Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial

BACKGROUND

Patients with borderline resectable pancreatic ductal adenocarcinoma have relatively low resection rates and poor survival despite the use of adjuvant chemotherapy. The aim of our study was to establish the feasibility and efficacy of three different types of short-course neoadjuvant therapy compared with immediate surgery.

METHODS

ESPAC5 (formerly known as ESPAC-5f) was a multicentre, open label, randomised controlled trial done in 16 pancreatic centres in two countries (UK and Germany). Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, biopsy proven pancreatic ductal adenocarcinoma in the pancreatic head, and were staged as having a borderline resectable tumour by contrast-enhanced CT criteria following central review. Participants were randomly assigned by means of minimisation to one of four groups: immediate surgery; neoadjuvant gemcitabine and capecitabine (gemcitabine 1000 mg/m2 on days 1, 8, and 15, and oral capecitabine 830 mg/m2 twice a day on days 1-21 of a 28-day cycle for two cycles); neoadjuvant FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, folinic acid given according to local practice, and fluorouracil 400 mg/m2 bolus injection on days 1 and 15 followed by 2400 mg/m2 46 h intravenous infusion given on days 1 and 15, repeated every 2 weeks for four cycles); or neoadjuvant capecitabine-based chemoradiation (total dose 50·4 Gy in 28 daily fractions over 5·5 weeks [1·8 Gy per fraction, Monday to Friday] with capecitabine 830 mg/m2 twice daily [Monday to Friday] throughout radiotherapy). Patients underwent restaging contrast-enhanced CT at 4-6 weeks after neoadjuvant therapy and underwent surgical exploration if the tumour was still at least borderline resectable. All patients who had their tumour resected received adjuvant therapy at the oncologist's discretion. Primary endpoints were recruitment rate and resection rate. Analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN, 89500674, and is complete.

FINDINGS

Between Sept 3, 2014, and Dec 20, 2018, from 478 patients screened, 90 were randomly assigned to a group (33 to immediate surgery, 20 to gemcitabine plus capecitabine, 20 to FOLFIRINOX, and 17 to capecitabine-based chemoradiation); four patients were excluded from the intention-to-treat analysis (one in the capecitabine-based chemoradiotherapy withdrew consent before starting therapy and three [two in the immediate surgery group and one in the gemcitabine plus capecitabine group] were found to be ineligible after randomisation). 44 (80%) of 55 patients completed neoadjuvant therapy. The recruitment rate was 25·92 patients per year from 16 sites; 21 (68%) of 31 patients in the immediate surgery and 30 (55%) of 55 patients in the combined neoadjuvant therapy groups underwent resection (p=0·33). R0 resection was achieved in three (14%) of 21 patients in the immediate surgery group and seven (23%) of 30 in the neoadjuvant therapy groups combined (p=0·49). Surgical complications were observed in 29 (43%) of 68 patients who underwent surgery; no patients died within 30 days. 46 (84%) of 55 patients receiving neoadjuvant therapy were available for restaging. Six (13%) of 46 had a partial response. Median follow-up time was 12·2 months (95% CI 12·0-12·4). 1-year overall survival was 39% (95% CI 24-61) for immediate surgery, 78% (60-100) for gemcitabine plus capecitabine, 84% (70-100) for FOLFIRINOX, and 60% (37-97) for capecitabine-based chemoradiotherapy (p=0·0028). 1-year disease-free survival from surgery was 33% (95% CI 19-58) for immediate surgery and 59% (46-74) for the combined neoadjuvant therapies (hazard ratio 0·53 [95% CI 0·28-0·98], p=0·016). Three patients reported local disease recurrence (two in the immediate surgery group and one in the FOLFIRINOX group). 78 (91%) patients were included in the safety set and assessed for toxicity events. 19 (24%) of 78 patients reported a grade 3 or worse adverse event (two [7%] of 28 patients in the immediate surgery group and 17 [34%] of 50 patients in the neoadjuvant therapy groups combined), the most common of which were neutropenia, infection, and hyperglycaemia.

INTERPRETATION

Recruitment was challenging. There was no significant difference in resection rates between patients who underwent immediate surgery and those who underwent neoadjuvant therapy. Short-course (8 week) neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Neoadjuvant chemotherapy with either gemcitabine plus capecitabine or FOLFIRINOX had the best survival compared with immediate surgery. These findings support the use of short-course neoadjuvant chemotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma.

FUNDING

Cancer Research UK.

Tucatinib vs Placebo, Both in Combination With Trastuzumab and Capecitabine, for Previously Treated ERBB2 (HER2)-Positive Metastatic Breast Cancer in Patients With Brain Metastases: Updated Exploratory Analysis of the HER2CLIMB Randomized Clinical Trial

Importance

It is estimated that up to 50% of patients with ERBB2 (HER2)-positive metastatic breast cancer (MBC) will develop brain metastases (BMs), which is associated with poor prognosis. Previous reports of the HER2CLIMB trial have demonstrated that tucatinib in combination with trastuzumab and capecitabine provides survival and intracranial benefits for patients with ERBB2-positive MBC and BMs.

Objective

To describe overall survival (OS) and intracranial outcomes from tucatinib in combination with trastuzumab and capecitabine in patients with ERBB2-positive MBC and BMs with an additional 15.6 months of follow-up.

Design, Setting, and Participants

HER2CLIMB is an international, multicenter, randomized, double-blind, placebo-controlled clinical trial evaluating tucatinib in combination with trastuzumab and capecitabine. The 612 patients, including those with active or stable BMs, had ERBB2-positive MBC previously treated with trastuzumab, pertuzumab, and trastuzumab emtansine. The study was conducted from February 23, 2016, to May 3, 2019. Data from February 23, 2016, to February 8, 2021, were analyzed.

Interventions

Patients were randomized 2:1 to receive tucatinib (300 mg orally twice daily) or placebo (orally twice daily), both in combination with trastuzumab (6 mg/kg intravenously or subcutaneously every 3 weeks with an initial loading dose of 8 mg/kg) and capecitabine (1000 mg/m2 orally twice daily on days 1-14 of each 3-week cycle).

Main Outcomes and Measures

Evaluations in this exploratory subgroup analysis included OS and intracranial progression-free survival (CNS-PFS) in patients with BMs, confirmed intracranial objective response rate (ORR-IC) and duration of intracranial response (DOR-IC) in patients with measurable intracranial disease at baseline, and new brain lesion-free survival in all patients. Only OS was prespecified before the primary database lock.

Results

At baseline, 291 of 612 patients (47.5%) had BMs. Median age was 52 years (range, 22-75 years), and 289 (99.3%) were women. At median follow-up of 29.6 months (range, 0.1-52.9 months), median OS was 9.1 months longer in the tucatinib-combination group (21.6 months; 95% CI, 18.1-28.5) vs the placebo-combination group (12.5 months; 95% CI, 11.2-16.9). The tucatinib-combination group showed greater clinical benefit in CNS-PFS and ORR-IC compared with the placebo-combination group. The DOR-IC was 8.6 months (95% CI, 5.5-10.3 months) in the tucatinib-combination group and 3.0 months (95% CI, 3.0-10.3 months) in the placebo-combination group. Risk of developing new brain lesions as the site of first progression or death was reduced by 45.1% in the tucatinib-combination group vs the placebo-combination group (hazard ratio, 0.55 [95% CI, 0.36-0.85]).

