Prognostic model to predict survival following first-line chemotherapy in patients with metastatic gastric adenocarcinoma

Prognostic significance of vascular endothelial growth factor immunohistochemical expression in gastric cancer: a meta-analysis

Vascular endothelial growth factor (VEGF) is considered as a prime mediator of angiogenesis, and has been implicated in carcinogenesis and metastasis. Various studies examined the relationship between VEGF protein overexpression with the clinical outcome in patients with gastric cancer, but yielded conflicting results. The prognostic significance of VEGF overexpression in gastric cancer remains controversial. Electronic databases updated to July 2011 were searched to find relevant studies. A meta-analysis was conducted with eligible studies which quantitatively evaluated the relationship between VEGF overexpression and survival of patients with gastric cancer. Survival data were aggregated and quantitatively analyzed. We performed a meta-analysis of 30 studies (n = 3,999 patients) that evaluated the correlation between VEGF overexpression detected by immunohistochemistry and survival in patients with gastric cancer. Combined hazard ratios suggested that VEGF-A overexpression had an unfavorable impact on overall survival (OS) (HR [hazard ratio] = 1.49, 95 % CI [confidence interval]: 1.22-1.77) and disease free survival (DFS) (HR = 1.85, 95 % CI: 1.38-2.32) in patients with gastric cancer. However, VEGF-C overexpression did not significantly correlate with OS (HR = 1.24, 95 % CI: 0.92-1.56) or DFS (HR = 1.15, 95 % CI: 0.78-1.52). VEGF-D is an unfavorable indicator of OS (HR = 1.68, 95 % CI: 1.02-2.34) and DFS (HR = 1.88, 95 % CI: 1.07-2.70) in patients with gastric cancer. VEGF-A and VEGF-D overexpression indicated a poor prognosis for patients with gastric cancer. VEGF-C overexpression was not associated with poor prognosis in patients with gastric cancer. The prognostic value of VEGF on survival still needs further larger prospective trials to be confirmed.

Survival in patients with stage IV noncardia gastric cancer - the influence of DNA ploidy and Helicobacter pylori infection

Background

Palliative surgery followed by postoperative chemotherapy is a challenging approach in the treatment of stage IV gastric cancer yet patients must be carefully selected on the basis of likely clinical benefit.

Methods

The records of 218 patients with histological diagnosis of gastric adenocarcinoma who underwent palliative surgery followed by postoperative chemotherapy were retrospectively reviewed. Twelve potential prognostic variables including tumour DNA index and serum IgG anti- Helicobacter pylori (HP) antibodies were evaluated for their influence on overall survival by multivariate analysis.

Results

The median survival was 13.25 months [95% Confidence Interval (CI) 12.00, 14.50]. Three factors were found to have an independent effect on survival: performance status (PS) [PS 60–70 vs. 90–100 Hazard Ratio (HR) 1.676; CI 1.171-2.398, p = 0.005], liver metastases (HR 1.745; CI 1.318-2.310, p < 0.001), and DNA Index as assessed by Image cytometry (2.2-3.6 vs. >3.6 HR 3.059; CI 2.185-4.283, p < 0.001 and <2.2 vs. >3.6 HR; 4.207 CI 2.751-6.433 <0.001). HP infection had no statistically significant effect on survival by either univariate or multivariate analysis.

Conclusion

Poor pre-treatment PS, the presence of liver metastasis and high DNA Index were identified factors associated with adverse survival outcome in patients with Stage IV gastric cancer treated with palliative gastrectomy and postoperative chemotherapy. HP infection had no influence on survival of these patients.

Bax expression is predictive of favorable clinical outcome in chemonaive advanced gastric cancer patients treated with capecitabine, oxaliplatin, and irinotecan regimen

OBJECTIVE

Bax protein is a key mediator of apoptosis, and it might be related to chemosensitivity. The purpose of this study was to evaluate the prognostic role of Bax in patients with advanced gastric cancer treated with triplet chemotherapy COI regimen (capecitabine, oxaliplatin, and irinotecan).

METHODS

Pretreatment tissue blocks were available for 23 consecutive patients, selected for good performance status (ECOG ≤ 1) and consenting for treatment with first-line COI at a single institution. Bax levels were classified as positive or negative by immunohistochemistry (bax N20; Santa Cruz Biotechnology) and related to outcome in terms of response rate, progression-free survival, and overall survival.

RESULTS

Bax-negative and -positive samples were 26% and 74%, respectively. Bax expression was associated with significantly higher response rate (87% vs 33%), progression-free survival (8.7 vs 4.9 months, P = .016), and overall survival (23.8 vs 12.7 months, P = .025). In multivariate analysis including Bax and performance status, low Bax independently predicted worse outcome, along with suboptimal performance status.

CONCLUSIONS

In advanced gastric cancer, Bax expression was related to clinical benefit with COI regimen. Whether Bax is a prognostic or mixed prognostic/predictive factor warrants prospective confirmation. It is to be defined if Bax predicts sensitivity to platinum analogs or to whatever chemotherapy regimen.

Phase II study of biweekly cetuximab in combination with irinotecan as second-line treatment in patients with platinum-resistant gastro-oesophageal cancer

BACKGROUND

The purpose of this phase II trial was to evaluate the efficacy and safety of cetuximab and irinotecan as second-line treatment in patients with gastro-oesophageal adenocarcinoma.

PATIENTS AND METHODS

Patients with failure to first-line platinum-based chemotherapy received cetuximab 500 mg/m(2) and irinotecan 180 mg/m(2) every second week until disease progression. Toxicity was evaluated according to The Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) v. 3.0. Antitumour activity was assessed according to Response Evaluation Criteria in Solid Tumours (RECIST) v. 1.0.

RESULTS

Sixty-three patients were enrolled, median age was 60 years, median performance status was 1 (0-1), 35 patients had two or more organs involved. The median number of courses was 5 (range 1-25). Response rate was 11% (6 partial response (PR)) and 37% had stable disease. Median progression free survival was 2.8 months and overall survival (OS) was 6.1 months. Grade 3-4 toxicity included: diarrhoea (6%), fatigue (5%), vomiting (5%) and neutropenia (16%). Two patients developed febrile neutropenia. Forty-six patients (73%) had developed grade 1-2 skin rash. Patients developing skin rash had a prolonged survival with an OS at 7.1 months.

CONCLUSIONS

The combination of cetuximab and irinotecan is active as second-line therapy in patients with gastro-oesophageal cancer. Cetuximab induced skin rash was associated with prolonged survival.

P21-activated kinase 4 overexpression in metastatic gastric cancer patients

INTRODUCTION

P21-activated kinase 4 (PAK), a subfamily of serine/threonine kinases originally known as a regulator of cytoskeletal dynamics and cell motility, has recently been revealed to play a key role in oncogenic signaling pathways. We studied the frequency and clinical features of PAK4-overexpressed metastatic gastric cancer.

