Randomized trial of adjuvant chemotherapy with mitomycin plus ftorafur versus mitomycin alone in resected locally advanced gastric cancer

Multidisciplinary treatment strategy for locally advanced gastric cancer: A systematic review

BACKGROUND

Multidisciplinary management of patients with locally advanced gastric cancer (LAGC) remains unstandardized worldwide. We performed a systemic review to summarize the advancements, regional differences, and current recommended multidisciplinary treatment strategies for LAGC.

METHODS

Eligible studies were identified through a comprehensive search of PubMed, Web of Science, Cochrane Library databases and Embase. Phase 3 randomized controlled trials which investigated survival of patients with LAGC who underwent gastrectomy with pre-/perioperative, postoperative chemotherapy, or chemoradiotherapy were included.

RESULTS

In total, we identified 11 studies of pre-/perioperative chemotherapy, 38 of postoperative chemotherapy, and 14 of chemoradiotherapy. In Europe and the USA, the current standard of care is perioperative chemotherapy for patients with LAGC using the regimen of 5-FU, folinic acid, oxaliplatin and docetaxel (FLOT). In Eastern Asia, upfront gastrectomy and postoperative chemotherapy is commonly used. The S-1 monotherapy or a regimen of capecitabine and oxaliplatin (CapOx) are used for patients with stage II disease, and the CapOx regimen or the S-1 plus docetaxel regimen are recommended for those with stage III Gastric cancer (GC). The addition of postoperative radiotherapy to peri- or postoperative chemotherapy is currently not recommended. Additionally, clinical trials testing targeted therapy and immunotherapy are increasingly performed worldwide.

CONCLUSIONS

Recent clinical trials showed a survival benefit of peri-over postoperative chemotherapy and chemoradiotherapy. As such, this strategy may have a potential as a global standard for patients with LAGC. Outcome of the ongoing clinical trials is expected to establish the global standard of multidisciplinary treatment strategy in patients with LAGC.

Prognostic and Predictive Factors for the Curative Treatment of Esophageal and Gastric Cancer in Randomized Controlled Trials: A Systematic Review and Meta-Analysis

BACKGROUND

An overview of promising prognostic variables and predictive subgroups concerning the curative treatment of esophageal and gastric cancer from randomized controlled trials (RCTs) is lacking. Therefore, we conducted a systematic review and meta-analysis.

METHODS

PubMed, EMBASE, CENTRAL, and ASCO/ESMO conferences were searched up to March 2019 for RCTs on the curative treatment of esophageal or gastric cancer with data on prognostic and/or predictive factors for overall survival. Prognostic factors were deemed potentially clinically relevant according to the following criteria; (1) statistically significant (p < 0.05) in a multivariate analysis, (2) reported in at least 250 patients, and (3) p < 0.05, in ≥ 33% of the total number of patients in RCTs reporting this factor. Predictive factors were potentially clinically-relevant if (1) the p-value for interaction between subgroups was <0.20 and (2) the hazard ratio in one of the subgroups was significant (p < 0.05).

RESULTS

For gastric cancer, 39 RCTs were identified (n = 13,530 patients) and, for esophageal cancer, 33 RCTs were identified (n = 8618 patients). In total, we identified 23 potentially clinically relevant prognostic factors for gastric cancer and 16 for esophageal cancer. There were 15 potentially clinically relevant predictive factors for gastric cancer and 10 for esophageal cancer.

CONCLUSION

The identified prognostic and predictive factors can be included and analyzed in future RCTs and be of guidance for nomograms. Further validation should be performed in large patient cohorts.

The Efficacy and Safety of (Neo)Adjuvant Therapy for Gastric Cancer: A Network Meta-analysis