Conclusions and Relevance

This subgroup analysis found that tucatinib in combination with trastuzumab and capecitabine improved OS while reducing the risk of developing new brain lesions, further supporting the importance of this treatment option for patients with ERBB2-positive MBC, including those with BMs.

Trial Registration

ClinicalTrials.gov Identifier: NCT02614794.

Pathological response and safety of FOLFOXIRI for neoadjuvant treatment of high-risk relapsed locally advanced colon cancer: study protocol for a single-arm, open-label phase II trial

INTRODUCTION

Neoadjuvant chemotherapy (NAC) has been demonstrated effective in several tumours, but its benefit has not yet been elucidated in colorectal cancer, especially locally advanced colorectal cancer (LACRC).

METHODS AND ANALYSIS

This is a single-arm, open-label, prospective phase II exploratory clinical trial. Patients with LACRC will receive four cycles of NAC with 5-fluorouracil, oxaliplatin and irinotecan (FOLFOXIRI), followed by operation and then adjuvant chemotherapy with capecitabine and oxaliplatin for two to five cycles or single-agent capecitabine for five cycles, or observation. The primary endpoint is the rate of tumour regression grade (TRG) 0-2 in the resected tumour tissue, which is evaluated by experienced pathologists according to the Ryan R TRG grading system. Secondary endpoints include objective response rate, pathologic complete response, microscopically complete resection rate, progression-free survival, distant metastasis-free survival, overall survival, toxicity and compliance to study treatment, molecular markers, quality of life to study treatment and the number of patients with 30-day postoperative mortality. The objective of this study is to analyse the efficacy and safety of FOLFOXIRI as the NAC regimen in patients with LACRC and to identify a promising treatment strategy in this setting.

ETHICS AND DISSEMINATION

Written informed consent will be required from and provided by all patients enrolled. The study protocol has been approved by the independent ethics committee of West China Hospital, Sichuan University (approval number: 2021403). This study will demonstrate the potential benefit of NAC with the FOLFOXIRI regimen. Results will be shared with policymakers and the academic community to promote the clinical management of colon cancer.

TRIAL REGISTRATION NUMBER

NCT05018182.

Pathological pseudoprogression to anti-PD-1 inhibitor in metastatic periampullary carcinoma: Case report

RATIONALE

Pseudoprogression has been deemed as a rare clinical phenomenon during the treatment of immune checkpoint inhibitors in patients with advanced cancers, especially in periampullary carcinoma, however, leaving potential molecular mechanism remain unknown.

PATIENT CONCERNS

Regular examination after radical pancreaticoduodenectomy because of periampullary carcinoma.

DIAGNOSES

Recurrent periampullary carcinoma with metastasis in liver.

INTERVENTIONS

Regimens of XELOX (oxaliplatin at a dose of 130 mg/m2, day 1 and oral capecitabine at a dose of 1000 mg/m2 twice a day, day 1-14, every 21 days), and tislelizumab at a dose of 200 mg, day 1, per 21 days, was prescribed as palliative treatment.

OUTCOMES

Pseudoprogression and symptom of hair and mustache repigmentation were also observed, which resulted in partial response finally.

LESSONS

Results of the present case suggested that pseudoprogression, along with hair and mustache repigmentation, possibly caused by anti-PD-1 inhibitors, may also happen in patients with periampullary carcinoma, which should be paid attention to. The potential mechanism should be further investigated.

A Randomized Phase III Study of Anlotinib Versus Bevacizumab in Combination With CAPEOX as First-Line Therapy for RAS/BRAF Wild-Type Metastatic Colorectal Cancer: A Clinical Trial Protocol

Background: Chemotherapy combined with antivascular endothelial growth factor (VEGF) or anti-epidermal growth factor receptor monoclonal antibodies is the most promising approach to prolong survival and improve the quality of life of patients with unresectable metastatic colorectal cancer (mCRC). Anlotinib is an oral antiangiogenic tyrosine kinase inhibitor that targets VEGF receptors 1/2/3, fibroblast growth factor receptors 1-4, and platelet-derived growth factor receptors a/β. Since anlotinib combined with oxaliplatin and capecitabine (CAPEOX) as a first-line treatment was previously shown to be effective and safe for patients with RAS/BRAF wild-type (WT) mCRC, we designed this randomized, open-label, parallel-group, non-inferiority, phase III study to evaluate the efficacy and safety of anlotinib plus CAPEOX versus bevacizumab plus CAPEOX in patients with RAS/BRAF WT mCRC. Methods/design: The primary inclusion criteria are Eastern Cooperative Oncology Group performance status 0/1, confirmed RAS/BRAF WT colorectal adenocarcinoma, and unresectable metastases assessed by a multidisciplinary team. The main exclusion criteria are as follows: high microsatellite instability or deficient mismatch repair status, resectable or potentially resectable metastases, and previous systemic therapy for mCRC. A total of 698 patients will be randomized into the anlotinib and bevacizumab groups in a 1:1 ratio. Patients will receive 4 to 8 cycles of induction therapy (CAPEOX plus anlotinib or bevacizumab), followed by maintenance treatment (capecitabine plus anlotinib or bevacizumab) until disease progression or unacceptable toxicity. Progression-free survival (PFS) assessed by an independent review committee is the primary endpoint, whereas investigator-assessed PFS, overall survival, objective response rate, disease control rate, duration of response, resection rate of liver metastases, quality of life, and safety are the secondary endpoints. Enrollment commenced in May 2021. Discussion: A prospective, randomized, phase III trial will provide a meaningful comparison of the efficacy and safety of anlotinib plus CAPEOX with standard treatment for patients with unresectable RAS/BRAF WT mCRC.

Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer

PURPOSE

Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC.

METHODS

Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin.

RESULTS

In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options.

CONCLUSION

In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.

Pyrotinib versus lapatinib therapy for HER2 positive metastatic breast cancer patients after first-line treatment failure: A meta-analysis and systematic review

INTRODUCTION

It is critical to select subsequent treatments for patients after the failure of trastuzumab therapy. Following the failure of standard trastuzumab therapy guidelines in the Chinese Society of Clinical Oncology, pyrotinib and capecitabine is a grade I recommended regimen for treating patients with HER2-positive metastatic breast cancer. Concurrently, in treating patients with HER2-positive metastatic breast cancer, lapatinib and capecitabine are also recommended regimens for those who have previously received taxanes, anthracyclines, and trastuzumab therapy. However, there is currently no systematic review and meta-analysis comparing pyrotinib with lapatinib among HER2+ MBC patients. Therefore, this study aims to perform a systematic review and meta-analysis and assess whether pyrotinib is superior to lapatinib in efficacy and safety.

METHODS

Relevant trials were searched in CNKI, Wanfang, VIP, PubMed, Embase, and Cochrane CENTRAL databases from inception until March 27th, 2022. The primary outcomes were PFS and OS, and the secondary outcomes were ORR and grade ≥3 AEs.

RESULTS

Five relevant studies were included in this study, including 2 RCTs and 3 retrospective cohort studies. Pyrotinib combined with chemotherapy is superior to lapatinib combined with chemotherapy among HER2+ metastatic breast cancer patients, with a significant improvement in PFS (prior trastuzumab therapy) (HR: 0.47, 95% CI: 0.39-0.57, p<0.001, I2 = 0%, FEM), PFS (trastuzumab resistance) (HR: 0.52, 95% CI: 0.39-0.68, p<0.001, I2 = 40%, FEM) and ORR (RR: 1.45, 95% CI: 1.26-1.67, p<0.001, I2 = 8%, FEM), but has higher grade ≥3 diarrhea incidence (RR: 2.68, 95% CI: 1.85-3.90, p<0.001, I2 = 44%, FEM).