PATIENTS AND METHODS

PAK4 overexpression was screened by Western blot in 18 human gastric cancer cell lines. Immunohistochemical staining of PAK4 protein was performed in tumor specimens of 49 metastatic gastric cancer patients who received palliative capecitabine/cisplatin as first-line treatment.

RESULTS

PAK4 protein overexpression was detected strongly in five gastric cell lines (AGS, MGK-28, MKN-74, SNU-216, SNU-601) and weakly in four cell lines (KATOIII, MKN-1, SNU-620, and SNU-719). PAK4 knockdown by small interfering RNA induced apoptosis in PAK4-overexpressed AGS gastric cancer cells. Immunohistochemical staining revealed PAK4 overexpressions in 4 (8.1%) of 49 metastatic gastric cancer specimens. None of the four patients with PAK4(+) responded to capecitabine/cisplatin chemotherapy, and PAK4(+) gastric cancer patients had a trend of poorer survival compared with PAK(-)(P = .876).

CONCLUSIONS

We demonstrated PAK4 overexpression in a subset of gastric cancer patients, implicating a role in gastric cancer tumorigenesis. Its prognostic significance and efficacy as a drug target should be further studied.

Phase II study of bolus 5-fluorouracil and leucovorin combined with weekly paclitaxel as first-line therapy for advanced gastric cancer

OBJECTIVE

We evaluated the efficacy and safety of bolus 5-fluorouracil (5-FU) and leucovorin combined with weekly paclitaxel (FLTAX) in advanced gastric cancer (GC) patients.

METHODS

Patients with untreated stage IV GC received paclitaxel 80 mg/m(2) as a 1-hour infusion, followed by 5-FU 600 mg/m(2) as a bolus infusion and L-leucovorin 250 mg/m(2) as a 2-hour infusion on days 1, 8 and 15. Treatment cycles were repeated every 28 days. The primary endpoint was response rate.

RESULTS

Thirty-five patients were enrolled. The median age was 62 years (range 34-75). Twenty-one patients (60%) had diffuse-type cancer and 11 had peritoneal metastasis. The confirmed response rate was 43% (95% CI 26-61) with 15 partial responses. Stable disease was observed in 16 (46%) patients. Median progression-free survival and overall survival were 6.8 months (95% CI 5.8-7.4) and 16.2 months (95% CI 10.0-22.8), respectively. Grade 3-4 adverse events were: neutropenia (54%), febrile neutropenia (3%), diarrhea (6%) and sensory neuropathy (11%).

CONCLUSION

FLTAX showed a desirable safety profile, and the efficacy against advanced GC was encouraging. FLTAX may be a good option for GC patients with deteriorated general condition, and a randomized clinical trial in such patients is currently underway.

Prognostic significance of a systemic inflammatory response in patients receiving first-line palliative chemotherapy for recurred or metastatic gastric cancer

Background

There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor prognosis in patients with advanced cancers. We evaluated the relationships between clinical status, laboratory factors and progression free survival (PFS), and overall survival (OS) in patients with recurrent or metastatic gastric cancer receiving first-line palliative chemotherapy.

Methods

We reviewed 402 patients with advanced gastric adenocarcinoma who received first-line palliative chemotherapy from June 2004 and December 2009. Various chemotherapy regimens were used. Eastern Cooperative Oncology Group performance status (ECOG PS), C-reactive protein (CRP), albumin, Glasgow prognostic score (GPS), and clinical factors were recorded immediately prior to first-line chemotherapy. Patients with both an elevated CRP (>1.0 mg/dL) and hypoalbuminemia (<3.5 mg/dL) were assigned a GPS of 2. Patients in whom only one of these biochemical abnormalities was present were assigned a GPS of 1, and patients with a normal CRP and albumin were assigned a score of 0. To evaluate the factors that affected PFS and OS, univariate and multivariate analyses were performed.

Results

According to multivariate analysis, the factors independently associated with PFS were ECOG PS (HR 1.37, 95% CI 1.02-1.84, P = 0.035), bone metastasis (HR 1.74, 95% CI 1.14-2.65, P = 0.009), and CRP elevation (HR 1.64, 95% CI 1.28-2.09, P = 0.001). The factors independently associated with OS were ECOG PS (HR 1.33, 95% CI 1.01-1.76, P = 0.037), bone metastasis (HR 1.61, 95% CI 1.08-2.39, P = 0.017), and GPS ≥ 1 (HR 1.76, 95% CI 1.41-2.19, P = 0.001).

Conclusions

The results of this study showed that the presence of a systemic inflammatory response as evidenced by the CRP, GPS was significantly associated with shorter PFS and OS in patients with recurrent or metastatic gastric cancer receiving first-line palliative chemotherapy. Bone metastasis and GPS were very useful indicator for survival in patients with recurrent or metastatic gastric cancer receiving palliative chemotherapy.

Esophageal cancer: a critical evaluation of systemic second-line therapy

The objective of this article was to review clinical trials that used antineoplastic second-line chemotherapy and/or targeted therapies in patients with esophageal cancer after first-line therapy. Computerized (MEDLINE) and manual searches were performed to identify articles published on this topic between 1996 and 2011. Twenty-five published trials and four abstracts presented at scientific meetings were identified. A total of 10 trials included only patients with squamous cell carcinomas (SCCs), four focused exclusively on adenocarcinoma (AC), the remaining 15 studies included both SCC and AC. The majority of trials (17 of 29) used docetaxel in combination with platinum analogs, eight used single-agent cytotoxic chemotherapy, and six evaluated targeted therapies. The numbers of patients were relatively small, ranging from eight to 55 patients. The response rates were generally low (between 0% and 39%), with only two small studies reporting objective responses of 50% and 63%, respectively. Time to progression ranged from 1.4 to 6.2 months, and the overall survival was disappointing at 4.0 to 11.4 months. Approximately 40% of patients who experience progressive disease after first-line chemotherapy are able to undergo second-line treatment. On the basis of data published so far, no standard second-line therapy has emerged. Future research will need to focus on individual therapy strategies such as genetic receptor mutations to increase the therapeutic outcome.

Salvage chemotherapy of biweekly irinotecan plus S-1 (biweekly IRIS) in previously treated patients with advanced gastric cancer

PURPOSE

This phase II trial first describes the combination chemotherapy of biweekly irinotecan plus S-1 (biweekly IRIS) for pretreated advanced gastric cancer (AGC) patients.

METHODS

Patients who had previously been treated with greater than or equal to one regimen were enrolled. They received S-1 35 mg/m(2) twice daily on days 1-14 and irinotecan 150 mg/m(2) on days 1 and 15, every 4 weeks. The primary endpoint was overall survival (OS).

