Prevalence of Malnutrition Among Gastric Cancer Patients Undergoing Gastrectomy and Optimal Preoperative Nutritional Support for Preventing Surgical Site Infections

BACKGROUND

Malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. The aim of this study was to investigate the prevalence of malnutrition and identify the optimal preoperative nutritional support for preventing postoperative surgical site infections (SSIs) in malnourished gastric cancer patients undergoing gastrectomy.

METHODS

We analyzed 800 patients with gastric cancer who underwent gastrectomy. Nutritional risk factors included weight loss >10 % within 6 months, body mass index <18.5 kg/m(2), Subjective Global Assessment Grade C, and serum albumin <3.0 g/dl. Adequate energy intake was defined as receiving ≥25 kcal/kg ideal body weight per day. Optimal nutritional support was examined in terms of both duration and calorie intake.

RESULTS

Overall, 152 patients (19.0 %) were classified as malnourished. The incidence of SSIs was significantly higher in malnourished patients than in well-nourished patients (35.5 vs. 14.0 %; p < 0.0001). The incidence of SSIs in malnourished patients was significantly lower in the well-supported group receiving adequate energy support for at least 10 days than in the poorly-supported group, which received inadequate or no energy support or adequate energy support for <10 days (17.0 vs. 45.4 %; p = 0.0006). In multivariate analysis, well-managed nutritional support was identified as an independent factor associated with fewer SSIs (odds ratio 0.14; 95 % confidence interval 0.05-0.37; p = 0.0002).

CONCLUSIONS

Malnutrition, a risk factor for SSI, was prevalent in gastric cancer patients preoperatively. Well-managed preoperative nutritional support decreased the incidence of postoperative SSIs in malnourished patients.

A randomized phase II study of the clinical effects of ultrasonically activated coagulating shears (Harmonic scalpel) in open gastrectomy for gastric cancer

PURPOSE

The Harmonic Ace ultrasonic scalpel has been popular in abdominal surgery; however, only a few clinical studies have evaluated the efficacy of this device in radical open gastrectomy for gastric cancer.

METHODS

The present study was designed as a multicenter, prospective, randomized, controlled trial. Patients with resectable gastric cancer were randomly assigned to gastrectomy using the Harmonic scalpel or conventional monopolar electrosurgery.

RESULTS

A total of 248 patients were enrolled, and 123 patients were included in the Harmonic group and 114 patients were included in the conventional group. The demographics of the patients were well balanced between the groups. There was no significant difference in the length of the operation from skin incision to resection of the gastric specimen (141 ± 36 min in the Harmonic group vs. 147 ± 13 min in the conventional group; p = 0.276) nor in the amount of blood lost (365 ± 293 vs. 336 ± 272 mL; p = 0.434). There was also no significant difference in the incidence of surgical complications or the post-surgical hospital stay between the groups.

CONCLUSION

The Harmonic scalpel procedure was not superior to the conventional monopolar electrosurgery with regard to reducing the length of the operation, blood loss, postoperative complications, or postoperative hospital stay in radical open gastrectomy.

Randomised phase III trial of second-line irinotecan plus cisplatin versus irinotecan alone in patients with advanced gastric cancer refractory to S-1 monotherapy: TRICS trial

AIM

The optimal second-line regimen for treating advanced gastric cancer (AGC) remains unclear. While irinotecan (CPT-11) plus cisplatin (CDDP) combination therapy and CPT-11 monotherapy have been explored in the second-line setting, the superiority of second-line platinum-based therapies for AGC patients initially treated with S-1 monotherapy has not yet been evaluated; therefore, we aimed to examine the survival benefit of CPT-11/CDDP combination over CPT-11 monotherapy.

METHODS

AGC patients showing progression after S-1 monotherapy for advanced cancer or recurrence within 6 months after completion of S-1 adjuvant therapy were randomly allocated to CPT-11/CDDP (CPT-11, 60 mg/m(2); CDDP, 30 mg/m(2), q2w) or CPT-11 (150 mg/m(2), q2w).

RESULTS

Sixty-eight advanced and 95 recurrent cases were evaluated. The median overall survivals were 13.9 (95% confidence interval [CI]: 10.8-17.6) and 12.7 (95% CI: 10.3-17.2) months for CPT-11/CDDP and CPT-11, respectively (hazard ratio: 0.834; 95% CI: 0.596-1.167, P = 0.288). No significant differences were observed in the secondary end-points, including progression-free survival (4.6 [95% CI: 3.4-5.9] versus 4.1 [95% CI: 3.3-4.9]months) and response rate (16.9% [95% CI: 8.8-28.3] versus 15.4% [95% CI: 7.6-26.5]). The incidences of grade 3-4 anaemia (16% versus 4%) and elevated serum lactate dehydrogenase levels (5% versus 0%) were higher for CPT-11/CDDP than for CPT-11. Exploratory subgroup analysis revealed that CPT-11/CDDP was significantly more effective for intestinal-type AGC, compared with CPT-11 (overall survival: 15.8 versus 14.0 months; P = 0.019).

CONCLUSION

No survival benefit was observed upon adding CDDP to CPT-11 after S-1 monotherapy failure.

C-reactive protein on postoperative day 3 as a predictor of infectious complications following gastric cancer resection

26

Background: Postoperative infectious complications (PICs) after gastric cancer resection remain a clinically relevant problem. Early detection of PICs, before critical illness develops, may be of considerable clinical benefit. The aims of this study were to investigate the predictive factors for PICs and to define the clinical parameters for their early detection in patients with gastric cancer resection. Methods: Clinical data of 417 consecutive patients undergoing elective gastrectomy for primary gastric cancer between 2009 and 2012 were retrospectively analyzed. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Univariate and multivariate logistic regression analyses identified clinical factors predicting PICs of grade III or more according to the Clavien-Dindo classification. Results: Forty-four patients developed PICs of grade ≥ III (10.6%, 95% confidence interval [CI] 7.6–13.5%). As a systemic inflammatory marker, C-reactive protein (CRP) on postoperative day (POD) 3 had superior diagnostic accuracy for PICs (AUC 0.802, 95% CI 0.735–0.870) with a calculated cut-off value of 17.7 mg/dl, yielding a sensitivity of 0.66 (95% CI 0.524–0.774) and a specificity of 0.84 (95% CI 0.821–0.850). Multivariate analysis identified CRP on POD 3 of 17.7 mg/dl or greater (odds ratio [OR] 8.094, 95% CI 3.568–19.342) as well as clinical stage ≥ II (OR 4.445, 95% CI 1.478–15.881) and operation time ≥ 250 min (OR 3.638, 95% CI 1.449–10.137) as significant predictive factors for PICs after gastrectomy. Conclusions: Elevated CRP levels on POD 3 will help physicians predict postoperative course and facilitate decision-making regarding the prompt, comprehensive clinical search and therapeutic approach for PICs.

A phase II trial of capecitabine plus cisplatin (XP) for patients with advanced gastric cancer who relapsed after S-1 adjuvant therapy, XP after TS-1 adjuvant failure (XParTS)

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Background: For gastric cancer, standard regimens including S-1 for adjuvant and first-line chemotherapy have been established in Japan, while for early relapse after adjuvant therapy there is no standard treatment. In our retrospective analysis, relapse-free interval of less than 6 months was associated with poor progression-free survival (PFS) and overall survival (OS). To evaluate the efficacy and safety of capecitabine plus cisplatin (XP) treatment, for patients with advanced gastric cancer who relapsed within 6 months after S-1 adjuvant therapy, we conducted a multicenter phase II trial in Japan (NCT Identifier: NCT01412294). Methods: Patients who had received adjuvant chemotherapy for gastric cancer including S-1 for more than 12 weeks, thereafter relapsed within 6 months, 20–74 years of age and HER2- negative, were assigned to receive capecitabine 1000 mg/m2 bid for 14 days plus cisplatin 80 mg/m2 (day 1) every 3-week. The primary endpoint was PFS and the secondary endpoints were OS, time to treatment failure, overall response rate (ORR) and safety. Planned sample size was 40 according to median PFS threshold of 2 months. Results: From June 2011 to April 2014, 40 patients were assigned. Median age was 64, 32 males (80%); adjuvant chemotherapy: regimen, S-1 monotherapy (n=34, 85%), and median number of course was 7.0 (3-18). In 40 patients median PFS was 20 weeks (95%CI, 17-24), which was longer than protocol-specified threshold of 2 months. Median OS was 77 weeks (95%CI, 34-NE), ORR was 8/40 (22% including 12 NE cases; 95%CI, 44-74). Most common grade ≥3 adverse events (AEs) were neutropenia (23%), anemia (18%), hypercreatinine (18%), fatigue (13%), diarrhea (7.5%), and anorexia (7.5%). Conclusions: XP was safe and effective for those patients with relatively poor prognosis after S-1 adjuvant failure. Since profile of S-1 and capecitabine was different, XP can be recommended rather than S-1 plus cisplatin, Japanese standard first- line regimen. Clinical trial information: NCT01412294.

