Accuracy of CT staging of locally advanced gastric cancer after neoadjuvant chemotherapy: cohort evaluation within a randomized phase II study

BACKGROUND

Accuracy of the radiologic diagnosis of gastric cancer staging after neoadjuvant chemotherapy remains unclear.

METHODS

Patients enrolled in the COMPASS trial, a randomized phase II study comparing two and four courses of S-1 plus cisplatin and paclitaxel and cisplatin followed by gastrectomy, were examined. The radiologic stage was determined by using thin-slice computed tomography (CT) or multidetector low CT by following Habermann's method.

RESULTS

A total of 75 patients registered in the COMPASS study who underwent surgical resection were examined in this study. The radiologic T and pathologic T stages were not significantly correlated (p = 0.221). The radiologic accuracy and rates of underdiagnosis and overdiagnosis were 42.7, 10.7, and 46.7%, respectively. When patients were stratified according to the pathologic response of the primary tumor, the correlation was not significant in either the responders (n = 32, p = 0.410) or the nonresponders (n = 43, p = 0.742). The radiologic accuracy was 37.5% in the responders and 42.7% in the nonresponders. The radiologic N and pathologic N stages were significantly correlated (p = 0.000). The radiologic accuracy and rates of underdiagnosis and overdiagnosis were 44, 29.3, and 26.7%, respectively. When stratifying the patients with measurable lymph nodes according only to the radiologic response, the correlation was significant in the nonresponders (n = 23, p = 0.035) but not in the responders (n = 28, p = 0.634). The radiologic accuracy was 39.3% in the responders and 52.1% in the nonresponders.

CONCLUSIONS

Restaging using CT after neoadjuvant chemotherapy for gastric cancer is considered to be inaccurate and unreliable. In particular, the radiologic T-staging determined after neoadjuvant chemotherapy should not be considered in clinical decision-making.

Methylene blue-assisted technique for harvesting lymph nodes after radical surgery for gastric cancer: a prospective randomized phase III study

BACKGROUND

This randomized Phase III trial will evaluate whether the methylene blue-assisted technique is efficient for harvesting lymph nodes after radical surgery for gastric cancer.

METHODS/DESIGN

Patients that undergo distal or total gastrectomy with radical nodal dissection will be randomly assigned to Group A: the standard group, the lymph nodes (LNs) will be harvested from the fresh specimen immediately after surgery, or Group B: the methylene blue-assisted group, where the LNs will be harvested from specimens fixed with 10% buffered formalin with methylene blue for 48 hours after surgery. The primary endpoint is the ratio of the number of the harvested LNs per time (minute). The secondary endpoint is the number of harvested LNs. A 25% reduction in the ratio of harvested lymph-node/time (minute) was determined to be necessary for this test treatment, considering the balance between the cost and benefit. Retrospective data was used to estimate the ratio of the number of the harvested LNs per time (minute) to be 40/30 minutes in Group A. A 25% risk reduction and a rate of 40/22.5 minutes is expected in Group B. Therefore, the sample size required ensuring a two-sided alpha error of 5% and statistical power of 80% is 52 patients, with 26 patients per arm. The number of patients to be accrued was set at 60 in total, due to the likelihood of enrolling ineligible patients.

TRIAL REGISTRATION

UMIN000008624.

Matched pair analysis to examine the effects of a planned preoperative exercise program in early gastric cancer patients with metabolic syndrome to reduce operative risk: The Adjuvant Exercise for General Elective Surgery (AEGES) study group

166

Background: Since obesity is a risk factor during surgery, the effects of a preoperative exercise program to reduce the incidence of peri- and postoperative complications in patients with a high BMI (> 25) and metabolic syndrome were investigated. An assessment of the effects of prospectively planned preoperative exercise was performed in a prospective matching study comparing an exercise testing group and a usual preoperative preparation group who underwent gastrectomy for gastric cancer in Japan. Methods: Stage I gastric cancer patients with metabolic syndrome diagnosed according to the criteria of the Japanese Ministry of Health, Labour and Welfare were enrolled in a surgery after preoperative exercise group. The control group was selected from a database using an individual matching approach for surgery, sex, weight, BMI, volume of visceral fat and institution. The primary end point was the frequency of postoperative complications (cardiovascular events, pneumonia, surgery-related abdominal complications, etc.). Results: A total of 72 patients (54 in the surgery alone group, 18 in the preoperative exercise group) were analyzed. The median operative time and amount of bleeding were 208 min and 130 ml in the surgery alone group and 248 min and 105 ml in the exercise group, respectively. Postoperative complications occurred in one case (5.5%) in the exercise group and 22 (40.7%) cases in the surgery alone group. Conclusions: Preoperative exercise is safe, and its benefits in reducing postoperative complications are promising and therefore warrant further investigation.