RESULTS

Among the 38 patients enrolled, 18 patients were treated as second line, and the remaining 20 patients were enrolled as third- or fourth line. A total of 208 cycles were administered with the median being four cycles (range 1-16). The median OS was 8.7 months [95% confidence interval (CI) 7.5-10.3], and the median progression-free survival was 6.3 months (95% CI 5.3-7.3). Low serum albumin (<3.5 mg/dL) was an independent adverse prognosticator for survival. Overall response rate was 17% (95% CI 4-30%). The major grade 3/4 toxicities were neutropenia (26%) and diarrhea (18%).

CONCLUSIONS

Biweekly IRIS showed the moderate activity as salvage treatment in AGC. Considering high neutropenia and gastrointestinal toxicity, patient selection should be warranted; serum albumin may be a predictive factor for treatment decision.

Biweekly cetuximab and irinotecan as second-line therapy in patients with gastro-esophageal cancer previously treated with platinum

BACKGROUND

Until recently there has been no proven second-line therapy for patients with advanced gastro-esophageal cancer (GEC). Since 2004, Denmark has had a national health program where non-proven therapy can be offered to patients with advanced cancer, after approval by an expert panel appointed by the National Board of Health. This program has accelerated the introduction and implementation of new therapies in Denmark. Inspired by therapy in metastatic colorectal cancer, a combination of cetuximab and irinotecan (Cetiri) was chosen for second-line therapy in GEC patients. We report our experience with Cetiri as second-line therapy in patients with GEC.

METHODS

All patients had histologically confirmed GEC and all patients had progressive disease during or after first-line platinum-containing chemotherapy. The patients received cetuximab 500 mg/m(2) on day 1 and irinotecan 180 mg/m(2) on day 1 every 2nd week until progression or unacceptable toxicity. Toxicity was prospectively evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 3.0.

RESULTS

From December 2007 to February 2009, 50 consecutive patients received Cetiri as second-line therapy. Median performance status (PS) was 1. The median number of courses was seven. Seven patients (14%) had a partial response. Median progression-free survival (PFS) was 3.3 months and overall survival (OS) was 5.5 months; two patients are still alive without progressive disease. Major toxicities were: diarrhea (8%), fatigue (10%), neutropenia (16%), and febrile neutropenia (2%).

CONCLUSION

Cetiri every two weeks is a convenient and well-tolerated second-line regimen in GEC patients. A promising effect was seen in patients with PS 0-1 and in patients who developed a rash.

Prognostic factor analysis of third-line chemotherapy in patients with advanced gastric cancer

BACKGROUND

Almost all patients with advanced gastric cancer will eventually develop progressive disease after first-line chemotherapy. However, the role of subsequent salvage chemotherapy remains controversial. The purpose of this study was to evaluate prognostic factors for the survival of patients with advanced gastric cancer who received third-line chemotherapy.

METHODS

We reviewed 502 patients with advanced gastric cancer who received palliative chemotherapy at the Onocology Department of Hwasun Chonnam National University Hospital (2004-2008). Among them, 174 received third-line chemotherapy. To evaluate the clinicopathologic factors that affected overall survival, univariate and multivariate analyses were performed on the baseline factors before beginning third-line chemotherapy.

RESULTS

Multivariate analysis found 4 prognostic factors affecting poor survival following third-line chemotherapy: performance status of 2-3 (hazard ratio [HR] 1.46, 95% confidence interval [CI] 1.06-2.02; P = 0.022), serum albumin level < 4 mg/dL (HR 1.82, 95% CI 1.32-2.53; P < 0.00), poor histologic type (HR 1.77, 95% CI 1.27-2.47; P = 0.001), and progression-free survival of <2.7 months following second-line chemotherapy (HR 1.51, 95% CI 1.09-2.08; P = 0.012). A prognostic index was constructed, dividing patients into low- (0-1 factor), intermediate- (2 or 3 risk factors), or high- (4 risk factors) risk groups. Median survival times for each group were 11.8, 6.7, and 3.3 months, respectively (P < 0.00).

CONCLUSIONS

This analysis suggests that some clinicopathologic factors might be helpful in identifying the subgroup of patients most likely to benefit from third-line chemotherapy for advanced gastric cancer.

A prognostic model to predict clinical outcomes with first-line gemcitabine-based chemotherapy in advanced pancreatic cancer

OBJECTIVE

Our aim was to devise a prognostic model for advanced pancreatic cancer based on clinical parameters.

METHODS

We retrospectively analyzed the medical records of 298 patients who received gemcitabine-based chemotherapy from January 1999 to November 2008.

RESULTS

The median survival of all patients was 7 months [95% confidence interval (CI) 6.2-7.8]. Multivariate analysis revealed poor prognostic factors for overall survival such as the presence of liver metastasis [p < 0.001, hazard ratio (HR) 2.628, 95% CI 1.620-4.264], the presence of ascites or peritoneal carcinomatosis (p = 0.005, HR 1.783, 95% CI 1.194-2.661), serum C-reactive protein levels >1.2 mg/dl (p = 0.021, HR 1.568, 95% CI 1.070-2.300), and serum albumin levels <3.5 g/dl (p = 0.021, HR 1.701, 95% CI 1.085-2.667). Of 298 patients, 168 patients (56.4%) were categorized as low-risk with 0 or 1 risk factor, 80 patients (26.8%) were categorized as intermediate-risk with 2 risk factors, and 50 patients (16.8%) were categorized as high-risk with 3 or 4 risk factors. The median survival duration for the low-, intermediate-, and high-risk groups was 10.0 months (95% CI 8.7-11.3), 6.7 months (95% CI 5.7-7.7), and 4.4 months (95% CI 3.2-5.6), respectively.

CONCLUSIONS

This prognostic model could help to select treatment for patients in clinical practice, and these risk-adapted treatment strategies should be further investigated in prospective studies in such patient populations.

A prognostic model to predict clinical outcome in gastric cancer patients with bone metastasis

BACKGROUND

The clinicopathological manifestations and treatment outcomes of bone metastasis of gastric cancer are largely unknown. We delineated a prognostic model to identify different risk groups on the basis of clinical parameters.

METHODS

Patients who had bone metastasis at the time of diagnosis of gastric cancer (synchronous metastasis) or who developed bone metastasis during follow-up (metachronous metastasis) were retrospectively reviewed from January 1998 to May 2008.