Background: Alternatives in treatment-strategies exist for resectable gastric cancer. Our aims were: (1) to assess the benefit of perioperative, neoadjuvant and adjuvant treatment-strategies and (2) to determine the optimal adjuvant regimen for gastric cancer treated with curative intent. Methods: PubMed, EMBASE, CENTRAL, and ASCO/ESMO conferences were searched up to August 2017 for randomized-controlled-trials on the curative treatment of resectable gastric cancer. We performed two network-meta-analyses (NMA). NMA-1 compared perioperative, neoadjuvant and adjuvant strategies only if there was a direct comparison. NMA-2 compared different adjuvant chemo(radio)therapy regimens, after curative resection. Overall-survival (OS) and disease-free-survival (DFS) were analyzed using random-effects NMA on the hazard ratio (HR)-scale and calculated as combined HRs and 95% credible intervals (95% CrIs). Results: NMA-1 consisted of 9 direct comparisons between strategies for OS (14 studies, n = 4187 patients). NMA-2 consisted of 16 direct comparisons between adjuvant chemotherapy/chemoradiotherapy regimens for OS (37 studies, n = 10,761) and 14 for DFS (30 studies, n = 9714 patients). Compared to taxane-based-perioperative-chemotherapy, surgery-alone (HR = 0.58, 95% CrI = 0.38⁻0.91) and perioperative-chemotherapy regimens without a taxane (HR = 0.79, 95% CrI = 0.58⁻1.15) were inferior in OS. After curative-resection, the doublet oxaliplatin-fluoropyrimidine (for one-year) was the most efficacious adjuvant regimen in OS (HR = 0.47, 95% CrI = 0.28⁻0.80). Conclusions: For resectable gastric cancer, (1) taxane-based perioperative-chemotherapy was the most promising treatment strategy; and (2) adjuvant oxaliplatin-fluoropyrimidine was the most promising regimen after curative resection. More research is warranted to confirm or reproach these findings.

Combination or single-agent chemotherapy as adjuvant treatment of gastric cancer: A systematic review and meta-analysis of published trials

BACKGROUND

Chemotherapy is standard care in resected gastric cancer (GC). Despite the evidence that combination chemotherapy (CT) increases overall survival (OS) as compared to single agent therapy in metastatic disease, no study proved this benefit in the adjuvant setting. We performed a systematic review and meta-analysis based on trial data on the role of combination over single agent CT as adjuvant treatment of GC.

METHODS

MEDLINE/PubMed and Cochrane Library were searched for randomized phase III trials that compared combination vs. single agent CT in patients treated with radical surgery for non-metastatic GC. Data extraction was conducted according to the PRISMA statement. Statistical analyses were conducted to calculate the summary hazard ratio (HR) for OS and disease free survival (DFS) and 95% Confidence Intervals (CIs) by using random-effects or fixed effects models based on the heterogeneity of included studies. A subgroup analysis was performed in patients treated with D2 lymphadenectomy.

RESULTS

A total of 3572 patients were available for this analysis, 1857 received D2 lymphadenectomy, and fluoropyrimidine was given in 97% of patients of the control arm. In the overall population, the combined therapy decrease the risk of death by 13% (HR=0.87; 95%CI, 0.79-0.95; p=0.004) with fixed effect and by 19% (HR=0.81; 95%CI, 0.68-0.97; p=0.02) with random effect; significant heterogeneity was found. When analysis was limited to studies that required D2 lymphadenectomy a significant reduction of the risk of death was found in favor of combination CT (HR=0.86; 95%CI, 0.76-0.98; p=0.02). In the 3487 patients valuable for DFS, combination CT decreased the risk of relapse by 23% (HR=0.77; 95%CI, 0.70-0.84; p<0.001) with fixed effect and by 27% (HR=0.73; 95%CI, 0.49-1.09; p=0.12) with random effect; significant heterogeneity was found.

CONCLUSIONS

This analysis reported that adjuvant combination CT decreases the risk of death over single agent therapy in patients with non-metastatic GC.

Dihydropyrimidine dehydrogenases and cytidine-deaminase gene polymorphisms as outcome predictors in resected gastric cancer patients treated with fluoropyrimidine adjuvant chemotherapy

BACKGROUND AND OBJECTIVES

Single nucleotide polymorphisms of dihydropyrimidine dehydrogenases gene (DPYD) induces dihydropyrimidine dehydrogenase enzyme (DPD) deficiency resulting in increased activity of 5-fluorouracil derivatives. Cytidine-deaminase gene (CDA) polymorphisms have been involved in prognosis in experimental tumours.

METHODS

Analysis of 50 consecutive resected gastric cancer patients who received adjuvant chemotherapy with Tegafur for polymorphisms of genes DPYD1 (A/G; Ile543Val), DPYD2 (C/T; Arg29Cys) and CDA (A/C; Lys27Gin). The status of alleles (wild-type or at least one polymorphism) was correlated with outcome and toxicity.

