Modified docetaxel, cisplatin, and 5-fluorouracil combination regimen and capecitabine maintenance in metastatic gastric cancer: toxicity and efficacy results

BACKGROUND

Little progress has been made, and there is an unmet medical need for treatment of metastatic gastric cancer (MGC). Docetaxel + cisplatin + 5-fluororacil (DCF) combination is an effective regimen with high rate of toxicity and is not well tolerated. We aimed to evaluate the efficacy and toxicity of a modified DCF (mDCF) combination regimen and capecitabine maintenance in MGC.

METHOD

Data of MGC patients were treated with first-line mDCF regimen (two weekly docetaxel 60 mg/m² day 1 iv, cisplatin 50 mg/m² day 1 iv, 5-fluouracil 400 mg/m² day 1 iv push, 2400 mg/m²; day 1-day 2 iv infusion, leucovorin 400 mg/m² day 1 iv push) were recorded. Capecitabine maintenance was given as 2500 mg/m²/ day 1-day 14 po, every 3 weeks, to patients who do not have progressive disease and grade 3 treatment-related toxicity. A retrospective analysis was made.

RESULTS

Forty patients were included. Mean age was 53 ± 11. Thirty-two patients had de novo metastasis. All patients' performance status was ECOG 1 or 2 (32/8). Median number of mDCF cycles given was 9 (min-max: 1-23). Overall response rate was 47.5%. Ten patients (25%) received capecitabine maintenance. Grade 3/4 toxicity was seen in 20 patients (50%). Hematologic grade 3/4 toxicity occurred in 13 patients (32.5%), and grade 3/4 neutropenia occurred in 11 patients (27.5%) and in 15 cycles. Nonhematologic grade 3/4 toxicity was seen in 7 patients (17.5%). Median follow-up time was 17.2 months. Median time to progression (TTP) was 10.8 ± 1.9 months (95% CI: 6.89-14.64). Median overall survival was 14.7 ± 1.73 months (95% CI: 11.30-18.10).

CONCLUSIONS

mDCF protocol was a tolerable chemotherapy regimen for the first-line treatment of MGC with higher ORR and longer TTP compared to standard DCF protocol. Capecitabine maintenance might increase TTP.

Predicting pathological response and overall survival in locally advanced gastric cancer patients undergoing neoadjuvant chemotherapy: the role of PET/computed tomography

BACKGROUND

Gastric cancer is the second leading cause of cancer-related deaths, with a 5-year survival rate of about 20-25%. The ability to predict pathological response (PR) to neoadjuvant chemotherapy (NACT); hence, overall survival (OS) probability of patients can allow the clinician to individualize treatment strategies. We investigated the role of F-18 fluorodeoxyglucose PET-computed tomography (F-18 FDG PET/CT) in predicting histopathologic response and prognosis in locally advanced gastric cancer (LAGC) patients undergoing NACT.

METHODS

F-18FDG PET/CT images taken before and after NACT, adenocarcinoma histopathology and operation pyesis reports of 43 LAGC patients were analyzed. Maximum (SUVmax) and mean (SUVmean) standardized uptake values, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of lesions were measured before and after NACT. Changes in percentage were calculated for ΔSUVmax%, ΔSUVmean%, ΔMTV%, ΔTLG%, and cutoff values were determined by receiver operating characteristic curve analysis. NACT response in pathology pyesis was determined according to the College of American Pathologists classification. PR and OS were analyzed with Kaplan-Meier and Cox proportional hazards regression models based on cutoffs found with PET measurements.

RESULTS

Cutoffs were ΔSUVmax = 33.31%, ΔSUVmean = 42.96%, ΔMTV = 30.38%, and ΔTLG = 28.14%, and all patients showed significance in PR and OS based on these cutoffs (all P < 0.01). PET/CT findings before and after NACT (ΔMTV > 30.38%, ΔTLG > 28.14%) predicted PR with 100% sensitivity and specificity. Multivariate analysis showed ΔSUVmean as an independent risk factor predicting OS (hazard ratio 0.348, 95% confidence interval 2.91-22.3, P = 0.03).

