Delayed leukoencephalopathy with stroke-like presentation in chemotherapy recipients

BACKGROUND

A transient leukoencephalopathy mimicking cerebrovascular accident has been described as a complication of chemotherapy, most commonly in recipients of intrathecal methotrexate for childhood leukaemia. Recently published neuroimaging data suggest a common pathophysiology associated with a variety of chemotherapy agents and modes of administration.

METHODS

We reviewed the medical literature for single reports and case series of patients presenting with stroke-like episodes while receiving systemic or intrathecal chemotherapy. We only included studies providing detailed neuroimaging data. Patients with cerebrovascular accidents were excluded.

RESULTS

We identified 27 reports of toxic leukoencephalopathy in patients treated with methotrexate (intrathecal, systemic), 5-fluorouracil and its derivative carmofur, and capecitabine. Diffusion weighted imaging (DWI) of all patients revealed well demarcated hyperintense lesions within the subcortical white matter of the cerebral hemispheres and the corpus callosum, corresponding to areas of decreased proton diffusion on apparent diffusion coefficient (ADC) maps (available in 21/27 patients). Lesions exceeded the confines of adjacent vascular territories. Complete resolution of symptoms within 1-4 days was accompanied by normalisation of ADC abnormalities. However, fluid attenuated inversion recovery (FLAIR) sequences frequently revealed persistent white matter abnormalities.

CONCLUSIONS

Several pathophysiological models of delayed leukoencephalopathy after exposure to intrathecal or systemic chemotherapy have been proposed. DWI findings in this cohort are indicative of cytotoxic oedema within cerebral white matter and lend support to an at least partially reversible metabolic derangement as the basis for this syndrome.

Rectal cancer adjuvant chemotherapy: when is more useful?

THE AIM of the study was to evaluate time-to-progression (TTP) of rectal cancer in a group of patients receiving adjuvant chemotherapy (CHT) after combined neoadjuvant treatment. A secondary end-point was to identify the possible influence of clinical TNM (cTNM) or pathological TNM (pTNM) on TTP and overall survival (OS).

PATIENTS AND METHODS

From January 2000 to December 2005, 101 consecutive rectal cancer patients who had been neoadjuvantly treated and had underne adjuvant CHT were retrospectively examined. The variables considered were age, gender and clinical and pathological effect of CHT administration.

RESULTS

The mean age was 59 years (29-78 years) and the male:female ratio, 61:40. Forty-two patients had a lower (< or =5 cm from the anal verge), 54 a middle (from 6 to 10 cm) and 5 a higher (=10 cm) rectal lesion. All the patients had received the full course of neoadjuvant radiotherapy (RT) while 26.7% patients had received a reduced number of neoadjuvant CHT cycles. All the patients had undergone surgery and had received adjuvant chemotherapy which was completed in only 77.2% of the cases. Tumour down-staging and complete remissions were reported in 75.2% and 14.8% of cases, respectively. TTP and OS at 3 years were 81.2% and 91.1%, respectively. Out of locally recurrent patients, 77.8% were N+ (p=0.0026) at the pathological evaluation.

CONCLUSION

In our series, neither administration of oxaliplatin-based adjuvant chemotherapy (p=0.44) nor age > or =70 years (p=0.51), clinical stage III (p=0.67), tumour down-staging (p=0.44) and achievement of pCR (p=0.66) appeared to have a significant impact on TTP; only pN+ (patients "not responders" to a neoadjuvant CHT-RT) influenced local relapse requiring more accurate postoperative treatment and confirming the literature data about the utility of adjuvant therapy in stage III disease.

[A case of triple negative recurrent breast cancer successfully treated with capecitabine+docetaxel combination chemotherapy]

