[Management of hand-foot syndrome in patient treated with capecitabine]

Capecitabine is one of the most effective oral regimens of chemotherapy against advanced or recurrent breast cancer. In addition, capecitabine could widely be used for treatment of colon cancer. It appears that more patients will be administered capecitabine because of its QOL benefits. However, Hand-Foot Syndrome(HFS)may appear to be about 50% of the patients who take this regimen. As a result, the patient's QOL is hindered and led to a reduction of the dosage or discontinuation of the treatment depending on the grade of adverse event. This time, we evaluated the efficacy of topical emollients, creams and vitamin B6 for prevention and reduction of HFS symptoms for patients who received capecitabine. We found the efficacy of preventative measures that the occurrence of HFS grade 1 or above could be decreased and delayed. We also noticed that these preventative measures appear to be decreased the occurrence of HFS grade 2 or above, which led to a reduction of dosage or discontinuation of the treatment. For continuation and completion of the treatment and securing of patient's QOL, the supportive measures are needed to control a variety of side effects, such as HFS and others, and a team care support is indispensable.

[Clinical effect and positioning of capecitabine for metastatic breast carcinoma]

We evaluated the effect of capecitabine for metastatic breast carcinoma. Of 18 metastatic breast carcinoma patients experienced in our institution from November 2002 to July 2007, all patients had resisted the anthracycline or taxanes therapy before. Of these patients, 7 had liver, 6 had bone, and 5 had lung metastases. The capecitabine response in these 18 patients was evaluated as follows: PR in 4, long SD in 6, SD in 3, and PD in 5. In particular, 3 patients with liver metastases showed remarkable tumor regression. Compared to the 3rd-and 4th-line, 2nd-line capecitabine proved more effective. Hand-foot syndrome was found in 4 patients. Only one patient discontinued the therapy due to nausea. These results showed that capecitabine may be a useful treatment regimen for chemotherapy-resistant metastatic breast carcinoma patients.

Is there a role for herbal medicine in the treatment of pancreatic cancer? Highlights from the "44th ASCO Annual Meeting". Chicago, IL, USA. May 30 - June 3, 2008

One of the greatest challenges in the treatment of pancreatic cancer remains its inherent lack of beneficial response to cytotoxic chemotherapy. According to the encyclopedic knowledge on herbal medicine regimen and clinical experience accumulated for centuries, traditional Chinese medicine can provide new avenues for alternative treatments of pancreatic diseases. Chinese herbal extracts have been widely used for the treatment of various cancers, but objective information on their efficacy in pancreatic cancer is lacking. This article provides a summary of herbal medicine, presented at the Annual Meeting of ASCO, 2008. The clinical applications of these active compounds warrant further investigation in randomized, controlled clinical trials.

Is there an optimal chemotherapy regimen for the treatment of advanced gastric cancer that will provide a platform for the introduction of new biological agents?

Globally, gastric cancer is the second most common cause of cancer-related death. The majority of gastric cancer patients will have at presentation or will ultimately develop overt metastatic disease. Meta-analysis has demonstrated not only that systemic chemotherapy can improve survival in patients with advanced disease but also that the best survival results in earlier randomized studies have been achieved with three-drug regimens containing a fluoropyrimidine, an anthracycline, and cisplatin. Although there has been little progress historically in improving median overall survival times beyond the 9-month plateau achievable with the standard epirubicin-cisplatin-infusional 5-fluoropyrimidine (ECF) combination, the availability of newer cytotoxic anticancer agents has provided some measure of optimism that current outcomes can be improved. A number of new triplet and doublet combinations incorporating docetaxel, oxaliplatin, irinotecan, capecitabine, and S-1 have been explored in randomized trials. Although some combinations, such as epirubicin-oxaliplatin-capecitabine, have been shown to be as effective as (or perhaps more effective than) ECF, and although promising early data have been derived for S-1 in combination with cisplatin, a lack of studies in which direct comparisons have been made currently hinders the identification of the optimal regimen in this setting. One factor that might contribute to the lack of clear progress is the absence of consensus on the utility of second-line cytotoxic treatments. It can therefore be concluded that, although there is no first-line regimen that is clearly the most appropriate platform for the investigation of biological agents, there are a number of combinations that have been shown to be effective and therefore good candidates.

Daily low-dose/continuous capecitabine combined with neo-adjuvant irradiation reduces VEGF and PDGF-BB levels in rectal carcinoma patients

Metronomic low-dose chemotherapy regimen was found to have an antiangiogenic effect in tumors. However, its effect on levels of circulating pro-angiogenic and anti-angiogenic factors is not fully explored.

MATERIALS AND METHODS

The levels of both VEGF and PDGF-BB were measured in three time points, in the serum of 32 rectal carcinoma patients receiving daily reduced-dose/continuous capecitabine in combination with preoperative pelvic irradiation.

RESULTS

We found a significant decrease in VEGF and PDGF-BB serum levels during the combination treatment (p < 0.0001), followed by an increase in the successive rest-period (p < 0.0001). In addition, substantial changes in platelets counts were observed during treatment in correlation with the changes of VEGF and PDGF-BB serum levels.

