Tumor Response Predicts Survival Time of Nivolumab Monotherapy for Advanced Gastric Cancer: A Subgroup Analysis of the DELIVER Trial (JACCRO GC-08)

BACKGROUND

This prospective observational study evaluated the real-world effectiveness of nivolumab monotherapy in previously treated advanced gastric cancer (GC). A preplanned 2-year final analysis was performed to confirm survival and tumor behavior with nivolumab monotherapy.

PATIENTS AND METHODS

The primary endpoint was overall survival (OS). The data regarding tumor size were prospectively collected and evaluated using the RECIST criteria. Exploratory analyses were performed for survival according to the tumor response and depth of response (DpR) in patients with measurable lesions who were receiving nivolumab monotherapy as third- or later-line therapy.

RESULTS

In 487 patients, the median OS and progression-free survival (PFS) were 5.8 (95% CI 5.3-6.9) months and 1.8 (95% CI 1.7-2.0) months, respectively. The response rate (RR) was 14.5% in 282 patients with measurable lesions. In 234 patients treated with third- or later-line, the DpR was found to be associated with PFS and OS in the Spearman analysis (r = 0.55 and 0.44, respectively) as well as using a discrete variable. When the DpR was divided into 5 groups (-20%≥DpR; -20%

CONCLUSION

The final analysis confirmed the efficacy of nivolumab monotherapy for patients with advanced GC in routine clinical practice. The exploratory analysis indicated that increasing DpR was associated with longer median PFS and OS in nivolumab treatment at a later-line setting.

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Key Words

• gastric cancer
• nivolumab
• real-world data
• tumor response

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MESH Headings Collapse

Grants

• Japan Clinical Cancer Research Organization

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Serum NY-ESO-1 antibody as a predictive biomarker for postoperative recurrence of gastric cancer: a multicenter prospective observational study

BACKGROUND

No reliable marker has been identified to predict postoperative recurrence of gastric cancer. We designed a clinical trial to investigate the utility of serum NY-ESO-1 antibody responses as a predictive marker for postoperative recurrence in gastric cancer.

METHODS

A multicenter prospective study was conducted between 2012 and 2021. Patients with resectable cT3-4 gastric cancer were included. Postoperative NY-ESO-1 and p53 antibody responses were serially evaluated every 3 months for 1 year in patients with positive preoperative antibody responses. The recurrence rate was assessed by the positivity of antibody responses at 3 and 12 months postoperatively.

RESULTS

Among 1001 patients, preoperative NY-ESO-1 and p53 antibody responses were positive in 12.6% and 18.1% of patients, respectively. NY-ESO-1 antibody responses became negative postoperatively in non-recurrent patients (negativity rates; 45% and 78% at 3 and 12 months, respectively), but remained positive in recurrent patients (negativity rates; 9% and 8%, respectively). p53 antibody responses remained positive in non-recurrent patients. In multivariate analysis, NY-ESO-1 antibody positivity at 3 months (P  < 0.03) and 12 months (P  < 0.001) were independent prognostic factors for a shorter recurrence-free interval.

CONCLUSIONS

Serum NY-ESO-1 antibodies may be a useful predictive marker for postoperative recurrence in gastric cancer.

CLINICAL TRIAL REGISTRATION

UMIN000007925.

Effects of postoperative oral elemental nutritional supplement on skeletal muscle loss after gastrectomy for gastric cancer

BACKGROUND

We previously showed that daily nutritional intervention with an oral elemental diet (ED) at 300 kcal/day for 6-8 weeks postoperatively decreased the percentage of body weight loss (%BWL), and that the effect was maintained for 1 year. This post hoc analysis aimed to determine whether this intervention decreased skeletal muscle mass loss 1-year post-gastrectomy.

METHODS

Data from consecutive, untreated patients with histopathologically confirmed stage I-III gastric adenocarcinoma who planned to undergo total gastrectomy (TG) or distal gastrectomy (DG) and were enrolled in a previously published randomized trial were used. The primary endpoint was the percentage of skeletal muscle mass index (%SMI) loss from baseline at 1 year postoperatively, based on abdominal computed tomography images obtained preoperatively and at 1 year postoperatively.

RESULTS

The overall median %SMI loss was lower in the ED versus control group, but the difference was not significant. The difference in %SMI loss in the ED and control groups was greater in patients with TG (10.1 vs. 13.0; P = 0.12) than in those with DG (5.5 vs. 6.8; P = 0.69). A correlation was observed between %BWL and %SMI loss in both groups (ED group, coefficient 0.591; control group, coefficient 0.644; P < 0.001 for both). Type of gastrectomy (coefficient 7.38; P = 0.001) and disease stage (coefficient - 6.43; P = 0.04) were independent predictors of postoperative skeletal muscle mass loss.

CONCLUSION

ED administration for 6-8 weeks following gastrectomy had no inhibitory effect on skeletal muscle loss at 1 year postoperatively.

CLINICAL TRIAL REGISTRATION

UMIN000023455.

Phase II study of S-1 plus docetaxel as first-line treatment for older patients with advanced gastric cancer (OGSG 0902)

BACKGROUND

Although there is insufficient evidence for the treatment of older patients with advanced gastric cancer, fluorouracil combined with platinum chemotherapy has been recognized as a standard first-line treatment for such populations in Japan despite the lack of efficacy and toxicity data.

METHODS

Patients aged 75 years or older with advanced gastric cancer were enrolled. S-1 plus docetaxel (docetaxel: 40 mg/m2, day 1; S-1: 80 mg/m2, days 1-14; q21 days) was repeated every 3 weeks. The primary endpoint was overall response rate. Secondary endpoints were safety, progression-free survival, time to treatment failure, and overall survival. The sample size was calculated as 30 under the hypothesis of an expected response rate of 40% and a threshold response rate of 20%, at a power of 90% and a two-sided alpha value of 5%.

RESULTS

From February 2010 to January 2015, 31 patients were enrolled and assessed for efficacy and toxicity. The response rate was 45.2% (95% CI 27.3%-64.0%; p = 0.001) and it exceeded the expected response rate set at 40%. Median progression-free survival was 5.8 months, the 1-year survival rate was 58.1%, and the median survival time was 16.1 months. The major grade 3/4 adverse events were neutropenia (58%), febrile neutropenia (13%), anemia (10%), anorexia (10%), and fatigue (6%).

CONCLUSIONS

These findings indicate that S-1 plus docetaxel as first-line treatment for older patients is feasible and that it has promising efficacy against advanced gastric cancer.

Clinical Significance of Increased Skeletal Muscle Mass During Nab-Paclitaxel Plus Gemcitabine Treatment in Patients With Advanced Pancreatic Cancer

OBJECTIVES

The clinical significance of increased skeletal muscle mass during nab-paclitaxel plus gemcitabine (AG) treatment in patients with advanced pancreatic cancer (APC) remains unknown. Therefore, we retrospectively investigated the characteristics of patients after AG treatment to evaluate the clinical significance of increased skeletal muscle mass during treatment.

METHODS

From January 2015 to August 2021, 67 patients with APC received AG as first-line chemotherapy at Higashiosaka City Medical Center. Of these patients, 39 received second-line (2L) chemotherapy after AG therapy, and 28 received best supportive care. Patients' characteristics at the end of AG treatment were compared retrospectively between these 2 groups, and the relevant factors at the end of first-line treatment for 2L chemotherapy induction were analyzed.

RESULTS

A performance status of 0 to 1 and increased skeletal muscle mass during AG therapy were independently associated with 2L chemotherapy induction in multivariate analysis. A high relative dose intensity (≥50%) in the first 8 weeks of AG treatment was more frequently found in patients with increased skeletal muscle mass during treatment ( P = 0.037).

CONCLUSIONS

Increased skeletal muscle mass during AG treatment might contribute to the higher prevalence of 2L chemotherapy induction in patients with APC.

Effect of the number of cycles of docetaxel + S-1 therapy on long-term survival in adjuvant chemotherapy for stage III gastric cancer. A pooled analysis of the OGSG0604 and OGSG1002 trials

BACKGROUND

S-1 plus docetaxel (DS) therapy followed by S-1 is the standard of care in Japan in postoperative adjuvant chemotherapy for stage III gastric cancer, but long-term survival and the number of DS cycles required are unclear. The purpose of this study was to investigate the impact of the number of cycles of DS therapy on the 5-year survival in stage III gastric cancer in a pooled analysis of two phase II trials (OGSG0604 and OGSG1002).

PATIENTS AND METHODS

Patients with histologically confirmed stage III gastric cancer who underwent gastrectomy with D2 lymphadenectomy were enrolled in this pooled analysis. They received DS therapy for four or eight cycles, followed by S-1 until 1 year postgastrectomy. The 5-year overall survival (OS) and the 5-year disease free survival (DFS) by the landmark analysis was evaluated.

RESULTS

In total, 113 patients from the OGSG0604 and OGSG1002 trials were enrolled in this study. The landmark analysis showed a 5-year OS that was better with four to eight cycles of DS therapy than with one to three cycles of DS therapy, with the best 5-year OS of 77.4% (95% confidence interval, 66.5-90.1%) for eight cycles. The 5-year DFS was approximately 66% when four or eight cycles of DS therapy were given.

CONCLUSION

Although eight cycles of DS therapy may prolong prognosis, the present study did not provide a clear conclusion as to how many DS therapy cycles are needed to improve prognosis after D2 gastrectomy for stage III gastric cancer.

TRIAL REGISTRATION

Registration number: UMIN00000714 and UMIN000004440.