Randomized controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric carcinoma (JCOG0110): Final survival analysis

103

Background: We conducted a RCT to compare splenectomy and spleen preservation in total gastrectomy and reported higher morbidity and larger blood loss in splenectomy at 2010 ASCO Annual Meeting. Survival analysis after 5-year follow-up is now complete. Methods: Proximal gastric adenocarcinoma of T2-4/N0-2/M0 not invading the greater curvature was eligible. During operation surgeons confirmed that R0 resection was possible with negative lavage cytology, and the patient was randomized into splenectomy or spleen-preserving arm. The primary endpoint was OS. The trial was designed to confirm non-inferiority of spleen preservation to splenectomy in OS with a non-inferiority margin of the hazard ratio (HR) as 1.21. The planned sample size was 500 pts with a power of 70% and a one-sided alpha of 5%. Results: Between June 2002 and March 2009, 505 patients (splenectomy 254, spleen-preservation 251) were enrolled from 36 institutions. The first 319 patients were treated without adjuvant therapy by protocol, but after the S-1 adjuvant effect was established in 2006, patients with pathological stage II and III tumors received adjuvant S-1 by amended protocol. The 5-year survivals were 75.1% and 76.4% in the splenectomy and spleen-preserving arms, respectively. The HR was 0.88 [90.7% CI 0.67-1.16] (<1.21); thus the non-inferiority of spleen preservation was confirmed (p=0.025). The 5-year RFS was 68.4% in splenectomy arm and 70.5% in spleen-preserving arm. The HR was 0.87 [95% CI 0.65-1.17]. Subset analyses showed slightly better survival of spleen preservation in patients having deeper tumors (T3/T4), lymph node metastases, tumors located mainly in the middle stomach, and in those enrolled in the first study period of no-adjuvant protocol. Conclusions: This is the largest RCT of splenectomy in gastric cancer, and demonstrated significant non-inferiority of spleen preservation for the first time. In total gastrectomy for proximal gastric cancer which does not invade the greater curvature, prophylactic splenectomy should be avoided not only for operative safety but also for survival benefit. Clinical trial information: NCT00112099.

Effect of renal function on continuation of S-1 adjuvant chemotherapy in gastric cancer patients

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Background: The results of ACTS-GC study showed that postoperative adjuvant chemotherapy with S-1 is the standard treatment for patients with stage II and stage III gastric cancer (GC) in Japan. In addition, completion of 12 months of S-1 treatment and a high relative performance (RP) value were reported to be related to improved survival. The plasma 5-fluorouracil concentration in patients receiving S-1 treatment is known to be significantly higher in patients with 50 ≤ Ccr < 80 mL/ min than in those with Ccr ≥ 80 mL/ min. The aim of this study was to investigate the association of the dose of S-1 based on renal function and compliance with S-1 treatment. Methods: This study is retrospective cohort study, included GC patients who were administered S-1 adjuvant chemotherapy at the Osaka National Hospital in Japan between August 2006 and August 2013. Cohort A comprised patients with Ccr ≥ 80 mL/min, those with 50 ≤ Ccr < 80 mL/min and dose reduction by one level, and those with Ccr < 50 mL/min and dose reduction by two levels. Cohort B included patients with Ccr < 50mL and dose reduction by one level. We compared the completion rate of 12 months of S-1 treatment and the RP value between cohorts A and B. Results: In total, 103 patients were included in this study: cohort A included 53 patients, and cohort B included 50 patients. The completion rate of 12 months of S-1 treatment was significantly higher in cohort A at 83% than in cohort B at 56% (OR: 3.8 [95% CI: 1.6–9.9], p = 0.003). The median RP value was significantly higher in cohort A at 93.8% than in cohort B at 74% (p = 0.007). In the subgroup analysis, no difference was found in the completion rate among patients with S-1 dose < 65 mg/m². Conclusions: Renal function was found to be an important factor for compliance with S-1 treatment as adjuvant chemotherapy for GC. The results of the present study suggest the need for dose reduction by one level in patients with Ccr < 80 mL/min.

A randomized 2X2 phase II trial comparing two and four courses of S-1/cisplatin (SC) and paclitaxel/cisplatin (PC) as neoadjuvant chemotherapy for locally resectable advanced gastric cancer: Survival results of COMPASS

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Background: The prognosis for stage III gastric cancer is not satisfactory even by S-1 adjuvant chemotherapy. Neoadjuvant chemotherapy is a promising approach but its optimal duration and regimen have not been established yet. Methods: We conducted a randomized phase II trial to compare two or four courses and regimen of SC or PC using a two-by-two factorial design.Key eligibility criteria was (i) T2-3/N+ or T4aN0 in case of schirrhous or junctional tumors, T2-3 with N+ to the major branched artery, T4aN+, T4b, para-aortic nodal metastases, or resectable minimal peritoneal metastases confirmed by laparoscopy and (ii) no other distant metastasis. Patients 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) as neoadjuvant chemotherapy. Then, patients received D2 gastrectomy with curative intent. The primary endpoint was 3-year overall survival. The planned sample size was 80 eligible patients in total so that the treatment group with the superior observed 3-year OS rate by 10% increase was to be selected with a probability of 88% or higher. Results: Eighty-three patients were assigned to SC (n=41, two courses in 21 and four courses in 20) and PC (n=42, two courses in 21 and four courses in 21). Pathological response rate was 42% (17/41) in SC and 33% (14/42) in PC, and 36% (15/42) in the two courses and 39% (16/41) in the four courses. Pathological CR was 0% (0/42) in the two courses and 10% (4/41) in the four courses. Grade 3/4 adverse events by chemotherapy and grade 3/4 surgical morbidities defined by Clavien-Dindo classification were both less than 10% in each arm without treatment-related death. The 3-year OS was 60.9% (95% CI, 44.3-73.9%) in SC and 64.3% (95% CI, 47.9-76.7%) in PC, and 64.3% (95% CI, 47.9-76.7%) in the two courses and 61.0% (95% CI, 44.4-74.0%) in the four courses. Conclusions: Two courses of SC as neoadjuvant chemotherapy is recommended for a test arm of future phase III study for patients with locally resectable advanced gastric cancer. Clinical trial information: UMIN000002595.

Optimal indications for palliative chemotherapy in elderly patients with metastatic or recurrent gastric cancer

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Background: Gastric cancer is the second causes of cancer-related deaths in the world and its incidence of advanced gastric cancer (AGC) in the elderly is increasing as a result of increased life expectancy. However, elderly patients have been underrepresented in many kinds of chemotherapy clinical trials. Therefore it is difficult to evaluate the efficacy and safety of chemotherapy for elderly patients and select the appropriate patients aged 70 years or older who are likely to benefit from the chemotherapy. Methods: There were 265 patients with primary unresectable or recurrent gastric cancer treated at our institution between April 2007 and March 2014. Of all, 90 patients aged 70 years or older were retrospectively identified. We evaluated the efficacy of the chemotherapy and prognostic significance of clinico-pathologic factors to identify the optimal indications for chemotherapy. Univariate and multivariate analyses were perfomed on the base-line characteristics such as patient’s performance status (PS), gender, chemotherapy regimens, history of gastrectomy, presense of co-morbidity, serum LDH level, serum C reactive protein, and nutritional status, at the initiation of the first-line chemotherapy. Results: The median overall survival time (OS) was 343 days and the median TTF on first-line chemotherapy was 111 days. The toxicity was mild and tolerable. There were no significant difference in overall survival between patients receiving monotherapy and combination therapy. On multivariate analyses, PS 1 or 2 (hazard ratio (HR), 1.883; 95% confidence interval (CI), 1.047–3.390), presence of primary tumor (HR, 1.916; 95% CI, 1.063–3.448) at the initiation of the first- line chemotherapy were identified as significant independent poor prognostic factors for overall survival. Especially in patients aged 75 years or older, only PS was an independent prognostic factor for OS (HR, 3.703; 95% CI, 1.314–9.900). Conclusions: Analysis of our results shows that patients aged 70 years or older with good performance status and absence of primary tumor might achieve clinical benefit from chemotherapy.