DISCUSSION

These results suggest that combined chemo-irradiation affect levels of pro-angiogenic factors during treatment, and may reflect an anti-angiogenic window induced during this treatment. The potential implications of this inducible phenomenon, including a possible clinical benefit from the administration of long lasting metronomic chemotherapy immediately following combined chemo-irradiation, would warrant further investigation.

Comparison of protracted infusion 5-fluorouracil and capecitabine in adjuvant chemoradiotherapy for rectal cancer

BACKGROUND/AIMS

5-Fluorouracil-based chemoradiotherapy is the most widely used treatment modality in the adjuvant treatment of rectal cancer. Capecitabine represents a valuable alternative to 5-Fluorouracil in this situation.

METHODOLOGY

Patients with stage II and stage III rectal adenocarcinoma, who were included in this analysis, received adjuvant chemoradiotherapy consisting of external-beam radiotherapy (50.4-54Gy) either with 5-Fluorouracil at a median dose of 300 mg/m2/day by protracted venous infusion for 5 days a week, or capecitabine at a median dose of 1650 mg/m2/day for 5 days a week after surgery. The data concerning the toxicity and the efficacy of the treatments were compared in patients treated with 5-Fluorouracil- and capecitabine-based chemoradiotherapy.

RESULTS

Forty-three patients received 5-Fluorouracil, and 24 patients received capecitabine during adjuvant radiotherapy. Although there were no differences between the groups in terms of toxicity rates, distant metastasis-free survival, disease-free survival, and overall survival rates; a trend for improved loco-regional recurrence-free survival rate was observed in the capecitabine arm (p = 0.063).

CONCLUSIONS

Capecitabine is at least as effective as 5-Fluorouracil in the postoperative treatment of rectal adenocarcinoma. Considering the trend for improved loco-regional recurrence-free survival rate in the capecitabine arm, it seems that the drug exerts better synergy with radiotherapy in this situation.

Phase II evaluation of capecitabine in refractory nonsquamous cell carcinoma of the cervix: a Gynecologic Oncology Group Study

We conducted a multi-institutional study to assess the activity and toxicity of capecitabine in patients with persistent or recurrent nonsquamous cancer of the cervix. Eligible patients were required to possess adequate renal, hepatic and bone marrow function and a Gynecologic Oncology Group performance status of 0-2. Histologic confirmation of the original primary cancer was mandated. Patients must have received one prior systemic chemotherapeutic regimen for cervical cancer that did not include the chemotherapy that may have been administered in conjunction with prior radiation therapy. The initial dose schedule was 2500 mg/m2 orally daily in two divided doses for 14 consecutive days, followed by a 7-day rest, such that each cycle was 21 days. Responses were assessed using response evaluation criteria in solid tumors. Twenty-one patients were entered into the trial. One patient was declared ineligible for wrong cell type; thus, 20 were evaluable for toxicity. A median of 2.5 cycles was administered (range 1-11). There was one septic death. Grade 4 neutropenia, renal, neurologic, and pulmonary toxicity was seen in 5%, 5%, 5%, and 10% patients, respectively. There were no responses. Nine patients (45%) each had stable disease and nine showed progression. The remaining two cases (10%) did not have subsequent disease assessment and response could not be assessed. Oral capecitabine at the dose and schedule tested has insignificant activity in nonsquamous cervical cancer patients previously treated with chemotherapy.

Capecitabine cardiotoxicity--case reports and literature review

This study presents 3 case reports of patients who experienced anginous pain during treatment with capecitabine. The interruption of capecitabine and sublingual or intravenous nitroglycerine treatment lead to recovery. Rechallenge of capecitabine with dose reduction of 30% lead to repeated anginous pain in 2 patients. Treatment with capecitabine had been replaced with weekly bolus 5FU-LV, without further cardiotoxicity. The literature contains data from about 50 patients who experienced cardiotoxicity during capecitabine treatment. The most frequent manifestations of capecitabine cardiotoxicity included: anginous pain in 38/53 (71.7%), arrhythmia in 6/53 (11.3%), myocardial infarction in 6/53 (11.3%). Cardiotoxicity of capecitabine lead to death in 6/53 (11.3%) patients. Risk factors for cardiotoxicity are associated with the grade 4 and the fatal outcome of cardiotoxicity (p = 0.035, p = 0.015), but not with the symptom recurrence upon capecitabine rechallenge (p = 0.18). The combination chemotherapy regimens are associated with the grade 4 of cardiotoxicity (p = 0.048), but not with the fatal outcome (p = 0.3). Rechallenge of capecitabine lead to symptoms recurrence in 10/16 patients. Neither the dose reduction of capecitabine (p = 0.18) nor the additional medical prophylaxis (p = 0.37) were important for the outcome of capecitabine rechallenge.

Neoadjuvant chemoradiation for rectal cancer: is more better?

