Efficacy of Negative-Pressure Wound Therapy for Preventing Surgical Site Infections after Surgery for Peritonitis Attributable to Lower-Gastrointestinal Perforation: A Single-Institution Experience

BACKGROUND AND PURPOSE

For patients at high risk, such as those with lower-gastrointestinal perforations, it is important to establish a preventive method that reduces the incidence of surgical site infections (SSIs) significantly. We applied negative-pressure wound therapy (NPWT) as part of a delayed primary closure approach to prevent SSIs. This study evaluated the value of this technique.

METHODS

We included prospectively 28 patients undergoing abdominal surgery for peritonitis caused by a lower-gastrointestinal perforation between May 2014 and November 2015. Historical controls comprised retrospective data on 19 patients who had undergone primary suturing for managing peritonitis incisions for a lower-gastrointestinal perforation from January to December 2013.

RESULTS

We found a significant association between the SSI incidence and the type of incision management (10.7% with NPWT and delayed closure vs. 63.2% with primary suturing; p < 0.001). There was no significant difference between the groups in the length of the hospital stay (22 days for NPWT and delayed closure vs. 27 days for primary suturing; p = 0.45). No severe adverse events were observed related to NPWT.

CONCLUSION

The use of NPWT and delayed primary closure was an effective measure for preventing SSI in patients undergoing abdominal surgery for peritonitis caused by lower-gastrointestinal perforation.

Skeletal Muscle Loss during Neoadjuvant Chemotherapy Is an Independent Risk Factor for Postoperative Infectious Complications in Patients with Advanced Esophageal Cancer

OBJECTIVE

Neoadjuvant therapy followed by surgery has been the standard treatment for advanced esophageal cancer. Severe toxicities may influence body composition, including skeletal muscle mass, and increase postoperative complications. The purpose of this study was to evaluate the influence of sarcopenia, changes in body composition, and adverse events during neoadjuvant chemotherapy (NACT) on postoperative complications in esophageal cancer patients.

METHODS

A total of 83 patients with esophageal cancer undergoing NACT followed by esophagectomy were included. Body composition was assessed before chemotherapy and before esophagectomy. The relationships between postoperative infectious complications and sarcopenia, changes in body composition, and adverse events during NACT were investigated.

RESULTS

Univariate analysis revealed that skeletal muscle loss during NACT, but not preoperative sarcopenia, was significantly higher in the complication (+) group. Febrile neutropenia tended to occur frequently in the complication (+) group. Multivariate analysis demonstrated that skeletal muscle loss was the only factor significantly associated with infectious complications (p = 0.029). Among adverse events, febrile neutropenia was significantly associated with a decrease in skeletal muscle mass.

CONCLUSION

Loss of skeletal muscle mass during NACT was a significant risk factor for postoperative infectious complications in patients with esophageal cancer. Prevention of severe adverse events may reduce postoperative infectious complications.

Randomized, Open-Label Phase II Study Comparing Capecitabine-Cisplatin Every 3 Weeks with S-1-Cisplatin Every 5 Weeks in Chemotherapy-Naïve Patients with HER2-Negative Advanced Gastric Cancer: OGSG1105, HERBIS-4A Trial

Lessons Learned.

Evidence has suggested that capecitabine‐cisplatin is similar or possibly superior to S‐1‐cisplatin in terms of safety and efficacy for Japanese patients with advanced gastric cancer (AGC).

As far as we are aware, our study is the first randomized trial of two regimens consisting of an oral fluoropyrimidine plus cisplatin in human epidermal growth receptor 2‐negative AGC patients with measurable lesions.

Background.

We performed a phase II study to evaluate the safety and efficacy of capecitabine plus cisplatin in comparison with S‐1 plus cisplatin for first‐line treatment of human epidermal growth receptor 2 (HER2)‐negative advanced gastric cancer in Japan.

Methods.

Eligible patients were randomly assigned to receive either capecitabine at 1,000 mg/m² twice daily for 14 days plus cisplatin at 80 mg/m² on day 1 every 3 weeks (n = 43) or S‐1 at 40–60 mg twice daily for 21 days plus cisplatin at 60 mg/m² on day 8 every 5 weeks (n = 41). The primary endpoint of the study was response rate.

Results.

Response rate did not differ significantly between the capecitabine‐cisplatin and S‐1‐cisplatin groups (53.5% vs. 51.2%, respectively, p > .999). S‐1‐cisplatin tended to confer a better progression‐free survival (PFS; median of 5.9 vs. 4.1 months, p = .284), overall survival (OS; median of 13.5 vs. 10.0 months, p = .290), and time to treatment failure (TTF; median of 4.5 vs. 3.1 months, p = .052) compared with capecitabine‐cisplatin. Common hematologic toxicities of grade 3 or 4 included anemia and neutropenia in both groups. However, anorexia, fatigue, and hyponatremia of grade 3 or 4 occurred more frequently in the capecitabine‐cisplatin group.

