Maintenance Therapy to Suppress Micrometastasis: The New Challenge for Adjuvant Cancer Treatment

The efficacy of immunotherapy combined with capecitabine versus immunotherapy alone as maintenance therapy in patients with de novo metastatic nasopharyngeal carcinoma: a retrospective propensity score matching study

BACKGROUND

Chemoimmunotherapy followed by immunotherapy maintenance is recommended as the standard treatment for metastatic nasopharyngeal carcinoma (NPC) patients. While capecitabine maintenance therapy has been shown to improve outcomes in these patients, data on the efficacy of combining capecitabine with immunotherapy maintenance remain limited. This study compared the efficacy of immunotherapy combined with capecitabine maintenance therapy (Immu/Cape) versus immunotherapy maintenance alone (Immu) in patients with de novo metastatic NPC (dmNPC) who received first-line chemoimmunotherapy.

PATIENTS AND METHODS

Patients with dmNPC receiving platinum-based chemoimmunotherapy were included in this study. Propensity score matching (PSM) analysis was employed to balance the baseline characteristics between the two treatment groups.

RESULTS

A total of 287 dmNPC patients were included in the study (100 in the Immu/Cape group and 187 in the Immu group). Patients in the Immu/Cape group demonstrated significantly prolonged progression-free survival (PFS; median PFS 41.5 versus 23.1 months, P < 0.001). After PSM, 83 patients remained in each group. Multivariable analysis indicated that the maintenance regimen was an independent prognostic factor for prolonged PFS (Immu/Cape versus Immu: hazard ratio 0.44, 95% confidence interval 0.26-0.73, P = 0.001). Subgroup analysis revealed that patients with polymetastatic disease (PMD) receiving Immu/Cape had significantly longer PFS compared with those receiving immunotherapy alone (3-year PFS rate: 49.2% versus 26.7%, P = 0.0087). In contrast, no significant benefit was observed in patients with oligometastatic disease (3-year PFS rate: 57.9% versus 54.2%, P = 0.27). Furthermore, in patients with detectable Epstein-Barr virus (EBV) DNA2-6 cycles, the Immu/Cape group exhibited significantly higher 3-year PFS rates compared with the Immu group (34.0% versus 19.8%, P = 0.032), whereas no PFS advantage was noted in patients with undetectable EBV DNA2-6 cycles (65.1% versus 52.6%, P = 0.13).

CONCLUSIONS

Immu/Cape maintenance therapy appears to be superior to immunotherapy alone in prolonging PFS in patients with dmNPC, particularly in those with PMD and detectable EBV DNA after two to six cycles of treatment.

Effect of Capecitabine Maintenance Therapy Plus Best Supportive Care vs Best Supportive Care Alone on Progression-Free Survival Among Patients With Newly Diagnosed Metastatic Nasopharyngeal Carcinoma Who Had Received Induction Chemotherapy: A Phase 3 Randomized Clinical Trial

IMPORTANCE

Capecitabine maintenance therapy improves survival outcomes in various cancer types, but data are limited on the efficacy and safety of capecitabine maintenance therapy in metastatic nasopharyngeal carcinoma (NPC).

OBJECTIVE

To investigate the efficacy and safety of capecitabine maintenance therapy in metastatic NPC.

DESIGN, SETTING, AND PARTICIPANTS

This randomized phase 3 clinical trial was conducted at Sun Yat-sen University Cancer Center from May 16, 2015, to January 9, 2020, among 104 patients with newly diagnosed metastatic NPC who had achieved disease control after 4 to 6 cycles of induction chemotherapy with paclitaxel, cisplatin, and capecitabine. The final follow-up date was May 30, 2021. All efficacy analyses were conducted in the intention-to-treat population.

INTERVENTIONS

Eligible patients were randomly assigned (1:1) to receive either capecitabine maintenance therapy (1000 mg/m2 orally twice daily on days 1-14) every 3 weeks plus best supportive care (BSC) (capecitabine maintenance group) or BSC alone after 4 to 6 cycles of induction chemotherapy.

MAIN OUTCOMES AND MEASURES

Progression-free survival (PFS). Secondary end points were objective response rate, duration of response, overall survival, and safety.