RESULTS

Polymorphisms frequencies wild-type/non-wild-type were 36/14 in DPYD1 (A/G; Ile543Val); 26/24 in DPYD2 (C/T; Arg29Cys); and 17/23 in CDA (A/C; Lys27Gin) or between homozygous/heterozygous were 39/11 in DPYD1; 33/17 in DPYD2 and 26/24 in CDA respectively. After 77 months of median follow-up (SD = 26.3), 18 patients died of tumour relapse. Better survival was observed in DPYD1 patients only, for non-wild-type over wild-type (P = 0.0214); and in patients with one or more heterozygous polymorphisms in any of the three genes tested (P = 0.0017). In 10 pts (20%) total dose was reduced by toxicity, only 3 of them were homozygous.

CONCLUSIONS

Gene polymorphisms of DPYD and CDA predict survival of gastric cancer patients treated with 5-fluorouracil-based adjuvant chemotherapy.

Upper gastrointestinal tumors: current status and future perspectives

Recent therapeutic developments that have provided new promising and successful approaches to the treatment of solid tumors are in large part due to the increasing understanding of their molecular biology. Despite this progress, these new therapies have provided minimal benefit in the treatment of upper gastrointestinal (GI) malignancies. Hence, the overall survival of patients with upper GI tumors remains dismal. These disappointing results are largely due to the lack of early detection strategies, inadequate medical treatments and the poor understanding of upper GI tumor biology. Clinically, the treatment paradigm has been evolving for these malignancies. Esophageal cancer is now commonly treated with preoperative chemoradiation in the USA, in both academic and community cancer centers, due to its theoretical advantages. Adjuvant chemotherapy and chemoradiation are also frequently used in patients with pancreatic cancer. Exciting prospects remain in the medical and surgical treatment of these malignancies with the inclusion of biologic agents in many protocols, newer chemotherapeutic agents (such as S-1 in the treatment of gastric cancer), and the use of minimally invasive procedures for the treatment of premalignant and, possibly, early malignant lesions of the esophagus and stomach. This review focuses on the current practice in the management of upper GI tumors and summarizes the recent advances in the field.

Positive VEGF immunostaining independently predicts poor prognosis in curatively resected gastric cancer patients: results of a study assessing a panel of angiogenic markers

Angiopoietin-2 (Ang-2) and vascular endothelial growth factor (VEGF) contribute to gastric cancer aggressiveness by up-regulating the expression of proteases. We evaluated the expression and the prognostic significance of angiogenic factors and proteases in 148 patients with R0-resected gastric cancer. Expression of VEGF, Ang-2, cyclooxygenase-2 (COX-2), urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1, matrix metalloproteinases (MMP)-1 and -9 were assayed by immunohistochemistry. After a mean of 63 +/- 4 months, 81 out of 148 patients had died due to disease. The probability of being free of recurrence was 62, 48, and 42% at 2, 5, and 10 years, respectively. Single bivariate analysis identified VEGF, Ang-2, COX-2, PAI-1, and MMP-9 expression, along with several clinicopathological parameters (grade of curability, lymph node ratio, pTNM, pT, pN), as variables associated with both decreased disease-specific survival and recurrence. On multivariate analysis, after adjusting for significant clinical covariables, positive VEGF immunostaining was the primary prognostic factor, and no other tumor marker variable could add any significant improvement for the prediction, for both disease-specific survival (p = 0.001; HR, 3.27; 95% CI, 1.76 to 6.10) and tumor recurrence (p = 0.002; HR, 2.81; 95% CI, 1.48 to 5.35). Our study suggests that VEGF alone may be clinically useful for establishing therapeutic decisions in gastric cancer patients.

The role of postoperative adjuvant chemotherapy following curative resection for gastric cancer: a meta-analysis

To evaluate the effect of adjuvant chemotherapy on survival rates after curative resection of gastric cancer, MEDLINE (1969-2006), EMBASE (1974-2006), bibliographies, and review articles were searched for relevant articles. The meta-analysis was finally based on 15 trials that included 3212 patients. RR for death in the treated group was 0.90 (95% CI, 0.84-0.96) (P = 0.0010). Little or no significant benefits were suggested in subgroup analyses between different population and regimens either. Postoperative adjuvant chemotherapy for gastric cancer confers slightly significant benefits compared to the surgery only group. The prognoses after surgery may differ among various population groups or because of different regimens.

