Phase III trial of adjuvant capecitabine/cisplatin (XP) versus capecitabine/cisplatin/RT (XPRT) in resected gastric cancer with D2 nodal dissection (ARTIST trial): Safety analysis

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Background: Although the adjuvant chemoradiation therapy has gained popularity and has become the standard of care in patients with resected gastric cancer in U.S., the role of chemoradiation therapy after extended D2 dissection has been questioned. We conducted a phase III trial to compare capecitabine/cisplatin (XP) vs XP + radiotherapy (RT) in curatively D2 resected gastric cancer patients in terms of disease free survival and overall survival. Methods: Eligibility criteria were as follows: stage Ib (T1N1, T2bN0) - IV (M1 excluded), curatively ≥ D2 resected gastric adenocarcinoma. XP only: X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 repeated every 3 weeks, 6 cycles; XP + RT: X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 x 2 cycles ⋄ RT 45 Gy (25 fractions) + X 1,650 mg/m2/d during RT ⋄ X 2,000 mg/m2/d D1∼14, CDDP 60 mg/m2 D1 x 2 cycles. The primary endpoint is 3-year disease-free survival. Results: From October 2004 to April 2008, 458 patients (XP arm: 228 patients; XP/RT arm: 230 patients) were enrolled. In XP arm, 172 (75%) of 228 enrolled patients completed 6 cycles of chemotherapy. In XP + RT arm, 188 (82%) of 230 patients completed the full course of XP 2 cycles - X + RT - XP 2 cycles. Conclusions: Safety and feasibility analysis of the two arms will be reported at the meeting.

No significant financial relationships to disclose.

Work situation and work-related difficulties in stomach cancer survivors compared with the general population

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Background: We aimed to investigate the work situation and work-related difficulties among stomach cancer survivors compared with the general population. Methods: We enrolled 426 stomach cancer survivors diagnosed 2001 to 2003 from two hospitals and 994 members without a history of cancer selected randomly from a representative sample of Korea adults. We identified work situation and work-related difficulties in two groups using multivariate logistic regression. Results: An employment rate of stomach cancer survivors decreased from 66.2% to 53.1% at average 28 months after their diagnosis and it was lower than that of general population (63.5%). The primary reason for not-working in survivors were that they were easily fatigued (31.2%) and had limitations in physical functioning (13.0%). Examining work-related difficulties, 50.6% of survivors who were working at the time of survey reported that they were easily fatigued and 37.5% of survivors reported that their capacity of work decreased whereas only 22.4%, 10.6% of general population reported. Survivors had housework- related difficulties because they were easily fatigued (74.4%) and emotionally distressful (12.2%) whereas 58.0% and 4.0% of general population reported. Older age (adjusted odds ratio [aOR]=18.12; 95% confidence interval [CI]=6.59 to 49.81), female (aOR=5.30; 95% CI=7.37 to 31.31), low income (aOR=1.87; 95% CI=1.04 to 3.33), poor physical functioning (aOR=0.97; 95% CI=0.95 to 0.98) and total gastrectomy (aOR=2.40; 95% CI=1.26 to 4.60) were more likely to increase the likelihood of not working in stomach cancer survivors. Conclusions: Stomach cancer and its treatment had a negative impact on employment rate as previous studies with other type of cancer. Our study found that stomach cancer survivors had an experience not only work-related but also housework-related difficulties. This information on stomach survivors’ might be help to make a better plan for the intervention of stomach cancer survivors’ return to work.

No significant financial relationships to disclose.

The SMAD4 protein and prognosis of pancreatic ductal adenocarcinoma

PURPOSE

SMAD4 (also called Dpc4) is a tumor suppressor in the TGF-beta signaling pathway that is genetically inactivated in approximately 55% of all pancreatic adenocarcinomas. We investigated whether prognosis after surgical resection for invasive pancreatic adenocarcinoma is influenced by SMAD4 status.

EXPERIMENTAL DESIGN

Using immunohistochemistry, we characterized the SMAD4 protein status of 249 pancreatic adenocarcinomas resected from patients who underwent pancreaticoduodenectomy (Whipple resection) at The Johns Hopkins Hospital, Baltimore, MD, between 1990 and 1997. The SMAD4 gene status of 56 of 249 (22%) pancreatic carcinomas was also determined. A multivariate Cox proportional hazards model assessed the relative risk of mortality associated with SMAD4 status, adjusting for known prognostic variables.

RESULTS

Patients with pancreatic adenocarcinomas with SMAD4 protein expression had significantly longer survival (unadjusted median survival was 19.2 months as compared with 14.7 months in patients with pancreatic cancers lacking SMAD4 protein expression; P = 0.03). This SMAD4 survival benefit persisted after adjustment for prognostic factors including tumor size, margins, lymph node status, pathological stage, blood loss, and use of adjuvant chemoradiotherapy. The relative hazard of mortality for cancers lacking SMAD4 after adjusting for other prognostic factors was 1.36 (95% confidence interval, 1.01-1.83; P = 0.04).