RESULTS

This study included 104 patients (84 men [80.8%]; median age, 47 years [IQR, 38-54 years]), with 52 assigned to the capecitabine maintenance group and 52 assigned to the BSC group. After a median follow-up of 33.8 months (IQR, 22.9-50.7 months), there were 23 events (44.2%) of progression or death in the capecitabine maintenance group and 37 events (71.2%) of progression or death in the BSC group. Median PFS survival was significantly higher in the capecitabine maintenance group (35.9 months [95% CI, 20.5 months-not reached]) than in the BSC group (8.2 months [95% CI, 6.4-10.0 months]), with a hazard ratio of 0.44 (95% CI, 0.26-0.74; P = .002). Higher objective response rates and longer median duration of response were observed in the capecitabine maintenance group (25.0%; 40.0 months) compared with the BSC group (objective response rate, 25.0% [n = 13] vs 11.5% [n = 6]; and median duration of response, 40.0 months [95% CI, not reached-not reached] vs 13.2 months [95% CI, 9.9-16.5 months]). The most common grade 3 or 4 adverse events during maintenance therapy were anemia (6 of 50 [12.0%]), hand-foot syndrome (5 of 50 [10.0%]), nausea and vomiting (3 of 50 [6.0%]), fatigue (2 of 50 [4.0%]), and mucositis (2 of 50 [4.0%]). No deaths in the maintenance group were deemed treatment-related.

CONCLUSIONS AND RELEVANCE

In this phase 3 randomized clinical trial, capecitabine maintenance therapy significantly improved PFS for patients with newly diagnosed metastatic NPC who achieved disease control after capecitabine-containing induction chemotherapy. Capecitabine exhibited manageable toxic effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02460419.

Discovery of a novel and selective cathepsin L inhibitor with anti-metastatic ability in vitro and in vivo against breast cancer cells

Asperphenamate is a natural product that has attracted considerable interest from researchers worldwide. In the last decade, aiming to increase the biological activity and improve druggability, modifications of the A-ring moiety in asperphenamate have been performed. Our laboratory has also recently reported functional derivatizations of the A ring and studied its effect on the inhibition of cysteine cathepsin L. However, the functional significance of the B-ring fragment toward cathepsin L has not been evaluated thus far. In this paper, forty-four derivatives of the B-ring substituted with different N-phenylsulfonyl groups were designed and synthesized. Among them, the paratrifluromethyl analog B-2a and the 2, 4-difluoro-5-chloro derivative B-11b showed more potent inhibitory activity against cathepsin L than the control compound, ABR, which displayed the strongest inhibitory effect on cathepsin L and S among all reported asperphenamate derivatives. In particular, compound B-2a showed more pronounced selectivity against cathepsin L than the other derivatives. Molecular docking revealed that the N-phenylsulfonylamide moiety was vital for the interactions between B-2a and cathepsin L. Moreover, B-2a displayed no toxicity against normal cells. Therefore, compound B-2a was selected for further studies. Wound-healing assays, Transwell chamber assays and breast cancer lung metastasis mouse models demonstrated that B-2a exhibited antimetastatic ability in vitro and in vivo.

Synthesis of Selenium-Quinone Hybrid Compounds with Potential Antitumor Activity via Rh-Catalyzed C-H Bond Activation and Click Reactions

In continuation of our quest for new redox-modulating catalytic antitumor molecules, selenium-containing quinone-based 1,2,3-triazoles were synthesized using rhodium-catalyzed C-H bond activation and click reactions. All compounds were evaluated against five types of cancer cell lines: HL-60 (human promyelocytic leukemia cells), HCT-116 (human colon carcinoma cells), SF295 (human glioblastoma cells), NCIH-460 (human lung cells) and PC3 (human prostate cancer cells). Some compounds showed good activity with IC50 values below 1 µM. The cytotoxic potential of the naphthoquinoidal derivatives was also evaluated in non-tumor cells, exemplified by L929 cells. Overall, these compounds represent promising new lead derivatives and stand for a new class of chalcogenium-containing derivatives with potential antitumor activity.

