Impact of plasma tissue inhibitor of metalloproteinase-1 on long-term survival in patients with gastric cancer

BACKGROUND

The expression of tissue inhibitor of metalloproteinase-1 (TIMP-1) is correlated with tumor invasion and metastases.

METHODS

The plasma TIMP-1 concentration was examined preoperatively in 149 patients with gastric cancer who underwent a surgical resection. The cutoff value of TIMP-1 was set at 112.5 ng/ml based on a previous report. These patients were followed up for more than 5 years prospectively.

RESULTS

Plasma TIMP-1 was positive in 30 of the 149 patients (20.1%). The overall survival rate was 78.2% at 5 years in patients with negative plasma TIMP-1, while this rate was 26.7% at 5 years in patients with positive plasma TIMP-1. By univariate analyses, T, N, M, and R category, and TIMP-1, were significant prognosticators. Multivariate analyses demonstrated T, N, and TIMP-1 to be significant prognosticators. The survival curve was clearly separated with respect to TIMP-1.

CONCLUSION

These results suggest that plasma TIMP-1 is a strong independent prognosticator for the long-term survival of patients with gastric cancer.

Contributions of meta-analyses based on individual patient data to therapeutic progress in colorectal cancer

Meta-analysis is the statistical process of combining information from several studies addressing the same question. Meta-analyses based on individual patient data are far more reliable and informative than those based on summary statistics obtained from the trialists or extracted from the published literature. Meta-analysis of randomized clinical trials may contribute to therapeutic progress through (1) establishing efficacy benefits beyond a reasonable doubt, (2) identifying sources of heterogeneity between trials, (3) studying subsets reliably, (4) confirming differences in toxicity profiles, (5) evaluating the cost-effectiveness of experimental therapies, (6) assessing surrogate endpoints, and (7) addressing ancillary questions. All of these potential contributions are illustrated with examples in early and advanced colorectal cancer.

Prognostic indicators in hepatocellular carcinoma: a systematic review of 72 studies

BACKGROUND

Although there are many studies of the predictors of death in hepatocellular carcinoma (HCC), most combine patients with and without cirrhosis and many combine those with compensated and decompensated cirrhosis.

OBJECTIVE

To perform a systematic review of the literature evaluating the predictors of death in patients with cirrhosis and HCC and to evaluate whether the predictors differ between patients with compensated and decompensated cirrhosis.

INCLUSION CRITERIA

(i) publication in English, (ii) adult patients, (c) >80% of the patients had cirrhosis, (iv) follow-up >6 months and (v) multivariable analysis. Quality was based on the accepted quality criteria for prognostic studies.

RESULTS

Of the 1106 references obtained, 947 were excluded because they did not meet the inclusion criteria. A total of 23 968 patients were included in 72 studies (median, 177/study); 77% male, median age 64, 55% Child-Pugh class A. The most robust predictors of death were portal vein thrombosis, tumour size, alpha-foetoprotein and Child-Pugh class. Sensitivity analysis using only 15 'good' studies and 22 studies in which all patients had cirrhosis yielded the same variables. In the studies including mostly compensated or decompensated patients, the predictors were both liver and tumour related. However, these studies were few and the results were not robust.

CONCLUSIONS

This systematic review of 72 studies shows that the most robust predictors of death in patients with cirrhosis and HCC are tumour related and liver related. Future prognostic studies should include these predictors and should be performed in specific patient populations to determine whether specific prognostic indicators are more relevant at different stages of cirrhosis.

Recent results of therapy for scirrhous gastric cancer

The prognosis of patients with scirrhous gastric cancer (SGC) is extremely poor. However, recent advances in therapeutic strategies against SGC, using effective anticancer drugs, have prolonged the survival of patients with SGC. This paper reviews the recent therapeutic outcomes of this type of gastric cancer and introduces a new treatment protocol for SGC.

Long term survivors with metastatic pancreatic adenocarcinoma treated with gemcitabine: a retrospective analysis

BACKGROUND

Metastatic pancreatic adenocarcinoma has a short median overall survival (OS) of 5-6 months. However, a subgroup of patients survives more than 1 year. We analyzed the survival outcomes of this subgroup and evaluated clinical and pathological factors that might affect survival durations.

METHODS

We identified 20 patients with metastatic or recurrent pancreatic adenocarcinoma who received single-agent gemcitabine and had an OS longer than 1 year. Baseline data available after the diagnosis of metastatic or recurrent disease was categorized as: 1) clinical/demographic data (age, gender, ECOG PS, number and location of metastatic sites); 2) Laboratory data (Hematocrit, hemoglobin, glucose, LDH, renal and liver function and CA19-9); 3) Pathologic data (margins, nodal status and grade); 4) Outcomes data (OS, Time to Treatment Failure (TTF), and 2 year-OS). The lowest CA19-9 levels during treatment with gemcitabine were also recorded. We performed a univariate analysis with OS as the outcome variable.

RESULTS

Baseline logarithm of CA19-9 and total bilirubin had a significant impact on OS (HR = 1.32 and 1.31, respectively). Median OS and TTF on gemcitabine were 26.9 (95% CI = 18 to 32) and 11.5 (95% CI = 9.0 to 14.3) months, respectively. Two-year OS was 56.4%, with 7 patients alive at the time of analysis.

CONCLUSION

A subgroup of patients with metastatic pancreatic cancer has prolonged survival after treatment with gemcitabine. Only bilirubin and CA 19-9 levels were predictive of longer survival in this population. Further analysis of potential prognostic and predictive markers of response to treatment and survival are needed.

Modelling prognostic factors in advanced pancreatic cancer

Pancreatic cancer is the fifth most common cause of cancer death. Identification of defined patient groups based on a prognostic index may improve the prediction of survival and selection of therapy. Many prognostic factors have been identified often based on retrospective, underpowered studies with unclear analyses. Data from 653 patients were analysed. Continuous variables are often simplified assuming a linear relationship with log hazard or introducing a step function (dichotomising). Misspecification may lead to inappropriate conclusions but has not been previously investigated in pancreatic cancer studies. Models based on standard assumptions were compared with a novel approach using nonlinear fractional polynomial (FP) transformations. The model based on FP-transformed covariates was most appropriate and confirmed five previously reported prognostic factors: albumin, CA19-9, alkaline phosphatase, LDH and metastases, and identified three additional factors not previously reported: WBC, AST and BUN. The effects of CA19-9, alkaline phosphatase, AST and BUN may go unrecognised due to simplistic assumptions made in statistical modelling. We advocate a multivariable approach that uses information contained within continuous variables appropriately. The functional form of the relationship between continuous covariates and survival should always be assessed. Our model should aid individual patient risk stratification and the design and analysis of future trials in pancreatic cancer.