CONCLUSIONS

Metabolic parameters obtained with F-18 FDG PET/CT scanning before and after NACT in LAGC patients can accurately predict PR and OS.

The role of surgery after prolonged primary chemotherapy for advanced oesophageal adenocarcinoma

BACKGROUND

Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy.

METHODS

This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables.

CONCLUSION

Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery.

Gastric organoids-an in vitro model system for the study of gastric development and road to personalized medicine

Gastric cancer ranks as the fifth most common human malignancy and the third leading cause of cancer related deaths. Depending on tumor stage, endoscopic or surgical resection supported by perioperative chemotherapy is the only curative option for patients. Due to late clinical manifestation and missing reliable biomarkers, early detection is challenging and overall survival remains poor. Organoids are cell aggregates cultured in three-dimensions that grow with similar characteristics as their tissue-of-origin. Due to their self-renewal and proliferative capacity, organoids can be maintained long term in culture and expanded in many cases in an unlimited fashion. Patient-derived organoid (PDO) libraries function as living biobanks, allowing the in depth analysis of tissue specific function, development and disease. The recent successful establishment of gastric cancer PDOs opens up new perspectives for multiple translational clinical applications. Here, we review different adult stem cell derived gastric organoid model systems and focus on their establishment, phenotypic and genotypic characterizations as well as their use in predicting therapy response.

Clinical outcomes of radical gastrectomy following trastuzumab-based chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer

PURPOSE

Patients who receive trastuzumab (T-mab) plus chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer sometimes respond remarkably well and can undergo radical surgery. However, the clinical outcomes of preoperative T-mab combined chemotherapy with radical gastrectomy remain unclear. We conducted this study to investigate the clinical outcomes of this multimodal treatment.

METHODS

From among a total of 199 patients who received T-mab-based chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer between 2011 and 2018, the subjects of this retrospective analysis were 20 patients who subsequently underwent radical gastrectomy.

RESULTS

Seven patients had gastroesophageal junction cancer and 13 had gastric cancer. Eleven patients had unresectable stage IV cancer and 9 had resectable metastatic disease. Chemotherapy regimens included capecitabine, cisplatin + T-mab (11 patients), and S-1, oxaliplatin + T-mab (nine patients). The median number of chemotherapy cycles before surgery was three (range, 2-62). During preoperative chemotherapy, grade 3/4 adverse events developed in six patients. None suffered grade ≥ 3b postoperative complications. The 3-year relapse-free survival (RFS) and overall survival (OS) rates were 58.9% and 89.5%, respectively.

CONCLUSION

Combined preoperative T-mab-based chemotherapy and surgery appears to be safe and effective for stage IV HER2-positive gastric or gastroesophageal junction cancer, with a clinically meaningful impact on RFS and OS.

Quercetin as an anticancer agent: Focus on esophageal cancer

Esophageal cancer (EC) is regarded as the sixth highest contributor to all cancer-related mortality, worldwide. In spite of advances in the treatment of EC, currently used methods remain ineffective. Quercetin, as a dietary antioxidant, is a plant flavonol from the flavonoid group of polyphenols, and can be found in numerous vegetables, fruits, and herbs. Quercetin can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential apoptosis effects, and antioxidant properties. Of the various types of cancer, the use of quercetin has now become prominent in the treatment of EC. In this review, we discuss how quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin, and low-cost relative to synthetic cancer drugs. However, most findings cited in the current study are based on in vitro and in vivo studies, and thus, further human-based research is necessitated. PRACTICAL APPLICATIONS: In spite of advances in the treatment of esophageal cancer, currently used methods remain ineffective, therefore, an alternative or complementary therapy is required. Quercetin, as a dietary antioxidant, can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential proapoptotic functions, and antioxidant properties. Quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin. The low cost of quercetin as supplement or dietary intake, relative to synthetic cancer drugs, is an advantage of the compound which should be considered.

