Effect of Kampo medicine Juzen-taiho-to on adverse events induced by cetuximab

396

Background: Cetuximab is now considered a standard treatment for advanced or unresectable colorectal cancer, unfortunately patients suffer a skin reaction as the main indication of the toxicity of cetuximab. It is recently reported that Kampo medicine (Goshajinkigan) is considered to be an effective agent for the neuropathy of oxaliplatin. Kampo medicine “Juzen-taiho-to” (TJ-48, Tsumura CO. Ltd.), which consists of 10 component herbs, is known as a tonic agent which improves the general systemic condition of cancer patients by reducing the adverse effects of chemotherapy, radiation therapy, and surgical treatment and to inhibit metastases. The aim of this study was to clarify the efficacy of TJ-48 for adverse events associated with cetuximab therapy.

Methods: From 2009, cetuximab was administered initially at a dose of 400 mg/m2 followed by weekly infusions at 250 mg/m2 to 20 patients with non-resectable or recurrent colorectal cancer. Eighteen patients received oral administration of 7.5 g/day of TJ-48 (TJ-48 group) every day in the first course and 7 patients did not receive TJ-48 (Control group). Adverse events were evaluated for every course according to CTCAE version 3.0.

Results: There was no statistically significant difference between the two groups based on any of patient characteristics. No patients complained of persistent Grade 3 infusion reaction. The percentage of Grade 2 or more skin reactions in each course tended to be lower in the TJ-48 group compared with the Control group (TJ-48 group 34% vs control group 57%). Incidence of Grade 2 anorexia in the TJ-48 group was significantly lower than in the Control group (TJ-48 group 34% vs control group 71%, p=0.03). There were no differences regarding tumor response between the two groups.

Conclusions: TJ-48 is useful to prevent anorexia in non-resectable or recurrent colorectal cancer patients treated with cetuximab regimen.

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The role of UGT1A1 polymorphisms (*28 and *6) in Japanese cancer patients

570

Background: Combination protocol using FU-LV with irinotecan (FOLFIRI) is currently regarded as standard first-line therapy in advanced colorectal cancer (CRC). Although irinotecan prolongs survival, it causes severe diarrhea and neutropenia. Recent pharmacogenetic studies on irinotecan have revealed significant associations of UDP-glucuronosyltransferase 1A1 (UGT1A1) polymorphisms *28 and *6, the latter being specifically detected in East Asians resulting in severe toxicity. It is necessary that the dose-finding trial that decided the optimal dose according to the gene polymorphism to draw out the maximum therapeutic effect while evading the side effect. Here we present the result of prospective trial of the safety about FOLFIRI therapy according to each gene type of UGT1A1 for Japanese patients with advanced CRC.

Methods: From 2008, 250 Japanese patients in TOKUSHIMA University were enrolled in this study. Homo group (*6/*6 and *28/*28 or a both hetero types), hetero group (It was *28 and either *6 was hetero type), and wild group (*28 and *6 were wild types) were defined. On the 23 patients with advanced CRC treated with FOLFIRI after standard chemotherapy, wild and homo groups were administered 150mg/m2 irinotecan, and homo group was 100mg/m2.

Results: On the 23 patients, the genotypes of UGT1A1 *28 were homozygous in 1 (0.5%) and heterozygous in 5 (28%), *6 were homozygous in 0 and heterozygous in 6 (26%). In *6 heterozygous patients, severe toxicities (grade 3 or more) were found (33%), but in *28 heterozygous patients were not (0%). There was no decrease of irinotecan doses in each group. In Japanese people, UGT1A1 *6 polymorphisms were higher than *28 (*6 homo 3%, hetero 27% vs *28 homo 0.5%, hetero 13%).

Conclusions: When the dosage of irinotecan is decided, it is necessary to consider the UGT1A1 *6 heterozygous in Japanese cancer patients.

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A randomized phase II trial of chemoradiotherapy with oral fluoropyrimidine inhibitory for dihydropyrimidine dehydrogenase for low rectal cancer: An interim report

524

Background: Preoperative chemoradiotherapy (CRT) has been widely used to improve local control of disease and to preserve anal sphincter in the treatment of rectal cancer. However, the response to CRT differs among individual tumors. In ASCO 2008 Gastrointestinal Cancers Symposium, we reported that the patients with up-regulation of 17 genes were suggested to be good responder of CRT. Our purpose of this study was to evaluate the toxicity and efficacy of CRT using UFT versus S-1 and explore biomarkers for response in patients with locally advanced rectal cancer.