CONCLUSIONS

The efficacy of pyrotinib combined with chemotherapy is superior to lapatinib combined with chemotherapy but has more safety risks.

Cell-free DNA Predicts Prolonged Response to Multi-agent Chemotherapy in Pancreatic Ductal Adenocarcinoma

The treatment of metastatic pancreatic ductal adenocarcinoma (PDAC) is frequently characterized by significant toxicity and rapid development of resistance to current approved therapies. More reliable biomarkers of response are needed to guide clinical decision making. We evaluated cell-free DNA (cfDNA) using a tumor-agnostic platform and traditional biomarkers (CEA and CA19-9) levels in 12 patients treated at Johns Hopkins University on NCT02324543 "Study of Gemcitabine/Nab-Paclitaxel/Xeloda (GAX) in Combination With Cisplatin and Irinotecan in Subjects With Metastatic Pancreatic Cancer." The pretreatment values, levels after 2 months of treatment, and change in biomarker levels with treatment were compared with clinical outcomes to determine their predictive value. The variant allele frequency (VAF) of KRAS and TP53 mutations in cfDNA after 2 months of treatment was predictive of progression-free survival (PFS) and overall survival (OS). In particular, patients with a lower-than-average KRAS VAF after 2 months of treatment had a substantially longer PFS than patients with higher posttreatment KRAS VAF (20.96 vs. 4.39 months). Changes in CEA and CA19-9 after 2 months of treatment were also good predictors of PFS. Comparison via concordance index demonstrated KRAS or TP53 VAF after 2 months of treatment to be better predictors of PFS and OS than CA19-9 or CEA. This pilot study requires validation but suggests cfDNA measurement is a useful adjunct to traditional protein biomarkers and imaging evaluation and could distinguish between patients who are likely to achieve prolonged responses versus those that will have early progression and may benefit from a change in treatment approach.

Significance

We report on the association of cfDNA with response durability for patients undergoing treatment with a novel metronomic chemotherapy regimen (gemcitabine, nab-paclitaxel, capecitabine, cisplatin, irinotecan; GAX-CI) for metastatic PDAC. This investigation offers encouraging evidence that cfDNA may prove to be a valuable diagnostic tool to guide clinical management.

Re-thinking the possible interaction between proton pump inhibitors and capecitabine

Proton Pump Inhibitors (PPI) rank within the top ten most prescribed medications in Europe and USA. A high frequency of PPI use has been reported amongst patients undergoing chemotherapy, to mitigate treatment-induced gastritis or gastro-oesophageal reflux. Several recent, mostly retrospective, observational studies have reported inferior survival outcomes among patients on capecitabine who concomitantly use PPI. Whilst this association is yet to be definitively established, given the prominence of capecitabine as an anti-cancer treatment with multiple indications, these reports have raised concern within the oncological community and drug regulatory bodies worldwide. Currently, the leading mechanism of interaction postulated in these reports has focussed on the pH altering effects of PPI and how this could diminish capecitabine absorption, leading to a decrease in its bioavailability. In this discourse, we endeavour to summarise plausible pharmacokinetic interactions between PPI and capecitabine. We provide a basis for our argument against the currently proposed mechanism of interaction. We also highlight the long-term effects of PPI on health outcomes, and how PPI use itself could lead to poorer outcomes, independent of capecitabine.

Cancer Trial Impact: Understanding Implementation of the Short Course Oncology Treatment (SCOT) Trial Findings in colorectal cancer at a National Level

AIMS

The Short Course Oncology Treatment (SCOT) trial indicated that 3 months of adjuvant doublet chemotherapy was non-inferior to 6 months of treatment for patients with colorectal cancer, with considerably less toxicity. The SCOT trial results were disseminated in June 2017. The aim of this study was to understand if SCOT trial findings were implemented in Scotland.

MATERIALS AND METHODS

A retrospective analysis was carried out on a dataset derived from a source population of 5.4 million people. Eligible patients were those with stage II or III colorectal cancer who received adjuvant chemotherapy. Logistic regression was applied to understand the extent of practice change to a 3-month adjuvant chemotherapy duration after the SCOT trial results were disseminated. Interrupted time series analysis was used to visualise differences in prescribing trends before and after June 2017 for the overall cohort, and by SCOT trial eligibility.

RESULTS

In total, 2310 patients were included in the study; 1957 and 353 treated pre- and post-June 2017, respectively. The median treatment duration decreased from 21 weeks (interquartile range 14-24) prior to June 2017 to 12 weeks (interquartile range 12-21 weeks) after June 2017 (P < 0.001). The proportion of patients receiving over 3 months of adjuvant treatment decreased from 75% to 42% (P < 0.001). This change was most noticeable for patients who met the SCOT trial eligibility criteria, and specifically for those with low-risk stage III disease and those treated with capecitabine and oxaliplatin (CAPOX). Although practice change occurred in all locations, there were differences between regions that could be explained by pre-SCOT trial prescribing trends.

DISCUSSION

A significant change in chemotherapy prescribing occurred after dissemination of the SCOT trial results. National, real-world data can be used to capture the extent of implementation of clinical trial results. In this case, implementation was aligned with clinical trial subgroup findings. This type of analysis could be conducted to evaluate the impact of other clinical trials.

Clinical Efficacy of Bevacizumab Plus XELOX Chemotherapy in Colorectal Cancer and Application Value of Mindfulness-Based Stress Reduction Intervention

BACKGROUND AND OBJECTIVES

Colorectal cancer (CRC) is a malignant tumor with an extremely high incidence rate worldwide. This study explores the influence of mindfulness-based stress reduction (MBSR) in the care of patients with CRC undergoing bevacizumab (BVZ) plus XELOX chemotherapy, aiming at providing reliable reference and guidance for further improving their rehabilitation and prognosis.

METHODS

Between January 2019 and March 2020, 88 patients with CRC admitted consecutively to Jiangsu Cancer Hospital in China were enrolled in the study. Of them, 42 patients receiving BVZ plus XELOX chemotherapy, conventional care and MBSR intervention were assigned to the intervention group, and the remaining 46 patients receiving XELOX chemotherapy and conventional care were included in the control group. Clinical efficacy, safety and improvement in functional status were compared. Patients' psychological state, treatment compliance and self-care ability were evaluated. Finally, prognostic quality of life (QoL) was recorded at 1-year follow-up.

RESULTS

The overall response rate and incidence of adverse events in the intervention group were not different in the control group, but the total control rate and improvement rate in the intervention group were higher. After treatment, Sedation-Agitation Scale (SAS) and Self-Rating Depression Scale (SDS) scores in the intervention group were decreased, compliance and self-care ability were improved, all of which were better than in the control group. Prognostic follow-up showed that the QoL in the intervention group was also higher than in the control group.

CONCLUSIONS

The combined use of BVZ in XELOX-based chemotherapy can improve the clinical outcome and functional status of patients with CRC. In addition, MBSR intervention implemented during chemotherapy can effectively optimize patients' psychological state and treatment compliance, strengthen their self-care ability and improve their prognostic QoL.