Synergistic Beneficial Effect of Docosahexaenoic Acid (DHA) and Docetaxel on the Expression Level of Matrix Metalloproteinase-2 (MMP-2) and MicroRNA-106b in Gastric Cancer

BACKGROUND

Gastric cancer (GC) is one of the most common cancers with the majority of patients recognized in advanced stages. The efficacy of using docosahexaenoic acid (DHA) as a supplementary agent has been suggested in treatment along with chemotherapeutics including docetaxel. However, the molecular signatures of such beneficial effects are not well-understood.

OBJECTIVE(S)

We aimed to evaluate the effects of DHA and docetaxel on the expression level of metastasis-related genes, including MMP-2 and talin-2, and their controlling miRNAs, miR-106b and miR-194, in metastatic GC cell line, MKN45.

METHOD(S)

GC cell line, MKN45, was cultured, and determination of IC50 of DHA was done by MTT test. Cells were treated with docetaxel, DHA, and their combination for 24 h, and then total RNA was extracted and cDNA synthesis was done using standard protocols. The expression level of target genes, MMP-2 and talin-2, and miR-106b and miR-194 were determined by using quantitative real-time PCR.

RESULTS

The expression level of MMP-2 was decreased significantly in all treated cells. However, talin-2 showed significant downregulation only after treatment with docetaxel. In contrary to increased expression after treatment with docetaxel, DHA led to a significant under-expression of miR-106b. The similar effect was seen for miR-194.

CONCLUSION(S)

Combination of docetaxel and DHA led to the significant downregulation of MMP-2. Also, DHA lowered the docetaxel-mediated upregulation of miR-106b oncomiR. In conclusion, supplementation of docetaxel therapy with DHA in GC patients would be considered as a beneficial approach in cancer treatment.

Oxaliplatin plus Capecitabine in the Perioperative Treatment of Locally Advanced Gastric Adenocarcinoma in Combination with D2 Gastrectomy: NEO-CLASSIC Study

LESSONS LEARNED

The NEO-CLASSIC study provided valuable insight for the clinical efficacy and tolerability profiles of perioperative chemotherapy with oxaliplatin and capecitabine, plus gastrectomy, in patients with localized resectable gastric cancer.The study was designed to explore the potential survival benefits of an eight-cycle, perioperative oxaliplatin and capecitabine (XELOX) schedule in the above-mentioned setting and to explore the feasibility of prolonging the cycles of preoperative chemotherapy. The projected endpoint was not met.

BACKGROUND

This multicenter, open-label study (NEO-CLASSIC) evaluated the efficacy and safety of oxaliplatin and capecitabine (XELOX), plus D2 gastrectomy, in localized resectable gastric cancer.

METHODS

Patients aged 18-75 years with histologically-confirmed gastric adenocarcinoma (stage T2-4a/N+M0) were given eight cycles of XELOX (four preoperatively, four postoperatively). Each 3-week cycle comprised capecitabine 1,000 mg/m2 twice daily on days 1-14 and oxaliplatin 130 mg/m2 on day 1. Curative D2 gastrectomy was scheduled 2-4 weeks after the last preoperative cycle. The primary objective of the study was to determine the objective response rate (ORR) of XELOX in the preoperative setting. Sample size was calculated by assuming that a minimum of 47 cases would be required to increase the ORR by 15% (from 40% to 55%). With an estimated 10% dropout rate, 55 patients would have to be recruited.