[A Case of Laparoscopic Uterine and Vaginal Resection for Local Recurrence after Abdominoperineal Resection for Anal Canal Cancer]

The patient was an 80s woman. She visited our hospital with chief complaint of melena, and further evaluation revealed anal canal cancer. We performed robot-assisted abdominoperineal resection(D3 lymphadenectomy)and lateral lymph node dissection. The pathological diagnosis was anal canal cancer, muc>por1>tub2, T3N1bM0, pStage Ⅲb. One year after the surgery, she had a mass in the soft tissue of perineum on CT scan and PET-CT showed abnormal accumulation, which was diagnosed as local recurrence. At the same time, she also had a mass with abnormal accumulation in ascending colon, and it was diagnosed as ascending colon cancer. In both cases, we judged radical resection was possible, and the policy of surgery was decided. First, laparoscopic ileocecal resection was performed. The local recurrence lesion became a mass, invading the soft tissue of the perineum, the posterior wall of the vagina, and the cervix. So, we performed laparoscopic excision of local recurrent region together with the uterus and the posterior wall of the vagina. Based on the result of pathological examination, the patient was diagnosed with ascending colon cancer(tub1, pT1bN1aM0, pStage Ⅲa), and recurrence of anal canal cancer. The postoperative course is good and there are no signs of recurrence for 6 months after the operation.

Soluble programmed cell death ligand 1 predicts prognosis for gastric cancer patients treated with nivolumab: Blood-based biomarker analysis for the DELIVER trial

BACKGROUND

The clinical value of soluble forms of programmed cell death-1 (sPD-1), PD ligand 1 (sPD-L1) and cytotoxic T lymphocyte-associated protein-4 (sCTLA-4) for gastric cancer (GC) patients treated with nivolumab monotherapy has remained unknown.

METHODS

Blood samples collected before nivolumab treatment from 439 GC patients enrolled in the DELIVER (Japan Clinical Cancer Research Organisation GC-08) trial were analysed for sPD-1, sPD-L1 and sCTLA-4. Corresponding baseline clinical data were also retrieved.

RESULTS

Higher plasma levels of sPD-1 (hazard ratio [HR] = 1.27, p = 0.020), sPD-L1 (HR = 1.86, p < 0.001) and sCTLA-4 (HR = 1.33, p = 0.008) were significantly associated with shorter overall survival (OS), whereas only higher sPD-L1 levels was significantly associated with shorter progression-free survival (HR = 1.30, p = 0.008). The sPD-L1 concentration was significantly associated with the Glasgow prognostic score (GPS) (p < 0.001), but both sPD-L1 (HR = 1.67, p < 0.001) and GPS (HR = 1.39, p = 0.009 for GPS 0 versus 1; HR = 1.95, p < 0.001 for GPS 0 versus 2) were independently associated with OS. Patients with a GPS of 0 and low sPD-L1 thus showed the longest OS (median, 12.0 months) and those with a GPS of 2 and high sPD-L1 showed the shortest OS (median, 3.1 months), yielding a HR of 3.69 (p < 0.001).

CONCLUSION

Baseline sPD-L1 levels have the potential to predict survival for advanced GC patients treated with nivolumab, with the prognostic accuracy of sPD-L1 being improved by its combination with GPS.

[A Case of Early Appendiceal Adenocarcinoma Coexisting with High-Grade Appendiceal Mucinous Neoplasm]

We report a case of a female in her fifties with early appendiceal adenocarcinoma coexisting with high-grade appendiceal mucinous neoplasm(HAMN)with a review of the literature. The patient presented to our hospital because of an enlarged appendix noted by contrast-enhanced CT performed for hematuria. Contrast-enhanced CT showed that the appendix had swollen to 10 mm and mucus had accumulated inside, which had no evidence of obvious malignancy. She was followed up on CT once a year. Four years after her first visit, she underwent laparoscopic appendectomy for a definitive diagnosis. There were no adhesions or inflammation in her abdominal cavity, and the appendix root was dissected with an automatic anastomosis device. Her resected specimen macroscopically showed mild wall thickening, but no obvious neoplastic lesion. Pathological examination revealed that in many areas centered on the tip of the appendix, highly columnar atypical epithelium with enhanced mucus production was densely proliferated in the form of glandular tubular and papillary. The nuclei of the proliferating epithelium were large and the fission image was conspicuous, but they remained in the mucosa. Pathological examination diagnosed as HAMN according to the WHO classification. The atypical epithelium in a small area at the tip was particularly strong in nuclear atypia, and showed a strong positive diffusely in p53, which was an image of well-differentiated tubular adenocarcinoma. The pathological diagnosis was V, Type 0-Ⅱb, 2 mm, tub1 in HAMN, pTis, Ly0, V0, Pn0, pPM0, pDM0, pRM0, R0. Six months have passed since the operation, but no recurrence has been observed.

A phase II study of S-1 therapy for patients with advanced and recurrent esophageal cancer resistant or intolerable to fluorouracil, platinum, and taxane therapy (OGSG 1404)

BACKGROUND

Fluorouracil (FU), platinum (PT), and taxane (TAX) therapy was the standard chemotherapy for esophageal squamous cell carcinoma (ESCC) before the era of anti-programmed death-1 antibodies. The aim of this phase II trial was to evaluate the efficacy and safety of S-1 monotherapy for patients with recurrent or metastatic (R/M) ESCC resistant or intolerable to FU, PT, and TAX therapy.

METHODS

Eligible patients had R/M ESCC; no prior S-1 use; were intolerant or refractory to prior FU, PT, and TAX therapy; aged ≧ 20 years; and Eastern Cooperative Oncology Group performance status 0 or 1. S-1 was administered orally from days 1 to 28, every 6 weeks until disease progression. The primary endpoint was the disease control rate (DCR) for each patient, assessed by Response Evaluation Criteria in Solid Tumors, version 1.1. Secondary endpoints were overall survival, progression-free survival, time to treatment failure, response rate, and toxicity.

RESULTS

Between October 2015 and December 2017, 17 patients were recruited, and the trial was terminated because of slow accrual. The DCR was 46.7%. The response rate was 13.3%. The median progression-free survival was 2.0 months. The median time to treatment failure was 1.9 months. The median overall survival was 8.4 months, and the 1 year overall survival rate was 30.5%.

CONCLUSIONS

Although this trial closed early because of slow accrual, we observed modest clinical activity with S-1 in patients with R/M ESCC who could not tolerate or whose tumors were refractory to FU, PT, and TAX therapy.

Do antihypertensive drugs really have antitumor effects? Baseline differences in hypertensive and non-hypertensive patients with advanced pancreatic cancer

Although the antitumor effects of antihypertensive drugs for patients with advanced pancreatic cancer (APC) have been investigated, their efficacy remains unclear. Previous studies suggest that hypertensive (HT) patients with APC are significantly older than non-HT patients with APC, and that other major baseline differences in patient characteristics which may affect prognosis exist between HT and non-HT patients. It is also possible that antihypertensive drugs lack antitumor activity. Therefore, we herein retrospectively investigated the baseline differences between HT and non-HT patients with APC. From January 2015 to April 2020, 56 patients with APC received nab-paclitaxel plus gemcitabine as first-line chemotherapy at Higashiosaka City Medical Center (Higashiosaka, Japan). Of these 56 patients, 30 were diagnosed with hypertension (HT group); the remaining 26 did not have hypertension (non-HT group). Differences between the two groups were compared and prognostic factors were evaluated. Patients in the HT group had significantly less sarcopenia, a significantly larger body mass index, were significantly older, and significantly more likely to have a regular doctor and primary site in the body and tail of the pancreas than those in the non-HT group. Although no significant difference was found in the treatment response, patients in the HT group were significantly more likely to move to second-line chemotherapy than those in the non-HT group. Survival curves showed that median overall survival (OS) in the HT group was significantly longer (10.5 months) than in the non-HT group (6.8 months, P = .04). Multivariate analysis did not identify the use of antihypertensive drugs as an independent prognostic factor of OS. We identified key baseline differences in the characteristics of APC patients with and without HT, suggesting that major selection bias could occur when investigating the efficacy of antihypertensive drugs in all populations. Therefore, it is possible that antihypertensive drugs lack antitumor activity. To determine the true efficacy of antihypertensive drugs for APC, HT, and non-HT patients in another population should be investigated, or a prospective, randomized, controlled trial conducted that is stratified by HT or non-HT status.

Real-world effectiveness of third- or later-line treatment in Japanese patients with HER2-positive, unresectable, recurrent or metastatic gastric cancer: a retrospective observational study

Background

Real-world evidence on the preference for and effectiveness of third- or later-line (3L +) monotherapy for HER2-positive gastric cancer is limited in Japan. This study evaluated the utility of nivolumab, irinotecan, and trifluridine/tipiracil (FTD/TPI) monotherapy as 3L + treatment in Japanese patients with HER2-positive gastric/gastroesophageal junction (G/GEJ) cancer who were previously treated with trastuzumab.

Methods

In this multicenter, retrospective, observational study (20 centers), data of eligible patients were extracted from medical records (September 22, 2017–March 31, 2020), with follow-up until June 30, 2020. Outcomes included overall survival (OS), real-world progression-free survival (rwPFS), time to treatment failure (TTF), objective response rate (ORR; complete response [CR] + partial response [PR]), and disease control rate (DCR).

