The use of trastuzumab in Japanese patients with HER2-positive advanced or metastatic gastric cancer

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Background: The Trastuzumab for Gastric Cancer (ToGA) study showed the efficacy of trastuzumab for HER2-positive gastric cancer (HGA). The aim of this study is to evaluate the benefit of trastuzumab for Japanese HGA patients.

Methods: ToGA was an open-label, international, phase III, randomized controlled trial undertaken in 122 centers in 24 countries. Median overall survival (OS) was 13.8 months in those assigned to trastuzumab plus chemotherapy (C+T) compared with 11.1 months in those assigned to chemotherapy alone (C) with hazard (HR) ratio of 0.74. Subgroup analyses of patients enrolled from Japan were undertaken to estimate the hazard ratio (HR) for OS in the Japanese population. Based upon the prescribed protocol for Japan, we calculated HR using multiple Cox regression model with prespecified covariates in the ToGA study in order to make up for the small number of Japanese patients and reduce the bias in the baseline characteristics between two groups.

Results: Sixteen institutes participated and 102 patients were enrolled, of which 101 patients were evaluable for this research. The median OS was 15.9 months in C+T arm versus 17.7 months in C arm. The HR for OS was 1.00 [95% CI: 0.59-1.69]. However, the HR for OS adjusted for the above covariates was estimated to be 0.68 [95% CI: 0.36-1.27]. There were differences between C+T arm and C arm in some baseline characteristics. Higher frequencies were seen in C arm as follow: intestinal type, prior gastrectomy, and smaller number of metastatic sites. For HER2 status, the percentage of patients with IHC0/FISH+ was lower in C+T arm (5.9%) than in C arm (18.0%), while that of patients with HER2 status IHC2+/FISH+ was higher in C+T arm (35.3%) than in C arm (26.0%).

Conclusions: Although ToGA's overall OS HR = 0.74 (p = 0.0046), in the Japan patient subgroup, the unadjusted hazard ratio was 1.00. However, there was an imbalance of the baseline characteristics between the treatment arms in Japanese population. When adjusted for these characteristics, the HR was 0.68 which is similar to those in the ToGA study. Adding trastuzumab to chemotherapy in Japanese population appears to confer a similar magnitude of benefit compared to the whole population enrolled in the ToGA study.

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Feasibility study of neoadjuvant chemotherapy with docetaxel, cisplatin, and fluorouracil (DCF) for clinical stage II/III esophageal squamous cell carcinoma

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Background: In JCOG 9907, neoadjuvant chemotherapy with cisplatin and 5-fluorouracil (CF) improved overall survival without additional serious adverse events in treating stage II/III esophageal squamous cell carcinoma (ESCC). However, ESCC patient survival remains unsatisfactory. We conducted a feasibility study of neoadjuvant chemotherapy with docetaxel plus CF (DCF) for clinical stage II/III ESCC.

Methods: Eligibility criteria included clinical stage II/III (non-T4) ESCC, PS 0–1, and age 20–70 years. Chemotherapy consisted of a 1-h infusion of docetaxel at 70 mg/m2 and 2-h infusion of cisplatin at 70 mg/m2 (day 1), and continuous infusion of 5-FU 750 mg/m2 (days 1 to 5). Antibiotic prophylaxis on days 5 to 15 was mandatory. This regimen was repeated every 3 weeks (maximum 3 cycles) until unacceptable toxicity, patient refusal, or disease progression was observed. After chemotherapy completion, transthoracic esophagectomy with extended (> D2) lymphadenectomy was performed. The primary endpoint was the completion rate of protocol treatment.

Results: From July 2009 to Feb 2010, 34 patients were enrolled, including 2 ineligibles. The 32 eligibles had a median age of 61 (range 36–70; male/female: 30/2), with PS0/1 of 20/12 and cStage IIA/IIB/III of 6/8/18. During chemotherapy, the most common grade-3 or -4 toxicities were neutropenia (88%), febrile neutropenia (3%), anorexia (9%), and stomatitis (6%). Thirty-one (97%) patients underwent surgery. The protocol completion rate was 87.5% (28/32). No treatment-related death was observed, and the operative morbidity incidence was comparable to those in previous studies. According to RECIST, the overall response rate was 61.5% after DCF completion. Primary-lesion pathological complete response was achieved in 26% of patients (8/31) who underwent esophagectomy.