Continuous Low-Dose Oral Cyclophosphamide and Methotrexate as Maintenance Therapy in Patients With Advanced Ovarian Carcinoma After Complete Clinical Response to Platinum and Paclitaxel Chemotherapy

PURPOSE

The aim of this study was to evaluate efficacy and safety of continuous, low dose of oral, metronomic chemotherapy as maintenance therapy in patients with advanced ovarian carcinoma after complete clinical response to platinum and paclitaxel chemotherapy.

PATIENTS AND METHODS

In this nonrandomized study, patients older than 18 years, with Eastern Cooperative Oncology Group performance status less than 2, with advanced ovarian carcinoma after complete clinical response to platinum and paclitaxel chemotherapy were enrolled in 2 arms--arm A (maintenance arm), treated with continuous low-dose oral cyclophosphamide 50 mg and methotrexate 2.5 mg, and arm B (observation arm). Both arms were followed up for progression-free survival and toxicity.

RESULTS

Thirty patients were accrued in each arm from January 2009 to December 2010 in Ain Shams University Hospitals, where they received the treatment and followed up for disease progression and toxicity. Patients had a median age of 53 years in maintenance arm and 52.5 years in the observational arm, respectively. Over 80% had papillary serous adenocarcinoma, and over 40% of them had a stage IV disease in both arms. After median follow-up of 27 months, patients achieved median progression-free survival of 18 months in maintenance arm (A) and 15.5 months in observational arm (B), respectively. Toxicity profile was excellent with no grade 3 or 4 toxicity reported.

CONCLUSIONS

Current study may provide an evidence of efficacy and tolerability of continuous low-dose oral cyclophosphamide and methotrexate as a maintenance therapy in patients with advanced ovarian carcinoma after complete clinical response to platinum and paclitaxel chemotherapy.

Identification of novel drugs to target dormant micrometastases

BACKGROUND

Cancer-specific survival has changed remarkably little over the past half century, mainly because metastases that are occult at diagnosis and generally resistant to chemotherapy subsequently develop months, years or even decades following definitive therapy. Targeting the dormant micrometastases responsible for these delayed or occult metastases would represent a major new tool in cancer patient management. Our hypothesis is that these metastases develop from micrometastatic cells that are suppressed by normal extracellular matrix (ECM).

METHODS

A new screening method was developed that compared the effect of drugs on the proliferation of cells grown on a normal ECM gel (small intestine submucosa, SISgel) to cells grown on plastic cell culture plates. The desired endpoint was that cells on SISgel were more sensitive than the same cells grown as monolayers. Known cancer chemotherapeutic agents show the opposite pattern.

RESULTS

Screening 13,000 compounds identified two leads with low toxicity in mice and EC50 values in the range of 3-30 μM, depending on the cell line, and another two leads that were too toxic to mice to be useful. In a novel flank xenograft method of suppressed/dormant cells co-injected with SISgel into the flank, the lead compounds significantly eliminated the suppressed cells, whereas conventional chemotherapeutics were ineffective. Using a 4T1 triple negative breast cancer model, modified for physiological metastatic progression, as predicted, both lead compounds reduced the number of large micrometastases/macrometastases in the lung. One of the compounds also targeted cancer stem cells (CSC) isolated from the parental line. The CSC also retained their stemness on SISgel. Mechanistic studies showed a mild, late apoptotic response and depending on the compound, a mild arrest either at S or G2/M in the cell cycle.

CONCLUSIONS

In summary we describe a novel, first in class set of compounds that target micrometastatic cells and prevent their reactivation to form recurrent tumors/macrometastases.

Adjuvant chemotherapy in resectable cholangiocarcinoma patients

BACKGROUND AND AIM

Cholangiocarcinoma patients usually have poor treatment outcome and a high mortality rate. The role of adjuvant chemotherapy (AC) is controversial. Our study aimed to evaluate benefits of AC in resectable cholangiocarcinoma patients.

METHODS

A retrospective study included 263 patients who underwent curative resection in Srinakarind University Hospital. These patients had pathological reports showing a clear margin (R0) or microscopic margin (R1) of lesion-free tissue.

