Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer

Cyclin D1 and epidermal growth factor polymorphisms associated with survival in patients with advanced colorectal cancer treated with Cetuximab

The study aimed to investigate whether polymorphisms in genes of the EGFR signaling pathway are associated with clinical outcome in advanced colorectal cancer (CRC) patients treated with single-agent Cetuximab. Polymorphisms of interest in the EGFR pathway include: cyclin D1 (CCND1) A870G, cyclooxygenase 2 (Cox-2) G-765C, epidermal growth factor (EGF) A61G, epidermal growth factor receptor (EGFR) codon R497 K, EGFR CA dinucleotide repeat in intron 1, interleukin (IL)-8 T-251A and vascular endothelial growth factor (VEGF) C936 T gene polymorphisms. Thirty-nine metastatic CRC patients were enrolled in the IMCL-0144 trial and treated with single-agent Cetuximab. Using the polymerase chain reaction-restriction fragment length polymorphism method, gene polymorphisms of CCND1, COX-2, EGF, EGFR, IL-8 and VEGF were assessed from genomic DNA extracted from blood samples. A significant association was found between the CCND1 A870G polymorphism and overall survival in our 39 CRC subjects. Patients with the AA homozygous genotype survived for a median of 2.3 months [95% confidence interval (CI)=2.1-5.7], whereas those with any G allele (AG, GG genotype) survived for a median of 8.7 months (95% CI=4.4-13.5) (P=0.019, log-rank test). When we analysed the cyclin D1 and EGF polymorphisms together, patients with favourable genotypes (EGF any A allele and CCND1 any G allele) showed a median survival time of 12 months (95% CI=4.8-15.2), whereas patients with any two unfavourable genotypes (EGF GG or CCND1 AA) showed a median survived time of 4.4 months (95% CI=2.1-5.7) (P=0.004, log-rank test). The findings of this pilot study suggest that the cyclin D1 A870G and the EGF A61G polymorphisms may be useful molecular markers for predicting clinical outcome in CRC patients treated with single-agent Cetuximab.

Role of Panitumumab in the Management of Metastatic Colorectal Cancer

Panitumumab (formerly known as ABX-EGF) is the first fully human monoclonal antibody directed against the epidermal growth factor receptor in clinical use. It has proven to be very well tolerated alone and in combination with other cytotoxic chemotherapeutic agents. Panitumumab has demonstrated efficacy as monotherapy and with standard chemotherapeutic agents in a wide variety of cancer types, including non-small-cell lung cancer, renal, and colorectal cancer (CRC). To date, no human antihuman antibodies have been detected, and unlike cetuximab, infusion reactions are infrequent, and no premedications are required when administering panitumumab. The only significant toxicity has been a rash similar to that seen with other agents targeting the epidermal growth factor receptor, and such reactions have been predominantly mild to moderate. In metastatic CRC, panitumumab has been safe and efficacious when given with other commonly used agents in this disease, including irinotecan and fluorouracil. Current studies under way are looking at panitumumab in combination with FOLFOX (fluorouracil/leucovorin/oxaliplatin) plus bevacizumab as well as with novel agents that have yet to come into common clinical practice. Recent progress in development of panitumumab in the management of CRC is reviewed, and management of associated rash is discussed herein.

Expression of epidermal growth factor receptor in squamous cell carcinomas of the anal canal is independent of gene amplification

