Phase II study of the antibody-drug conjugate TAK-264 (MLN0264) in patients with metastatic or recurrent adenocarcinoma of the stomach or gastroesophageal junction expressing guanylyl cyclase C

Background The first-in-class antibody-drug conjugate TAK-264 (formerly MLN0264) consists of an antibody targeting guanylyl cyclase C (GCC) conjugated to monomethyl auristatin E (MMAE) via a peptide linker. This phase II study evaluated the efficacy and safety of TAK-264 in patients with adenocarcinoma of the stomach or gastroesophageal junction expressing GCC, who had progressed on ≥1 line of prior therapy. Methods This study used a two-stage design, with an interim analysis conducted after stage I to determine whether to continue to stage II or discontinue on the grounds of futility. Adult patients with gastric and gastroesophageal junction adenocarcinoma expressing low, intermediate, or high GCC levels received TAK-264 1.8 mg/kg as a 30-min intravenous infusion once every 21 days, for up to 1 year. The primary endpoint was objective response rate. Radiographic assessments of tumor burden were performed every 2 cycles (6 weeks). Results A total of 38 patients participated in the study. Patients received a median of 2 (range 1-14) cycles; 8 (21%) received at least 6 cycles. The most common adverse events were nausea (53%), fatigue (32%), and decreased appetite (29%). Grade ≥3 events including anemia, diarrhea, and neutropenia were seen in 14 (37%) patients. Systemic exposure to TAK-264 was maintained throughout each treatment cycle. Two patients (6%) with intermediate GCC expression had objective responses. Conclusions TAK-264 demonstrated a manageable safety profile in this patient population. The stage I interim analysis did not support continuation to stage II of the study.

Effect of TCM music therapy for hospice care of patients with gastrointestinal cancer

AIM

To evaluate the effect of TCM music therapy for hospice care of patients with gastrointestinal cancer.

METHODS

One hundred and six patients with gastrointestinal cancer treated from April 2013 to January 2016 in the hospice ward of our hospital were randomly divided into either an observation group to receive TCM music therapy or a control group to receive basic therapy. Hamilton Depression Scale (HAMD) score, Karnofsky performance scale (KPS) score, and nursing satisfaction were compared between the two groups.

RESULTS

At 2 and 4 wk after treatment, the HAMD scores were significantly increased and the KPS scores were significantly decreased in both groups (P < 0.05), and the improvement was significantly better in the observation group than in the control group (P < 0.05). The rate of nursing satisfaction was significantly higher in the observation group than in the control group (90.57% vs 69.81%).

CONCLUSION

Chinese music therapy can significantly improve the hospice care of patients in terms of reducing depression and improving the functional status of patients.

Treatment Options in Oligometastatic Disease: Stereotactic Body Radiation Therapy - Focus on Colorectal Cancer

BACKGROUND

Improvements in systemic therapy for metastatic colorectal cancer (CRC) have markedly extended survival, rendering local control of metastases to critical organs of increasing importance, especially in the oligometastatic setting where the disease may not yet have acquired the ability to widely disseminate. While surgical resection remains the gold standard for oligometastases in many organs, stereotactic body radiation therapy (SBRT) presents a non-invasive alternative for achieving local control.

METHODS

A literature review was performed to identify and summarize the findings of key prospective and retrospective studies that have shaped the field of SBRT for oligometastases to the lung, liver, and spine with a focus on oligometastases from CRC in particular.

RESULTS

Modern dose-escalated SBRT regimens can achieve 1-year local control rates of 77-100%, 90-100%, and 81-95% for oligometastases involving the lung, liver, and spine, respectively. Rates of grade 3 or greater toxicity with contemporary SBRT techniques are consistently low at <10% in the lung, <5% in the liver, and <2%/8% for neurologic/non-neurologic toxicity in the spine, respectively.

CONCLUSION

SBRT appears safe and effective for treating oligometastases involving the lung, liver, and spine. Randomized trials comparing SBRT to surgical resection and other local therapeutic modalities for the treatment of CRC oligometastases bear consideration.

Differences in symptom occurrence, severity, and distress ratings between patients with gastrointestinal cancers who received chemotherapy alone or chemotherapy with targeted therapy

BACKGROUND

Approximately 28% of patients with gastrointestinal (GI) cancers will receive targeted therapy (TT) because of the associated increases in survival. Only four studies have examined the symptom experience of these patients. To date, no studies have evaluated for differences in symptom occurrence, severity, and distress between patients who received chemotherapy (CTX) alone (n=304) or CTX with TT (n=93).

METHODS

Patients completed self-report questionnaires, approximately one week after they received CTX. A modified version of the Memorial Symptom Assessment Scale (MSAS) was used to obtain data on symptom occurrence, severity, and distress. Binary logistic regression analyses were used to test for differences in symptom occurrence rates between the two treatment groups. Ordinal logistic regression analyses were used to test for differences in severity and distress ratings between the two treatment groups.

RESULTS

Patients who received CTX with TT were significantly younger (P=0.009); were diagnosed with cancer longer (P=0.004); had a higher number of prior treatments (P=0.024); had metastatic disease, specifically to the liver (P<0.001); had a diagnosis of anal, colon, rectum, or colorectal cancer (CRC) (P<0.001); and were positive for detection of B-Raf proto-oncogene, serine/threonine kinase (BRAF) and Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations (both P<0.001). In addition, CTX treatment regimens were significantly different between the two groups (P<0.001). After controlling for significant covariates, patients who received TT reported lower occurrence rates for lack of energy, cough, feeling drowsy, and difficulty sleeping (all, P<0.05). Patients who received TT reported lower severity scores for dry mouth (P=0.034) and change in the way food tastes (P=0.035). However, they reported higher severity scores for "I don't look like myself" (P=0.026). No differences in symptom distress scores were found between the two treatment groups.

CONCLUSIONS

This study is the first to evaluate for differences in the symptom experience of GI cancer patients who received CTX alone or CTX with TT using a multidimensional symptom assessment scale. While between group differences in patients' symptom experiences were identified, both treatment groups warrant ongoing assessments to optimally manage their symptoms.

Clinical Performance of CEA, CA19-9, CA15-3, CA125 and AFP in Gastrointestinal Cancer Using LOCI™-based Assays

BACKGROUND/AIM

Few data are available regarding the clinical performance of LOCI™-based tumor marker assays. We investigated the diagnostic power of carcinogenic antigen, carbohydrate antigen 19-9, carbohydrate antigen 15-3, carbohydrate antigen 125 and alpha-fetoprotein for detection of gastrointestinal (GI) cancer.

PATIENTS AND METHODS

We analyzed sera from 204 patients (107 with GI cancer, 73 with benign GI diseases and 24 healthy controls) using the Dimension™ Vista1500 analyzer.

RESULTS

Levels of biomarkers in healthy controls were in the expected ranges and were only slightly higher in benign GI controls. Established tumor-type-associated markers were elevated in specific cancer types and discriminated well between cancer and benign controls. Best performance was found for CEA in colorectal cancer (area under the curve=0.84, sensitivity=51.7% at 95% specificity vs. benign), CA19-9 in gallbladder/pancreatic cancer (AUC=0.85, sensitivity=60.6%) and AFP in liver cancer (AUC=0.87, sensitivity=68.4%).

CONCLUSION

Our study demonstrated the high diagnostic power of well-known biomarkers. LOCI™-based tumor marker assays give reliable results in routine diagnostics.

Role of mathematical medicine in gastrointestinal carcinoma: Current status and perspectives

Mathematical medicine has already played an important role in clinical and basic research as a major interdisciplinary branch of medicine. Mathematical medicine has an important role not only in imaging diagnosis, image storage and transmission in gastrointestinal (GI) cancer, but also in tumor precision therapy. Specifically, in the field of minimally invasive treatment such as precise ablation, 3-dimension modeling, navigation, and surgical simulation significantly improve the therapeutic safety and efficiency in GI cancer. In addition, in the era of big data, data analysis and individualized therapy using mathematical medicine will become a trend in the future, offering an effective method for diagnosing and treating GI cancer and promoting clinical and scientific research.