Conclusions: Neoadjuvant DCF was well tolerated. Although these data are preliminary, the protocol is highly promising and warrants further investigation.

No significant financial relationships to disclose.

Prostaglandin E1 analog increases spinal cord blood flow at the point of compression during and after experimental spinal cord injury

STUDY DESIGN

An in vivo study using a spinal cord compression model in rats.

OBJECTIVES

To evaluate the effect of prostaglandin E1 (PGE1) on the change in thoracic spinal cord blood flow and on hind-limb motor function.

BACKGROUND

Until now, effect of PGE1 on spinal cord blood flow at the point of compression has not been tested.

METHODS

Our newly developed blood flow measurement system was a combination of a noncontact-type Laser Doppler system and a spinal cord compression device. The rat thoracic spinal cord was exposed and spinal cord blood flow at the point of compression was measured before, during and after compression. The functioning of the animals' hind-limbs was evaluated by the BBB Scale and by measuring the frequency of voluntary standing.

RESULTS

During the compression period, spinal cord blood flow was significantly higher in the PGE1-treated rats than in the control rats, which did not receive PGE1. After decompression, the spinal cord blood flow rapidly recovered to about 60% of the precompression level in the control rats. When the animals were treated with PGE1, blood flow after decompression reached about 90% of the precompression level.Twenty-gram compression for 40 mins induced motor deficiencies in the rat hind-limbs. The application of PGE1 significantly improved motor function of the rat hind-limbs after spinal cord injury.

CONCLUSIONS

The application of PGE1 increased spinal cord blood flow during and after spinal cord compression, and improved motor function after the spinal cord injury.

Use of genotype subset selections of multi-UGT1As polymorphisms to predict severe neutropenia and tumor responses of metastatic CRC patients received FOLFIRI regimen

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Introduction: The pharmacogenetics of irinotecan indicate that a common polymorphism in the uridine diphosphate glucuronosyltransferase 1As (UGT1As) gene predict severe toxicity. However the tumor response to irinotecan is variable and unpredictable. Methods: Two multi-center phase II studies of FOLFIRI (FLIGHT-1 and FLIGHT-2 study) were conducted for patients with metastatic colorectal cancer (CRC) in Japan. FLIGHT-1 study was first-line chemotherapy, and FLIGHT-2 study was FOLFOX-refractory second-line chemotherapy. 103 patients have been enrolled in these studies (53 patients in FLIGHT-1 and 50 patients in FLIGHT-2) from 20 institutions by April 2007 from November 2005. Seventy one patients were analyzed UGT1As polymorphisms, UGT1A1*28 (TA6>TA7), UGT1A1*6 (G>A), UGT1A1*60 (T>C), UGT1A7 (N129K; T>G), UGT1A7 (-57 T>G), UGT1A9*22 (T10>T9). Results: Out of 71 patients, 34 had G3/4 neutropenia or leukopenia, and 23 had tumor responses (CR +PR). G3/4 neutropenia was more frequent in patients with *6, N129K(G), -57(G), *22 allele than patients without these allele (p<0.05). Other polymorphism was not the predictive factor for toxicity and tumor response, independently. On the other hand, genotype subset selection of multi-UGT1As polymorphisms was useful to predict severe toxicities and tumor responses. Only 7 patients of 22 patients with TA6/TA6 and T10/T10, or TA6/TA7 and -57(T/T), or *6(G/G) and *60(T/T) had grade3/4 toxicity. Similarly, high risk group of toxicity or high and low tumor responses groups was also predicted by genotype subset selections. Conclusions: Genotype subset selections of multi-UGT1As polymorphisms were the excellent predictor for severe toxicities and tumor responses of metastatic CRC patients received FOLFIRI regimen.

