplatin/S-1 compared with cisplatin/infusional fluorouracil in patients with advanced, untreated gastric, or gastroesophageal adenocarcinoma. The secondary end points were response rate, progression-free survival, time to treatment failure, and safety.

RESULTS

The median OS was 8.6 months in the cisplatin/S-1 arm and 7.9 months in the cisplatin/infusional fluorouracil arm (HR, 0.92; 95% CI, 0.80 to 1.05; P = .20). Significant safety advantages were observed in the cisplatin/S-1 arm compared with the cisplatin/infusional fluorouracil arm for the rates of grade 3/4 neutropenia (32.3% v 63.6%), complicated neutropenia (5.0% v 14.4%), stomatitis (1.3% v 13.6%), hypokalemia (3.6% v 10.8%), and treatment-related deaths (2.5% v 4.9%; P < .05).

CONCLUSION

Cisplatin/S-1 did not prolong OS of patients with advanced gastric or gastroesophageal adenocarcinoma compared with cisplatin/infusional fluorouracil, but it did result in a significantly improved safety profile.

Synergistic antitumor effects of FGFR2 inhibitor with 5-fluorouracil on scirrhous gastric carcinoma

Scirrhous gastric carcinoma (SGC) carries the highest mortality because of a frequent metastasis to lymph node (LN). S1, a 5-fluorouracil (5-FU) analog, is clinically available for gastric cancer at an advanced stage. Fibroblast growth factor receptor 2 (FGFR2) is required for the proliferation of SGC. The objective of this study is to clarify the benefit of a combination of S1 and kinase inhibitors including FGFR2 inhibitor Ki23057 in gastric cancer. OCUM-2MLN and KATO-III were derived from SGC. MKN-7 and MKN-74 were derived from non-SGC. MTT assay was used to examine the growth-inhibitory activity of 5 small-synthetic molecules including Ki23057, Sunitinib, Glivec, Lapatinib or SU11274, in cells cultured with 5-FU. Combination effects of 5-FU with Ki23057 on proliferation, apoptosis and mRNA expression were examined. S1 and/or Ki23057 were administered to murine models of SGC created by the orthotopic inoculation of OCUM-2MLN cells. Ki23057 at 100 nM significantly (p < 0.01) inhibited the proliferation and decreased the phosphorylation of FGFR2 in SGC cells, but not in non-SGC. Ki23057 showed synergistic antitumor effects for SGC cells in combination with 5-FU using CalcuSyn analysis, but Sunitinib, Glivec, Lapatinib and SU11274 did not. The combination of Ki23057 and 5-FU decreased DPD expression and increased apoptosis rates and p21 expression level of SGC cells. The combined administration of S1 and Ki23057 significantly (p < 0.05) decreased orthotopic tumors as well as LN metastasis more effectively than S1 alone. These findings suggested that the combined treatment with 5-FU and Ki23057 produced synergistic antitumor effects and is therapeutically promising for SGC treatment.

Docetaxel: its role in current and future treatments for advanced gastric cancer

A globally accepted standard chemotherapy remains undetermined in gastric cancer, but the recent introduction of active "new-generation agents" such as taxanes, irinotecan (CPT-11), oxaliplatin, S-1, and capecitabine, offers hope for markedly improving patient outcomes. Docetaxel, as well as the other new-generation agents, plays a key role in the development of the new-era chemotherapy, and the incorporation of taxanes has provided several regimens, such as docetaxel/cisplatin/5-fluorouracil (5-FU) (DCF), that could become standard treatment. The DCF regimen is now regarded as a standard treatment option in advanced gastric cancer in selected patients in good condition. Many institutions and cooperative groups continue to study a variety of docetaxel-based combinations with "new-generation cytotoxic agents" in various treatment settings, and recent attention has been focused on the incorporation of biological agents, such as cetuximab, bevacizumab, everolimus, and sunitinib, into docetaxel-containing combinations as another innovative approach. The ongoing clinical trials of a number of new regimens will clarify their clinical benefits in gastric cancer treatment. Along with the development of more active docetaxel combination regimens, the identification of predictive biomarkers for each regimen has been intensively studied recently. This review focuses on docetaxel as a key agent in gastric cancer chemotherapy, and discusses the role of this taxane in current and future treatments for advanced gastric cancer.

Randomized clinical trials in gastric cancer

Minimally invasive resection has emerged as a surgical technique for gastric cancer, and there has been continued investigation to determine the appropriate extent of lymphadenectomy in gastric cancer patients. There has also been significant progress in evaluating the role of chemotherapeutic regimens used in the neoadjuvant and adjuvant settings for patients with resectable disease. We also summarize a selection of RCT trials focused on the perioperative care of the gastric cancer patient.