Association of IL4, IL13, and IL4R polymorphisms with gastrointestinal cancer risk: A meta-analysis

Background

Previous studies have suggested that IL4, IL13, and IL4R are associated with serum IgE levels and allergies, and common variants of these genes may alter cancer risk. To clarify these associations, we conducted a meta-analysis to investigate the associations of IL4, IL13, and IL4R polymorphisms with gastrointestinal cancer risk.

Methods

We used 27 eligible case–control studies describing the associations of six polymorphisms of IL4, IL13, and IL4R with gastrointestinal cancer risk to calculate summary odds ratios (ORs) and 95% confidence intervals (CIs) using five different genetic models. The Q-statistic and I² statistic were calculated to examine heterogeneity.

Results

The IL4 rs2070874 T allele seems to be associated with an increased risk of gastrointestinal cancer (OR 1.11; 95% CI, 1.00–1.24 for T allele vs. C allele). This association was significant in studies conducted outside of Asia (OR 1.28; 95% CI, 1.03–1.58 for T allele vs. C allele) and in studies investigating the association with gastric cancer (OR 1.17; 95% CI, 1.03–1.34 for T allele vs. C allele). However, the IL4R rs1801275 heterozygote seems to be associated with a reduced risk of gastrointestinal cancer (OR 0.79; 95% CI, 0.65–0.96 for AG vs. AA). Other polymorphisms did not show any significant associations with gastrointestinal cancer risk in any of the genetic models and subgroup analyses.

Conclusions

Our results suggest that certain polymorphisms of IL4 and IL4R may affect susceptibility to gastrointestinal cancer. However, further studies are required to confirm these findings.

•

This meta-analysis included 27 eligible case–control studies.

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IL4 rs2070874 T allele may increase the risk of gastrointestinal cancer.

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IL4R rs1801275 variant may reduce the risk of gastrointestinal cancer.

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Polymorphisms in IL4 and IL4R may affect susceptibility to gastrointestinal cancer.

Application of genome editing technologies in gastrointestinal cancers

Genome editing is a site-directed modification technology for gene targeting and a powerful tool to edit the target DNA by site-specific DNA knockout or knockin. Genome editing has achieved a considerable success from lower microbes to human in the past years and may play a very important role in tumor staging, precision medicine as well as prognosis evaluation in gastrointestinal cancers. This review discusses the mechanisms of different genome-editing strategies and describes each of the common nuclease-based platforms, including transcription activator-like effector nucleases, zinc finger nucleases and the CRISPR/Cas9 system. We also summarize the progress made in applying genome editing to the research of gastrointestinal cancers.

Metastasis-associated long noncoding RNAs in gastrointestinal cancer: Implications for novel biomarkers and therapeutic targets

Long non-coding RNAs (lncRNAs), a newly discovered class of ncRNA molecules, have been widely accepted as crucial regulators of various diseases including cancer. Increasing numbers of studies have demonstrated that lncRNAs are involved in diverse physiological and pathophysiological processes, such as cell cycle progression, chromatin remodeling, gene transcription, and posttranscriptional processing. Aberrant expression of lncRNAs frequently occurs in gastrointestinal cancer and plays emerging roles in cancer metastasis. In this review, we focus on and outline the regulatory functions of recently identified metastasis-associated lncRNAs, and evaluate the potential roles of lncRNAs as novel diagnostic biomarkers and therapeutic targets in gastrointestinal cancer.

Particle Radiation Therapy for Gastrointestinal Cancers

Particle irradiation of cancerous disease has gained great traction in recent years. The ability for particle therapy centers to deliver radiation with a highly conformal dose distribution while maintaining minimal exit or excess dose delivered to normal tissue, coupled with various biological advantages particularly found with heavy-ion beams, enables treatment of diseases inapproachable with conventional radiotherapy. Here, we present a review of the current status of particle therapy with regard to cancers of the gastrointestinal tract, including esophagus, liver, pancreas, and recurrent rectal cancer.

Final results and outcomes by prior bevacizumab exposure, skin toxicity, and hypomagnesaemia from ASPECCT: randomized phase 3 non-inferiority study of panitumumab versus cetuximab in chemorefractory wild-type KRAS exon 2 metastatic colorectal cancer

PURPOSE

The primary analysis of the ASPECCT study demonstrated that panitumumab was non-inferior to cetuximab for overall survival (OS) in patients with chemotherapy-refractory wild-type KRAS exon 2 metastatic colorectal cancer (mCRC). Here, we report the final analysis results of ASPECCT.

PATIENTS AND METHODS

Patients with wild-type KRAS exon 2 mCRC who progressed on or were intolerant to irinotecan- or oxaliplatin-based chemotherapy were randomised to receive panitumumab 6 mg/kg once every 2 weeks or cetuximab (400 mg/m²) followed by 250 mg/m² weekly. The primary end-point was OS assessed for non-inferiority. Patients were followed for survival for 24 months after the last patient was randomised and a final analysis was conducted. No formal hypothesis testing was done. Post hoc analyses of outcomes by prior bevacizumab exposure, worst-grade skin toxicity (0-1 versus 2-4) and worst-grade hypomagnesaemia (0 versus 1-4) were conducted.

RESULTS

Nine hundred ninety-nine patients were randomised and received ≥1 treatment dose (panitumumab, n = 499; cetuximab, n = 500). Median OS was 10.2 months with panitumumab versus 9.9 months with cetuximab (hazard ratio = 0.94; 95% confidence interval = 0.82-1.07). Median progression-free survival was 4.2 months with panitumumab and 4.4 months with cetuximab (hazard ratio = 0.98; 95% confidence interval = 0.87-1.12). Longer OS was observed for patients with increased skin toxicity and with hypomagnesaemia in both arms. Furthermore, OS was longer for patients with prior bevacizumab exposure treated with panitumumab than with cetuximab. The observed safety profiles were consistent with previous studies.

CONCLUSION

Consistent with the primary analysis, the final analysis of ASPECCT showed panitumumab was non-inferior to cetuximab for OS for patients with chemotherapy-refractory, wild-type KRAS exon 2 mCRC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01001377.

Oncolytic viruses against cancer stem cells: A promising approach for gastrointestinal cancer

Gastrointestinal cancer has been one of the five most commonly diagnosed and leading causes of cancer mortality over the past few decades. Great progress in traditional therapies has been made, which prolonged survival in patients with early cancer, yet tumor relapse and drug resistance still occurred, which is explained by the cancer stem cell (CSC) theory. Oncolytic virotherapy has attracted increasing interest in cancer because of its ability to infect and lyse CSCs. This paper reviews the basic knowledge, CSC markers and therapeutics of gastrointestinal cancer (liver, gastric, colon and pancreatic cancer), as well as research advances and possible molecular mechanisms of various oncolytic viruses against gastrointestinal CSCs. This paper also summarizes the existing obstacles to oncolytic virotherapy and proposes several alternative suggestions to overcome the therapeutic limitations.

A dose-finding study for oxaliplatin, irinotecan, and S-1 (OIS) in patients with metastatic or recurrent gastrointestinal cancer

PURPOSES

To determine the maximum tolerated dose (MTD), recommended dose (RD), and activity of combined oxaliplatin, irinotecan, and S-1 chemotherapy for metastatic or recurrent gastrointestinal (GI) cancer.