Results

Of 127 enrolled patients, the overall analysis population comprised 117 patients (median [range] age, 71 [38–89] years). The most commonly prescribed 3L + monotherapy was nivolumab (n = 100), followed by irinotecan (n = 12) and FTD/TPI (n = 5). The median (95% confidence interval [CI]) OS, rwPFS, and TTF were 6.2 (4.5–8.0), 1.9 (1.5–2.3), and 1.8 (1.5–2.2) months, respectively, at median (range) 150 (25–1007) days of follow-up. The ORR (CR + PR) and DCR were 9.0% (1% + 8%) and 32.0%, respectively. Factors such as higher neutrophil–lymphocyte ratio (≥ 2.54), Glasgow prognostic score (≥ 1), Eastern Cooperative Oncology Group performance status (ECOG PS; ≥ 2), and hepatic metastasis significantly impacted OS.

Conclusions

The observed OS in this study for HER2-positive G/GEJ cancer was shorter than that reported previously, suggesting that the effectiveness of nivolumab, irinotecan, or FTD/TPI as 3L + therapy may be limited.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10147-022-02162-4.

Three-Year Outcomes of a Phase II Study of Perioperative Capecitabine Plus Oxaliplatin Therapy for Clinical SS/SE N1-3 M0 Gastric Cancer (OGSG 1601)

Background

We previously reported the good feasibility and favorable efficacy of perioperative capecitabine plus oxaliplatin (CapeOx) in patients (pts) with clinical T3(SS)/T4a(SE) N1-3 M0 gastric cancer (GC) in a phase II study in which the pathological response rate, the primary endpoint, of 54.1% was demonstrated. Here, we report 3-year follow-up data.

Methods

The eligibility criteria included clinical T3(SS)/T4a(SE) N1-3 M0 GC according to the Japanese Classification of Gastric Carcinoma-3rd English Edition (JCGC). Three cycles of neoadjuvant CapeOx (capecitabine, 2000mg/m² for 14 days; oxaliplatin, 130mg/m² on day 1, every 3 weeks) were administered, followed by 5 cycles of adjuvant CapeOx after D2 gastrectomy. Three-year overall survival and relapse-free survival are presented here, and analyzed by cohorts based on pathologic response rate (pRR).

Results

Thirty-seven pts were enrolled from July 2016 to May 2017, and fully evaluated for efficacy and toxicity. Thirty-three pts (89.2%) completed the planned three cycles of neoadjuvant CapeOx and underwent gastrectomy, with an R0 resection rate of 78.4% (n = 29). The overall survival (OS) rate and relapse-free survival (RFS) rate at 3 years was 83.8% (95% CI, 72.7-96.5%) and 73.0% (95% CI, 60.0-88.8%), respectively. Further, the 3-year OS rate in pts with pathological response of grade 1a (n = 13) and grade 1b or higher (n = 20) was 69.2% (95% CI: 48.2-99.5%) and 100.0%, respectively, based on JCGC. Pathological response rate was classified according to JCGC as follows: grade 0, the tumor was not affected; grade 1a, less than one-third of the tumor was affected; grade 1b, one to two thirds of the tumor was affected; grade 2, greater than or equal to two thirds was affected; and grade 3, no residual tumor. A pathological response was defined as grade 1b or greater.

Conclusion

Perioperative CapeOx showed good feasibility and favorable prognosis, especially in pts with pathological response of grade 1b or higher and was found to be useful in predicting prognosis. The data obtained using this novel approach warrant further investigation (Trial ID: UMIN000021641, jRCTs051180109).

[A Case of Robotic-Assisted Total Pelvic Exenteration for Locally Advanced Rectal Cancer Invading the Prostate]

The patient was a 60s man, whose chief complaint of melena and weight loss. He visited our hospital, and further evaluation revealed rectal cancer(Rb)invading the prostate with obturator lymph node metastasis. The clinical diagnosis was T4b (prostate)N3M0, Stage Ⅲc. He was administered 4 courses of CAPOX plus bevacizumab. After chemotherapy the primary tumor and lymph nodes showed PR, the diagnosis of ycT4bN1bM0, Stage Ⅲc. We performed robot-assisted total pelvic exenteration. He has been cancer-free for 5 months.

[A Case of Laparoscopic Total Pelvic Exenteration for Sigmoid Colon Cancer Using Infrared Illumination System (IRIS)]

The patient was 80s woman, whose chief complaint of fever and abdominal pain. She visited our hospital, and further evaluation revealed sigmoid colon cancer invading the uterus and abdominal wall. The pooling of pus in the uterus was formed and we diagnosed as pyometra. The clinical diagnosis was T4b(uterus, abdominal wall)N0M0, cStage Ⅱc. We performed laparoscopic sigmoidectomy, uterus and bilateral ovaries. We report a case in which the intraoperative infrared illumination system(IRIS)was used to support the identification of the ureter by near-infrared light and total pelvic exenteration could be safely performed.

Baseline Factors Predictive of the Receipt of Second-Line Chemotherapy After Nab-Paclitaxel Plus Gemcitabine for Patients With Advanced Pancreatic Cancer

OBJECTIVE

Second-line (2L) chemotherapy is important for improved survival in patients with advanced pancreatic cancer (APC). However, approximately half of patients with APC do not receive 2L chemotherapy because of disease progression or adverse events. Baseline factors predictive of the receipt of 2L chemotherapy remain unknown. Therefore, we investigated predictive factors for the receipt of 2L chemotherapy in patients with APC.

METHODS

Between January 2015 and March 2020, 53 patients with APC received nab-paclitaxel plus gemcitabine (AG) as first-line chemotherapy at our institute. Of these 53 patients, 29 patients received 2L chemotherapy, and 23 patients received best supportive care. Patients' characteristics were compared retrospectively, and predictive factors for the receipt of 2L chemotherapy were evaluated.

RESULTS

Sarcopenia and hypoalbuminemia at baseline were independent negative predictive factors for the receipt of 2L chemotherapy in multivariate analysis. Although the presence of sarcopenia did not affect the relative dose intensity through 8 weeks of AG therapy, patients with hypoalbuminemia had a significantly lower relative dose intensity.

CONCLUSIONS

Sarcopenia and hypoalbuminemia at baseline might be negative predictive factors for the receipt of 2L chemotherapy after AG treatment in patients with APC.

Effectiveness of third- or later-line therapy in patients with HER2-positive advanced gastric cancer: Results from an observational retrospective study in Japan

277

Background: The real-world effectiveness of third- or later-line (3L+) therapies in patients (pts) with HER2-positive gastric cancer remains unknown. We report a multicenter, retrospective, observational study at 20 centers in Japan to investigate the outcomes of 3L+ therapy in pts with HER2-positive advanced gastric/gastroesophageal junction (G/GEJ) cancer previously receiving trastuzumab (UMIN000040853). Methods: Pts aged ≥20 years with HER2-positive advanced G/GEJ cancer who were previously treated with trastuzumab and newly initiated on nivolumab, irinotecan, or trifluridine/tipiracil monotherapy as 3L+ therapy (Sep 2017 to Mar 2020) were evaluated for overall survival (OS), progression-free survival (PFS), duration of response (DOR), time to treatment failure (TTF), objective response rate (ORR), and disease control rate (DCR). An exploratory analysis for factors affecting OS was conducted using a multivariate Cox regression model, with HER2 status as a covariate. Results: The overall analysis population was 117 pts (median: age, 71 years; number of prior treatment lines, 2; days since the initiation of first-line treatment, 431 days). Median (95% confidence interval) OS, PFS, and TTF were 6.2 months (4.5–8.0), 1.9 months (1.5–2.3), and 1.8 months (1.5–2.2), respectively, at a median follow-up of 150 days. Outcomes by treatment groups are shown in the Table. ORR and DCR in 100 pts with evaluable target lesions were 9.0% and 32.0%, respectively, and median DOR was 8.4 months. A higher neutrophil-lymphocyte ratio (≥2.540), Glasgow prognostic score (≥1), ECOG PS (≥2), and hepatic metastasis significantly impacted OS. Conclusions: The real-world effectiveness of 3L+ therapies was limited in this study. New HER2 treatment agent is expected to improve outcomes in pts with HER2-positive G/GEJ cancer.[Table: see text]

Real-world effectiveness of nivolumab in advanced gastric cancer: the DELIVER trial (JACCRO GC-08)

BACKGROUND

There is no large real-world data regarding efficacy and safety of immunotherapy in gastric cancer (GC). Although some tumors can grow rapidly after immunotherapy, the patient proportions and survival outcomes are unclear in GC.

METHODS

A multicenter, prospective observational study was performed to evaluate clinical outcomes including survival time, safety, and tumor behavior of nivolumab treatment for patients with advanced GC. Primary endpoint was overall survival (OS), and secondary endpoints included response rate (RR), disease control rate (DCR), progression-free survival (PFS), tumor growth rate (TGR) at first evaluation, and safety.

RESULTS

Of 501 enrolled patients, 487 were evaluable (median age 70 years, 71% male, performance status 0/1/2 [42%/44%/14%], 21% HER2-pos, 42% patients with ascites). Median OS was 5.82 months (95% CI 5.29-7.00) with a 1-year survival rate of 30% and median PFS of 1.84 months (95% CI 1.71-1.97). The DCR was 39.4% and the RR was 14.2% (95% CI 10.3-18.8) in 282 patients with measurable lesions. In 219 patients evaluable for TGR, 20.5% were identified as hyperprogressive disease (HPD). OS from the first evaluation of patients with HPD was shorter compared with non-HPD (HR 1.77, 95% CI 1.25-2.51, P = 0.001), but it was not worse than that of patients with progression and non-HPD (HR 1.05, 95% CI 0.72-1.53, P = 0.8). A multivariate analysis revealed the presence of peritoneal metastasis was a prognostic factor for OS and PFS.

CONCLUSIONS

Our real-world data demonstrated the comparable survival time to a previous clinical trial and revealed the frequency and prognosis of patients with HPD in advanced GC treated with nivolumab.