RESULTS

Bone metastasis was identified in 203 (2.4%) of 8,633 patients: 126 patients (62%) with synchronous metastasis and 77 patients with metachronous metastasis. The median time to event was 16 months (range 4-87). As for treatment, 120 patients (59%) received systemic chemotherapy. The median survival time was 103 days (95% CI 80-126). Poor performance status [Eastern Cooperative Oncology Group 3-4; relative risk (RR) = 1.91, p = 0.011], multiple bone metastasis (RR = 2.593, p = 0.002), and abnormal carcinoembryonic antigen (RR = 1.779, p = 0.004) implied independent factors for survival. For patients who had zero to two of these factors identified, chemotherapy had a beneficial effect (175 vs. 43 days; p < 0.0001).

CONCLUSION

We recommend that the therapeutic approach with bone metastasis be customized to facilitate the risk stratification, so as to consequently provide the most appropriate therapy for each patient.

Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: a retrospective analysis

OBJECTIVE

Most patients with gastric cancer present with locally advanced or metastatic disease and usually receive palliative therapy. We sought to identify factors influencing overall survival in patients with stage IV gastric cancer receiving palliative chemotherapy.

PATIENTS AND METHODS

The records of 311 patients with histological diagnosis of gastric adenocarcinoma were retrospectively reviewed and 17 clinicopathological and therapeutic parameters were evaluated for their influence on overall survival.

RESULTS

In multivariate analysis nine factors were found to independently influence survival: no previous palliative gastrectomy [Hazard ratio (HR, 12; CI 7.969-18.099)], single agent chemotherapy instead of combination chemotherapy (HR, 1.35; CI 1.068-1.721), histological grade III (HR, 1.39; 95% CI 1.098-1.782), the presence of hepatic (HR, 1.6; 95% CI 1.246-2.073) and abdominal metastasis (HR, 1.33; 95% CI 1.039-1.715), CA 72-4 > 7 U/L (HR, 1.39; 95% CI 1.026-1.887), LDH > 225 U/L (HR, 1.72; 95% CI 1.336-2.236], need for blood transfusions (HR, 1.58; 95% CI 1.213-2.082), and weight loss > 5% (HR, 1.96; 95% CI 1.352-2.853) at the time of initial diagnosis. Patients were stratified as low (0-2 factors), intermediate (3-6 factors) and high (7-9 factors) risk and the median survival was 76, 40 and 11 weeks, respectively.

CONCLUSION

Nine clinical and laboratory factors that adversely affect survival in patients with stage IV gastric cancer who receive chemotherapy were identified. Their concurrent presence seems to have an additive effect as patients with seven to nine factors have the worse prognosis. Palliative gastrectomy and combination chemotherapy appear to be associated with improved survival.

Phase I trial of capecitabine plus everolimus (RAD001) in patients with previously treated metastatic gastric cancer

Purpose

Everolimus is a novel inhibitor of the mammalian target of rapamycin pathway, which is aberrantly activated in cancer cell. We conducted a phase I study of capecitabine plus everolimus (RAD001) in refractory gastric cancer patients.

Methods

Patients with metastatic gastric cancer and progression after prior chemotherapy were eligible. Four dose levels were planned as follows: Level 1, 5 mg bid/day of everolimus (D1-D21) and 500 mg/m² bid/day of capecitabine (D1-14); Level 2, 5 mg bid/day of everolimus (D1-D21) and 750 mg/m² bid/day of capecitabine (D1-14); Level 3, 5 mg bid/day of everolimus (D1-D21) and 1000 mg/m² bid/day of capecitabine (D1-14); and Level 4, 10 mg bid/day of everolimus (D1-D21) and 1000 mg/m² bid/day of capecitabine (D1-14). Treatment was repeated every 3 weeks until disease progression, patient refusal, or any serious adverse event.

Results

Fifteen patients were enrolled in this study between November 2009 and April 2010. Fifteen patients were enrolled (median age, 50 years; men, 9). Six patients had received two previous chemotherapy regimens; six patients had three previous chemotherapy regimens before the study treatment. Thus, the majority of patients were heavily pretreated. The dose-limiting toxicities were grade 3 infection, grade 3 mucositis, and grade 3 hyperglycemia and hyponatremia. After a median follow-up duration of 5.6 months (range, 2.3–8.1 months), median PFS was 1.8 months (95% CI, 0.8–2.8 months). The maximum best change observed was a 28.7% decrease in sum of longest diameters when compared with baseline.

Conclusions

The combination of capecitabine and everolimus showed satisfactory toxicity profile and modest clinical benefit in patients with refractory gastric cancer. The recommended dose of capecitabine and everolimus was 650 mg/m² twice daily and 5 mg twice daily, respectively.

A prognostic model in patients who receive chemotherapy for metastatic or recurrent gastric cancer: validation and comparison with previous models

PURPOSE

To make up for the limitations of previous prognostic models, we developed and validated a model in patients with metastatic or recurrent gastric adenocarcinoma (AGC), and to compare with previous models.

METHODS

A total of 2,805 patients received chemotherapy for AGC in Asan Medical Center between January 2000 and December 2008 and were randomly split into training and validation sets of 1,870 and 935 patients, respectively. A prognostic model was developed from the training set.

RESULTS

The median follow-up duration was 26.5 months (range, 10.8-116.3), during which time 2,495 patients (88.9%) died. Eight factors associated with poor prognosis were identified by multivariate analysis: ECOG performance status ≥2 (2 points), no gastrectomy, peritoneal metastasis, bone metastasis (2 points), lung metastasis, alkaline phosphatase > 120 IU/l, albumin < 3.3 g/dL, and total bilirubin > 1.2 mg/dL. A prognostic model was developed by dividing patients into good (0-1 points), moderate (2-3), and poor (≥4) risk groups. The overall survival (OS) curves for three risk groups differed significantly for both the training and the validation sets (P < 0.001 each). In the training set, the median OS for the three risk groups was 14.0, 9.4, and 5.1 months, respectively. Application of three previous prognostic models to our validation set showed that the four models, including ours, had similar ability to predict survival outcomes (c-statistics, 0.5520-0.5836).

CONCLUSION

Validation and comparison of prognostic models indicated that our model was as effective as the previous models to stratify the patients with AGC.

Is hypoalbuminemia an independent prognostic factor in patients with gastric cancer?

BACKGROUND

Studies have indicated that hypoalbuminemia is associated with decreased survival of patients with gastric cancer. However, the prognostic value of albumin may be secondary to an ongoing systemic inflammatory response. The aim of the study was to assess the relation between hypoalbuminemia, the systemic inflammatory response, and survival in patients with gastric cancer.

METHODS

Patients diagnosed with gastric carcinoma attending the upper gastrointestinal surgical unit in the Royal Infirmary, Glasgow between April 1997 and December 2005 and who had a pretreatment measurement of albumin and C-reactive protein (CRP) were studied.