Immunohistochemical detection of expression of the epidermal growth factor receptor (EGFR) has been utilized to identify eligible patients with solid malignant tumors, including colorectal adenocarcinoma, for monoclonal antibody therapy (eg, cetuximab). The EGFR status in squamous cell carcinoma of the anal canal, an uncommon malignancy traditionally treated with chemoradiation, has not been well investigated. In this study, 38 primary squamous cell carcinomas of the anal canal were immunohistochemically examined for EGFR expression and analyzed by fluorescence in situ hybridization (FISH) for EGFR gene copy numbers. The results showed a variable degree of EGFR expression in 21 (55%) tumors, among which 13 (62%) cases exhibited a 2+ to 3+ staining pattern according to the Dako EGFR phamDx interpretation guide. There were no significant differences among tumors stratified by stage, degree of keratinization, or tissue block storage times. FISH analysis showed that none of the 34 cases with interpretable results had EGFR gene amplification. Increased gene copy numbers due to polysomy 7 were seen in seven of 18 (39%) cases that expressed EGFR protein and four of 16 (25%) cases that did not (P=0.3876). Ten (56%) tumors with positive EGFR staining showed a balanced disomy 7 pattern and one case with monosomy 7 exhibited strong EGFR expression (3+). These results demonstrate that EGFR is overexpressed in more than one-half of the squamous cell carcinomas of the anal canal through mechanisms other than gene amplification. These observations may have important therapeutic implications since EGFR-based targeted therapies have shown promise for other malignant neoplasms.

Advances in chemotherapy for colorectal cancer

Gastroenterologists have a primary role in the management of colorectal cancer patients in that they frequently establish the diagnosis, direct or perform tumor staging evaluations, and initiate referrals for oncologic treatment. Several important advances have been made in the adjuvant treatment of colon and rectal cancers and in therapy of metastatic disease. These advances include the development of more effective combination chemotherapy regimens and molecularly targeted antibodies. These antibodies are directed against regulators of angiogenesis (vascular endothelial growth factor) and tumor cell growth (epidermal growth factor receptor) and have been shown to enhance the efficacy of cytotoxic chemotherapy. In the treatment of localized rectal cancer, the integration of chemotherapy and radiation with surgery has resulted in neoadjuvant approaches that achieve improved tumor control, sphincter preservation, and reduce treatment-related toxicities. This review presents an update of the current approach to colon and rectal cancer treatment, highlighting recent chemotherapeutic advances in the management of these highly prevalent malignancies.

Palliative treatments for patients with inoperable gastroesophageal cancers

Most patients with cancers of the stomach, oesophagus or gastroesophageal junction ultimately develop metastatic or inoperable disease, rendering them incurable. They can, however, benefit from a variety of palliative interventions involving the multidisciplinary team, including chemotherapy, radiotherapy, endoluminal stenting, laser, or surgery. Often a combination of such strategies will be used to control symptoms, and maintain or improve quality of life. In this article, we review these multidisciplinary interventional approaches in patients with gastroesophageal cancers, and highlight future trends.

Les carcinomes de primitif inconnu

PURPOSE

Carcinoma of unknown primary site is a common clinical syndrome, accounting for 2% of cancer patients. Diagnosis is a recurrent challenge for internists. Treatment is difficult and prognosis is still poor. This review presents one synthesis of diagnosis strategies and therapeutic trials. It envisages the interest of new molecular biology methods as well as therapeutic perspectives.

CURRENT KNOWLEDGE AND KEY POINTS

Pathologic examination completed with immunohistochemical tests, and, depending on cases, with electron microscopy, cytogenetics, and molecular biology is a key-point for diagnosis. Diagnosis work-up, based on histological type and on individualization of some clinical presentation, proceeds in three steps. Positron emission tomography is recommended when a curative treatment is planed, particularly in cases of isolated metastasis. Functional status analysed using the performance status and simple biologic parameters (serum lactate dehydrogenase, serum alkaline phosphatase) permit us to assess prognosis. Chemotherapy is offered for patients with a good general health status.

FUTURE PROSPECTS AND PROJECTS

Further evaluation of positron emission tomography, as well as cost-benefit analyses, is warranted. Further randomised trials are necessary to determine the optimal chemotherapy regimen in good-risk patients and the interest of chemotherapy in patients with poor-risk disease. Gene expression profiling and proteomic evaluation, as well as pharmacogenomic offer new investigation fields.