Phase I/II trial of 2-weekly docetaxel combined with cisplatin plus fluorouracil in metastatic esophageal cancer (JCOG0807)

We carried out a phase I/II trial of adding 2-weekly docetaxel to cisplatin plus fluorouracil (CF) therapy (2-weekly DCF regimen) in esophageal cancer patients to investigate its safety and antimetastatic activity. Patients received 2-weekly docetaxel (30 mg/m² [dose level (DL)1] or 40 mg/m² [DL2] with a 3 + 3 design in phase I, on days 1 and 15) in combination with fixed-dose CF (80 mg/m² cisplatin, day 1; 800 mg/m² fluorouracil, days 1–5) repeated every 4 weeks. The primary endpoint was dose-limiting toxicity (DLT) in phase I and central peer review-based response rate in phase II. At least 22 responders among 50 patients were required to satisfy the primary endpoint with a threshold of 35%. Sixty-two patients were enrolled in phase I and II. In phase I, 10 patients were enrolled with DLT of 0/3 at DL1 and 2/7 in DL2. Considering DLT and treatment compliance, the recommended phase II dose was determined as DL1. In phase II, the response rate was 62% (P < 0.0001; 95% confidence interval, 48–75%); median overall survival and progression-free survival were 11.1 and 5.8 months, respectively. Common grade 3/4 adverse events were neutropenia (25%), anemia (36%), hyponatremia (29%), anorexia (24%), and nausea (11%). No febrile neutropenia was observed. Pneumonitis caused treatment-related death in one patient. The 2-weekly DCF regimen showed promising antimetastatic activity and tolerability. A phase III study comparing this regimen with CF therapy is planned by the Japan Clinical Oncology Group. This study was registered at the UMIN Clinical Trials Registry as UMIN 000001737.

[A case of advanced gastric cancer successfully treated with second-line chemotherapy followed by curative conversion gastrectomy]

We report a case of advanced gastric cancer that was successfully treated with second-line chemotherapy followed by curative conversion gastrectomy. The patient was a 71-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the lower third of the stomach. Abdominal computed tomography (CT) revealed multiple lymph node metastases and metastasis to the peritoneal cavity. The clinical diagnosis was cT4N3aP1H0M1(LYM), cStage IV. The patient was treated with S-1 (80 mg/m² on days 1-28, every 6 weeks [q6w]) in November 2009. Temporarily, both the size of the primary lesion and the swelling of the lymph nodes were markedly reduced. However, after 10 courses of chemotherapy, the primary lesion was found to be enlarged again. The patient was then treated with S-1(80 mg/m², on days 1-14, every 6 weeks [q3w]) plus CPT- 11 (150 mg/m² on day 1, q3w) as the second-line chemotherapy. After 8 courses, an abdominal CT showed no peritoneal or lymph node metastases, but gastric endoscopy revealed the presence of a residual primary lesion. After staging laparoscopy, distal gastrectomy with D2 lymphadenectomy was performed. The histological diagnosis was ypT3 (SS) N1M0, Stage IIB. Analysis of the histological features of the primary tumor and peritoneal metastases resulted in their classifications as Grade 1a and Grade 3, respectively. After surgery, there were no serious adverse events. The patient has been in good health without recurrence for over 3 years after surgery.

[A case of metachronous triple cancer treated with a multimodal approach including surgical resection]

We report a patient with metachronous triple cancer of the hypopharynx, esophagus, and tongue. A 37-year-old man with hypopharyngeal cancer underwent hypopharyngolaryngectomy and cervical lymphadenectomy in 1999. Submental lymphadenectomy following adjuvant radiotherapy was performed for lymph node recurrence in 2000. The patient then underwent esophagectomy for esophageal cancer in 2004. Subsequently, the patient underwent 2 partial resections and 1 subtotal resection of the tongue for tongue cancer in 2005, 2007, and 2008, respectively. The pathological findings for each cancer were squamous cell carcinoma. Two rounds of radiotherapy were performed for bone metastasis of the esophageal cancer and for the local recurrence of the tongue cancer. A total of 7 lines of chemotherapy, including superselective arterial infusion chemotherapy, were administered to treat the recurrences. The patient died in 2013, but he showed long-term survival of 13 years from the first operation owing to the multimodality treatment.

[A case of HER2-positive advanced gastric cancer with extensive lymph node metastasis treated via chemotherapy with a trastuzumab-containing regimen followed by conversion surgery]

A 62-year-old man presented with type 3 gastric cancer (tub1, HER2 positive) in the cardia, with 10-cm direct invasion into the lower esophagus, and extensive lymph node metastasis (Virchow and paraaortic nodes). Trastuzumab (Her), in the XP regimen (capecitabine and cisplatin [CDDP] plus Her; Xeloda®: 2,000 mg/m² on day 1-14, CDDP: 80 mg/m² on day 1, Her: 8(6) mg/kg on day 1), was administered every 3 weeks and repeated for 6 courses. After administering 6 courses of the XP plus Her regimen, without severe adverse events in the patient, computed tomography (CT) revealed shrinkage of both the main tumor and the metastatic sites, by 51%. Esophagectomy and proximal gastrectomy with 3-field lymphadenectomy and gastric tube reconstruction was performed via right thoracotomy and laparotomy (R0). However, Grade 3 pneumonia occurred postoperatively, and the patient was discharged on day 67 after surgery. After treatment, the tumor was histologically evaluated as Grade 1b gastric cancer, and remnant cancer cells also expressed HER2. The patient was too frail to receive adjuvant chemotherapy, and he died of pneumonia 11 months after surgery, without obvious relapse. Perioperative chemotherapy with a regimen containing Her has a possible role in treating advanced HER2-positive gastric cancer. Multiple invasive conversion surgeries might decrease the feasibility of adjuvant chemotherapy and worsen the prognosis.

[Chemotherapy for gastric cancer patients over 75 years of age]

PURPOSE

The efficacy of chemotherapy for advanced or recurrent gastric cancer in patients who were aged over 75 years was investigated.

MATERIALS AND METHODS

Progression free survival (PFS) and overall survival (OS) of advanced gastric cancer patients who received first-line chemotherapy with TS-1 plus cisplatin or TS-1 in our hospital from 2009 to 2013 were determined. The patients were divided into two groups: H and L. H group patients were aged over 75 years, and L group patients were aged less than 75 years.

RESULTS

Median PFS and median OS of patients in the H and L groups who received TS-1 plus cisplatin chemotherapy were not significantly different. PFS was 77[range, 13-211] days and 139[range, 53-211]days for the H and L groups, respectively(p=0.141), while OS was 523[range, 22-1,030] days and 402 [range, 322-623] days, respectively (p=0.620). Similarly, median PFS and median OS of patients who received TS-1 chemotherapy were not significantly different between the H and L groups. PFS was 103[range, 51-156]days and 152.5[range, 85-278]days for the H and L groups, respectively (p=0.230), while OS was 414 [range, 224-714]days and 605[range, 452-1,077] days, respectively ( p=0.1337).

CONCLUSION

PFS and OS were not significantly different in younger patients with advanced gastric cancer who received TS-1 plus cisplatin or TS-1 chemotherapy compared to that in similarly treated elderly patients with advanced gastric cancer.

Optimal treatment change criteria for advanced gastric cancer with non-measurable peritoneal metastasis: symptom/tumor marker-based versus CT-based

BACKGROUND

For advanced gastric cancer (AGC) with peritoneal metastasis, decision-making regarding treatment change is often challenging because of the absence of measurable lesions. We attempted to clarify which criterion for treatment change contributes more to longer survival.

PATIENTS AND METHODS

We retrospectively reviewed 50 patients with non-measurable peritoneal metastasis in whom first-line chemotherapy for AGC was changed based on aggravated clinical symptoms or tumor markers (TMs), or radiologically-confirmed disease progression. Prognostic factors for overall survival (OS) were investigated.

RESULTS

Patients whose treatment was changed based on symptoms/TMs had significantly longer OS than patients with computed tomographic-based treatment change (p=0.04). On multivariate analysis, treatment change based on symptoms/TMs was identified as an independent prognostic factor for favorable OS (hazard ratio=0.321, 95% confidence interval=0.154-0.668, p=0.002).

CONCLUSION

The present study suggests that aggravated clinical symptoms/elevated TMs could be a sensitive predictor for disease progression in patients with AGC with non-measurable peritoneal metastasis.

[Tolerability of XELOX in postoperative adjuvant chemotherapy for colorectal cancer]

A regimen of capecitabine plus oxaliplatin(XELOX)has become one of the standard postoperative adjuvant chemotherapies for colon cancer. However, few tolerability studies have been conducted in Japan. In this study, we retrospectively examined treatment continuation and the adverse events that occurred during 8 courses of postoperative adjuvant chemotherapy with XELOX in 21 patients with colorectal cancer who had undergone curative resection. The completion rate for 8 courses of treatment with XELOX was 71.4%, while the median relative dose intensities of capecitabine and oxaliplatin were 85.0% and 75.0%, respectively. Although the incidence of subsequent Grade 3 or higher hand-foot syndrome was 14.3%, the rate of peripheral neuropathy was 0%. Our hospital had a high rate of XELOX treatment continuation, suggesting that XELOX adjuvant chemotherapy would be well tolerated in clinical practice as well.