RESULTS

Fifty-five patients were enrolled, and one was excluded because of screening failure. R0 resections were achieved in 45 of 54 intent-to-treat patients (83.3%), and four patients received R1 resections (Fig. 1). There were no complete responses, 27 (50.0%) partial responses, 22 cases (40.7%) of stable disease, and 4 (7.4%) of progressive disease. The objective response rate was 50.0%. Median follow-up was 52.97 months; 30 patients (55.6%) had disease progression (Table 1), and median progression-free survival was 20.10 (95% confidence interval: 4.31-35.89) months; median overall survival was 30.77 months (95% confidence interval was not yet available) (Fig. 2). Fifty-four patients completed 209 cycles of preoperative chemotherapy; 42 patients received 133 cycles of postoperative chemotherapy (Table 3). The rate of grade 3-4 adverse events was 8.5% (29/342 cycles); the most frequent events were neutropenia (9/342 cycles) and leukopenia (4/342 cycles).

CONCLUSION

These findings suggest that combination therapy with capecitabine and oxaliplatin as perioperative chemotherapy, followed by D2 gastrectomy, is effective and safe in late-stage, locally advanced gastric cancer. Although enrollment exceeded the 47 patients required to identify an increase in the ORR by 15% (from 40% to 55%), results did not meet the primary endpoint.

Perioperative chemotherapy versus neoadjuvant chemoradiation for patients with adenocarcinoma of the distal esophagus in Austria: a retrospective analysis

Background

The aim of this study was to compare the outcome of patients with adenocarcinoma of the distal esophagus (AEG type I) treated with neoadjuvant chemoradiation or perioperative chemotherapy.

Methods

Eligible patients from four Austrian centers were selected to conduct a retrospective analysis. All patients treated between January 2007 and October 2017 with chemotherapy according to EOX-protocol (Epirubicin, Oxaliplatin, Xeloda) or chemoradiation according to CROSS-protocol (carboplatin/paclitaxel + RTX 41.4 Gy), before esophagectomy were included. Primary outcomes disease-free survival (DFS) and overall survival (OS) as well as secondary outcomes downstaging of T- or N-stage and achievement of pathological complete response pCR (ypT0N0M0) were analyzed. Data of 119 patients were included.

Results

Complete data was available in 104 patients, 53 patients in the chemoradiation group and 51 patients in the chemotherapy group. The mean number of lymph nodes removed was significantly higher in the EOX group (EOX 29 ± 15.5 vs. CROSS 22 ± 8.8; p < 0.05). Median follow-up in the CROSS group was 17 months (CI 95% 8.8–25.2) and in the EOX group 37 months (CI 95% 26.5–47.5).

In the chemotherapy group, the OS rate after half a year, − 1, and 3 years was 92%, 75%, and 51%. After chemoradiation, overall survival after half a year was 85 %, after 1 year 66%, and after 3 years 17%. In the EOX group DFS after ½, − 1, and 3 years was 90%, 73%, and 45%, in the chemoradiation group after half a year 81%, after 1 year 55% and after 3 years 15%. Pathological complete response (pCR) was achieved in 23% of patients after CROSS and in 10% after EOX (p < 0.000).

Conclusions

There seem to be clear advantages for chemoradiation, concerning the major response of the primary tumor, whereas a tendency in favor for chemotherapy is seen in regards to systemic tumor control. Furthermore, the type of neoadjuvant treatment has a significant influence on the number of lymph nodes resected.

Selecting treatment sequence for patients with incidental gallbladder cancer: a neoadjuvant approach versus upfront surgery