RESULTS

Most of the patients had stage III/IV disease and received palliative treatment. The minimum follow-up was 15 months. During follow-up, 157 (72%) patients died of their cancer. On univariate analysis, stage (p < 0.001), treatment (p < 0.001), albumin level (p < 0.001), and CRP level (p < 0.001) were significant predictors of survival. On multivariate analysis, stage (p < 0.001), treatment (p < 0.001), and CRP level (p < 0.001) remained significant predictors of survival. Albumin was no longer an independent predictor of survival.

CONCLUSIONS

Low albumin concentrations are associated with poorer survival in patients with gastric cancer. However, the strength of this relation with survival is dependent on the presence of a systemic inflammatory response, as evidenced by an elevated CRP level. Therefore, it appears that the relation between hypoalbuminemia and poor survival is secondary to that of the systemic inflammatory response.

Bax predicts outcome in gastric cancer patients treated with 5-fluorouracil, leucovorin, and oxaliplatin palliative chemotherapy

BACKGROUND

Platinum and 5-fluorouracil (5-FU)-based regimens have been used the most frequently in palliative chemotherapy for gastric cancer. The present study evaluated the prognostic significance of Bax, excision repair cross-complementation group 1 (ERCC1), and thymidylate synthase (TS) in advanced gastric cancer patients treated with 5-FU, leucovorin, and oxaliplatin (FOLFOX) palliative chemotherapy.

METHODS

Seventy-two patients with metastatic or recurrent gastric cancer were treated with FOLFOX regimen. Pretreatment tumor biopsy specimens were analyzed for Bax, ERCC1, and TS expression by immunohistochemistry.

RESULTS

High expression of Bax, ERCC1, and TS was observed in 31 (43%), 33 (46%), and 35 (49%) patients, respectively. The median overall survival (OS) of patients was 12 months. Low expression of Bax was associated with poor OS (median, 9 months vs. 18 months; 2-year, 10% vs. 48%; p=0.0005) in univariate analysis, while expression of ERCC1 and TS was not correlated with patient outcome. In multivariate analysis, low expression of Bax was a significant independent predictor of poor OS (p=0.028). Low expression of Bax was significantly associated with poor survival of patients with metastatic or recurrent gastric cancer treated with FOLFOX chemotherapy.

CONCLUSIONS

Immunohistochemical staining for Bax with pretreatment biopsy specimen may be useful in selecting FOLFOX regimen as a treatment option for advanced gastric cancer patients.

High FDG uptake in PET/CT predicts worse prognosis in patients with metastatic gastric adenocarcinoma

PURPOSE

We evaluated the role of FDG-PET/CT in patients with metastatic gastric adenocarcinoma before palliative chemotherapy to predict prognosis and chemotherapeutic response.

METHODS

The study included 35 consecutive newly diagnosed patients with metastatic gastric adenocarcinoma who underwent FDG-PET/CT before palliative chemotherapy. Maximum standardized uptake value (SUVmax) of the primary tumor was assessed to evaluate survival and chemotherapeutic response. Survival analysis was performed for time to progression and overall survival using the Kaplan-Meier method. Cox proportional hazard models were used to determine independent prognostic factors.

RESULTS

All primary tumors were visualized using FDG-PET/CT (mean SUVmax = 8.1 ± 4.5, range 2.5-22.1). Sensitivity, specificity, and accuracy of FDG-PET/CT in detection of solid organ metastasis were 95.2% (20/21), 100% (14/14), and 97.1% (34/35), respectively. No significant difference of primary tumor SUVmax was found among the chemotherapeutic response groups. Univariate survival analysis demonstrated ECOG performance status (≥2), presence of solid organ metastasis, number of organs involved in distant metastasis (≥2), and SUVmax of the primary tumor (>8) as significant predictors for poor overall survival. Multivariate survival analysis showed SUVmax of the primary tumor (P = 0.048), presence of solid organ metastasis (P = 0.015), and ECOG performance status (P = 0.002) as significant independent prognostic predictors for overall survival.

CONCLUSIONS

High FDG uptake of the primary tumor in patients with metastatic gastric adenocarcinoma is associated with poor overall survival. Assessment of tumor FDG uptake has limited value for prediction of chemotherapeutic response, but provides useful information regarding prognosis.

Retrospective analyses of cisplatin-based doublet combination chemotherapy in patients with advanced gastric cancer

BACKGROUNDS

Cisplatin-based chemotherapy, in combination with fluoropyrimidines or taxanes, have demonstrated efficacy against advanced gastric cancer (AGC). This retrospective study was performed with the data obtained from our cancer chemotherapy registry and eight another cancer centers.

METHODS

In 2008, a total of 283 AGC patients were treated with cisplatin-based doublet chemotherapy in the first-line setting: capecitabine plus cisplatin (XP, n = 77), S-1 plus cisplatin (SP, n = 97), taxanes (docetaxel, paclitaxel) plus cisplatin (TP, n = 72), and 5-fluorouracil plus platinum (FP, n = 37). The primary endpoint of this study was overall survival (OS) and the secondary endpoints were safety, response rate and progression-free survival (PFS).

RESULTS

The median age was 54 years with a range of 28-78 years and median delivered number of chemotherapy cycles were XP: 4, SP: 5, TP: 5 and FP: 5, respectively. Objective tumor responses (38%; 95% CI, 32-43%) were 40% for XP, 42% for SP, 36% for DP, and 24% for FP. The estimated median PFS was 4.5 months (95% CI, 3.6-5.4 months) and the median OS was 12.3 months (95% CI, 10.8-13.7 months). No statistically significant difference was found between each regimen used as first-line chemotherapy. At multivariate analysis, independent prognostic parameters for OS were prior gastrectomy, peritoneal dissemination, performance status and hemoglobin level

CONCLUSION

All of the cisplatin-based doublet chemotherapy regimens appear to be active as first-line chemotherapy for AGC. With better patient selection according to clinical parameters and molecular markers, clinical outcomes of AGC patients in first-line setting can be improved.

Systemic chemotherapy for peritoneal disseminated gastric cancer with inadequate oral intake: a retrospective study

BACKGROUND

Oral fluoropyrimidines are widely used as standard treatment for gastric cancer, but peritoneal disseminated gastric cancer patients are often ineligible for chemotherapy using oral anticancer agents because of inadequate oral intake. The purpose of this study was to evaluate the treatment outcome and identify the prognostic factors in gastric cancer patients with inadequate oral intake resulting from peritoneal dissemination.

METHODS

Seventy-nine patients with peritoneal disseminated gastric cancer receiving systemic chemotherapy as the first-line treatment option at our hospital between April 1999 and December 2006, and who were administered intravenous drip infusion because of inadequate oral intake, were retrospectively analyzed.