A prospective multicenter observational study for chemotherapy-induced nausea and vomiting in gastric cancer in Japan

155

Background: There has been no nationwide survey on CINV or validation of the guideline in Japan. The aim of the study was to investigate the occurrence of CINV in gastric cancer patientstreated with chemotherapy for the first time. Methods: A nationwide survey on CINV was conducted by the CINV study group of Japan. 108 institutions participated in the study. A 7-day diary for CINV was provided to the patients prior to chemotherapy to record the daily occurrence and severity of CINV and the amount of food intake. Acute and delayed CINV was defined as nausea and vomiting which developed within or later than 24 hours after the start of chemotherapy, respectively. We evaluated the frequency and the risk factors of CINV. The medical staff also filled out questionnaires about their patients’ CINV. Results: A total of 154 patients were registered during the period from April 2011 to December 2012. There were 109 males and 45 females with a median age of 65 (range: 25-82). HEC was given to 152 and MEC was administered to 2 patients. CDDPwas included in all of HEC regimens. For preventing CINV, a three-drug regimen of aprepitant, 5-TH3 receptor antagonist (5- TH3 RA ), and dexamethasone was applied in 131 cases and a two-regimen of 5- TH3 RA and dexamethasone in 23. Acute nausea (AN) was ovserved in 19 patients (12.3%), while delayed nausea (DN) was experienced by 74 patients (48%). Acute vomiting (AV) occurred in 1 case (0.6%), while delayed vomiting (DV) was observed 15 cases (9.7%). The risk factors of CINV in gastric cancer were female and motion sickness. The age, pregnancy or morning sickness didn’t show any correlation with an occurrence of CINV. The staff predicted an occurrence of AN and DN in 96 patients (62.3%) and 132 (85.7%). However only experienced 19 (12.3%) and 74 (48.1%) patients showed symptoms of AN and DV, respectively. Conclusions: CINV in patients with gastric cancer seems to be under control with a management according to the guideline, however delayed CINV remains to be high and needs to be targeted by further investigation. Clinical trial information: UMIN000005971.

Potential predictive markers of chemotherapy for advanced gastric cancer: Biomarker study in GC0301/TOP-002, randomized phase III study of irinotecan plus S-1 versus S-1

55

Background: Irinotecan plus S-1(IRI-S) achieved longer median survival than S-1 monotherapy and was well tolerated for patients with advanced gastric cancer (AGC) in GC0301/TOP-002, but it did not show significant superiority (Gastric Cancer 2011). According to subset analyses, IRI-S may have extra survival benefit in some group of patients, prompting to explore prognostic or predictive markers.We correlated expression of 5 genes related to DNA and anticancer drug metabolism (TS, DPD, Topo-I, ERCC1, TP) with outcome of patients in each arm. Methods: Paraffin-embedded primary tumor specimens before chemotherapy were available from 126 of 326 patients. mRNA expression in microdissected tumors was measured by real-time RT-PCR, and categorized into low and high using the median as a cut-off. Multivariate analysis for overall survival (OS) adjusting baseline factors, gene expression and treatment (S-1/IRI-S) was performed with a Cox regression model. Interaction tests were also carried out between gene expression and treatment. Results: Although baseline factors of the subjects were similar to the entire GC0301/TOP-002 trial, median survival seemed opposite; 13.1M for S-1 and 11.4M for IRI-S arm, p=0.192. 92 samples, 47 of S-1 and 50 of IRI-S arm, were assessable for 5 genes. Multivariate analyses showed that liver metastasis correlated with poor prognosis (HR, 2.73; 95% CI, 1.50-5.01; P=0.011), but no gene was significantly correlated with OS. There were interactions between the treatment effect for DPD and TP. HRs between high and low DPD were 3.02 in S-1 and 0.96 in IRI-S arm, p=0.012 for interaction; while those for TP were 2.98 in S-1 and 0.38 for IRI-S arm, p=0.002. In patients with low TS and high Topo-I (n=18), OS was 11.2M for S-1 and 18.6M for IRI-S arm, p=0.531. Conclusions: The correlative analyses suggest DPD and TP are predictive factor for the first-line treatment of AGC including S-1 and irinotecan. Combined biomarker analyses with the previous randomized phase III study including S-1 or irinotecan is warranted to verify these findings.

Risk factors for surgical complications after D2 gastrectomy following neoadjuvant chemotherapy for gastric cancer

164

Background: The feasibility and safety of D2 surgery following neoadjuvant chemotherapy (NAC) has not yet been fully evaluated in patients with gastric cancer. Moreover, the risk factors for surgical complications after D2 gastrectomy following NAC are also unknown. The aim of the present study was to identify risk factors for postoperative complications after D2 surgery following NAC. Methods: This study was conducted as an exploratory analysis of a prospective randomized phase II trial of NAC. This randomized phase II trial compared two and four courses of neoadjuvant S-1/cisplatin (SC) and paclitaxel/cisplatin (PC) using a two-by-two factorial design for locally advanced gastric cancer. Sample size was set at 60 to 80 to achieve 10% improvement of 3-year OS by four courses or by PC with approximately 80% probability of the correct selection. The surgical complications were assessed and classified according to the Clavien-Dindo classification. The uni- and multivariate logistic regression analyses were performed to identify risk factors for morbidities. Results: Among the 83 patients who were registered in the phase II trial, 69 patients received NAC and D2 gastrectomy. Postoperative complications were identified in 18 patients, and the overall morbidity rate was 26.1%. The results of the univariate and multivariate analyses of various factors potentially affecting the overall surgical morbidity identified a creatinine clearance (CCr) < 60ml/min (P = 0.016) as the sole significant independent risk factor for overall morbidity. The incidence of pancreatic fistula was significantly higher in the patients with a low CCr than in those with a high CCr. Conclusions: A low CCr was found to be a significant risk factor for surgical complications associated with D2 gastrectomy after NAC. Careful attention is therefore required for these patients. Clinical trial information: UMIN000002595.