Prognostic factors for patients with hepatocellular carcinoma with macroscopic portal vein or inferior vena cava tumor thrombi receiving external-beam radiation therapy

Prognostic factors in patients with hepatocellular carcinoma (HCC) with tumor thrombosis are not well established, especially for those given external-beam radiation therapy (EBRT). Patients (n = 136) with HCC who had portal vein (PV) or inferior vena cava (IVC) tumor thrombus received EBRT between January 1998 and October 2007. Demographic variables, laboratory values, tumor characteristics, and treatment modalities were determined at diagnosis and before EBRT. The total radiation dose ranged from 30 to 60 Gy (median, 50 Gy) and was focused on the tumor thrombi. Predictors of survival were identified using the univariate and multivariate analysis. Of the 136 patients, the tumor thrombus completely disappeared in 41 patients (30.1%), 36 patients (26.5%) had a partial response, 49 patients (36%) had stable disease, and 10 patients (7.4%) had progressive disease. On multivariate analysis, pretreatment unfavorable predictors were associated with lower albumin, higher gamma-glutamyltransferase and alpha-fetoprotein levels, poorer Child-Pugh classification, intrahepatic multifocality, lymph node metastases, poorer response to EBRT, and 2-dimension EBRT technique. Survival rates at 1, 2, and 3 years were 31.8%, 17.5%, and 8.8% for patients with PV tumor thrombi; 66.3%, 21.1%, and 15.8% for IVC tumor thrombi; and 25%, 8.3%, and 0% for PV plus IVC tumor thrombi, respectively. Overall median survival was 9.7 months. This study provides detailed information about the survival outcomes and prognostic factors of HCC with tumor thrombi in a relatively large cohort of patients treated with radiation, and the results will help in understanding the potential factors that influence survival for patients with HCC after EBRT.

Combined chemotherapy of hydroxycampothecin with oxaliplatin as an adjuvant treatment for human colorectal cancer

Colorectal cancer (CRC) is a major cause of morbidity and mortality for cancer worldwide, but many patients with CRC are resistant to chemotherapy. We therefore investigated the therapeutic mechanism and clinical effect of combined chemotherapy of hydroxycampothecin (HCPT) with oxaliplatin (L-OHP) on CRC. HCPT represents a potential antitumor agent of Chinese herb. Mice carrying the xenografted human LS174T CRC cells were injected into peritoneal cavities with different drugs: HCPT + L-OHP (OH), HCPT, L-OHP, or saline. Treatment of mice with OH caused the decrease in the volume of tumor and the expression of p53, but increased the apoptotic rate and Fas-L expression, compared to those of animals treated with HCPT or L-OHP, or control animals. Thus, the combination of HCPT with L-OHP could more effectively induce the apoptosis of CRC cells. Furthermore, 56 patients with CRC were treated with HCPT and L-OHP (28 cases, OH group) or L-OHP plus leucovorin plus 5-fluorouracil (28 cases, OFL group), then reviewed the response rate, survival rate and toxicity. The one-year survival rate was 35.07% in OH group and 24.21% in OFL group. However, the occurrence of anemia (51.8%) or diarrhea (60.7%) was higher in OH group than that of 19.6% or 46.4% in OFL group. The clinical results suggest that HCPT plus L-OHP combined chemotherapy could increase the survival time of patients. Taken together, the present study indicates that the combined chemotherapy of HCPT with L-OHP could become a new adjuvant treatment for CRC.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer

BACKGROUND

The long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data.

METHODS

Ninety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable.

RESULTS

On survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour.

CONCLUSION

The various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Epidemiology and survival of hepatocellular carcinoma in Turkey: outcome of multicenter study

OBJECTIVE

Hepatocellular cancer (HCC) is one of the important health problems in Turkey. We aimed to determine the clinical and demographic features of HCC in the Turkish population and to evaluate the prognostic and survival features.

METHOD

Two hundred and twenty-one patients with HCC from five hospitals in Turkey are included in this study.

RESULTS

In 44.4% of the 221 patients with hepatitis B virus and in 21.3% of the 221 patients with hepatitis C virus were found to be responsible for HCC etiology. It has been shown that HCC developed on cirrhosis basis in 74.2% of the patients. HCC was presented with single solitary nodule in 69.2% of the patients. Non-liver metastasis was present in 12.5% of the patients. In 21.7% of the patients, alpha-fetoprotein (AFP) levels were above the diagnostics level of 400 ng/ml. The median overall survival (OS) of 221 patients was 14 months. The median OS of the patients with Child-Pugh A class was significantly longer than that with Child-Pugh B and C classes. The OS of the individuals with normal AFP levels was also longer than that with high AFP levels. The OS of the patients with Stage I HCC according to tumor node metastasis (TNM) classification, the female patients and the treated patients group was found to be significantly good.

CONCLUSIONS

In conclusion, the viral etiology (hepatitis B and C infections) in Turkish population is found to be an important factor in HCC development. The Child-Pugh classification, AFP levels, TNM classification, being female and treatment were determined to be important prognostic factors in HCC patients.

Lactate dehydrogenase-5 (LDH-5) expression in human gastric cancer: association with hypoxia-inducible factor (HIF-1alpha) pathway, angiogenic factors production and poor prognosis

BACKGROUND

Lactate-dehydrogenase-5 (LDH-5) is an important isoenzyme converting pyruvate to lactate under hypoxic conditions and might play an important role in the development and progression of malignancies. However, the role of LDH-5 in gastric cancer is still unclear. In this study, we investigated the clinical significance of LDH-5 expression in gastric carcinoma.

METHODS

LDH-5 expression in 152 patients with different grade and stage gastric carcinoma was analyzed by immunohistochemistry. In addition, hypoxia-inducible factor 1alpha (HIF-1alpha) as a marker of tumor hypoxia, as well as vascular endothelial growth factor (VEGF) and cyclooxygenase-2 (COX-2) as angiogenesis parameters were also assessed in this study. Correlations between the expression of investigated proteins and various clinicopathological factors including survival were determined.

RESULTS

There were 94 cases (61.8%) showing high LDH-5 expression, and 95 patients (62.5%) had high HIF-1alpha expression. Positive correlation was found between LDH-5 expression and HIF-1alpha, VEGF, and COX-2. The overexpression of LDH-5 was more prevalent in advanced tumors having positive vessel invasion. Patients with overexpression of LDH-5 showed far lower disease-free (63.5% vs 82.7%) and overall (56.3% vs 78.4%) survival rates compared with patients with low LDH-5 expression. HIF-1alpha expression was shown to have no significance on survival. In multivariate analysis, high LDH-5 expression kept its independence as a negative prognostic indicator.

CONCLUSION

The results of the current study show that LDH-5 expression may be a useful prognostic factor for patients with gastric carcinoma.

Endoscopic submucosal dissection as a staging measure may not lead to worse prognosis in early gastric cancer patients with additional gastrectomy

BACKGROUND

Endoscopic submucosal dissection is a novel endoluminal technique that enables resection of early stage gastrointestinal malignancies in an en bloc fashion.

AIM

To assess whether preceding endoscopic submucosal dissection affected the prognoses of patients who underwent additional gastrectomy with lymph node dissection due to suspicion of nodal metastasis from endoscopic submucosal dissection specimens.

PATIENTS AND METHODS

Thirty-one patients with early gastric cancer who underwent gastrectomy after endoscopic submucosal dissection were retrospectively investigated in terms of their survival and tumour recurrence. Additional gastrectomy was performed when histology of the endoscopic submucosal dissection specimens revealed that the tumours did not meet the criteria for node-negative cancers.

RESULTS

Twenty-three (74%) and eight (26%) patients had undergone endoscopic submucosal dissection previously due to clinical diagnoses of node-negative cancers and possible node-positive cancers, respectively. Histology of the resected stomachs and lymph nodes revealed residual carcinoma of the stomach in two (6.5%) patients and nodal metastases in four (13%) patients. All patients remain alive without recurrence (median follow-up, 3.4 years; range, 0.6-5.2 years).

CONCLUSIONS

Based on the histology of endoscopic submucosal dissection specimens, preceding endoscopic submucosal dissection itself had no negative influence on a patient's prognosis when additional gastrectomy was performed. It may be permissible to resect some early gastric cancers by endoscopic submucosal dissection as a first step to prevent unnecessary gastrectomy, if technically resectable.

