A phase I combination chemotherapy study of biweekly paclitaxel and S-1 administration in patients with advanced gastric cancer

Phase I study of adjuvant chemotherapy with nab-paclitaxel and S-1 for stage III Lauren's diffuse-type gastric cancer after D2 resection (NORDICA study)

PURPOSE

The prognosis of diffuse-type gastric cancer (DGC) is poorer than that of intestinal type, but S-1 is a potential treatment option in DGC. This study explored the maximal tolerated dose (MTD) and the recommended dose for phase II study (RP2D) of nab-paclitaxel combined with S-1 (AS regimen) as adjuvant chemotherapy in stage III DGC.

METHODS

Patients with stage III DGC were recruited into this phase I dose-escalation study between July 2019 and June 2020 in Zhongshan Hospital. Nab-paclitaxel and S-1 (80-120 mg/day, d1-14, q3w) were administrated for 6 cycles, and then 8 cycles of S-1 monotherapy were applied. The patients received nab-paclitaxel at 180, 220, or 260 mg/m² according to the 3 + 3 design based on dose-limiting toxicity (DLT). The primary endpoint was RP2D. Secondary endpoints were the 1-year disease-free survival (DFS) rate and adverse events (AEs).

RESULTS

One case experienced DLT in 180-mg/m² dose group, subsequently three additional subjects were enrolled. DLT was not observed in the 220- and 260-mg/m² dose groups (both n = 3). Therefore, the MTD has not reached, and the RP2D of nab-paclitaxel would be 260 mg/m² . Five participants showed progressive disease, with three and two participants in the 180- and 220-mg/m² dose groups, respectively. The 6-, 12-, and 18-month DFS rates were 100%, 63.6%, and 50.9%, respectively. The most frequently observed AEs were neutropenia (83.3%) and leukopenia (66.7%).

CONCLUSION

The RP2D of nab-paclitaxel as adjuvant chemotherapy in DGC was 260 mg/m² . The AS regimen had a tolerable AE profile in stage III DGC.

A phase I study of S-1 in combination with nab-paclitaxel in patients with unresectable or recurrent gastric cancer

BACKGROUND

In Japan, S-1, an oral fluoropyrimidine, plus cisplatin is a standard regimen for advanced gastric cancer, whereas nab-paclitaxel is a treatment option. We aimed to evaluate the tolerance, pharmacokinetics, safety, and clinical efficacy of S-1 combined with nab-paclitaxel in patients with advanced gastric cancer in a phase 1 study.

METHODS

The primary objective was to determine the maximum tolerated dose (MTD) and recommended dose (RD) of S-1 plus nab-paclitaxel. The study was designed in accordance with a standard 3 + 3 method. Patients received 3-week cycles of treatment. S-1 was administered orally at 80 mg/m² twice daily for 14 days, and nab-paclitaxel was administered as an intravenous infusion at 180, 220, or 260 mg/m² on day 1 or 8.

RESULTS

Among the 16 patients enrolled, dose-limiting toxicity was observed in one patient at level 2a (S-1 80 mg/m² twice daily plus nab-paclitaxel 220 mg/m² on day 1). The MTD was not obtained, but the RD was established as level 3a (S-1 80 mg/m² twice daily plus nab-paclitaxel 260 mg/m² on day 1). The most common grade 3-4 toxicity was neutropenia (62.5 %). The overall response rate was 54.5 %. The pharmacokinetic profiles of coadministered S-1 and paclitaxel were comparable to those of nab-paclitaxel or S-1 alone.

CONCLUSIONS

Based on the present results, the RD was determined as level 3a (S-1 80 mg/m² twice daily plus nab-paclitaxel 260 mg/m² on day 1). This combination therapy was well tolerated and showed antitumor efficacy in patients with advanced gastric cancer.