[A case of rectal stenosis due to peritoneal dissemination from gastric cancer that was treated with chemoradiation therapy]

An 82-year-old man underwent total gastrectomy(D2 lymph node dissection)in August 2006. The pathological findings indicated T4a, N3, M0, Stage IIIC gastric cancer, but adjuvant chemotherapy was not initiated. In October 2009, he presented to the hospital with dyschezia. During colonoscopy, the scope could not pass through the colon, thus indicating rectal stenosis. The biopsy findings indicated the presence of signet ring cell carcinoma, which was determined to be due to the peritoneal dissemination from the gastric cancer. To avoid the need for creating a stoma, radiation therapy(2 Gy×20; total dose, 40 Gy)and chemotherapy(weekly paclitaxel and S-1)were initiated. Rectal stenosis was improved and complete remission was maintained until May 2013.

[A case of gastric cancer with intensive peritoneal dissemination treated with long-term chemotherapy and surgery]

A 45-year-old man was transferred to our hospital because of advanced gastric cancer and peritoneal dissemination. After he received an S-1 plus cisplatin( CDDP) regimen for 6 courses, the primary lesion and ascites had disappeared. However, the primary lesion recurred, and he underwent treatment with 16 courses of an S-1 plus docetaxel regimen. He subsequently developed peripheral neuropathy, and was switched to the irinotecan (CPT-11) regimen. As he experienced appetite loss, it was impossible to continue the chemotherapy. Therefore, he underwent a salvage surgery and an R0 resection was performed. However, 9 months after the surgery, he experienced paraaortic lymph node recurrence and peritoneal dissemination. The patient died 13 months after the surgery.

Laparoscopic esophagojejunostomy using the EndoStitch and a circular stapler under a direct view created by the ENDOCAMELEON

Laparoscopic esophagojejunostomy using a circular stapler is associated with technical difficulties in the purse-string sutures used to insert the anvil head and in obtaining an adequate visual field to prevent rolling the mesentery and the wall of the jejunum on the mesenteric side into the anastomosis. To overcome these difficulties, we used the EndoStitch to create the purse-string suture and the ENDOCAMELEON to create the visual field to stretch the jejunum. After resecting the esophagus, purse-string sutures were placed using the EndoStitch. A total of five to six needle deliveries were performed. Next, the anvil head was inserted into the esophagus. The main unit of the EEA was inserted from the end of the resected jejunum. Then, the scope was changed to the ENDOCAMELEON. The main unit was slowly moved toward the anvil head. After making sure that the mesentery and the wall of the jejunum on the mesenteric side were not rolled into the anastomosis under the visual field created by the ENDOCAMELEON, the main unit was then fired. Thereafter, esophagojejunostomy was successfully completed. This technique was applied in 20 patients between April 2010 and May 2012. Laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer was completed in all 20 patients. No case required conversion to open surgery. Neither anastomotic leakage nor stenosis was observed. This method is simple and useful for laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer.

Priority of lymph node dissection for Siewert type II/III adenocarcinoma of the esophagogastric junction

OBJECTIVE

The purpose of this study was to clarify the priority of nodal dissection in Siewert types II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

The priority of nodal dissection was evaluated based on the therapeutic value index calculated by multiplying of the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

A total of 176 patients (95 type II and 81 type III) were examined. Among the lymph nodes that had a metastatic incidence exceeding 10 %, the stations showing the first to fourth highest index were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the node at the root of the left gastric artery (No. 7) in the total cohort, as well as in each type. The next station was the lower thoracic paraesophageal lymph node (No. 110), followed by the nodes along the proximal splenic artery (No. 11p) in type II, whereas it was the nodes along the proximal splenic artery (No. 11p) followed by the para-aortic nodes (No. 16a2), the nodes at the celiac artery (No. 9), and the nodes around the splenic hilum (No. 10) in type III.

CONCLUSIONS

These results suggest that the highest priority nodal stations to be dissected were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the nodes at the root of the left gastric artery (No. 7), regardless of the Siewert subtype, but the subsequent priority was different depending on the subtype.