Advances in the pharmacological treatment of gastro-oesophageal cancer

Despite a sharp decline in the incidence of gastric cancer during the second half of the 20th century, this malignancy remains the second leading cause of cancer mortality in the world. The incidence and mortality rate of gastric cancer increase with age; at present, the median ages at diagnosis are 67 years for men and 72 years for women in the US. This article reviews and discusses current medical treatment options for both the general population and elderly gastric cancer patients. Management of localized gastric cancer has changed significantly over recent years. Adjuvant chemoradiation is not generally recommended outside the US. After decades of trials of adjuvant chemotherapy with inconclusive results, a significant survival benefit for perioperative combination chemotherapy - as compared with surgery alone - in patients with resectable or locally advanced gastro-oesophageal cancer was recently demonstrated in the UK MAGIC trial. A further large, randomized trial from Japan demonstrated a significant survival benefit for adjuvant chemotherapy with S-1 after D2 resection for gastric cancer. However, both trials are applicable only to the population in which the trials were conducted. Specific data on elderly patients are missing. For patients with metastatic disease, oral fluoropyrimidines, such as capecitabine, have been developed. In Asian patients, treatment with the oral fluoropyrimidine S-1 is safe and effective. Docetaxel, oxaliplatin and irinotecan have demonstrated activity against gastric cancer in appropriately designed, randomized, phase III trials and have increased the available treatment options significantly. In addition, according to preliminary data, trastuzumab in combination with chemotherapy has significantly improved activity when compared to chemotherapy alone in patients with human epidermal receptor (HER)-2-positive gastric and gastro-oesophageal cancers. Thus, therapeutic decisions in patients with advanced gastric cancer may be adapted to the molecular subtype and co-morbidities of the individual patient. Data from retrospective analyses suggest that oxaliplatin seems to be better tolerated than cisplatin in elderly patients.

Advances in the management of gastric cancer

Gastric cancer is a common malignancy in our country and patients continue to present at an advanced stage. Following confirmation of diagnosis, CT scan, endoscopic ultrasound and laparoscopy are the essential staging modalities. Radical gastrectomy remains the initial treatment of choice. Although controversy persists about the extent of lymph node dissection, there is a general consensus in performing D2 dissection but with preservation of pancreas and spleen. Patients who have high risk of relapse are treated with postoperative chemoradiotherapy. The regimen of preoperative chemotherapy followed by gastrectomy and postoperative chemotherapy has also become important in recent years. Both these chemotherapeutic options confer survival advantage and patients need to be appraised about various treatment strategies at the very outset.

Recommendations on current approach to gastric cancer

The management of gastric cancer has been updated by the Grupo Español de Tratamiento de Tumores Digestivos (TTD). A multidisciplinary approach is essential in these patients including a precise diagnosis and staging and correct nutritional evaluation. For resectable disease, surgical resection remains the treatment mainstay and both perioperatory chemotherapy and postoperatory chemo-radiotherapy are considered standard complementary treatments. In advanced disease chemotherapy should always be considered. There are different reference schemes (TCF, XC, ECF, EXC) and the therapeutic option has to be individualised. Recently a phase III trial has shown a significant improvement in overall survival when trastuzumab is added to cisplatin-capecitabine or cisplatin-5-fluorouracil in patients with HER2+ advanced gastric cancer. Currently, there are several ongoing clinical trials evaluating the role of other new drugs against cellular targets. It would be desirable to incorporate biomarker studies in these trials in order to identify the best treatment for each patient.

Expression of thymidylate synthase determines the response of gastric cancer patients undergoing gastrectomy to 5-fluorouracil-based adjuvant chemotherapy

PURPOSE

We investigated whether the intensity of thymidylate synthase (TS) staining in tissue samples obtained from gastric cancer (GC) patients undergoing gastrectomy could predict response to 5-FU-based adjuvant chemotherapy after gastrectomy.

METHOD AND MATERIALS

Clinicopathological features of 124 patients with histologically proven GC who underwent radical gastrectomy were retrospectively reviewed. Tissue samples obtained from these patients were immunohistochemically stained for assessing TS expression. We arbitrarily classified the TS staining results as low (<20% cytoplasmic immunostaining) and high (> or =20% cytoplasmic immunostaining) TS expression.

RESULTS

The clinicopathological features of the low TS expression group patients were typically similar to those of the high TS expression group patients. However, multivariate forward stepwise logistic regression analysis revealed that low TS expression was independently associated with females and responders to 5-FU-based adjuvant chemotherapy. The median follow-up duration for the 124 GC patients who had undergone curative resection was 41.3 months. The GC patients who showed poor tumor differentiation and high TS expression had short disease-free survival (DFS) and overall survival (OS).

CONCLUSIONS

Low TS expression is significantly associated with female GC patients and responders to 5-FU-based adjuvant chemotherapy. It predicts longer DFS and OS in selected GC patients treated with 5-FU-based adjuvant chemotherapy after curative resection. The results suggest that prospective assessment of TS staining intensity in tissue samples obtained from GC patients undergoing gastrectomy would be useful to predict the patients who would be benefited from 5-FU-based adjuvant chemotherapy after gastrectomy.