METHODS

Oxaliplatin and irinotecan were administered intravenously on day 1, and S-1 was administered orally on days 1-7, every 2 weeks. This phase I study used the following dose levels for oxaliplatin/irinotecan/S-1: level 1, 85/120/60 mg/m²; level 2, 85/120/80 mg/m²; level 3, 85/120/100 mg/m²; level 4, 85/150/100 mg/m²; and level 5, 85/180/100 mg/m². Treatment was repeated for a maximum of 12 cycles, until disease progression, or until unacceptable toxicity.

RESULTS

Twenty-four patients were enrolled between October 2012 and February 2014 (median age 59 years). During the first cycle, one of the six patients in levels 1, 3, and 4 developed a dose-limiting toxicity (grade 3 febrile neutropenia), and none of the three patients in level 5 developed a dose-limiting toxicity. As the planned maximum dose did not reach the MTD, the level 5 dose was defined as the RD. Twenty-one patients were evaluated for response, which included 2 cases of complete response and 8 cases of partial response, with an overall response rate of 47.6 %.

CONCLUSIONS

The combination of oxaliplatin, irinotecan, and S-1 provided an acceptable toxicity profile and modest clinical benefits in patients with advanced GI cancer. The RD was 85 mg/m² of oxaliplatin, 180 mg/m² of irinotecan, and 100 mg/m² of S-1 every 2 weeks.

Heritable Gastrointestinal Cancer Syndromes

Although almost all gastrointestinal cancers develop from sporadic genomic events, approximately 5% arise from germline mutations in genes associated with cancer predisposition. The number of these genes continues to increase. Tumor phenotypes and family history provide the framework for identifying at-risk individuals. The diagnosis of a hereditary cancer syndrome has implications for management of patients and their families. Systematic approaches that integrate family history and molecular characterization of tumors and polyps facilitate identification of individuals with this genetic predisposition. This article summarizes diagnosis and management of hereditary cancer syndromes associated with gastrointestinal cancers.

Molecular Detection of Gastrointestinal Neoplasia: Innovations in Early Detection and Screening

Emerging molecular tools promise to extend the diagnostic reach of the endoscopist and open doors to population screening for gastrointestinal (GI) cancers. This review briefly addresses biological considerations in marker detection and types of markers, highlights examples of tools under development at each organ site, and appraises the possibility of universal GI cancer screening. The outlook is positive, but further technical refinement and rigorous clinical validation are needed before most of these new approaches are ready for clinical application.

Phase 1 Dose Escalation Study of MEDI-565, a Bispecific T-Cell Engager that Targets Human Carcinoembryonic Antigen, in Patients With Advanced Gastrointestinal Adenocarcinomas

INTRODUCTION

MEDI-565, a bispecific, single-chain antibody targeting human carcinoembryonic antigen on tumor cells and the CD3 epsilon subunit of the human T-cell receptor complex, showed antitumor activity in carcinoembryonic antigen-expressing tumors in murine models.

PATIENTS AND METHODS

This phase I, multicenter, open-label dose escalation study enrolled adults with gastrointestinal adenocarcinomas. MEDI-565 was given intravenously over 3 hours on days 1 through 5 in 28-day cycles, with 4 single-patient (0.75-20 μg) and 5 standard 3 + 3 escalation (60 μg-3 mg; 1.5-7.5 mg with dexamethasone) cohorts. Primary objective was determining maximum tolerated dose; secondary objectives were evaluating pharmacokinetics, antidrug antibodies, and antitumor activity.

RESULTS

Thirty-nine patients were enrolled (mean age, 59 years; 56% male; 72% colorectal cancer). Four patients experienced dose-limiting toxicities (2 at 3 mg; 2 at 7.5 mg + dexamethasone): hypoxia (n = 2), diarrhea, and cytokine release syndrome (CRS). Five patients reported grade 3 treatment-related adverse events: diarrhea, CRS, increased alanine aminotransferase, hypertension (all, n = 1), and hypoxia (n = 2); 6 experienced treatment-related serious adverse events: diarrhea, vomiting, pyrexia, CRS (all, n = 1), and hypoxia (n = 2). MEDI-565 pharmacokinetics was linear and dose-proportional, with fast clearance and short half-life. Nineteen patients (48.7%) had antidrug antibodies; 5 (12.8%) had high titers, 2 with decreased MEDI-565 concentrations. No objective responses occurred; 11 (28%) had stable disease as best response.

CONCLUSIONS

The maximum tolerated dose of MEDI-565 in this patient population was 5 mg administered over 3 hours on days 1 through 5 every 28 days, with dexamethasone. Pharmacokinetics were linear. No objective responses were observed.

Management of radiation and chemotherapy related acute toxicity in gastrointestinal cancer

Possible toxic effects following radiation and chemotherapy of gastrointestinal tumours may cause a depletion of the mucosal barrier within the radiation volumes with severe mucositis. Diarrhoea, nausea, emesis and severe malabsorption followed by infections with dehydration and electrolyte disorders have to be encountered. For prevention and treatment of oropharyngeal mucositis an oral care protocol, oral cryotherapy together with benzydamine mouthwash may be recommended. Lower gastrointestinal diarrhoea is best treated by Octreotide (>100 μg s.c. bid) if loperamide is ineffective and amifostine (340 mg/m(2) IV) to prevent radiation proctitis. Enteral nutrition may be necessary with severe malnutrition or no enteral food intake for >7days or insufficient intake (<60%) for >10 days. With severe generalized mucositis or severe radiation induced enteritis parenteral nutrition will be initiated. Following the application of highly emetogenic chemotherapy regimen, 5-HT3 antagonists, dexamethasone and aprepitant, whereas in moderate risk levels 5-HT3 antagonist plus dexamethasone may be sufficient.

Oesophagus side effects related to the treatment of oesophageal cancer or radiotherapy of other thoracic malignancies

The oesophagus as a serial organ located in the central chest is frequent subject to "incidental" dose application in radiotherapy for several thoracic malignancies including oesophageal cancer itself. Especially due to the radiosensitive mucosa severe radiotherapy induced sequelae can occur, acute oesophagitis and strictures as late toxicity being the most frequent side-effects. In this review we focus on oesophageal side effects derived from treatment of gastrointestinal cancer and secondly provide an overview on oesophageal toxicity from conventional and stereotactic fractionated radiotherapy to the thoracic area in general. Available data on pathogenesis, frequency, onset, and severity of oesophageal side effects are summarized. Whereas for conventional radiotherapy the associations of applied doses to certain volumes of the oesophagus are well described, the tolerance dose to the mediastinal structures for hypofractionated therapy is unknown. The review provides available attempts to predict the risk of oesophageal side effects from dosimetric parameters of SBRT.

Role of B7-H1 in gastrointestinal cancer

Immune evasion is a hallmark of cancer. Although cancer cells have been shown to be able to be recognized by T cells, host immune system fails to develop effective antitumor activity and tumor control. B7-H1, an immune inhibitory molecule, plays an important role in the immune evasion process. B7-H1 inhibits T cell immunity during immune priming and effector phases and is also implicated in intrinsic proliferation, apoptosis and migration of tumor cells. Targeting B7-H1 using blockade antibodies has generated immense antitumor activity in preclinical tumor models. Durable response for a variety of tumor types was also documented in clinical trials. Thus, B7-H1 targeted immune therapy offers a new line of tumor treatment. Gastrointestinal cancer is one of the leading causes of tumor morbidity. However, traditional therapy has not been able to effectively improve survival. This review will focus on the role of B7-H1 in immune evasion and the latest progression of the B7-H1 blockade immune therapy in gastrointestinal cancer.

Impact of home enteral nutrition in malnourished patients with upper gastrointestinal cancer: A multicentre randomised clinical trial

BACKGROUND

Weight loss is frequent in patients with gastrointestinal (GI) cancer. Nutritional status deteriorates throughout anti-cancer treatment, mostly after major surgery, increasing complications, reducing tolerance and worsening the final prognosis. Enteral nutrition is safe and effective in malnourished patients undergoing major GI surgery. Randomised trials aimed at investigating the effects of home enteral nutrition (HEN) in post-surgical patients with GI cancer are lacking. This study compares HEN and counselling in limiting weight loss during oncologic treatment.