Randomized controlled trial of the LigaSure vessel sealing system versus conventional open gastrectomy for gastric cancer

PURPOSE

LigaSure, a bipolar electronic vessel sealing system, has become popular in abdominal surgery but few clinical studies have been conducted to evaluate its effectiveness in radical gastrectomy for gastric cancer.

METHODS

In this multicenter, prospective, randomized controlled trial, patients with curative gastric cancer were randomly assigned to undergo gastrectomy either with LigaSure or a conventional technique.

RESULTS

Of the 160 patients enrolled, 80 were randomized to the LigaSure group and 78 to the conventional group. Patient characteristics were well balanced in the two groups. There were no significant differences between the LigaSure and conventional groups in blood loss (288 vs. 260 ml, respectively; P = 0.748) or operative time (223 and 225 min, respectively; P = 0.368); nor in the incidence of surgical complications or duration of postoperative hospital stay. In a subgroup analysis of patients who underwent gastrectomy that preserved the distal part of the greater omentum, the use of LigaSure significantly reduced blood loss (179 vs. 245 ml; P = 0.033), and the duration of the operation (195 vs. 221 min; P = 0.039).

CONCLUSIONS

LigaSure did not contribute to reducing intraoperative blood loss, operative time, or other adverse surgical outcomes. The usefulness of the device may be limited to a specific part of the surgical procedure in open gastrectomy.

Randomized phase II trial of S-1 plus irinotecan versus S-1 plus paclitaxel as first-line treatment for advanced gastric cancer (OGSG0402)

BACKGROUND

S-1-based regimens are commonly used for advanced gastric cancer (AGC) in Japan. We performed this trial to evaluate the efficacy and safety of S-1 plus irinotecan (SIri) and S-1 plus paclitaxel (SPac) as first-line treatments for AGC in order to select the optimal regimen for a subsequent phase III trial.

PATIENTS AND METHODS

Patients with previously untreated, locally advanced or metastatic measurable gastric adenocarcinoma were randomly assigned to receive SIri (irinotecan 80 mg/m(2) was administered intravenously (i.v.) on day 1 and 15, while 40 mg/m(2) S-1 was orally administered twice daily for three weeks from days 1-21 followed by a two-week pause) or SPac (paclitaxel 50 mg/m(2) was administered i.v. on day 1 and 8, while 40 mg/m(2) S-1 was orally administered twice daily for two weeks from day 1-14 followed by a one-week pause) regimen. The primary end-point was the overall response rate (ORR), and the secondary end-points were progression-free survival (PFS), overall survival (OS), and toxicity.

RESULTS

A total of 102 patients were enrolled. The ORR was 33.3% for SIri and 31.4% for SPac, which did not achieved the predicted ORR in either group. PFS and OS were 5.7 and 12.4 months for SIri, 4.6 and 11.9 months for SPac respectively. No treatment-related deaths occurred during the study. Although grade 3/4 neutropenia and anemia were more frequent in the Siri group, both regimens were well-tolerated.

CONCLUSION

Both regimens were well-tolerated in patients with AGC, but we conclude that neither regimen was optimal for a phase III trial.

Pretreatment skeletal muscle depletion as an adverse prognostic factor in metastatic gastric cancer

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Background: Body composition has emerged as an important prognostic factor in cancer patients. Especially, skeletal mass depletion has been associated with poor performance status, toxicity of chemotherapy and shortened survival in cancer patients. However, the impact of pre-treatment skeletal muscle index on survival or toxicity in metastatic gastric cancer patients remains uncertain. Methods: In this retrospective study, we reviewed 98 metastatic gastric cancer (mGC) patients who received S-1 based combination chemotherapy as first-line treatment from April 2006 to March 2013. Pre-treatment skeletal muscle mass was quantified by CT cross sectional area at the third lumbar vertebrae and evaluated as lumbar skeletal muscle index (SMI) (cm2/m2) after normalization for stature (m2). Patients were categorized into 2 groups depending on initial SMI: 35 patients with SMI ≤ 40 and 63 patients with SMI > 40. Results: Median overall survival was significantly shorter in the SMI ≤ 40 group than in the SMI >40 group (439 days versus 565 days; p= 0.03). Progression free survival was also better in the SMI> 40 group without statistical significance (175 days versus 151 days; p= 0.17). Toxicity (grade 3 or 4) was more common in the SMI ≤ 40 group than in the SMI >40 group. (41.1% versus 11.1%; p=0.001). In multivariate analysis, performance status of 2 (HR 4.711, 95%CI 1.065 to 20.832, p=0.04), presence of primary tumor (HR 2.322, 95%CI 1.007 to 5.357, p=0.04) and pre-treatment SMI (HR 2.525, 95%CI 1.145 to 5.568, p=0.02) were independent prognostic factors for OS. Conclusions: The present study suggests that skeletal muscle depletion at the initiation of first-line chemotherapy might be an independent prognostic factor for mGC patients.

Total bilirubin as a predictive marker for irinotecan-induced toxicity in patients with gastrointestinal cancer

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Background: Irinotecan (CPT-11) is widely used for the treatment of patients with gastrointestinal cancer. However, CPT-11 can cause severe neutropenia and diarrhea.It has been reported that the AUC of SN-38, an active metabolite of CPT-11, correlated with Pre-treatment serum total bilirubin level (PTB), but there is no criteria of dose setting based on the PTB. Therefore, we retrospectively searched the PTB which can serve as an indicator for dose setting of CPT-11. Methods: We investigated the incidence of neutropenia and diarrhea at the first 28 days in patients with gastrointestinal cancer who were administered CPT-11 alone in Osaka National Hospital from June 2006 to July 2013. Correlation between PTB and grade 3-4 neutropenia or diarrhea were assessed. When toxicity of correlation exists, ROC (receiver operating characteristic) analysis was conducted to explore the cut-off value of the PTB. In addition, the incidence of febrile neutropenia (FN) in the cut-off value was compared. Results: 87 patients were analyzed. Of these, 65 were gastric cancer, 22 were colorectal cancer. Although PTB was significantly higher in patients who experienced grade 3-4 neutropenia than those who didn’t (p<0.001), PTB was not associated with grade 3-4 diarrhea. As the results of ROC analysis, cut-off value of PTB associated with grade 3-4 neutropenia was determined to 0.8 mg/dL. The incidence of FN was significantly higher in 20% of patients with PTB ≥ 0.8 mg/dL compared with 1.6% of patients with PTB < 0.8 mg/dL (OR: 15.5, p=0.01). On the other hand, in subgroup analysis showed no difference in the incidence of FN and neutropenia in patients whose dose was less than 100 mg/m². Conclusions: PTB was a predictive marker for CPT-11-induced severe neutropenia and FN. Results of this study suggested needs of dose reduction to less than 100 mg/m2 in patients with PTB ≥ 0.8mg/dL.

Skeletal muscle loss after total gastrectomy, exacerbated by adjuvant chemotherapy

168

Background: Skeletal muscle loss is associated with physical disability, nosocomial infections, postoperative complications, and decreased survival. Preventing the loss of skeletal muscle mass after gastrectomy may lead to improved outcomes. The aims of this study were to assess changes in skeletal muscle mass after total gastrectomy (TG) and to clarify the clinical factors affecting significant loss of skeletal muscle after TG. Methods: One hundred and two patients undergoing TG for primary gastric cancer underwent abdominal computed tomography (CT) before and 1 year after TG to precisely quantify postoperative changes in skeletal muscle and adipose tissue. Univariate and multivariate logistic regression analyses identified clinical factors contributing to significant loss of skeletal muscle after TG. Results: At 1 year after TG, the mass of both skeletal muscle and adipose tissue was reduced by 6.20±6.80% and 65.8±36.1% of the preoperative values, respectively, and 26 patients (25.5%) showed a significant loss of skeletal muscle of more than 10%. Adjuvant chemotherapy with S-1 for ≥6 months (hazard ratio 26.75, 95% confidence interval 3.511 to 203.9) was identified as the single independent risk factor for a significant loss of skeletal muscle. Conclusions: Skeletal muscle loss was exacerbated by extended adjuvant chemotherapy after TG. Further research should identify appropriate nutritional interventions for maintaining skeletal muscle mass and leading to improved outcomes.

Randomized, open-label, phase III study comparing irinotecan with paclitaxel in patients with advanced gastric cancer without severe peritoneal metastasis after failure of prior combination chemotherapy using fluoropyrimidine plus platinum: WJOG 4007 trial

PURPOSE

This phase III study compared treatment with weekly paclitaxel and biweekly irinotecan in patients with advanced gastric cancer refractory to treatment with fluoropyrimidine plus platinum.