SAMIT: A phase III randomized clinical trial of adjuvant paclitaxel followed by oral fluorinated pyrimidines for locally advanced gastric cancer

LBA4002

Background: Adjuvant chemotherapy with tegafur/uracil (UFT) used to be a tentative Japanese standard treatment and has been replaced by S-1 according to the result of the ACTS-GC trial, although there has been no direct comparison. Paclitaxel (PTX) has been widely used as one of the key drugs for unresectable GC. A randomized phase III trial with a two-by-two factorial design was planned to assess the survival benefit of sequential use of PTX and oral fluorinated pyrimidines (FPs) in comparison with FPs alone, and to compare UFT and S-1. Methods: Patients with serosa-invading GC who underwent R0/1 resection with extended (D2) lymph node dissection were randomized to receive either UFT 267mg/m2 daily (arm A), S-1 80mg/m2 daily for 2 weeks every 3 weeks (B), weekly PTX 80 mg/m2 followed by UFT (C), or PTX followed by S-1 (D) for 24 weeks. The primary endpoint was disease-free survival (DFS). 708 patients per groups were necessary to detect a hazard ratio of 0.8 with 90% power for superiority of the sequential arms, C+D, vs. A+B (two-sided 5.0% significance level). The number of patients was set to 370 per arm (total 1480) with an 88% power for noninferiority (1.33 as the margin) of UFT vs. S-1. Results: Between August 2004 and October 2007, 1,495 patients from 232 centers were randomized with the full analysis set of 1,433. Demographics were well balanced among arm A (n=359), B (n=364), C (n=355), and D (n=355); mean age was 64, 86% were PS 0, 68% of tumors were 8 cm or greater and 85% were clinically node positive. Grade 3-4 neutropenia or anorexia occurred in 11% or 6%, 13% or 7%, 13% or 2%, and 23% or 5% for arm A, B, C, and D, respectively. Other % grade 3-4 toxicities were less than 5%. Median follow-up was 1,875 days and 728 events occurred. Difference in DFS between C+D and A+B were not statistically significant (HR=0.92, 95%CI 0.80-1.07, p= 0.273). HR of A+C vs. B+D was 1.23 (95%CI 1.07-1.43) and hence the null hypothesis was not rejected. Conclusions: There was a trend for better DFS for sequential use of PTX followed by FPs. Comparison between the FPs demonstrated that UFT was inferior to S-1. Sequential PTX/S-1 is safe and effective for locally advanced GC in an adjuvant setting. Clinical trial information: C000000082.

A prospective cohort study to reduce operative risk in stage I gastric cancer patients with metabolic syndrome: Preoperative exercise versus surgery alone

e15112

Background: Although obesity influences the technical difficulty of surgery, a reasonable marker of abdominal obesity is not confirmed and effective intervention has never been applied to reduce the operative risk in patients with abdominal obesity. Methods: To reduce the surgical difficulty and risk in gastric cancer patients with abdominal obesity, a preoperative exercise protocol was designed for stage I gastric cancer patients who were diagnosed to have metabolic syndrome (MetS). Results: In total, 51 patients (33 who underwent surgery alone, 18 who were treated with preoperative exercise) were registered in this study. Visceral fat areas (VFA) were estimated by CT scan, and they were associated most strongly with waist, followed by HDL cholesterol, and BMI. In the exercise group, all patients completed protocol treatment, without disease progression and > grade2 exercise-associated adverse events. VFA of the exercise group were larger than that of the surgery alone group at registration (221cm2 /180cm2, p=0.028), then reduced after exercise to non-significant level with surgery alone group (201cm2 /180cm2, p=0.264). There were no significant differences of intraoperative blood loss (262mL/201mL: p=0.465) and incidence of perioperative morbidity (27.7%/29%, p=1.000) between exercise and non-exercise groups. Multivariate logistic regression analysis detected intraoperative blood loss (> 380mL) as significant risk factor (p=0.023) for perioperative morbidity. Conclusions: Waist was surrogate marker for VFA in this study, thus can be a candidate of simple indicator of abdominal obesity. Preoperative interventional exercise did not directly reduce operative risk of gastric cancer with MetS; however, it was associated indirectly with risk reduction by improving surgical difficulty.

Multicenter, phase II study of trastuzumab and paclitaxel to treat HER2-positive, metastatic gastric cancer patients naive to trastuzumab (JFMC45-1102)

4096

Background: The ToGA study indicated that first-line treatment using trastuzumab (T-mab) combined with capecitabine and cisplatin conferred a survival (OS) benefit to patients with HER2-positive metastatic gastric cancer (mGC). However, no reports have described the efficacy and safety of second-line treatment of HER2-positive mGC patients with T-mab who were naïve to the drug. Methods: JFMC45-1102 was a multicenter, Phase II study. Patients positive for HER2 (IHC3+ or IHC2+/FISH+) with gastric adenocarcinoma confirmed histologically; older than ≥ 20 y; who received one or more prior chemotherapies but no prior therapy with T-mab; and normal left ventricular ejection fraction (LVEF ≥ 50%) were eligible. Patients received paclitaxel (80 mg/m2on days 1, 8, and, 15 q4w) plus T-mab (8 mg/kg initial dose, followed by 6 mg/kg q3w). Treatment continued until their disease progressed; there was unacceptable toxicity or patient’s refused further treatment. The primary endpoint was overall response rate (ORR) evaluated according to RECIST ver. 1.0. Threshold and expected ORR were estimated at 15% and 30%, and secondary endpoints included progression free survival (PFS), time to treatment failure (TTF), overall survival (OS) and safety. Results: Fourty-six patients were enrolled between September 2011 and March 2012. Patients characteristics were: gender (M/F) 37/9; median age 69; ECOG PS0/1/2, 35/10/1; unresectable/recurrence 25/21; number of prior treatments (1/2), 41/5. The ORR was 37.2% (95% CI: 23.0-53.3%). The median PFS and TTF were 5.2 months (95% CI 3.9-6.6) and 5.2 months (95% CI 3.9-6.6), respectively. The protocol was discontinued for 27 patients (87.1%) for disease progression, and one patient each (3.2%) for severe adverse events, physician’s recommendation, patient refusal, and treatment related death. Conclusions: Combination chemotherapy of paclitaxel plus T-mab showed promising activity and was tolerated well by patients naïve to T-mab who were positive for HER2 and treated previously for mGC. Clinical trial information: UMIN000006223.