A 73-year-old woman underwent pectoralis-preserving mastectomy for left breast cancer (papillotubular carcinoma, f, T2, ly0, v0, N1 (21/21), T2N1M0 (Stage IIB), ER (-), PgR (-), HER2 (-)) in August 2004. It was called a triple negative breast cancer. She received systemic chemotherapy using AC followed by paclitaxel. In February 2006 (disease- free interval of one year and five months), skin and chest wall recurrences in the left breast were revealed. Systemic chemotherapy using capecitabine (1,800 mg/body/day) monotherapy resulted in PD after 4 courses. Subsequently, treatment with capecitabine+cyclophosphamide combination therapy resulted in PD after 6 courses. Since November 2006, treatment with capecitabine+docetaxel combination chemotherapy was initiated. Each course consisted of capecitabine at a dosage of 1,800 mg/body/day for 2 weeks and docetaxel at a dosage of 60 mg/body (day 8 only) followed by withdrawal for 1 week. After 3 courses, a marked response was seen, and a total of 6 courses were performed. No serious side effect was revealed, and a marked response has been maintained. It is suspected that capecitabine+docetaxel combination therapy is useful for a triple negative recurrent breast cancer which is refractory to systemic chemotherapy.

Oral vinorelbine plus capecitabine (oral vincap) combination in patients with advanced breast cancer (ABC). A phase II study of the GOIM (Gruppo Oncologico dell'Italia Meridionale)

BACKGROUND

Vinorelbine i.v. and capecitabine are two of the most effective single agents in previously treated advanced breast cancer (ABC). A number of studies have been reported with the combination of these agents. Actually, the availability of oral formulation for vinorelbine allows a full oral combination of the two agents. The aim of this study was to evaluate the activity and toxicity of this novel combination.

PATIENTS AND METHODS

Thirty-eight advanced breast cancer patients refractory to anthracyclines and taxanes were included in this study. Treatment consisted of vinorelbine 60 mg/m(2) (days 1 + 8), and capecitabine 2000 mg/m(2) (days 2-7 and 9-16) every 3 weeks.

RESULTS

A total of 228 courses were given with a mean of three cycles/patient (range 1-12). Five patients (13.1%) had no toxicity at all. Hematologic side-effects were: neutropenia grade 2-3 in seven patients (18.9%) and grade 4 in one patient (2.7%), anemia grade 1 in 11 patients (29.7%), grade 2-3 in five patients (13.5%), thrombocytopenia grade 1 in six patients (16.2%) and grade 3 in one patient (2.7%). Non-hematologic side-effects were: fatigue grade 1 in five patients (13.5%), hand-foot syndrome grade 1 in two patients (5.4%) and grade 2 in two patients (5.4%), nausea/vomiting grade 1 in two patients (5.4%), grade 2 in three patients (8.1%) and grade 3 in one patient (2.7%), constipation grade 1 in two patients (5.4%), peripheral neurotoxicity grade 1 in three patients (8.1%) and grade 2 in one patient (2.7%), gastric pain grade 1 in two patients (5.4%), stomatitis grade 1 in three patients (8.1%) and grade 2 in one patient (2.7%). Out of 38 patients assessable, we observed two (5.4%) CR, 13 (34 %) PR, 14 (37.8%) SD and nine (26.3%) PD. The median time to progression was 4.5 months (range 1-18 months), the median response duration was 7 months (range 2-18 months) and the median survival duration was 10 months (range 2-26+).

CONCLUSIONS

The oral vincap should be considered as an alternative to single agent capecitabine or vinorelbine in ABC refractory to antra-taxane combination.

[A pilot clinical trial of gemcitabine and capecitabine chemotherapy for the treatment of advanced renal cell carcinoma failing immunotherapy]

We have treated 8 patients with metastatic renal cell carcinoma for whom prior immunotherapy proved uneffective. The patients consisted of 6 males and 2 females, with a median age of 68 years. One patient had a primary site in place and 5 patients had multiple organs involvement. The chemotherapy consisted of gemcitabine 1,000 mg/m(2) div at day 1, 8 and capecitabine 1,657 mg/m(2)/day p.o. at day 1-14, followed by a week rest period. Then, the regimen was repeated every 3 weeks. No treatment response was observed. There were two SD, three SD to PD, and two PD after a median of 3 cycles of treatment. The median time to disease progression was 9.1 months, and the one-year progression- free survival rate was 83%. Adverse effects were observed in 3 cases (37.5%), however, treatment was well tolerated. Despite the limited anti-tumor efficacy, it would be meaningful that the treatment brought disease stabilization to the majority of this group of patients.