Conclusion.

Capecitabine‐cisplatin failed to demonstrate superior efficacy compared with S‐1‐cisplatin. The higher incidence of severe adverse events with capecitabine‐cisplatin suggests that S‐1‐cisplatin should remain the standard first‐line chemotherapy for HER2‐negative advanced gastric cancer in Japan.

Early results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for locally advanced gastric cancer

Background

Neoadjuvant chemotherapy (NAC) is a promising method of improving the survival of resectable gastric cancer. Cisplatin/S-1 (CS) and docetaxel/cisplatin/S-1 (DCS) are both effective against metastatic gastric cancer. This report clarified the impact of these regimens on early endpoints, including the pathological responses, chemotherapy-related toxicities, and surgical results.

Methods

Patients with M0 and either T4 or T3 in case of junctional cancer or scirrhous type received two or four courses of cisplatin (60 mg/m2 at day 8)/S-1 (80 mg/m2 for 21 days with 1 week rest) or docetaxel (40 mg/m2 at day 1)/cisplatin (60 mg/m2 at day 1)/S-1 (80 mg/m2 for 14 days with 2 weeks rest) as NAC. Patients then underwent D2 gastrectomy and adjuvant S-1 chemotherapy for 1 year. The primary endpoint was the 3-year overall survival.

Results

Between October 2011 and September 2014, 132 patients were assigned to receive CS (n = 66; 33 in 2 courses and 33 in 4 courses) or DCS (n = 66; 33 in 2 courses and 33 in 4 courses). The respective major grade 3 or 4 hematological toxicities (CS/DCS) were leukocytopenia (14.1%/26.2%), neutropenia (29.7%/47.7%), anemia (14.1%/12.3%), and platelet reduction (3.1%/1.5%). The rate of pathological response, defined as a complete response or < 10% residual cancer remaining, was 19.4% in the CS group and 15.4% in the DCS group, and 15.6% in the two-course group and 19.0% in the 4-course group. The R0 resection rate was 72.7% in the CS group and 81.8% in the DCS group and 80.3% in the two-course group and the 74.2% in the four-course group. No treatment-related deaths were observed.

Conclusions

Our results do not support three-drug therapy with a taxane over two-drug therapy, or any further treatment beyond two cycles as an attractive candidate for the test arm of NAC.

Time to initiation or duration of S-1 adjuvant chemotherapy; which really impacts on survival in stage II and III gastric cancer?

BACKGROUND

Surgical resection with S-1 adjuvant chemotherapy (AC) is the standard of care for stage II-III gastric cancer (GC). However, it is unclear if time to initiation and duration of S-1 AC impact on survival.

METHODS

A multi-institutional GC database identified 498 patients who were treated with S-1 AC after D2 or more extended radical surgery for stage II-III gastric cancer. Patients were divided into four groups according to the interval between surgery and initiation of AC and the duration of AC as follows: group A (n = 226), who received AC earlier (≤6 weeks) and for longer (≥6 months) after surgery; group B (n = 160), who received AC later (>6 weeks) and for longer after surgery; group C (n = 46), who received AC earlier but for a shorter period (<6 months) after surgery; and group D (n = 66), who received AC later and for a shorter period after surgery. Prognostic factors for overall survival (OS) were investigated using multivariate analysis.

RESULTS

The 5-year OS was 69.5%. Pathological stage II disease (hazard ratio (HR), 0.334; 95% confidence interval (CI), 0.215-0.499), with an OS of 85.8% versus 60.5% for stage III disease, as well as a longer duration (≥6 months) of S-1 (HR, 0.498; 95% CI, 0.355-0.706), with an OS of 74.3% versus 53.0% for a shorter duration (<6 months) of S-1, were identified as significant prognostic factors for long-term survival. Time to initiation was not associated with OS.

CONCLUSIONS

A duration of S-1 AC of ≥6 months, but not time to initiation within 6 weeks, impacts on OS in stage II-III gastric cancer.

[Two Cases of Locally Recurrent Rectal Cancer Undergoing Preoperative Chemoradiationtherapy]

Case 1 is a 68-year-old woman with locally recurrent rectal cancer(LRRC)developed 5 years after resection of primary rectal cancer. The tumor seized right lateral side in pelvic. We performed tumor excision after preoperative chemoradiation comprised external beam radiation with oral S-1(tegafur/gimeracil/oteracil). He has been relapse-free for 3 years 3months after surgery. Case 2 is a 74-year-old man with LRRC developed 2 years after resection of primary rectal cancer. The tumor was located dorsal to anastomosis site in pelvic. We performed abdominoperineal resection for LRRC after preoperative chemoradiation with oral S-1. He has been relapse-free for 2 years. It was suggested that preoperative radiotherapy combined with oral FU for local recurrence after rectal cancer may contribute to distant and local control.