[A Case of Giant Intestinal GIST That Was Resected Just after TAE]

A 42-year-old woman visited our hospital complaining of fever and diarrhea. She had abdominal swelling and muscular defense. CT revealed a lobulated tumor occupying the lower abdomen. The tumor contained solid and cystic areas. The main artery vascularizing the tumor was the ileocecal artery, so we considered the tumor to be derived from the intestine or mesentery. We anticipated massive bleeding due to resection, and immediately after the embolization of the artery just before the operation. A vascular bundle from the terminal ileum and mesentery was found on the dorsal side of the tumor, and an outflow from the inferior mesenteric vein was also observed. We ligated each vessel and performed ileocecal resection. The operation lasted 4 hours and 18 minutes, with an estimated blood loss of 2,585 mL, requiring the transfusion of 6 units of concentrated red blood cells. According to histopathological findings, tumor cells with spindle-shaped to ellipsoidal nuclei proliferated in bundles and intricately, and immunostaining was positive for c-kit and DOG-1. We identified the tumor as high-risk GIST. The clinical course after the operation was uneventful. She continued to take imatinib for 3 years and is currently alive and without recurrence for 6 years after the operation.

Effects of an oral elemental nutritional supplement in gastric cancer patients with adjuvant S-1 chemotherapy after gastrectomy: A multicenter, open-label, single-arm, prospective phase II study (OGSG1108)

AIM

Post-surgical weight loss influences chemotherapy compliance and may be a risk factor for survival. Intake of an oral elemental nutritional supplement (OENS) can reduce weight loss after gastric cancer (GC) surgery. We assessed whether therapy completion levels would increase in patients receiving postoperative adjuvant chemotherapy in combination with an OENS.

METHODS

This was a multicenter, open-label, single-arm, phase II study in GC patients who underwent curative total or distal gastrectomy (TG/DG) and received adjuvant S-1 chemotherapy. The primary endpoint was the S-1 completion rate for 1 year with a relative performance (RP) value of ≥70%; secondary endpoints included factors affecting the completion rate of S-1, RP value after eight S-1 courses, S-1 and OENS persistence rates, nutritional index, OENS compliance, and safety.

RESULTS

In 71 efficacy-evaluable patients, the S-1 completion rate was 69.0% (TG, 68.0%; DG, 69.6%) and the RP value was 87.5 (TG, 89.1; DG, 87.5). Over eight treatment courses, median persistence rates were 89.0% for S-1 and 93.8% for the OENS. The mean OENS compliance was 81.8% at the fourth S-1 course and 52.9% at the eighth course. The incidence of Grade 3 or 4 adverse events was 27.2%, most commonly neutropenia (12.3%).

CONCLUSIONS

The completion rate of S-1 for 1 year in patients who could take the OENS exceeded the pre-defined threshold level. Randomized controlled trials are warranted to confirm the role of OENS in adjuvant chemotherapy.

A case report of simple mucinous cyst of pancreas detected by rupture

Introduction

Simple mucinous cyst (SMC) of pancreas is a disease defined by the Baltimore Consensus in 2014. Pancreatic mucus-producing neoplasms are considered to be premalignant tumors, but SMC is not considered to have a risk of malignancy or recurrence.

Presentation of case

The case was a woman in her 50s with a chief complaint of abdominal pain. A blood exam showed an increase in the inflammatory response, and a slight increase of Amylase. CT showed a cystic lesion 80 mm in size at tail of the pancreas, and disproportionate fat stranding and ascites around it. We diagnosed peritonitis associated with the rupture of a cystic lesion accompanied by pancreatitis. Abdominal pain was improving, and we decided to proceed with the detailed examination. MRI showed a uniform hyper-intensity on T2WI, and a nodular-like hypo-intensity was observed inside, which was enhanced. During the follow-up, the lesion had gradually grown and re-ruptured. As we could not deny malignancy by image findings, distal pancreatectomy was performed. The intracystic fluid was browny and turbid, and Amylase, CEA and CA19-9 of the cystic fluid were elevated. We diagnosed it SMC by histopathological findings. Currently, she had no recurrence for 1 year.

Discussion

SMC is a type of true cysts, so rupture was rare. However, if the cyst wall becomes weak due to complications such as acute pancreatitis. It is probable that our case had pancreatitis and the cyst wall was weakened.

Conclusion

SMC detected by rupture was very rare, so we report this case.

•

SMC of the pancreas in which surgery was required due to rupture was rare case.

•

This is unique that it looked like an nodule due to the gathering of cystic walls.

•

Non-neoplastic lesions should be considered if nodule grow and shrink over time.

Oral nutritional supplements versus a regular diet alone for body weight loss after gastrectomy: a phase 3, multicenter, open-label randomized controlled trial

BACKGROUND

Body weight loss (BWL) after gastrectomy is associated with not only a deteriorated quality of life but also a poor prognosis. Oral nutritional supplements (ONS) may be used to minimize BWL, which is observed in the first 3 months after gastrectomy and becomes stable thereafter, although the results of several randomized trials remain controversial.

METHODS

We performed a multicenter, open-label randomized controlled trial including 1003 gastric cancer patients undergoing curative gastrectomy. Patients were assigned to the ONS group or the control group. In the former, 400 ml (400 kcal) per day for 12 weeks as enteral nutrition was planned, and the actual intake amount was recorded daily by patients themselves. The primary endpoint was BWL 1 year after gastrectomy.

RESULTS

BWL data were available in 880 patients (ONS 437, control 443). BWL at 3 months was significantly lower in the ONS group than in the control group (7.1 ± 5.6% and 8.5 ± 5.8%, p = 0.0011). However, the difference gradually declined after 6 months and was not significant 1 year after surgery (9.3 ± 8.2% and 9.8 ± 8.7%, p = 0.37). In the ONS group, 50.4% of patients took more than 200 ml/day of ONS (average 301 ml) and showed significantly less BWL (8.2 ± 7.2%) at 1 year than the control (p = 0.0204).

CONCLUSION

The administration of ONS for 12 weeks after gastrectomy did not improve BWL at 1 year. However, the improvement in BWL remained until 1 year after surgery in patients who took more than 200 kcal/day of ONS.

Randomized phase II study of CPT-11 versus PTX versus each combination chemotherapy with S-1 for advanced gastric cancer that is refractory to S-1 or S-1 plus CDDP: OGSG0701

BACKGROUND

To compare irinotecan-alone, paclitaxel-alone, and each combination chemotherapy with S-1 in patients with advanced gastric cancer (AGC) that is refractory to S-1 or S-1 plus cisplatin (SP).

METHODS

Patients with AGC after first-line chemotherapy with S-1 or SP, or patients during adjuvant chemotherapy or within 26 weeks after adjuvant chemotherapy completion with S-1 with confirmed disease progression were eligible. Patients were randomly divided into four groups based on treatment: irinotecan-alone (irinotecan; 150 mg/m², day 1, q14 days), paclitaxel-alone (paclitaxel; 80 mg/m², days 1, 8, 15, q28 days), S-1 plus irinotecan (irinotecan; 80 mg/m², days 1, 15, S-1; 80 mg/m², days 1-21, q35 days), and S-1 plus paclitaxel (paclitaxel; 50 mg/m², day1, 8, S-1; 80 mg/m², days 1-14, q21 days). The primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS), response rate, and safety.

RESULTS

From July 2008 to March 2012, 127 patients were enrolled. No difference in median OS was observed in the irinotecan vs. paclitaxel groups or in the monotherapy groups vs. the S-1 combination therapy groups. Median PFS was longer in the paclitaxel group compared with the irinotecan group (4.1 vs. 3.6 months, p = 0.035), although no difference was observed when comparing monotherapy vs. S-1 combination. The most common grade 3 to 4 hematological adverse events were neutropenia with no difference in incidence rate across the treatment groups.

CONCLUSIONS

There was no difference in OS between irinotecan and paclitaxel no in OS prolongation of S-1 combination therapy in second-line chemotherapy.

Randomized phase II study of docetaxel versus paclitaxel in patients with esophageal squamous cell carcinoma refractory to fluoropyrimidine- and platinum-based chemotherapy: OGSG1201

BACKGROUND

There is no standard chemotherapy for esophageal squamous cell carcinoma (ESCC) refractory to first-line fluoropyrimidine- and platinum-based chemotherapy. We therefore performed a randomized, selection-design phase II trial to compare docetaxel (DTX) and paclitaxel (PTX) in this setting.

PATIENTS AND METHODS

Eligible patients were randomly assigned to receive either DTX (70 mg/m² on day 1 of each 21-day cycle) or PTX (100 mg/m² on days 1, 8, 15, 22, 29 and 36 of each 49-day cycle). The primary end-point was overall survival (OS), and secondary end-points included progression-free survival (PFS), time to treatment failure (TTF), response rate (RR) and safety.

RESULTS

Seventy-eight eligible patients (N = 39 in each group) were included for efficacy analysis. OS was significantly longer in the PTX group than in the DTX group (median, 8.8 versus 7.3 months; hazard ratio [HR], 0.62; P = 0.047). A significant benefit of PTX over DTX was also apparent in PFS (median, 4.4 versus 2.1 months; HR, 0.49; P = 0.002) and TTF (median, 3.8 versus 2.1 months; HR, 0.45; P < 0.001). RR (25.6% versus 7.7%, P = 0.065) were higher in the PTX group than in the DTX group. Compared to the PTX group, neutropenia (28% versus 80%) and leukopenia (28% versus 76%) of grade ≥3 as well as febrile neutropenia (0% vs. 46%, P < 0.0001) occurred more frequently in the DTX group.

CONCLUSION

PTX showed a significantly better efficacy as well as a more manageable toxicity compared with DTX.