RESULTS

There were 138 patients who received AC. This group had a significantly lower mean age than patients not receiving adjuvant chemotherapy (NAC) group (57.7 ± 8.5 vs 60.4 ± 9.0 years, P = 0.01). The level of serum albumin above 3 g/dL was more common in AC group than the NAC one (87.7% vs 79.2%, P = 0.04). Patients who received AC had significantly longer overall median survival time (21.6 vs 13.4 months, P = 0.01). Patients with a combination of gemcitabine and capecitabine regimen had the longest survival time (median overall survival time of gemcitabine and capecitabine 31.5, 5-fluorouracil and mitomycin 17.3, 5-fluorouracil alone 22.2, capecitabine alone 21.6, and gemcitabine alone 7.9 months, P = 0.02). Benefits of AC were likely to be found in patients who had high-risk features, that is, high level of carbohydrate antigen 19-9, advanced stage, T4 stage, lymph node involvement, and R1 margin.

CONCLUSIONS

AC significantly prolongs survival time in resectable cholangiocarcinoma patients, particularly in the high risk group.

Has discovery-based cancer research been a bust?

The completion of the human genome sequence sparked optimism about prospects for new anticancer drug development, but clinical progress over the last decade has proven slower than expected. Here it is proposed that unrealistically high expectations of first-generation discovery-based diagnostics have contributed to this problem. Hypothesis-based single-molecule tests (e.g., mutation screening of KRAS, EGFR, BRAF or KIT genes) continue to change clinical practice incrementally, whereas first-generation multiplex assays--such as gene expression profiling and proteomics--have identified few high-impact therapeutic targets despite numerous correlations with prognosis. To move forward, second-generation multiplex diagnostics should be based not on statistical patterns/associations alone, but on clinically interpretable ('high-signal-to-noise') data such as change-of-function mutations, gene amplifications, recurrent chromosomal anomalies, and abnormal phosphorylation profiles of ERK or mTOR signaling cascades.

Discovery of a Series of Thiazole Derivatives as Novel Inhibitors of Metastatic Cancer Cell Migration and Invasion

Effective inhibitors of cancer cell migration and invasion can potentially lead to clinical applications as therapy to block tumor metastasis, the primary cause of death in cancer patients. To this end we have designed and synthesized a series of thiazole derivatives that showed potent efficacy against cell migration and invasion in metastatic cancer cells. The most effective compound, 5k, was found to have an IC₅₀ value of 176 nM in the dose-dependent transwell migration assays in MDA-MB-231cells. At the dose of 10 μM, 5k also blocked about 80% of migration in HeLa and A549 cells and 60% of invasion of MDA-MB-231 cells. Importantly, the majority of the derivatives exhibited no apparent cytotoxicity in the clonogenic assays. The low to negligible inhibition of cell proliferation is a desirable property of these anti-migration derivatives because they hold promise of low toxicity to healthy cells as potential therapeutic agents. Mechanistic studies analyzing the actin cytoskeleton by microscopy demonstrate that compound 5k substantially reduced cellular f-actin, and prevented localization of fascin to actin-rich membrane protrusions. These results suggest that the anti-migration activity may result from impaired actin structures in protrusions that are necessary to drive migration.

Micrometastasis in non-small-cell lung cancer: Detection and staging

BACKGROUND:

The clinical relevance of bone marrow micrometastasis (BMM) in non–small-cell lung cancer is undetermined, and the value of such analyses in advanced stage patients has not been clearly assessed previously. This study was conducted to estimate the accuracy of both polymerase chain reaction (PCR) and immunohistochemistry (IHC) in micrometastases detection and determine the best site for bone marrow biopsy in order to find micrometastasis.

METHODS:

This prospective cross-sectional study was performed in the Department of Thoracic Surgery, Alzahra University Hospital from September 2008 to June 2009. To evaluate the bone marrow, a 3-cm rib segment and an aspirated specimen from the iliac bone prior to tumor resection were taken. PCR and IHC were performed for each specimen to find micrometastasis.

RESULTS:

Of 41 patients, 14 (34%) were positive for BMM by PCR compared with two positive IHC (4.8%). All BMMs were diagnosed in rib segments, and iliac specimens were all free from metastatic lesion. Our data showed no significant association between variables such as age, sex, histology, tumor location, side of tumor, involved lobe, smoking, or weight loss and presence of BMM.