A phase II study of nab-paclitaxel in combination with ramucirumab in patients with previously treated advanced gastric cancer

BACKGROUND

Nanoparticle albumin-bound (nab)-paclitaxel was developed to improve paclitaxel solubility and does not need premedication to avoid infusion-related reactions associated with solvent-based (sb)-paclitaxel. We conducted a phase II trial to investigate the efficacy and safety of nab-paclitaxel plus ramucirumab combination therapy for previously treated advanced gastric cancer.

PATIENTS AND METHODS

Patients with unresectable advanced gastric cancer refractory to first-line chemotherapy were administered nab-paclitaxel 100 mg/m2 intravenously on days 1, 8 and 15, plus ramucirumab 8 mg/kg intravenously on days 1 and 15 of a 28-day cycle. The primary end-point was Independent Review Committee (IRC)-assessed overall response rate (ORR). Secondary end-points were progression-free survival (PFS), overall survival (OS), disease control rate (DCR), safety and quality of life (QOL).

RESULTS

Forty-five patients were enrolled; 43 received the study treatment. The ORR assessed by the IRC was 54.8% (90% confidence interval [CI] 41.0-68.0) and the primary end-point was met. The DCR was 92.9% (95% CI 80.5-98.5). The IRC-assessed median PFS was 7.6 months (95% CI 5.4-8.1). The median OS was not reached at the data cutoff. The main treatment-related grade 3 or 4 adverse events were decreased neutrophil count (76.7%), decreased white blood cell count (27.9%), anaemia (11.6%), decreased appetite (7.0%), febrile neutropenia (4.7%), hypertension (4.7%) and proteinuria (4.7%). No treatment-related deaths occurred. No QOL deterioration was observed during study treatment.

CONCLUSION

Nab-paclitaxel plus ramucirumab combination therapy shows promising activity and manageable toxicities and could be a useful second-line treatment option for patients with previously treated advanced gastric cancer.

Histopathological tumor regression or ypN: Which better predicts survival of patients who received neoadjuvant chemotherapy and surgery for non-type 4 locally advanced gastric cancer?

114

Background: Histopathological tumor regression with < 10% residual tumor is a globally accepted prognostic factor in gastric cancer patients who received neoadjuvant chemotherapy (NAC) and curative surgery, however, impact of ypN remains unclear. Methods: Previously, Japan Clinical Oncology Group (JCOG) had conducted 3 phase II trials to evaluate NAC with irinotecan/CDDP (JCOG0001) and S-1/CDDP (JCOG0405) for extensive nodal disease, and with S-1/CDDP (JCOG0210) for large type 3 and type 4 (linitis plastica) disease. Prognostic factors, including ypN and histopathological tumor regression with < 10% residual tumor, were analyzed in patients with curative resection excluding type 4 advanced gastric cancer in these trials by univariable and multivariable analyses using the Cox proportional hazards model. Results: Among 85 patients, 5-year OS was 46.0% (95% CI, 35.0-56.4). Median OS was not reached in patients with < 10% residual tumor (n = 26), whereas that was 2.7 years (95% CI, 1.4-4.5) in patients with > 10% residual tumor (n = 59) (p = 0.008). Median OS was not reached in patients with ypN0-1 (n = 25), whereas that was 2.6 years (95% CI, 1.5-4.0) in patients with ypN2-3 (n = 60) (p = 0.003). On multivariable analysis, only ypN2-3 was an independent predictor of OS (hazard ratio, 3.67; 95% CI, 1.55 to 8.69), whereas < 10% residual tumor was not (hazard ratio, 2.24; 95% CI, 0.98 to 5.10). Conclusions: It is suggested that ypN may have greater impact on the survival than histopathological tumor regression in patients who received NAC and surgery for AGC.

A survival analysis of a prospective multicenter observational study of surgical palliation in patients treated for malignant gastric outlet obstruction caused by incurable advanced gastric cancer