Low serum level of cholinesterase at recurrence of pancreatic cancer is a poor prognostic factor and relates to systemic disorder and nerve plexus invasion

OBJECTIVES

Systemic disorder is a characteristic of advanced pancreatic cancer. Clinical prognostic factors in earlier disease state than terminal stage are expected to be sensitive markers for the foresight of systemic disorder. This study aimed to find the associations between these sensitive markers and morphological factors of primary tumor that may indicate finding a way of pathogenesis of systemic disorder.

METHODS

The current study examined 75 patients who received macroscopic curative resection for pancreatic cancer in our institution as follows: (1) identification of clinical prognostic factors at initial recurrence after resection of primary tumor and (2) analysis of correlations between clinical prognostic factors and histological findings in primary tumor.

RESULTS

Important prognostic factors were peritoneal dissemination and serum levels of carbohydrate antigen 19-9 and cholinesterase. Only low levels of serum cholinesterase correlated to nerve plexus invasion in histological findings of primary tumor. Patients with low cholinesterase levels show systemic disorder, including poor performance status, anemia, and hypoalbuminemia.

CONCLUSIONS

Nerve invasion may thus result in low functional state of the liver followed by systemic disorder. This mechanism may be useful for elucidating cancer cachexia in future studies.

Effect of timing of metastasis/disease recurrence and histologic differentiation on survival of patients with advanced gastric cancer

BACKGROUND

Patients with advanced gastric cancer have a median survival (MS) of <9 months. It is unclear whether the MS of patients who have advanced cancer at the time of diagnosis (synchronous, Group A) is different from that for patients who develop advanced cancer after curative surgery (metachronous, Group B). It was hypothesized that survival would be similar.

METHODS

The medical records of all patients treated at the University of Texas M. D. Anderson Cancer Center who were in either Group A or Group B were reviewed. Survival of patients was assessed by the Kaplan-Meier method. A Cox proportional hazards model was used for multivariate hazards ratios that were adjusted for the effects of location of recurrence, histologic differentiation, patient sex and age, the location of the primary tumor, and timing of disease recurrence (Group A or Group B) on survival.

RESULTS

In all, 773 consecutive patients qualified for the analysis. The distribution of age, race, histologic differentiation, and primary tumor location was similar in both groups. The MS of Group A (n = 603 patients) and Group B (n = 170 patients) was the same (7.6 months). Similarly, the location of the primary tumor and patient sex were found to have no impact on survival. Patients with poorly differentiated tumors (World Health Organization grade 3 or 4) were found to have a shorter survival compared with those with well-differentiated or moderately differentiated tumors (grade 1 or 2; P = .004). Patients with distant metastases had a shorter survival (P = .01) than those with locoregional disease recurrence.

CONCLUSIONS

The data show that MS is similarly poor in patients with advanced gastric cancer with synchronous metastasis (Group A) or those with metachronous metastasis/disease recurrence (Group B). Poor differentiation and anatomically distant site of metastasis were found to impact MS adversely.

Prognostic factors in patients with advanced pancreatic adenocarcinoma treated with intra-arterial chemotherapy

OBJECTIVES

The aim of this study is to identify the prognostic factors of a large group of patients with pancreatic cancer who underwent the same regimen of intra-arterial chemotherapy.

METHODS

5-fluorouracil (1000 mg/m2), leucovorin (100 mg/m2), epirubicin (60 mg/m2), and carboplatin (300 mg/m2) were administered every 3 weeks into celiac axis (FLEC regimen). Kaplan-Meyer survival curve for univariate analysis and Cox regression model for multivariate one were used to determine factors predictive of survival.

RESULTS

Data of 211 patients with advanced pancreatic cancer who underwent FLEC regimen were analyzed. Eighty-nine had locally advanced disease, and 112 had distant metastases. Median overall survival was 9.2 months. In both univariate and multivariate analyses, pain reduction after treatment (< or =30% of baseline level vs >30%; overall survival, 7.6 vs 11.5 months), stage of disease (III vs IV; overall survival, 10.5 vs 6.6 months), and number of administered cycles (< or =3 vs >3; overall survival, 5.9 vs 12.3 months) were significant and independent predictors of survival.

CONCLUSIONS

Pain reduction, stage of disease, and number of administered cycles are independent prognostic factors of overall survival in a multivariate analysis of patients with advanced pancreatic cancer receiving FLEC regimen intra-arterially.

False-positive findings for tumor markers after curative gastrectomy for gastric cancer

The objective of this study was to assess the frequency and characteristics of false-positive results for tumor markers after curative gastrectomy for gastric cancer. Carcinoembryonic antigen and/or carbohydrate antigen 19-9 were periodically assessed for 168 patients who underwent curative gastrectomy. Cancer recurrence was observed for 17 (10.1%) patients and 151 (89.9%) were disease-free during the mean follow-up period of 23.1 months after the operation. The frequency of false-positive findings for tumor markers after gastrectomy was 14.3% (24/168) for all followed-up patients. Three different patterns of marker elevation were observed in the false-positive group. A false-positive finding for these markers was observed for patients with early-stage cancer and for those with chronic benign diseases, for example bronchitis, liver dysfunction, diabetes mellitus, and renal dysfunction. For most patients with false-positive findings for a marker a spontaneous decrease in the tumor marker was observed 1-2 months after the marker was first observed at a high level after the operation. Surgeons and oncologists should therefore keep in mind the high frequency of false-positive findings for tumor markers after curative gastrectomy for gastric cancer.

Incidence, risk factors and consequences of portal vein and systemic thromboses in hepatocellular carcinoma

INTRODUCTION

Hemostatic activation may be important for tumor biology. Hepatocellular carcinoma (HCC) is commonly associated with portal vein thrombosis (PVT). Little is known about factors predictive for PVT in patients with HCC or its correlation with systemic venous thromboembolism (VTE).

METHODS

We conducted a retrospective chart review of 194 consecutive patients diagnosed with HCC at the University of Rochester between 1998 and 2004 to identify the frequency and risk factors for PVT and its correlation with VTE and survival.

RESULTS

Sixty patients (31%) had PVT with a higher rate in the non-transplant group compared to transplanted patients (34% vs. 24%; p=0.15). In multivariate analysis, Child Turcotte Pugh (CTP) class, stage, major vessel involvement, serum albumin, and serum AFP were independently associated with PVT (p<0.05 for each). The presence of PVT was associated with reduced survival (median survival 2.3 months for those with PVT versus 17.6 months for those without PVT, HR 2.05, p=0.004). The incidence of systemic VTE in the total population was 6.7%, and patients with PVT had a higher rate of systemic VTE compared to patients without PVT (11.5% vs. 4.4%; p=0.04).

CONCLUSION

PVT is common in patients with HCC, indicates advanced disease, is associated with worse survival and correlates with systemic VTE, suggesting a common mechanism of hemostatic activation. Advanced stage, higher CTP class, major vessel involvement, low serum albumin, and high AFP levels are predictive of PVT in patients with HCC.

[Prognostic factors in patients with non-active treatment of hepatocellular carcinoma]

OBJECTIVE

To evaluate factors associated with poor survival in patients with non-active treatment of hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

Between May 2003 and June 2005, 50 patients with HCC were deemed unsuitable for active treatment, following the Barcelona Clinic Liver Cancer staging system. Symptomatic treatment was provided. Kaplan-Meier curves were constructed and compared by the log-rank test to identify factors associated with poor survival. Independent factors predictive of survival were evaluated by multivariate Cox regression analysis.