A case report of curative distal gastrectomy for stage IV gastric cancer after chemoradiotherapy in a patient with a gastrojejunal gastric bypass

Background

Advanced gastric cancer in the lower third of the stomach often results in stricture of the gastric cavity and digestive symptoms. Gastrojejunostomy has been suggested to improve such symptoms, and the advent of new anticancer agents for gastric cancer has improved the response rate of the disease, which makes it possible to perform R0 gastrectomy in part of patients with stage IV gastric cancer. We experienced a rare case in which a patient with stage IV gastric cancer and cancerous pyloric stenosis was treated with R0 surgery after undergoing a gastrojejunal bypass procedure and multidisciplinary treatment. There have not been any previous reports about cases in which a previous gastrojejunostomy was utilized as a reconstruction route during distal gastrectomy in a patient with gastric cancer that had been treated with chemotherapy and/or CRT.

Case presentation

An 80-year-old female with advanced gastric cancer and pyloric stenosis was admitted to Kagoshima University Hospital. As peritoneal washing cytology produced a positive result, laparoscopic gastrojejunostomy (modified Devine procedure) was performed to improve food passage, and S-1 (100 mg/body, days 1–14) plus paclitaxel (120 mg/body, days 1 and 15) was administered. Although the tumor was temporarily reduced in size, an abdominal computed tomography scan obtained after four courses of chemotherapy showed progressive disease. Thus, chemoradiotherapy (56 Gy, S-1: 60 mg/body, CDDP: 5 mg/body, days 1–5) was indicated. Marked tumor shrinkage and negative peritoneal washing cytological results were achieved. Curative gastrectomy with D2 lymphadenectomy was performed. We carried out distal gastrectomy and lymph node dissection, and the gastrojejunostomy produced as a gastric bypass in the previous operation was preserved. The patient has not suffered a tumor relapse in 4 years since the surgery.

Conclusions

We surgeons increase a chance to perform R0 gastrectomy for stage IV gastric cancer following intensive chemotherapy and/or CRT. We should choose proper position of gastrojejunostomy in producing alimentary bypass for stage IV gastric cancer patients to facilitate curative surgery.

Emerging role of S-1 in gastric cancer

Gastric cancer remains one of the most important malignancies worldwide in terms of incidence and mortality. The treatment is based on the combination of local surgery and radiation therapy as well as systemic chemotherapy and targeted molecules. Fluoropyrimidines and particularly 5-fluorouracil (FU) represent still the backbone for gastric cancer chemotherapy and new molecular versions of this molecule have been brought to clinical practice in order to improve benefits and reduce adverse effects. S-1 is an oral prodrug of 5-FU, which has demonstrated high effectiveness for gastric cancer treatment and a favorable safety profile. Currently, there are geographic differences in the treatment of gastric cancer and in the use of S-1, which is a mainstay of gastric cancer management in Eastern countries, but is not part of the standard care in the rest of the world. In this review, we gathered data from phase I, II, and III trials of S-1 in gastric cancer, in order to define its real benefit-risk ratio and assess whether geographic differences in S-1 use are justified by unchangeable factors.

Biweekly S-1 plus paclitaxel (SPA) as second-line chemotherapy after failure from fluoropyrimidine and platinum in advanced gastric cancer: a phase II study

PURPOSE

Second-line chemotherapy is now considered a standard therapy option in patients with advanced gastric cancer (AGC) who failed from first-line chemotherapy. Single agents, such as irinotecan, docetaxel or paclitaxel, provided an overall response rate of about 10 %. However, the efficacy was not satisfactory. The authors conducted a phase II study to investigate biweekly regimen of S-1 plus paclitaxel in Chinese AGC in second-line setting, with response rate as the primary end point.

PATIENTS AND METHODS

Patients with AGC failed from first-line chemotherapy with fluoropyrimidine/platinum who had measurable lesions were enrolled. Paclitaxel was administered intravenously on day 1 at a dose of 120 mg/m(2), and oral S-1 was administered twice a day from days 1 to 7, followed by a 7-day drug-free interval.

