Neoadjuvant Cis-DDP in esophageal cancers: an experience at a regional cancer centre, India

Molecular mechanisms associated with chemoresistance in esophageal cancer

Esophageal cancer (EC) is one of the most incident and lethal tumors worldwide. Although surgical resection is an important approach in EC treatment, late diagnosis, metastasis and recurrence after surgery have led to the management of adjuvant and neoadjuvant therapies over the past few decades. In this scenario, 5-fluorouracil (5-FU) and cisplatin (CISP), and more recently paclitaxel (PTX) and carboplatin (CBP), have been traditionally used in EC treatment. However, chemoresistance to these agents along EC therapeutic management represents the main obstacle to successfully treat this malignancy. In this sense, despite the fact that most of chemotherapy drugs were discovered several decades ago, in many cases, including EC, they still represent the most affordable and widely employed treatment approach for these tumors. Therefore, this review summarizes the main mechanisms through which the response to the most widely chemotherapeutic agents used in EC treatment is impaired, such as drug metabolism, apoptosis resistance, cancer stem cells (CSCs), cell cycle, autophagy, energetic metabolism deregulation, tumor microenvironment and epigenetic modifications.

Synergistic Effect of Eicosapentaenoic Acid on Antiproliferative Action of Anticancer Drugs in a Cancer Cell Line Model

BACKGROUND/AIMS

It has been found experimentally and clinically that eicosapentaenoic acid (EPA) exerts an anticancer effect and that it has a minimal adverse event profile relative to other anticancer drugs. Any synergy between EPA and other anticancer drugs could be of therapeutic relevance, especially in elderly or high-risk patients. Therefore, we investigated the synergism between anticancer drugs and EPA experimentally.

METHODS

EPA was coadministered in vitro with various anticancer drugs (paclitaxel, docetaxel, 5-fluorouracil and cis-diamminedichloridoplatinum[II]) to TE-1 cells, which were derived from human esophageal cancer tumors. Cell proliferation was measured by the water soluble tetrazolium-1 method.

RESULT

Sub-threshold concentrations of EPA, which alone produced no anticancer effect, caused a synergistic suppressive effect on TE-1 cell proliferation when combined with other anticancer agents.

CONCLUSION

Coadministration of EPA with other anticancer drugs may represent a new therapeutic paradigm offering a reduced side effect profile.

Emerging tyrosine kinase inhibitors for esophageal cancer

INTRODUCTION

Because of the poor prognosis for patients with esophagogastric cancers (EGCs), increasing attention has focused on targeted agents.

AREAS COVERED

Targets include epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), Her2, mammalian target of rapamycin (mTOR), and MET. We briefly discuss preclinical data and the rationale for targeting these pathways and summarize the results of clinical trials of tyrosine kinase inhibitors (TKIs) against these targets.

EXPERT OPINION

While anti-EGFR therapy has been extensively investigated, completed Phase III trials suggest that this is not a promising target. A Phase III trial of an anti-VEGF antibody failed to show improvement in the primary endpoint of overall survival but response rates and progression-free survival were improved; a Phase III trial of an anti-VEGF receptor 2 antibody in second-line therapy did show improved survival. As such, Phase II and III evaluations of anti-VEGF TKIs are ongoing. The only Food and Drug Administration-approved targeted therapy in EGC is trastuzumab, an anti-Her2 antibody, and the results of a Phase III evaluation of lapatinib, an anti-Her2 TKI, are awaited. Phase III evaluation of an mTOR inhibitor has been negative. Finally, MET inhibition appears to have significant clinical potential and early testing of MET TKIs is underway.