RESULTS

The mean age was 65.6 +/- 11.9 years and 84% of the patients were men. Forty-eight percent of the patients had hepatitis C infection and 58% were Child-Pugh grade A. HCC was multinodular in 54% and the total tumor size was more than 5 cm in 90% of patients. Thirty-four percent of the patients had malignant portal thrombosis and four patients had metastases. Thirty-eight percent of the patients had received previous treatment. The median follow-up was 9.2 months and 1- and 2-year survival was 46% and 17.5%, respectively. Poor survival was associated with male sex, alpha-fetoprotein values of > 400 ng/ml, albumin levels of < 3 g/dl, and metastases. Independent predictors identified by multivariate Cox regression analysis were male sex, albumin levels of < 3 g/dl, and alpha-fetoprotein values of > 400 ng/ml. The median survival in patients with two or more independent factors was significantly lower than that in patients with none or only one factor (14.2 vs. 4.1 months).

CONCLUSION

Survival in patients with non-active treatment of hepatocellular carcinoma can be estimated and the factors involved allow separate groups of patients with different short- to medium-term prognoses to be identified.

The potential role of intrinsic hypoxia markers as prognostic variables in cancer

Tumor hypoxia is related to tumor progression and therapy resistance, which leads to poor patient outcome. It has been suggested that measuring the hypoxic status of a tumor helps to predict patient outcome and to select more targeted treatment. However, current methods using needle electrodes or exogenous markers have limitations due to their invasiveness or necessity for preinjection. Recent studies showed that hypoxia-regulated genes could be alternatively used as endogenous hypoxia markers. This is a review of 15 hypoxia-regulated genes, including hypoxia-inducible factor-1 and its targets, and their correlation with tumor hypoxia and patient outcome from 213 studies. Though most of the studies showed significance of these genes in predicting prognosis, there was no definitive prognostic and hypoxia marker. In conclusion, this review suggests the need for further studies with standardized methods to examine gene expression, as well as the use of multiple gene expressions.

Association of tyrosine PRL-3 phosphatase protein expression with peritoneal metastasis of gastric carcinoma and prognosis

PURPOSE

In gastric carcinoma, high expression of PRL-3, a protein tyrosine phosphatase, is associated with lymph node metastasis. We studied the relationship between PRL-3 expression and peritoneal metastasis in gastric carcinoma.

METHODS

Immunohistochemical analysis using the anti-PRL-3 antibody was done in 639 patients with gastric carcinoma including 89 with peritoneal metastases. We then compared the clinicopathologic characteristics of the PRL-3-positive and PRL-3-negative carcinomas.

RESULTS

PRL-3 was expressed in 70.4% of the primary gastric carcinomas overall; in 80.9% of the cancers with peritoneal metastasis and in 68.7% of those without peritoneal metastasis (P = 0.020). PRL-3 expression was higher in peritoneal metastasis than in the corresponding primary gastric cancers (P = 0.028). PRL-3 expression was correlated with tumor stage (coefficient = 0.343, P = 0.01) and cancer progression, including lymphatic invasion (coefficient = 0.325, P = 0.02), extent of lymph node metastasis (coefficient = 0.322, P = 0.01), and peritoneal metastasis (coefficient = 0.316, P = 0.03). Patients who were PRL-3-negative had a better survival rate than those who were PRL-3-positive at all stages (stage I: log-rank P = 0.046, Wilcoxon P = 0.048; stage II: log-rank P = 0.035, Wilcoxon P = 0.041; stage III: log-rank P = 0.027, Wilcoxon P = 0.033; stage IV: log-rank P = 0.032, Wilcoxon P = 0.030).

CONCLUSIONS

Peritoneal metastasis appears to be correlated with PRL-3 expression, tumor stage, lymphatic invasion, and extent of lymph node metastasis. PRL-3 expression was negatively correlated with prognosis in patients with gastric cancer.

Colorectal carcinoma: a retrospective, descriptive study of age, gender, subsite, stage, and differentiation in Iran from 1995 to 2001 as observed in Tehran University

PURPOSE

Colorectal carcinoma is one of the most common cancers in the world as well as in Iran. There are differences in subsite of the carcinoma when considering age and gender. This study was designed to describe the distribution of colorectal carcinoma by age at diagnosis, gender, and subsite of the tumor. These factors also are evaluated in conjunction with disease stage and tumor differentiation at the time of diagnosis.

METHODS

Data from 419 patients from a population that receives no screening between April 1995 and March 2001 operated on in the Cancer Institute and Imam Khomieni Hospital with a diagnosis of colorectal cancer were used to describe distribution of the colorectal carcinoma by age, gender, tumor subsite and pathology, and stage at diagnosis.

RESULTS

There were 403 (96.2 percent) cases of adenocarcinoma. Males and females constituted 52.4 and 47.6 percent of cases, respectively. The mean age was 52.3 years. Patients were divided into two age groups (40 years and younger, and older than 40 years); 16.4 percent of patients had tumors in the proximal colon and 83.6 percent in distal parts. Most patients were Stage II and III (48.1 and 33.4 percent, respectively). Tumor subsite distribution was almost the same between the two age groups (aged 40 years and younger: proximal, 18.5 percent, and distal, 81.5 percent; older than aged 40 years: proximal, 15.7 percent, and distal, 84.3 percent). Most patients in the younger age group were Stage III (45 percent) and in the older age group were Stage II (53.2 percent; P<0.001). Tumor differentiation proportions in patients aged 40 years and younger were: good, 24.4 percent; moderate, 53.6 percent; poor, 22 percent; and in patients older than aged 40 years were: good, 41.5 percent; moderate, 52.6 percent; poor, 5.9 percent (P<0.001). There were no differences in stage and tumor differentiation between two genders, but most of the patients with tumors in proximal colon were males (62.5 percent; P=0.1).

CONCLUSIONS

Most of the colorectal carcinomas were in distal parts in our study, so most of these carcinomas can be detected by proctosigmoidoscopy. Because younger patients had more advanced disease, the importance of screening and "clinical suspicion" in the young is important.

Sequential administration of 5-fluorouracil (5FU)/leucovorin (LV) followed by irinotecan (CPT-11) at relapse versus CPT-11 followed by 5-FU/LV in advanced colorectal carcinoma. A phase III randomized study

PURPOSE

The purpose of the present study was to evaluate the differences in the sequence of administration of 5-fluorouracil (5-FU)/leucovorin (LV) followed by irinotecan (CPT-11), or CPT-11 followed by 5-FU/LV in advanced colorectal cancer (ACC).

PATIENTS AND METHODS

Chemotherapy-naïve patients with ACC were allocated to the following treatment groups: group A, a bolus of 20 mg/m(2) LV and 425 mg/m(2) 5-FU for 5 days until progression/relapse, and upon progression treatment with weekly CPT-11 (100 mg/m(2)), and group B, CPT-11 followed at progression/relapse by 5-FU/LV at the same doses and schedules as in group A.

RESULTS

120 patients were randomized to receive one of the two treatment sequences and their pretreatment characteristics were equally balanced between treatment arms. No statistically significant difference was found in the objective response rate to CPT-11 (p = 0.45); partial response (PR) was 23.3% for group A patients and 33.3% for group B. Following documented progression and second line treatment there was a significant difference between the response rate in group A (23.3%) and group B where no patients were found to respond to second-line treatment with 5-FU/LV (p = 0.024). The median overall survival was 42.0 weeks (range, 36.6-47.4 weeks) for group A and 32.0 weeks (range, 28.2-35.8 weeks) for group B. The median time to progression for patients in group A following first-line 5-FU/LV was 18 weeks (range, 10-36 weeks) and 12 weeks (range, 10-16 weeks) for group B following first-line CPT-11 (p = 0.0005). Toxicity, according to WHO, was similar between groups.