PATIENTS AND METHODS

Patients with upper GI cancer and candidate to major surgery were included in the protocol when the nutritional risk screening (NRS 2002) score was ≥3. All patients were supported with enteral nutrition through a jejunostomy after surgery and randomly assigned to continue enteral nutrition or receiving nutritional counselling after discharge. Nutritional and performance status, quality of life (QoL) and tolerance to cancer treatment have been evaluated at 2 and 6 months after discharge.

RESULTS

Seventy-nine patients were randomised; 38 continued enteral nutrition at home and 41 patients received nutritional counselling only. After 2 months, patients on HEN maintained their mean body weight, while patients in the nutritional counselling group showed a weight loss of 3.6 kg. Patients supported on HEN had a higher chance to complete chemotherapy as planned (48% versus 34%). QoL was not worsened by HEN. No complications were reported.

CONCLUSIONS

HEN is a simple and feasible treatment to support malnourished patients with upper GI cancer after major surgery and during chemotherapy in order to limit further weight loss.

Optimal postoperative nutrition support for patients with gastrointestinal malignancy: A systematic review and meta-analysis

OBJECTIVE

To improve clinical outcomes, parenteral nutrition, standard enteral nutrition and immuno-enhanced nutrition are widely used in the gastrointestinal tumor patients undergoing surgery, but the optimal management of postoperative nutrition support remains uncertain.

METHODS

We systematically searched the PUBMED, EMBASE and CNKI to identify latent studies which the effects of standard EN compared with PN or IEN on gastrointestinal tumor patients until the end of November, 2015. The quality of included trials was assessed according to the handbook for Cochrane reviewer. Statistical analysis was carried out by RevMan5.1 software.

RESULTS

30 randomized controlled trials containing 3854 patients were contained in our meta-analysis, the results indicated that postoperative SEN could absolutely reduce the incidence of postoperative infectious (P < 0.00001) and non-infectious complications (P = 0.0003), together with its positive effect on the length of hospital stay (P < 0.00001). Additionally, enteral nutrition enhanced with immune stimulation was confirmed to be better, with a significant difference between groups in terms of total infectious (P < 0.00001) and non-infectious complications (P = 0.04), and IEN could also significantly shorten the length of hospital stay (P < 0.00001).

CONCLUSION

Early use of Enteral nutrition in digestive tumor patients after surgery could significantly reduce the postoperative complications and shorten the length of hospital stay, IEN should be the optimal management, while the use of parenteral nutrition should be restrict to few patients with severe intolerance to enteral nutrition.

Exosomes: novel implications in diagnosis and treatment of gastrointestinal cancer

BACKGROUND

Amongst all cancer subtypes, gastrointestinal tumours are responsible for most cancer-related deaths. In most of the cases, the limitation of the prognosis of patients with malignant gastrointestinal tumours can be attributed to delayed diagnosis of the disease. In the last decade, secondary prevention strategies, in particular tumour screenings, have been identified to significantly improve the identification of patients with early-stage disease, leading to more effective therapeutic interventions. Therefore, new screening methods and further innovative treatment approaches may lead to an increase in progression-free and overall survival rates.

PURPOSE

Exosomes are small microvesicles with a size of 50-150 nm. They are formed in the endosomal system of many different cell types, where they are packed with nucleotides and proteins from the parental cell. After their release into the extracellular space, exosomes can deliver their cargo into recipient cells. By this mechanism, tumour cells can recruit and manipulate the adjacent and systemic microenvironment in order to support invasion and dissemination. Cancer-derived exosomes in the blood may provide detailed information about the tumour biology of each individual patient. Moreover, tumour-derived exosomes can be used as targetable factors and drug delivery agents in clinical practice.

CONCLUSION

In this review, we summarise new aspects about novel implications in the diagnosis and treatment of gastrointestinal cancer and show how circulating exosomes have come into the spotlight of research as a high potential source of 'liquid biopsies'.

Preoperative Chemoradiation With VMAT-SIB in Rectal Cancer: A Phase II Study

PURPOSE

The aim of this study was to investigate the efficacy and toxicity of volumetric modulated arc therapy (VMAT)-simultaneous integrated boost (SIB) in preoperative combined treatment of locally advanced rectal cancer.

METHODS

Radiation therapy was performed using the VMAT-SIB technique. The dose to mesorectum and pelvic lymph nodes was 45 Gy (1.8 Gy/fraction). A concomitant boost was delivered on GTV + 2-cm margin with a total dose of 57.5 Gy (2.3 Gy/fraction). The following concomitant chemotherapy was administered: capecitabine (825 mg/m² twice daily, 5 days per week) and oxaliplatin (130 mg/m² on days 1, 17, and 35). Efficacy was evaluated in terms of complete pathological response (pCR). Acute toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 3.0 criteria.

RESULTS

A total of 18 patients (7 women; median age 62 years; clinical stage: 4 local recurrences, 6 cT4, 5 cT3, 3 cT2, 2 cN0, 7 cN1, 9 cN2) were enrolled. Sixteen patients underwent surgical resection (9 low anterior resection, 6 abdominal perineal amputations; 1 transanal excision) and 2 patients did not undergo surgery for early metastatic progression or death from acute pulmonary edema. R0 resection was achieved in all patients who underwent surgery. Overall, 4 patients had a pCR and 7 patients only a microscopic residual of disease (pT0-Tmic: 11/18 = 61.1%; 95% CI, 36.2-86.1). Acute grade ≥ 3 toxicity was as follows: 1 case of leukopenia, 1 skin toxicity, 1 genitourinary toxicity, and 5 gastrointestinal toxicities, with an overall incidence of 8 (44.4%) of 18 patients. One-, 3-, and 5-year cumulative local control was 100%, 68.6%, and 68.6%, respectively. One-, 3-, and 5-year cumulative disease-free survival was 88.9%, 66.7%, and 66.7%, respectively. One-, 3-, and 5-year cumulative overall survival was 85%, 63.8%, and 63.8%, respectively.

CONCLUSION

The regimen used in this study showed excellent results in terms of pathologic responses. However, despite the use of the VMAT technique, more than one-third of patients had severe acute toxicity.

Is mucin a determinant of peritoneal dissemination of gastrointestinal cancer? Analysis of mucin depletion in two preclinical models

BACKGROUND

Mucinous gastrointestinal cancers may indicate a higher propensity for widespread peritoneal seeding than their non-mucinous counterparts. We hypothesized that mucin content of gastrointestinal cancer cells and tumors is an indicator of cell viability and a determinant of the peritoneal tumor burden and tested our hypothesis in relevant experimental models.

METHODS

MKN45 and LS174T models of human gastrointestinal cancer were treated with known mucin-depleting agents in vitro and in vivo, their mucin production was evaluated with Western blot immunohistochemistry, PAS staining and ELISA, and its correlation with cell viability and peritoneal tumor burden was analyzed.

RESULTS

A relationship was found between the viability of cancer cells and their mucin levels in vitro. In agreement, when treated animal models were categorized into low- and high-burden groups (based on the weight and number of the peritoneal nodules), tumoral mucin levels were found to be significantly higher in the latter group.

CONCLUSIONS

Tumoral mucin is apparently among the factors that dictate the pattern and extent of the peritoneal spread of gastrointestinal cancer, where it allows for enhanced dissemination and redistribution. If further tested and validated, our hypothesis could lay the basis for the development of novel mucin-targeted strategies.