[Evaluation of the Usefulness of Pharmaceutical Outpatient Clinic for Gastric Cancer Patients Receiving Capecitabine plus Oxaliplatin as Postoperative Adjuvant Chemotherapy]

Capecitabine plus oxaliplatin(CapeOX)is widely used as postoperative adjuvant chemotherapy for gastric cancer. The CapeOX regimen often causes digestive symptoms, such as nausea and vomiting under postoperative conditions, and oxaliplatin- induced neurological symptoms, for which supportive intervention is needed. The pharmaceutical outpatient clinic of Jichi Medical University provides pharmaceutical intervention for cancer patients. This study evaluated the usefulness of the pharmaceutical outpatient clinic for gastric cancer patients receiving postoperative adjuvant chemotherapy. The primary endpoint was defined as the effect of the number of outpatient pharmacist interventions on the relative dose intensity of the CapeOX regimen. The secondary endpoint was the correlation between the number of outpatient pharmacist interventions and the worst grade of each side effect. It was observed that patients who received at least 5 outpatient pharmacist interventions had significantly higher dose intensities(p=0.019). Outpatient pharmaceutical interventions were associated with the reduction of side effect symptoms that could be managed with preventive and supportive care. These results showed that continuous intervention by outpatient pharmacists contribute to the optimization of dose intensity and reduction of side effects in gastric cancer patients receiving CapeOX as postoperative adjuvant chemotherapy.

Treatment of HR+/HER2− breast cancer in urban mainland China: results from the CancerMPact Survey 2019

Purpose

To report the treatment utilization patterns for hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2−) breast cancer in urban mainland China (CancerMPact®).

Methods

The results presented are from an online survey conducted in September 2019 with 45 physicians treating breast cancer patients from 11 cities in mainland China.

Results

Surveyed physicians reported that Stage I HR+/HER2(−) breast cancer patients are often treated with surgery alone (42%), whereas the use of surgery in combination with systemic therapy with or without radiotherapy increases in later stages (Stage II 67%, Stage III 77%). Doxorubicin–cyclophosphamide (AC)-based regimens were the most common in both the neoadjuvant and adjuvant settings in HR+/HER2(−) breast cancer patients, across all stages. In metastatic patients, use of surgery and radiotherapy decreases in favor of utilization of systemic therapy alone. Pre- and post-menopausal metastatic patients were frequently treated with hormone therapy or AC-based regimens in first line. Regardless of the first-line therapy administered, capecitabine-based regimens were commonly used in second line. In third line, chemotherapy regimens containing capecitabine or gemcitabine were given to nearly 40% of HR+/HER2(−) breast cancer patients. There were no standard of care regimens established for fourth or greater lines of treatment. In metastatic HR+/HER2(−) breast cancer, physicians reported 50% objective response rates in first-line settings with a progression-free survival of 16 months.

Conclusion

HR+/HER2(−) breast cancer patients in urban mainland China were prescribed chemotherapy regimens more frequently than CDK4/6 inhibitors. Treatment practices varied, with physicians reporting the use of multiple modalities and treatment regimens for their patients.

Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy

PURPOSE

Prospective data on the efficacy of a watch-and-wait strategy to achieve organ preservation in patients with locally advanced rectal cancer treated with total neoadjuvant therapy are limited.

METHODS

In this prospective, randomized phase II trial, we assessed the outcomes of 324 patients with stage II or III rectal adenocarcinoma treated with induction chemotherapy followed by chemoradiotherapy (INCT-CRT) or chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT) and either total mesorectal excision (TME) or watch-and-wait on the basis of tumor response. Patients in both groups received 4 months of infusional fluorouracil-leucovorin-oxaliplatin or capecitabine-oxaliplatin and 5,000 to 5,600 cGy of radiation combined with either continuous infusion fluorouracil or capecitabine during radiotherapy. The trial was designed as two stand-alone studies with disease-free survival (DFS) as the primary end point for both groups, with a comparison to a null hypothesis on the basis of historical data. The secondary end point was TME-free survival.

RESULTS

Median follow-up was 3 years. Three-year DFS was 76% (95% CI, 69 to 84) for the INCT-CRT group and 76% (95% CI, 69 to 83) for the CRT-CNCT group, in line with the 3-year DFS rate (75%) observed historically. Three-year TME-free survival was 41% (95% CI, 33 to 50) in the INCT-CRT group and 53% (95% CI, 45 to 62) in the CRT-CNCT group. No differences were found between groups in local recurrence-free survival, distant metastasis-free survival, or overall survival. Patients who underwent TME after restaging and patients who underwent TME after regrowth had similar DFS rates.

CONCLUSION

Organ preservation is achievable in half of the patients with rectal cancer treated with total neoadjuvant therapy, without an apparent detriment in survival, compared with historical controls treated with chemoradiotherapy, TME, and postoperative chemotherapy.

Isolated gastric variceal bleeding related to non-cirrhotic portal hypertension following oxaliplatin-based chemotherapy: A case report

BACKGROUND

Sinusoidal obstruction syndrome has been reported after oxaliplatin-based chemotherapy, but liver fibrosis and non-cirrhotic portal hypertension (NCPH) are rarely reported.

CASE SUMMARY

Here, we describe the case of a 64-year-old woman who developed isolated gastric variceal bleeding 16 mo after completing eight cycles of oxaliplatin combined with capecitabine chemotherapy after colon cancer resection. Surprisingly, splenomegaly and thrombocytopenia were not accompanied by variceal bleeding, which has been reported to have predictive value for gastric variceal formation. However, a liver biopsy showed fibrosis in the portal area, suggesting NCPH. The patient underwent endoscopic treatment and experienced no further symptoms.

CONCLUSION

It is necessary to guard against long-term complications after oxaliplatin-based chemotherapy. Sometimes splenic size and platelet level may not always accurately predict the occurrence of portal hypertension.

Long-Term Outcomes and Exploratory Analyses of the Randomized Phase III BILCAP Study

PURPOSE

The BILCAP study described a modest benefit for capecitabine as adjuvant therapy for curatively resected biliary tract cancer (BTC), and capecitabine has become the standard of care. We present the long-term data and novel exploratory subgroup analyses.

METHODS

This randomized, controlled, multicenter, phase III study recruited patients age 18 years or older with histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer after resection with curative intent and an Eastern Cooperative Oncology Group performance status of < 2. Patients were randomly assigned 1:1 to receive oral capecitabine (1,250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation. The primary outcome was overall survival (OS). This study is registered with EudraCT 2005-003318-13.

RESULTS

Between March 15, 2006, and December 4, 2014, 447 patients were enrolled; 223 patients with BTC resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. At the data cutoff of January 21, 2021, the median follow-up for all patients was 106 months (95% CI, 98 to 108). In the intention-to-treat analysis, the median OS was 49.6 months (95% CI, 35.1 to 59.1) in the capecitabine group compared with 36.1 months (95% CI, 29.7 to 44.2) in the observation group (adjusted hazard ratio 0.84; 95% CI, 0.67 to 1.06). In a protocol-specified sensitivity analysis, adjusting for minimization factors, nodal status, grade, and sex, the OS hazard ratio was 0.74 (95% CI, 0.59 to 0.94). We further describe the prognostic impact of R status, grade, nodal status, and sex.

CONCLUSION

This long-term analysis supports the previous analysis, suggesting that capecitabine can improve OS in patients with resected BTC when used as adjuvant chemotherapy after surgery and should be considered as the standard of care.