CONCLUSIONS

Treating patients with CPT-11 upon progression to 5-FU/LV treatment seems to be superior to the opposite sequence. We used these treatments as sequential monotherapies (at progression/relapse), and the best results are gained when 5-FU/LV is followed by CPT-11 at disease progression or relapse.

Chemotherapy for advanced gastric cancer: across the years for a standard of care

Chemotherapy is of crucial importance in advanced gastric cancer patients, in order to obtain palliation of symptoms and improve survival. The most extensively studied drugs as single agents are 5-fluorouracil, cisplatin, doxorubicin, epirubicin, mitomycin C and etoposide. Newer chemotherapeutic agents include the taxanes (docetaxel and paclitaxel), oral fluoropyrimidines (capecitabine and S-1), oxaliplatin and irinotecan. Randomised trials comparing monotherapy with combination regimens have consistently shown increased response rates in favour of combination regimens, whereas only marginally improved survival rates were usually found. Several combination therapies have been developed and have been examined in Phase III trials. However, in most cases, they have failed to demonstrate a survival advantage over the reference arm. There is no internationally accepted standard of care, and uncertainty remains regarding the choice of the optimal chemotherapy regimen. The objective of this article is to review the present literature available on major Phase II - III clinical trials, in which patients suffering from advanced gastric cancer were treated with cytotoxic chemotherapy.

Prognostic factors for survival of patients with advanced gastric cancer treated with cisplatin-based chemotherapy

PURPOSE

The present study evaluated baseline patient- or tumor-related prognostic factors in patients with advanced gastric adenocarcinoma.

PATIENTS AND METHODS

A total of 304 consecutive patients with newly diagnosed metastatic or recurrent gastric cancer treated with one or more cycles of cisplatin-based chemotherapy at the Korea Cancer Center Hospital were enrolled in the current study.

RESULTS

Among the original 304 patients, only 4 patients were alive at the time of this analysis. The median survival for all patients was 7.3 (95% CI, 6.3-8.2) months. Five independent prognostic factors were identified by a multivariate analysis: poor performance status (hazard ratio [HR], 1.46; 95% CI, 1.32-2.92), elevated total bilirubin (HR, 2.04; 95% CI, 1.73-2.35), presence of peritoneal metastasis (HR, 1.73; 95% CI, 1.57-1.90), presence of bone metastasis (HR, 3.11; 95% CI, 2.69-3.53), and more than 1 metastatic site (HR, 1.22; 95% CI, 1.06-1.38). A prognostic index was constructed that divided the patients into a good (n = 162), moderate (n = 82), or poor (n = 60) risk group. The 1-year survival rates for the good, moderate, and poor risk groups were 34.6, 20.7, and 1.7%, respectively, and the survival differences among the groups were highly significant (P < 0.0001).

CONCLUSION

Five prognostic factors were identified from patients receiving first-line cisplatin-based chemotherapy for advanced gastric cancer. A simple prognostic index was then developed that produced distinct survival rates among the different risk groups. Therefore, this prognostic model could help clinicians and patients in clinical decision-making and treatment tailoring based on the estimated prognosis.

Lactate dehydrogenase as a prognostic factor for survival time of terminally ill cancer patients: A preliminary study

This study evaluated lactate dehydrogenase (LDH) as a prognostic factor for survival time in terminal cancer patients. We prospectively followed 93 consecutive inpatients with terminal cancer in one general hospital. Cox's proportional hazard model was used to adjust the influence of some clinical and laboratory variables on survival time. For 25 patients, LDH levels at 2 weeks and 1 week before death were compared by paired t test. In multivariate analysis, elevated LDH level (313 IU/L) was confirmed as an unfavourable indicator for survival time (hazard ratio=2.087, p=0.002). Serum LDH levels were significantly increased as the patients approached death. A combined index comprising LDH levels, C reactive protein levels, uric acid levels, presence of moderate to severe pain, fatigue, hypotension and performance status demonstrated a good stratification value for predicting survival time. Our results showed that serum LDH level can be a useful predictor of survival time of terminally ill cancer patients.

Prognostic factors in patients with gemcitabine-refractory pancreatic cancer

OBJECTIVE

The purpose of this study was to identify prognostic factors in patients with gemcitabine-refractory pancreatic cancer and to determine criteria for selecting candidates for second-line treatment.

METHODS

The records of 74 patients who were treated with gemcitabine (GEM) and followed up until disease progression were reviewed retrospectively. Sixteen clinical variables at the time of disease progression after GEM chemotherapy were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival.

RESULTS

At the time of analysis, 71 patients had died because of tumor progression. The overall median survival time was 5.1 months after first-line chemotherapy with GEM was initiated. Median survival time after disease progression was 2.0 months. Three factors, performance status, peritoneal dissemination and C-reactive protein level, were identified as independent prognostic factors in multivariate analysis. Median survival time in the good prognosis group (patients with performance status 0 or 1, no peritoneal dissemination and C-reactive protein <5.0 mg/dl) was 3.4 months.

CONCLUSIONS

Performance status, serum level of C-reactive protein and peritoneal dissemination were identified as important prognostic factors in patients with GEM-refractory pancreatic cancer. These factors should be considered in determining the treatment following first-line chemotherapy in patients with advanced pancreatic cancer.

Lactate dehydrogenase 5 (LDH-5) expression in endometrial cancer relates to the activated VEGF/VEGFR2(KDR) pathway and prognosis

PURPOSE

Lactate dehydrogenase (LDH-5) is a major lactate dehydrogenase isoenzyme catalyzing the transformation of pyruvate to lactate for anaerobic acquisition energy. In this study, the expression of LDH-5 was assessed in the normal and malignant endometrium. Its role in prognosis and tumor angiogenesis and hypoxia was also examined.

EXPERIMENTAL DESIGN

Tissue specimens from 68 patients with clinical stage I endometrial adenocarcinoma of the endometrioid cell type and 20 samples from normally cycling endometrium were investigated immunohistochemically for the expression of LDH-5. The vascular density and the expression of angiogenesis/hypoxia-related proteins (VEGF, HIF1alpha, HIF2alpha, phosphorylated VEGFR2/KDR, VEGF/KDR complex) were also assessed.

RESULTS

Unlike other normal epithelia, the glandular endometrial cells consistently expressed LDH-5 suggesting a role of this enzyme in the normal menstrual cycle. Endometrial adenocarcinomas displayed LDH-5 expression in 31/68 (45.5%) cases with those having a high LDH-5 expression being connected with a low lymphocytic response; this may suggest an important role of LDH-5 and, presumably, lactate release in tumor escape from host immuno-surveillance. More importantly, LDH-5 was significantly associated with the expression of phosphorylated VEGFR2/KDR receptors in cancer cells and tumor-associated vasculature. LDH-5 was one of the most powerful and independent prognostic variables.

CONCLUSIONS

LDH-5 expression is an independent prognostic marker in endometrial cancer, linked with impaired host immune response and activation of VEGFR2/KDR receptors in both cancer cells and tumor-associated vasculature. Adjuvant radio-chemotherapy may, therefore, be useful in these cases, while the administration of VEGF- tyrosine kinase receptor inhibitors emerges as a therapeutic option.

