Adjuvant 5-fluorouracil plus doxorubicin in D2-3 resected gastric carcinoma: 15-year experience at a single institute

Novel Doxorubicin Derivatives: Synthesis and Cytotoxicity Study in 2D and 3D in Vitro Models

Purpose: Multidrug resistance (MDR) of tumors to chemotherapeutics often leads to failure of cancer treatment. The aim of the study was to prepare novel MDR-overcoming chemotherapeutics based on doxorubicin (DOX) derivatives and to evaluate their efficacy in 2D and 3D in vitro models. Methods: To overcome MDR, we synthesized five DOX derivatives, and then obtained non-covalent complexes with human serum albumin (HSA). Drug efficacy was evaluated for two tumor cell lines, namely human breast adenocarcinoma MCF-7 cells and DOX resistant MCF-7/ADR cells. Additionally, MCF-7 cells were entrapped in alginate-oligochitosan microcapsules, and generated tumor spheroids were used as a 3D in vitro model to study cytotoxicity of the DOX derivatives. Results: Due to 3D structure, the tumor spheroids were more resistant to chemotherapy compared to monolayer culture. DOX covalently attached to palmitic acid through hydrazone linkage (DOX-N2H-Palm conjugate) was found to be the most promising derivative. Its accumulation levels within MCF-7/ADR cells was 4- and 10-fold higher than those of native DOX when the conjugate was added to cultivation medium without serum and to medium supplemented with 10% fetal bovine serum, respectively. Non-covalent complex of the conjugate with HSA was found to reduce the IC50 value from 32.9 µM (for free DOX-N2H-Palm) to 16.8 µM (for HSA-DOX-N2H-Palm) after 72 h incubation with MCF-7/ADR cells. Conclusion: Palm-N2H-DOX conjugate was found to be the most promising DOX derivative in this research. The formation of non-covalent complex of Palm-N2H-DOX conjugate with HSA allowed improving its anti-proliferative activity against both MCF-7 and MCF-7/ADR cells.

Serum Helicobacter pylori CagA antibody may not be used as a tumor marker for diagnosing gastric cancer in east Asian countries

Gastric cancer (GC) is a highly malignant cancer with increasing incidence and mortality worldwide. Serum Helicobacter pylori CagA antibody has been widely reported to play an important role in diagnosing GC. However, published data on this subject are inconclusive. Therefore, we performed a meta-analysis to evaluate the sensitivity and specificity of serum H. pylori CagA antibody in the diagnosis of GC. We conducted a comprehensive search to identify eligible related studies, in which the pooled sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curves could be determined. A total of 12 studies including 1,524 cases and 3,324 controls who fulfilled all of the inclusion criteria were included for analysis. The summary estimates for serum H. pylori CagA antibody in the diagnosis of GC in these studies were pooled sensitivity 0.71 (95 % CI 0.69-0.73), specificity 0.40 (95 % CI 0.39-0.42), DOR 2.11 (95 % CI 1.55-2.8), and the area under the curve was 0.636. Our meta-analysis showed that serum H. pylori CagA antibody should not be used for detecting GC.

Correlation between serum CA724 and gastric cancer: multiple analyses based on Chinese population

Serum tumor biomarker carbohydrate antigen 724 (CA724) is noticeable for gastric cancer. Correlation between CA724 and gastric cancer was investigated based on Chinese population. Chinese Biomedical Database, Chinese Journal Full-text Database and PubMed were searched. Gastric cancer patients were proven by biopsy, and control included health volunteers or benign gastric diseases. Participants received at least one test of CA724, CA125, CA153, CA199, CA242 or CEA. Meta-analysis, summary ROC (SROC) and post hoc analysis were performed by RevMan 5.0 and SPSS 11.5. Totally, 33 eligible studies were analyzed. Meta-analysis showed CA724 had the highest odds ratio 32.86 compared to control, orderly followed by CA242, CA199, CEA, CA125 and CA153. Accumulated accuracy rate of CA724 was 77 %, superior to others. In SROC analysis, specificity of all studies was above 0.70, but sensitivity of few studies was above 0.70; CA724 was selected as the preferable single test, followed by CA242, CA199, CEA, CA125 and CA153. If threshold of both specificity and sensitivity up to 0.70, CA153 was unacceptable; if up to 0.80, only CA724 and CA242 were considerable. In CA724-combined patterns, CA724+CEA+CA199 combination performed best by increasing sensitivity to 0.74 without impairing specificity, while CA724 + CA199 pattern was not a proper combination. CA724 was the most correlative serum tumor biomarker for gastric cancer in Chinese population. Sensitivity of serum CA724 is limited, but CA724+CEA+CA199 combination is considerable to improve sensitivity without impairing specificity.