Methods: Fifty patients who received preoperative CRT (40Gy radiotherapy) were randomly assigned to either UFT or S-1. UFT and S-1 were administered during the radiotherapy course. S-1 was a novel oral fluoropyrimidine inhibitory for dihydropyrimidine dehydrogenase and had potent radiosensitizing property. Biopsy specimens were obtained from rectal cancer before preoperative CRT and were analyzed by focused DNA microarray (132 genes). To pick up the predictive factors, the 132 genes were selected in the view of sensitivity of 5FU. Response to CRT was determined by RECIST and histopathologic examination of surgically resected specimens and classified as responders (CR, PR and grade 2, 3) or nonresponders (SD, PD and grade 0, 1).

Results: UFT group (n=25) and S-1 group (n=25) were enrolled. Response rate (grade 2 or 3) to CRT determined by histopathologic examination of surgically resected specimens was 58% in the UFT group and was 75% in the S-1 group. Response rate evaluated by RECIST criteria was 62% in the UFT group and was 77% in the S-1 group. National Cancer Institute Common Toxicity Criteria grade 2 or 3 toxicity was observed in 8% of the patients in the UFT group and 23% of patients in the S-1 group. Grade 2 or 3 toxicity in the UFT group was neutropenia and was diarrhea, neutropenia and dermatitis in the S-1 group. In ASCO 2010, we will report each candidate biomarker genes for response to CRT in the UFT and S-1 group.

Conclusions: The results have suggested that CRT using UFT or S-1 is feasible and effective for patients with locally advanced rectal cancer.

[Table: see text]

Role of thrombospondin 1 (THBS1) expression in peritoneal metastasis of gastric cancer treated with taxanes

57

Background: To clarify the utility of taxanes and to pick up the prognostic factors in the treatment with 5FU- based chemotherapy for peritoneal metastasis of gastric cancer.

Methods: Responder analysis: 18 patients with peritoneal metastasis of gastric cancer were enrolled in phase I study. The regimen consists of S-1 (80-120 mg) for 14 days and intraperitoneal infusion of PTX (dose escalation: 40 - 100 mg/m2) at day 1 and 14, which was repeated 2 cycles. To pick up the predictive factors, the 137 genes, which were selected in the viewpoint of sensitivity of 5FU, CPT11 and taxanes, were analyzed using focused DNA microarray for the 12 patients. Role of THBS1 expression: THBS1 expressions were evaluated in immunohistochemical (IHC) staining of surgical specimens of 59 patients with peritoneal metastasis of gastric cancer who were administered 5FU-based chemotherapy. THBS1 positive was defined > 30% of the population stained moderate to strong.

Results: Responder analysis: Expressions of THBS1 gene of the 6 patients who had clinical benefits (2: partial response, 2: positive adenocarcinoma cells in peritoneal cytology became negative, 2: remarkable decrease of ascites) were more than 2 folds higher than those of no responders. THBS1 expression was confirmed in 5 (83.3%) using IHC staining, who had significantly higher survival rate compared with that of the negative. Role of THBS1 expression: 17 patients (28.8%) was THBS1 positive and had significantly better prognosis compared with negative patients (1year survival: 64.7% vs 34.7%). 38 patients treated with regimes including taxanes revealed a tendency of improved overall survival rates (p=0.05). Overall survival of 15 patients with THBS1 positive administered taxanes was significantly higher than that of the negative patients. (1 year survival: 66.7% vs 42.4%)

Conclusions: PTX could improve the survival of peritoneal metastasis of gastric cancer. THBS1 is a prognostic factor especially in the patients treated with taxanes, which leads to tailor-made therapy.

[Table: see text]

A randomized phase II study of modified OPTIMOX1 or FOLFOX in advanced colorectal cancer

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Background: A combination of leucovorin (LV) and fluorouracil (FU) with oxaliplatin (FOLFOX) is a standard first-line regimen for advanced or unresectable colorectal cancer. Sensory neurotoxicity is its dose-limiting toxicity, but the OPTIMOX1 (stop and go) approach offers a reasonable strategy. This study evaluates a new strategy of intermittent oxaliplatin treatment that is based on FOLFOX4 or modified FOLFOX6 (+/− bevacizumab), a simplified leucovorin and fluorouracil regimen with normal-dose oxaliplatin.