RESULTS

A total of 30 patients with pretreated AGC were accrued. No complete responses were observed. Partial responses were documented in 10 (33.3 %) patients. Ten (33.3 %) patients had stable disease. The median progression-free survival was 3.6 months and the overall survival was 7.2 months. The main toxicity was bone marrow suppression. The most frequent grade 3/4 hematological toxicities were neutropenia and anemia, which were observed in 8 (26.7 %) and 6 (20 %) patients, respectively. The most common grade 3/4 non-hematological toxicity was neuropathy, which was reported in 4 (13.3 %) patients.

CONCLUSION

Biweekly S-1 plus paclitaxel showed promising activity with acceptable toxicities as second-line chemotherapy in pretreated patients with AGC. This regimen deserves further investigation in a phase III trial.

Multicenter phase II study of weekly paclitaxel plus S-1 combination chemotherapy in patients with advanced gastric cancer

BACKGROUND

A multicenter phase II study was conducted to evaluate the efficacy and safety of a combination regimen of weekly paclitaxel plus S-1 in patients with advanced gastric cancer.

METHODS

Patients with previously untreated metastatic or recurrent gastric cancer received intravenous paclitaxel 50 mg/m(2) on days 1, 8, and 15, plus oral S-1 40 mg/m(2) b.i.d. on days 1 to 14 followed by 2 weeks off, in a 28-day cycle.

RESULTS

A total of 54 patients were registered. All of them had measurable disease and were determined to be eligible for the present study. Two complete responses and 23 partial responses were confirmed, giving an overall response rate of 46.3%. At a final follow up of 3 years, the median progression-free survival and median overall survival were 6.0 and 14.3 months, respectively. Grade 3 neutropenia occurred in 14 patients, and grade 4 in 1 patient (total, 27.8%). The most serious nonhematological toxicity was diarrhea, where grade 3 occurred in 5 patients (9.3%). There were no treatment-related deaths.

CONCLUSION

A combination of weekly paclitaxel plus S-1 was found to be well tolerated and effective in patients with advanced gastric cancer. Further investigation with comparative trials is needed for confirmation.

Phase I and pharmacokinetic study of sequential paclitaxel and trabectedin every 2 weeks in patients with advanced solid tumors

PURPOSE

This phase I study evaluated the feasibility, safety, pharmacokinetics (PK), and preliminary evidence of anticancer activity of the sequential administration of paclitaxel and trabectedin on an every-2-week schedule in patients with refractory solid malignancies. The study also sought to determine the maximum tolerated dose (MTD) level on this schedule, as well as to recommend doses for disease-directed studies.

EXPERIMENTAL DESIGN

Twenty-seven patients were treated with paclitaxel (80-120 mg/m(2); 1-hour i.v. infusion, day 1) and trabectedin (0.525-0.775 mg/m(2); 3-hour i.v. infusion, day 2) with doses increased in successive cohorts. Blood sampling for PK and drug-drug interaction studies was done.

RESULTS

Neutropenia, which resulted in treatment delay exceeding 1 week, was the principal dose-limiting toxicity for this paclitaxel-trabectedin regimen and precluded dose escalation above 120 mg/m(2) paclitaxel and 0.650 mg/m(2) trabectedin. At the MTD (120 mg/m(2) paclitaxel and 0.650 mg/m(2) trabectedin), the safety profile was favorable in patients receiving cumulative treatment. Relevant drug-drug PK interactions between paclitaxel and trabectedin were not identified. A patient with soft tissue sarcoma had a complete response and several patients with various refractory solid malignancies showed protracted stable disease as their best response.

CONCLUSIONS

The MTD level of sequential paclitaxel 1-hour infusion (day 1) and trabectedin 3-hour infusion (day 2) administered every 2 weeks is 120 and 0.650 mg/m(2), respectively. The manageable toxicities at the MTD, preliminary evidence of antitumor activity, and lack of notable PK drug-drug interactions warrant further disease-directed studies of this regimen in relevant tumor types and settings.