Comparison of short-term outcomes and perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer

OBJECTIVE

To compare the perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer.

METHODS

Patients with gastric adenocarcinoma proven by endoscopy and biopsy were eligible, while patients with preoperative staging of T4, N2-3, or M1 were excluded. Eligible patients willing to undertake laparoscopic surgery in the consecutive cohort were assigned to the laparoscopy-assisted gastrectomy (LAG) group, while concurrent patients were assigned to the conventional open gastrectomy (OG) group. All operations were performed with the intention of radical resection. Various immunological parameters were tested in peripheral venous blood collected at preoperative 1(st) day and postoperative 2(nd) day (POD2) and 7(th) day (POD7). SPSS 13.0 software was used for statistical analysis.

RESULTS

Thirty patients were included, 15 each in the LAG and OG groups. The general characteristics and short-term outcomes (harvested lymph nodes number, hospital stay, complications, and mortality rate) of the two groups were comparable, but the operation time was significantly longer in LAG (P = 0.001). Moreover, intergroup comparisons indicated no significant differences between the groups in levels of neutrophils, T-lymphocytes, natural killer cells, IgG, IgM, IgA, C3, C4, interleukin-6, or interleukin-10 at any time point (P>0.05). However, there was a gradual decrease in natural killer cell count in the LAG group up to POD7 (P = 0.008).

CONCLUSION

The changes in systemic immunity markers were comparable between laparoscopy-assisted and open gastrectomy for gastric cancer. However, there was a trend of suppression of natural killer cells in the laparoscopy-assisted gastrectomy group.

Two dosages of oral fluoropyrimidine S-1 of 35 and 40 mg/m2 bid: comparison of the pharmacokinetic profiles in Korean patients with advanced gastric cancer

Objective

In this study, we compared the pharmacokinetic profiles of 5-fluorouracil (5-FU), tegafur, 5-chloro-2,4-dihydroxypyridine (CDHP) and potassium oxonate (Oxo) after administration of S-1 at 35 or 40 mg/m² bid for 28 consecutive days, in Cycles 1 and 3, in patients with advanced gastric cancer.

Methods

Three patients were enrolled for each dosage. S-1 dosage was assigned based on body surface area (BSA), which is different from the Japanese dosing system. The median daily dose per BSA was 76 mg/m², ranging from 70 to 88 mg/m².

Results

Plasma levels of 5-FU, tegafur, CDHP and Oxo at 4 h post-dose reached steady-state on day 8. The estimated steady-state level was dependent on S-1 dosage. There were no intercyclic differences of pre-dose and 4 h post-dose levels between Cycles 1 and 3, implying no cumulative effect of S-1 was shown probably due to 2-week drug-resting period. Pharmacokinetic profiles on day 28 were similar to previous Japanese report. C_max and AUC_{0–48 h} values of each S-1 component increased depending on S-1 dosage. Pharmacokinetic parameters were not correlated with tumor response or toxicity.

Conclusions

We suggest that these pharmacokinetic profiles of Asian population could provide a basis for schedule optimization and for additional studies on interaction with other antitumor drugs.

Cloning and pharmacological characterization of a novel gene encoding human nucleoside transporter 1 (hNT1) from a human breast cancer cDNA library

AIMS

We isolated a novel gene encoding human nucleoside transporter 1 (hNT1), from a human breast cancer cDNA library.

MAIN METHODS

A nondirectional cDNA library was screened by an EST clone (GenBanktrade mark/EMBL/DDBJ: BU944345). A Xenopus laevis oocyte expression system was used for functional characterization. Membrane localization in the human breast was determined by immunohistochemistry.

KEY FINDINGS

Isolated hNT1 cDNA consisted of 246 base pairs that encoded an 82-amino acid protein. By RT-PCR analysis, hNT1 mRNA was strongly detected in the breast cancer tissues. When expressed in X. oocytes, hNT1 mediated the high affinity transport of [(3)H]5-fluorouracil (5-FU) with a K(m) value of 69.2+/-24.5 nM in time- and pH-dependent, and Na(+)-independent manners. A cis-inhibition experiment revealed that hNT1 mediated transport of [(3)H]5-FU is strongly inhibited by various nucleosides such as pyrimidine, uracil, uridine, guanosine, inosine, thymidine, adenosine, cytidine and purine suggesting that hNT1 may be involved in the trans epithelial transport of these endogenous substrates. Immunohistochemical analysis revealed that the hNT1 protein is localized in the lactiferous duct epithelium.

