Serum levels of hepatocyte growth factor and epiregulin are associated with the prognosis on anti-EGFR antibody treatment in KRAS wild-type metastatic colorectal cancer

Background:

Ligands of transmembrane receptor tyrosine kinases have important roles in cell proliferation, survival, migration and differentiation in solid tumours. We conducted this study to evaluate the relationship between concentration of serum ligands and prognosis of patients with metastatic colorectal cancer (mCRC) treated with anti-epidermal growth factor receptor (EGFR) antibodies.

Methods:

Between August 2008 and August 2011, serum samples were obtained from KRAS wild-type patients who met the inclusion criteria and received an anti-EGFR antibody treatment. Serum concentration of ligands was measured by an enzyme-linked immunosorbent assay, and somatic mutations of KRAS, BRAF, PIK3CA and BRAF were analysed by direct sequencing.

Results:

A total of 103 patients were enrolled in the present study. At the pretreatment serum levels, patients with high levels of hepatocyte growth factor (HGF) had shorter progression-free survival (PFS) and overall survival (OS) compared with those with low levels of HGF (median PFS: 6.4 months vs 4.4 months; P<0.001, median OS: 15.3 months vs 8.0 months; P<0.001, respectively). Patients with high levels of epiregulin (EREG) also had shorter PFS and OS compared with those with low levels of EREG (median PFS: 6.6 months vs 4.9 months; P=0.016, median OS: 13.8 months vs 7.4 months; P=0.048, respectively). In addition, patients whose serum levels of ligands were elevated at progressive disease had shorter PFS and OS compared with other patients.

Conclusions:

Our study indicated that high levels of HGF and EREG were associated with resistance to treatment with anti-EGFR antibodies in KRAS wild-type patients with mCRC. Our findings will contribute to the newly combination therapy on the treatment of anti-EGFR antibodies.

Feasibility of endoscopic mucosal resection as salvage treatment for patients with local failure after definitive chemoradiotherapy for stage IB, II, and III esophageal squamous cell cancer

Local failure after definitive chemoradiotherapy (CRT) for stage IB, II, and III esophageal cancer is one of the causes of poor outcome. Endoscopic mucosal resection (EMR) is an effective treatment for superficial esophageal cancer. However, its feasibility as a salvage treatment for local recurrent or residual tumors after definitive CRT for stage IB, II, and III esophageal cancer remains unclear. Between January 2000 and February 2008, 274 patients with stage IB, II, and III esophageal squamous cell cancer excluding T4 received definitive CRT at the National Cancer Center Hospital, Japan. Of these patients, nine patients with local recurrence after achieving complete response and two patients with residual tumor underwent salvage EMR. The technique of salvage EMR involved a strip biopsy method. We retrospectively reviewed the 11 patients (13 lesions). Characteristics of all 11 patients were as follows: median age of 69 (range: 45-78); male/female: 10/1; baseline clinical stage (Union for International Cancer Control 7th) IB/IIA/IIB/III: 1/3/7/0. The depth of resected tumor was limited to the mucosal layer in seven lesions and submucosal in six lesions. En bloc resection was performed on six lesions (46%). The vertical margin was free of cancer cells in 11 lesions (84.6%). No major complications, such as hemorrhage requiring blood transfusion and perforation, were experienced. At a median follow-up period of 38.9 months (range: 5.3-94 months) after salvage EMR, no recurrence was detected in six patients (54%). Local recurrence was detected in five patients (27%). Of these patients, two had lung metastasis simultaneously, and one was also detected lung metastasis 2 months after the detection of local recurrence. The 5-year survival rate after salvage EMR was 41.6%. Salvage EMR is a feasible treatment option for local recurrent or residual lesions after definitive chemotherapy and/or radiotherapy for stage IB, II, and III esophageal squamous cell cancer.

Relationship between methylation status of PTEN and point mutation of the EGFR L2 domain and efficacy of cetuximab in metastatic colorectal cancer

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Background: The KRAS mutation has been associated with resistance to cetuximab, an anti-epidermal growth factor receptor (EGFR) monoclonal antibody, in metastatic colorectal cancer (mCRC). However, the predictive biomarkers of cetuximab resistance in KRAS wild-type mCRC remain unknown. We explored the possible roles of PTEN methylation and mutation of the EGFR L2 domain, which is the site of binding to cetuximab, in cetuximab resistance in KRAS wild-type mCRC.

Methods: The subjects were 247 mCRC patients screened for KRAS status at the National Cancer Center Hospital between September 2008 and April 2010. Genomic DNA was extracted from formalin- fixed paraffin-embedded colorectal cancer tissue samples. Mutation analysis of KRAS and the EGFR L2 domain was performed by direct sequencing. Methylation analysis of PTEN was performed by quantitative real-time methylation-specific PCR with a set of primers specific to the methylated and unmethylated sequences, using sodium bisulfate-modified DNA.