Application of pressure mapping techniques to measure push and gripping forces with precision

Gripping and push forces, also named coupling forces, have induced effects on the transmission of the vibration in the upper limb. The assessment of the vibration exposure with powered tools thus requires that these man/machine coupling parameters are controlled and monitored. To date, no reliable metrological systems enable their precise measurements. This study first investigated how much precision could be expected from the pressure mapping technique for the determination of coupling forces by means of numerical integration. Then a specific procedure was worked out and validated to instrument hand-held tools and measure the coupling forces with regard to the appropriate current standards. The proposed method was applied as a case study on an ordinary breaker and an anti-vibration breaker.

[Clinical observation of XELOX (Capecitabine puls Oxaliplatin): an adjuvant chemotherapy regimen used in stage III colorectal cancer]

OBJECTIVE

To evaluate the efficacy and safety of an adjuvant chemotherapy regimen: XELOX (Capecitabine puls Oxaliplatin) used after curative resection for stage III colorectal cancer.

METHODS

From Jan. 1998 to Jan. 2004, 256 cases with stage III colorectal cancer randomized received de Gramont, modified FOLFOX4 (mFOLFOX4) and XELOX regimens. The 3-year disease-free survival (DFS) and overall survival (OS) were compared within the three groups and relative prognosis factors within mFOLFOX4 and XELOX groups. Therapeutic adverse events were recorded and analyzed with Kaplan-Meier test.

RESULTS

98, 87 and 71 cases were respectively enrolled in the de Gramont, mFOLFOX4 and XELOX groups, mFOLFOX4 and XELOX had superior efficacy compared with de Gramont regimen. The two former could significantly improve 3-year DFS (79.7% vs. 66.2%, P = 0.015; 81.5% vs. 66.2%, P = 0.004) and medium survival time (40.2 mon vs. 37.8 mon, P = 0.024; 41.4 mon vs. 37.8 mon, P = 0.014). Meanwhile they could respectively decrease the ratio of recurrence risk by 18.0% (P = 0.024) and 21.0% (P = 0.003). The relative benefit of mFOLFOX4 versus XELOX didn't differ for 3-year DFS [hazard ratio (HR): 0.84, 95% confidence interval (CI): 0.79-1.12, P = 0.13] and OS (HR: 0.87, 95% CI: 0.84-1.06, P = 0.54). In the analysis of DFS in relative prognosis factors, XELOX had a better trend of survival advantage. mFOLFOX4 had higher adverse events within these regimens, especially in grade 3 or 4 neutropenia and peripheral neurologic adverse events.

CONCLUSION

XELOX maintains its efficacy and safety ratio in advanced colorectal cancer. Patients have good tolerance and compliance. The regiment is deserves to be applied in clinical treatment. Oxaliplatin;

Results of a phase I trial of intravenous vinorelbine plus oral capecitabine as first-line chemotherapy of metastatic breast cancer

The management of metastatic breast cancer becomes increasingly intricate, requiring new drugs and combinations. We present here the results of a phase I study evaluating the maximal tolerated dose of vinorelbine combined with capecitabine as first-line chemotherapy. Vinorelbine was administered intravenously on days 1 and 15, and capecitabine was given orally twice daily from day 1 to 14 (three cycles every 21 days). Three out of six patients receiving vinorelbine at 25mg/m2/day and capecitabine at 2000 mg/m2/day presented with a dose-limiting toxicity, consisting of protracted grade 3 neutropenia, hand-foot syndrome and/or liver test disturbances. Despite of a dose reduction in vinorelbine (20mg/m2/day), one patient among four developed a dose-limiting febrile neutropenia. This regimen cannot be recommended as first-line treatment of metastatic breast cancer. These findings are not in agreement with previous publications of this schedule, or with promising results using both drugs orally.

Capecitabine vs continuous infusion 5-FU in neoadjuvant treatment of rectal cancer. A retrospective review

BACKGROUND

Standard therapy for locally advanced rectal cancer (LARC) is concurrent neo-adjuvant chemo-radiation using infusional 5-fluorouracil (CIV-5-FU). Capecitabine (CAP) offers a convenient oral replacement for CIV-5-FU. There is no randomized trial comparing infusional 5-FU to capecitabine. We retrospectively compared the safety and efficacy of CAP-based regimens with well-established CIV-5-FU-based regimens in LARC.