CLINICAL TRIAL REGISTRATION

UMIN000007940.

Survival analysis by tumor response from real-world data in advanced gastric cancer treated with nivolumab: The DELIVER trial (JACCRO GC-08)

4044

Background: The phase III ATTRACTION-2 trial demonstrated survival benefit of nivolumab (Nivo) as third- or later-line treatment in previously treated advanced gastric or gastroesophageal junction (GEJ) cancer, with response rate (RR) of 11% (Kang YK, et al. Lancet 2017). It has been shown that some tumors grow rapidly after Nivo treatment, but the proportion and survival are still uncertain. We therefore prospectively investigated clinical outcomes from real-world data of Nivo treatment in advanced gastric cancer (GC). Methods: The DELIVER trial was a prospective, multicenter, observational study which assessed patients (pts) with advanced gastric or GEJ adenocarcinoma treated with Nivo alone and ECOG PS 0-2 (UMIN000030850). The aims were to evaluate the efficacy and safety of Nivo treatment in real world. Primary endpoint was overall survival (OS), secondary endpoints were RR, disease control rate (DCR), progression-free survival (PFS), tumor growth rate (TGR) at 1st evaluation, and safety. The sub-group analyses were performed for survival according to tumor response and clinical factors. The survival data was fixed at the timepoint of 1 year after the last enrollment. Results: In 501 pts enrolled from Mar 2018 to Aug 2019, 487 pts were evaluable (median age 70y, 71% male, ECOG PS0/1/2 42/44/14%, no. of prior regimen 1/2/≥3 2/39/59%, 21% HER2-pos, 42% pts with ascites). Median OS was 5.8 months (m) (95%CI 5.3-7.0) with 1y-survival rate of 30%, and median PFS was 1.8 m (95%CI 1.7-2.0), at 454 events for PFS and 389 events for OS. The DCR were 39.4%, and RR was 14.2% in 282 pts with measurable lesions. Median OS and PFS by tumor response (CR/PR/SD/PD) were Not Reached (NR)/NR/11.3/4.1m and NR/11.7/3.8/1.4m, respectively. A sub-group analysis of OS by clinical factors is the following: male/female; 6.5/5.0m ( p= 0.002), tub/por/sig; 8.1/5.4/4.1m ( p< 0.0001), albumin < 3.5/≥3.5; 4.2/8.9m ( p< 0.0001), w/peritoneal mets/w/o; 4.9/8.4m ( p< 0.0001), and w/ascites/w/o; 3.7/8.9m ( p< 0.0001). These findings were also observed in PFS. In 219 evaluable pts for TGR, 20.5% pts were identified as hyper-progressive disease (HPD). An exploratory approach by logistic regression analysis indicated that level of free-T3 in blood before Nivo treatment was higher in the HPD compared to the non-HPD group (2.5 vs. 2.2 pg/ml, p= 0.005). Survival time was comparable between the HPD group and PD without HPD group. Median period from 1st evaluation to death was 2.8 m for HPD, 5.7 m for non-HPD, and 2.4 m for PD at 1st evaluation without HPD. Conclusions: The real-world data of Nivo treatment in advanced GC indicated comparable survival to previous result in a clinical trial. Differences in survival time by tumor response or some clinical factors were observed in Nivo treatment. In addition, our study revealed the rate of HPD and the prognosis in advanced GC pts treated with Nivo. Clinical trial information: UMIN000030850.

Randomized phase II study comparing docetaxel versus paclitaxel in patients with esophageal squamous cell carcinoma who are refractory to fluoropyrimidine and platinum-based chemotherapy: OGSG1201

4037

Background: Fluoropyrimidine and platinum-based chemotherapy are considered first-line therapy options for patients with unresectable advanced or recurrent metastatic esophageal squamous cell carcinoma(ESCC). After fluoropyrimidine and platinum-based chemotherapy is failed, taxanes (docetaxel(DTX) and paclitaxel(PTX)) was mainly used as a second-line treatment for ESCC. Therefore, we conducted a trial to compare DTX and PTX in patients with unresectable advanced or recurrent ESCC who were failed to previous fluoropyrimidine and platinum-based chemotherapy. Methods: We did a randomized, an open-labeled and multicentre phase 2 study. Inclusion criteria included age 20 to 80 years with unresectable advanced or recurrent ESCC, Eastern Cooperative Oncology Group (ECOG) performance status score of 0 or 1. Patients who were refractory to fluoropyrimidine and platinum-based chemotherapy. Treatment consisted of DTX 70 mg/m2 repeated every 21 days or PTX 100 mg/m2 once weekly on days 1, 8, 15, 22, 29, and 36 of a 49-day cycle. Results: 80 patients were enrolled between May 2012 and April 2019. 41 patients received DTX and 39 patients received PTX. After assessment of eligibility, two patients proved uneligible (one for double cancer, one for contraindication to DTX) and were excluded from the analysis. But, 80 patients were evaluable for the toxicity analyses. A median follow-up time was 32 months. Overall survival was significantly longer in the PTX group than in the DTX group (median, 8.8 months vs. 7.3 months; hazard ratio, 0.62; 95% CI, 0.38 to 0.9998; P = 0.047). The median progression-free survival was significantly longer in the PTX group than in the DTX group (median, 4.4 months vs. 2.1 months; hazard ratio, 0.49; 95% CI, 0.30 to 0.78; P = 0.002). The median time to treatment failure was significantly longer in the PTX group than in the DTX group (median, 3.8 months vs. 2.1 months; hazard ratio, 0.45; 95% CI, 0.28 to 0.73; P＜0.001). The most common adverse events of grade 3 or higher were a decreased neutrophil count (in 28% of the PTX group and in 80% of the DTX group). Febrile neutropenia was also more frequent in the DTX group than the PTX group (46％ vs. 0%). There was one death from sudden death in which treatment-related mortality could not be ruled out. Conclusions: Secound-line treatment with PTX, as compared with DTX, reduced the risk of ESCC. Clinical trial information: UMIN000007940.

Multicenter prospective trial of total gastrectomy versus proximal gastrectomy for upper third cT1 gastric cancer

BACKGROUND

The appropriate surgical procedure for patients with upper third early gastric cancer is controversial. We compared total gastrectomy (TG) with proximal gastrectomy (PG) in this patient population.

METHODS

A multicenter, non-randomized trial was conducted, with patients treated with PG or TG. We compared short- and long-term outcomes between these procedures.

RESULTS

Between 2009 and 2014, we enrolled 254 patients from 22 institutions; data from 252 were included in the analysis. These 252 patients were assigned to either the PG (n = 159) or TG (n = 93) group. Percentage of body weight loss (%BWL) at 1 year after surgery, i.e., the primary endpoint, in the PG group was significantly less than that of the TG group (- 12.8% versus - 16.9%; p = 0.0001). For short-term outcomes, operation time was significantly shorter for PG than TG (252 min versus 303 min; p < 0.0001), but there were no group-dependent differences in blood loss and postoperative complications. For long-term outcomes, incidence of reflux esophagitis in the PG group was significantly higher than that of the TG group (14.5% versus 5.4%; p = 0.02), while there were no differences in the incidence of anastomotic stenosis between the two (5.7% versus 5.4%; p = 0.92). Overall patient survival rates were similar between the two groups (3-year survival rates: 96% versus 92% in the PG and TG groups, respectively; p = 0.49).

CONCLUSIONS

Patients who underwent PG were better able to control weight loss without worsening the prognosis, relative to those in the TG group. Optimization of a reconstruction method to reduce reflux in PG patients will be important.

Genomic pathway of gut microbiome to predict efficacy of nivolumab in advanced gastric cancer: DELIVER trial (JACCRO GC-08)

161

Background: Nivolumab (Nivo) monotherapy demonstrated survival benefit in previously treated gastric cancer (GC) patients (pts) (Kang YK, et al. Lancet 2017). About 60% of the pts did not respond to Nivo in late-lines, and its predictive markers are needed in GC. Several studies revealed that the efficacy of anti-PD-1-based immunotherapy was associated with composition of gut microbiome in various types of cancers, but little is known about GC. We therefore investigated whether genomic information in gut microbiome will serve as predictors for Nivo in advanced GC. Methods: The observational/translational study (DELIVER trial: UMIN000030850) has enrolled 501 pts with advanced GC treated with Nivo alone from March 2018 to August 2019 to discover gut microbiome biomarkers using fecal samples which were collected before treatment with Nivo. Primary endpoint was the relationship between genomic pathway in gut microbiome and efficacy of Nivo, whether progressive disease (PD) or not at the first evaluation according to RECIST criteria. Secondary endpoints included several relationships between markers of microbiome and clinical outcomes. Genomic data were measured by genome shotgun sequence at central lab. Biomarkers were analyzed by Wilcoxon rank sum test in the first 200 pts (training cohort). The top 30 candidates in an ascending order of p-value were validated in the last 300 pts (validation cohort) using Bonferroni method. Results: One hundred eighty of 200 pts and 257 of 301 pts were available for massive metagenomic and clinical data in the training cohort and validation cohort, respectively. The PD was 62.2% (95%CI 54.7-69.3) in the training cohort and 53.2% (95%CI 47.0-59.4) in the validation cohort. More diverse microbiome was observed in pts with non-PD compared to pts with PD. Although there was no statistically significant pathway to be validated for a primary endpoint under Bonferroni method, we found that bacterial invasion of epithelial cells pathway in the KEGG pathway was associated with clinical outcome of Nivo in both training cohort ( p= 0.057) and validation cohort ( p= 0.014). Upregulation of the pathway was related to PD at the first evaluation for Nivo treatment. An exploratory analysis of genus showed that Odoribacter and Veillonella were associated with tumor response to Nivo in both cohorts. Conclusions: Our translational study indicated for the first time that bacterial invasion of epithelial cells pathway in gut microbiome may potentially become a novel biomarker for treatment with Nivo in advanced GC. In addition, we found gastric cancer-specific gut microbiome to predict response to immune checkpoint inhibitors. Clinical trial information: UMIN000030850.