A semimechanistic population pharmacokinetic and pharmacodynamic model incorporating autoinduction for the dose justification of TAS-114

TAS-114 is a dual deoxyuridine triphosphatase (dUTPase) and dihydropyrimidine dehydrogenase (DPD) inhibitor expected to widen the therapeutic index of capecitabine. Its maximum tolerated dose (MTD) was determined from a safety perspective in a combination study with capecitabine; however, its inhibitory effects on DPD activity were not assessed in the study. The dose justification to select its MTD as the recommended dose in terms of DPD inhibition has been required, but the autoinduction profile of TAS-114 made it difficult. To this end, an approach using a population pharmacokinetic (PPK)/pharmacodynamic (PD) model incorporating autoinduction was planned; however, the utility of this approach in the dose justification has not been reported. Thus, the aim of this study was to demonstrate the utility of a PPK/PD model incorporating autoinduction in the dose justification via a case study of TAS-114. Plasma concentrations of TAS-114 from 185 subjects and those of the endogenous DPD substrate uracil from 24 subjects were used. A two-compartment model with first-order absorption with lag time and an enzyme turnover model were selected for the pharmacokinetic (PK) model. Moreover, an indirect response model was selected for the PD model to capture the changes in plasma uracil concentrations. Model-based simulations provided the dose justification that DPD inhibition by TAS-114 reached a plateau level at the MTD, whereas exposures of TAS-114 increased dose dependently. Thus, the utility of a PPK/PD model incorporating autoinduction in the dose justification was demonstrated via this case study of TAS-114.

Analysis of capecitabine metabolites in conjunction with digital autoradiography in a murine model of pancreatic cancer suggests extensive drug penetration through the tumor

Previously published digital autoradiography of 3 H-labeled capecitabine reveals a near-uniform distribution of activity throughout a murine pancreatic model. This is in contrast both to 14 C-labeled gemcitabine, and established expectations, as the dense stroma of pancreatic cancer is understood to inhibit drug penetration. Capecitabine is a pro-drug for 5 FU. The positioning of the radiolabel on capecitabine leaves open the possibility that much of the autoradiographic signal is generated by nontoxic compounds. Studies were performed on tumors derived via organoid culture from a murine KPC tumor. As before, we performed autoradiography comparing 3 H capecitabine to the gemcitabine analog 18 F-FAC. The metabolism of capecitabine in this model was studied through LC-MS of tumor tissue. The autoradiographs confirmed that the 3 H label from capecitabine was much more uniformly distributed through the tumor than the 18 F from the gemcitabine analog. LC-MS revealed that approximately 75% of the molar mass of capecitabine had been converted into 5 FU or pre-5 FU compounds. The remainder had been converted into nontoxic species. Therapeutically relevant capecitabine metabolites achieve a relatively even distribution in this pancreatic cancer model, in contrast to the gemcitabine analog 18 F-FAC. In a human xenograft model, (BxPC3), the 3 H label from capecitabine was also uniformly spread across the tumor autoradiographs. However, at 2 h post-administration the metabolism of capecitabine had proceeded further and the bulk of the agent was in the form of nontoxic species.

[A Case of Rectal Cancer and Multiple Lung Metastases That Had Complete Response Treated by XELOX plus Bevacizumab after Primary Lesion Resection]

A 54-year-old woman visited our hospital complaining of abdominal distension. Endoscopic examination revealed type 3 tumor in the rectum located 15 cm from the anal edge. Enhanced computed tomography showed multiple ground glass-like shadows in both lungs that were suspected of multiple metastases. We diagnosed as having rectal cancer with multiple lung metastases. After placing the stent transanally to release the intestinal obstruction, we performed laparoscopic high anterior resection. Then, the patient received chemotherapy with 10 courses of XELOX plus bevacizumab and 9 courses of the regimen without oxaliplatin. A whole-body CT revealed complete response. And while taking capecitabine the patient remains well and without recurrence. We describe the present case with reference to the literature.

Proton pump inhibitors and colorectal cancer: A systematic review

BACKGROUND

The use of proton pump inhibitors (PPI) is common worldwide, with reports suggesting that they may be overused. Several studies have found that PPI may affect colorectal cancer (CRC) risk.

AIM

To summarize current knowledge on the relationship between PPI and CRC from basic research, epidemiological and clinical studies.

METHODS

This systematic review was based on the patients, interventions, comparisons, outcome models and performed according to PRISMA guidelines. MEDLINE, EMBASE, Scopus, and Web of Science databases were searched from inception until May 17, 2021. The initial search returned 2591 articles, of which, 28 studies met the inclusion criteria for this review. The studies were categorized as basic research studies (n = 12), epidemiological studies (n = 11), and CRC treatment studies (n = 5). The quality of the included studies was assessed using the Newcastle-Ottawa Scale or Cochrane Risk of Bias 2.0 tool depending on the study design.

RESULTS

Data from basic research indicates that PPI do not stimulate CRC development via the trophic effect of gastrin but instead may paradoxically inhibit it. These studies also suggest that PPI may have properties beneficial for CRC treatment. PPI appear to have anti-tumor properties (omeprazole, pantoprazole), and are potential T lymphokine-activated killer cell-originated protein kinase inhibitors (pantoprazole, ilaprazole), and chemosensitizing agents (pantoprazole). However, these mechanisms have not been confirmed in human trials. Current epidemiological studies suggest that there is no causal association between PPI use and increased CRC risk. Treatment studies show that concomitant PPI and capecitabine use may reduce the efficacy of chemotherapy resulting in poorer oncological outcomes, while also suggesting that pantoprazole may have a chemosensitizing effect with the fluorouracil, leucovorin, oxaliplatin (FOLFOX) regimen.

CONCLUSION

An unexpected inhibitory effect of PPI on CRC carcinogenesis by way of several potential mechanisms is noted. This review identifies that different PPI agents may have differential effects on CRC treatment, with practical implications. Prospective studies are warranted to delineate this relationship and assess the role of individual PPI agents.

Rim enhancement on hepatobiliary phase of pre-treatment 3.0 T MRI: A potential marker for early chemotherapy response in colorectal liver metastases treated with XELOX

PURPOSE

To assess the value of the enhanced features on the hepatobiliary phase (HBP) of pre-treatment Gd-EOB-DTPA MRI in evaluating response to chemotherapy in colorectal liver metastases (CRLMs).

METHODS

We retrospectively studied 65 patients with CRLMs who underwent Gd-EOB-DTPA enhanced MRI before chemotherapy from October 2015 to November 2017. The diagnosis of liver metastasis was established on the basis of imaging findings. Two radiologists evaluated the size, contrast-enhanced (CE) patterns of the maximum lesion on the HBP. According to the different CE patterns, we quantified area signal intensity (SI) by applying SI ratio (such as SI_center/outer and SI_rim/center). All of the above parameters were analyzed in terms of chemotherapy response.

RESULTS

Rim enhancement on the HBP was more frequent in the responding group of 28 patients (72%) than in the non-responding group of eight patients (31%). Additionally, there was a significant association between chemotherapy response and quantitative parameters: including diameter (P = 0.04), SI_center/outer (P = 0.047) and SI_rim/center (P = 0.012). The HBP CE pattern (P = 0.007) and SI_center/outer (P = 0.022) were independent factors for chemotherapy response. The areas under the curve (AUCs) of the above-mentioned parameters were significant associated with response to chemotherapy, in which diameter, HBP CE patterns, SI_center/outer, and SI_rim/center were 0.638, 0.706, 0.712, and 0.673, respectively. Moreover, the combination of these parameters obtained the largest AUC of 0.821.

CONCLUSION

The CE patterns, in particular with rim enhancement, and SI ratio parameters on the HBP are useful indicators for early evaluation of therapeutic response after chemotherapy in patients with CRLMs.