MATERIALS AND METHODS

We collected published data on 542 patients treated on either CIV-5-FU (197) or CAP (345) with concurrent radiation (external radiation treatment, XRT) for LARC. This included Phase I or II studies published or available from Pubmed. Safety was assessed by determining proportion of patients who experienced grade III/IV adverse effects. Efficacy was assessed by determining pathological complete response (pCR). Chi-square tests were used to compare the two regimens. A P value less than 0.05 was considered statistically significant. Statistical tests were further corrected for multiplicity using the method of Benjamini and Yekutieli (Ann Stat, 29(4):1165-1188, 2001).

RESULTS

pCR was significantly higher in patients getting CAP vs CIV-5-FU (25 vs 13%; P = 0.008,.P adj = 0.034). Both regimens were generally well tolerated. There was no grade IV toxicity reported. Grade III hand foot syndrome was more common in the CAP group, and grade III diarrhea was more common in the CIV group.

CONCLUSIONS

CAP when compared to CIV seems to have superior efficacy with reasonable toxicities. It is reasonable to treat LARC with CAP + XRT.

[Two advanced/recurrent breast cancer cases effectively treated by trastuzumab/capecitabine combination therapy]

Trastuzumab/capecitabine combination therapy was performed for two advanced/recurrent breast cancer cases with acute deterioration of the disease. The time until partial response in the first case was 7 months and in the second case 12 months. Adverse events were slight, though a standard dose as a single drug was used for each drug. The treatment time course was shortened because capecitabine was an oral drug. Therefore, this combination therapy was expected to maintain high quality of life and obtain a high response rate.

[Gemcitabine combined with capecitabine in the treatment for 41 patients with relapsed or metastatic biliary tract carcinoma]

OBJECTIVE

To investigate the efficacy of the combination of gemcitabine with capecitabine in the chemotherapy for patients with relapsed or metastatic biliary tract carcinoma.

METHODS

Forty-one patients with unresectable relapsed or metastatic carcinoma of the biliary tract were treated from March 2000 to December 2004. The regimen consisted of intravenous administration of gemcitabine plus oral intake of capecitabine every 3 weeks for more than 2 cycles. The parameters including tumor response, clinical benefit rate,survival and safety were observed.

RESULTS

Thirty-six patients were valuable and 5 patients were excluded from this series due to various reasons. Eleven patients (30.1%) had a partial response and another 11 patients (30.1%) experieced stable disease with a clinical benefit rates of 61.1%. The median overall survival time and time to progression were 10 months and 6 months, respectively. The one-year survival rate was 40.0%. The adverse events including nausea, diarrhea and hand-foot syndrome, fatigue, neutropenia, thrombocytopenia were frequently observed, which were usually in grade I or II, rarely in grade III and none in grade IV (NCI-CTC).

CONCLUSION

Our results show that the regimen of gemcitabine combined with capecitabine is effective and well tolerated in patients with unresectable relapsed or metastatic carcinoma of the biliary tract.

Preoperative chemoradiation with capecitabine in locally advanced rectal cancer

BACKGROUND

Preoperative radiation therapy in combination with 5-fluoracil (5-FU) improves local tumour control in locally advanced rectal cancer. The aim of our study was to evaluate the toxicity and efficacy of preoperative chemoradiation using the oral 5-FU prodrug capecitabine in locally advanced rectal cancer.

METHODS

Sixty patients with locally advanced rectal cancer were treated with preoperative chemoradiation. Radiotherapy consisted of a total dose of 50 Gy delivered in 25 fractions to the pelvis. Chemotherapy was concurrently administered and consisted of oral capecitabine only on radiotherapy days. Surgery was performed six to ten weeks after completion of chemoradiation.

RESULTS

The patient population consisted of 19 females and 41 males, with a median age of 61 years. All but two patients received the full dose of chemoradiation. No grade 3 or 4 haematological toxicities developed. Two patients (3%) developed grade 3 radiation dermatitis and one a grade 3 diarrhoea. All patients underwent definitive surgery; 19 patients underwent an abdominal perineal resection (APR), 25 a low anterior resection (LAR) and 16 patients a Hartmann's procedure. One patient with a low anterior resection developed an anastomotic leakage (4%). Final pathology demonstrated eight patients (13%) with a complete pathological response. Primary tumour and nodal downstaging occurred in 67 and 84% of the patients, respectively. Two patients (3%) had an R1 resection, one after an APR and one after an LAR.