CONCLUSION:

PCR could use as a promising method for BMM detection. BMM in a sanctuary site (rib) is not associated with advanced stages of lung cancer. In addition, when predictor variables such as age, sex, histology, tumor location, smoking, or weight loss are analyzed, no correlation can be found between micrometastasis prevalence and any of those variables.

Prognostic effects of oral anti-cancer drugs as adjuvant chemotherapy for 2 years after gastric cancer surgery

PURPOSE

We conducted this retrospective study to evaluate the effectiveness of giving oral anti-cancer drugs for 2 years as postoperative adjuvant chemotherapy to gastric cancer patients.

METHODS

The subjects were 76 patients with stage II and III gastric cancer, who underwent curative surgery between 1989 and 2008. We divided the 20 years chronologically into the UFT term (1989-2003) and the S-1 term (2004-2008). The patients from each term were then divided into three groups according to the length of drug administration; namely, the surgery alone group, the 1-year group, and the 2-year group.

RESULTS

The survival time of the 2-year group was better than that of the surgery alone group, not only in the UFT term, but also in the S-1 term (P = 0.0224). Longer relapse-free survival was evident in the S-1 term, especially for the 2-year group (P = 0.0110). A multivariate analysis showed both the stage of the cancer and 2 years of postoperative adjuvant chemotherapy to be independent factors predictive of prolonged survival (P = 0.0040 and P = 0.0022, respectively).

CONCLUSIONS

The 2-year administration of oral anti-cancer drugs as postoperative adjuvant chemotherapy might improve the outcome of stage II, III gastric cancer patients. Randomized control trials are warranted to prove the effectiveness of this 2-year regimen.

Tumor cell seeding during surgery-possible contribution to metastasis formations

In spite of optimal local control in breast cancer, distant metastases can develop as a systemic part of this disease. Surgery is suspected to contribute to metastasis formation activating dormant tumor cells. Here we add data that seeding of cells during surgery may add to the risk of metastasis formation. The change in circulating epithelial tumor cells (CETC) was monitored in 66 breast cancer patients operated on with breast conserving surgery or mastectomy and during the further course of the disease, analyzing CETC from unseparated white blood cells stained with FITC-anti-EpCAM. An increase in cell numbers lasting until the start of chemotherapy was observed in about one third of patients. It was more preeminent in patients with low numbers of CETC before surgery and, surprisingly, in patients without involved lymph nodes. Patients with the previously reported behavior—Reincrease in cell numbers during adjuvant chemotherapy and subsequent further increase during maintenance therapy—were at increased risk of relapse. In addition to tumor cells already released during growth of the tumor, cell seeding during surgery may contribute to the early peak of relapses observed after removal of the primary tumor and chemotherapy may only marginally postpone relapse in patients with aggressively growing tumors.

Disseminated tumour cells as a prognostic biomarker in colorectal cancer

BACKGROUND

The study was performed to determine detection rate and prognostic relevance of disseminated tumour cells (DTC) in patients receiving curatively intended surgery for colorectal cancer (CRC).

METHODS

The study population consisted of 235 patients with CRC prospectively recruited from five hospitals in the Oslo region. Bone marrow (BM) aspirates were collected at the time of surgery and the presence of DTC was determined by two immunological methods; immunomagnetic selection (using an anti-EpCAM antibody) and immunocytochemistry (using a pan-cytokeratin antibody). Associations between the presence of DTC and metastasis-free, disease-specific and overall survival were analysed using univariate and multivariate methods.

RESULTS

Disseminated tumour cells were detected in 41 (17%) and 28 (12%) of the 235 examined BM samples by immunomagnetic selection and immunocytochemistry, respectively, with only five samples being positive with both methods. The presence of DTC was associated with adverse outcome (metastasis-free, disease-specific and overall survival) in univariate and multivariate analyses.

CONCLUSION

The presence of DTC was associated with adverse prognosis in this cohort of patients curatively resected for CRC, suggesting that DTC detection still holds promise as a biomarker in CRC.