Design of a multicentre randomized controlled trial to evaluate the effectiveness of a tailored clinical support intervention to enhance return to work for gastrointestinal cancer patients

Background

Gastrointestinal (GI) cancer is frequently diagnosed in people of working age, and many GI cancer patients experience work-related problems. Although these patients often experience difficulties returning to work, supportive work-related interventions are lacking. We have therefore developed a tailored work-related support intervention for GI cancer patients, and we aim to evaluate its cost-effectiveness compared with the usual care provided. If this intervention proves effective, it can be implemented in practice to support GI cancer patients after diagnosis and to help them return to work.

Methods/Design

We designed a multicentre randomized controlled trial with a follow-up of twelve months. The study population (N = 310) will include individuals aged 18–63 years diagnosed with a primary GI cancer and employed at the time of diagnosis. The participants will be randomized to the intervention or to usual care. ‘Usual care’ is defined as psychosocial care in which work-related issues are not discussed. The intervention group will receive tailored work-related support consisting of three face-to-face meetings of approximately 30 min each. Based on the severity of their work-related problems, the intervention group will be divided into groups receiving three types of support (A, B or C). A different supportive healthcare professional will be available for each group: an oncological nurse (A), an oncological occupational physician (B) and a multidisciplinary team (C) that includes an oncological nurse, oncological occupational physician and treating oncologist/physician. The primary outcome measure is return to work (RTW), defined as the time to a partial or full RTW. The secondary outcomes are work ability, work limitations, quality of life, and direct and indirect costs.

Discussion

The hypothesis is that tailored work-related support for GI cancer patients is more effective than usual care in terms of the RTW. The intervention is innovative in that it combines oncological and occupational care in a clinical setting, early in the cancer treatment process.

Trial registration

METC protocol number NL51444.018.14/Netherlands Trial Register number NTR5022. Registered 6 March 2015.

Application of next-generation sequencing in gastrointestinal and liver tumors

Malignant transformation of normal cells is associated with the evolution of genomic alterations. This concept has led to the development of molecular testing platforms to identify genomic alterations that can be targeted with novel therapies. Next generation sequencing (NGS) has heralded a new era in precision medicine in which tumor genes can be studied efficiently. Recent developments in NGS have allowed investigators to identify genomic predictive makers and hereditary mutations to guide treatment decision. The application of NGS in gastrointestinal cancers is being extensively studied but continues to face substantial challenges. In our review, we discuss various NGS platforms and highlight their role in identifying familial mutations and markers of response or resistance to cancer therapy. We also provide a balanced discussion of the challenges that limit the routine use of NGS in clinical practice.

Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review

Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.

Emerging role of cystic fibrosis transmembrane conductance regulator - an epithelial chloride channel in gastrointestinal cancers

Cystic fibrosis transmembrane conductance regulator (CFTR), a glycoprotein with 1480 amino acids, has been well established as a chloride channel mainly expressed in the epithelial cells of various tissues and organs such as lungs, sweat glands, gastrointestinal system, and reproductive organs. Although defective CFTR leads to cystic fibrosis, a common genetic disorder in the Caucasian population, there is accumulating evidence that suggests a novel role of CFTR in various cancers, especially in gastroenterological cancers, such as pancreatic cancer and colon cancer. In this review, we summarize the emerging findings that link CFTR with various cancers, with focus on the association between CFTR defects and gastrointestinal cancers as well as the underlying mechanisms. Further study of CFTR in cancer biology may help pave a new way for the diagnosis and treatment of gastrointestinal cancers.

The impact of preoperative corticosteroids on the systemic inflammatory response and postoperative complications following surgery for gastrointestinal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis examined the impact of preoperative corticosteroids on interleukin 6 (IL-6), C-reactive protein (CRP), and complications following surgery for gastrointestinal cancer.

METHODS

A systematic review was performed using appropriate keywords. Random-effects meta-analysis was performed.

RESULTS

11 RCTs with 474 patients, were included. Corticosteroids were significantly associated with lower IL-6 on postoperative day 1 (mean difference -148pg/mL, 95% CI -205 to -92, p<0.001), 2 (-33pg/mL, 95% CI -58 to -8, p=0.01), and 3 (-31pg/mL, 95% CI -52 to -11, p=0.002), lower CRP on day 3 (-45mg/L, 95% CI -68 to -21, p<0.001), and 7 (-14mg/L, 95% CI -27 to -1, p=0.04), and fewer postoperative infective complications (OR 0.47, 95% CI 0.26-0.83, p=0.01).

CONCLUSION

Corticosteroids were associated with reduction in the postoperative systemic inflammatory response and complications following surgery for gastrointestinal cancer.

Epigenetic field cancerization in gastrointestinal cancers

Epigenetic alterations, including aberrant DNA methylation, play an important role in human cancer development. Importantly, epigenetic alterations are reversible and can be targets for therapy or chemoprevention for various types of human cancers. A field for cancerization, or a field defect, is formed by the accumulation of genetic and/or epigenetic alterations in normal-appearing tissues and can correlate with risk of cancer development. Thus, a better understanding of epigenetic field cancerization may represent a useful translational opportunity for cancer risk assessment, including previous history and exposure to carcinogenic factors, and for cancer prevention. In this article, we summarize current knowledge regarding epigenetic field cancerization and its clinical implications in gastrointestinal cancers, including colorectal cancer, gastric cancer and esophageal cancer.

Esophageal squamous cell cancer in a highly endemic region

AIM: To identify risk factors associated with esophageal cancer in Zambia and association between dietary intake and urinary 8-iso prostaglandin F2α (8-isoPGF2α).

METHODS: We conducted a prospective, case control study at the University Teaching Hospital. Subjects included both individuals admitted to the hospital and those presenting for an outpatient upper endoscopy. Esophageal cancer cases were compared to age and sex-matched controls. Cases were defined as patients with biopsy proven esophageal cancer; controls were defined as subjects without endoscopic evidence of esophageal cancer. Clinical and dietary data were collected using a standard questionnaire, developed a priori. Blood was collected for human immunodeficiency virus (HIV) serology. Urine was collected, and 8-isoPGF2α was measured primarily by enzyme-linked immunosorbent assay and expressed as a ratio to creatinine.

RESULTS: Forty five controls (mean age 54.2 ± 15.3, 31 male) and 27 cases (mean age 54.6 ± 16.4, 17 males) were studied. Body mass index was lower in cases (median 16.8) than controls (median 23.2), P = 0.01. Histopathologically, 25/27 (93%) were squamous cell carcinoma and 2/27 (7%) adenocarcinoma. More cases smoked cigarettes (OR = 11.24, 95%CI: 1.37-92.4, P = 0.02) but alcohol consumption and HIV seropositivity did not differ significantly (P = 0.14 for both). Fruit, vegetables and fish consumption did not differ significantly between groups (P = 0.11, 0.12, and 0.10, respectively). Mean isoprostane level was significantly higher in cases (0.03 ng/mg creatinine) than controls (0.01 ng/mg creatinine) (OR = 2.35, 95%CI: 1.19-4.65, P = 0.014).

CONCLUSION: Smoking and isoprostane levels were significantly associated with esophageal cancer in Zambians, but diet, HIV status, and alcohol consumption were not.

Chemotherapy with or without autologous cytokine-induced killer cell transfusion as the first-line treatment for stage IV gastrointestinal cancer: a phase II clinical trial

OBJECTIVE

To investigate the efficacy of autologous cytokine-induced killer (CIK) cell therapy combined with chemotherapy versus chemotherapy alone for the treatment of stage IV gastrointestinal (GI) cancer in the first-line setting.

METHODS

Thirty-three patients diagnosed with stage IV GI cancer were divided into chemotherapy plus CIK group (chemo-CIK, n = 16) and chemotherapy-alone group (chemo-alone, n = 17). Autologous peripheral blood mononuclear cells were separated by flow cytometry, cultured in vitro to induce CIK cells, and transfused into patients on days 14 and 16 of the first and second chemotherapy cycles.