A phase II study of perioperative capecitabine plus oxaliplatin for clinical SS/SE N1-3 M0 gastric cancer (OGSG1601)

203

Background: D2 gastrectomy followed by adjuvant S-1 is one of the standard therapy for the patients (pts) with stage III gastric cancer (GC) in Japan; however, the outcome is not satisfactory. We examined the efficacy of perioperative capecitabine and oxaliplatin (CapeOx) in pts with clinical SS/SE N1-3 M0 GC. Methods: The eligibility criteria included histopathologically confirmed clinical T3(SS)/T4a(SE) N1-3 M0 GC according to the Japanese Classification of GC (JCGC; 3rd English Edition). Three cycles of neoadjuvant CapeOx (NAC; capecitabine, 2,000 mg/m2 for 14 days; oxaliplatin, 130 mg/m2 on day 1, every 3 weeks) were administered, followed by five cycles of adjuvant CapeOx after D2 gastrectomy. The primary endpoint was the pathological response rate (pRR) according to JCGC ( ≥Grade 1b). Results: Thirty-seven pts were enrolled from April 2016 to May 2017, and fully evaluated for efficacy and toxicity. Thirty-three pts (89.2%) completed the planned three cycles of NAC and underwent gastrectomy, with an R0 resection rate of 78.4% (n = 29) and a pRR of 54.1% (n = 20, p = .058; 90% confidence interval [CI], 39.4–68.2) were demonstrated. The relative dose intensity (RDI) of capecitabine and oxaliplatin were 90.5% and 91.9%, respectively. Among 27 pts who initiated AC, 21 (63.6%) completed the treatment, and the RDI of capecitabine and oxaliplatin were 80.9% and 65.1%, respectively. Grade 3–4 toxicities during NAC included neutropenia (8%), thrombocytopenia (8%), and anorexia (8%) and during AC included neutropenia (37%), diarrhea (4%), and anorexia (4%), but no treatment-related death was reported. The overall survival (OS) rate and relapse free survival (RFS) rate at 3 years was 83.8% (95% CI, 72.7-96.5%) and 73.0% (95% CI, 60.0-88.8%), respectively. Subgroup analyses according to residual tumor after surgery (R status) showed a 3-year OS and RFS rate of 86.2% (95% CI, 74.5-99.7%) and 75.7% (95% CI, 63.0-90.8%) for R0. Conclusions: Perioperative CapeOx showed good feasibility and favorable prognosis with sufficient pathological response, although statistical significance at .058 did not reach the commonly accepted cutoff of .05. The data obtained using this novel approach warrant further investigations. Clinical trial information: 000021641.

Comparison of 5-year postoperative outcomes after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: Results from a multi-institutional randomized controlled trial

AIM

We previously reported in a randomized controlled trial that Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change and nutritional status 1 year after distal gastrectomy for gastric cancer. We describe the long-term follow-up data 5 years after distal gastrectomy.

METHODS

We analyzed consecutive gastric cancer patients who were randomly assigned to undergo Billroth I or Roux-en-Y reconstruction after distal gastrectomy. We evaluated body weight change, nutritional status, late complications, quality of life (QOL) using the European Organization for Research and Treatment of Cancer Core QOL Questionnaire, and dysfunction using the Dysfunction After Upper Gastrointestinal Surgery for Cancer, 5 years after surgery.

RESULTS

A total of 228 patients (Billroth I = 105; Roux-en-Y = 123) were eligible for efficacy analyses in this study. Body weight loss 5 years after surgery did not differ significantly between the Billroth I and Roux-en-Y groups (10.0% ± 7.9% and 9.6% ± 8.4%, respectively; P = .70). There were no significant differences in other aspects of nutritional status between the two groups. Reflux esophagitis occurred in 19.0% of the patients in the Billroth I group vs 4.9% in the Roux-en-Y group (P = .002). Regarding QOL, Billroth I was significantly inferior to Roux-en-Y on the diarrhea scale (Billroth I: 28.6, Roux-en-Y: 16.0; P = .047). Regarding dysfunction, no score differed significantly between the two groups.

CONCLUSIONS

Billroth I and Roux-en-Y reconstructions were generally equivalent regarding body weight change, nutritional status, and QOL 5 years after distal gastrectomy, although Roux-en-Y more effectively prevented reflux esophagitis and diarrhea.

[A Case of Early Rectal Cancer Accompanied by Multiple Liver Abscesses]

An 81-year-old female who suffered from headache and general fatigue was diagnosed multiple liver abscesses by abdominal computed tomography(CT). Antibiotics and percutaneous transhepatic abscess drainage(PTAD)were performed, liver abscesses were improved. During the treatment, followed abdominal CT indicated lower rectal tumor. An early rectal cancer accompanied by multiple liver abscesses was diagnosed and performed surgery. The histological diagnosis was Rb, type 1, tub2, pT1b(SM 8,000 μm), Ly0, V1a, pN0, pStage Ⅰ. After surgery, the patient remains free from liver abscess. We report early colorectal cancer with multiple liver abscesses in Japanese literature.

[A Case of Locally Advanced Appendiceal Cancer with Radical Resection after CAPOX plus Bevacizumab]

We report a case of a male in his sixties with appendiceal cancer who underwent radical resection following CAPOX plus bevacizumab neoadjuvant chemotherapy. The patient presented to our hospital with a chief complaint of chronic low abdominal pain. Contrast-enhanced CT before neoadjuvant chemotherapy revealed an inhomogeneous tumor in the ileocecal region. Invasion to the bladder and the sigmoid colon was also observed. A colonoscopy showed an elevated lesion, which was caused by extramural invasion to the sigmoid colon. Pathological examination of the sigmoid colon tumor revealed well differentiated tubular adenocarcinoma and KRAS codon13 G13D. Hence, we diagnosed the patient with locally advanced appendiceal cancer with invasion to the bladder and sigmoid colon. We administered CAPOX plus bevacizumab as neoadjuvant chemotherapy. Contrast-enhanced abdominal CT after neoadjuvant chemotherapy revealed shrinkage of the primary tumor and reduction in the invasion to the bladder and sigmoid colon. We performed ileocecal resection(+D3), a partial sigmoidectomy, and partial bladder resection on the 135th day from the diagnosis. The resected specimen showed an appendiceal tumor with invasion to the bladder and sigmoid colon. The pathological diagnosis was Ⅴ, yType 5, tub2>tub1, ypT4b, ypN0, ycH0, ycM0, ycPUL0, Ly1b, V1b(VB), Pn01b, pStage Ⅱa, and the histological treatment effect of preoperative therapy was Grade 1b. Our experience indicates that in patients with locally advanced appendiceal cancer, multimodal treatment with neoadjuvant chemotherapy is an effective option.

A case of multiple serous cystadenoma of pancreas

Introduction

Typically, SCN is single and doesn't invade around tissue. In our case, tumors were multiple and had gradually grown and caused vein stenosis. This is extremely rare and unique resected multiple SCN case. In addition, I report that it was thought to be educational that even benign tumors could cause such changes.

Presentation of case

A 60-year-old female was diagnosed with 3 multilocular cystic tumors in distal pancreas by contrast enhanced computed tomography (CT) at the preoperative staging for rectal neoplasm. The diameters of cystic tumors were 22/23/29 mm. The CT showed that the tumors had multiple internal septa enhanced in the arterial phase and the second tumor contained internal calcifications located centrally. The main pancreatic duct was not dilated. Although SCN often occurred single and multiple SCN was very rare, we diagnosed that the tumors were suspected microcystic type SCN because they had typical image findings. So, we planned to follow up every six months after resection for rectal neoplasm. 2 years and half later, they had gradually grown, and splenic vein stenosis appeared. The pancreatic parenchyma atrophy and dilatation of the main pancreatic duct had been gradually progressing. We performed distal pancreatectomy because of possibility of malignancy. The histopathological findings showed that 2 cystic tumors the side of pancreatic head had a connection and had typical findings of SCA of pancreas. The other tumor was independent from two tumors. They had no malignant findings.

Discussion

At first, we expected tumor invasion had caused the changes. But tumors had no malignant findings, so we considered that compression from the tumor had caused stenosis, and obstructive pancreatitis had induced the pancreatic parenchyma atrophy.

Conclusion

We learned from this case that not only invasion but also compression caused vein stenosis and pancreatic duct dilation.

•

Multiple serous cystic neoplasms are rare tumors.

•

The tumors had gradually grown and main pancreatic duct dilatation had appeared.

•

We performed laparotomy because we couldn't deny local infiltration.

•

The main pancreatic duct dilatation had been caused by the compression.

•

This is unique that even benign tumors could cause pancreatic duct dilatation.

Predictive implications of decreased CA19-9 at 8 weeks during nab-paclitaxel plus gemcitabine for the induction of second-line chemotherapy for patients with advanced pancreatic cancer

Background

Second‐line (2L) chemotherapy after nab‐paclitaxel plus gemcitabine (AG) is important for improving the survival of patients with advanced pancreatic cancer (APC). However, many patients fail to receive 2L chemotherapy because of rapid disease progression. Therefore, early recognition of any ineffectiveness during AG might lead to an increased induction rate of 2L chemotherapy.