Methods: Previously untreated patients were randomly assigned to either FOLFOX administered every 2 weeks until progression (arm FOL) or FOLFOX for six cycles, maintenance without oxaliplatin for six cycles, and continued every six cycles until progression (arm OPT).

Results: Sixty patients (arm FOL [n=35], arm OPT [n=33]) were enrolled. The median number of treatment cycles was 10 (range, 3-28) in arm FOL and 12.5 (range, 1-32) in arm OPT. Cumulative dose of oxaliplatin was 850 mg/m2 in arm FOL and 552.5 mg/m2 in arm OPT. Median progression-free survival was 8.5 months in patients allocated to arm FOL compared with 15 months in patients allocated to arm OPT. Response rates evaluated by RECIST criteria were 50% with arm FOL and 64% with arm OPT. National Cancer Institute Common Toxicity Criteria grade 3 toxicity was observed in 37.1% of the patients in arm FOL and 24.0% of patients in arm OPT. Grade 3 sensory neuropathy was observed in 22.8% of the patients in arm FOL and 6% of patients in arm OPT.

Conclusions: Our modified OPTIMOX1 regimen may be effective and safe treatment to prevent oxaliplatin-induced neuropathy in advanced or unresectable colorectal cancer patients.

No significant financial relationships to disclose.

Effect of nicardipine and magnesiumon cerebral infarction - brain surface perfusion technique

The protective effect of pre- and postischemia treatment of the brain by surface perfusion with nicardipine (Nic) and/or magnesium (Mg) was evaluated in a rat focal cerebral ischemia model. Artificial cerebrospinal fluid was perfused into the subarachnoid space of rats, containing Nic or Nic/Mg prior to vessel occlusion and Nic/Mg after occlusion. Reductions in the total amount of glutamate in the microdialysis perfusate and the volume of infarction tissue stained with 2,3,5-triphenyltetrazolium chloride were significant in all treated groups, even in rats treated after ischemia. An additive effect of Mg was also observed. These results suggest that this method may have clinical applications in patients suffering from ischemic insult.

Hemodynamic alterations in dogs with shock induced by intravenous injection of heartworm extract

To elucidate one way of the shock mechanisms, the hemodynamic alterations were examined in 7 dogs with heartworm (HW) extract-induced shock. The first alteration observed after injection of HW extract was a decrease in right ventricular end-diastolic pressure (RVEDP). After that, left ventricular (LV) end-diastolic pressure, LV systolic pressure, and LV dp/dt fell significantly, followed by a decrease in the cardiac output of all dogs to below the detectable level (1.00 l/min). Since RVEDP depends on blood flow into the right ventricle, the decrease in RVEDP means a reduction in venous return. Therefore, this study showed that the first trigger of a decrease in blood pressure in HW extract-induced shock is the reduction in venous return.

Enantiomer separations by capillary electrochromatography using chiral stationary phases

The applicability of capillary electrochromatography (CEC) using packed capillary column to enantiomer separations was investigated. As chiral stationary phases, OD type packing materials of 5 and 3 microm particle diameters, originally designed for conventional high-performance liquid chromatography (HPLC) were employed. The chiral packing materials were packed by a pressurized method into a 100 microm I.D. fused-silica capillary. Several racemic enantiomers, such as acidic, neutral and basic drug components, were successfully resolved, typically by using acidic or basic solutions containing acetonitrile as mobile phases. The separation efficiencies for some enantiomers in the chiral CEC system using the 5 microm OD type packing were superior to those obtained in HPLC using chiral packings. The plate heights obtained for several enantiomers were 8-13 microm or the reduced plate height of 1.6-2.6, which indicates the high efficiency of this chiral CEC system.