RESULTS

All patients received 5-fluorouracil (5-FU)-based chemotherapy. Of the 79 treated patients, 71 had ascites as peritoneal dissemination and the remaining 8 had only gastrointestinal stenosis without ascites. Eleven (15%) patients showed an improvement in ascites. Proportion of oral intake improvement was 33%. Median time to progression and overall survival time was 1.7 months [95% confidence interval (CI), 0.9-2.4 months] and 3.3 months (95% CI, 2.1-4.5 months), respectively. Four independent poor prognostic factors were identified in multivariate analysis: serum albumin < 3.0 g/dl [hazard ratio (HR) 1.69, P = 0.03], performance status ≥ 3 (HR 1.78, P = 0.05), massive ascites (HR 1.79, P = 0.04), and serum C-reactive protein ≥ 2.0 mg/dl (HR 2.03, P < 0.01).

CONCLUSION

The efficacy of 5-FU-based chemotherapy for peritoneal disseminated gastric cancer patients with inadequate oral intake was unsatisfactory.

Clinicopathologic features and clinical outcomes of gastric cancer that initially presents with disseminated intravascular coagulation: a retrospective study

BACKGROUND AND AIM

Few systematic studies have been published on prognosis and clinical outcome of gastric cancer patients with disseminated intravascular coagulation (DIC) as the first presentation of malignancy. We evaluated the clinicopathologic features and clinical outcomes of this population.

METHODS

We reviewed the medical records of patients with metastatic or recurred gastric cancer that initially presented with DIC.

RESULTS

Twenty-one patients were included. Median age was 47 years (range, 24-72 years). Eighteen patients (85.7%) had bone metastasis, and nine patients (42.9%) had hemorrhagic complication of DIC. Fourteen patients received palliative chemotherapy, and seven patients received best supportive care (BSC). The most common factor influencing the decision to abandon the palliative chemotherapy was uncontrolled bleeding (57.1%). The median overall survival (OS) of all patients was 58 days (range, 2-342 days). The OS was significantly shorter in BSC than in the chemotherapy group (median, 16 vs 99 days, P < 0.001). In multivariate analysis, chemotherapy was independently associated with longer OS. In the chemotherapy group, the response to treatment was evaluable in 11 patients: two (18.2%) had a partial response, five (45.5%) had stable disease and four (36.4%) had progressive disease. The OS of patients with progressive disease was significantly longer in the chemotherapy group than in the BSC group (median, 92 vs 16 days, P = 0.009).

CONCLUSIONS

The prognosis is poor with gastric cancer that initially presents with DIC but palliative chemotherapy, compared with BSC, prolongs OS. Therefore, early and intensive management for correctable DIC followed by chemotherapy should be considered in this population.

Recent advances in chemotherapy for advanced gastric cancer

Although medical treatment has been shown to improve quality of life and prolong survival, no significant progress has been made in the treatment of advanced gastric cancer (AGC) within the last two decades. Thus, the choice of optimum standard first-line chemotherapy regimen for AGC remains debatable, and most responses to chemotherapy are partial and of short duration, with a median survival of approximately 7-11 mo and survival at 2 years rarely more than 10%. Recently, remarkable progress in tumor biology has led to the development of new agents that target critical aspects of oncogenic pathways. For AGC, several molecular targeting agents are now under evaluation in international randomized studies, and trastuzumab, an anti-HER2 monoclonal antibody, has shown antitumor activity against HER-2 positive AGC. However, this benefit is limited to only about 20% of patients with AGC (patients with HER-2 positive AGC). Therefore, there remains a critical need for both the development of more effective agents and the identification of predictive and prognostic molecular markers to select those patients who will benefit most from specific chemotherapeutic regimens and targeted therapies.

Progression-free survival in first-line chemotherapy is a prognostic factor in second-line chemotherapy in patients with advanced gastric cancer

PURPOSE

First-line chemotherapy (Cx-1) in advanced gastric cancer (AGC) provides survival benefit. However, it is unclear who should proceed to second-line chemotherapy (Cx-2).

METHODS

We reviewed patients who received Cx-2 for AGC following progressive disease after Cx-1 from 2000 to 2005 at the National Cancer Center Hospital, Tokyo. To evaluate the prognostic factors in Cx-2, Cox regression multivariate analysis was performed.

RESULTS

Of 995 patients who received Cx-1 in this study period, 466 met the eligibility criteria. The median progression-free survival in Cx-1 (PFS-1) was 133 days. The median survival time from the date of starting second-line chemotherapy (MST-2) was 207 days. Multivariate analysis revealed that the factors affecting short survival time in Cx-2 were poor performance status (> or = 2), low serum albumin level (<3.5 mg/dL), elevated C-reactive protein level (> or = 1.0 mg/dL), patients with bone, liver or peritoneal metastasis, and patients without previous gastrectomy (p < 0.01). PFS-1 was an independent prognostic factor for survival (PFS-1 <120, MST-2 133 days, PFS-1 > or = 120, MST-2 258 days, hazard ratio 0.71, 95% confidence interval 0.58-0.86, p < 0.01). The Cx-2 regimen (irinotecan vs. taxane) did not correlate with survival.

CONCLUSION

PFS-1 is one of the prognostic factors of Cx-2 in patients with AGC.

Clinical characteristics and treatment outcomes of gastric cancer patients with isolated para-aortic lymph node involvement

BACKGROUND

Although gastric cancer with isolated para-aortic lymph node (PAN) involvement is considered an advanced disease, the clinical characteristics of it have not been comprehensively elucidated.

PATIENTS AND METHODS

We reviewed the medical records of 1,277 patients received palliative chemotherapy with advanced gastric cancer according to metastatic sites: PAN-only metastasis, single organ metastasis other than PAN, and multiple organ metastasis. Time to other organ metastasis (TTOM) was determined only in PAN-only metastasis group as the time interval between initial diagnosis of recurrence or de novo metastasis and confirming distant metastasis beyond PAN area.

RESULTS

The median overall survival (OS) of patients with PAN-only metastasis was significantly longer than that of patients with single organ metastasis other than PAN or multiple organ metastasis (13.8 months vs. 11.4 months vs. 8.4 months; P < 0.001). In the PAN-only metastasis group, patients with recurrent diseases showed longer TTOM beyond the PAN area (10.7 vs. 7.7 months; P = 0.037) and OS (23.8 vs. 12.8 months; P = 0.010) than those with de novo metastatic disease and it was validated by multivariate analysis.

CONCLUSION

Patients with isolated PAN metastasis showed an excellent prognosis compared with patients with metastasis at other sites and it was primarily evident in patients with recurrent PAN metastasis.

Outcomes of multiple salvage chemotherapy for advanced gastric cancer: implications for clinical practice and trial design

PURPOSE

We analyzed the natural history of advanced gastric cancer with sequential salvage chemotherapy following first-line treatment.