Determination of the optimal cutoff percentage of residual tumors to define the pathologic response rate (pathRR) of gastric cancer (GC) treated with preoperative therapy (JCOG1004-A)

4104

Background: PathRR is a common endpoint used to assess the efficacy of preoperative therapy for GC. PathRR is estimated based on the percentage of the residual tumor area in the preexisting tumor bed. Various cut-off definitions that have used for past studies (e.g. 10%, 33%, 40%, 50%, 67%) often impair the comparability of pathRRs between studies. Methods: Individual patient data from four JCOG trials evaluating preoperative chemotherapy were used (JCOG0001, irinotecan+cisplatin, n=55; JCOG0002, S-1, n=55; JCOG0210, S-1+cisplatin, n=50; JCOG0405, S-1+cisplatin, n=53). Pathological specimens were evaluated from 173 out of 188 patients (92%) who underwent surgery. Residual and preexisting tumor areas were traced on a virtual microscopic slide by one pathologist and another confirmed these areas. The hazard ratio (HR) in overall survival was calculated for each cut-off percentage by stratified Cox regression analysis including the study as a stratification factor, and concordance probability estimates (CPE) were also calculated. Results: The numbers of patients with 0-10%/11-33%/34-50%/51-66%/67-100% residual tumors were 43/33/27/23/47, respectively. Overall, HR was the largest in the 10% cut-off and CPE was the largest in 33%. When patients with R1/R2 resections were excluded, both HR and CPE were the largest in the 10% cut-off. In subgroup analyses, almost all cut-offs predicted survival well regardless of the histologic type (intestinal/diffuse), and no cut-off predicted survival for type 4 (linitis plastica type) tumors. Conclusions: PathRR is not recommended for clinical trials including type 4 tumors. The 10% cut-off is recommended for non-type 4 tumors, though 33% is also applicable. [Table: see text]

Early results of a randomized phase II, compass trial to compare regimen and duration of neoadjuvant chemotherapy for gastric cancer

4102

Background: Prognosis for stage III gastric cancer was not satisfactory even by D2 gastrectomy and adjuvant chemotherapy. Neoadjuvant chemotherapy is another promising approach. This study investigated the outcomes of two and four courses of neoadjuvant S-1/cisplatin (SC) and paclitaxel/cisplatin (PC) using a two-by-two factorial design for locally advanced gastric cancer. Methods: Patients with stage II schirrhous/junctional tumors, stage III, or resectable stage IV, received S-1 (80 mg/m2 for 21 days with 1 week rest)/cisplatin (60 mg/m2 at day 8) or paclitaxel/cisplatin (80 mg/m2 and 25 mg/m2, respectively, on days 1, 8, and 15 with 1 week rest). The primary endpoint was 3-year OS. Key secondary endpoints included pathological/clinical response, R0 resection, and adverse events. Sample size was set at 60 to 80 to achieve 10% improvement of 3-year OS by four courses or by PC with approximately 80% probability of the correct selection. Results: Between Oct 2009 and July 2011, 83 patients were assigned to arm A (2 courses of SC, n=21), arm B (4 courses of SC, n=20), arm C (2 courses of PC, n=21), and arm D (4 courses of PC, n=21). Clinical response (arm A/B/C/D) was 29%/40%/33%/24%. R0 resection (arm A/B/C/D) was 76%/75%/57%/76%. Pathological response (arm A/B/C/D), defined as tumor regression more than two third in the primary tumor, was 43%/40%/29%/38%. Pathological complete response (arm A/B/C/D) was 0%/10%/0%/10%. Major grade 3/4 toxicities (arm A/B/C/D) were anemia (14%/15%/0%/28.6%), neutropenia (10%/15%/14%/33%), nausea (0%/10%/5%/5%), and appetite loss (5%/10%/0%/5%). Pathological complete response by per-protocol analysis (arm B/D) was 17% and 12%. Treatment discontinuation (number of patients, arm A/B/C/D) was disease progression (1/3/0/1), toxicities (1/4/0/3), and others (0/1/0/0). No surgical mortality was observed. Grade 3 morbidity classified by Clavien-Dindo was leakage in 5% (arm A), pancreatic fistula in 5% (arm C), and postoperative hemorrhage in 5% (arm B). Conclusions: Pathological complete response could be induced by four courses of neoadjuvant chemotherapy without a marked increase of toxicities, regardless of a SC or PC regimen. Clinical trial information: UMIN000002595.