Efficacy of Reduced-Intensity Chemotherapy With Oxaliplatin and Capecitabine on Quality of Life and Cancer Control Among Older and Frail Patients With Advanced Gastroesophageal Cancer: The GO2 Phase 3 Randomized Clinical Trial

Importance

Older and/or frail patients are underrepresented in landmark cancer trials. Tailored research is needed to address this evidence gap.

Objective

The GO2 randomized clinical trial sought to optimize chemotherapy dosing in older and/or frail patients with advanced gastroesophageal cancer, and explored baseline geriatric assessment (GA) as a tool for treatment decision-making.

Design, Setting, and Participants

This multicenter, noninferiority, open-label randomized trial took place at oncology clinics in the United Kingdom with nurse-led geriatric health assessment. Patients were recruited for whom full-dose combination chemotherapy was considered unsuitable because of advanced age and/or frailty.

Interventions

There were 2 randomizations that were performed: CHEMO-INTENSITY compared oxaliplatin/capecitabine at Level A (oxaliplatin 130 mg/m2 on day 1, capecitabine 625 mg/m2 twice daily on days 1-21, on a 21-day cycle), Level B (doses 0.8 times A), or Level C (doses 0.6 times A). Alternatively, if the patient and clinician agreed the indication for chemotherapy was uncertain, the patient could instead enter CHEMO-BSC, comparing Level C vs best supportive care.

Main Outcomes and Measures

First, broad noninferiority of the lower doses vs reference (Level A) was assessed using a permissive boundary of 34 days reduction in progression-free survival (PFS) (hazard ratio, HR = 1.34), selected as acceptable by a forum of patients and clinicians. Then, the patient experience was compared using Overall Treatment Utility (OTU), which combines efficacy, toxic effects, quality of life, and patient value/acceptability. For CHEMO-BSC, the main outcome measure was overall survival.

Results

A total of 514 patients entered CHEMO-INTENSITY, of whom 385 (75%) were men and 299 (58%) were severely frail, with median age 76 years. Noninferior PFS was confirmed for Levels B vs A (HR = 1.09 [95% CI, 0.89-1.32]) and C vs A (HR = 1.10 [95% CI, 0.90-1.33]). Level C produced less toxic effects and better OTU than A or B. No subgroup benefited from higher doses: Level C produced better OTU even in younger or less frail patients. A total of 45 patients entered the CHEMO-BSC randomization: overall survival was nonsignificantly longer with chemotherapy: median 6.1 vs 3.0 months (HR = 0.69 [95% CI, 0.32-1.48], P = .34). In multivariate analysis in 522 patients with all variables available, baseline frailty, quality of life, and neutrophil to lymphocyte ratio were independently associated with OTU, and can be combined in a model to estimate the probability of different outcomes.

Conclusions and Relevance

This phase 3 randomized clinical trial found that reduced-intensity chemotherapy provided a better patient experience without significantly compromising cancer control and should be considered for older and/or frail patients. Baseline geriatric assessment can help predict the utility of chemotherapy but did not identify a group benefiting from higher-dose treatment.

Trial Registration

isrctn.org Identifier: ISRCTN44687907.

Treatment Outcomes of Well-Differentiated High-Grade Neuroendocrine Tumors

INTRODUCTION

Recent classification of neuroendocrine neoplasms has defined well-differentiated high-grade neuroendocrine tumors (NET G3) as a distinct entity from poorly differentiated neuroendocrine carcinoma. The optimal treatment for NET G3 has not been well-described. This study aimed to evaluate metastatic NET G3 response to different treatment regimens.

MATERIALS AND METHODS

This was a retrospective study of patients with NET G3 within the Mayo Clinic database. Patients' demographics along with treatment characteristics, responses, and survival were assessed. Primary endpoints were progression-free survival (PFS) and overall survival. Secondary endpoints were objective response rate (ORR) and disease control rate (DCR).

RESULTS

Treatment data was available in 30 patients with median age of 59.5 years at diagnosis. The primary tumor was mostly pancreatic (73.3%). Ki-67 index was ≥55% in 26.7% of cases. Treatments included capecitabine + temozolomide (CAPTEM) (n = 20), lutetium 177 DOTATATE (PRRT; n = 10), Platinum-etoposide (EP; n = 8), FOLFOX (n = 7), and everolimus (n = 2). CAPTEM exhibited ORR 35%, DCR 65%, and median PFS 9.4 months (95% confidence interval, 2.96-16.07). Both EP and FOLFOX showed similar radiographic response rates with ORR 25.0% and 28.6%; however, median PFS durations were quite distinct at 2.94 and 13.04 months, respectively. PRRT had ORR of 20%, DCR of 70%, and median PFS of 9.13 months.

CONCLUSION

Among patients with NET G3, CAPTEM was the most commonly used treatment with clinically meaningful efficacy and disease control. FOLFOX or PRRT are other potentially active treatment options. EP has some activity in NET G3, but responses appear to be short-lived. Prospective studies evaluating different treatments effects in patients with NET G3 are needed to determine an optimal treatment strategy.

IMPLICATIONS FOR PRACTICE

High-grade well-differentiated neuroendocrine tumors (NET G3) are considered a different entity from low-grade NET and neuroendocrine carcinoma in terms of prognosis and management. The oral combination of capecitabine and temozolomide is considered a good option in the management of metastatic NET G3 and may be preferred. FOLFOX is another systemic option with reasonable efficacy. Similar to other well-differentiated neuroendocrine tumors, peptide receptor radionuclide therapy seems to have some efficacy in these tumors.

[Disseminated Bone Marrow Carcinomatosis from Breast Cancer Improved by Capecitabine-A Clinical Case Report]

A 63-year-old woman who underwent breast cancer surgery 9 years ago visited our hospital with palpitations. Laboratory examination revealed severe anemia and thrombocytopenia. Positron emission tomography-computed tomography(PET- CT)demonstrated fluorodeoxyglucose(FDG)uptake at several vertebrae, including the pelvis, ribs, and sternum. Accordingly, bone marrow aspiration cytology was performed and atypical large cells were confirmed. After the diagnosis of disseminated carcinomatosis caused by multiple bone metastases from breast cancer, capecitabine monotherapy was started. At 6 months after the diagnosis, the anemia and thrombocytopenia improved to within normal limits. FDG uptake of multiple bones also improved according to PET-CT. Capecitabine administration was stopped at 30 months due to cancer progression. Chemotherapy with docetaxel, epirubicin, cyclophosphamide(EC), and vinorelbine was alternately continued after capecitabine; nevertheless, the cancer progressed gradually. She died at 62 months without either anemia or thrombocytopenia.

Radiolytic degradation of anticancer drug capecitabine in aqueous solution: kinetics, reaction mechanism, and toxicity evaluation

The occurrence of anticancer drugs in the environment has attracted wide attention due to its potential environmental risks. The aim of this study was to investigate degradation characteristics and mechanism of anticancer drug capecitabine (CPC) by electron beam (EB) irradiation. The results showed that EB was an efficient water treatment process for CPC. The degradation followed pseudo-first-order kinetics with dose constants ranged from 1.27 to 3.94 kGy^-1. Removal efficiencies in natural water filtered or unfiltered were lower than pure water due to the effect of water matrix components. The degradation was restrained by the presence of NO₂^-, NO₃^- and CO₃^2-, and fulvic acid due to competition of reactive radical •OH. It demonstrated that oxidizing radical played important role in irradiation process. The appropriate addition of H₂O₂ and K₂S₂O₈ providing with oxidizing agents •OH and •SO₄^- was favorable to improve degradation efficiency of CPC. The possible transformation pathways of CPC including cleavage of the ribofuranose sugar and defluorination were proposed based on intermediate products and were consistent with the theoretical calculation of charge and electron density distribution. Toxicity of CPC and intermediate products were estimated by ECOSAR program. It was found that CPC was transformed to low toxicity products with EB.