Follow-up of gastric cancer: a review

Although there is broad agreement in the staging, classification, and surgery for gastric cancer, there is no consensus regarding follow-up after gastrectomy. Follow-up varies from investigations on clinical suspicion of relapse to intensive investigations to detect recurrences early, assuming that this improves survival and quality of life. Advanced gastric cancers recur mainly by locoregional recurrence or distant metastasis. Local recurrences detected at endoscopy or on computed tomography (CT) are invariably incurable. For early gastric cancers, endoscopy can detect new primaries, but the incidence of these tumors is low, and many thousands of procedures are required to detect each operable case. CT is much better at detecting liver metastasis and, although these are usually multiple and unresectable, there are several reports of good survival following liver resection for isolated metastasis. Tumor markers have been used with some success to detect subclinical recurrences and could be used to target more invasive or expensive procedures. In chemotherapy, many newer agents are promising significantly improved survival, but again, the evidence for greater benefit when administered prior to the patient becoming symptomatic is lacking. Overall, it appears that follow-up policy is as much decided by the wealth and facilities of the institution as by any significant evidence base. Although the early detection of recurrent cancer is an emotive issue for both patients and surgeons, considering the amount of time and money invested in follow-up, and the lack of evidence of efficacy, a randomized controlled trial of intensive follow-up is required.

Postoperative chemotherapy for gastric cancer

INTRODUCTION

Adjuvant chemotherapy for gastric cancer after potentially curative surgery has been under clinical investigation for more than four decades. However, potentially curative resection can be performed in only 30%-50% of patients. The objective of this article is to review briefly the clinical trials available in the current literature using adjuvant cytotoxic chemotherapy in patients with gastric cancer after potentially curative surgical resection.

METHODS

Computerized (MEDLINE) and manual searches were performed to identify papers published on this topic between 1965 and 2005. Only articles with an English abstract were reviewed for inclusion; information abstracted included histologic proof of diagnosis, number of patients, dose and modality of treatment, survival duration, and side effects.

RESULTS

Forty-three reports were identified. Single-agent chemotherapy was evaluated in four clinical trials, and postoperative combination chemotherapy was evaluated in 33 trials. Furthermore, we identified five meta-analyses. Five-year survival rates ranged from 12%-91.2%, and the median survival durations were 13-60+ months. Adjuvant chemotherapy, when compared with surgery alone, seems to result in longer survival.

CONCLUSION

The high rate of recurrence, even in patients undergoing state-of-the art curative resection, suggests that effective adjuvant chemotherapy might indeed be an attractive concept to improve the overall outcome of patients with gastric cancer. However, because there is no standard regimen for postoperative treatment at the moment, patients with R0-resected (no residual tumors) gastric cancer should be offered the opportunity to participate in prospective clinical trials.

Prognostic Value of Cytokeratin-Positive Bone Marrow Cells of Gastric Cancer Patients

BACKGROUND

Epithelial cells in the bone marrow of patients with gastric cancer suggest tumor dissemination; however, their prognostic implications are controversial. We prospectively evaluated the correlation of bone marrow findings, recurrence rate, and disease-free survival after long-term follow-up.

METHODS

Bone marrow were aspirated from both iliac crests and stained with monoclonal cytokeratin (CK)-18 antibody in 209 patients before their initial operation. Patients were followed up for a median of 56 months.

RESULTS

Overall, 39 (19%) of 209 patients and 15 (14%) of 109 R0-resected patients had CK-positive cells. CK-positive patients had more local, regional, and distant recurrence than CK-negative patients (P < .05). We found a significantly shorter disease-free survival (P < .05) in the patients with >2 CK-positive cells per 2 x 10(6) bone marrow cells (mean, 35 months) than in patients with <or=2 CK-positive cells per 2 x 10(6 )bone marrow cells (mean, 70 months) or in patients with no CK-positive cells (mean, 86 months). Multivariate analysis confirmed that >2 CK-positive cells per 2 x 10(6) bone marrow cells was an independent prognostic factor for tumor-related death (P < .05).

CONCLUSIONS

Not only the mere presence of CK-positive epithelial cells in bone marrow, but also the cell number, correlates with prognosis. Our findings suggest that classifying CK-positive bone marrow cells in these patients will facilitate future studies.

Chemotherapy for advanced gastric or gastroesophageal cancer: defining the contributions of docetaxel

Despite continuing decline in its incidence, gastric cancer remains the fourth most commonly diagnosed malignancy and is the second leading cause of cancer death around the world. There are > 50% of patients who develop metastatic cancer, which in the majority is beyond cure and, despite many advances that have been achieved in the management of gastric cancer over the past 15 years, patient prognosis remains very poor. The need for the development of more effective therapies that are likely to further improve survival time cannot be overemphasised. A number of new active classes of agents have been identified and these include camptothecins, taxanes, platinols and oral fluoropyrimidines. This review explicitly focuses on the development of docetaxel in the treatment of advanced gastric or gastroesophageal cancer. Docetaxel, a potent taxane, is active as a single agent and in combination with other active agents. Most importantly, the final results of a pivotal randomised Phase III trial have demonstrated a higher overall response rate, longer time to progression and longer overall survival when docetaxal was added to cisplatin plus 5-fluorouracil and compared with cisplatin plus 5-fluorouracil (a reference regimen). This regimen with docetaxel, cisplatin and 5-fluorouracil is intense and proper patient selection and monitoring of the patients is recommended. Future developments will lead to the incorporation of docetaxel in regimens with improved safety profile.

Lactate dehydrogenase 5 expression in operable colorectal cancer: strong association with survival and activated vascular endothelial growth factor pathway--a report of the Tumour Angiogenesis Research Group

PURPOSE

Lactate dehydrogenase 5 (LDH-5) regulates, under hypoxic conditions, the anaerobic transformation of pyruvate to lactate for energy acquisition. Several studies have shown that serum LDH may be an ominous prognostic marker in malignant tumors. The clinical significance of tissue LDH-5, however, remains largely unexplored.

PATIENTS AND METHODS

We investigated the immunohistochemical expression of LDH-5 in a series of 128 stage II/III colorectal adenocarcinomas treated with surgery alone. In addition, markers of tumor hypoxia (hypoxia-inducible factor 1 alpha [HIF1alpha]), angiogenesis (vascular endothelial growth factor [VEGF] and phosporylated kinase domain receptor [pKDR]/flk-1 receptor) and the tumor vascular density (CD31 positive standard vascular density [sVD] and pKDR positive activated vascular density [aVD]) were assessed.

RESULTS

The expression of LDH-5, together with that of HIF1alpha and pKDR, was both nuclear and cytoplasmic. Assessment, with minimal interobserver variability, was achieved using a previously described scoring system. LDH-5 was significantly associated with HIF1alpha (P = .01), aVD (P = .001) and, particularly, with pKDR expression in cancer cells (P = .0001). Tissue LDH-5 expression was linked with elevated serum LDH levels, but serum levels failed to reflect tissue expression in 71% of LDH-5 positive cases. In univariate analysis tissue LDH-5 was associated with poor survival (P = .0003, HR 15.1), whereas in multivariate analysis this isoenzyme was the strongest independent prognostic factor (P = .0009). VEGF, pKDR, aVD, sVD and vascular invasion were all significantly related to unfavorable prognosis.

CONCLUSION

The immunohistochemical assessment of tissue LDH-5 and pKDR provides important prognostic information in operable colorectal cancer. The strong association between LDH-5 and pKDR expression would justify their use as surrogate markers to screen patients for tyrosine kinase inhibitor therapy.

