A phase I study of palliative chemoradiation therapy with paclitaxel and cisplatin for local symptoms due to an unresectable primary advanced or locally recurrent gastric adenocarcinoma

Reconsidering the Role of Radiotherapy for Inoperable Gastric Cancer: A Systematic Review of Gastric Radiotherapy Given With Definitive and Palliative Intent

AIMS

The role of radiotherapy (RT) for inoperable gastric cancer (IGC) is commonly low-dose, given reactively for symptoms (e.g. bleeding), in contrast to the oesophagus, where high quality evidence exists for higher doses of RT. This systematic review aims to evaluate the use of, and evidence for, definitive and high-dose palliative RT for IGC and whether a change in practice is warranted.

MATERIALS AND METHODS

Following registration with PROSPERO (CRD42022297080), MEDLINE, EMBASE and The Cochrane Library were searched in accordance with PRISMA standards for studies evaluating definitive (non-metastatic disease, BED10 >45Gy) or high-dose palliative RT (for symptom/local control, minimum BED10 >30Gy). A manual search of meeting proceedings and clinical trial registries was also performed.

RESULTS

31 studies were selected for analysis. 10 definitive studies totalling n = 354 patients receiving RT with 45-50.4Gy/25-28#, showed median overall survival ranging between 11 and 26.4 months, clinical complete response range 12%-45%, G3 gastrointestinal toxicity 0-31% (range) and RT completion rates ranging from 81% to 100%. 21 high-dose palliative studies (n = 955) mostly evaluated haemostatic control and reported 38 different RT regimens (most commonly 30Gy/10#). Bleeding response rate (RR) was 59.6%-90%, pain RR 45.5-100%, obstruction RR 52.9%-100%, G3 gastrointestinal toxicity <5% and RT completion 68%-100%. An additional American National Cancer Database review >4700 non metastatic IGC patients which combined both definitive and palliative doses found significant benefit to RT in addition to chemotherapy. Evidence regarding a dose-response relationship is conflicting, limited by retrospective data. Two studies report high quality -of-life (QOL) scores following gastric RT.

CONCLUSION

There is a body of mainly non-randomised, observational evidence showing high-dose RT is efficacious, safe and may maintain QOL for patients with IGC. A change in practice will require a prospective randomised controlled trial, which should explore the role of prophylactic, high-BED RT combined with optimal systemic therapy using modern IMRT techniques and RT quality assurance.

Severe hyponatremia caused by nab-paclitaxel-induced syndrome of inappropriate antidiuretic hormone secretion: A case report in a patient with metastatic pancreatic adenocarcinoma

Incidence of pancreatic ductal adenocarcinoma (PDAC) is increasing. Most patients have advanced disease at diagnosis and therapeutic options in this setting are limited. Gemcitabine plus nab-paclitaxel regimen was demonstrated to increase survival compared with gemcitabine monotherapy and is therefore indicated as first-line therapy in patients with metastatic PDAC and performance status Eastern Cooperative Oncology Group (ECOG) 0-2. The safety profile of gemcitabine and nab-paclitaxel combination includes neutropenia, fatigue, and neuropathy as most common adverse events of grade 3 or higher. No case of severe hyponatremia associated with the use of nab-paclitaxel for the treatment of PDAC has been reported to date.We report the case of a 72-year-old Caucasian man with a metastatic PDAC treated with gemcitabine and nab-paclitaxel regimen, who presented with a severe hyponatremia (grade 4) caused by a documented syndrome of inappropriate antidiuretic hormone secretion (SIADH). This SIADH was attributed to nab-paclitaxel after a rigorous imputability analysis, including a rechallenge procedure with dose reduction. After dose and schedule adjustment, nab-paclitaxel was pursued without recurrence of severe hyponatremia and with maintained efficacy.Hyponatremia is a rare but potentially severe complication of nab-paclitaxel therapy that medical oncologists and gastroenterologists should be aware of. Nab-paclitaxel-induced hyponatremia is manageable upon dose and schedule adaptation, and should not contraindicate careful nab-paclitaxel reintroduction. This is of particular interest for a disease in which the therapeutic options are limited.

Continuous low-dose irradiation by I-125 seeds induces apoptosis of gastric cancer cells regardless of histological origin

The efficacy of conventional radiation therapy for gastric cancer is controversial. In this study, we evaluated the in vitro and in vivo effects of continuous low-dose-rate irradiation by I-125 seeds on different histological types of gastric cancer cell lines. Three human gastric cancer cell lines (MKN74, MKN45, and NUGC4) were treated with or without continuous low-dose irradiation by I-125 seeds in vitro and in vivo. Cell viability, apoptosis, caspase-3 assay, and cell-cycle distribution were examined in vitro. Body weight and tumor volumes of BALB/c nude mice bearing MKN74, MKN45, and NUGC4 gastric cancer xenografts were measured, and in vivo cell proliferation and apoptosis assays were performed by Ki67 and TUNEL staining, respectively. Continuous low-dose-rate irradiation by I-125 seeds reduced cell viability and induced cell apoptosis through the activation of caspase-3, and led to the accumulation of cells in the G 2/M phase in vitro. It also suppressed the growth of gastric cancer xenografts in nude mice, while inhibiting cell proliferation and inducing apoptosis as demonstrated by Ki67 and TUNEL staining. Therefore, our data suggest that continuous low-dose-rate irradiation by I-125 seeds could be a promising new option for gastric cancer treatment, regardless of histological origin.

Gastric cancer: current status of diagnosis and treatment

Gastric cancer is the second leading cause of death from malignant disease worldwide and most frequently discovered in advanced stages. Because curative surgery is regarded as the only option for cure, early detection of resectable gastric cancer is extremely important for good patient outcomes. Therefore, noninvasive diagnostic modalities such as evolutionary endoscopy and positron emission tomography are utilized as screening tools for gastric cancer. To date, early gastric cancer is being treated using minimally invasive methods such as endoscopic treatment and laparoscopic surgery, while in advanced cancer it is necessary to consider multimodality treatment including chemotherapy, radiotherapy, and surgery. Because of the results of large clinical trials, surgery with extended lymphadenectomy could not be recommended as a standard therapy for advanced gastric cancer. Recent clinical trials had shown survival benefits of adjuvant chemotherapy after curative resection compared with surgery alone. In addition, recent advances of molecular targeted agents would play an important role as one of the modalities for advanced gastric cancer. In this review, we summarize the current status of diagnostic technology and treatment for gastric cancer.

Paclitaxel chemotherapy for the treatment of gastric cancer

A comprehensive review of phase I and phase II clinical trials of paclitaxel and paclitaxel-containing chemotherapy regimens for advanced gastric cancer was performed. Response rates, median progression-free survivals, and median overall survivals were examined, together with the treatment regimens and the numbers of patients registered in each trial. Although paclitaxel monotherapy produced considerable improvement in tumor response and prognosis, combination doublet or triplet chemotherapy with fluoropyrimidines and/or platinum compounds showed better results than the paclitaxel monotherapy. With regard to the schedule of paclitaxel administration, weekly injection seemed to show less toxicity and better results than administration every 3 weeks. Adjuvant therapies, chemoradiation therapies, and paclitaxel treatment for gastric ascites were also investigated and are discussed.