RESULTS

The median progression-free survival (PFS) was 5.6 months for patients in the chemo-CIK group and 3.83 months for those in the chemo-alone group. The difference was borderline significant (P = 0.06), indicating a potential advantage for combined CIK cell transfusion with chemotherapy in improving PFS. A favored objective response rate was also observed in the chemo-CIK group than in the chemo-alone group. This study also revealed that CIK cell transfusion restored the cellular immunity in these GI cancer patients. The percentage of natural killer T cells, NK cells, CD3(+) T cells, and T-cell subgroups CD4(+) proportion in the peripheral blood of cancer patients significantly increased after the CIK cell transfusion, while the change in T-cell subgroups CD8(+) and CD4(+)/CD8(+) did not differ significantly.

CONCLUSIONS

The study showed that the addition of CIK cell transfusion to traditional chemotherapy in the first-line setting was associated with a prolonged PFS and enhanced T-lymphocyte subset activity, supporting a potential treatment choice for advanced GI cancer patients.

A phase III study evaluating oral glutamine and transforming growth factor-beta 2 on chemotherapy-induced toxicity in patients with digestive neoplasm

BACKGROUND

Patients with gastrointestinal (GI) cancer are exposed to cachexia, which is highly correlated with chemotherapy-induced side effects. Research suggests that specific immunonutrients could prevent such toxicities.

AIMS

The primary objective of this phase III study was to evaluate the efficacy of glutamine and transforming growth factor-β2 (TGF-β2) in the prevention of grade 3-4 non-hematological toxicities induced by chemotherapy in patients with GI cancer.

PATIENTS AND METHODS

We designed a double-blind, randomized, controlled and multicenter trial stratified according to center, type of chemotherapy, presence of cachexia, and age. Patients were randomized to receive either Clinutren Protect(®) (CP) or a control isocaloric diet (without TGF-β2 or glutamine).

RESULTS

Between November 2007 and October 2011, 210 patients were enrolled in the study, of which 201 were included in the intention-to-treat analysis. Grade 3-4 non-hematological toxicities were not significantly different between the CP and control groups when evaluated by univariate and multivariate analyses. Likewise, no difference was observed regarding grade 3-4 hematological toxicities or reasons for treatment interruption.

CONCLUSION

This randomized study does not support the hypothesis that oral glutamine and TGF-β2 supplementation is effective to reduce grade 3 or 4 non-hematological toxicities induced by chemotherapy in patients with GI neoplasm.

Metabolic analysis and mechanism of lipids, amino acids and carbohydrates in gastrointestinal cancer

Metabolomics has recently been applied in a variety of biomedical research fields. However, there have been no articles on the application of metabonomics in gastrointestinal cancer and the relevant detailed mechanisms. In this article, the application of metabolomics in early diagnosis of gastrointestinal cancer is reviewed, and the metabolic role and metabolic mechanism of lipids, amino acids and carbohydrates, as well as the future challenge of metabolomics in the clinical application are summarized.

Ubiquitin proteasome system research in gastrointestinal cancer

The ubiquitin proteasome system (UPS) is important for the degradation of proteins in eukaryotic cells. It is involved in nearly every cellular process and plays an important role in maintaining body homeostasis. An increasing body of evidence has linked alterations in the UPS to gastrointestinal malignancies, including esophageal, gastric and colorectal cancers. Here, we summarize the current literature detailing the involvement of the UPS in gastrointestinal cancer, highlighting its role in tumor occurrence and development, providing information for therapeutic targets research and anti-gastrointestinal tumor drug design.

Dual time-point (18)F-FDG PET/CT to assess response to radiofrequency ablation of lung metastases

AIM

To establish the usefulness of dual time-point PET/CT imaging in determining the response to radiofrequency ablation (RFA) of solitary lung metastases from gastrointestinal cancer.

MATERIALS AND METHODS

This prospective study included 18 cases (3 female, 15 male, mean age 71±15 yrs) with solitary lung metastases from malignant digestive tract tumors candidates for RFA. PET/CT images 1h after injection of 4.07MBq/kg of (18)F-FDG (standard images) were performed at baseline, 1 month, and 3 months after RFA. PET/CT images 2h after injection centered in the thorax at 1 month after RFA were also performed (delayed images). A retention index (RI) of dual time-point images was calculated as follows: RI=(SUVmax delayed image-SUVmax standard image/SUVmax standard image)*100. Pathological confirmation of residual tumor by histology of the treated lesion was considered as local recurrence. A negative imaging follow-up was considered as complete response.

RESULTS

Local recurrence was found in 6/18 lesions, and complete response in the remaining 12. The mean percentage change in SUVmax at 1 month and at 3 months showed a sensitivity and specificity for PET/CT of 50% and 33%, and 67% and 92%, respectively. The RI at 1 month after RFA showed a sensitivity and specificity of 83% and 92%, respectively.

CONCLUSIONS

Dual time point PET/CT can predict the outcome at one month after RFA in lung metastases from digestive tract cancers. The RI can be used to indicate the need for further procedures to rule out persistent tumor due to incomplete RFA.

Group II p21-activated kinases as therapeutic targets in gastrointestinal cancer

P21-activated kinases (PAKs) are central players in various oncogenic signaling pathways. The six PAK family members are classified into group I (PAK1-3) and group II (PAK4-6). Focus is currently shifting from group I PAKs to group II PAKs. Group II PAKs play important roles in many fundamental cellular processes, some of which have particular significance in the development and progression of cancer. Because of their important functions, group II PAKs have become popular potential drug target candidates. However, few group II PAKs inhibitors have been reported, and most do not exhibit satisfactory kinase selectivity and “drug-like” properties. Isoform- and kinase-selective PAK inhibitors remain to be developed. This review describes the biological activities of group II PAKs, the importance of group II PAKs in the development and progression of gastrointestinal cancer, and small-molecule inhibitors of group II PAKs for the treatment of cancer.

Aquaporins: Their role in gastrointestinal malignancies

Aquaporins (AQPs) are small (~30 kDa monomers) integral membrane water transport proteins that allow water to flow through cell membranes in reaction to osmotic gradients in cells. In mammals, the family of AQPs has thirteen (AQP0-12) unique members that mediate critical biological functions. Since AQPs can impact cell proliferation, migration and angiogenesis, their role in various human cancers is well established. Recently, AQPs have been explored as potential diagnostic and therapeutic targets in gastrointestinal (GI) cancers. GI cancers encompass multiple sites including the colon, esophagus, stomach and pancreas. Research in the last three decades has revealed biological aspects and signaling pathways critical for the development of GI cancers. Since the majority of these cancers are very aggressive and rapidly metastasizes, identifying effective targets is crucial for treatment. Preclinical studies have utilized inhibitors of specific AQPs and knock down of AQP expression using siRNA. Although several studies have explored the role of AQPs in colorectal, esophageal, gastric, hepatocellular and pancreatic cancers, there is no comprehensive review compiling the available information on GI cancers as has been published for other malignancies such as ovarian cancer. Due to the similarities and association of various sites of GI cancers, it is helpful to consider these results collectively in order to better understand the role of specific AQPs in critical GI cancers. This review summarizes the current knowledge of the role of AQPs in GI malignancies with particular focus on diagnosis and therapeutic applications.

Confocal endomicroscopy: Is it time to move on?

Confocal laser endomicroscopy permits in-vivo microscopy evaluation during endoscopy procedures. It can be used in all the parts of the gastrointestinal tract and includes: Esophagus, stomach, small bowel, colon, biliary tract through and endoscopic retrograde cholangiopancreatography and pancreas through needles during endoscopic ultrasound procedures. Many researches demonstrated a high correlation of results between confocal laser endomicroscopy and histopathology in the diagnosis of gastrointestinal lesions; with accuracy in about 86% to 96%. Moreover, in spite that histopathology remains the gold-standard technique for final diagnosis of any diseases; a considerable number of misdiagnosis rate could be present due to many factors such as interpretation mistakes, biopsy site inaccuracy, or number of biopsies. Theoretically; with the diagnostic accuracy rates of confocal laser endomicroscopy could help in a daily practice to improve diagnosis and treatment management of the patients. However, it is still not routinely used in the clinical practice due to many factors such as cost of the procedure, lack of codification and reimbursement in some countries, absence of standard of care indications, availability, physician image-interpretation training, medico-legal problems, and the role of the pathologist. These limitations are relative, and solutions could be found based on new researches focused to solve these barriers.