113

Background: We previously reported that surgical palliation maintained patients’ quality of life (QOL) while improving the solid food intake with an acceptable surgical safety in patients with malignant gastric outlet obstruction (GOO) caused by advanced gastric cancer. To elucidate the impact of the improvement in the QOL on the survival, we performed a survival analysis according to the changes in the QOL. Methods: Eligibility criteria included (1) no or liquids-only oral intake, (2) aged ≥20 , (3) surgically fit, (4) ECOG PS of 0-2, and (5) written informed consent. Patients underwent either palliative gastrectomy or gastrojejunostomy. Validated QOL instruments (EORTC QLQ-STO22 and EuroQol-5D) assessed the QOL at baseline, 2 weeks, 1 month, and 3 months following surgical palliation, and postoperative improvement in the oral intake was also evaluated. Univariate and multivariate survival analyses were performed according to baseline characteristics and changes in QOL 2 weeks, 1 month, and 3 months after the operation. Results: The median survival time in the 104 patients was 11.30 months. In the univariate analysis, the survival was significantly better in the patients who received gastrectomy, received adjuvant chemotherapy, had a better PS, and had a worse baseline EQ5D score. Changes in the QOL scores had no marked impact on the survival at 2 weeks and 1 month after operation. However, in patients with an improved or stable EQ5D score at 3 months post-surgery, the survival was significantly better (p = 0.0043). An improved oral intake on the GOO score system (GOOSS) had a positive impact on the survival. A multivariate analysis in the patients survived more than 3 months after the operation revealed that adjuvant chemotherapy, a better baseline PS, a worse baseline EQ5D, an improved or stable EQ5D score, and an improved oral intake on the GOOSS at 3 months after surgical palliation were independent prognostic factors. Conclusions: In patients who received surgical palliation for malignant GOO caused by advanced gastric cancer, an improved oral intake and QOL score at 3 months after operation predicted a good survival. Clinical trial information: 000023494.

Randomized, open-label, phase II study comparing five-weekly S-1 plus cisplatin (SP) with tri-weekly capecitabine plus cisplatin (XP) in chemotherapy-naïve patients with HER2 negative advanced gastric cancer (AGC): OGSG 1105 HERBIS-4A trial

102

Background: This phase II study aimed to investigate the safety and efficacy of XP compared to SP in the first-line treatment of HER2 negative AGC. Methods: Patients were randomly assigned to receive either SP (S-1 at 40–60 mg twice daily for 21 days plus cisplatin at 60 mg/ m2 on day 8, every 5 weeks) or XP (capecitabine 1,000 mg/m2 twice daily for 14 days plus cisplatin 80 mg/m2 on day 1, every 3 weeks). Primary endpoint was response rate (RR), and secondary endpoints were progression-free survival (PFS), overall survival (OS), time to treatment failure (TTF), and adverse events. Results: 84 eligible patients were randomly assigned to receive SP ( N = 41) or XP ( N = 43). No statistical difference was observed in overall RR between the SP and XP groups [51.2% (95% CI, 35.1% to 67.1%) vs. 53.5% (95% CI, 37.7% to 68.8%), P = 1.000]. Despite not significant, however, SP vs. XP showed a trend toward better PFS [median, 5.9 months vs. 4.1 months; hazard ratio (HR), 0.763; 95% CI, 0.462 to 1.259; P = .284] and OS (median, 13.5 months vs. 10.0 months; HR, 0.776; 95% CI, 0.485 to 1.244; P = .290). This trend in the SP vs. XP comparison was more pronounced in TTF (median, 4.5 months vs. 3.1 months; HR, 0.651; 95% CI, 0.421 to 1.006; P = .052). Common grade 3 to 4 hematological toxicities were neutropenia and anemia (SP group, 23% and 23%; XP group, 35% and 28%). Grade 3-4 anorexia and hyponatremia were more frequently seen in the XP group (31% and 16%) compared to the SP group (13% and 5%). Treatment-related deaths occurred in one patient (2.3%) in the XP group. Conclusions: XP failed to demonstrate the superior efficacy over SP. Higher incidence of severe toxicities by XP suggests SP as the standard 1st line chemotherapy for HER2 negative AGC in Japan. Clinical trial information: UMIN000006755.

Survival of second-line irinotecan-based chemotherapy in early relapse patients with gastric cancer after adjuvant chemotherapy: Exploratory subgroup analysis of TRICS trial

99

Background: Second-line chemotherapy (SLC) was reported to improve the survival of advanced gastric cancer (AGC). The TRICS trial which a randomized phase III study of second-line irinotecan plus cisplatin versus irinotecan alone in patients with AGC refractory to S-1 monotherapy, revealed that both irinotecan based chemotherapies were effective with favorable long-term survivals and generally well tolerated. Eligible patients included patients with recurrence within 6 months after the completion of adjuvant therapy with S-1 (early relapse cases), or patients with tumor progression after first-line S-1 for an advanced cancer (progressive cases), in this trial. However, it is unclear whether survivals in early relapse cases were different from these in progressive cases or not. Methods: A total of 168 patients registered to the TRICS trial were classified as early relapse group (n = 111) or progressive group (n = 57), and 168 (irinotecan plus cisplatin, early relapse 56/83, 67%; irinotecan alone, 55/85, 65%) and 163 (55/81, 68%; 53/82, 65%) patients were analyzed for survival. Adjusted OS and adjusted PFS were constructed adjusted Kaplan-Meier curve with inverse probability weight, and were estimated by inverse probability of treatment weighting method (IPTW). Results: In baseline characteristics, PS 0 were more frequently seen in early relapse group than in progressive group (86% vs 72%, p = 0.0328), and median age of early relapse group was younger than progressive group (66 vs 72, p = 0.0162). The median OS was 13.9 months in early relapse group and 10.0 months in progressive group (HR:0.746, p = 0.1019). The adjusted median OS was 14.0 months in early relapse group and 10.6 months in progressive group (IPTW HR:0.864, p = 0.1019). Early relapse group showed better trends in PFS compared to the progressive group (4.7M vs 3.6M, HR: 0.650, p = 0.0149). The adjusted median PFS was 4.8 months in early relapse group and 3.7 months in progressive group (IPTW HR:0.673, p = 0.0008). Conclusions: Irinotecan based chemotherapies were effective especially in early relapse cases after adjuvant therapy with S-1, in second-line setting of AGC.