SAMIT: A phase III randomized clinical trial of adjuvant paclitaxel followed by oral fluorinated pyrimidines for locally advanced gastric cancer

LBA4002

The full, final text of this abstract will be available at abstract.asco.org at 7:30 AM (EDT) on Monday, June, 3, 2013, and in the Annual Meeting Proceedings online supplement to the June 20, 2013, issue of Journal of Clinical Oncology. Onsite at the Meeting, this abstract will be printed in the Monday edition of ASCO Daily News.

Risk factors for 6-month continuation of S-1 adjuvant chemotherapy for gastric cancer

BACKGROUND

The factors that affect the 6-month continuation of adjuvant chemotherapy with S-1 have not been fully evaluated. The objective of this retrospective study was to clarify the risk factors for 6-month continuation of S-1 adjuvant chemotherapy.

METHODS

The study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage 2 or 3 disease, had a serum creatinine level of ≤ 1.2 mg/dl, and received adjuvant S-1 between June 2002 and March 2011.

RESULTS

One hundred of these patients were eligible for the present study. A comparison of 6-month continuation of S-1 stratified by various clinical factors, using the log-rank test, revealed a marginally significant difference in creatinine clearance (CCr) between those patients who continued for 6 months and those who did not. A CCr of 60 ml/min was regarded as the critical point. Uni- and multivariate Cox's proportional hazard analyses demonstrated that CCr was the only significant independent factor for the prediction of 6-month continuation. The 6-month continuation rate was 72.9 % in the patients with CCr ≥ 60 ml/min, and 40.0 % in patients with CCr <60 ml/min (P = 0.015). Adverse events occurred more frequently and earlier in the patients with CCr <60 ml/min than in those with CCr ≥ 60 ml/min.

CONCLUSIONS

CCr <60 ml/min was a significant risk factor for 6-month continuation of S-1 adjuvant chemotherapy, even though the renal function was judged as normal by the serum creatinine level. Careful attention is therefore required for S-1 continuation in patients with CCr <60 ml/min.

Human epidermal growth factor receptor 2 (Her-2) and S-1 adjuvant chemotherapy in stage 2/3 gastric cancer patients who underwent D2 gastrectomy

PURPOSES

The trastuzumab for Gastric Cancer study newly defined tumors that were positive for human epidermal receptor-2 (Her-2) and created a Her-2-oriented treatment strategy that is also applicable in the adjuvant setting for stage 2/3 cancers. However, there is currently no information available on the rate of Her-2 positivity and the relapse-free survival (RFS) stratified by Her-2 status in stage 2/3 patients.

METHODS

The Her-2 status, defined by the current standard method, was examined in 100 gastric cancer patients who underwent curative D2 surgery, who were pathologically diagnosed with stage 2/3 cancer, and received adjuvant S-1 chemotherapy between June 2002 and December 2011.

RESULTS

Ten of the 100 patients were Her-2 positive. Her-2-positive status was more frequently seen in tumors with a differentiated histology. The 5-year RFS rate was 56.3 % in Her-2-positive cases, and 48.8 % in Her-2 negative cases, which was not significantly different (P = 0.786).

CONCLUSIONS

The Her-2-positive rate for stage 2/3 gastric cancer patients was low, at only 10 %. Although the RFS was not significantly different based on the Her-2 status, the low positive rate made interpretation difficult. A multi-center study with a large sample size is necessary to clarify the prognostic impact of Her-2 in stage 2/3 gastric cancer patients.

Phase II trial of paclitaxel and cisplatin as neoadjuvant chemotherapy for locally advanced gastric cancer

PURPOSE

Paclitaxel-cisplatin (TC) combination is effective and well tolerated in patients with unresectable gastric cancer. We investigated the efficacy and safety of TC for locally advanced gastric cancers in a neoadjuvant setting.

METHODS

Patients received 2-4 courses of paclitaxel (80 mg/m(2)) and cisplatin (25 mg/m(2)) on days 1, 8, and 15 in a 4-weekly schedule, followed by radical gastrectomy. Primary endpoint was the pathological response rate: percentage of tumors in which one-third or more parts were affected.

RESULTS

All 52 patients enrolled were eligible. Thirty-six (69.7 %) patients completed two or more courses of chemotherapy. Forty-three patients (82.7 %) underwent surgery, 33 (63.5 %) had R0 resection, and there was no treatment-related death. The pathological response was 34.6 % (95 % CI 22.0-49.1) for all registered patients; the null hypothesis of tumor response ≤10 % was rejected (p < 0.0001). The 3-year overall survival was 41.5 % (95 % CI 27.4-55.0).

CONCLUSIONS

The neoadjuvant chemotherapy with TC was safe and effective for patients with locally advanced gastric cancer, and further study is needed to confirm the effectiveness of this regimen.

Phase II study of preoperative chemotherapy with S-1 and cisplatin followed by gastrectomy for clinically resectable type 4 and large type 3 gastric cancers (JCOG0210)

BACKGROUND AND OBJECTIVES

We conducted a phase II study to evaluate the safety and efficacy of preoperative chemotherapy with S-1 + cisplatin followed by gastrectomy in patients with linitis plastica (type 4) or large ulcero-invasive-type (type 3) gastric cancer.