Assessing the efficacy of targeted therapy using circulating epithelial tumor cells (CETC): the example of SERM therapy monitoring as a unique tool to individualize therapy

Purpose

In malignant tumors, predictive markers have been developed with respect to targeted therapies. One of the first targeted therapies was the hormone-blocking treatment of tumors of the male and female reproductive system. A typical therapy in breast cancer is the use of the selective estrogen receptor modulator, tamoxifen. However, only some of the patients, positive for the target molecules, respond to the selected therapy. It would, therefore, be highly desirable to have a tool to promptly assess the therapeutic efficacy of the applied agent in the individual patient.

Methods

Longitudinal observation of CETC provides a unique tool for monitoring therapy response. About 178 patients with breast cancer were followed prospectively during hormone therapy, requiring only 1 ml of peripheral blood, using a fluorochrome-labeled antibody against surface-epithelial antigen. Image analysis allowed CETC numbers to be calculated in relation to blood volume and monitoring over the entire course of treatment.

Results

A more than tenfold increase in CETC during therapy was a strong indicator of looming relapse (P = 0.0001 hazard ratio 5.5; 95% confidence interval 1,297–23,626), and a Cox regression analysis of age, tumor size, receptor expression, nodal status and previous treatment resulted in a regression model, in which CETC behavior was the parameter with the highest independent correlation to relapse-free survival.

Conclusions

The change in the number of CETC (increase or decrease) may, in the future, be used to guide therapy in order to change to other available treatment options in good time.

Pro-oncogenic and anti-oncogenic pathways: opportunities and challenges of cancer therapy

Carcinogenesis is the uncontrolled growth of cells gaining the potential to invade and disrupt vital tissue functions. This malignant process includes the occurrence of 'unwanted' gene mutations that induce the transformation of normal cells, for example, by overactivation of pro-oncogenic pathways and inactivation of tumor-suppressive or anti-oncogenic pathways. It is now recognized that the number of major signaling pathways that control oncogenesis is not unlimited; therefore, suppressing these pathways can conceivably lead to a cancer cure. However, the clinical application of cancer intervention has not matched up to scientific expectations. Increasing numbers of studies have revealed that many oncogenic-signaling elements show double faces, in which they can promote or suppress cancer pathogenesis depending on tissue type, cancer stage, gene dosage and their interaction with other players in carcinogenesis. This complexity of oncogenic signaling poses challenges to traditional cancer therapy and calls for considerable caution when designing an anticancer drug strategy. We propose future oncology interventions with the concept of integrative cancer therapy.

Unblocking blockbusters: using boolean text-mining to optimise clinical trial design and timeline for novel anticancer drugs

Two problems now threaten the future of anticancer drug development: (i) the information explosion has made research into new target-specific drugs more duplication-prone, and hence less cost-efficient; and (ii) high-throughput genomic technologies have failed to deliver the anticipated early windfall of novel first-in-class drugs. Here it is argued that the resulting crisis of blockbuster drug development may be remedied in part by innovative exploitation of informatic power. Using scenarios relating to oncology, it is shown that rapid data-mining of the scientific literature can refine therapeutic hypotheses and thus reduce empirical reliance on preclinical model development and early-phase clinical trials. Moreover, as personalised medicine evolves, this approach may inform biomarker-guided phase III trial strategies for noncytotoxic (antimetastatic) drugs that prolong patient survival without necessarily inducing tumor shrinkage. Though not replacing conventional gold standards, these findings suggest that this computational research approach could reduce costly ‘blue skies’ R&D investment and time to market for new biological drugs, thereby helping to reverse unsustainable drug price inflation.

Hypoxia in microscopic tumors

Tumor hypoxia has been commonly observed in a broad spectrum of primary solid malignancies. Hypoxia is associated with tumor progression, increased aggressiveness, enhanced metastatic potential and poor prognosis. Hypoxic tumor cells are resistant to radiotherapy and some forms of chemotherapy. Using an animal model, we recently showed that microscopic tumors less than 1mm diameter were severely hypoxic. In this review, models and techniques for the study of hypoxia in microscopic tumors are discussed.

Loading doses for costly cancer biologicals: sound pharmacology or unnecessary extravagance?