SIGNIFICANCE

Our present results indicate that a newly isolated cDNA clone, hNT1, is a key molecule for the breast handling of 5-FU in humans.

Changing patterns of prognosticators during 15-year follow-up of advanced gastric cancer after radical gastrectomy and adjuvant chemotherapy: a 15-year follow-up study at a single korean institute

BACKGROUND

We evaluated the long-term natural history of gastric cancer after radical gastrectomy and adjuvant chemotherapy through a 15-year follow-up study at a single institute.

METHODS

Five hundred patients with advanced gastric adenocarcinoma who received radical gastrectomy and adjuvant chemotherapy were included in this long-term follow-up study. Patients were evaluated by imaging studies and upper gastrointestinal series or endoscopy every 6 months until the 10th year after surgery. Since then, the patients have been followed yearly in the same manner.

RESULTS

The median follow-up period was 190.5 months. The recurrence rate in 5-year survivors was 10.8%. The dominant recurrence pattern was peritoneal carcinomatosis within 5 years and distant metastasis after 5 years post gastrectomy. Tumor stage was a clear-cut prognosticator within 5 years post gastrectomy, but was no longer informative in 5-10 years. At this period, only stage IV (IB-IIIB vs IVM0) was a significantly poor prognosticator. After 10 years, second primary cancer (seven cases) became as important an issue as recurrence of primary gastric cancer (six cases).

CONCLUSIONS

In patients with gastric carcinoma treated with radical gastrectomy and adjuvant chemotherapy, late recurrence after 5 years post gastrectomy was not rare. Prognosticators were varied depending on the length of time after surgery. Tumor factors including stage were prognosticators within 5 years post gastrectomy, but tumor factors except stage IV had no prognostic value after 5 years. In the 5-10 years post gastrectomy, only stage IV (IB-IIIB vs IVM0) was a poor prognosticator. Also, after 10 years, there were no prognosticators.

Prognostic impact of resection margin involvement after extended (D2/D3) gastrectomy for advanced gastric cancer: a 15-year experience at a single institute

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate whether microscopic positive margins are detrimental to the outcome of gastric cancer patients treated with extended (D2/3) gastrectomy.

METHODS

Among 2,740 consecutive patients who had undergone extended gastrectomy for advanced gastric cancer between January 1987 and December 2002, 49 patients (1.8%) had positive resection margins on final histology.

RESULTS

Among 49 patients, 29 (59.2%) had proximal involved margins and 20 (40.8%) had distal involved margins. The median survival time of the positive margin group was 34 months. The negative margin group had a significantly longer median survival time of 69 months (P = 0.025). When both groups of patients were stratified according to nodal stage, a positive resection margin determined a worse prognosis only in patients with node-negative disease (174 months vs. 37 months, P = 0.0001). In patients with nodal metastasis, the median survival time was similar in both groups.

CONCLUSIONS

Our results suggest that a positive microscopic margin is associated with a worse outcome in patients with node-negative disease. Therefore, a more aggressive treatment, such as re-operation, is needed in node-negative patients with a positive microscopic disease.

Multi‐Institutional Phase II Study of S‐1 Monotherapy in Advanced Gastric Cancer with Pharmacokinetic and Pharmacogenomic Evaluations

This study describes the first phase II study of S-1, a novel oral fluoropyrimidine, in a non-Japanese Asian population with advanced gastric cancer. S-1 was administered twice daily for 28 days every 6 weeks. A pharmacokinetic study was performed on day 28 of cycles 1 and 3. Genomic DNA from peripheral mononuclear cells was analyzed using a cDNA microarray-based comparative genomic hybridization (CGH) method. Thirty-one patients were initially given a dose of 35 mg/m(2) twice daily (bid) (group 1); then, the protocol was amended by increasing the dose to 40 mg/m(2) bid for an additional 31 patients (group 2) because of good tolerability to S-1. The overall response rate was 19.3% (95% confidence interval, 9.2%-29.5%). Over a median follow-up duration of 265 days, the median time to progression and overall survival time were 126 and 264 days, respectively. The 1-year survival rate was 34%. There was no grade 4 toxicity and the major adverse event was anemia. Pharmacokinetic parameters were similar to those of the previous Japanese reports. Microarray CGH identified 18 genes with copy number changes that were associated with hemoglobin reduction with S-1 treatment. A logistic regression analysis, integrating one clinical parameter (initial hemoglobin level) combined with three genetic copy number variations (HIST1H2BL, C10orf127, and XPNPEP2), provided a predictive model for the development of severe hemoglobin reduction. In conclusion, this study showed the feasibility of using S-1 at 35 mg/m(2) bid in gastric cancer. We suggest that the pharmacogenomic markers identified in this study may be potential candidates for predicting anemia after S-1 treatment.