Gastric carcinoma

Although gastric cancer is still a worldwide major public health concern, it remains relatively uncommon in the Western countries. Despite improvement in surgical morbidity and mortality, as well as significant advancement of chemotherapy and radiotherapy options, the survival for gastric cancer has not significantly improved over the past decades. In the United States, standard of care for localized resectable gastric cancer is with adjuvant chemoradiotherapy. In this article, we summarize salient randomized and phase II and III clinical trials representing current treatment for gastric cancer.

Postoperative chemotherapy for gastric cancer

INTRODUCTION

Adjuvant chemotherapy for gastric cancer after potentially curative surgery has been under clinical investigation for more than four decades. However, potentially curative resection can be performed in only 30%-50% of patients. The objective of this article is to review briefly the clinical trials available in the current literature using adjuvant cytotoxic chemotherapy in patients with gastric cancer after potentially curative surgical resection.

METHODS

Computerized (MEDLINE) and manual searches were performed to identify papers published on this topic between 1965 and 2005. Only articles with an English abstract were reviewed for inclusion; information abstracted included histologic proof of diagnosis, number of patients, dose and modality of treatment, survival duration, and side effects.

RESULTS

Forty-three reports were identified. Single-agent chemotherapy was evaluated in four clinical trials, and postoperative combination chemotherapy was evaluated in 33 trials. Furthermore, we identified five meta-analyses. Five-year survival rates ranged from 12%-91.2%, and the median survival durations were 13-60+ months. Adjuvant chemotherapy, when compared with surgery alone, seems to result in longer survival.

CONCLUSION

The high rate of recurrence, even in patients undergoing state-of-the art curative resection, suggests that effective adjuvant chemotherapy might indeed be an attractive concept to improve the overall outcome of patients with gastric cancer. However, because there is no standard regimen for postoperative treatment at the moment, patients with R0-resected (no residual tumors) gastric cancer should be offered the opportunity to participate in prospective clinical trials.

Time-related improvement of survival in resectable gastric cancer: the role of Japanese-style gastrectomy with D2 lymphadenectomy and adjuvant chemotherapy

BACKGROUND

We investigated the change of prognosis in resected gastric cancer (RGC) patients and the role of radical surgery and adjuvant chemotherapy.

METHODS

We retrospectively analyze the outcome of 426 consecutive patients from 1975 to 2002, divided into 2 time-periods (TP) cohort: Before 1990 (TP1, n = 207) and 1990 or after (TP2; n= 219). Partial gastrectomy and D1-lymphadenectomy was predominant in TP1 and total gastrectomy with D2-lymphadenectomy it was in TP2. Adjuvant chemotherapy consisted of mitomycin C (MMC), 10-20 mg/m2 i.v. 4 courses or MMC plus Tegafur 500 mg/m2 for 6 months.

RESULTS

Positive nodes were similar in TP2/TP1 patients with 56%/59% respectively. Total gastrectomy was done in 56%/45% of TP2/TP1 respectively. Two-drug adjuvant chemotherapy was administered in 65%/18% of TP2/TP1 respectively. Survival at 5 years was 66% for TP2 versus 42% for TP1 patients (p < 0.0001). Survival by stages II, IIIA and IIIB for TP2 versus TP1 patients was 70 vs. 51% (p = 0.0132); 57 vs. 22% (p = 0.0008) and 30 vs. 15% (p = 0.2315) respectively. Multivariate analysis showed that age, stage of disease and period of treatment were independent variables.

CONCLUSION

The global prognosis and that of some stages have improved in recent years with case RGC patients treated with surgery and adjuvant chemotherapy.

Adjuvant and neoadjuvant therapy for gastric cancer

Although the incidence of gastric cancer is decreasing, it remains a significant source of cancer-related mortality. Surgery remains the best chance for cure from gastric cancer. Adjuvant and neoadjuvant therapy have played increasing roles in attempting to reduce the disease-specific mortality and prolong survival. In this article, the authors review the literature and summarize the salient points regarding the roles of adjuvant and neoadjuvant therapy for gastric cancer.