PATIENTS AND METHODS

Patients were randomly assigned to receive either paclitaxel (80 mg/m(2) on days 1, 8, and 15, every 4 weeks) or irinotecan (150 mg/m(2) on days 1 and 15, every 4 weeks). Primary end point was overall survival (OS), and secondary end points were progression-free survival (PFS), response rate, adverse events, and proportion of patients who received third-line chemotherapy.

RESULTS

Of 223 patients, 219 were eligible for analysis. Median OS was 9.5 months in 108 patients allocated to the paclitaxel group and 8.4 months in 111 patients allocated to the irinotecan group (hazard ratio [HR], 1.13; 95% CI, 0.86 to 1.49; P = .38). Median PFS was 3.6 months in the paclitaxel group and 2.3 months in the irinotecan group (HR, 1.14; 95% CI, 0.88 to 1.49; P = .33). Response rate was 20.9% in the paclitaxel group and 13.6% in the irinotecan group (P = .24). Common grade 3 to 4 adverse events were neutropenia (paclitaxel group, 28.7%; irinotecan group, 39.1%), anemia (21.3%; 30.0%), and anorexia (7.4%; 17.3%). Treatment-related deaths occurred in two patients (1.8%) in the irinotecan group. Third-line chemotherapy was administered in 97 patients (89.8%) after paclitaxel treatment and in 80 patients (72.1%) after irinotecan treatment (P = .001).

CONCLUSION

No statistically significant difference was observed between paclitaxel and irinotecan for OS. Both are reasonable second-line treatment options for advanced gastric cancer.

[A case of paclitaxel-resistant recurrent gastric cancer responsive to S-1 plus docetaxel]

We report the case of a patient with paclitaxel (PTX) -resistant recurrent gastric cancer who was effectively treated with S-1 plus docetaxel( DOC). A 62-year-old woman underwent total gastrectomy for Stage IV advanced gastric cancer (type 4, por 2>sig, pT4a (SE), pN3a, pP1, CY1) in 2009. Although S-1 was administered as first-line chemotherapy, recurrent peritoneal metastasis was diagnosed 22 months after surgery. S-1 plus irinotecan (CPT-11) was administered as second-line chemotherapy, and this was followed by weekly PTX (80 mg/m2) as third-line chemotherapy. However, computed tomography (CT) showed increased ascites and peritoneal wall thickening in the pelvis. As the tumor proved resistant to PTX, making the treatment ineffective, S-1( 80 mg/m2, day 1-14, q3w) plus DOC( 40 mg/m2, day 1, q3w) was initiated. Two months later, the ascites and peritoneal wall thickening in the pelvis disappeared. Twelve months after initiation of S-1 plus DOC chemotherapy, no sign of recurrence has been noted.

[Analysis of weekly paclitaxel chemotherapy for esophageal cancer]

PURPOSE

Public knowledge-based application for paclitaxe(l PAC) has been approved for advanced or recurrent esophageal cancer. We investigated the feasibility of weekly PAC chemotherapy as a second-line or subsequent regimen for metastatic or recurrent esophageal cancer.

MATERIALS AND METHODS

Patients received PAC( 100 mg/m2 intravenously) on days 1, 8, 15, 22, 29, and 36 of each 8-week period. We analyzed the toxicity and efficacy in 6 patients treated with the weekly PAC chemotherapy.

RESULTS

Grade 3-4 toxicities were neutropenia, leukopenia, and anemia. Two patients had stable disease and 2 had progressive disease.

CONCLUSION

By managing the side effects, weekly PAC therapy is considered a feasible regimen that can be administered on an outpatient basis.

[Analysis of patients with gastrointestinal neuroendocrine tumor]

PURPOSE

We investigated the background factors, histopathological results, and prognosis of patients with gastrointestinal neuroendocrine tumors.

MATERIALS AND METHODS

The medical records of 42 patients with gastrointestinal neuroendocrine tumors who were diagnosed and treated at our hospital from 2002 to 2012 were collected and retrospectively reviewed.

RESULT

The ratio of male to female patients was 29:13; the mean age was 66.1 years. The tumors were located in the esophagus( 2 patients), stomach( 13 patients), duodenum( 9 patients), colon( 1 patient), and rectum( 18 patients). Regarding the depth of the tumor, invasion of the submucosa( SM) was observed in 26 patients; invasion of the muscularis propria( MP), in 1 patient; invasion of the subserosa( SS), in 3 patients; penetration of the serosa( SE)( AD), in 1 patient, invasion of the adjacent structures( SI)( AI), in 3 patients; and the extent of tumor invasion was unknown in 1 patient. Patients who experienced relapse had a poor prognosis, and all the patients died.

[A case of neuroendocrine cell carcinoma of the esophagus with lung metastases successfully treated with CPT-11/CDDP]

A 70-year-old man presented with dysphagia to another institution and was referred to our hospital. We diagnosed the patient with primary neuroendocrine cell carcinoma and squamous cell carcinoma of the esophagus. Following 2 courses of CDDP+5-FU+ADM combination neoadjuvant chemotherapy, the primary tumor had reduced in size. Thereafter, we performed subtotal esophagectomy by right thoracotomy, retrosternal gastric tube reconstruction, and 2-field lymph node dissection. Computed tomography scan 3 months after the surgery revealed lung metastasis. He received CPT-11+CDDP chemotherapy, and the disease was diagnosed as cCR. At present, he is alive without any evidence of recurrence 12 months after the surgery.

[A case of surgical resection of lesions caused by extrahepatic seeding of hepatocellular carcinoma after percutaneous radiofrequency ablation]

We report a rare case of laparoscopic resection of lesions caused by extrahepatic seeding of hepatocellular carcinoma following percutaneous radiofrequency ablation (RFA). A 52-year-old man had undergone RFA for the treatment of hepatocellular carcinoma in April 2012. After 5 months, his serum tumor marker levels increased remarkably, and computed tomography (CT) revealed a 5 cm tumor and a small 1 cm nodule on the side of the spleen. He also had intrahepatic recurrence, but those lesions seemed to be controlled by transarterial embolization. Therefore, we performed laparoscopic resection of the extrahepatic lesion in November 2012. Histopathological examination revealed a moderately differentiated hepatocellular carcinoma. Two months later, the patient's serum tumor marker levels had decreased dramatically. The remaining intrahepatic recurrence has been stable, and we have not detected any other extrahepatic recurrence thus far. Our case supports the utility of surgical resection for the treatment of extrahepatic seeding of hepatocellular carcinoma.

[A case of advanced gastric cancer with para-aortic lymph node metastasis successfully treated with preoperative S-1/Lentinan chemotherapy followed by curative gastrectomy]

We report a case of advanced gastric cancer successfully treated with preoperative S-1/Lentinan (LTN)chemotherapy followed by curative gastrectomy. The patient was a 75-year-old man with right hypochondralgia. Endoscopic examination revealed a huge type 2 gastric cancer in the middle body of the stomach. Abdominal computed tomography (CT) revealed multiple perigastric lymph node metastases and bulky para-aortic lymph node metastases. The clinical diagnosis was cT 4N3M1( LYM) with cStage IV. We thought a complete resection would be difficult, so he was treated with S-1( 80 mg/m2 day 1-28/q6w) and LTN (2 mg weekly) in May 2010. After 3 courses, the primary lesion was markedly reduced, and gastric endoscopic biopsy showed no malignant lesion. After 4 courses, abdominal CT showed no lymph node swelling at the perigastric and para-aortic areas. After 5 courses, distal gastrectomy with D2 lymphadenectomy was performed. The histological diagnosis was ypT2( MP) N0M0, Stage IB. Histological features of the primary tumor and lymph nodes were judged to be Grade 2 and Grade 3, respectively. After surgery, S-1/LTN treatment was continued for 1 year. During this period, there were no serious adverse events. The patient has been in good health without recurrence for 28 months after surgery.

Overview of adjuvant and neoadjuvant therapy for resectable gastric cancer in the East

This review presents the current status of adjuvant and neoadjuvant treatment options for primary resectable gastric cancer in the East, with updated data from recent studies. Marked disparities between the East and the West in standard surgical procedures (D2 vs. D1/0 lymphadenectomy) and their outcomes result in significant geographical variation in preferred adjuvant treatments. Currently, oral fluoropyrimidine-based postoperative adjuvant chemotherapy, 1 year of S-1 chemotherapy, or capecitabine plus oxaliplatin for 6 months are the standards of care after curative resection with D2 lymphadenectomy for stage II/III gastric cancer in the East, though there is still some room for improvement. The role of postoperative adjuvant chemoradiotherapy (CRT) following curative D2 gastrectomy has long been debated in the East. However, the first prospective randomized controlled trial comparing CRT with chemotherapy alone failed to demonstrate a survival benefit, thus further studies are required. Chemotherapy has been pursued as a neoadjuvant approach in East Asia because of a rare locoregional recurrence after curative D2 gastrectomy. Locally advanced, marginally resectable gastric cancer with poor prognosis, such as large type 3 or 4 tumors, para-aortic and/or bulky nodal disease, and serosa-positive gastric cancer, is the main target of neoadjuvant chemotherapy. Promising efficacy has been demonstrated in several phase II studies with the safe use of D2 or more extended surgery following neoadjuvant chemotherapy. Although the results of ongoing phase III trials are awaited, Asian findings could be relevant and generalizable to other regions when D2 surgery is performed by experienced surgeons.