[Unpleasant Journey from Helicobacter pylori-associated Gastritis to Gastric Cancer: Cancer Prevention by Taking a Detour]

As a commensal or a pathogen, Helicobacter pylori can change the balance of a complex interaction that exists among gastric epithelial cells, microbes, and their environment. Therefore, unraveling this complex relationship of these mixtures can be expected to help prevent cancer as well as troublesome unmet medical needs of H. pylori infection. Though gastric carcinogenesis is a multi-step process, precancerous lesion can be reversible in the early phase of mucosal damage before reaching the stage of no return. However, biomarkers to predict rejuvenation of precancerous atrophic gastritis have not been identified yet and gastric cancer prevention is still regarded as an impregnable fortress. However, when we take the journey from H. pylori-associated gastritis to gastric cancer, it provides us with the clue for prevention since there are two main preventive strategies: eradication and anti-inflammation. The evidence supporting the former strategy is now ongoing in Japan through a nation-wide effort to eradicate H. pylori in patients with chronic gastritis, but suboptimal apprehension to increasing H. pylori resistance to antibiotics and patient non-compliance still exists. The latter strategy has been continued in the author'sresearch center under siTRP (short-term intervention to revert premalignant lesion) strategy. By focusing on the role of inflammation in the development of H. pylori-associated gastric carcinogenesis, this review is intended to explain the connection between inflammation and gastric cancer. Strategies on H. pylori eradication, removal of inflammation, and reverting preneoplastic lesion will also be introduced. In the end, we expect to be able to prevent gastric cancer by take a detour from the unpleasant journey, i.e. from H. pylori-associated gastritis to gastric cancer.

Epigenetic inactivation of the extracellular matrix metallopeptidase ADAMTS19 gene and the metastatic spread in colorectal cancer

BACKGROUND

ADAMTS19 encodes a member of the ADAMTS (a disintegrin and metalloproteinase domain with thrombospondin motifs) protein family with emerging roles in carcinogenesis and metastasis. ADAMTS shares several distinct protein modules including a propeptide region, a metalloproteinase domain, a disintegrin-like domain, and a thrombospondin type 1 (TS) motif. In a previous work, we found ADAMTS19 frequently hypermethylated in colorectal cancer (CRC). We explored the association of methylation with tumor genotype and phenotype.

RESULTS

The methylation status of the CpG island in the promoter of ADAMTS19 was determined in 252 colorectal, 65 pancreatic, 33 breast and 169 ovarian primary tumors, 70 CRC metastases, and 10 CRC cell lines. Tumor-specific methylation of ADAMTS19 was significantly more frequent in gastrointestinal than in gynecological cancers (odds ratio (OR) = 2.9, confidence interval (CI) = (1.9-4.7), p = 5.2 × 10(-7)) and was independent of the methylation of adjacent loci in CRC. Hypermethylation associated with CRC with mutated BRAF oncogene (OR = 10.1, CI = (3.1-42.9), p = 6.3 × 10(-6)) and with the mucinous phenotype in CRC (OR = 2.1, CI = (1.1-4.1), p = 0.023) and ovarian cancer (OR = 60, CI = (16-346), p = 4 × 10(-16)). Methylation was significantly more frequent in CRC metastases homing to the ovary and omentum than in those homing to the liver and lung (OR = 6.1, CI = (1.8-22.2), p = 0.001). Differentiating local from distant metastatic spread, methylation negatively associated with tumor progression (p = 0.031) but positively with depth of invasion (p = 0.030). Hypermethylation associated with transcriptional repression in CRC cell lines, and treatment with 5'-AZA-2'-deoxycytidine led to reactivation of mRNA expression. shRNA-mediated silencing of ADAMTS19 had no effect on the in vitro proliferation rate of CRC cells but significantly diminished their collective migration speed (56 %, p = 3.3 × 10(-4)) and potential to migrate in collagen I (64 %, p = 4.3 × 10(-10)).

CONCLUSIONS

Our results highlight the frequent involvement of ADAMTS19 epigenetic silencing in CRC and mucinous ovarian cancer. The mechanistic preferences for the target organ of metastatic spread may lead to the development of diagnostic CRC biomarkers. The association with the mucinous phenotype also may have diagnostic applications for ovarian cancer.

Cinobufacini combined with chemotherapy for treatment of gastrointestinal cancers

AIM: To evaluate the clinical effects of cinobufacini combined with chemotherapy in the treatment of gastrointestinal malignancies.

METHODS: One hundred and twenty patients with gastrointestinal malignancies were divided into either a study group or a control group. The study group was given cinobufacini combined with chemotherapy, and the control group was given chemotherapy alone. The clinical effects were compared between the two groups.

RESULTS: The response rate was significantly higher in the study group than in the control group (61.7% vs 43.3%, P < 0.05). Before treatment, there was no significant difference in KPS score between the two groups (study group vs control group: 56.8 points ± 5.9 points vs 55.9 points ± 6.3 points, P > 0.05); after treatment, the KPS score was significantly higher in the study group than in the control group (78.9 points ± 6.7 points vs 65.8 point ± 6.0 points, P < 0.05). The incidence of toxic side effects was significantly lower in the study group than in the control group (8.3% vs 21.7%, P < 0.05).

CONCLUSION: Cinobufotalin combined with chemotherapy for patients with gastrointestinal cancers significantly reduces the occurrence of side effects and complications associated with chemotherapy.

High CYP2C19 phenotypic variability in gastrointestinal cancer patients

PURPOSE

CYP2C19 contributes to the metabolism of several chemotherapeutic agents. The CYP2C19 homozygous null function genotype strongly predicts activity phenotype in healthy populations. An additional acquired loss of function has been reported in up to one-third of cancer patients. It is not known whether this phenomenon also occurs in patients with earlier stage or in resected disease.

METHODS

This study investigated whether acquired loss of CYP2C19 function was detectable in patients with stage III-IV or resected gastrointestinal cancer. CYP2C19 genotype was determined in 49 patients, and subjects were probed for CYP2C19 activity on three test occasions.

RESULTS

An acquired loss of CYP2C19 activity was observed in 20% of stage III-IV and 17% of resected patients at the first test. Significant (p < 0.01) genotype-phenotype discordance was observed in both groups. There were no direct associations between this discordance and inflammatory markers, tumour burden or chemotherapeutic history. Notably, hepatic CYP2C19 function was not stable over time and phenotype conversion occurred in 23 patients over the period of testing.

CONCLUSION

Reliance on germ-line genotype to infer a poor metaboliser status could substantially underestimate the number of patients with deficient CYP2C19 function. This could compromise the interpretation of genotype-based clinical association studies.

The influence of industry sponsorship on the reporting of subgroup analyses within phase III randomised controlled trials in gastrointestinal oncology

PURPOSE

Correct interpretation of subgroup analyses (SGA) is important as it influences selection of therapeutic interventions for patient subsets. The primary aim of our study was to compare reporting of SGA between industry and non-industry sponsored trials.

METHODS

We performed a systematic literature review and extracted data from journal articles (JA) and conference abstracts (CA) published over a decade reporting SGA results of phase III randomised controlled gastrointestinal (GI) oncology trials with patient participants of ≥150.