No significant financial relationships to disclose.

Phase I trial of sorafenib in combination with interferon-alpha in Japanese patients with unresectable or metastatic renal cell carcinoma

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Background: Sorafenib (SOR) is a multi-kinase inhibitor, targeting Raf kinase and the receptor tyrosine kinases VEGFR-2 and PDGFR-β. Interferon-α (IFN) is most commonly used for metastatic renal cell carcinoma (RCC) in Japan. In this phase I study, we investigated the safety profile, pharmacokinetics (PK), and tumor response of SOR/(recombinant)IFN combination in Japanese patients (pts) with RCC. Methods: After 2 weeks of IFN-alone treatment, a total of 18 pts (6 in each cohort) with unresectable/metastatic RCC received 28-day cycles of continuous SOR 200 (Cohort 1 [C1]) or (Cohorts 2 and 3 [C2 and C3]) 400 mg bid combined with intramuscular IFN 6 (C1 and C2) or 9 (C3) MIU three times a week (tiw). Objectives were safety/tolerability and recommended dose of SOR/IFN as primary, and tumor response and PK as secondary. Results: Pt characteristics were: median 64.5 y.o.; ECOG-PS 0:1, 14:4; prior anticancer therapy in 13 pts. All pts completed Cycle 1 and entered Cycle 2 or later cycles. At data cut-off (September 30, 2008), dose-limiting toxicities were reported in all cohorts, including G3 fatigue, G3 anorexia, and G3 skin disorders. Common drug-related grade 3/4 adverse events (AEs) included fatigue (50%), lipase increased (44%) and neutropenia (39%), all of which were reversible and manageable. AEs resulting in treatment discontinuation in Cycle 2 or later cycles were seen in 5 pts in Cohort 3. One death was reported in C1 at Cycle 18 due to gastrointestinal and intraabdominal hemorrhage. It seemed attributable to DIC accompanied by RCC. Five PR (1 in C1 and 4 in C3) and 11 SD (4 in C1, 5 in C2, and 2 in C3) were achieved as the best response. IFN had no relevant impact on PK of SOR. Conclusions: SOR/IFN combination has promise for clinical benefit in RCC, and its recommended dose was continuous SOR 400 mg bid and IFN 6 MIU tiw.

[Table: see text]

Phase II study of gemcitabine chemotherapy alone for locally advanced pancreatic carcinoma: JCOG 0506

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Background: Fluorouracil (5-FU) chemoradiotherapy has been accepted as standard care for locally advanced pancreatic cancer (LAPC); however, it has not been shown to be superior to chemotherapy alone in gemcitabine (Gem) era. The present multicenter phase II study was conducted to evaluate the efficacy and the safety for the screening of Gem monotherapy against LAPC. Methods: Eligibility criteria included the following: patients (pts) with histologically or cytologically proven pancreatic adenocarcinoma or adenosquamous carcinoma, pts with UICC clinical stage III (T4N0–1 and M0), all lesions are assumed to be included in the radiation field of 15 cm square, age 20 or older, no prior treatment for LAPC, ECOG performance status of 0, 1 or 2, and adequate organ function. Gem was given intravenously at a dose of 1,000 mg/m2 over 30 minutes on days 1, 8 and 15, repeated every 4 weeks until disease progression. The primary endpoint was %1-year overall survival. A sample size of 50 was required with one-sided alpha of 0.20, beta of 0.10, expected %1-year survival of 40% and threshold %1-year survival of 25%. Results: Between Jan. 06 and Feb. 07, 50 pts from 14 institutions were registered. Patient characteristics were: median age; 67.5 (45–80), male/female; 35/15, PS 0/1/2; 30/20/0, pancreatic head/body-tail; 26/24. The major grade 3–4 adverse events were neutropenia (62%), leucopenia (32%), thrombocytopenia (18%), fatigue (12%), infection-biliary tree (10%), anorexia (8%), and nausea (6%). Hematological toxicity was mostly transient and there was no episode of infection with grade 3–4 neutropenia. There were no treatment-related deaths during the study. Serum CA 19–9 level was reduced by >50% in 37.5% of 40 pts with baseline CA19–9 >100U/ml. Up to the final follow-up in Apr. 08, the median overall survival was 1.25 years (95% CI, 1.06–1.71 years) with a %1-year survival of 64.8% (95% CI, 49.6–76.4%), and the null hypothesis (%1-y survival=25%) was rejected (p<0.0001). Conclusions: Gem monotherapy demonstrated far better survival than historical data of 5-FU chemoradiotherapy in LAPC pts with mild toxicities. In future randomized trial, we will select Gem chemotherapy as a referential arm to compare with the chemoradiotherapy regimen which is under phase II evaluation for LAPC.