CONCLUSION

Preoperative chemoradiation with oral capecitabine is safe and well tolerated in locally advanced rectal cancer patients. This preoperative treatment has a considerable downstaging effect on the tumour and lymph nodes.

[Chemotherapy for pancreatic cancer]

Chemotherapy is expected to play an important role in the treatment of pancreatic cancer because most of pancreatic cancers are being discovered at locally advanced or metastatic stages and recurrence rate is high even after the curative resection. Gemcitabine is a key agent for the first-line therapy of advanced pancreatic cancer. It can enhance the quality of life and prolong the survival of patients. Combination of erlotinib or capecitabine with gemcitabine showed a marginal survival benefit over single-agent gemcitabine. If patient's performance state is good, gemcitabine-based platinum combination therapy showed overall survival benefit compared with gemcitabine monothrapy. If the first-line palliative chemotherapy fails, 5-FU, capcitabine, or tegafur with or without combination can be used as the second-line agents. Adjuvant chemotherapy using 5-FU or gemcitabine after curative resection has overall survival benefit. However, neoadjuvant chemotherapy has not been proven to be effective in the treatment of pancreatic cancer.

Pooled analysis of diarrhea events in patients with cancer treated with lapatinib

PURPOSE

To characterize diarrhea events in patients with cancer treated with lapatinib as monotherapy or in combination with capecitabine or taxanes.

PATIENTS AND METHODS

Eleven clinical trials (phase I, II, or III) in patients with metastatic cancer were analyzed. Lapatinib was administered at doses ranging from 1,000 to 1,500 mg/day as monotherapy (n = 926) or in combination with capecitabine (n = 198) or taxanes (n = 687). Diarrhea events were characterized based on severity, time to onset, duration, required interventions, and clinical outcomes.

RESULTS

In the pooled analysis of nine studies, diarrhea occurred in 55% of lapatinib-treated patients and 24% of patients not receiving lapatinib. All grade diarrhea occurred in 51% of patients treated with lapatinib monotherapy and 65% treated with lapatinib plus capecitabine. In a separate analysis, 48% of patients treated with lapatinib plus a taxane experienced diarrhea. Overall, most diarrhea events were grade 1/2. Grade 3 events occurred in <10% of patients and grade 4 events were rare (<or=1%). Most diarrhea events resolved with conventional approaches and without dose modification. Approximately 40% of patients treated with lapatinib monotherapy or combination therapy experienced a first diarrhea event within 6 days of treatment initiation, with a median duration of 7-9 days. Lapatinib-containing chemotherapy regimens do not cause severe diarrhea when proactive monitoring and intervention is introduced.

CONCLUSION

Most diarrhea events in lapatinib-treated patients are low grade, requiring infrequent lapatinib dose modification or interruption. Proactive management of diarrhea is crucial to prevent more serious complications in lapatinib-treated patients.

A phase II study of capecitabine plus gemcitabine in patients with locally advanced or metastatic pancreatic cancer

PURPOSE

This open-label, multicenter phase II study was conducted to investigate the efficacy and safety of capecitabine plus gemcitabine combination chemotherapy as first-line treatment in patients with locally advanced or metastatic pancreatic cancer.

PATIENTS AND METHODS

We enrolled 63 patients who received capecitabine 830 mg/m(2) orally twice daily on days 1-21 plus gemcitabine 1000 mg/m(2) as a 30-min infusion on days 1, 8 and 15 every 4 weeks for up to six cycles.

RESULTS

A total of 14 patients had partial responses giving an overall response rate of 22% (95% confidence interval [CI] 13-34%) in the intent-to-treat population. The median time to progression and overall survival were 3.9 months (95% CI 3.5-5.7) and 7.5 months (95% CI 5.0-10.0), respectively, and 1-year survival rate was 27.1% in the intent-to-treat population. Capecitabine plus gemcitabine was well tolerated. Grade 3 hematological adverse events were neutropenia (21%) and thrombocytopenia (2%); the only grade 4 hematological events were anemia (2%) and neutropenia (6%). Non-hematological adverse events were mainly gastrointestinal events and hand-foot syndrome, which affected 16% of patients. Grade 3/4 non-hematological events were infrequent.

CONCLUSION

The combination of capecitabine plus gemcitabine appears to be active and well tolerated as first-line treatment in patients with advanced/metastatic pancreatic cancer.