Inhibition of PRL-3 gene expression in gastric cancer cell line SGC7901 via microRNA suppressed reduces peritoneal metastasis

High expression of PRL-3, a protein tyrosine phosphatase, is proved to be associated with lymph node metastasis in gastric carcinoma from previous studies. In this paper, we examined the relationship between PRL-3 expression and peritoneal metastasis in gastric carcinoma. We applied the artificial miRNA (pCMV-PRL3miRNA), which is based on the murine miR-155 sequence, to efficiently silence the target gene expression of PRL-3 in SGC7901 gastric cancer cells at both mRNA and protein levels. Then we observed that, in vitro, pCMV-PRL3miRNA significantly depressed the SGC7901 cell invasion and migration independent of cellular proliferation. In vivo, PRL-3 knockdown effectively suppressed the growth of peritoneal metastases and improved the prognosis in nude mice. Therefore, we concluded that artificial miRNA can depress the expression of PRL-3, and that PRL-3 might be a potential therapeutic target for gastric cancer peritoneal metastasis.

Prognostic factors in patients with recently diagnosed incurable cancer: a systematic review

GOALS OF WORK

To review the literature and develop a conceptual framework about prognostic factors for people presenting to medical oncologists with recently diagnosed incurable cancer.

MATERIALS AND METHODS

Medline was searched from January 2000 to October 2003 to identify articles testing associations between clinical or laboratory variables and survival time in adults with advanced solid tumours and median survival of 3 to 24 months. We recorded how frequently prognostic factors were significantly associated with survival in univariable and multivariable analyses.

RESULTS

There were 53 studies included. The factors associated with survival were organised into four categories related to attributes of the host the tumour, the treatment and the interactions between host, tumour and treatment (symptoms, quality of life, performance status and laboratory tests). Co-morbidity was consistently associated with shorter survival. Age and gender were not consistently associated with survival duration, except in lung cancer where females survived longer. Tumour-related factors associated with shorter survival included primary tumour (lung), metastatic site (liver, brain and visceral) and disease extent. Symptoms associated with shorter survival included those of the anorexia-cachexia syndrome, dyspnoea, pain and impaired physical well being. Performance status was strongly associated with survival in most studies. Laboratory tests associated with shorter survival included anaemia, thrombocytopenia, hypoalbuminaemia and elevated serum levels of both alkaline phosphatase and lactate dehydrogenase.

CONCLUSION

Prognostic factors in patients with advanced cancer can be conceptualised as attributes of the host, tumour, treatment and interactions between the three reflected in symptoms, quality of life performance status and laboratory tests.

Effects of natural polysaccharides on the growth and peritoneal carcinomatosis of human gastric adenocarcinoma in a nude mouse model

We have examined the effects of natural polysaccharides isolated from Phellinus gilvus (PG) in vitro and in vivo against gastric cancer. PG decreased cell proliferation and increased cell apoptosis in a dose-dependent manner in vitro. PG also led to a marked inhibition of tumor growth and significant decrease in the incidence of peritoneal carcinomatosis. Histological analysis of tumor confirmed dramatic increase in tumor cell apoptosis by PG, indicating reduced tumor cell proliferation. These data showed that polysaccharides isolated from PG significantly inhibited tumor growth and metastasis in an orthotopic model of human gastric adenocarcinoma, without detectable problematic adverse effects.

Prognostic factors of young patients with colon cancer after surgery

AIM: To investigate the prognostic factors of 96 young patients with colon cancer within a cancer center by univariate and multivariate analysis.

METHODS: A total of 723 patients with colon cancer were treated surgically during a period of 10 years. Ninty six of them were 40 years old or younger. R0, R1 and R2 operations were performed in 69 (71.9%), 4 (4.1%) and 23 patients (24%), respectively. Left hemicolectomy was performed in 43 patients, right hemicolectomy in 37 patients, transverse colon resection in 9 patients and low anterior resection in 7 patients. Cox multivariate regression analysis was performed to identify predictors of survival.

RESULTS: The operation mortality was 0%, 54 patients died within 111 mo after operation due to occurrence or metastases of the tumor. Liver, lung and bone metastases occurred in 3, 1 and 5 patients, respectively. The mean survival time for all patients was 77.9 ± 5.01 mo and the overall 3-, 5- and 10- year survival rates were 66.68%，58.14% and 46.54%, respectively. In the univariate survival analysis, patient age，type of operation, radical resection, blood transfusion, histological type, diameter of tumor, depth of tumor invasion, lymphatic invasion, distant metastases, liver metastases and TNM stage were found to be predictors of survival in young patients with colon cancer. In the Cox-regression analysis, blood transfusion and lymphatic invasion were determined as independent prognostic factors of survival.

CONCLUSIONS: Age, type of operation, radical resection, blood transfusion, histological type, diameter of tumor, depth of tumor invasion, lymphatic invasion, distant metastasis and TNM stage are the predictors of survival in young patients with colon cancer after surgery.

Does a patient’s self-reported health-related quality of life predict survival beyond key biomedical data in advanced colorectal cancer?

The purpose of this study was to determine whether baseline patients' self reported health-related quality of life (HRQOL) parameters could predict survival beyond key biomedical prognostic factors in patients with metastatic colorectal cancer. The analysis was conducted on 299 patients. HRQOL baseline scores were assessed using the European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Core30 (EORTC QLQ-C30). The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap resampling technique was used to assess the stability of the outcomes. The final multivariate Cox regression model retained four variables as independent prognostic factors for survival: white blood cell (WBC) count with a hazard ratio (HR) of 1.961 (95% CI, 1.439-2.672; P<0.001), alkaline phosphatase with HR=1.509 (95% CI, 1.126-2.022; P=0.005), number of sites involved with HR=1.108 (95% CI, 1.024-1.198; P=0.01) and the patient's score on the social functioning scale with HR=0.991 (95% CI, 0.987-0.996; P<0.001) which translates into a 9% decrease in the patient's hazard of death for any 10 point increase. The independent prognostic importance of social functioning and the stability of the final Cox regression model were also confirmed by the additional bootstrap model averaging analysis, based on 1000 bootstrap-generated samples. The results suggest that social functioning, acts as a prognostic measure of survival beyond a number of previously known biomedical parameters.

Irinotecan (CPT-11) combined with bolus 5-fluorouracil/leucovorin (Saltz regimen) as first-line chemotherapy of patients with advanced colorectal cancer

Concerns about the safety of irinotecan (CPT-11) plus bolus 5-fluorouracil (5-FU)/leucovorin (LV) (the so-called Saltz regimen) have been previously reported. This prospective, multicenter, non-randomized study evaluated the anti-tumoral effect and toxicity of the Saltz regimen as first-line chemotherapy of 130 patients with advanced colorectal cancer (CRC). The median numbers of treatment cycles and infusions received per patient were 3 and 12, respectively. Eight (6.1) and 37 patients (28.5%) showed complete and partial responses, respectively [overall response rate=34.6% (95% confidence interval=20.7-48.5%)]. After a median follow up period of 9 months, 70 patients had died. The median progression-free survival and overall survival were 6.78 (0.3-33.8) and 8.26 months (range 0.3-33.8), respectively. The combined CPT-11/5-FU/LV treatment was well tolerated and no toxic deaths were reported. The most common grade 3/4 hematological toxicity was neutropenia (28% of patients and 3% of infusions), but no febrile neutropenia was reported. Delayed diarrhea was the most reported grade 3/4 non-hematological toxicity (21% of patients and 2% of infusions). Other non-hematological toxicities showed very low incidences. During the study five patients died due to factors not associated with disease progression. We conclude that the Saltz regimen administered on an outpatient basis was safe and well tolerated in patients with advanced CRC. Close monitoring of external patients together with an early treatment of toxicity was found to be essential to prevent severe and potentially fatal gastrointestinal or thromboembolic events previously reported with this CPT-11 combined regimen.