Salvage gastrectomy following a combination of biweekly paclitaxel and S-1 for stage IV gastric cancer

BACKGROUND AND AIM

We investigated the clinical benefits of salvage gastrectomy for stage IV gastric cancer patients whose distant lesions showed complete response after chemotherapy.

METHODS

We enrolled 18 stage IV gastric cancer patients whose distant metastases had disappeared or were controlled by a combination of biweekly paclitaxel (PTX) and S-1. After chemotherapy, these patients received gastrectomy with lymph node dissection. The postoperative outcome was analyzed with respect to both the histological effects of chemotherapy and tumor behavior.

RESULTS

Of the 18 patients, 8 had distant lymph node metastases, 9 had peritoneal dissemination, and five had multiple liver metastases prior to chemotherapy. Fourteen patients received curative surgery (R0). No severe postoperative complications were encountered. Pathological evaluation revealed grade 3 and grade 2 tumor regression in the primary lesion in one and five patients, respectively, and grade 3 and grade 2 tumor regression in the lymph nodes in one and six patients, respectively. Univariate analysis of the patients' prognosis identified R number, gross tumor type, histological grade of tumor regression, and gender as significant factors. Multivariate analysis showed that only the R number was an independent prognostic factor.

CONCLUSION

R0 salvage gastrectomy following a combination of biweekly PTX and S-1 may have significant clinical efficacy for advanced gastric cancer patients.

Phase I/II trial of combination therapy with S-1 and weekly paclitaxel in patients with unresectable or recurrent gastric cancer

PURPOSE

We aimed to examine the safety and antitumor effects of a combination of S-1 and paclitaxel in patients with unresectable or recurrent gastric cancer in a phase I/II setting.

PATIENTS AND METHODS

The study was designed as a phase I/II clinical trial. In phase I portion, the dose of paclitaxel was escalated to estimate the maximum-tolerated dose (MTD) and recommended dose (RD) of paclitaxel with fixed dose of S-1. S-1 (daily dose, 80 mg/m(2)) was given orally on days 1-21 every 35-day cycle (rest on days 22-35). Paclitaxel was administered intravenously on days 1, 8 and 15, at an initial dose of 40 mg/m(2), stepping up to 70 mg/m(2) in 10-mg/m(2) increment. Dose-limiting toxicity (DLT) was defined as grade 4 hematological toxicity, grade 3 or higher nonhematological toxicity, and treatment discontinuation due to adverse reactions during the first course of treatment. In phase II portion, the efficacy and toxicity at the RD of paclitaxel with S-1 were assessed.

RESULTS

The MTD of paclitaxel was estimated to be 60 mg/m(2), because >33.3% of patients (2/3) developed DLTs. DLT included postponement of treatment due to grade 2 neutropenia, and grade 3 stomatitis, anorexia, and nausea. Therefore, the RD of paclitaxel was estimated to be 50 mg/m(2). In the phase II portion, 22 patients were evaluated with 50 mg/m(2) paclitaxel and 80 mg/m(2) S-1 in a 35-day cycle. The response rate was 54.5% (95% CI, 32.2-75.6%). The median survival time was 283 days (95% CI, 218-508 days). The median number of treatment courses was 4 (range 1-10), indicating that this regimen could be given repeatedly.

CONCLUSIONS

This phase I/II trial of combination therapy with S-1 and paclitaxel in patients with unresectable or recurrent gastric cancer showed that this regimen has substantial antitumor activity and can be given safely.

A multicenter phase II study of biweekly paclitaxel and S-1 combination chemotherapy for unresectable or recurrent gastric cancer

PURPOSE

This Phase II study assessed the activity and safety of biweekly paclitaxel and oral S-1 as treatment for unresectable and recurrent gastric cancer. The maximum tolerated dose for this regimen had been established previously in a Phase I study performed in Japanese patients.