Neoadjuvant chemoradiation is now considered the clear preferable adjuvant standard of care in the management of stage II/III rectal cancer. Neoadjuvant fluorouracil (5-FU) plus radiation results in a decrease in local relapse rates and a favorable toxicity profile in comparison with postoperative adjuvant 5-FU plus radiation therapy. Recent nonrandomized comparative studies have shown that capecitabine (Xeloda) plus radiation result in downstaging and pathologic complete responses equivalent to those of 5-FU plus radiation, making this combination an acceptable alternative neoadjuvant treatment. The addition of oxaliplatin (Eloxatin) or irinotecan (Camptosar) to 5-FU or capecitabine concurrently with radiation therapy appears to result in more favorable pathologic responses in phase I/II trials. These combinations should be investigated further in larger phase III studies before they are endorsed in the routine neoadjuvant treatment of rectal cancer. This article will review the progress of chemoradiation over the past 2 decades, current standards of care, and investigational treatments in the neoadjuvant treatment of rectal cancer.

Capecitabine-associated coronary vasospasm: a case report

Capecitabine (Xeloda) is an oral 5-fluorouracil pro-drug used in the treatment of two of the commonest cancers: breast and colorectal. This report concerns a 43-year-old woman with metastatic cancer of the sigmoid colon who developed cardiac chest pain 5 days after starting capecitabine therapy. Capecitabine-induced cardiac symptoms have previously been reported but infrequently. In the main they have documented pain and electrocardiogram (ECG) changes associated with exercise. This case report is of a patient with minimal cardiac risk factors, who had ischaemic cardiac pain with widespread ECG changes at rest that resolved with a nitrate infusion. Coronary vasospasm is proposed as the probable mechanism for the cardiac ischaemia and dramatic ECG changes. Capecitabine is now in widespread use and so physicians will encounter an increasing number of patients using this therapy. In the light of this, it is important that doctors in emergency and acute medicine are aware of its treatable cardiac side effects.

Irinotecan plus capecitabine as first-line chemotherapy in advanced colorectal cancer

Capecitabine, an oral 5-fluorouracil (5-FU) prodrug, is increasingly replacing intravenous i.v. 5-FU/leucovorin in colorectal cancer treatment. THE AIM of this study was to evaluate efficacy and safety of the combination chemotherapy of irinotecan plus capecitabine (XELIRI), in patients with advanced colorectal adenocarcinoma.

PATIENTS AND METHODS

Forty patients received first-line chemotherapy with capecitabine (1.000 mg/m2 twice daily) on days 1-14 and irinotecan (240 mg/m2) on day 1 of a 21-day cycle. Baseline characteristics: 24 men, 16 women; median age 64.5 years. Most common metastatic sites were the liver (55%), lymph nodes (45%), lung (22.5%) and bones (17.5%).

RESULTS

There were 12 partial responses (30%), 11 cases of stable disease (27.5%), and 17 cases of disease progression (42.5%). The median survival was 16 months (range, 6-26 months) and median progression-free survival was 7 months (range, 3-14 months). Frequently encountered therapy-related events were leukopenia and gastrointestinal side effects including diarrhea.

CONCLUSION

XELIRI is a well-tolerated regimen, with an activity comparable to, but more convenient than, irinotecan-5-FU i.v. combinations in patients with previously untreated advanced colorectal cancer.

[A case of occult breast cancer successfully treated by capecitabine in combination with weekly paclitaxel followed by FEC (75)]

A 78-year-old woman was referred to our hospital complaining of a hard nodule on the left side of her neck. Histological examination of this nodule showed metastatic carcinoma from breast cancer. Further examination revealed paraaortic lymph node swelling and no breast tumors. We diagnosed her tumors as occult breast cancer and its metastasis to lymph nodes (cT0N3cM1, Stage IV). We used weekly paclitaxel followed by a FEC75 regimen. The neck nodule size did not change after administration twice. We added capecitabine to the weekly paclitaxel, which had decreased the size of the nodule immediately. After this chemotherapy, PET-CT revealed that the lymph node metastasis had disappeared completely. It was considered that the addition of capecitabine in the early phase of the regimen was useful for this case.

Palliative treatment for elderly patients with colon cancer in ten Italian medical oncology units

BACKGROUND

Palliative chemotherapy significantly reduces mortality in patients with stage IV colon cancer, but is less prescribed with rising age. In this paper, we highlight the pattern of palliative treatment and possible effects on survival among elderly patients.

PATIENTS AND METHODS

From January to December 2004, 78 files on the management of stage IV colorectal cancer (CRC) patients over 70 years, collected from 10 Italian Centres, were retrospectively examined. Determinants of receipt of palliative chemotherapy and their relation to toxicity and survival were considered.

RESULTS

The proportion of elderly patients receiving first-line palliative chemotherapy was 98.7% and it was evaluated according to age, gender, educational level and comorbidities; patients receiving second-line therapy comprised 47.4%, those receiving third-line therapy 14.1% and those treated with a fourth-line therapy totalled 2.6%. Forty-one percent of patients received best supportive care (BSC) alone.

CONCLUSION

In Italy, a proportion of elderly patients with metastatic chemonaive CRC are usually treated with a tolerability and overall survival similar to those for the younger population. Among progressive patients after second-line therapy, 45.8% usually undergo third line therapy; the remaining 54.2% undergo BSC.