Clinical outcome and indications for palliative gastrojejunostomy in unresectable advanced gastric cancer: multi-institutional retrospective analysis

BACKGROUND

Palliative gastrojejunostomy (GJJ) for gastric outlet obstruction (GOO) associated with unresectable advanced gastric cancers (UAGC) is the most commonly used treatment modality, but its indication remains controversial. In this multi-institutions study, we investigated the clinical outcome of GJJ for UAGC and predictors of outcome and survival.

METHODS

A retrospective analysis was performed on 211 patients who underwent palliative GJJ for GOO caused by UAGC from 29 institutions between 2007 and 2009. Operative outcome including postoperative morbidity, mortality, assessment of oral intake by GOO Scoring System (GOOSS) and survival time were recorded. Prognostic factors for overall survival and risk factors for hospital death were investigated by univariate and multivariate analyses.

RESULTS

Postoperative oral food intake was recorded in 203 (96 %) patients. The average GOOSS improved from 1.1 at baseline to 2.5 at 1 month after surgery and remained above 2 for up to 6 months. Overall morbidity, 30-day mortality and hospital death rates were 22, 6 and 11 %, respectively. Median survival time was 228 days and 1-year survival rate was 31 %. Poor performance status (PS), prior chemotherapy and high C-reactive protein (CRP) level were significant independent predictors of poor survival. Poor PS and high CRP were also identified as significant risk factors of hospital death.

CONCLUSIONS

Palliative GJJ is beneficial for GOO caused by UAGC in terms of improvement of oral food intake, with acceptable morbidity and mortality. However, its indication for patients with poor PS, high CRP level, and a history of chemotherapy is less clear.

A phase I/II study of biweekly docetaxel (D) in combination with fixed-dose cisplatin plus fluorouracil (CF) in patients (pts) with advanced esophageal cancer (AEC) (JCOG0807)

e15016

Background: Thougha triplet chemotherapy with D plus CF (DCF) has shown promising activity, high incidence of adverse events (AEs) especially in febrile neutropenia (FN) was observed in previous studies for head and neck cancer (TAX323, 324) and gastric cancer (TAX325). To reduce its AEs with keeping activity, we conducted a multicenter open-label phase I/II study of biweekly D plus CF for AEC. Methods: Eligibility criteria included histologically proven AEC with measurable disease, age 20 to 75, non-resectable or recurrent disease, performance status (PS) 0 to 1. Pts received escalating doses of D (dose level (DL) 1: 30 mg/m2, DL 2: 40 mg/m2, on days 1, 15) in combination with fixed dose of CF (cisplatin 80 mg/m2 on day 1, fluorouracil 800 mg/m2on days 1-5) repeated every 4 weeks with 3+3 design in phase I part (P-I). The primary endpoint of P-I was dose limiting toxicity (DLT) and that of phase II part (P-II) was response rate (RR) defined by central peer review. Based on a SWOG two stage design (p0=35%, p1=50%; one-sided a=0.1, β =0.2) at least 22 responders among 50 eligible pts should be observed to satisfy the primary endpoint. Results: Between Feb 2009 and Mar 2010, 62 pts were enrolled for P-I and P-II. In P-I, 10 pts were enrolled with DLT of 0/3 in DL1 and 2/7 in DL2. Considering DLT and treatment compliance, the recommended dose for P-II was determined as DL1. Thus, 3 (P-I) and additional 52 pts (P-II) were analyzed: 53 for efficacy (excluded 2 ineligible pts) and 55 for safety. Pts characteristics were as follows: male/female 49/6, age median 61 (range 44 to 75), PS 0/1 39/16. The RR was 62% (95% confidence interval, 48-75%, p<0.0001) by central peer review. Median OS and PFS were 11.1 and 5.8 months. Grade 3/4 toxicity was observed in neutropenia (25%), anemia (36%), hyponatremia (29%), anorexia (24%) and nausea (11%). No grade 3/4 FN was observed. Treatment related death occurred in one patient due to pneumonitis. Conclusions: Biweekly D (30mg/m2) combined with CF showed promising activity and tolerability. A phase III study comparing CF with DCF is warranted. Clinical trial information: UMIN000001737.

Risk factors of pancreatic fistula after pancreaticoduodenectomy - patients with low drain amylase level on postoperative day 1 are safe from developing pancreatic fistula

BACKGROUND/AIMS

Based on the criteria of International Study Group on Pancreatic Fistula (ISGPF), the risk factors for grade B/C pancreatic fistula (PF) after pancreaticoduodenectomy (PD) were analyzed in this study.

METHODOLOGY

Between October 2006 and August 2010, 114 consecutive patients underwent PD at National Hospital Organization Osaka National Hospital. We compared the clinicopathological features between patients with grade B/C PF and those with PF-free/grade A PF. We also examined the relationship between PF formation and the drain amylase level on post-operative day (POD) 1 and POD 3.

RESULTS

Eighteen patients (15.8%) developed grade B/C P. Of these patients, four patients underwent reoperation. The mortality rate in patients with grade B/C PF was 5.6%(1/18). The non-dilated pancreatic duct (≤ 3mm) was the only independent risk factor for grade B/C PF by a multivariate analysis (p=0.026). There were 45 patients who showed low (≤ three times serum amylase level)drain amylase level on POD 1 and none of them developed PF.

CONCLUSIONS

Although our study demonstrated that the non-dilated pancreatic duct is significantly correlated with the increased incidence of grade B/CPE patients with low amylase level of drainage fluid on POD 1 are thought to be safe from developing PE.

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.

Optimal criteria of treatment change for advanced gastric cancer patients with nonmeasurable peritoneal metastasis alone

103

Background: Palliative chemotherapy is the mainstay for the treatment of advanced gastric cancer (AGC) patients with peritoneal metastasis. In general, chemotherapy regimen is changed when patients show disease progression on CT scan. However, nearly 40% of these patients have no measurable lesions. It remains uncertain how clinicians can decide the timing of treatment change for AGC patients with non-measurable peritoneal metastasis alone. Methods: There were 217 patients with primary unresectable or recurrent gastric cancer at our institution between April, 2005 and March, 2012. Among them, 50 patients, who had histologically proven non-measurable peritoneal metastasis alone, were retrospectively identified and investigated in this study. They underwent measurements of tumor markers (TM) every month and abdominal CT scan every 2 months. For these 50 patients, chemotherapy regimen was changed based on the following different 2 criteria; 1. elevated TM and/or aggravated clinical symptoms alone (n=21), 2. radiologically confirmed disease progression (n=29). We assessed whether these two different criteria have any impact on overall survival (OS) by univariate and multivariate analyses. Results: Median survival time of all 50 patients was 604 days. Multivariate analysis identified pre-treatment performance status of 0-1 (hazard ratio (HR) 0.211, 95% confidence interval (CI) 0.045–0.998, P=0.049), initial hemoglobin level of 10 mg/dl or more (HR 0.114, 95% CI 0.014–0.936, P=0.043) and the TM / symptom based treatment change (HR 0.124, 95% CI 0.043–0.360, P=0.001) as significant prognostic factors for favorable OS. Conclusions: Early decision making of treatment change based on elevated TM and/or aggravated clinical symptoms alone might contribute to longer OS in AGC patients with non-measurable peritoneal metastasis alone.

Impact of pretreatment systemic inflammatory response on survival in AGC patients receiving first-line chemotherapy

88

Background: Systemic inflammatory response plays an important role in cancer progression. However, little is known about how it affects the advanced gastric cancer (AGC) patients receiving first-line chemotherapy. We assessed the impact of pre-treatment systemic inflammatory response on survival in AGC patients receiving S-1 based first-line chemotherapy. Methods: OGSG 0402 multi-institutional phase II trial randomly assigned 102 patients with previously untreated, locally advanced and/or metastatic measurable gastric adenocarcinoma to receive S-1 plus irinotecan (SI arm) (n=51) or S1 plus paclitaxel (SP arm) (n=51) to evaluate these two S-1 based regimens as first-line treatment for AGC [ASCO-GI 2009: abstract 9.]. Among these patients, 99 patients were identified in this study excluding 2 patients who had died before receiving the allocated treatment and one patient who was lost to follow-up. All patients had performance status (PS) of 0-1 except for one with PS of 2. Pre-treatment clinical findings, such as gender, age, body mass index (BMI), tumor status (unresectable vs. recurrent, intestinal vs. diffuse), number of metastatic sites, serum levels of albumin (Alb) and C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and platelet lymphocyte ratio (PLR), were assessed as prognostic factors for overall survival (OS) and progression-free survival (PFS) in univariate and multivariate analyses. Results: Median OS and PFS were 390 days and 175 days for SI arm, and 363 days and 140 days for SP arm, respectively. Multivariate analysis identified the CRP level of 0.5 mg/dl or above (hazard ratio 1.96, 95% confidence interval 1.08 to 3.55, P=0.026) as a significant prognosticator for poor OS, and age of 60 years or greater (hazard ratio 1.92, 95% confidence interval 1.06–3.47, P=0.032) for shorter PFS. Conclusions: Pre-treatment CRP level was a most potent prognosticator for OS, reflecting the impact of systemic inflammatory response on survival, in AGC patients receiving first-line chemotherapy.