No significant financial relationships to disclose.

Periodontal regeneration of transplanted rat teeth subcutaneously after cryopreservation

The periodontal regeneration of transplanted teeth after cryopreservation in liquid nitrogen overnight was previously examined using an animal model. The results showed that overnight cryopreservation did not have any severe adverse effects on periodontal healing. For clinical application, it is necessary to make the period of storage longer than in the preliminary study. In this study, the regeneration of periodontal tissues after cryopreservation for 4 weeks was examined. The maxillary molars of 4-week-old Wistar rats were extracted and transplanted into the abdominal subcutaneous tissue either immediately or after cryopreservation in a deep freezer at -80 degrees C. The donor teeth were frozen in a rate-controlling freezer. At 1, 2 and 4 weeks after transplantation, they were excised and observed under light microscopy. The cryopreserved teeth had acellular cementum with a rough surface at 1 week. With an increase in cementoblasts and the appearance of periodontal ligament and alveolar bone, the surface had become smooth at 2 weeks. There was no progressive root resorption. Although the process took somewhat more time, the teeth cryopreserved for 4 weeks showed regeneration that was similar to that of the immediately transplanted teeth.

Diabetes insipidus and cognitive function

It has been well known that several neuropeptides may affect human behavior, and that some endocrinopathies are associated with impaired higher function of the brain. There have been increasing evidences that vasopressin has both peripheral and central effects, the latter of which is involved in memory. In experimental animals, male mice with a null mutation in the V1a receptor (V1aR) exhibit a profound impairment in social recognition and changes in anxiety-like behavior. An AVP fragment analog has been reported to facilitate memory retention and recall in mice through protein kinase C-independent pathways. In human, a few recent reports have suggested that a familial central diabetes insipidus, caused by a heterozygous mutation in the gene for vasopressin prohormone, have minor disturbances in central nervous system. Taken together, it is hypothesized that the subject with central diabetes insipidus may frequently present with an impaired cognitive ability. It is justified to examine the cognitive function, when we make a diagnosis of central diabetes insipidus and to perform a clinical study to investigate whether central diabetes insipidus may be associated with impairment of higher brain functions.

Factors affecting the risk of brain metastases after chemoradiotherapy for locally advanced non-small-cell lung cancer (LA-NSCLC)