Adjuvant chemotherapy with 5-fluorouracil, doxorubicin and mitomycin-C (FAM) for 6 months after curative resection of gastric carcinoma

AIM

This study aimed to evaluate the efficacy and safety of 5-fluorouracil (5-FU), doxorubicin and mitomycin-C (FAM) adjuvant chemotherapy in patients who had undergone curative resection of gastric carcinoma.

METHODS

From Nov 1999 to Jan 2002, 291 consecutive patients with stage IB-IIIB gastric adenocarcinoma were given FAM adjuvant chemotherapy. Chemotherapy comprised intravenous 5-FU 600 mg/m(2) (days 1, 8, 29 and 36), doxorubicin 30 mg/m(2) (days 1 and 29) and mitomycin-C 10 mg/m(2) (day 1), every 8 weeks for 6 months.

RESULTS

The median follow-up time was 60.6 months, 92 patients died, and 93 patients had recurrent disease. The 5-year overall survival (OS) rates were 85.9% for stage IB, 72.1% for stage II, 58.0% for stage IIIA, and 48.2% for stage IIIB (p=0.002). The 5-year relapse-free survival (RFS) rates were 85.2% for stage IB, 71.2% for stage II, 53.3% for stage IIIA, and 39.2% for stage IIIB (p<0.001). A total of 769 cycles of chemotherapy were delivered, and 15 patients experienced grade 3 or higher leukopenia. The most common grade 3 or higher non-hematologic toxicity was nausea/vomiting (11 patients), followed by stomatitis (3 patients).

CONCLUSIONS

Adjuvant chemotherapy with FAM for 6 months for gastric carcinoma indicated comparable RFS and OS with an acceptable toxicity profile.

Pilot study of postoperative adjuvant chemoradiation for advanced gastric cancer: Adjuvant 5-FU/cisplatin and chemoradiation with capecitabine

AIM: To evaluate the efficacy and toxicity of postoperative chemoradiation using FP chemotherapy and oral capecitabine during radiation for advanced gastric cancer following curative resection.

METHODS: Thirty-one patients who had underwent a potentially curative resection for Stage III and IV (M0) gastric cancer were enrolled. Therapy consists of one cycle of FP (continuous infusion of 5-FU 1000 mg/m² on d 1 to 5 and cisplatin 60 mg/m² on d 1) followed by 4500 cGy (180 cGy/d) with capecitabine (1650 mg/m² daily throughout radiotherapy). Four wk after completion of the radiotherapy, patients received three additional cycles of FP every three wk. The median follow-up duration was 22.2 mo.

RESULTS: The 3-year disease free and overall survival in this study were 82.7% and 83.4%, respectively. Four patients (12.9%) showed relapse during follow-up. Eight patients did not complete all planned adjuvant therapy. Grade 3/4 toxicities included neutropenia in 50.2%, anemia in 12.9%, thrombocytopenia in 3.2% and nausea/vomiting in 3.2%. Neither grade 3/4 hand foot syndrome nor treatment related febrile neutropenia or death were observed.

CONCLUSION: These preliminary results suggest that this postoperative adjuvant chemoradiation regimen of FP before and after capecitabine and concurrent radiotherapy appears well tolerated and offers a comparable toxicity profile to the chemoradiation regimen utilized in INT-0116. This treatment modality allowed successful loco-regional control rate and 3-year overall survival.

Transport mechanism and substrate specificity of human organic anion transporter 2 (hOat2 [SLC22A7])

Human organic anion transporter 2 (hOat2[SLC22A7]) is highly expressed in the human liver. Although localization, gene expression, substrate specificity and transport mechanisms of other human Oat isoforms such as human Oat1 (hOat1), human Oat3 (hOat3) and human Oat4 (hOat4) have been elucidated, information concerning human Oat2 (hOat2) is less defined. The objective of this study was to provide further information on the transport mechanism and substrate specificity of hOat2. When expressed in Xenopus laevis oocytes, the transport of organic compounds mediated by hOat2 was not affected by the replacement of extracellular sodium with lithium, choline and mannitol. The uptake of estrone sulfate (ES) in hOat2-expressing oocytes was significantly trans-stimulated by preloading the oocytes with fumarate and succinate, but not glutarate. Moreover, we observed that hOat2 mediates the transport of bumetanide, ES, glutarate, dehydroepiandrosterone sulfate, allopurinol, prostaglandin E2, 5-fluorouracil, paclitaxel and L-ascorbic acid. These compounds are identified for the first time as hOat2 substrates. A wide range of structurally unrelated organic compounds inhibited the hOat2-mediated uptake of tetracycline, except for sulfobromophthalein. All of these findings indicate that hOat2 is a sodium-independent multi-specific organic anion/dimethyldicarboxylate exchanger. Our present findings thus provide further insights into the role of hOat2 in hepatic drug transport.