Gastric cancer

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.

p53 and VEGF expression are independent predictors of tumour recurrence and survival following curative resection of gastric cancer

This study was undertaken to determine the value of tumour microvessel density (MVD) and the expression of p53 and vascular endothelial growth factor (VEGF) as prognostic markers in patients with gastric cancer operated on for cure. In all, 156 patients with curatively resected gastric cancer constituted the basis of this blinded retrospective evaluation. Patients were treated with either surgery alone (n=53) or surgery plus adjuvant chemotherapy (n=103). Tumour MVD, p53 expression, and VEGF expression were assayed using immunohistochemical techniques. After a mean follow-up of 43 months, 64 (41%) patients had died and 55 (35%) patients developed tumour recurrence. Positive correlations between MVD and both p53 (P=0.005) and VEGF (P=0.005) expression were observed. Both MVD >/=100 (P=0.05) and positive VEGF expression (P<0.02) were associated with shorter disease-free survival, and positive VEGF expression (P=0.01) was also associated with shorter overall survival. Multivariate analysis confirmed that, in addition to the pathological tumour stage, lymph node ratio, the extent of lymphadenectomy and perineural invasion, p53 expression, and VEGF expression were independently associated with both disease-free survival (P<0.0005 and 0.02, respectively) and overall survival (P<0.02 and 0.01, respectively). Finally, patients whose tumours did not show p53 expression had a survival benefit compared to those expressing p53 when treated with adjuvant chemotherapy (P=0.01). This investigation demonstrates that p53 expression and VEGF expression are independent prognostic factors for both disease-free survival and overall survival in patients with curatively resected gastric cancer, and that p53 status may also influence response to chemotherapy.

Gastric cancer: advances in adjuvant and adjunct therapy

Patients with gastric carcinoma remain at high risk for local and systemic relapses, even after a successful surgery (R0 resection). To reduce the rate of relapse and increase cure rates, several clinical adjuvant trials have been reported. Only a few studies have reported positive results and most have failed to demonstrate any benefit for the treated patients. The trials with positive results from chemotherapy or chemoimmunotherapy have not gained global acceptance. The Intergroup 0116 trial has gained acceptance in North America, but it has not been accepted globally. In North America, where gastric surgery is often less than optimal, the Intergroup 0116 trial has provided evidence of benefit in overall survival time and time-to-cancer progression for patients treated with postoperative chemoradiotherapy. This trial recruited 556 patients with resected gastric cancer from stage IB through IV and an R0 resection was mandatory for registration. The results of this trial have spurred many other studies and controversies. In our opinion, all of the patients in the West who have had a curatively resected node-positive gastric carcinoma (R0 resection) should be offered an option of receiving postoperative chemoradiotherapy.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.

Cisplatin, tegafur, and leucovorin: a moderately effective and minimally toxic outpatient neoadjuvant chemotherapy for locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

To evaluate the efficacy and toxicity of cisplatin, tegafur, and leucovorin as neoadjuvant chemotherapy (CT) for patients with advanced, nonmetastatic squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Patients with SCCHN according to World Health Organization (WHO) performance status of 2 or less and adequate organ function were enrolled. The CT regimen (PTL) was 50 mg/m(2) cisplatin (P) on Day 1, 800 mg per day oral tegafur (T), and 60 mg per day oral leucovorin (L) for 14 days. The CT was administered at outpatient clinics for 14-day cycles. PTL was initiated with the intent of organ preservation and it was continued for a maximum of six cycles before locoregional therapy. Reevaluation after three cycles led to the termination of CT when the response was less than a partial response. CT was discontinued immediately upon evidence of tumor progression or excessive toxicity.

RESULTS

From March 1996 through July 1999, 97 patients were enrolled consecutively. All participants were men with a median age of 56 years (range, 37-70 years). The primary tumor sites were the tongue base, 14, and the hypopharynx, 83. Sixteen percent of the tumors were Stage III, 84% were Stage IV, 62% were Stage T4, and 44% were Stage N2-3. The median number of CT cycles was six. On an intent-to-treat basis, 26 patients (27%) achieved complete responses and 32 patients (33%) achieved partial responses. The overall response rate was 60% (95% confidence interval, 50-70%). The most common toxicities of WHO Grade 3 or higher included (percent of patients): anemia, 8.3%; stomatitis, 6.3%; thrombocytopenia, 3.1%; and vomiting, 3.1%. With a median follow-up period of 3 years, the overall survival and disease-free survival rates were 40% and 38%, respectively. Organ preservation was achieved in 70% (29 of 37) of the surviving patients.