Capecitabine and oxaliplatin for advanced esophagogastric cancer

BACKGROUND

We evaluated capecitabine (an oral fluoropyrimidine) and oxaliplatin (a platinum compound) as alternatives to infused fluorouracil and cisplatin, respectively, for untreated advanced esophagogastric cancer.

METHODS

In a two-by-two design, we randomly assigned 1002 patients to receive triplet therapy with epirubicin and cisplatin plus either fluorouracil (ECF) or capecitabine (ECX) or triplet therapy with epirubicin and oxaliplatin plus either fluorouracil (EOF) or capecitabine (EOX). The primary end point was noninferiority in overall survival for the triplet therapies containing capecitabine as compared with fluorouracil and for those containing oxaliplatin as compared with cisplatin.

RESULTS

For the capecitabine-fluorouracil comparison, the hazard ratio for death in the capecitabine group was 0.86 (95% confidence interval [CI], 0.80 to 0.99); for the oxaliplatin-cisplatin comparison, the hazard ratio for the oxaliplatin group was 0.92 (95% CI, 0.80 to 1.10). The upper limit of the confidence intervals for both hazard ratios excluded the predefined noninferiority margin of 1.23. Median survival times in the ECF, ECX, EOF, and EOX groups were 9.9 months, 9.9 months, 9.3 months, and 11.2 months, respectively; survival rates at 1 year were 37.7%, 40.8%, 40.4%, and 46.8%, respectively. In the secondary analysis, overall survival was longer with EOX than with ECF, with a hazard ratio for death of 0.80 in the EOX group (95% CI, 0.66 to 0.97; P=0.02). Progression-free survival and response rates did not differ significantly among the regimens. Toxic effects of capecitabine and fluorouracil were similar. As compared with cisplatin, oxaliplatin was associated with lower incidences of grade 3 or 4 neutropenia, alopecia, renal toxicity, and thromboembolism but with slightly higher incidences of grade 3 or 4 diarrhea and neuropathy.

CONCLUSIONS

Capecitabine and oxaliplatin are as effective as fluorouracil and cisplatin, respectively, in patients with previously untreated esophagogastric cancer. (Current Controlled Trials number, ISRCTN51678883 [controlled-trials.com].).

Capecitabine as salvage treatment in relapsed nasopharyngeal carcinoma: a phase II study

PURPOSE

To evaluate the efficacy of capecitabine (Xeloda) as rescue treatment (2nd, 3rd and 4th line) in patients with relapsed nasopharyngeal carcinoma (NPC) in a phase II study.

PATIENTS AND METHODS

Between 5/2002-11/2005, 23 relapsed NPC patients (17 locoregional relapse, 3 metastatic, 3 locoregional + metastatic) received capecitabine 2500 mg/m(2)/d, days 1-14 every 3 weeks, until progression or for a maximum of 6 cycles.

PATIENT CHARACTERISTICS

23 patients (14 men, 9 women) with median age 46 years (range 15-59); ECOG performance status 1 n=21, 2 n=2; histology: undifferentiated carcinoma (WHO type III) n=21, non-keratinizing epidermoid carcinoma (WHO type II), n=2. Capecitabine was given as 2nd--(13 patients), 3rd--(7 patients), and 4th--(3 patients) line chemotherapy. Previous chemotherapy regimes were epirubicin + cisplatin, paclitaxel + carboplatin, paclitaxel + 5-fluorouracil and leucovorin (5-FU/LV) or methotrexate. 104 cycles were given (median 5, range 2-6). Two (9%) patients achieved complete response (CR); 9 (39%) partial response (PR); 9 (39%) stable disease (SD) and 3 (13%) progressed (PD). Toxicity was mild without toxic deaths or grade 4 toxicities. The most frequent toxicities (grades 1-3) were anemia (38%), hand-foot syndrome (23%), leukopenia (13%) and diarrhea (7%). Median follow-up was 10 months (range 2-44). Median overall survival was not reached at 18 months and actuarial one-year survival was 62% (95% confidence interval/CI: 41-80). Median progression-free survival was 14 months.

CONCLUSION

Capecitabine is active in relapsed NPC patients, achieving 48% objective responses, with mild toxicity. It is an attractive therapy to be administered in an outpatient setting.