Results: Of the 247 mCRC patients, 136 patients had wild-type KRAS (55%). In 9 of these patients, the quality of the DNA was sufficient for analysis of PTEN methylation levels. Eight of the 9 patients received a cetuximab-based regimen (with irinotecan: 4, monotherapy: 4). The best response was PR in 4 patients (25%), SD in 2 (12.5%), and PD in 2 (12.5%). The best response of the one patient with methylated PTEN treated with cetuximab and irinotecan was SD. Mutation analysis of the EGFR L2 domain was performed in 65 of the 136 patients with wild-type KRAS. All of them received a cetuximab-based regimen (with irinotecan: 50, monotherapy: 15). The best response was PR in 13 patients (20%), SD in 26 (40%), PD in 20 (31%). The one patient who had a mutation at exon 9 showed a partial response to cetuximab and irinotecan.

Conclusions: Methylation of PTEN and mutation of the EGFR L2 domain were analyzed in Japanese mCRC patients. Our findings do not provide sufficient evidence that EGFR L2 domain mutation and methylation of PTEN are correlated with resistance to cetuximab.

No significant financial relationships to disclose.

Prophylactic administration of epinephrine in oxaliplatin-related hypersensitivity reaction

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Background: Alongside disease progression or neurotoxicity, oxaliplatin-related hypersensitivity reaction is a common reason for treatment discontinuation and remains a critical issue. It is unclear whether prophylactic administration of epinephrine to patients with this severe hypersensitivity reaction is effective and safe.

Methods: We retrospectively reviewed 839 consecutive colorectal cancer patients treated with oxaliplatin-containing regimens at our hospital between April 2005 and March 2010. The medical records of those patients who had received prophylactic epinephrine (1:1000 solution) were examined. Hypersensitivity reaction was graded according to CTCAE version 3.0.

Results: Twelve patients (8 male and 4 female; median age, 66 years) had received prophylactic epinephrine. The hypersensitivity reaction, even though the patients were receiving prophylactic corticosteroid and antihistamine drugs, was grade 0/1/2/3 = 0/0/10/2. The median number of epinephrine doses administered was 6 (range, 1 to 21). The worst grade of hypersensitivity for rechallenge with oxaliplatin under prophylactic administration of epinephrine was grade 0/1/2/3 = 4/3/4/1. Reasons for treatment discontinuation were disease progression in 10 patients and neurotoxicity in one patient. The remaining one patient developed grade 3 hypersensitivity reaction during 4 cycles of treatment under prophylactic administration of epinephrine, but the reaction subsided after additional administration of epinephrine and corticosteroid. Common adverse events with administration of epinephrine were hypertension (4 patients), palpitation (3 patients) and headache, dizziness, fatigue, and bladder pain (1 patient each).

Conclusions: Prophylactic administration of epinephrine may be effective and tolerated in patients with moderate to severe oxaliplatin-related hypersensitivity reaction.

No significant financial relationships to disclose.

Feasibility study of adjuvant chemotherapy with S-1 plus cisplatin for gastric cancer

PURPOSE

To evaluate the feasibility of S-1 plus cisplatin as adjuvant chemotherapy for stage III gastric cancer after curative resection.

METHODS

Japanese patients with stage III gastric cancer who underwent gastrectomy with D2 lymph node resection were enrolled. Treatment consisted of 3 cycles of S-1 (80 mg/m(2)/day, b.i.d.) for 21 days followed by a 14-day rest, and cisplatin (60 mg/m(2) iv) on day 8. After that, S-1 monotherapy was given on days 1-28 every 6 weeks until 1-year postsurgery. After protocol amendment, the first chemotherapy cycle consisted of S-1 monotherapy; cisplatin was added to cycles 2, 3, and 4, followed by S-1 monotherapy up to 1-year postsurgery. The primary endpoint was the completion rate of three cycles of S-1 plus cisplatin.

RESULTS

A total of 63 enrolled patients have been evaluated. Grade 3/4 toxicities included neutropenia (40%), anorexia (28%), and febrile neutropenia (4%) before protocol amendment (n = 25), and neutropenia (37%), anorexia (8%), and febrile neutropenia (3%) after amendment implementation (n = 38). Excluding ineligible cases, treatment completion rates were 57% (12/21) before and 81% (30/37) after the protocol amendment.

CONCLUSIONS

The amended S-1 plus cisplatin is more feasible than the original protocol because of early dose reduction of S-1 prior to cisplatin addition and greater recovery time from surgery prior to cisplatin. This treatment should be considered as a feasible experimental arm for the next postoperative adjuvant phase III trial.