Multicentre observational study of quality of life after surgical palliation of malignant gastric outlet obstruction for gastric cancer

BACKGROUND

Quality of life (QoL) is a key component in decision-making for surgical palliation, but QoL data in association with surgical palliation in advanced gastric cancer are scarce. The aim of this multicentre observational study was to examine the impact of surgical palliation on QoL in advanced gastric cancer.

METHODS

The study included patients with gastric outlet obstruction caused by incurable advanced primary gastric cancer who had no oral intake or liquid intake only. Patients underwent palliative distal/total gastrectomy or bypass surgery at the physician's discretion. The primary endpoint was change in QoL assessed at baseline, 14 days, 1 month and 3 months following surgical palliation by means of the EuroQoL Five Dimensions (EQ-5D™) questionnaire and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire gastric cancer module (QLQ-STO22). Secondary endpoints were postoperative improvement in oral intake and surgical complications.

RESULTS

Some 104 patients (23 distal gastrectomy, 9 total gastrectomy, 70 gastrojejunostomy, 2 exploratory laparotomy) were enrolled from 35 institutions. The mean EQ-5D™ utility index scores remained consistent, with a baseline score of 0·74 and the change from baseline within ± 0·05. Gastric-specific symptoms showed statistically significant improvement from baseline. The majority of patients were able to eat solid food 2 weeks after surgery and tolerated it thereafter. The rate of overall morbidity of grade III or more according to the Clavien-Dindo classification was 9·6 per cent (10 patients) and the 30-day postoperative mortality rate was 1·9 per cent (2 patients).

CONCLUSION

In patients with gastric outlet obstruction caused by advanced gastric cancer, surgical palliation maintained QoL while improving solid food intake, with acceptable morbidity for at least the first 3 months after surgery. Registration number 000023494 (UMIN Clinical Trials Registry).

[A Case of Diaphragmatic Metastasis from Adenocarcinoma of the Rectum Treated via Surgical Resection]

A 67-year-oldman underwent lower anterior resection for rectal cancer andresection of liver metastatic tumor 5 years later. Seven years and 2 months after the initial surgery, a soft tissue mass was detected in the left diaphragm. Further retrospective review of CT scan images showedthat the diaphragmatic tumor was present just before the hepatectomy. Partial resection of the left diaphragm was performed, and no relapse has occurred since then for 2 years. Most cases of diaphragmatic metastasis are considered to arise from dissemination, but we considered this case as more likely to be hematogenous. When surgery is chosen to treat metastatic tumors of colorectal cancer, checking for other metastasis via preoperative imaging andperforming curative resection is important.

Randomized Controlled Trial of Adjuvant Chemotherapy with Fluoropyrimidines Versus Surgery-alone for Gastric Cancer

AIM

This prospective randomized study compared the survival of patients with stage IB-IIIA gastric cancer treated with surgery alone or surgery followed by adjuvant chemotherapy.

PATIENTS AND METHODS

Patients with pathological stage IB-IIIA disease were randomly assigned to the following groups: surgery alone (n=116), or surgery followed by adjuvant chemotherapy with 5-fluorouracil, doxifluridine, or uracil-tegafur for 12 months (n=113).

RESULTS

The overall survival rate was 86.1% in the adjuvant group and 78.5% in the surgery-alone group. The overall survival rate did not significantly differ between the adjuvant-chemotherapy and surgery-only groups (p=0.163). In the subgroup analyses, patients with stage II disease and those receiving uracil-tegafur treatment in the adjuvant group showed significantly better prognosis than those in the surgery-alone group (p=0.036 and 0.005, respectively).