METHODS

Eligibility criteria included histologically proven adenocarcinoma of the stomach; clinically resectable gastric cancer of type 4 or type 3. Patients received two 28-day courses of preoperative chemotherapy of S-1 (80-120 mg/body, p.o., days 1-21) and cisplatin (CDDP; 60 mg/m(2), i.v., day 8). Primary endpoints were completion of protocol treatment and incidence of treatment-related death (TRD).

RESULTS

Among the 49 eligible patients with the median age of 61 years, 36 completed the protocol treatment comprising two courses of preoperative chemotherapy and R0/1 resection (73.5% completion, 80% CI, 63.7-81.7%). One TRD was observed during the first course of chemotherapy. Median survival and 3-year overall survival were 17.3 months and 24.5%, respectively.

CONCLUSIONS

Preoperative chemotherapy with S-1 + CDDP followed by gastrectomy is a safe and promising treatment for type 4 and large type 3 gastric cancers. Based on the results of this study, we are now conducting a phase III study (JCOG0501) to confirm the superiority of this treatment.

Randomized comparisons of IL-6 and lean body mass between open versus laparoscopic distal gastrectomy for gastric cancer

55

Background: Laparoscopic distal gastrectomy (LA) for gastric cancer may reduce breakdown of the muscle protein due to less surgical stress, compared with open surgery (OP). Methods: This study was performed as an exploratory analysis of a phase III trial comparing OP and LA for stage I gastric cancer in KCCH by limiting the period between May and Dec of 2011. IL-6 was measured before and 12 hours after surgery. Prealbumin and body composition were examined before and 7 days after surgery. %LBM was defined as percentile of LBM at 7 days to LBM before surgery. Values were expressed as median and range. Results: Twenty-seven patients were randomized to OP in 14 and LA in 13. Baseline: Body weight, LBM, prealbumin, and IL-6 were similar between both. Surgery and pathology D1/D1+/D2 lymph node dissections were 0/9/5 in OP and 0/9/4 in LA (p=0.785). Blood loss (g, range) and operation time (minutes, range) were 160 (50-475) and 174.5 (85-276) in OP, respectively, and 40 (5-270) and 267 (168-360) in LA, respectively, which were both significantly different (p=0.009 and 0005, respectively). Pathological T and N were similar between both. Morbidity and mortality: Any complications > grade 2 defined by Clavien-Dindo classification were 2 (14.3%) including grade 3B anastomotic stenosis and 3A pancreatic fistula in OP and 1 (7.7%) grade 2 transient ischemic attack in LA (p=0.586). Measurements: IL-6 (pg/ml, range) after 12 hours was 36.3 (14.4-405.0) in OP and 53.3 (24.1-217.0) in LA (p=1.000). Prealubumin (mg/dl, range) was 17.3 (11.7-23.7) in OP and 17.8 (10.5-28.7) in LA (p=0.680). %LBM (range) was 96.9 (93-101) in OP and 96.5 (93-100) in LA (p=1.000). When excluding the patients who developed morbidity > grade 2, IL-6 (range) was 32.1 (14.4-405.0) in OP and 49.5 (24.1-217.0) in LA (p=0.356). Prealubumin (mg/dl, range) was 17.7 (13.7-23.7) in OP and 17.8 (10.5-28.7) in LA (p=0.729). %LBM (range) was 97.1 (93-101) in OP and 97.2 (94-100) in LA (p=1.000). Conclusions: Laparoscopic approach has no impact on surgical stress and breakdown of the muscle protein after distal gastrectomy.

Efficacy analyses of a randomized phase III clinical trial of combined therapy with CPT-11/CDDP versus CPT-11 alone in patients with advanced or recurrent gastric cancer refractory to prior S-1 chemotherapy

69

Background: There has been no established regimen as the second-line treatment for advanced gastric cancer (AGC), though CPT-11 showed survival benefit over BSC. Combination of CPT-11 with CDDP is one of the promising regimens as the second-line chemotherapy after S-1 mono-therapy. Methods: This is a prospective, multicenter randomized phase III study comparing CPT-11+CDDP (Arm A) vs. CPT-11 alone (Arm B) in patients with advanced or recurrent gastric cancer resistant to S-1 mono-therapy or prior adjuvant chemotherapy using S-1. Eligibility criteria include histologically confirmed gastric adenocarcinoma, age over 20 years old, PS: 0-2, adequate organ functions and written informed consent. Arm A: patients received CPT 11 60mg/m2 and CDDP 30mg/m2 on day 1, q2w. Arm B: patients received CPT-11 150mg/m2on day 1, q2w. Stratification was made according to PS, advanced or recurrence cases, institution and presence or absence of measurable target lesions. Primary endpoint was overall survival (OS), secondary endpoints were progression free survival (PFS), time to treatment failure (TTF), response rate (RR), and safety. Results: 168 patients were registered between 2007 and 2011. Arm A (n=84) and Arm B (n=84) were well balanced for baseline factors. Median age was 67 vs 68 years old, number of advanced/recurrence after resection was 36/48 vs 35/49, and median number of treatment course was 5 vs. 6 (range:0-31, 0-39). Common grade 3/4 toxicities in Arm A vs. Arm B were neutropenia; 35.4% vs. 27.2% (p=0.259), anemia; 15.9% vs. 3.7% (p=0.009), diarrhea; 0% vs. 2.5% (p=0.152), nausea; 3.7% vs. 4.9% (p=0.687), vomiting; 1.2% vs. 3.7% (p=0.305), anorexia 6.1% vs. 8.6% (p=0.534). The rate of patients who were required dose modification for these toxicities was 22.9% vs 21.4%. The pooled OS, PFS and RR for both Arms were as follows; 13.8 months (95% CI, 10.7 to 17.5), 4.5 months (95% CI, 3.7 to 5.1), and 13.7%. Conclusions: There was no significantly difference in the incidence and severity of adverse events in both Arms except for anemia. Updated efficacy data of secondary endpoints will be presented. Clinical trial information: UMIN000002571.