Pleiotropic effects of mitiglinide in type 2 diabetes mellitus

This study investigated the effects of mitiglinide in 16 patients with type 2 diabetes mellitus treated with 30 mg/day mitiglinide, divided into three doses given just before each meal, for approximately 12 months. A 450 kcal meal tolerance test was performed at baseline and after 3, 6 and 12 months, and levels of plasma glucose and immunoreactive insulin were measured. Various parameters of glucose metabolism and lipid metabolism, urinary albumin and markers of atherosclerosis, coagulation and fibrinolysis were also determined. Mitiglinide showed a rapid stimulatory effect on insulin secretion and reduced the levels of plasma glucose. The free fatty acid level significantly decreased at 60 min after the meal tolerance test. Mitiglinide also significantly lowered glycosylated haemoglobin and raised 1,5-anhydroglucitol after 6 months, and significantly decreased urinary albumin after 12 months. These data indicate that mitiglinide may have beneficial effects not only on glycaemic control but also on lipid metabolism and urinary albumin excretion, and may have a role in the prevention of the vascular complications of diabetes.

Site-specific differences in central processing of visceral stimuli from the rectum and the descending colon in men

BACKGROUND

It has been reported that different brain activation areas are demonstrated during somatosensory and visceral stimulation. However, no study thus far has investigated how activated patterns in the human brain differ during visceral stimulation of different sites of the digestive tracts. The aim of this study was to determine possible site-specific differences in brain responses and perceptions during visceral stimulation of two different sites, the intraluminal distentions of the rectum and descending colon.

METHODS

Regional cerebral blood flow was assessed in 32 healthy right-handed male subjects using H(2)(15)O positron emission tomography during distention of the rectum (R group, n = 16) or descending colon (DC group, n = 16) at 40 or 20 mmHg.

KEY RESULTS

R group reported significantly higher scores of abdominal pain (P < 0.05) and urge to defecate (P < 0.001) during the application of stimulus at 40 mmHg compared with DC group but not of abdominal bloating or anxiety. In comparisons of response to the 40-mmHg stimulus, R group showed significantly greater activation in posterior midcingulate cortex (MCC) and right anterior and posterior insula, whereas DC group showed greater activation in subgenual anterior cingulate cortex (ACC), perigenual ACC and left orbitofrontal and superior temporal cortices.

CONCLUSIONS & INFERENCES

These findings suggest that central projections of painful visceral stimulation from the rectum and descending colon differ in affective, cognitive and nociceptive processing in the brain, which may result in different perceptions of visceral stimulation from different sites.

Predictive factors of outcome and clinical management of adjuvant S-1 chemotherapy for gastric cancer

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Background: Adjuvant S-1 chemotherapy has become a standard treatment for stage II and III gastric cancer, following the Adjuvant Chemotherapy Trial of TS-1 for Gastric Cancer (ACTS-GC). This study was designed to identify factors that can be used for predicting the outcome and clinical management of adjuvant S-1 chemotherapy in patients with stage II and III gastric cancer. Methods: We retrospectively examined 97 consecutive patients with stage II or III gastric cancer who received S-1 chemotherapy after gastrectomy to investigate factors associated with outcome and clinical management. S-1 (80 mg/m2/day) was orally administered twice daily for 28 consecutive days, followed by a 14-day rest period. As a rule, this protocol was continued for one year after gastrectomy. According to toxicity profiles, dose reduction or dose schedule modification was performed. Results: Patients consisted of 63 males and 34 females (median age, 59 years; range, 35–80 years), and those undergoing total gastrectomy/subtotal gastrectomy = 40/57. The median follow-up period after gastrectomy was 43.0 months (range, 5.3–73.4 months). As for adjuvant S-1 chemotherapy, dose reduction and dose schedule modification were conducted in 59% and 40% of the patients, respectively. Of the patients needing dose reduction, 79% underwent reduction within three months of treatment. The most common reason for dose reduction during the treatment period was anorexia (47%), followed by diarrhea (32%), leukopenia (24%) and rash (16%) with overlapping reasons. The duration period of the treatment was at least 3 months in 88%, at least 6 months in 82%, and scheduled 12 months in 73%. Twenty six patients discontinued treatment due to adverse event (20 patients), recurrent disease (2 patients) and other reasons (4 patients). The median duration until treatment discontinuation was 4.0 months. To date, 15 patients have recurrent disease. Significant predictive factors for recurrence were not statistically identified. Conclusions: Most patients (73%) could complete the scheduled treatment duration by dose reduction and dose schedule modification.

No significant financial relationships to disclose.