CONCLUSION

This study did not find a significant survival benefit to be associated with adjuvant chemotherapy with fluoropyrimidines in patients with stage IB-IIIA gastric cancer. However, it may be effective for patients with stage II disease. Additionally, uracil-tegafur is a promising agent for adjuvant chemotherapy of gastric cancer if S-1 is not available because of its toxicity.

ABSOLUTE: A phase 3 trial of nanoparticle albumin-bound paclitaxel (nab-PTX) versus solvent-based paclitaxel (sb-PTX) in patients with pre-treated advanced gastric cancer (AGC)—Efficacy and QOL results

4010

Background: Sb-PTX is a standard second-line treatment for patients (pts) with AGC. Nab-PTX was developed to avoid the toxicities with use of solvents in sb-PTX and potentially improve efficacy. Based on ABSOLUTE trial, we conducted the additional analysis to evaluate the efficacy and QOL of nab-PTX and sb-PTX. Methods: Pts who were refractory to a fluoropyrimidine-containing first-line treatment were randomly assigned (1:1:1) to receive intravenous q3w nab-PTX (260 mg/m2) on day 1 of a 21-day cycle, and q1w nab-PTX (100 mg/m2) or q1w sb-PTX (80 mg/m2) on days 1, 8, and 15 of a 28-day cycle. The primary objective was to evaluate whether q3w nab-PTX and q1w nab-PTX were non-inferior to q1w sb-PTX in terms of overall survival (OS). Tumor shrinkage at 8 weeks and at the time of the best response were also investigated. For the QOL analysis, EQ-5D score were collected at baseline and every 8 weeks during the first 24 weeks, and thereafter at every 24 weeks. Time to deterioration of EQ-5D score was compared between each arm as a minimally important difference of 0.05. Results: 741 pts were randomly assigned to q3w nab-PTX, q1w nab-PTX, or q1w sb-PTX. Median OS (months) were 10.3, 11.1, and 10.9, respectively. Q1w nab-PTX was non-inferior to q1w sb-PTX (hazard ratio 0.97, 97.5% CI 0.76-1.23; non-inferiority one-sided p = 0.0085), whereas q3w nab-PTX was not non-inferior to q1w sb-PTX (1.06, 95% CI 0.87-1.31; non-inferiority one-sided p = 0.062).The response rate of target lesions at 8 weeks and at the time of the best response (%) were 22.1 and 27.7 for q3w nab-PTX, 28.2 and 34.9 for q1w nab-PTX, and 18.0 and 25.6 for q1w sb-PTX. Median time to deterioration of EQ-5D score (months) were 2.1 in q3w nab-PTX, 3.8 in q1w nab-PTX, and 3.7 in q1w sb-PTX. Conclusions: Q1w nab-PTX was non-inferior to q1w sb-PTX in terms of OS. In addition, q1w nab-PTX showed favorable effect in comparison with q1w sb-PTX in terms of response rate of target lesions and time at best response. QOL was similar between q1w nab-PTX and q1w sb-PTX. These results suggest that q1w nab-PTX is a useful second-line treatment for pts with AGC. Clinical trial information: 132059.

A prospective multicenter observational study of surgical palliation examining postoperative quality of life in patients treated for malignant gastric outlet obstruction caused by incurable advanced gastric cancer

6

Background: Decision-making for surgical palliation remains one of the most challenging clinical scenarios since quality of life (QOL) is a key component of cancer care. We conducted this study to examine the impacts of surgical palliation on postoperative QOL in patients (pts) with malignant gastric outlet obstruction (GOO) caused by incurable primary gastric cancer (GC). Methods: Eligibility included (1) no oral intake or liquids only requiring parenteral nutrition (2) aged ≥20 (3) surgically fit (4) ECOG PS of 0-2 and (5) written IC. Patients underwent either palliative distal/total gastrectomy (DG/TG) or gastrojejunostomy (GJS). Treatment choice was left to the discretion of the physician. Validated QOL instruments (EORTC QLQ-STO22 and EuroQol-5D) assessed QOL at baseline, 2 weeks (wks), 1 month (m), and 3 months following the surgical palliation, and two observational outcomes (postoperative improvement of oral intake, and safety of surgical intervention) were evaluated. Results: 104 pts, 71 males and 33 females with a median age of 68 years, were enrolled. The types of surgery were DG in 23 pts, TG in 9 pts, GJS in 70 in pts, and exploratory laparotomy in 2 pts. Baseline QOL questionnaires were completed by 103 (99.0%) pts. Among the 104 pts, 98 (94.2%), 100 (96.1%), and 81 (77.9%) completed the 2-wk, 1-m, and 3-m follow-up survey, respectively. The mean baseline EQ-5D score was 0.74 (SD, 0.21). During the follow-up period, the mean scores remained consistent with the baseline scores; the change from baseline score was within ± 0.05 for the index. Many pts came to eat solid food at 2 wks postsurgery and remained tolerable thereafter (from 0 at baseline to 82, 85, 75 pts at 2 wks, 1 m, and 3 ms, respectively). Overall morbidity rate of ≥grade 3 on Clavien-Dindo classification and 30-day postoperative mortality rate was 9.6% (10 pts) and 2.0% (2 pts) with a median hospital stay of 13 days and re-operation rate of 3.9% (4 pts). Conclusions: In pts with malignant GOO caused by advanced GC, surgical palliation maintained patient QOL while improving solid food intake with an acceptable surgical safety. Clinical trial information: UMIN000023494.