CONCLUSION

The outpatient PTL regimen was a moderately effective and minimally toxic CT for SCCHN. PTL should be studied further in combination with other active agents or radiotherapy for patients with SCCHN.

Adjuvant and preoperative chemotherapy for gastric cancer

Gastric cancer is the second most frequently diagnosed malignancy worldwide, and the risk of relapse remains high in the majority of patients undergoing resection. Attempts to reduce this risk and prolong survival have led to numerous adjuvant chemotherapy trials that either had no benefit for patients or occasionally had controversial results. The recently reported Intergroup 0116 trial shows conclusive evidence of survival benefit for patients treated with postoperative chemoradiotherapy. In this Intergroup trial, which involves over 600 patients, a regimen of postoperative chemotherapy plus chemoradiotherapy was shown to prolong overall and disease-free survival in gastric cancer patients with stage IB through IV disease following a curative (R0) resection. This approach should be considered the standard of care in patients with gastric cancer who have undergone curative resection. Preoperative chemotherapy shows promise in downstaging tumors and increasing the rate of curative resection, but randomized trials are needed to assess survival benefits. Efforts to combine existing treatment modalities and new agents with novel mechanisms of action hold promise for the future.

Adjuvant therapy for resected gastric carcinoma

Despite its continued decline over the past 40 years, gastric carcinoma is a common gastrointestinal cancer and a major health problem around the world. In Asian countries, such as Korea, Japan, Taiwan, and China, it remains one of the leading causes of cancer-related death. Similarly, it is a common malignancy in many South American countries, Eastern European countries, and many countries of the former Soviet Union. In North America, the incidence of gastric carcinoma is low; however, the incidence of proximal gastric carcinoma has risen over the past 15 years. In 2001, approximately 21,700 new cases and 12,800 deaths were estimated in the United States as a result of gastric carcinoma. In the United States, gastric cancer ranks 14th among all cancers in incidence rate and 10th in overall mortality rate. An early detection program has been established in Japan, where nearly 6,000,000 adults are screened annually. This type of mass screening for gastric cancer is not practiced elsewhere, however. Because the risk of relapse remains high for patients after a curative resection, there is a great need for effective adjuvant therapy for patients with gastric carcinoma.

Adjuvant chemotherapy in gastric cancer: 5-year results of a randomised study by the Italian Trials in Medical Oncology (ITMO) Group

BACKGROUND

The aim of this study was to determine the efficacy of the EAP regimen (etoposide, adriamycin and cisplatin) followed by the Machover schedule (fluorouracil and folinic acid) given as adjuvant treatment to patients with poor prognostic factors (N+ or T3/4).

PATIENTS AND METHODS

Before randomisation, the subjects were stratified on the basis of node involvement (N+ or N-) and the time from surgery to randomisation (< or = 21 days or > 22 days). The surgical procedures for sub-total or total gastrectomy with D2 dissection were standardised among the participating centres.

RESULTS

Between December 1992 and December 1997, 274 patients were enrolled: 137 in the treatment arm and 137 in the control arm. The majority of the patients (90%) were N+. After a median follow up of 66 months (range 2-83), the 5-year overall survival (OS) was 52% in the treatment arm and 48% in the control arm [hazard ratio (HR) 0.93; 95% confidence interval (CI) 0.65-1.34]; the 5-year disease-free survival (DFS) was 49% and 44%, respectively (HR: 0.83; 95% CI 0.59-1.17). Among the patients with N-/N+ (1-6), the 5-year OS was 61% in the treatment group and 60% in the control group; in those with N+ (1-6), it was 42% and 22%. The treatment was completed by 87% of patients. Drug-related grade 3/4 WHO toxicities included leukopenia (21%), nausea and vomiting (14%), mucositis (9%), neutropenia (3%) and thrombocytopenia (2%). There were two deaths due to sepsis.

CONCLUSIONS

Although our results are not statistically significant, there was a limited relative risk reduction in the patients receiving adjuvant therapy (17% in DFS and 7% in OS). The data suggest that D2 surgery may have a favourable impact on OS.