RESULTS

In JA, SGA was reported in 100/145 (69%) trials: 41/54 industry sponsored (76%; 95% confidence interval [CI]: 63-86%) and 59/91 non-industry sponsored (65%; 95% CI: 55-74%) trials (p = 0.16). In CA, SGA was reported in 86/204 (42%) trials: 43/83 industry sponsored (52%; 95% CI: 41-62%) and 43/121 non-industry sponsored (36%; 95% CI: 28-44%) trials (p = 0.02). Number of SGA performed per trial was significantly larger for industry compared to non-industry sponsored trials in both JA (median 6 versus 2, p = 0.003) and CA (median 1 versus 0, p = 0.023). Claims of subgroup effect were made in 52% of trials in JA and 50% in CA, with significant test of interaction evident in only 25% of JA and 16% of CA, with no difference between industry and non-industry trials. Industry sponsored trials with a significant primary end-point reported more SGA (p < 0.001 JA; p = 0.046 CA).

CONCLUSIONS

Industry sponsored trials reported more SGA. Claimed subgroup effects were often not accompanied by significant interaction test; thus circumspection should be adopted when using SGA to deviate from standard therapeutic decision-making in GI oncology.

Micronutrients: A double-edged sword in microbial-induced gastric carcinogenesis

Epidemiologic studies throughout the world have uniformly demonstrated significant relationships between the intake of dietary micronutrients and gastric cancer risk. An exciting concept that has gained considerable traction recently is that micronutrients modulate gene expression within Helicobacter pylori, the strongest identified risk factor for gastric carcinogenesis. We present evidence here that essential micronutrients have a direct effect on H. pylori virulence, which subsequently affects interactions at the host-pathogen interface, thereby facilitating the development of premalignant and malignant lesions in the stomach. Further, these fundamental concepts provide a framework for understanding mechanisms driving the development of other malignancies that arise from foci of gastrointestinal inflammation.

PD-1 and PD-L1 blockade in gastrointestinal malignancies

Immunotherapy represents a major breakthrough in cancer therapy in recent years. Immune-checkpoint blockade using PD-1 and PD-L1 antibodies appears to be one of the most promising immunotherapy approaches. Immunotherapy differs from conventional cancer treatment because of its ability to produce durable responses in some patients. In this review article, we explore the available evidence and summarise current clinical trials for PD-1 and PD-L1 blockade in gastrointestinal malignancies. The challenge now is to develop strategies to increase the efficacy of PD-1 and PD-L1 blockade in gastrointestinal cancer patients, such as combination therapy with chemotherapy, radiotherapy or other immunotherapy, along with validating biomarkers to select patients and personalise treatment.

Loss of H2Bub1 Expression is Linked to Poor Prognosis in Nodal Negative Colorectal Cancers

To correlate H2Bub1 expression with outcome in colorectal cancer, H2Bub1 expression was analyzed by immunohistochemistry on a tissue microarray containing 1800 colorectal cancers. Results were compared to clinicopathological parameters.H2Bub1 IHC was seen in 1256 (79.3%) of 1584 interpretable CRC and was considered weak in 26.2% and strong in 53.1% of cancers. H2Bub1 expression was completely lost in 20.7% of the cases. Loss of H2Bub1 expression was associated with high tumor grade (p = 0.0211), high tumor stage (p = 0.0003), positive nodal status (p = 0.0139) and histological tumor type (p = 0.0202). No link was found between H2Bub1 expression and tumor localization (p = 0.1262), peritumoral lymphocytic infiltration (p = 0.2523) or vascular invasion (p = 0.5970).Loss of H2Bub1 expression in CRC was strongly associated with poor patient survival (p = 0.0006). This observation held true also in a subset survival analysis of nodal negative (N0) and nodal positive (N1) cancers (p = 0.0296 and p = 0.0197, respectively). In the subgroup of p53 negative cancers no prognostic impact of H2Bub1 staining was seen (p = 0.1924), whereas in p53 positive CRC H2Bub1 expression loss was associated with poor prognosis (p = 0.0031). Strikingly worsened outcome was found for nodal negative cancers presenting with accumulation of p53 when H2Bub1 expression was lost (p = 0.0006).Our data demonstrate that a reduced H2Bub1 expression is a strong prognostic biomarker both in nodal negative and nodal positive CRC. H2Bub1 expression measurement might help to select nodal negative CRC patients that may benefit from adjuvant therapy.

Malrotation of the Intestine in Adult and Colorectal Cancer

Malrotation of the gut is a congenital anomaly and usually presents in childhood. Rarely, it may present in adults. Patients may be asymptomatic, and malrotation is detected during investigations, operation or autopsy. It can cause longstanding abdominal symptoms like pain, dyspepsia or acute abdomen due to volvulus. In adults, malrotation is found with different gastrointestinal malignancies like gastric, hepatobiliary, pancreatic and, in particular, colorectal neoplasms. We are reporting a case of 60-year-old female presented with carcinoma caecum along with malrotation of the gut. It is the first case report from India. We also reviewed documented cases of malrotation associated with colorectal malignancies. A large number of cases have been reported in Japan as compared to rest of the world. Malrotation in adults is probably associated with gastrointestinal malignancies. Possible causes of this association can be genetic factors or gut changes like chronic inflammation. These associations need further study to consider intestinal malrotation as premalignant lesion which may be very important in follow-up of children with malrotation.

Reprint of: Connections between single-cell biomechanics and human disease states: gastrointestinal cancer and malaria

We investigate connections between single-cell mechanical properties and subcellular structural reorganization from biochemical factors in the context of two distinctly different human diseases: gastrointestinal tumor and malaria. Although the cell lineages and the biochemical links to pathogenesis are vastly different in these two cases, we compare and contrast chemomechanical pathways whereby intracellular structural rearrangements lead to global changes in mechanical deformability of the cell. This single-cell biomechanical response, in turn, seems to mediate cell mobility and thereby facilitates disease progression in situations where the elastic modulus increases or decreases due to membrane or cytoskeleton reorganization. We first present new experiments on elastic response and energy dissipation under repeated tensile loading of epithelial pancreatic cancer cells in force- or displacement-control. Energy dissipation from repeated stretching significantly increases and the cell's elastic modulus decreases after treatment of Panc-1 pancreatic cancer cells with sphingosylphosphorylcholine (SPC), a bioactive lipid that influences cancer metastasis. When the cell is treated instead with lysophosphatidic acid, which facilitates actin stress fiber formation, neither energy dissipation nor modulus is noticeably affected. Integrating recent studies with our new observations, we ascribe these trends to possible SPC-induced reorganization primarily of keratin network to perinuclear region of cell; the intermediate filament fraction of the cytoskeleton thus appears to dominate deformability of the epithelial cell. Possible consequences of these results to cell mobility and cancer metastasis are postulated. We then turn attention to progressive changes in mechanical properties of the human red blood cell (RBC) infected with the malaria parasite Plasmodium falciparum. We present, for the first time, continuous force-displacement curves obtained from in-vitro deformation of RBC with optical tweezers for different intracellular developmental stages of parasite. The shear modulus of RBC is found to increase up to 10-fold during parasite development, which is a noticeably greater effect than that from prior estimates. By integrating our new experimental results with published literature on deformability of Plasmodium-harbouring RBC, we examine the biochemical conditions mediating increases or decreases in modulus, and their implications for disease progression. Some general perspectives on connections among structure, single-cell mechanical properties and biological responses associated with pathogenic processes are also provided in the context of the two diseases considered in this work.

Gastrointestinal cancers in the era of theranostics: Updates and future perspectives

Theranostics are one of the practical aspects of personalized medicine. This concept was designed to describe a material combining diagnosis, treatment and follow up of a disease. It evolved and included molecular targeting and nanotechnologies that incorporate both diagnosis and therapeutics. In this editorial, we are presenting briefly the concept and evolution of theranostics, highlighting many applications of theranostics in daily practice and discussing future perspectives and aspects of this model in gastro-intestincal cancers.