Aim

We investigated the significance of treatment response at 8 weeks as a predictive factor for the induction of 2L chemotherapy after AG.

Methods and results

From January 2015 to January 2019, 41 patients with APC underwent AG as first‐line chemotherapy at our institute. Thirty‐three patients were evaluated at 8 weeks. Sixteen patients (48%) underwent 2L chemotherapy and 17 (52%) underwent no 2L chemotherapy. Clinical features and treatment response at 8 weeks were, retrospectively, compared among patients. Predictive factors for the induction of 2L chemotherapy were analyzed. Patients with an objective response by 8 weeks received 2L chemotherapy more frequently (P = .026). Decreased CA19‐9 (<50%) at 8 weeks was identified as an independent negative predictive factor for the induction of 2L chemotherapy.

Conclusions

Decreased CA19‐9 (<50%) at 8 weeks may indicate the ineffectiveness of AG and signify that a move to 2L chemotherapy may be required without delay.

A phase II trial of dose-reduced nab-paclitaxel for patients with previously treated, advanced or recurrent gastric cancer (OGSG 1302)

BACKGROUND

For unresectable or recurrent advanced gastric adenocarcinoma (AGC), tri-weekly administration of nanoparticle albumin-bound paclitaxel (nab-PTX) at 260 mg/m² achieved a response rate of 27.8% in a phase II trial in Japan. However, frequent neutropenia and peripheral neuropathy limit its use in clinical settings. We, thus, conducted a single-arm phase II trial to investigate the efficacy and safety of a reduced dose (220 mg/m²) of tri-weekly nab-PTX.

METHODS

Eligible patients included those with AGC and ECOG performance status of 0-2 who had received one or more prior chemotherapy containing fluoropyrimidine regimens. A reduced dose of nab-PTX (220 mg/m²) was administered tri-weekly. The primary endpoint was response rate (RR). Secondary endpoints were overall survival (OS), progression-free survival (PFS), disease-control rate (DCR), incidence of adverse events, relative dose intensity (RDI) and proportion of patients receiving subsequent chemotherapy.

RESULTS

Among 33 patients enrolled, 32 were treated with protocol therapy. RR was 3.1% [95% confidence interval (CI), 0-16.2%], which did not reach the protocol-specified threshold (p = 0.966). DCR was 37.5% (95% CI, 21.1-56.3%). Median OS and PFS were 6.3 (95% CI, 4.4-14.2) and 2.2 (95% CI, 1.8-3.1) months, respectively. RDI was 97.8%. Twenty (62.5%) patients received subsequent chemotherapy. Toxicity was relatively mild with the most common grade ≥ 3 adverse events being neutropenia (38%), anemia (13%), fatigue (19%), anorexia (16%), and peripheral neuropathy (13%).

CONCLUSION

Tri-weekly nab-PTX with a reduced dose (220 mg/m²) is not recommended for AGC in a second-line or later setting, despite demonstrating less toxicity than at 260 mg/m². Clinical trial registration The OGSG1302 trial was registered with UMIN-CTR as UMIN000000714.

Bridge to surgery using a self-expandable metallic stent for stages II-III obstructive colorectal cancer

BACKGROUND

Bridge to surgery (BTS) using a self-expandable metallic stent (SEMS) for the treatment of obstructive colorectal cancer improves the patient's quality of life. This study aimed to examine prognostic factors of obstructive colorectal cancer.

METHODS

We analyzed stage II-III resectable colon cancer cases (Cur A) retrospectively registered between January 2005 and December 2017. Overall, 117 patients with Cur A obstructive colorectal cancer were evaluated: 67 of them underwent emergency surgery (ES Group) and 50 of them after BTS with SEMS placement (BTS group). We compared surgical results and prognoses between the two groups.

RESULTS

A total of 50 patients underwent endoscopic SEMS placement, which technical success of 96% and morbidity rate of 18%. Primary anastomosis rates were 77.6% in ES and 95.7% in BTS (p <  0.001); postoperative complication, 46.3% in ES and 10.5% in BTS (p <  0.001); pathological findings of lymphatic invasion, 66.7% in ES and 100% in BTS (p <  0.001); venous invasion were 66.8% in ES and 92% in BTS (p = 0.04); and recurrence of 25.4% in ES and 39.1% in BTS. The 3-year overall survival was significantly different between two groups (ES, 86.8%:BTS, 58.8%), BTS is worse than ES (log-rank test; p <  0.001). Venous invasion independently predicted worsened recurrence-free and overall survival.

CONCLUSIONS

The vascular invasiveness was correlated with tumor progression after SEMS placement, and the survival rate was lower in BTS. SEMS potentially worsens prognostic outcomes in stage II-III obstructive colorectal cancer.

Efficacy of S-1 in second-line chemotherapy after nab-paclitaxel plus gemcitabine for patients with advanced pancreatic cancer

BACKGROUND

Second-line (2 L) chemotherapy is important for improved survival. However, the efficacy of S-1 after nab-paclitaxel plus gemcitabine (AG) for advanced pancreatic cancer (APC) remains unclear.

AIM

We retrospectively investigated the clinical impact of S-1 after AG.

METHODS AND RESULTS

From January 2015 to July 2018, 37 patients with APC underwent AG as first-line chemotherapy at our institute. Of these patients, 14 (38%) underwent S-1 as 2 L chemotherapy after AG (S-1 group), five (14%) received another agent after AG, and 18 (49%) underwent no 2 L chemotherapy (best supportive care [BSC] group). The clinical features were retrospectively compared between the S-1 and BSC groups. Prognostic factors for residual survival (RS) were analyzed using a Cox proportional hazards model. The induction rate of 2 L chemotherapy was 51%, and most patients received S-1 monotherapy (74%). The disease control rate and progression-free survival duration were 57.1% and 2.8 months, respectively. The median RS duration in the S-1 and BSC groups was 5.2 and 2.4 months, respectively; this difference was statistically significant (hazard ratio, 0.33; P = .005). The median overall survival duration in the S-1 and BSC groups was 12.3 and 5.0 months, respectively; this difference was also statistically significant (hazard ratio, 0.26; P = .001). The efficacy of S-1 in 2L chemotherapy for RS was identified in the multivariate analysis, as was age (<65 vs ≥65 y) and the presence of liver metastasis.

CONCLUSION

The antitumor activity of S-1 was retained after AG, and the induction of S-1 after AG might improve the prognosis of patients with APC.

Comparison of S-1-cisplatin every 5 weeks with capecitabine-cisplatin every 3 weeks for HER2-negative gastric cancer (recurrent after S-1 adjuvant therapy or chemotherapy-naïve advanced): pooled analysis of HERBIS-2 (OGSG 1103) and HERBIS-4A (OGSG 1105) trials

BACKGROUND

We previously reported the HERBIS-4A phase II trial comparing S-1 plus cisplatin (SP) with capecitabine plus cisplatin (XP) in chemotherapy-naïve patients with HER2-negative advanced gastric cancer (GC). We performed a pooled analysis of HERBIS-4A and HERBIS-2, the phase II trial comparing SP with XP in HER2-negative recurrent GC patients with a recurrence-free interval after S-1 adjuvant therapy of ≥ 6 months.

PATIENTS AND METHODS

Patients were randomly assigned to receive either SP [S-1 (40-60 mg twice daily for 21 days) plus cisplatin (60 mg/m² on day 8), every 5 weeks] or XP [capecitabine (1000 mg/m² twice daily for 14 days) plus cisplatin (80 mg/m² on day 1), every 3 weeks].

RESULTS

In the pooled analysis, SP (n = 44-50) showed a longer progression-free survival [6.4 versus 5.1 months; hazard ratio (HR), 0.666; P = 0.062], overall survival (14.8 versus 10.6 months; HR, 0.695; P = 0.099), and time to treatment failure (4.6 versus 3.6 months; HR, 0.668; P = 0.045) as well as a higher disease control rate (86.4% versus 68.1%, P = 0.149) compared with XP (n = 47-51). A significant survival advantage for SP over XP was apparent in patients with a performance status of 0, a differentiated-type tumor histology, or a primary tumor localization to the upper portion of the stomach.

CONCLUSION

Our pooled analysis supports the use of SP in the first-line setting for patients with HER2-negative advanced or recurrent GC with a recurrence-free interval of ≥ 6 months.

CLINICAL TRIAL REGISTRATION

The HERBIS-2 trial was registered with UMIN-CTR as UMIN000006105.