Phase II study of S-1 plus docetaxel as first-line treatment for elderly patients with advanced gastric cancer (OGSG0902)

129

Background: There is not enough evidence for the treatment of elderly patients with advanced gastric cancer. S-1 plus CDDP is one of the standard treatment for advanced gastric cancer in japan, but the efficacy remains insufficient due to the drug toxicity such as renal function disorders. The efficacy and safety of S-1 plus docetaxel as first-line treatment for elderly patients with unresectable advanced or recurrent gastric cancer were investigated. Methods: 75 years or older patients with unresectable advanced or recurrent gastric cancer were enrolled. Docetaxel was administered i.v. (40mg/m2) on day 1, while S-1 was administered orally (80mg/m2/day, b.i.d.) for 14 days followed by a 7-day rest. This schedule was repeated every 3 weeks. The primary endpoint was response rate (RR) of S-1 plus docetaxel; secondary endpoints were safety, progression free survival (PFS), time to treatment failure (TTF) and overall survival (OS). Sample size was set to be 30, which was determined to reject the response rate of 20% under the expectation of 40% with the power of 90% and two-sided alpha of 5%. Results: 31 patients were enrolled and assessable for efficacy. The response rate was 45.2% (95%CI 27.3-64.0, p = 0.001), and disease control rate was 77.4%. The median progression-free survival time was 5.8 months, the 1-year survival rate was 58.1%, and the median survival time was 16.1months. In 31 patients assessed for safety, the major grade 3/4 toxic effects were neutropenia (58%), febrile neutropenia (13%), anemia (10%), anorexia (10%), and fatigue (6%). Conclusions: These findings indicate that S-1 plus docetaxel as first-line treatment for elderly patients is feasible and shows promising efficacy against advanced gastric cancer. Clinical trial information: UMIN000002785.

Randomized clinical trial comparing standard diet with perioperative oral immunonutrition in total gastrectomy for gastric cancer

BACKGROUND

Total gastrectomy for gastric cancer is associated with excessive weight loss and decreased calorie intake. Nutritional support using eicosapentaenoic acid modulates immune function and limits catabolism in patients with advanced cancer, but its impact in the perioperative period is unclear.

METHODS

This was a randomized phase III clinical trial of addition of eicosapentaenoic acid-rich nutrition to a standard diet in patients having total gastrectomy for gastric cancer. Patients were randomized to either a standard diet or standard diet with oral supplementation of an eicosapentaenoic acid (ProSure®), comprising 600 kcal with 2·2 g eicosapentaenoic acid, for 7 days before and 21 days after surgery. The primary endpoint was percentage bodyweight loss at 1 and 3 months after surgery.

RESULTS

Of 127 eligible patients, 126 were randomized; 124 patients (61 standard diet, 63 supplemented diet) were analysed for safety and 123 (60 standard diet, 63 supplemented diet) for efficacy. Across both groups, all but three patients underwent total gastrectomy with Roux-en-Y reconstruction. Background factors were well balanced between the groups. Median compliance with the supplement in the immunonutrition group was 100 per cent before and 54 per cent after surgery. The surgical morbidity rate was 13 per cent in patients who received a standard diet and 14 per cent among those with a supplemented diet. Median bodyweight loss at 1 month after gastrectomy was 8·7 per cent without dietary supplementation and 8·5 per cent with eicosapentaenoic acid enrichment (P = 0·818, adjusted P = 1·000). Similarly, there was no difference between groups in percentage bodyweight loss at 3 months (P = 0·529, adjusted P = 1·000).

CONCLUSION

Immunonutrition based on an eicosapentaenoic acid-enriched oral diet did not reduce bodyweight loss after total gastrectomy for gastric cancer compared with a standard diet. Registration number: UMIN000006380 ( http://www.umin.ac.jp/).

Feasibility of weekly intraperitoneal versus intravenous paclitaxel therapy delivered from the day of radical surgery for gastric cancer: a preliminary safety analysis of the INPACT study, a randomized controlled trial

BACKGROUND

Peritoneal carcinomatosis is common after curative resection of gastric cancer. Intraperitoneal administration of paclitaxel (PTX) is known to control ovarian peritoneal metastases.