At MSKCC, over 50% of the patients presenting with gallbladder cancer have been diagnosed incidentally following elective cholecystectomy for presumed benign disease. While traditional management of incidental gallbladder cancer (IGBC) dictates re-resection with the ultimate goal of achieving cure, surgical decision-making must take into account that this malignancy is characterized by poor tumor biology with frequent distant recurrence. Since early and frequent distant recurrence is the most common cause of surgical failure, the surgical oncologist's goal should be to selectively re-resect only those patients most likely to benefit from an operation. The astute surgeon recognizes the high-risk patients who likely have micrometastatic disease at the time of diagnosis and alters the treatment sequence, delivering neoadjuvant chemotherapy. This strategy acts as a selection tool, as those progressing at distant sites during therapy are spared the morbidity and mortality of surgery and furthermore has the potential to treat micrometastatic disease. However, a chemotherapy first approach must be applied selectively since a poor response risks local progression to unresectability and a decrease in functional status that comes from the toxicities of dual agent chemotherapy that can impair surgical candidacy. To balance these risks and benefits, two other criteria for a neoadjuvant approach must be met: i) reliable identification of those patients who are at high risk of distant recurrence and who are, therefore, most likely to benefit from a systemic therapy first approach and ii) availability of effective chemotherapy options. In this review, we will outline the data and judgement we use to select a treatment sequence at our institution.

Multimodal treatments for resectable esophagogastric junction cancer: a systematic review and network meta-analysis

Background:

Currently, preoperative chemoradiotherapy, perioperative chemotherapy and preoperative chemotherapy are recommended by NCCN, ESMO and Japanese guidelines respectively for resectable esophageal and junctional cancer. However, these recommendations are mainly based on esophageal cancer research. Therefore, specific for esophagogastric junction cancer, we conducted the first systematic review and network meta-analysis to rank all potential treatments simultaneously and hierarchically.

Methods:

Record retrieval was conducted in PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, ASCO and ESMO Meeting Library from inception to September 2018. Regarding time-to-event survival data, randomized controlled trials featuring comparisons between different multimodal treatments against resectable esophagogastric junction cancer were eligible. Overall survival was the endpoint. Network calculation was based on a random-effects model and the relative ranking of each node was numerically indicated by P-score (CRD42018110369, registration identifier of the meta-analysis in PROSPERO.).

Results:

Eight studies were included in our systematic review, corresponding to 1218 patients. Regarding overall survival, ‘PreCRT’ (preoperative chemoradiotherapy) topped the hierarchy (HR 1.00, P-score = 0.823), better than ‘PeriCT’ (perioperative chemotherapy; HR 1.32, P-score = 0.591) and ‘PreCT’ (preoperative chemotherapy; HR 1.54, P-score = 0.428). In sensitivity analyses, irrespective of interchanging to fixed-effects model or removing potentially heterogeneous studies, relative rankings remained stable and ‘PreCRT’ was still the optimal node.

Conclusion:

Preoperative chemoradiotherapy could potentially be the optimal multimodal treatment, which displayed more overall survival benefits than perioperative chemotherapy and preoperative chemotherapy among resectable esophagogastric junction cancer patients. To further verify our pooled results, more randomized trials will be needed to compare preoperative chemoradiotherapy with perioperative chemotherapy (especially FLOT-based regimens).

The 4th St. Gallen EORTC Gastrointestinal Cancer Conference: Controversial issues in the multimodal primary treatment of gastric, junctional and oesophageal adenocarcinoma

Multimodal primary treatment of localised adenocarcinoma of the stomach, the oesophagus and the oesophagogastric junction (AEG) was reviewed by a multidisciplinary expert panel in a moderated consensus session. Here, we report the key points of the discussion and the resulting recommendations. The exact definition of the tumour location and extent by white light endoscopy in conjunction with computed tomography scans is the backbone for any treatment decision. Their value is limited with respect to the infiltration depth, lymph node involvement and peritoneal involvement. Additional endoscopic ultrasound was recommended mainly for tumours of the lower oesophagogastric junction (i.e. AEG type II and III according to Siewert) and in early cancers before endoscopic resection. Laparoscopy to diagnose peritoneal involvement was thought to be necessary before the start of neoadjuvant treatment in all gastric cancers and in AEG type II and III. In general, perioperative multimodal treatment was suggested for all locally advanced oesophageal tumours and for gastric cancers with a clinical stage above T1N0. There was consensus that the combination of fluorouracil, folinic acid, oxaliplatin and docetaxel is now a new standard chemotherapy (CTx) regimen for fit patients. In contrast, the optimal choice of perioperative CTx versus neoadjuvant radiochemotherapy (neoRCTx), especially for AEG, was identified as an open question. Expert treatment recommendations depend on the tumour location, biology, the risk of incomplete (R1) resection, response to treatment, local or systemic recurrence risks, the predicted perioperative morbidity and patients' comorbidities. In summary, any treatment decision requires an interdisciplinary discussion in a comprehensive multidisciplinary setting.