Mitomycin C: a clinical update

Mitomycin C was reviewed in this journal 25 years ago and an update of its clinical usefulness is appropriate. The current review is based on representative publications covering clinical trials performed throughout the world. Single agent activity in each of the major neoplastic diseases has been reassessed when possible and the most important combinations evaluated. It is concluded that mitomycin C has a definite place in the treatment of localized bladder cancer, is active, but needs to be redefined, in the context of newer regimens for breast, head and neck, and non-small cell lung cancers, is active in, but is being displaced by, other drugs in cervical, gastric and pancreatic cancers, and is probably no longer of therapeutic value in colon cancer. It is also recognized that as many newer treatments have clinical success, the therapeutic role of mitomycin C will require continuing re-investigation.

Phase I assessment of the pharmacokinetics, metabolism, and safety of emitefur in patients with refractory solid tumors

PURPOSE

To determine the toxicities, dose-limiting toxicities (DLT), maximum-tolerated dose, and pharmacokinetic profile of emitefur (BOF-A2) in patients with advanced solid tumors.

METHODS

This was a phase I dose-escalating trial in which cohorts of patients received BOF-A2 (cohort 1, 300 mg/m(2) orally [PO] tid; cohort 2, 200 mg/m(2) PO tid; cohort 3, 200 mg/m(2) bid; and cohort 4, 250 mg/m(2) bid) for 14 consecutive days followed by 1 week of rest (cycle 1). Pharmacokinetics, toxicity, and tumor response were monitored.

RESULTS

Nineteen patients received 110 cycles (three patients in cohort 1, three patients in cohort 2, 10 patients in cohort 3, and three patients in cohort 4). DLT (grade 3 stomatitis, diarrhea, leukopenia) was observed in cohorts 1, 2, and 4. Pharmacokinetics indicated that prolonged systemic expression of fluorouracil (5-FU) is maintained after administration of BOF-A2 at a dose of 200 mg bid for 14 days. The mean steady-state concentration of plasma 5-FU was > or = 24 ng/mL, which was 184-fold greater than the minimum effective cytotoxic concentration in vitro. Lack of variation of 5-FU trough levels within a day at steady-state indicates suppression of circadian variation. One patient in cohort 3 achieved a partial response and five patients maintained stable disease in excess of 6 months.

CONCLUSION

BOF-A2 at a dose of 200 mg PO bid for 14 days followed by 7 days of rest is well tolerated. Prolonged exposure to 5-FU above the predicted preclinical minimum effective concentration is maintained, without evidence of circadian variation. Furthermore, evidence of antitumor activity is suggested.

Efficacy of adjuvant chemotherapy after curative resection for gastric cancer: a meta-analysis of published randomised trials. A study of the GISCAD (Gruppo Italiano per lo Studio dei Carcinomi dell'Apparato Digerente)

BACKGROUND

Several studies have investigated the possible role of the adjuvant chemotherapy after curative resection for gastric cancer failing to show a clear indication; previous meta-analyses suggested small survival benefit of adjuvant chemotherapy, but the statistical methods used were open to criticisms.

MATERIALS AND METHODS

Randomised trials were identified by means of Medline and CancerLit and by selecting references from relevant articles. Systematic review of all randomised clinical trials of adjuvant chemotherapy for gastric cancer compared with surgery alone, published before January 2000, were considered. Pooling of data was performed using the fixed effect model. Death for any cause was the study endpoint. The hazard ratio and its 95% confidence intervals (95% CI), derived according to the method of Parmar, were the statistics chosen for summarising the relative benefit of chemotherapy versus control.

RESULTS

Overall 20 articles (21 comparisons) were considered for analysis. Three studies used single agent chemotherapy, seven combination of 5-fluorouracil (5-FU) with anthracyclin, ten combination of 5-FU without anthracyclines. Information on 3658 patients, 2180 deaths, was collected. Chemotherapy reduced the risk of death by 18% (hazard ratio 0.82, 95% CI: 0.75-0.89, P < 0.001). Association of Anthracyclines to 5-FU did not show a statistically significant improvement when compared with the effect of the other regimens.

CONCLUSIONS

Chemotherapy produces a small survival benefit in patients with curatively resected gastric cancer. However, taking into account the limitations of literature based meta-analyses, adjuvant chemotherapy is still to be considered as an investigational approach.