Induction of pathologic complete response by long-term neoadjuvant chemotherapy for gastric cancer: Early results of a randomized phase II study—A COMPASS trial

71

Background: Prognosis for stage III gastric cancer was not satisfactory even by D2 gastrectomy followed by S-1 adjuvant chemotherapy. Neoadjuvant chemotherapy will be another promising approach to improve the survival as demonstrated in some European trials, however, optimal duration and regimen have not been clarified yet. Methods: This trial compared efficacy of neoadjuvant chemotherapy using two and four courses of SC regimen; S-1 (80 mg/m2 for 21 days with 1 week rest) / cisplatin (60 mg/m2 at day 8), or PC regimen; paclitaxel / cisplatin (80 mg/m2 and 30 mg/m2, respectively at days 1, 8, and 15 with 1 week rest), by a two by two factorial design for stage II schirrhous / junctional tumors, stage III, or resectable stage IV. The primary endpoint was 3-year OS. Key secondary endpoints included pathological / clinical response, R0 resection, and adverse events. Sample size was set at 60 to 80 to achieve 10% improvement of 3-year OS by four courses or by PC with approximately 80% probability of the correct selection. Results: Between Oct 2009 and July 2011, 83 patients were assigned to arm A (2 courses of SC, n=21), arm B (4 courses of SC, n=20), arm C (2 courses of PC, n=21), and arm D (4 courses of PC, n=21). Clinical response (arm A/B/C/D) was 29%/40%/33%/24%. R0 resection (arm A/B/C/D) was 76%/75%/57%/76%. Pathological response (arm A/B/C/D), defined as tumor regression more than two third in the primary tumor, was 43%/40%/29%/38%. Pathological complete response (arm A/B/C/D) was 0%/10%/0%/10%. Major grade 3/4 toxicities (arm A/B/C/D) were anemia (14%/15%/0%/28.6%), neutropenia (10%/15%/14%/33%), nausea (0%/10%/5%/5%), and appetite loss (5%/10%/0%/5%). No surgical mortality was observed. Grade 3 morbidity classified by Clavien-Dindo was leakage in 5% (arm A), pancreatic fistula in 5% (arm C), and postoperative hemorrhage in 5% (arm B). Conclusions: This randomized phase II study suggested that pathological complete response could be induced by long-term neoadjuvant chemotherapy without increase of toxicities regardless of SC or PC regimen. Clinical trial information: UMIN000002595.

Result of HER2 status in Japanese metastatic gastric cancer: Prospective cohort study (JFMC44-1101)

10

Background: Randomized phase III (ToGA trial) has demonstrated that the addition of trastuzumab to standard chemotherapy improved overall survival in patients (pts) with HER2-positive metastatic gastric cancer (mGC). In screening of the ToGA trial, HER2 positivity rate was 22.1 % in total, but the rates varies between countries. Therefore, to determine the HER2 incidence rate in Japanese mGC, we planned prospective cohort study JFMC44-1101. Methods: JFMC44-1101 is a multicenter epidemiological trial assessing HER2 status in Japan. Patients with histologically confirmed gastric adenocarcinoma, not suitable for curative resection were eligible. HER2 status was centrally assessed both immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH) using formalin fixed paraffin embedded (FFPE) tissues from tumor. HER2 positive is defined as either IHC3+ or FISH+ in accordance with ToGA trial. Overall and subgroup estimates calculated with 95%CI. Results: Between September 2011 to June 2012, 1466 pts were registered from 157 sites. Patients characteristics were; gender (M/F):1044/422, median age (min-max): 68 (25-99), advance / recurrence: 1068 / 398. Samples are 768 from biopsy and 698 from excision. In August 2012, 1427/1466 pts were assessed. Overall, HER2 positivity was 20.5% (293 pts). Each IHC status (0/1+/2+/3+) with FISH+ was 3.0% / 11.3% / 46.9% / 97.2%, respectively. The frequency of IHC 0/1+ with FISH+ was almost as high as IHC 2+ with FISH+ (5.6%/4.2%). HER2 positivity rate of background factors were; male/female:23.6%/14.3%, biopsy/ excision: 22.7%/19.0%, advance / recurrence: 21.6%/17.6%. Conclusions: JFMC44-1101 confirmed the incidence of HER2 positivity in Japanese mGC. HER2-positivity rate and HER2 status were similar to the ToGA screening population. Clinical trial information: UMIN000006190.