CONCLUSION

Patients undergoing Whipple resection for pancreatic adenocarcinoma survive longer if their cancers express SMAD4.

Frequent germline deletion polymorphism of chromosomal region 8p12-p21 identified as a recurrent homozygous deletion in human tumors

A number of carcinomas show high frequency of loss of heterozygosity (LOH) at chromosome 8p, suggesting that putative tumor suppressor genes are present in this region. While searching for homozygous deletions in a panel of pancreatic and biliary tumors, we discovered a homozygous deletion at the microsatellite AFMa224wh5 in chromosome region 8p12-p21. We applied a six-step algorithm comprising germline analysis, breakpoint sequencing, population screening, online gene mapping, allelic discrimination of tumor-associated LOH, and family history analysis. The results indicated that the deletion was likely due to a normal 102-bp deletion polymorphism present in nearly 10% of the study population, not likely to involve a recessive cancer-associated gene. Researchers need to be aware that germline insertion/deletion polymorphisms can affect the results of positional cloning efforts in human neoplasms. This problem would be accentuated in studies of cell lines where a paired sample of constitutional DNA is often unavailable.

In vivo assessment of antiviral reactivity in chronic HIV infection

PURPOSE AND METHOD

Chronic infection with HIV renders individuals incapable of mounting an effective host antiviral response, as defined by in vitro assays. Therefore, to determine whether antiviral reactivity could be detected in vivo, we interrupted effective antiviral treatment prospectively in nine chronically infected aviremic individuals. Low-dose interleukin-2 (IL-2) was administered before and after treatment interruption to compensate for any potential IL-2 production deficiency. In vivo antiviral reactivity was monitored subsequent to the interruption of antiviral therapy via viral and lymphocyte dynamics. The study was terminated when the plasma HIV RNA concentration reached a plateau, defined as four successive determinations that were <25% from the mean.

RESULTS

Plasma viral relapse occurred in all participants; reaching a peak concentration within 2.5 weeks. However, over the subsequent 2 weeks viremia was reduced an order of magnitude coincident with a 2-fold lymphocytosis of the CD8 + T cell subset. A second treatment interruption resulted in attenuation of the peak and trough virus concentrations by <10-fold in 3 of 4 participants, while the CD8 + T cell concentrations remained elevated.

CONCLUSION

These findings indicate that chronic HIV infection prior to successful antiviral therapy does not preclude host antiviral reactivity. In addition, in vivo antiviral reactivity as revealed by viral and lymphocyte dynamics after antiviral treatment interruption can be useful to monitor the efficacy of different therapies.

Hypermethylation of multiple genes in pancreatic adenocarcinoma

Hypermethylation of CpG islands is a common mechanism by which tumor suppressor genes are inactivated. We studied 45 pancreatic carcinomas and 14 normal pancreata for aberrant DNA methylation of CpG islands of multiple genes and clones using methylation-specific PCR (MSP) and bisulfite-modified sequencing. Using MSP, we detected aberrant methylation of at least one locus in 60% of carcinomas. The genes analyzed included RARbeta (methylated in 20%), p16 (18%), CACNA1G (16%), TIMP-3 (11%), E-cad (7%), THBS1 (7%), hMLH1 (4%), DAP kinase (2%), and MGMT (0%). In addition, aberrant methylation was found in three CpG islands (MINT31, -1, and -2) in 38, 38, and 14% of carcinomas, respectively. Hypermethylation was largely confined to the carcinomas with only three loci (E-cad, DAP kinase, and MINT2) harboring methylation in some normal pancreata (36, 21, and 14%, respectively). Simultaneous methylation of at least four loci was observed in 5 of 36 (14%) pancreatic adenocarcinomas. We defined this subgroup of pancreatic adenocarcinomas as "CpG island-methylator-phenotype positive (CIMP+)." Two of four carcinomas with microsatellite instability harbored promoter hypermethylation of hMLH1, and both cases were CIMP+. Thus, we conclude that many pancreatic carcinomas hypermethylate a small percentage of genes, whereas a subset displays a CIMP+ phenotype.

Restoration of immunity with interleukin-2 therapy

HIV replication can now be effectively suppressed using antiretroviral combination regimens. The search continues, however, for ways to restore the immune response and eliminate reservoirs of latent infection. Interleukin-2 (IL-2) may augment the immune response in HIV-infected persons. This article discusses the rationale for using IL-2 in those with HIV disease and reviews key trials of IL-2 treatment regimens.