The role of chemotherapy in the management of gastric cancer

Despite a marked decline in the incidence of gastric carcinoma in Western countries, the majority of patients presents with advanced inoperable tumors. In this setting, usually the aim of therapy is palliation, with the exception of chemotherapy administered in the attempt to downstage the tumor and to facilitate potentially curative surgery in patients with locally advanced nonmetastatic disease. This review will focus on the use of chemotherapy for advanced gastric cancer and after curative surgery, providing an overview of future directions for clinical research: preoperative (neoadjuvant) systemic chemotherapy, intraperitoneal treatment, and newer drugs.

Randomized clinical trial of adjuvant mitomycin plus tegafur in patients with resected stage III gastric cancer

PURPOSE

The efficacy of adjuvant chemotherapy in gastric cancer is controversial. We conducted a phase III, randomized, multicentric clinical trial with the goal of assessing the efficacy of the combination of mitomycin plus tegafur in prolonging the disease-free survival and overall survival of patients with resected stage III gastric cancer.

PATIENTS AND METHODS

Patients with resected stage III gastric adenocarcinoma were randomly assigned, using sealed envelopes, to receive either chemotherapy or no further treatment. Chemotherapy was started within 28 days after surgery according to the following schedule: mitomycin 20 mg/m(2) intravenously (bolus) at day 1 of chemotherapy; 30 days later, oral tegafur at 400 mg bid daily for 3 months. Disease-free survival and overall survival were estimated using the Kaplan-Meier analysis and the Cox proportional hazards model.

RESULTS

Between January 1988 and September 1994, 148 patients from 10 hospitals in Catalonia, Spain, were included in the study. The median follow-up period was 37 months. The tolerability of the treatment was excellent. The overall survival and disease-free survival were higher in the group of patients treated with chemotherapy (P =.04 for survival and P =.01 for disease-free survival in the log-rank test). The overall 5-year survival rate and the 5-year disease-free survival rate were, respectively, 56% and 51% in the treatment group and 36% and 31% in the control group.

CONCLUSION

Our positive results are consistent with the results of recent studies; which conclude that there is a potential benefit from adjuvant chemotherapy in resected gastric cancer.

Effectiveness of immunochemotherapy for gastric cancer: a review of the current status

Currently, the most effective treatment of gastric cancer is surgical resection of the tumor with lymphadenectomy, which is the standard treatment in Japan. It is important to determine whether chemotherapy or immunochemotherapy regimens may prolong the survival of patients with gastric cancer. Although gastric cancer cells, in general, have a low sensitivity to chemotherapy and a low immunogenicity related to stimulation of immune competent cells, a new method including biochemical modulation and nonspecific immunopotentiation with biological response modifiers (BRMs) has permitted us to augment the clinical efficacy of immunochemotherapy for gastric cancer. Further, promising new drugs are being developed and await testing for their possible benefit in an adjuvant setting, and recent advances in molecular biology may open a new avenue for tumor antigen-specific immunotherapy for gastric cancer. We will review the current status of immunochemotherapy for gastric cancer and examine its clinical benefit for survival.

Developments in fluoropyrimidine therapy for gastrointestinal cancer

The combination of 5-fluorouracil and leucovorin is the standard treatment in metastatic colorectal cancer and in Dukes' C colon cancer. There is, however, no agreement on the method for administration in metastatic colorectal cancer. Several new studies published in 1998 suggest that infusional 5-fluorouracil gives a higher response rate and better toxicity profile compared with a standard bolus 5-fluorouracil/leucovorin regimen. The median survival rate, however, is not different. Several new active drugs are being developed for advanced colorectal cancer. It has not yet been shown that these drugs as single agents are superior to an optimal 5-fluorouracil regimen. Combination trials of 5-fluorouracil/leucovorin with oxaliplatin, CPT-11 and raltitrexed are ongoing, and it can be expected that several of these combinations will be more active than 5-fluorouracil/leucovorin. The challenge for the future will be to show the most active combination and the best sequence of these combinations. The development of the orally administered fluoropyrimidines was rapid in 1998. Randomized studies comparing UFT, capecitabine, and eniluracil plus 5-fluorouracil with 5-fluorouracil/leucovorin are ongoing.