Violacein synergistically increases 5-fluorouracil cytotoxicity, induces apoptosis and inhibits Akt-mediated signal transduction in human colorectal cancer cells

Despite recent additions to the armory of chemotherapeutic agents for colorectal cancer (CRC) treatment, the results of chemotherapy remain unsatisfactory. 5-Fluorouracil (5-FU) still represents the cornerstone of treatment and resistance to its actions is a major obstacle to successful chemotherapy. Therefore, new active agents in CRC and agents that increase the chemosensitivity of cancer cells to 5-FU are still urgently required. Violacein, a pigment isolated from Chromobacterium violaceum in the Amazon river, has a diverse spectrum of biological activities, and represents a novel cytotoxic drug with known antileukemic properties. To assess the suitability of violacein as a chemotherapeutic agent in CRC its cytotoxic effects were evaluated both as a single agent and in combination with 5-FU. Its underlying mechanisms of action were further investigated by studying its effects on the cell cycle, apoptosis and cell survival pathways [phosphatidylinositol-3-kinase/Akt, p44/42 mitogen activated protein kinase and nuclear factor kappaB (NF-kappaB)] in colon cancer cell lines. Violacein inhibits the growth of all four colon cancer cell lines tested. It induces apoptosis, and potentiates the cytotoxic effect of 5-FU in a poorly differentiated microsatellite unstable cell line (HCT116). Violacein causes cell cycle block at G(1), upregulates p53, p27 and p21 levels and decreases the expression of cyclin D1. Violacein leads to dephosphorylation of retinoblastoma protein and activation of caspases and a pancaspase inhibitor abrogates its biological activity. Our data provide evidence that violacein acts through the inhibition of Akt phosphorylation with subsequent activation of the apoptotic pathway and downregulation of NF-kappaB signaling. This leads to the increase in chemosensitivity to 5-FU in HCT116 colon cancer cells. Taken together, our findings suggest that violacein will be active in the treatment of colorectal tumors and offers new prospects for overcoming 5-FU resistance.

Gemcitabine treatment in patients with inoperable locally advanced/metastatic pancreatic cancer and prognostic factors

OBJECTIVE

Most patients with pancreatic cancer show an inoperable locally advanced/ metastatic tumour at the time of diagnosis. The present study was aimed at determining the prognostic factors in patients with advanced pancreatic carcinoma treated with gemcitabine.

MATERIAL AND METHODS

Sixty-seven unresectable or metastatic pancreatic cancer patients treated with gemcitabine were included in the study and a total of 258 cycles of treatment were applied.

RESULTS

The overall response rate was 5%. Thirty-one percent of the patients had stable disease, whereas progressive disease was seen in 49%. Clinical benefit response rate was 15%. The median duration of response was 7.3 months. Median progression-free survival was 3 months, while median overall survival was 9 months. Univariate analysis revealed that worse results were found in patients with performance status (PS) = 2, and in patients with primary tumour location in the body or tail of the pancreas (p<0.05). Multivariate analysis of data revealed that the most important factor was PS of the patient, as the patients with PS = 2 had worse results than the patients with PS = 0-1 (p<0.05).

CONCLUSIONS

Low PS is a negative predictive factor for the survival of patients with advanced pancreatic carcinoma treated with gemcitabine.

Meta-analysis of individual patient data from randomized trials: a review of methods used in practice

BACKGROUND

Meta-analyses based on individual patient data (IPD) are regarded as the gold standard for systematic reviews. However, the methods used for analysing and presenting results from IPD meta-analyses have received little discussion.

METHODS

We review 44 IPD meta-analyses published during the years 1999-2001. We summarize whether they obtained all the data they sought, what types of approaches were used in the analysis, including assumptions of common or random effects, and how they examined the effects of covariates.

RESULTS

Twenty-four out of 44 analyses focused on time-to-event outcomes, and most analyses (28) estimated treatment effects within each trial and then combined the results assuming a common treatment effect across trials. Three analyses failed to stratify by trial, analysing the data is if they came from a single mega-trial. Only nine analyses used random effects methods. Covariate-treatment interactions were generally investigated by subgrouping patients. Seven of the meta-analyses included data from less than 80% of the randomized patients sought, but did not address the resulting potential biases.

CONCLUSIONS

Although IPD meta-analyses have many advantages in assessing the effects of health care, there are several aspects that could be further developed to make fuller use of the potential of these time-consuming projects. In particular, IPD could be used to more fully investigate the influence of covariates on heterogeneity of treatment effects, both within and between trials. The impact of heterogeneity, or use of random effects, are seldom discussed. There is thus considerable scope for enhancing the methods of analysis and presentation of IPD meta-analysis.

Lactate dehydrogenase 5 (LDH5) relates to up-regulated hypoxia inducible factor pathway and metastasis in colorectal cancer

Lactate dehydrogenase 5 (LDH5) is one of the five LDH isoenzymes and, apparently, the most important for promoting anaerobic glycolysis. LDH5 is transcriptionally regulated by the hypoxia inducible factors (HIF) 1alpha and 2alpha. In this study, the possible aggressive advantages that colorectal tumours may gain from a high LDH5 content was investigated. To this end, 75 colorectal adenocarcinomas were studied immunohistochemically for the expression of LDH5, and the results were related to tumor differentiation, lymph node and distant metastases, the expression of HIF1alpha and HIF2alpha, vascular density (VD) and vascular endothelial growth factor (VEGF). A high LDH5 content was noted in 51 of 75 (68%) colorectal adenocarcinomas. The reactivity was nuclear and/or cytoplasmic. Nuclear LDH5 reactivity was correlated with lymph node involvement and distant metastases. There was a direct association between LDH5 up-regulation and HIF1alpha and HIF2alpha accumulation. HIF1alpha was linked with VEGF, VD and also with extramural invasion, nodal and distant metastases. It is concluded that a high LDH5 content in tumor cells is directly related to an up-regulated HIF pathway and is linked with an aggressive phenotype in colorectal adenocarcinomas.

Gastric cancer

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.

Randomised phase II evaluation of irinotecan plus high-dose 5-fluorouracil and leucovorin (ILF) vs 5-fluorouracil, leucovorin, and etoposide (ELF) in untreated metastatic gastric cancer

An open-label randomised comparison of efficacy and tolerability of irinotecan plus high-dose 5-fluorouracil (5-FU) and leucovorin (LV) (ILF) with etoposide plus 5-FU/LV (ELF) in patients with untreated metastatic or locally advanced gastric cancer. One cycle of ILF comprised six once-weekly infusions of irinotecan 80 mg m⁻², LV 500 mg m⁻², 24-h 5-FU 2000 mg m⁻², and ELF comprised three once-daily doses of etoposide 120 mg m⁻², LV 300 mg m⁻², 5-FU 500 mg m⁻². In all, 56 patients received ILF and 58 ELF. Median age was 62 years, Karnofsky performance 90%, and disease status was comparable for both arms. The objective clinical response rates after 14 weeks treatment (primary end point) were 30% for ILF and 17% for ELF (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.29–1.13, P=0.0766). Overall response rates over the entire treatment period for ILF and ELF were 43 and 24%, respectively (RR 0.56, 95% CI 0.33–0.97; P=0.0467). For ILF and ELF, respectively, median progression-free survival was 4.5 vs 2.3 months, time to treatment failure was 3.6 vs 2.2 months (P=0.4542), and overall survival was 10.8 vs 8.3 months (P=0.2818). Both regimens were well tolerated, the main grade 3/4 toxicities being diarrhoea (18%, ILF) and neutropenia (57%, ELF). The data from this randomised phase II study indicate that ILF provides a better response rate than ELF, and that ILF should be investigated further for the treatment of metastatic gastric cancer.