A phase I study of triplet combination chemotherapy of paclitaxel, cisplatin and S-1 in patients with advanced gastric cancer

OBJECTIVE

S-1 and cisplatin combination therapy is a standard regimen for patients with advanced gastric cancer in Japan. The primary objective of this study was to determine the maximum tolerated dose and dose-limiting toxicities of a triplet regimen adding paclitaxel to S-1 and cisplatin combination therapy.

METHODS

Patients with previously untreated metastatic or recurrent gastric cancer were enrolled. Patients received S-1 (40 mg/m(2) p.o., twice daily, on days 1-21 every 35 days), cisplatin (30 mg/m(2) divided, on days 1 and 15) and paclitaxel (divided on days 1 and 15). The starting dose of paclitaxel was 50 mg/m(2) (level 1); the dose was escalated to 60 (level 2), 70 (level 3) and 80 mg/m(2) (level 4) in a stepwise fashion. Dose-limiting toxicity was determined during the first treatment cycle.

RESULTS

Eighteen patients enrolled. During the first cycle, no dose-limiting toxicity was observed at dose levels 1 and 2. At dose level 3, one of the six patients had dose-limiting toxicity (one patient had grade 4 neutropenia) and at dose level 4, one of the six patients had dose-limiting toxicity (one patient had febrile neutropenia, hypoalbuminemia and fatigue of grade 3). The maximum tolerated dose was not reached at level 4; however, grade 3 hyponatremia and hypokalemia in two of the six patients occurred during the second treatment course at level 4. From the point of view of safety in the outpatient setting, the recommended dose of paclitaxel was determined at 70 mg/m(2). The overall response rate was 50%.

CONCLUSIONS

The recommended dose of paclitaxel added to S-1 (80 mg/m(2) days 1-21) plus cisplatin (30 mg/m(2) days 1 and 15) was 70 mg/m(2) on days 1 and 15 of a 5-week cycle.

Randomized phase III study of irinotecan (CPT-11) versus weekly paclitaxel (wPTX) for advanced gastric cancer (AGC) refractory to combination chemotherapy (CT) of fluoropyrimidine plus platinum (FP): WJOG4007 trial

4002

Background: A combination CT of FP has been regarded as the standard first-line treatment for AGC. Although two randomized trials showed a survival benefit of second-line CT (CPT-11 or docetaxel) compared with best supportive care, no standard regimen has been established. In Japan, wPTX has been used more frequently than docetaxel as the second‑line CT. The objective of this study was to compare CPT-11 with wPTX in patients (pts) with AGC refractory to FP. Methods: Patients with AGC refractory to the first‑line FP regimen were randomized 1:1 to either CPT-11 (150 mg/m2, q2w) or wPTX (80 mg/m2, days 1, 8, 15, q4w). The primary endpoint was overall survival (OS) and secondary endpoints were progression‑free survival (PFS), overall response rate (ORR), adverse events and receiving rates of third-line CT. To demonstrate an increase in median OS from 5 months (wPTX) to 7.5 months (CPT-11) with 2-sided alpha 5% and 80% power, 220 pts were required. Results: Between Aug 2007 and Aug 2010, 223 pts were enrolled; 112 pts were randomized to CPT-11 and 111 pts to wPTX. Baseline characteristics were well balanced between arms. Median OS was 8.4 months for CPT-11 and 9.5 months for wPTX (HR 1.132; 95% CI, 0.86-1.49; p=0.38). Median PFS was 2.3 months for CPT-11 and 3.6 months for wPTX (HR 1.14; 95% CI, 0.88-1.49; p=0.33). The ORR was 13.6% (12/88) for CPT-11 and 20.9% (19/91) for wPTX (p=0.20). The most common grade 3/4 adverse events were neutropenia (39.1% for CPT-11 vs. 28.7% for wPTX), anemia (30.0% vs. 21.3%), anorexia (17.3% vs. 7.4%) and fatigue (12.7% vs. 6.5%). Four (4%) CPT-11 and three (3%) wPTX recipients died within 30 days after the last administration. Subsequent CT was performed in 80 pts (71%) for CPT-11 and 97 pts (89%) for wPTX. Seventy-five pts (67%) in the CPT-11 group and 87 pts (80%) in the wPTX group received the crossover CT. Conclusions: The WJOG4007 trial, the first phase III study comparing second-line CT regimens for AGC, did not demonstrate the superiority of CPT-11 over wPTX. Thus, wPTX can be adopted as a control arm of future phase III trials of second-line CT for AGC.

Prospective randomized trial of preoperative enteral immunonutrition followed by elective total gastrectomy for gastric cancer

BACKGROUND

Perioperative enteral immunonutrition is thought to reduce postoperative morbidity in patients undergoing major gastrointestinal surgery. This study assessed the clinical effects of preoperative enteral immunonutrition in well nourished patients with gastric cancer undergoing total gastrectomy.

METHODS

Well nourished patients with primary gastric cancer, fit for total gastrectomy, were randomized to either a control group with regular diet, or an immunonutrition group that received regular diet supplemented with 1000 ml/day of immunonutrients for 5 consecutive days before surgery. The primary endpoint was the incidence of surgical-site infection (SSI). Secondary endpoints were rates of infectious complications, overall postoperative morbidity and C-reactive protein (CRP) levels on 3-4 days after surgery.

RESULTS

Of 244 randomized patients, 117 were allocated to the control group and 127 received immunonutrition. SSIs occurred in 27 patients in the immunonutrition group and 23 patients in the control group (risk ratio (RR) 1.09, 95 per cent confidence interval 0.66 to 1.78). Infectious complications were observed in 30 patients in the immunonutrition group and 27 in the control group (RR 1.11, 0.59 to 2.08). The overall postoperative morbidity rate was 30.8 and 26.1 per cent respectively (RR 1.18, 0.78 to 1.78). The median CRP value was 11.8 mg/dl in the immunonutrition group and 9.2 mg/dl in the control group (P = 0.113).

CONCLUSION

Five-day preoperative enteral immunonutrition failed to demonstrate any clear advantage in terms of early clinical outcomes or modification of the systemic acute-phase response in well nourished patients with gastric cancer undergoing elective total gastrectomy.

REGISTRATION NUMBER

ID 000000648 (University Hospital Medical Information Network (UMIN) database).

Phase II feasibility study of adjuvant S-1 plus CPT-11 for stage III gastric cancer patients after curative D2 gastrectomy (OGSG 0801)

142

Background: An adjuvant chemotherapy with S-1 has become the standard treatment for patients (pts) with stage II/III gastric cancer (GC) in Japan. But, it is assumed that the survival benefit for stage III pts who received S-1 is modest. S-1 plus CPT-11 has not shown the superiority in median overall survival (OS), but shown the well response rate (56%) and tolerability in Phase III trial (TOP-002 study). The aims of this phase II study were to evaluate the feasibility and safety of adjuvant S-1 plus CPT-11 in pts with stage III GC who underwent D2 surgery.

Methods: Pts with pathological stage IIIA and IIIB GC who underwent gastrectomy D2 dissection, age 20-75 years, performance status < 1, and informed consent received oral S-1 (80 mg/m2/day) administration for consecutive 3 weeks and intravenous CPT-11 (80 mg/m2) on day 1, 15, repeated every 5 weeks (1 cycle). The treatment was repeated for 4 cycles, followed by S-1 administration until 1 year after surgery. The primary endpoint was feasibility of the 4 cycles administration of S-1 plus CPT-11.

Results: We enrolled forty-five pts, 22 males and 23 females with a median age of 61 years, between December 2008 and April 2010. Pathological stages included IIIA in 25 pts and IIIB in 20 pts. The feasibility of planned 4 cycles of treatment was 62.2% (95% CI 46.5-76.2%, p=0.068) with 28 pts out of 45 pts. Non-hematological toxicities of grade 3 or more involved diarrhea in 13%, anorexia in 16%, nausea in 7% and vomiting in 4%. No Grade 4 toxicities were observed.