[A Case of Severe Aortic Thrombosis during the First Chemotherapy Regimen of CapeOX plus Bevacizumab for Metastatic Colon Cancer]

A 61-year-old man underwent CapeOX plus bevacizumab chemotherapyafter right hemicolectomyfor metastatic ascending colon cancer. On the 7th dayafter the first administration, he had sudden abdominal pain and nausea. Contrast-enhanced computed tomographyrevealed aortic thrombosis and a superior mesenteric artery(SMA)embolism that was considered to be associated with bevacizumab. Bevacizumab was discontinued and anticoagulation therapyusing heparin and urokinase was performed. Brain infarction of the left middle cerebral arteryoccurred on the 15th dayafter the first administration and thrombectomywas performed. Anticoagulation therapyusing heparin, bayaspirin, and edoxaban tosilate hydrate was performed. The aortic thrombosis and SMA embolism resolved with treatment, but the patient died following an increase in peritoneal dissemination. It should be noted that unexpectedlysevere aortic thrombosis occurred during the first administration of CapeOX plus bevacizumab for metastatic colon cancer.

[The Current and Future Status of Perioperative Therapy in Pancreatic Cancer]

In metastatic pancreatic cancer, combined chemotherapy such as FOLFIRINOX and gemcitabine plus nab-paclitaxel became standard of care. Current standard of care in preoperative settingwas adjuvant S-1 for 6 months in Japan. Neoadjuvant gemcitabine plus S-1 became the new standard in 2019. In Western countries, gemcitabine plus capecitabine and modified FOLFIRINOX without bolus 5-FU and with reduction of irinotecan to 150mg/m2 became standard of care. We will implement in current and future status of preoperative therapy.

Prognostic value of carbohydrate antigen125 and carcino embryonic antigen expression in patients with colorectal carcinoma and its guiding significance for chemotherapy

The aim of this study is to evaluate the predictive value of carbohydrate antigen125 (CA125) and carcino embryonic antigen (CEA) expression and its guiding role of choosing chemotherapy regimen in post-operation patients with colorectal carcinoma.The clinical data of all patients, including laboratory data and pathological data, were collected from the electronic medical records. Kaplan-Meier Log rank test, COX regression model and subgroup analyses were employed to assess the correlation between the expression of CA125 and CEA in patients with colorectal carcinoma and the survival, and the effect on chemotherapy efficacy.Kaplan-Meier showed that CA125 expression is negatively related to the progression-free survival (PFS) of the post-operative patients, Median PFS was 1140 days in the patients with high expression, and Median PFS was 1387 days in the patients with low expression (χ = 4.715, P = .030); CEA expression is also negatively associated with the PFS of the post-operative patients, Median PFS was 1197 days in the patients with high expression, and Median PFS was 1424 days in the patients with low expression (χ = 4.992, P = .025). Subgroup analysis also showed that the patients with normal CA125 and CEA had better prognosis, median PFS was 1505 days, and the patients with CA125 and (or) CEA high expression had poor prognosis and median PFS was 1162 days (χ = 13.346, P = .001), and found that there was no statistical difference in patients with oxaliplatin plus capecitabine (XELOX) and oxaliplatin, 5-fluorouracil and Calcium folinate (FOLFOX) chemotherapy in patients with CA125 and CEA low expression. However, in these patients with CA125 or (and) CEA high expression, the median PFS of patients treated with XELOX was 1082 days, and the median PFS of patients treated with FOLFOX chemotherapy was 1335 (χ = 4.547, P = .033).Expression of CA125 and CEA associated with the survival of patients, and have some guiding significance for chemotherapy in patients with colorectal cancer after operation; Compared with XELOX, FOLFOX chemotherapy is more effective for CA125 or (and) CEA high expression patients with colorectal carcinoma.

[A Phase Ⅱ Study of Systemic Chemotherapy with Capecitabine and Cisplatin Followed by Surgery for Advanced Gastric Cancer with Extensive Lymph Node Metastasis(OGSG1401)]

BACKGROUND

Gastric cancer with extensive lymph node metastasis(ELM)is commonly considered unresectable and has a poor prognosis. We conducted a phase Ⅱ study to evaluate the safety and efficacy of capecitabine and cisplatin(XP)as preoperative chemotherapy for gastric cancer with ELM.

METHODS

The patients received 2 21-day cycles of XP therapy(ca- pecitabine at 2,000mg/m2 twice daily for 2 weeks and cisplatin at 80 mg/m2 on day 1)followed by gastrectomy with D2 plus para-aortic nodal dissection. After R0 resection, S-1 chemotherapy was administered for 1 year. The primary end point was response rate(RR). The planned sample size was 30.

RESULTS

Between April 2015 and November 2016, 4 patients were enrolled, but the enrollment was terminated because of poor patient recruitment. The clinical RR was 50%, and R0 resection was achieved in 75% of the patients. The common Grade 3 adverse events during XP therapy were leukocytopenia(25%), anemia(25%), and hyperlipidemia(25%). The common Grade 3 surgical morbidity was abdominal abscess(33%)and pancreatic fistula(33%). The pathological RR was 25%.

CONCLUSIONS

Preoperative XP therapy was feasible, but its efficacy was difficult to evaluate because of the small sample size.

[Long-Term Survival of a Patient with Advanced Recurrent Rectal Cancer Treated with a Multidisciplinary Therapy including Five Operations-A Case Report]

A 68-year-old female with rectal cancer underwent low anterior resection with regional lymph node dissection. The final pathological diagnosis was Stage Ⅲa, and an adjuvant therapy(S-1)was provided for 6 months. One year after the surgery, an anastomotic recurrence was detected. Therefore, pelvic chemoradiotherapy with folinic acid and 5-fluorouracil(FL)was provided, and resection was performed with the Hartmann procedure. Following the second surgery, chemotherapy with bevacizumab(BV)and capecitabine plus oxaliplatin(CapeOX)was provided, and the patient showed no signs of recurrence for several years. However, lung metastasis appeared, which was resected. A year later, the patient underwent hepatectomy and radiofrequency ablation for liver metastasis. Another year later, she underwent lung resection again because of new lung metastasis. During the periods between the surgeries, various chemotherapy regimens were followed continuously, however, the patient died of progressive recurrence 8 years and 4 months after the initial surgery. Recurrences and distant metastases are poor prognostic factors for rectal cancers. However, combined effective chemotherapy and radiotherapy with surgery may improve the patient's chances of survival.

[Long-Term Survival of a Patient with Metastatic Ovarian Cancer and Local Recurrence of Rectal Cancer]

A 60s woman with upper rectal cancer underwent low anterior resection; the patient was diagnosed with pSSN1, Stage Ⅲa cancer. She received adjuvant therapy with UFT. Three years after the primary resection, metastasis to the right ovary and local recurrence were diagnosed. She was treated with CAPOX plus bevacizumab(Bev), capecitabine, FOLFIRI, and irinotecan plus S-1. Because only the ovarian metastasis increased rapidly, we were able to perform surgery and R0 resection. Two years after resection, local recurrence became apparent, and chemotherapy was reinitiated. After treating the patient with chemotherapy and chemo-radiation therapy for 2 years, R0 resection was performed. Twelve years after primary tumor resection and 9 years after primary resection, we observed recurrence-free survival.