RENAL TRANSPORT OF ORGANIC COMPOUNDS MEDIATED BY MOUSE ORGANIC ANION TRANSPORTER 3 (MOAT3): FURTHER SUBSTRATE SPECIFICITY OF MOAT3

Organic anion transporter 3 [Oat3(Slc22a8)] plays an important role in the renal handling of organic compounds. The substrate specificity of rat Oat3 and human Oat3 has been elucidated; information on mouse Oat3 (mOat3) is less defined. The aim of this study was to extend the substrate selectivity of mOat3. When expressed in Xenopus laevis oocytes, mOat3 mediated the uptake of p-aminohippuric acid and estron sulfate (ES). In addition to these substrates, we found that several organic compounds such as prostaglandin E(2), prostaglandin F(2alpha), allopurinol, 6-mercaptopurine (6-MP), 5-fluorouracil (5-FU), and l-carnitine are substrates of mOat3, compounds identified for the first time. The apparent K(m) values for the uptake of mOat3 that mediated the transport of 6-MP, 5-FU, and l-carnitine were 4.01 +/- 0.7 microM, 53.9 +/- 8.9 nM, and 61.9 +/- 1.1 nM, respectively. Northern blot analysis revealed that gene coding for mOat3 is predominant in the kidney and, to a lesser extent, in the brain and the eye. Our findings thus provide further insights into the role of Oat3 in renal drug transport.

Postoperative chemoradiotherapy for gastric cancer

BACKGROUND

We report the results of postoperative chemoradiotherapy after curative resection in gastric cancer patients.

PATIENTS AND METHODS

Patients with gastric cancer staged IB to IV(M0) were treated with chemoradiotherapy after curative resection with extensive (D2) lymph node dissection. Nodal metastases were observed in 261 (90%) patients. The chemotherapy consisted of fluorouracil 400 mg/m(2) plus leucovorin 20 mg/m(2) for 5 days, followed by 4500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two 5-day cycles of chemotherapy were given 4 weeks after the completion of radiotherapy.

RESULTS

Of 290 patients accrued, 229 (79%) patients completed chemoradiotherapy as planned. With a median follow-up of 49 months, 114 (34%) patients have relapsed: 33 (29%) locoregional relapses, 76 (67%) peritoneal relapses and 41 (36%) distant metastases. The 5-year overall and relapse-free survivals were 60% and 57%, respectively. Tolerance was acceptable, the main toxicity being neutropenia.

CONCLUSIONS

This postoperative chemoradiotherapy after curative resection of gastric cancer was feasible, with acceptable toxicities. Whether this adjuvant therapy in gastric cancer patients that have undergone a D2 lymph node dissection impacts on survival or reduces the incidence of relapses remains to be studied.

Infusional fluorouracil, etoposide, and cisplatin (FEP) in advanced and relapsed gastric cancer

We evaluated the efficacy and tolerability of a combination chemotherapy including infusional fluorouracil (5-FU), etoposide, and cisplatin (FEP) in 89 patients with advanced/relapsed gastric cancer. Primary endpoints were progression-free and overall survival. Secondary endpoints were response rates, response duration, and toxicity. The treatment schedule was as follows: 5-FU 1,000 mg/m2 and etoposide 100 mg/m2 were administered on 3 consecutive days and cisplatin at 80 mg/m2 was administered on day 2, and repeated every 3 weeks. The median times to progression and overall survival were 4 and 8 months, respectively. One-year progression-free and overall survival rates were 10% and 33%, respectively. The overall response rate for 25 eligible patients with measurable disease was 20% (5/25, complete response 2, partial response 3) with median response duration of 7 months. Median actual dose intensities of 5-FU, etoposide, and cisplatin were 700 mg/m2/wk, 70 mg/m2/wk, and 21 mg/m2/wk, respectively. Median relative dose intensities of 5-FU, etoposide, and cisplatin were 0.70, 0.70, and 0.63, respectively. In conclusion, the FEP regimen was found to produce therapeutic results similar to those of other combination chemotherapeutic studies and to have an acceptable toxicity. This regimen could be used as one of the options for advanced gastric cancer chemotherapy in patients unsuitable for doxorubicin-based regimens.