PATIENTS AND METHODS

Patients with either linitis plastica or T4 cancer with high risk of peritoneal metastasis or recurrence but whose cancer was considered resectable were preregistered. After their cancer had been confirmed intraoperatively as resectable, the patients were randomized into either group A (PTX at 60 mg/m² intraperitoneally on the day of surgery and on days 14, 21, 28, 42, 49, and 56) or group B (PTX at 80 mg/m² administered intravenously by the identical schedule) before being treated by evidence-based chemotherapy. The primary end point was the 2-year survival rate. Safety, the secondary end point, was also analyzed. The study has been registered as UMIN000002957.

RESULTS

Of 177 preregistered patients, 83 underwent treatment (39 by intraperitoneal administration and 44 by intravenous administration). There was no difference in patient demographics between the two groups. The incidences of surgical complications were similar between the groups, except for transient bowel obstruction observed exclusively in group A. The relative dose intensity of PTX was 81.4 % for group A and 76.3 % for group B. There was one death due to pulmonary thrombosis and a case of anaphylaxis that led to termination of the protocol treatment (group B). Other adverse events were mild and manageable.

CONCLUSIONS

Intraperitoneal administration of PTX from the day of gastrectomy did not result in a higher incidence of surgical complications and adverse reactions when compared with intravenous administration of PTX.

Multicenter randomized phase II study of cisplatin and fluorouracil plus docetaxel (DCF) compared with cisplatin and fluorouracil plus Adriamycin (ACF) as preoperative chemotherapy for resectable esophageal squamous cell carcinoma (OGSG1003)

BACKGROUND

This phase II trial evaluated the efficacy of cisplatin and fluorouracil (CF)-based combination neoadjuvant chemotherapy on the outcome of patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC). We compared the recurrence-free survival (RFS) associated with CF plus Adriamycin (ACF) with that associated with CF plus docetaxel (DCF) to select an alternative regimen in a new phase III trial investigating the optimal neoadjuvant treatment of patients with ESCC.

PATIENTS AND METHODS

Patients with resectable advanced ESCC were randomly assigned to either ACF (Adriamycin 35 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 7 days) every 4 weeks or DCF (docetaxel 70 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 5 days) every 3 weeks. Surgery was scheduled after completion of two cycles of chemotherapy. The primary end point was RFS, analyzed by the intention-to-treat.

RESULTS

Between October 2011 and October 2013, 162 patients at 10 institutions were enrolled in the study, all of whom were eligible and randomly assigned to the two groups (81 to the ACF group and 81 to the DCF group). The R0 resection rates for the ACF and DCF groups were equivalent (95.9% versus 96.2%, P = 0.93). The 2-year RFS and overall survival rates for DCF versus ACF were 64.1% versus 42.9% (hazard ratio 0.53, 95% confidence interval 0.33-0.83, P = 0.0057) and 78.6% versus 65.4% (P = 0.08), respectively.

CONCLUSION

Compared with ACF, DCF chemotherapy was associated with prolonged RFS for patients with resectable advanced ESCC. Thus, DCF chemotherapy has potential as a standard neoadjuvant therapy for resectable ESCC.

CLINICAL TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry of Japan (identification number UMIN000004555/000004616).

[Investigation of Administration Technique of Regorafenib in Our Center]

Regorafenib is an oral multikinase inhibitor; the CORRECTtrial evaluated its efficacy in patients with metastatic colorectal cancer following disease progression with standard therapies. However, regorafenib has toxicities that develop quickly. Few studies have reported the safe dose and usage of regorafenib to avoid these adverse events in Japanese patients. We examined the side effects and safe administration technique of regorafenib in this study. We administered regorafenib to 15 patients with metastatic colorectal cancer following disease progression with standard therapies. Between August 2013 and January 2014, 5 patients received 160 mg oral regorafenib once daily on days 1-21 of a 28 day course(group A). Between February 2014 and July 2015, 10 patients received initiating therapy with 120 mg regorafenib, with the intention of increasing the dose(group B). We retrospectively assessed side effects, number of dose courses, and total dose of regorafenib in both groups. The median dosing course was 5 coureses in group B, which was more than the 1 course in group A. The median total dose was 10,800 mg in group B, which is about 4 times as much as the 2,400 mg in group A. In group B, 7 out of 10 patients (70%)were successful in the dose escalation of regorafenib from 120 to 160 mg daily over 3-5 courses. The disease control rate was 40% in both groups. The rate of adverse events of Grade 3 or higher was 60% in group A, compared to 40% in group B within 2 courses. The overall survival time was 308 days in group B, which was significantly longer than the 168 days in group A. Initiating therapy with 120 mg regorafenib with the intention of increasing the dose improves safety and allows an increase in dosing courses, as well as in the total dose of regorafenib and overall survival time.