Single Patient Classifier Assay, Microsatellite Instability, and Epstein-Barr Virus Status Predict Clinical Outcomes in Stage II/III Gastric Cancer: Results from CLASSIC Trial

PURPOSE

Clinical implications of single patient classifier (SPC) and microsatellite instability (MSI) in stage II/III gastric cancer have been reported. We investigated SPC and the status of MSI and Epstein-Barr virus (EBV) as combinatory biomarkers to predict the prognosis and responsiveness of adjuvant chemotherapy for stage II/III gastric cancer.

MATERIALS AND METHODS

Tumor specimens and clinical information were collected from patients enrolled in CLASSIC trial, a randomized controlled study of capecitabine plus oxaliplatin-based adjuvant chemotherapy. The results of nine-gene based SPC assay were classified as prognostication (SPC-prognosis) and prediction of chemotherapy benefit (SPC-prediction). Five quasimonomorphic mononucleotide markers were used to assess tumor MSI status. EBV-encoded small RNA in situ hybridization was performed to define EBV status.

RESULTS

There were positive associations among SPC, MSI, and EBV statuses among 586 patients. In multivariate analysis of disease-free survival, SPC-prognosis [hazard ratio (HR): 1.879 (1.101-3.205), 2.399 (1.415-4.067), p=0.003] and MSI status (HR: 0.363, 95% confidence interval: 0.161-0.820, p=0.015) were independent prognostic factors along with age, Lauren classification, TNM stage, and chemotherapy. Patient survival of SPC-prognosis was well stratified regardless of EBV status and in microsatellite stable (MSS) group, but not in MSI-high group. Significant survival benefit from adjuvant chemotherapy was observed by SPC-Prediction in MSS and EBV-negative gastric cancer.

CONCLUSION

SPC, MSI, and EBV statuses could be used in combination to predict the prognosis and responsiveness of adjuvant chemotherapy for stage II/III gastric cancer.

[Multivisceral resection with and without HIPEC in cancer surgery]

BACKGROUND

Multivisceral resections seem to be naturally associated with an elevated morbidity rate. Data regarding the impact of multivisceral resections on progression-free and overall survival are only available in insufficient quantities.

OBJECTIVE

Data on multivisceral resections in cancer surgery are presented exemplified by gastric cancer, colorectal cancer and peritoneal metastases, focusing on overall and progression-free survival as well as morbidity and mortality.

MATERIAL AND METHODS

A PubMed search was carried out including the following terms: multivisceral resection, peritoneal metastases, cytoreduction, morbidity, HIPEC (hyperthermic intraperitoneal chemotherapy) RESULTS: Multivisceral resections should only be performed if an R0 status can be achieved for all tumor entities. Preoperative performance of an FDG-PET-CT scan (fluorodeoxyglucose positron emission tomography computed tomography scan) can help in the selection of appropriate patients. In gastric cancer, extensive lymphatic metastases are associated with a poor overall survival despite multivisceral resection. Recurrent rectal cancer shows elevated morbidity rates and also decreased overall survival rates. Maximum cytoreductive surgery can be conducted for peritoneal metastasized appendiceal neoplasms and colorectal cancer with acceptable morbidity and without an increased risk for reduced overall survival.

CONCLUSION

After adequate patient selection and exclusion of stage IV distant metastatic disease, multivisceral resections can be offered to patients with the goal of an R0 resection.