METHODS

We studied 532 patients with unresectable gastric adenocarcinoma who were treated at Yonsei Cancer Center (2000-2008). The patients were managed with multiple sequential salvage chemotherapy as allowed by performance status and toxicity profiles. The tumor response was assessed every two cycles.

RESULTS

Four hundred sixty patients received palliative chemotherapy and 72 received supportive care only. The median overall survival was 12.0 months for all patients, 12.1 months for the chemotherapy group, and 2.5 months for the supportive care group (P < 0.001). In the chemotherapy group, 87% received first-line chemotherapy, 47% second-line, 23% third-line, 9% fourth-line, and 3% fifth-line. Response rates were 24.8, 12.6, 10.9, 2.6, and 0% and disease control rates were 76.3, 60.1, 54.2, 54.2, and 53.3% for first- to fifth-line treatment, respectively. The median progression-free survival was 5.5, 3.4, 2.5, 1.9, and 2.0 months and overall survival was 12.1, 7.9, 5.5, 5.0, and 6.8 months. Performance status and metastatic pattern were consistent prognostic factors throughout salvage treatment.

CONCLUSIONS

Clinical trials may be feasible in second- or third-line salvage chemotherapy for gastric cancer. Future clinical trials in these settings should take into account the low response rate, short progression-free survival, and the prognostic factors for optimal trial design.

Advanced gastric cancer--slow but steady progress

Progress in gastric cancer has been slow, but steady. Historically, patients commonly presented with significant disease related co-morbidity and received treatment of marginal benefit but unfortunately associated with significant toxicity. Today there is no universally accepted reference standard chemotherapy for this disease. However, there is reason for optimism. Meta-analyses of randomized trials have shown a benefit for first-line combination chemotherapy. Current three drug chemotherapy regimens remain toxic, though perhaps less so than previously, and can result in a small but significant survival advantage in carefully chosen patients. Incremental improvements have been observed in both treatment-related toxicity and survival after first-line therapy. More patients are candidates for chemotherapy beyond progression with first-line therapy and response rates with second-line regimens are similar to those seen in other solid tumor malignancies. Although there is no randomized data to support its use second-line treatment should be considered in appropriate patients. Even before the integration of targeted therapies in the treatment of gastric cancer, it was evident that survival for more than 2 years is possible in a subset of patients and large retrospective studies have highlighted clinicopathologic factors associated with improved survival. Presently, with the addition of targeted therapy, especially anti-angiogenic and anti-Her2 therapy, and a better understanding of the biology of the disease, perhaps a sense of optimism should indeed suppress the nihilism commonly associated with this disease.

A prognostic model in patients treated for metastatic gastric cancer with second-line chemotherapy

BACKGROUND

This retrospective study was carried out to evaluate the prognostic significance of clinical factors in patients treated for metastatic gastric cancer with second-line chemotherapy.

PATIENTS AND METHODS

We evaluated the prognostic significance of various clinical factors in 126 patients, who were treated with second-line chemotherapy.

RESULTS

Median progression-free and overall survival (OS) for second-line chemotherapy were 3.3 and 5.3 months, respectively, with an overall response rate of 11.1%. Multivariate analysis identified three independent prognostic factors: performance status: Eastern Cooperative Oncology Group zero to one [hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.7-5.4], hemoglobin (Hb) level: >/=10 g/dl (HR 2.2, 95% CI 2.1-2.4) and time-to-progression (TTP) under first-line therapy: >/=5 months (HR 0.5, 95% CI 0.3-0.8). From the obtained data, a prognostic index was constructed, dividing the patients into three risk groups: good (n = 40), intermediate (n = 36) and poor risk group (n = 56). The median survival for good, intermediate and poor risk groups were 13.5, 6.0 and 2.9 months, respectively, whereas the 1-year OS rates were 50.2%, 14.2% and 2.6%, respectively (P = 0.00001).

CONCLUSIONS

With inadequate data from randomized controlled trials at the moment, our report indicates that second-line chemotherapy is effective and beneficial in patients with good performance status, higher Hb level along with higher TTP under first-line therapy.

A randomised phase II study of combination chemotherapy with epirubicin, cisplatin and capecitabine (ECX) or cisplatin and capecitabine (CX) in advanced gastric cancer

BACKGROUND

Both cisplatin/capecitabine (CX) and epirubicin plus CX (ECX) have clearly demonstrated efficacy against advanced gastric cancer (AGC).

METHODS

Chemotherapy-naïve patients with histologically confirmed, measurable AGC were randomised to receive CX (cisplatin 75mg/m(2) iv on day 1 and capecitabine 1000mg/m(2) bid po on days 1-14) or ECX (epirubicin 50mg/m(2) plus CX) every 3weeks. The primary endpoint was progression-free survival (PFS).

RESULTS

Of the 91 registered patients, 45 patients were treated with CX and 44 with ECX. A total of 241 CX (median, 6; range, 1-12) and 201 ECX (median, 5; range, 1-11) cycles were delivered. Treatment duration was similar for both arms (4.4 for CX versus 4.2months for ECX). There was no relevant difference in the occurrence of overall grade 3 or 4 toxicities between the CX and ECX arms (80% versus 78%, respectively; P=0.516). However, none in the CX and 12% in the ECX arm discontinued treatment because of toxicity. There were no significant differences in therapeutic efficacy between CX and ECX with respect to the response rate (38% versus 37%, respectively) and PFS (6.4 versus 6.5months).

CONCLUSION

Both CX and ECX appear to be active as first-line chemotherapy for AGC, and the safety profiles are acceptable. Given the comparable efficacy results, CX could be a reasonable standard chemotherapy for untreated AGC patients.

Predictors of peritoneal carcinomatosis in patients with gastric cancer treated at a single institution in Brazil

BACKGROUND

Peritoneal carcinomatosis is a common pattern of recurrence in gastric cancer and is associated with a poor prognosis. Determining predictive factors for peritoneal recurrence can help the selection of patients suitable for more aggressive treatment strategies.

METHODS

A retrospective chart review of 162 patients diagnosed with gastric cancer with no peritoneal carcinomatosis and treated at a single institution in Brazil from January 1994 to December 2004 was carried out. Univariate and multivariate analyses were performed to identify patient and tumor-related characteristics associated with the development of peritoneal metastasis.

RESULTS

Twenty-three (14.2%) patients developed peritoneal carcinomatosis. Three independent factors associated with the development of peritoneal metastasis were identified by multivariate analysis: signet-ring cell histology (odds ratio [OR] = 4.9; P = 0.018), the presence of vascular invasion (OR = 4.8; P = 0.022), and the presence of visceral metastasis at diagnosis (OR = 5.1; P = 0.011). Tumor stages T3 or T4 showed a trend towards significance (P = 0.062).