Chemotherapeutic options for gastroesophageal junction tumors

A doublet of a fluoropyrimidine and a platinum compound remains the reference regimen in palliative chemotherapy for esophagogastric cancers. Newer regimens involve the substitution of infusional 5-fluorouracil (FU) for a shorter infusional schedule or oral 5-FU prodrugs and the replacement of cisplatin with oxaliplatin. Although the addition of epirubicin to the standard 2-drug regimen is part of routine practice, there are no randomized data to support a benefit. In contrast, the docetaxel-based docetaxel/cisplatin/5-FU regimen has been shown to modestly improve survival compared with 5-FU/cisplatin alone but at the expense of significant additional toxicity, which has hindered widespread acceptance of this regimen. Irinotecan-containing regimens have also been evaluated in a few phase III evaluations but are not clearly superior to 5-FU/cisplatin or even infusional 5-FU alone. Nevertheless, their favorable toxicity profile indicates that infusional 5-FU/irinotecan regimens also represent a first-line therapy option. In addition to its primary role in palliative therapy, there are also now established peri- or postoperative chemotherapy strategies that increase survival rates by approximately 10-15% compared with surgery alone. Preoperative chemoradiation in esophageal and gastroesophageal junction tumors has also been shown to improve outcomes.

Neoadjuvant treatment for resectable cancer of the esophagus and the gastroesophageal junction: a meta-analysis of randomized clinical trials

BACKGROUND

There is no general agreement on the effect of neoadjuvant treatment for esophageal cancer on patient survival.

METHODS

A meta-analysis was performed to determine the effect of preoperative treatment on survival of patients with resectable esophageal cancer and the effect of preoperative treatment on patient mortality. A standard variance-based method was used to derive summary estimates of the absolute difference in both 2-year survival and treatment-related mortality.

RESULTS

Eleven randomized trials involving 2311 patients were analyzed. Preoperative chemotherapy improved 2-year survival compared with surgery alone: the absolute difference was 4.4% (95% confidence interval [CI],.3%-8.5%). Marginal evidence of heterogeneity was eliminated by restricting attention to the four most recent studies, which increased the estimate to 6.3% (95% CI, 1.8%-10.7%). For combined chemoradiotherapy, the increase was 6.4% (nonsignificant; 95% CI, -1.2%-14.0%). Treatment-related mortality increased by 1.7% with neoadjuvant chemotherapy (95% CI, -.9%-4.3%) and by 3.4% with chemoradiotherapy (95% CI, -.1%-7.3%), compared with surgery alone.

CONCLUSIONS

There seems to be a modest survival advantage for patients who receive neoadjuvant chemotherapy followed by surgery, as compared with surgery alone. There is an apparent increase in treatment-related mortality, mainly for patients who receive neoadjuvant chemoradiotherapy.

A pilot study of irinotecan (CPT-11) as single-agent therapy in patients with locally advanced or metastatic esophageal carcinoma

BACKGROUND AND AIMS

This study assessed the efficacy and safety of irinotecan (CPT-11) in the treatment of patients with unresectable esophageal carcinoma.

PATIENTS AND METHODS

Ten patients with esophageal squamous cell carcinoma (SCC) and three with adenocarcinoma (AC) were treated with CPT-11. Eight of the 13 patients were pretreated by surgery, radio-, or chemotherapy. CPT-11 was administered in repeated 6-week cycles consisting of CPT-11 once weekly for 4 weeks, followed by a 2-week rest. The starting dose of CPT-11 was 125 mg/m(2) given intravenously over 60 min; subsequent doses were adjusted based on tolerance and toxicity. Nine patients were evaluable for response.

RESULTS

Two patients showed a partial response (one SCC, one AC) and two others disease stabilization (one SCC, one AC). The mean time to progression was 3.8 months. Mean survival since study entry was 6.1 months. In the 103 administrations we observed grade 3 or 4 toxicity on six occasions with diarrhea, five with neutropenia, and one with nausea and vomiting. Toxicity required dose reductions in five patients; in two of these patients treatment was stopped because of severe toxicity. No treatment related deaths occurred.

CONCLUSION

CPT-11 as single-agent therapy is modestly effective against squamous cell cancer of the esophagus.