A retrospective comparison of concurrent 5-fluorouracil or oral UFT in postoperative chemoradiation for gastric adenocarcinoma

PURPOSE

5-fluoro-uracil (FU) is a common agent in postoperative chemoradiation in gastric adenocarcinoma. However, FU is not well tolerated in a significant proportion of patients. UFT, a fixed combination of the oral FU prodrug tegafur with uracil, is one of the agents used instead of FU in such cases. We retrospectively compared the toxicity, local and distant control and survival rates with FU or oral UFT during concurrent radiotherapy to assess the role of UFT instead of FU.

PATIENTS AND METHODS

We conducted a retrospective analysis of survival, disease control and toxicity data in 52 patients treated with postoperative chemoradiation following total or subtotal gastrectomy for gastric adenocarcinoma with either FU or UFT between January 2003 and December 2004.

RESULTS

Median follow-up was 20 months (range: 3-59), median survival time was 23 (+/-6.08) months and 1-3 years overall survival (OS) rates were 64.9-39% for all patients. Compared with the UFT regimen, the incidence of treatment interruption was greater with FU (p=0.023), but no significant differences were seen in local control (p=0.40), distant recurrences (p=0.83) and survival rates (p=0.8657) among patients.

CONCLUSION

Concurrent UFT with radiotherapy seems to be a more tolerable and an equally effective regimen in the postoperative treatment of gastric adenocarcinoma when compared to FU.

Synergistic antiproliferative effect of mTOR inhibitors in combination with 5-fluorouracil in scirrhous gastric cancer

The aim of this study is to clarify the benefit of combination chemotherapy in gastric cancer based on a cell-signal inhibitor and an anticancer drug. Two scirrhous gastric cancer cell lines and two non-scirrhous gastric cancer cell lines were used. Five anticancer drugs (5-fluorouracil [5FU], paclitaxel, oxaliplatin, irinotecan, and gemcitabine) and four cell-signal inhibitors, mammalian target of rapamycin (mTOR) inhibitor, glycogen synthase kinase 3beta, p38alphabetaMAPK, and cyclin-dependent kinase, were used. The proliferation of cancer cells was examined by MTT assay and in vivo study. The apoptosis of cancer cells and the expression of apoptosis-related molecules were examined by flow cytometry, real-time PCR, and immunostaining. mTOR inhibitors with 5FU showed a synergistic antiproliferative effect in scirrhous gastric cancer, whereas the other signal inhibitors showed no synergistic effect with any anticancer drugs. mTOR inhibitor decreased the IC(50) of 5FU and increased the apoptosis rate in scirrhous gastric cancer cells, but not in non-scirrhous gastric cancer cells. The pan-caspase inhibitor, zVAD-fmk, inhibits apoptosis induced in combination with 5FU and mTOR inhibitor. mTOR inhibitor decreased dihydropyrimidine dehydrogenase, thymidylatesynthase, and bcl-2 expression, and increased caspase-3 and p21 expression of scirrhous gastric cancer cells, but did not affect those of non-scirrhous gastric cancer cells. In an in vivo study, mTOR inhibitor significantly enhanced the therapeutic efficacy of S1, an analog of 5FU. These findings suggest that mTOR inhibitor interacts with 5FU in a synergistic manner in scirrhous gastric cancer cells by the activation of the apoptosis signal. Therefore, mTOR inhibitor is a promising therapeutic agent in combination with 5FU in scirrhous gastric cancer.

The expression and significance of P-glycoprotein, lung resistance protein and multidrug resistance-associated protein in gastric cancer

BACKGROUND

To detect the expression of multidrug resistance molecules P-glycoprotein (P-gp), Lung resistnce protein (LRP) and Multidrug resistance-associated protein (MRP) and analyze the relationship between them and the clinico-pathological features.

METHODS

The expressions of P-gp, LRP and MRP in formalin-fixed paraffin-embedded tissue sections from 59 gastric cancer patients were determined by a labbelled Streptavidin-Peroxidase (SP) immunohistochemical technique, and the results were analyzed in correlation with clinicopathological data. None of these patients received chemotherapy prior to surgery.

RESULTS

The positive rates of P-gp, LRP, MRP were 86.4%, 84.7% and 27.1%, respectively. The difference between the positive rate of P-gp and MRP was significant statistically, as well as the difference between the expression of MRP and LRP. No significant difference was observed between P-gp and LRP, but the positively correlation between the expression of P-gp and LRP had been found. No significant correlation between the expression of P-gp, LRP, MRP and the grade of differentiation were observed. The expression of P-gp was correlated with clinical stages positively (r = 0.742), but the difference with the expression of P-gp in different stages was not significant.

CONCLUSION

The expressions of P-gp, LRP and MRP in patients with gastric cancer without prior chemotherapy are high, indicating that innate drug resistance may exist in gastric cancer.