Tumor response and growth rate of nivolumab treatment in advanced gastric cancer: Real-world data from a large observational/translational study, JACCRO GC-08 (deliver trial)

4527

Background: Nivolumab (Nivo) demonstrated survival benefit in previously treated gastric cancer (GC) patients (pts), with a response rate (RR) of 11% and a disease control rate (DCR) of 40% (Kang YK, et al. Lancet 2017). There are few real-world data of Nivo and its predictive markers are needed in GC. It has been demonstrated that some tumors grow rapidly after Nivo treatment, but the proportion is uncertain. Methods: DELIVER trial was a prospective, multicenter, observational/translational study which assessed pts with advanced GC treated with Nivo alone and ECOG Performance Status (PS) 0-2 (UMIN000030850). The aims were to evaluate the efficacy and safety of Nivo in real world, and to discover novel host-related immune-biomarkers (gut microbiome, genetic polymorphism, gene expression, and metabolome) using fecal and blood samples which were collected before and after Nivo treatment. The RR, DCR, progression-free survival, overall survival, and tumor growth rate (TGR) were estimated as the efficacy. The response was evaluated by first imaging based on RECIST version 1.1. The TGR was calculated as a percentage increase in tumor volume during 1 month (Champiat et al. Clin Cancer Res 2017). Results: A total of 501 pts was enrolled in this study from Mar 2018 to Aug 2019, and 487 pts were evaluable for analysis (median age 70-y, 71% male, ECOG PS0/1/2 42%/44%/14%, tub/por/sig 45%/41%/5%, 21% HER2-pos, 42% pts with ascites). The DCR was 39.2% (95%CI 34.9-43.7) in evaluable pts. In 282 pts with measurable lesions, the RR was 6.7% (95%CI 4.1-10.3) and DCR was 36.5%. Sub-analysis by patient background indicated that DCR was 41% for PS0, 42% for PS1, and 24% for PS2. In addition, the DCR was lower in pts with ascites compared to those without ascites (28.6% vs. 47.0%, p= 0.005). The TGR decreased after introduction of Nivo in 124 (56.6%) of 219 evaluable pts for TGR; however, 20.5% pts were identified as experiencing hyper-progressive disease (HPD) which was defined as a ≥2-fold increase of the TGR before and after Nivo. When defining HPD as a ≥2-fold increase of tumor growth kinetics ratio and 50% increase of tumor burden, 9.6% pts experienced it. Conclusions: The real-word data of the large observational trial showed a comparable DCR to that of clinical trial in advanced GC treated with Nivo. This trial revealed the tumor behavior and some pts who experienced rapid tumor growth after Nivo treatment in clinical practice; biomarkers for HPD and the definition should be established. Clinical trial information: UMIN000030850 .

[Clinical Significance of Palliative Esophageal Stent Placement for Esophageal Cancer]

BACKGROUND

Since the introduction of the guideline for the diagnosis and treatment of esophageal carcinoma in 2007, the indication for placing an esophageal stent has changed, especially with respect to the treatment of esophageal stricture after chemoradiotherapy(CRT). For CRT cases, irradiation after stent placement and stent placement after CRT are not recommended due to the risk of perforation.

METHODS

Thirty-eight patients who underwent esophageal stenting in our department between January 2007 and December 2018 and who were diagnosed with thoracic esophageal cancer were included in this study. We retrospectively examined the safety and treatment effect of esophageal stent placement.

RESULTS

Prior cancer therapy was observed in 16 cases(8 cases of chemotherapy and 8 cases of CRT). In the no prior therapy group, 13 cases were treated with BSC and 9 cases with chemotherapy. Esophageal stent placement after CRT was performed in 8 cases. Esophageal stent was placed 9(6-14)months after CRT. The stent patency period was 5(1-11)months, and the survival period after stent placement was 6(1-12)months. There was no difference in the frequency of complications and treatment outcomes of the CRT group compared with the non-CRT group.

CONCLUSION

Cases undergoing esophageal stent placement after CRT can expect therapeutic effects similar to those of other cases. However, complications such as perforation can be fatal; thus, careful consideration should be given to each individual case for esophageal stent placement after CRT.

Real-world efficacy and biomarker of nivolumab for advanced gastric cancer

388

Background: Although nivolumab demonstrated survival benefit and a manageable safety profile in previously-treated advanced gastric cancer in a phase III trial (ATTRACTION-2), the efficacy of nivolumab in real-world and predictive factors of responses to nivolumab for advanced gastric cancer remain unclear. We evaluated the efficacy of nivolumab and compared clinicopathological characteristics with responses to nivolumab and long-term survivals in patients with gastric cancer. Methods: 205 patients with unresectable or recurrent gastric cancer who were treated with nivolumab as 3rd or more line treatment were enrolled from 23 institutions. Tissue specimens were collected in 199 patients. PD-L1 expression of tumor specimens defined as tumor positive score (TPS) and combined positive score (CPS) and mismatch repair (MMR) were analyzed by immunohistochemistry. Tumor responses were assessed according to RECIST version 1.1. Hyper progressive disease (HPD) was defined as ≥two folds increase in tumor growth rate. Results: 138 out of 205 enrolled patients had measurable lesions. Response rate and HPD rate were 16.7% (23/138) and 22.0% (29/132), respectively. Response rate was significantly higher in patients with performance status (PS) 0-1, non-peritoneal diseases, CPS ≥10, and MMR deficient patients. On the other hand, PS 2-3 and liver metastases were predictive factors of HPD. Patients with CPS≥10 and MMR deficiency showed significantly better progression-free (P = 0.005, P = 0.001) and overall survivals (P = 0.005, P = 0.002). TPS showed no significant association with any outcomes. Conclusions: Real-world efficacy of nivolumab was shown in previously-treated advanced gastric cancer. CPS and MMR could be the useful biomarkers for the efficacy of nivolumab treatment as well as PS and metastasis site. Clinical trial information: UMIN000032164.

A phase II trial of low-dose nab-paclitaxel for patients with previously treated or recurrent advanced gastric cancer (OGSG1302)

350

Background: Paclitaxel is a key drug in second-line chemotherapy for advanced or recurrent gastric cancer (AGC) and nanoparticle albumin-bound paclitaxel (nab-PTX) is also widely used in Japan. A previous phase II trial in Japan showed the effectiveness of nab-PTX (260 mg/m2) administered every 3 weeks (q3w) in patients with AGC with a response rate (RR) of 27.8%; however, toxicity was major concern with grade ≥3 neutropenia (49.1%) and peripheral neuropathy (23.6%). To solve this problem, we investigated the efficacy and safety of low-dose q3w nab-PTX regimen in AGC. Methods: Eligibility requirements included: aged ≥20 years, HER2-negative, histologically confirmed, unresectable or recurrent gastric adenocarcinoma, one or more prior chemotherapy containing fluoropyrimidine regimens, presence of measurable lesion(s) according to RECIST ver. 1.1, ECOG PS of 0–2, and adequate organ function. Nab-PTX was administered at a dose of 220 mg/m2 every 3 weeks. The primary endpoint was the RR. Secondary endpoints were overall survival (OS), progression-free survival (PFS), disease-control rate (DCR), incidence of adverse events, relative dose intensity and proportion of patients who received subsequent chemotherapy. Results: Thirty-three patients were enrolled from 10 institutions in Japan. Of the 32 patients treated with protocol therapy, RR (CR, PR) was 3.1% (95% CI, 0–16.2%), which was not reached the protocol-specified threshold (p = 0.966). DCR (CR, PR, SD) was 37.5% (95% CI, 21.1–56.3%), median OS and PFS were 6.3 months (95% CI, 4.4–14.2) and 2.2 months (95% CI, 1.8-3.1). Relative dose intensity was 97.8% (215 mg/m2). 62.5% of patients received subsequent chemotherapy. Most common grade ≥3 adverse events were neutropenia (38%), anemia (13%), fatigue (19%), anorexia (16%), and peripheral neuropathy (13%). Conclusions: Low-dose regimen of q3w nab-PTX was slightly less toxic, although it did not demonstrate the same effect as the original regimen in response rate. Therefore, it is not recommended for AGC in second or later line setting. Clinical trial information: UMIN 000012701.

Comparing five-weekly S-1 plus cisplatin with tri-weekly capecitabine plus cisplatin in patients with HER2-negative recurrent gastric cancer after S-1 adjuvant therapy or chemotherapy naïve advanced gastric cancer: A pooled analysis of HERBIS-2 (OGSG 1103) and HERBIS-4A (OGSG 1105) trials

379

Background: HERBIS-2 trial was a phase II trial where S-1 plus cisplatin (SP) and capecitabine plus cisplatin (XP) were compared in recurrent HER2 negative gastric cancer (GC) patients with recurrence free interval (RFI) by S-1containing adjuvant of ≥ 6 months. We performed pooled analyses of HERBIS-2 and HERBIS-4A trial where SP and XP were compared in chemotherapy-naive HER2 negative gastric cancer (GC) patients as these trials being identical. Methods: Both HERBIS-2 and 4A trials, patients were randomly assigned to receive either SP (S-1 at 40–60 mg twice daily for 21 days plus cisplatin at 60 mg/ m2on day 8, every 5 weeks) or XP (capecitabine 1,000 mg/m2twice daily for 14 days plus cisplatin 80 mg/m2on day 1, every 3 weeks). Results: In HERBIS-2 which was s closed early due to poor accrual, SP ( N= 10) tended to confer a better overall survival (OS) compared with XP ( N= 9)[18.7 (95%CI, 2.8 – NR) months vs.13.4 (95% CI, 5.2 – 31.3) months; hazard ratio (HR), 0.443 (95% CI, 0.156 – 1.258); P= .117]. In pooled analyses with HERBIS-2 and 4A, SP ( N= 50) vs. XP ( N = 51) showed longer progression free survival (6.4 vs.5.1 months; HR, 0.666; P= .62), OS (14.8 vs. 10.6 months; HR, 0.695; P= .099), time to treatment failure (4.6 vs. 3.6 months; HR, 0.668; P= .045), and higher disease control rate (86.4% vs. 68.1%, P= .149). Subgroup analysis revealed that OS benefit in SP arm compared to XP arm was significantly larger if the patient having PS of 0 [HR, 0.554 (95% CI, 0.309 to 0.959; interaction P= .035], or the tumor arising from upper area of stomach [HR, 0.266 (95% CI, 0.070 to 0.731); interaction P= .013] or harboring differentiated type cancer [HR, 0.433 (95% CI, 0.228 to 0.822); interaction P= .011], respectively. Conclusions: Our data suggest the use of SP in the 1stline setting in HER2 negative advanced or recurrent GC with RFI by S-1 adjuvant of ≥ 6 months. Pooled analyses further suggest SP as the standard 1st line chemotherapy for HER2 negative AGC irrespective of S-1 adjuvant in Japan. Clinical trial information: UMIN000006755/UMIN000006105.