PATIENTS AND METHODS

Chemotherapy was performed using two anticancer agents, S-1 and paclitaxel. Oral S-1 (80 mg/m(2)) was administered twice a day after meals for two consecutive weeks from Day 1 to 14, followed by a 2 week recovery period; paclitaxel (120 mg/m(2)) was administered intravenously, biweekly, on Days 1 and 15. The patient received cycles of this regimen every 4 weeks (q 28-day cycles). The primary end point was the response rate according to the Response Evaluation Criteria in Solid Tumors.

RESULTS

A total of 39 patients (median age, 65 years) were enrolled; 13 other patients were screened, but found to be ineligible. All patients had unresectable and recurrent gastric cancer. The most common treatment-related Grade 3/4 adverse events were neutropenia (37.5%), appetite loss, diarrhea, decreased sodium (each 5%), and anemia, increased alanine aminotransferase, general fatigue, and dizziness (each 2.5%). Almost all the patients experienced alopecia. Intent-to-treat analysis showed a response rate of 43.6%. With a median follow-up of 14 months (range 8-21 months), median survival was 256 days and the median time to progression was 4 months.

CONCLUSION

A combination regimen of biweekly paclitaxel and oral S-1 was well tolerated and showed promising activity against unresectable and recurrent gastric cancer.

Successful treatment of advanced gastric cancer by surgical resection following combination chemotherapy with oral S-1 and biweekly paclitaxel

We report on the successful treatment of advanced gastric cancer by surgical resection following neoadjuvant chemotherapy. A 67-year-old man was referred to our hospital with a diagnosis of pancreatic cancer. Meticulous examination, however, revealed the presence of gastric cancer with ascites and large lymph node metastasis adjacent to the pancreas. We selected combination chemotherapy with oral S-1 and biweekly paclitaxel. After two courses, both the primary tumor and metastatic lymph nodes were greatly reduced, and the ascites had disappeared. Using laparoscopy, there was no evidence of peritoneal metastases, and the cytological examination was negative. The patient underwent distal gastrectomy with D2 lymph node dissection. Histological examination revealed that the cancer cells were still present in part, but no lymph node metastases were found. The tumor was pathologically diagnosed as pT2, pN0, P0, M0, CY0, and p-stage II. The patient is healthy over 4 years after surgery without recurrence.

Phase I/II study of S-1 combined with paclitaxel in patients with unresectable and/or recurrent advanced gastric cancer

Both paclitaxel and S-1 are effective against gastric cancer, but the optimal regimen for combined chemotherapy with these drugs remains unclear. This phase I/II study was designed to determine the maximum tolerated dose (MTD), recommended dose (RD), dose-limiting toxicity (DLT), and objective response rate of paclitaxel in combination with S-1. S-1 was administered orally at a fixed dose of 80 mg m-2 day-1 from days 1 to 14 of a 28-day cycle. Paclitaxel was given intravenously on days 1, 8, and 15, starting with a dose of 40 mg m-2 day-1. The dose was increased in a stepwise manner to 70 mg m-2. Treatment was repeated every 4 weeks unless disease progression was confirmed. In the phase I portion, 17 patients were enrolled. The MTD of paclitaxel was estimated to be 70 mg m-2 because 40% of the patients given this dose level (two of five) had DLT. The RD was determined to be 60 mg m-2. In the phase II portion, 24 patients, including five with assessable disease who received the RD in the phase I portion, were evaluated. The median number of treatment courses was six (range: 1-17). The incidence of the worst-grade toxicity in patients given the RD was 28 and 8%, respectively. All toxic effects were manageable. The response rate was 54.1%, and the median survival time was 15.5 months. Our phase I/II trial showed that S-1 combined with paclitaxel is effective and well tolerated in patients with advanced gastric cancer.