Conclusions: Adjuvant S-1 plus CPT-11 therapy had moderate hematological toxicities, but observed several severe non-hematological toxicities. Therefore, predicted feasibility was not achieved. Although the follow-up period is too short to evaluate OS and feasibility of S-1 administration, it is hoped that this regimen will be a candidate for future phase III trial seeking for the optimal adjuvant chemotherapy for stage III GC pts after D2 dissection if OS will be improved.

Multicenter phase II study of triplet combination chemotherapy with paclitaxel, cisplatin, and S-1 for advanced gastric cancer (OGSG 0703)

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Background: Docetaxel combined with cisplatin and 5-fluorouracil is active in advanced gastric cancer, but not generally accepted because of its substantial toxicities. We conducted a multicenter phase II study of triplet combination using paclitaxel, cisplatin and S-1 (PCS) as first-line treatment for advanced gastric cancer.

Methods: Patients with previously untreated, locally advanced or metastatic measurable gastric cancer, a performance status < 2, age of 20-75 years, and adequate organ functions were given intravenous paclitaxel at 70 mg/m2 and cisplatin at 30 mg/m2 on days 1 and 15, plus oral S-1 at 40 mg/m2 b.i.d. on days 1 to 21, followed by 2-week rest, repeated every 5 weeks. Treatment was continued until disease progression or unacceptable toxicity occurred, or the patient refused the therapy. Study endpoints included overall response rate (ORR) as primary, progression free survival (PFS), overall survival (OS), and toxicity. Sample size of 40 patients was determined to reject the ORR of 55% under the expectation of 75% with a power of 80% and a one-sided α of 5%.

Results: A total of 52 patients were enrolled in this study, among whom 49 were assessable for efficacy and 51 assessable for toxicity. ORR was 46.9% (95% CI: 32.5-61.7%). The median PFS and median OS were 5.4 months (95% CI: 4.1-7.0) and 11.5 months (95% CI: 7.3-16.1), respectively. Frequent grade 3/4 toxicities were neutropenia (51%), leucopenia (25%), anemia (20%), hyponatremia (16%), anorexia (14%), diarrhea (8%) and fatigue (8%). There was no treatment-related death.

Conclusions: Triplet combination chemotherapy with PCS demonstrated superior feasibility with promising antitumor activity, though which did not meet the statistical hypothesis, for advanced gastric cancer.

Phase II feasibility study of adjuvant S-1 plus docetaxel for stage III gastric cancer patients after curative D2 gastrectomy (OGSG 0604)

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Background: An adjuvant chemotherapy with S-1 has become the standard treatment for patients (pts) with stage II/III gastric cancer (GC) who have undergone gastrectomy with D2 dissection in Japan, but it is assumed that the survival benefit for stage III pts who received S-1 is modest. S-1 plus docetaxel has shown that the response rate and median overall survival (OS) were 56% and 14.3 months in pts with advanced GC. The aims of this phase II study were to evaluate the feasibility and safety of adjuvant S-1 plus docetaxel in pts with stage III GC with D2 surgery.

Methods: Pts with pathological stage III GC who underwent gastrectomy with D2 dissection received oral S-1 (80 mg/m2/day) administration for 2 consecutive weeks and intravenous docetaxel (40 mg/m2) on day 1, repeated every 3 weeks (1 cycle). The treatment was started within 45 days after surgery, and repeated for 4 cycles, followed by S-1 administration until 1 year after surgery. The primary endpoint was feasibility of the 4 cycles administration of S-1 plus docetaxel; secondary endpoints were safety, progression-free survival (PFS), OS, and feasibility of S-1 administration until 1 year after surgery.

Results: We enrolled 53 pts, 42 males and 11 females with a median age of 65 years (range, 43-78), between May 2007 and August 2008. Pathological stages included IIIA in 36 pts and IIIB in 17 pts. The feasibility of planned 4 cycles of treatment was 77.4% (95% CI 63.8-87.7%, p < 0.001) with 41 pts out of 53 pts. Grade 4 neutropenia was observed in 28% of pts with grade 3 febrile neutropenia in 9%. Non-hematological toxicities of grade 3 or more involved fatigue in 6%, anorexia in 9%, and nausea in 6%. No treatment-related deaths occurred. Reasons for discontinuation were recurrent cancer in 1 pt, adverse events in 10, and miscellaneous in 1, respectively. 3 year overall survival was 78.8% (95% CI 68.4-90.7) and 3 year disease free survival was 50.3% (95% CI 34.4-73.3).

Conclusions: Adjuvant S-1 plus docetaxel therapy is feasible and has only moderate toxicity in stage III gastric cancer pts. We believe that this regimen will be a candidate for future phase III trials seeking the optimal adjuvant chemotherapy for stage III gastric cancer patients.

Significance of surgical treatment of liver metastases from gastric cancer

BACKGROUND/AIM

The optimal treatment of liver metastases from gastric cancer (LMGC) remains uncertain. We retrospectively compared surgical treatment with chemotherapy alone and identified prognostic determinants.

PATIENTS AND METHODS

We reviewed the records of 50 consecutive patients with LMGC: 25 patients with gastrectomy plus hepatic resection (group A), 13 patients with palliative gastrectomy (group B), and 12 patients with chemotherapy alone (group C). We compared the overall survival among these three groups, and assessed prognostic factors.

RESULTS

Median survival time in groups A, B, and C was 33.4, 10.5, and 8.7 months, respectively. Univariate analysis found T stage, number of liver metastases, and treatment group to be significant prognostic factors. In the multivariate analysis, T stage was shown to be an independent prognostic determinant, while gastrectomy plus hepatic resection was of marginal significance compared with chemotherapy alone.

CONCLUSION

T Stage was a significant prognostic determinant, and gastrectomy plus hepatic resection could be a promising treatment for patients with LMGC.

Optimal indications for second-line chemotherapy in advanced gastric cancer

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Background: It remains uncertain whether every patient with advanced gastric cancer (AGC) who progresses after first-line chemotherapy should receive second-line chemotherapy. We conducted the present study to identify the optimal indications for second-line chemotherapy.

Methods: In this retrospective study, 101 patients were included in univariate and multivariate analyses to identify clinicopathological variables independently associated with longer survival post progression (SPP), defined as the time from recognition of disease progression on first-line chemotherapy to death from any cause or last follow-up.

Results: Median SPP of all patients was 340 days. On multivariate analysis, both performance status (PS) 2 (hazard ratio (HR), 14.234; 95% confidence interval (CI), 2.766–73.258), serum albumin (Alb) level < 3.5 g/dl (HR, 2.088; 95% CI, 1.047–4.060) at initiation of second-line chemotherapy, and time to progression (TTP) < 170 days on first-line chemotherapy (HR, 2.497; 95% CI, 1.227–5.083) were identified as independent prognostic factors for shorter SPP. Median SPP was 496, 375, and 232 days in patients with 0, 1, and 2 of these 3 negative prognostic factors, respectively (p = 0.0002).

Conclusions: The present study suggests that second-line chemotherapy would be less beneficial in patients with 2 or more of the following 3 negative prognostic factors: PS 2, Alb < 3.5 g/dl at initiation of second-line chemotherapy, and TTP < 170 days on first-line chemotherapy.

Posttherapy nodal status, not graded histologic response, predicts survival after neoadjuvant chemotherapy for advanced gastric cancer

BACKGROUND

Neoadjuvant chemotherapy (NAC) has been attempted as a means of improving survival of potentially resectable advanced gastric cancer (AGC). In the course of exploring the most promising NAC regimen, a superior surrogate marker reflecting overall survival (OS) is necessary. We investigated prognostic factors in AGC patients who underwent NAC followed by gastric resection and evaluated whether histologic response to NAC was predictive of survival.

METHODS

Seventy consecutive patients with gastric cancer treated with NAC followed by surgical resection between Jan 1, 2000, and Dec 31, 2009, at Osaka National Hospital were identified from a prospective database. Prognostic factors for OS were investigated by univariate and multivariate analyses.

RESULTS

Median survival time for all patients was 668 days after surgical resection. Age less than 65 years (hazard ratio 0.463, 95% confidence interval 0.244-0.879) and pathologic nodal stage of N0-1 (hazard ratio 0.318, 95% confidence interval 0.160-0.635) were identified as significant independent prognostic factors for longer OS, whereas graded histologic response of primary tumor to NAC was statistically significant on univariate analysis, but not on multivariate analysis, as a prognostic factor.

CONCLUSIONS

Posttherapy nodal status, not graded histologic response, predicts survival after NAC for AGC and could serve as a reliable surrogate marker for OS in the course of exploring the most promising regimen for NAC.