17019

Background: With an improvement in treatment outcome in patients with LA-NSCLC undergoing radical chemoradiotherapy, brain metastasis has become a greater problem. We assessed the cumulative incidence of brain metastases and its risk factors in such patients with LA-NSCLC. Methods: Between 1993 and 2003, 85 consecutive patients with stage IIIA or IIIB NSCLC underwent chemoradiotherapy in our institution. The characteristics of these patients were as follows: median age, 64 years (range, 39 to 74 years); stage IIIA/IIIB, 30/55 patients; squamous-cell/nonsquamous-cell histologies, 39/46 patients. Concurrent and sequential chemoradiotherapy were administered for 78 and 7 patients, respectively. Only two patients underwent surgical resection after chemoradiotherapy. Fifty-seven patients received conventional thoracic radiotherapy with a total dose of 59.5 ± 1.4 Gy (range, 40 to 70 Gy), and 28 received twice-daily radiotherapy with a total dose of 71.5 ± 6.5 Gy (range, 43 to 86 Gy). Thirty-eight patients received a combination chemotherapy consisting of cisplatin and docetaxel, and the remaining 47 received the other platinum-based regimens. Results: At a median follow-up time of 51 months (range, 9 to 131 months), median survival time was 25 months, with a 3-year survival rate of 36.9%. The median disease-free survival time was 13 months. During treatment and observation periods, 21 (24.7%) patients had developed brain metastases. Thirteen (15.3%) patients experienced brain metastases as the first site of relapse, and in nine (10.6%), brain was the sole site of relapse. The cumulative risk of brain metastases was 15.4% at 1-year, 21.1% at 2-year, and 25.7% at 3-year, respectively. In a multivariate analysis using Cox proportional hazard model, T-factor (T4 vs. T1–3) was the most predictive of brain failure (hazard ratio, 3.51; 95% confidence interval, 1.35 to 9.13; p = 0.01). Conclusions: In patients with LA-NSCLC undergoing chemoradiotherapy, brain was one of the most common sites of failure when locoregional control was achieved. Although efficacy of prophylactic cranial irradiation (PCI) on survival remains unclear for such patients with NSCLC, identification of patients more likely to have a benefit from PCI would be useful.

No significant financial relationships to disclose.

Drugs share antidiabetic and antiatherosclerotic actions through “the common soil”

There have been increasing evidences that atherosclerosis is not the result of diabetes mellitus, but that both type 2 diabetes mellitus and atherosclerosis may share common pathogenesis, as Stern proposed as 'common soil' hypothesis in 1995. There are several candidates for 'common soil', such as insulin resistance, vascular inflammation and endothelial dysfunction. Recently many of clinical studies have indicated that some drugs can prevent or delay the development of cardiovascular diseases (CVD). Furthermore, many studies have suggested that some classes of drugs may prevent the development of type 2 diabetes. It is to be noted that most of the drugs may have both actions, i.e., to prevent development of new diabetes and to prevent CVD. Furthermore, they are reported to inhibit inflammation or endothelial dysfunction. Taken together, it is hypothesized that the drug which may have antiatherogenetic action may also have antidiabetic action, and vice versa. This hypothesis may provide the new insights into perspectives of drug development both to prevent type 2 diabetes and to prevent CVD.

Development of MBR with reduced operational and maintenance costs

To reduce MBR O&M costs, a new MBR process that conducts efficient simultaneous biological nitrogen and phosphorus removal (BNR) was developed. In the development of this process, various approaches were taken, including reduction of power demand, chemical consumption and sludge disposal costs. To address power demand reductions, air supply requirements for membrane cleaning were reduced. The process adopted an improved membrane that requires less air for cleaning than conventional membranes. It also introduced cyclic aeration, which alternately supplies washing air to the two series of membrane units. Adoption of biological phosphorus removal eliminated chemical costs for phosphorus removal and contributed to the reduction of sludge disposal costs. By combining these technologies, compared to conventional MBR processes, an approximately 27% reduction in O&M costs was achieved.

A rare case of the cutaneous form of adult T-cell leukaemia/lymphoma: assessment of remission by PCR for clonal T-cell receptor gamma gene rearrangements in an electron beam-irradiated cutaneous lesion

Adult T-cell leukaemia/lymphoma is a lymphoproliferative disorder aetiologically associated with human T-cell lymphotropic virus type I infection. A cutaneous lesion often develops in the disease, and in rare cases, is even the only manifestation. Here we report a rare case of 'cutaneous' adult T-cell leukaemia/lymphoma with neither atypical cells in the peripheral blood nor lymph node involvement. All nodular lesions were completely eliminated after local electron beam irradiation (20 Gy/nodule in total). To evaluate whether or not there were residual lymphoma cells in the skin, we performed PCR to detect clonal T cell receptor gamma gene rearrangements. The sample from the nodule before irradiation showed evidence of a rearranged band, which was not detected at the same site after treatment nor in any peripheral blood. The findings suggest that this procedure is useful for the evaluation of therapeutic effects and the early detection of lymphoma recurrence.