CONCLUSIONS

Patients with gastric cancer presenting with signet-ring histology, vascular invasion, or visceral metastasis appear to be at higher risk for the development of peritoneal carcinomatosis.

A retrospective analysis of second-line chemotherapy in patients with advanced gastric cancer

Background

Because treatment of advanced gastric cancer (AGC) patients after failure with first-line chemotherapy remains controversial, we performed this retrospective analysis based on the data obtained from 1455 patients registered in a first-line treatment cohort with respect to receiving or not receiving subsequent chemotherapy.

Methods

The decision for administering second-line chemotherapy was, in most cases, at the discretion of the physician. Seven-hundred twenty-five (50%) received second-line chemotherapy after first-line failure. Univariate and multivariate analyses were performed on the recognized baseline parameters for survival.

Results

At the time of initiating second-line chemotherapy, the patients' median age was 56 years (range, 22 to 86) and 139 (19%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or more. Seven (1%) complete and 108 (15%) partial responses to second-line chemotherapy were observed for an overall response rate of 16% (95% confidence interval [CI], 13 to 19%). The median progression-free and overall survivals, calculated from the start of second-line chemotherapy, were 2.9 months (95% CI, 2.6 to 3.3) and 6.7 months (95% CI, 5.8 to 7.5), respectively. Multivariate analysis revealed that low baseline hemoglobin level (hazard ratio [HR], 0.74; 95% CI 0.61–0.90) and a poor performance status (HR, 0.66; 95% CI, 0.52–0.83) were independent negative prognostic factors for overall survival.

Conclusion

Performance status, along with baseline hemoglobin level, could be used to identify the subgroup of patients most likely to benefit from second-line chemotherapy for AGC.

Second-line chemotherapy for patients with advanced gastric cancer: who may benefit?

No established second-line chemotherapy is available for patients with advanced gastric cancer failing to respond or progressing to first-line chemotherapy. However, 20–40% of these patients commonly receive second-line chemotherapy. We evaluated the influence of clinico-pathologic factors on the survival of 175 advanced gastric cancer patients, who received second-line chemotherapy at three oncology departments. Univariate and multivariate analyses found five factors which were independently associated with poor overall survival: performance status 2 (hazard ratio (HR), 1.79; 95% CI, 1.16–2.77; P=0.008), haemoglobin ⩽11.5 g l⁻¹ (HR, 1.48; 95% CI, 1.06–2.05; P=0.019), CEA level >50 ng ml⁻¹ (HR, 1.86; 95% CI, 1.21–2.88; P=0.004), the presence of greater than or equal to three metastatic sites of disease (HR, 1.72; 95% CI, 1.16–2.53; P=0.006), and time-to-progression under first-line chemotherapy ⩽6 months (HR, 1.97; 95% CI, 1.39–2.80; P<0.0001). A prognostic index was constructed dividing patients into low- (no risk factor), intermediate- (one to two risk factors), or high- (three to five risk factors) risk groups, and median survival times for each group were 12.7 months, 7.1 months, and 3.3 months, respectively (P<0.001). In the absence of data deriving from randomised trials, this analysis suggests that some easily available clinical factors may help to select patients with advanced gastric cancer who could derive more benefit from second-line chemotherapy.

Impact of insulin-like growth factor type 1 receptor, epidermal growth factor receptor, and HER2 expressions on outcomes of patients with gastric cancer

PURPOSE

Expression levels of insulin-like growth factor type 1 receptor (IGF-IR), epidermal growth factor receptor (EGFR), and HER2 expressions have been linked to clinical outcomes in several solid tumors. However, the clinical significance of these biomarkers in gastric cancer (GC) remains unclear. This study was designed to delineate the clinical implications of these three biomarkers in GC.

EXPERIMENTAL DESIGN

The study group comprised 87 patients who underwent gastrectomy at National Cancer Center Hospital and subsequently received chemotherapy for recurrent or residual tumors. Using immunohistochemical techniques, we analyzed the expressions of IGF-IR, EGFR, and HER2 on formalin-fixed paraffin-embedded specimens of surgically removed primary tumors.

RESULTS

IGF-IR expression (defined as >10% membranous staining) was found in 67 tumors (77%), EGFR expression in 55 (63%), and HER2 expression in 16 (18%). Positive coexpression of IGF-IR and EGFR was found in 48 tumors (55%), that of IGF-IR and HER2 in 16 (18%), and that of EGFR and HER2 in 13 (15%). Multivariate survival analysis showed that IGF-IR-positive expression [hazard ratio (HR) 2.14, 95% confidence interval (95% CI) 1.20-3.82; P = 0.01], performance status 1 or 2 (HR 1.83, 95% CI 1.15-2.91; P = 0.01), and diffuse type tumors (HR 1.71; 95% CI 1.08-2.70; P = 0.02) were significant predictors of poor survival.

CONCLUSIONS

IGF-IR expression in surgical GC specimens, poor performance status, and diffuse type tumors are significant predictors of poor outcomes in patients with GC. Our data suggest that anti-IGF-IR strategies may prove valuable in such patients.

Impacts of excision repair cross-complementing gene 1 (ERCC1), dihydropyrimidine dehydrogenase, and epidermal growth factor receptor on the outcomes of patients with advanced gastric cancer

Using laser-captured microdissection and a real-time RT-PCR assay, we quantitatively evaluated mRNA levels of the following biomarkers in paraffin-embedded gastric cancer (GC) specimens obtained by surgical resection or biopsy: excision repair cross-complementing gene 1 (ERCC1), dihydropyrimidine dehydrogenase (DPD), methylenetetrahydrofolate reductase (MTHFR), epidermal growth factor receptor (EGFR), and five other biomarkers related to anticancer drug sensitivity. The study group comprised 140 patients who received first-line chemotherapy for advanced GC. All cancer specimens were obtained before chemotherapy. In patients who received first-line S-1 monotherapy (69 patients), low MTHFR expression correlated with a higher response rate (low: 44.9% vs high: 6.3%; P=0.006). In patients given first-line cisplatin-based regimens (combined with S-1 or irinotecan) (43 patients), low ERCC1 correlated with a higher response rate (low: 55.6% vs high: 18.8%; P=0.008). Multivariate survival analysis of all patients demonstrated that high ERCC1 (hazard ratio (HR): 2.38 (95% CI: 1.55-3.67)), high DPD (HR: 2.04 (1.37-3.02)), low EGFR (HR: 0.34 (0.20-0.56)), and an elevated serum alkaline phosphatase level (HR: 1.00 (1.001-1.002)) were significant predictors of poor survival. Our results suggest that these biomarkers are useful predictors of clinical outcomes in patients with advanced GC.