Eosinophil activation and in situ interleukin-5 production by mononuclear cells in skin lesions of patients with drug hypersensitivity

In order to determine the inflammatory mechanisms of skin lesions in patients with drug hypersentivity, we examined eosinophil activation and interleukin-5 (IL-5) production in infiltrating lymphocytes. First, we showed that the number of peripheral eosinophils and the level of serum IL-5 at the eruption-active stage were both significantly higher than those in healed skin eruptions. Histological and immunohistological examination revealed that CD4+ T cells and eosinophils significantly more densely infiltrated drug eruptions than control skin lesions. The infiltrating eosinophils were also shown to be activated by immunostaining using anti-secreted formed eosinophilic cationic protein monoclonal antibody. The expression of mRNA for IL-5 in the infiltrating mononuclear cells at drug eruptions was shown by in situ hybridization. These results suggest that infiltrating CD4+ T cells might regulate both peripheral and tissue eosinophils and facilitate allergic inflammation at drug eruptions by means of IL-5 production.

In vitro interleukin-5 (IL-5) production by peripheral blood mononuclear cells from patients with drug hypersensitivity

It has been shown that CD4+ lymphocytes and eosinophils pathologically infiltrate the dermis in skin eruptions due to hypersensitivity to the administration of certain drugs associated with peripheral eosinophilia. However, the mechanisms involved in drug related skin eruptions with eosinophilia are largely unknown. There are several methods of diagnosing drug hypersensitivity, but no single in vitro method is available for the detection of the sensitizing drug. In order to elicit the mechanism of drug related skin eruption with eosinophilia and to establish effective methods for diagnosing drug hypersensitivity, we studied in vitro IL-5 production by peripheral mononuclear cells (PBMC) from patients with drug related skin eruptions (n = 8). Significant increase in IL-5 from exposure to drug alone (n = 3) and drug with PHA (n = 3) were noted, whereas PBMC from normal subjects (n = 7) exhibited no such stimulation. Six of the eight cases showed a significant decrease in the number of peripheral blood eosinophils when the skin eruptions healed compared with those at the onset. Histopathological features revealed mild to moderate infiltration of eosinophils. Immunohistopathologically, infiltration of CD4+ and CD8+ lymphocytes and CD4+ cells were predominant within the dermis of drug related skin eruption sites in all cases. This study suggested that the IL-5 production of sensitized mononuclear cells might be a critical mediator in drug hypersensitivity with eosinophilia and an important diagnostic marker.

Subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery

A 48-year-old male presented with a rare subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery. The aneurysm was resected and replaced with a Gore Tex artificial graft. Computed tomography, angiography and cerebral blood flow findings suggest that defect of the right internal carotid artery occurred in the developmental stage. There was no past history of trauma, nor histological evidence of inflammatory or sclerotic changes in the aneurysmal wall. The two vascular lesions may have been influenced by a synchronous causative factor in his developmental stage.

Clinical and laboratory changes after administration of milbemycin oxime in heartworm-free and heartworm-infected dogs

Adverse reactions to oral administration of milbemycin oxime were investigated in heartworm (HW)-free and HW-infected dogs given either the minimal HW prophylactic dose (0.25 mg/kg of body weight) or the hookworm anthelmintic dose (0.5 mg/kg). In 12 HW-free control dogs treated with lactose excipient (100 mg/kg), abnormal signs were not observed. There were no differences between the 2 doses in prevalence of clinical signs of disease and laboratory test results. In 60 HW-free dogs (50 dogs administered the low dose, and 10 dogs given the high dose) and 46 nonmicrofilaremic HW-infected dogs (35 dogs administered the low dose, and 11 dogs given the high dose), only a transient and slight paleness of the visible mucous membranes, intestinal hyperperistalsis, or both were observed in some dogs. In 77 microfilaremic (MF) dogs (41 dogs administered the low dose, and 36 dogs given the high dose), weakness or loss of appetite was observed in 13 dogs (16.9%). Paleness of the visible mucous membranes was observed in 16 dogs (20.8%), intestinal hyperperistalsis was observed in 27 dogs (35.1%), and respiratory signs, such as mild labored respiration, were observed in 13 dogs (16.9%). Dullness of heart sounds was noticed in 4 dogs (5.2%). In 12 (9 dogs administered the low dose, and 3 dogs given the high dose) of 89 MF dogs (13.5%), adult heartworms migrated from the pulmonary arteries to the right atrium, causing signs of caval syndrome, including heart murmurs, jugular pulsations, and weakness. In HW-free dogs, rectal temperature tended to decrease gradually, and heart and respiratory rates were transiently decreased.(ABSTRACT TRUNCATED AT 250 WORDS)