The rising cost of new molecularly-targeted anticancer drugs has become a major issue in oncology. One small but significant factor contributing to this problem is the routine co-administration of loading doses, which may inflate the cost of the first treatment by as much as US$1000. Here, we question the cost-effectiveness of this practice in cancer patients on several grounds, including non-urgent pace of disease, lack of evidence for survival benefit, weak dose-dependency of biopharmaceutical efficacy in cancer and the unproven validity of the 'volume of distribution' concept applied to target-specific drugs.

VEGF signaling inhibitors: more pro-apoptotic than anti-angiogenic

The vascular endothelial growth factor (VEGF) family of polypeptide growth factors regulates a family of VEGF receptor (VEGFR) tyrosine kinases with pleiotropic downstream effects. Angiogenesis is the best known of these effects, but additional VEGF-dependent actions include increased vascular permeability, paracrine/autocrine growth factor release, enhancement of cell motility, and inhibition of apoptosis. In theory, therapeutic inhibition of angiogenesis should reduce tumor perfusion and thus increase tumor hypoxia and chemoresistance, but in clinical practice the VEGF antibody bevacizumab acts as a broad-spectrum chemosensitizer. Since VEGFR expression occurs in many tumor types, such chemosensitization is more readily explained by direct inhibition of tumor cell survival signals than by indirect stromal/vascular effects. The emerging model of anti-VEGF drug action being mediated primarily by tumoral (as distinct from endothelial) VEGFRs has clinically important implications for optimizing the anti-metastatic efficacy of this expanding drug class.

Six-year stabilisation of a relapsed pelvic mass from rectal cancer after oxaliplatin-containing chemotherapy

Chemotherapy alone without a multimodality approach has never been demonstrated to cure metastatic colorectal cancer patients. We report the case of a young woman referred in 1999 to our institution for a pelvic relapse of rectal cancer remained stable after oxaliplatin, 5-fluorouracil, and folinic acid therapy and never grown in size up to now, more than 6 years after the last relapse. Death of all the cancer cells, neuroendocrine cells selection, or cell dormancy are some of the discussed explanations to this unique observation. An intriguing question remains open: Should this patient be considered cured?

Reversing hepatocellular carcinoma progression by using networked biological therapies

The liver is distinguished from other tissues by (a) its detoxifying function, (b) its resistance to apoptosis, and (c) its regenerative response to damage. Hepatocellular carcinoma arises when chronic insults, such as hepatitis or iron overload, constitutively activate this regenerative program. Here, we propose that the proliferative response of the liver to damage underlies the resistance of hepatocellular carcinoma to cytotoxic therapy, and that hepatocellular carcinoma growth should therefore be more readily controlled by using a networked combination of noncytotoxic interventions to interrupt the damage-inducible regenerative pathway. To this end, hepatocellular carcinoma boasts a wealth of potential drug targets, including viral replication, the antiapoptotic immunosuppressant alpha-fetoprotein, hepatic iron overload, inflammatory signaling, extracellular proteases, and growth factors. By blocking these positive feedback loops in parallel, and so returning the host environment to a more normal state, epigenetic repression of tumor-suppressor gene function may be reversed and tumor dormancy restored. Noncytotoxic maneuvers that short circuit damage resistance loops may thus represent an indirect form of gene therapy meriting incorporation into hepatocellular carcinoma clinical trials.

Enhanced surgery-induced angiogenesis among premenopausal women might partially explain excess breast cancer mortality of blacks compared to whites: an hypothesis

There is excess breast cancer mortality for African-Americans (AA) compared to European-Americans (EA) of 1.5-2.2 fold that first appeared in 1970s and has been worsening since. This disparity may not be explained solely by reduced access to medical care. We proposed that surgery to remove a primary tumor induces angiogenesis of distant dormant micrometastases in 20% of premenopausal node-positive patients. This hypothesis helps explain the reduced benefit of mammography for women aged 40-49. Interestingly, for AA the average age at diagnosis is 46 while for EA it is 57. The resultant increased proportion of AA premenopausal breast cancer suggests a possible explanation for the AA/EA excess mortality. Early detection, which began in the 1970s, is more effective in postmenopausal women than in premenopausal women. Since AA breast cancer is mostly premenopausal and EA breast cancer is mostly postmenopausal, it might be anticipated that starting in the 1970s because of surgery-induced early mortality, outcome would be superior for EA compared to AA.