[A Case of Two Curative Resections for the Peritoneal Dissemination of Transverse Colon Cancer]

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.

[Stage Ⅳ Breast Cancer with Difficulty in Initiating Chemotherapy-A Case Report]

We report a case of breast cancer(T4b[skin], N1, M1[lung], ER-, PR-, HER2 3+)in a 63-year-old woman with liver dysfunction of unknown cause(T-Bil 3.6mg/dL, ALP 3,483 U/L, AST 214 U/L, ALT 320 U/L, g / -GTP 1,943 U/L). Further- more, serum CA19-9(4,670 U/mL)and HbA1c(8.8%)levels were both elevated. First, she underwent chemotherapy with trastuzumab and capecitabine. Subsequently, liver dysfunction relieved gradually. CA19-9 and HbA1c levels were also decreased, but the tumor size was NC. Subsequently, trastuzumab, pertuzumab, and docetaxel were administered, as liver function became normal. The tumor shrank significantly after this treatment. Finally, she underwent mastectomy. Five years after the first visit, she has continued chemotherapy, with lung metastases almost scarred(CR).

[Subcutaneous Metastasis from Rectal Carcinoma after Low Anterior Resection-A Case Report]

A 63-year-old woman was admitted to our hospital owing to advanced rectal carcinoma. The patient underwent laparoscopic lowanterior resectionwith D3 lymph node dissection and partial resection of the uterus. The histopathological diagnosis was fT4bN2M0, fStage Ⅲb. Thus, capecitabine plus oxaliplatin(CapeOX)therapy as adjuvant chemotherapy was scheduled for 6 months. However, after the 4th course of chemotherapy, contrast-enhanced CT revealed multiple metastases of the rectal carcinoma including metastases in the liver, peritoneum, retroperitoneum, and subcutaneous tissue of the left lower back. The patient received palliative treatment and died 8 months after surgery. Only a fewcases of subcutaneous metastasis of rectal carcinoma have been reported. Therefore, we herein report this case with a review of the literature.

Tumor Size Improves the Accuracy of the Prognostic Prediction of Lymph Node-Negative Gastric Cancer

BACKGROUND

Tumor size has been regarded as the "T" stage of many solid tumors because of its effect on prognosis. However, the prognostic impact of tumor size in gastric cancer (GC) is still controversial.

MATERIALS AND METHODS

A total of 436 patients with curatively resected GC and those without lymph node metastasis in our center were retrospectively enrolled. The appropriate cutoff points for tumor size were determined. Potential prognostic factors were analyzed. In addition, a pathological tumor-size (pTS) classification system was proposed to evaluate the superiority of its prognostic prediction of node-negative GC patients compared with that of the pT staging system.

RESULTS

The ideal cutoff points for tumor size were 4 and 8 cm. In the multivariate analysis, tumor size was identified as an independent prognostic factor for node-negative GC patients after surgery, as was pT stage. The pTS classification was found to be more appropriate for predicting the overall survival of node-negative GC patients after curative surgery than pT stage, and the -2 log-likelihood of the pTS classification (1680.782) was smaller than the value of pT (1695.239).

CONCLUSIONS

As an independent prognostic factor, tumor size should be incorporated into the pT staging system to enhance the accuracy of the prognostic prediction of node-negative GC patients.

Efficacy of XELOX adjuvant chemotherapy for gastric mixed adenoneuroendocrine carcinoma: A case report

RATIONALE

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare neoplasm, and consensus on the treatment is unavailable.

PATIENT CONCERN

A 60-year-old Chinese man presented with obstructive symptoms while eating and paroxysmal stomach pain for more than a month.

DIAGNOSIS

MANEC was diagnosed based on clinical manifestations, imaging findings, and pathological examinations.

INTERVENTIONS

The patient underwent radical gastrectomy and received XELOX adjuvant chemotherapy (oxaliplatin 200 mg day 1 + capecitabine 1.5 g twice a day) after surgery.

OUTCOMES

After 4 cycles of XELOX adjuvant chemotherapy were administered, abdominal computerized tomography and liver magnetic resonance showed liver metastasis.

LESSONS

The therapy of gastric MANEC is based on surgical operation, and adjuvant chemotherapy program has an important influence on its prognosis. Therefore, further studying the effectiveness of XELOX adjuvant chemotherapy for gastric MANEC is necessary.

Quality of life in non-metastasic colorectal cancer patients in FOLFOX or XELOX therapy

OBJECTIVE

To evaluate and to compare quality of life of patients with non- metastasic colorectal cancer treated either with FOLFOX or with XELOX  scheme.

METHOD

Descriptive prospective study during 24 months (October 2015- October 2017) for patients with non-metastasic colorectal cancer in chemotherapy adyuvant treatment. EORTC QLQ-C30 questionnaire was filled by patients at the beginning and at week 12 of adjuvant treatment. Variables collected: exposure (chemotherapeutic scheme administered), control (demographic data, disease data, treatment data) and response (scores obtained from the questionnaire). The data statistical  analysis was carried out with the SPSS® 15.0 programme.

RESULTS

30 patients were included. Statistically significant differences were  found in emotional role item at the middle of the treatment (FOLFOX 92  points vs. XELOX 82 points; p = 0,036). Patients with FOLFOX presented a  clinically relevant worsening in terms of daily activities, constipation and  insomnia. Patients treated with XELOX a clinically relevant worsening in daily  activities, constipation, fatigue, nausea, vomiting, anorexia and diarrhoea were observed.

CONCLUSIONS

Patients with XELOX scheme referred to have worse  emotionally status in the middle of the adjuvant treatment than patients  treated with FOLFOX scheme and presented a worsening in items fatigue,  nausea, vomiting, anorexia and diarrhoea.

[A Case of Conversion Surgery Following Combined Chemotherapy with Molecular Targeting Agent for Unresectable Colorectal Liver Metastases]

A 76-year-old woman complaining of constipation was diagnosed with advanced rectosigmoid colon cancer with unresectable liver metastases. We performed a laparoscopic high-anterior resection due to the obstruction. The patient then received a capecitabine plus oxaliplatin(CapeOX)plus cetuximab(Cmab)combination chemotherapy. After 7 cycles of CapeOX with Cmab, the multiple liver metastases had reduced remarkably in size. Therefore, a liver metastases resection was performed. The patient underwent 6 cycles of postoperative CapeOX with Cmab therapy and has survived 7 years with no recurrence after the primary surgery.

[XELIRI plus Bmab Therapy as a Secondary Treatment for Recurrent Colorectal Cancer with Long-Term Survival]

A 71-year-old woman complained of melena, and laparoscopic right hemicolectomy was performed for advanced colorec- tal cancer. Pathological examination revealed pStage Ⅲa(RAS-positive)disease. After the operation, UFT/LV was administered. However, peritoneal recurrence was confirmed. We changed the chemotherapeutic regimen to CapeOX plus Bmab and capecitabine plus Bmab. After 5 years and 9 months, pulmonary metastasis was observed. Therefore, we again changed the chemotherapeutic regimen to biweekly XELIRI plus Bmab. After 43 courses, the patient had stable disease. During biweekly XELIRI plus Bmab therapy, Grade 4 neutropenia occurred, so we reduced the CPT-11 dose by 20%. After dose reduction the patient experienced no more Grade 3/4 adverse events. We experienced a case of colorectal cancer wherein biweekly XELIRI plus Bmab therapy contributed to disease control as second-line treatment.