Biological agents versus chemotherapy in the treatment of colorectal cancer

Biological agents are commonly incorporated as an adjunct to cytotoxic chemotherapy in the treatment of patients with advanced colorectal cancer. In contrast to cytotoxic chemotherapy, biological agents have minimal single agent activity and are largely considered to be cytostatic. Recent data supports the use of either combination regimens with chemotherapy and/or biological therapy. Interest in combining biological agents of co-existing molecular pathways is the most recent strategic approach. However, with the advent of these novel therapies, questions have arisen regarding appropriate clinical indication and potential treatment-related toxicities. The role of biological agents in the treatment of colorectal cancer and their role in contrast to cytotoxic chemotherapy will be explored.

A review of erlotinib and its clinical use

Erlotinib is an orally available, reversible tyrosine kinase inhibitor of the epidermal growth factor receptor. Encouraging activity as a single agent and in combination with other targeted agents has been demonstrated in Phase II trials in many tumour types. Erlotinib has an established role in the treatment of advanced, refractory non-small cell lung cancer-based on a pivotal trial demonstrating a survival advantage over best supportive care. In a Phase III trial, the addition of erlotinib to gemcitabine improved survival in advanced pancreatic cancer. The toxicity profile of erlotinib includes diarrhoea and rash, with no haematological side effects. Predictive factors for response include the presence of a rash, epidermal growth factor receptor expression and mutation status. This article reviews the current clinical status of erlotinib.

Resin 90Y-microsphere brachytherapy for unresectable colorectal liver metastases: modern USA experience

PURPOSE

Salvage therapy for patients with unresectable colorectal liver metastases that were refractory to oxaliplatin and irinotecan was performed via radioactive microspheres. High doses of radiation were delivered to tumors from permanently implanted 90Y microspheres, delivered through the hepatic arterial vessels.

METHODS AND MATERIALS

Patients from 7 institutions were selected for treatment after screening-defined vascular access to all the tumors, and imaging-confirmed microspheres would be implanted only in the liver tumors. All patients were followed with laboratory and imaging studies at regular intervals until death. Toxicities, both acute and late, were recorded, and actuarial survival determined.

RESULTS

A total of 208 patients were treated from April 2002 to April 2005. Median follow-up of the 129 men and 79 women is 13 months (range, 1-42 months). Median survival is 10.5 months for responders but only 4.5 months in nonresponders. No treatment-related procedure deaths or radiation-related venoocclusive liver failures were found. Computed tomography partial response was 35%; positron emission tomography response of 91% and reduction in carcinoembryonic antigen of 70% were achieved.

CONCLUSIONS

In this group of heavily pretreated patients, radioactive microspheres produced an encouraging median survival, with acceptable toxicity, and a significant objective response rate, which suggests that further investigation of this approach is warranted.

Cetuximab in advanced non-small cell lung cancer

Non-small cell lung cancer (NSCLC) remains a major problem in the western civilization and developing countries. Since most patients with NSCLC have advanced disease at diagnosis, to date, chemotherapy, with third-generation platinum-based doublets, represents the standard of care. Advances in the knowledge of tumour biology and mechanisms of oncogenesis has granted the singling out of several molecular targets for NSCLC treatment. Epidermal growth factor receptor (EGFR), a member of ErbB family, is one of the most studied target. Cetuximab is a chimeric (human-murine) monoclonal antibody directed against the extracellular domain of the EGFR that blocks ligand (TGF-alpha, EGF) access to the receptor. In the present paper we discuss about the activity, tolerability and efficacy of cetuximab, the EGFR monoclonal blocking antibody with the largest amount of clinical data being available on the treatment of advanced NSCLC.

The complexity of targeting EGFR signalling in cancer: from expression to turnover

The epidermal growth factor receptor (ErbB1 or EGFR) has been found to be altered in a variety of human cancers. A number of agents targeting these receptors, including specific antibodies directed against the ligand-binding domain of the receptor and small molecules that inhibit kinase activity are either in clinical trials or are already approved for clinical treatment. However, identifying patients that are likely to respond to such treatments has been challenging. As a consequence, it still remains important to identify additional alterations of the tumor cell that contribute to the response to EGFR-targeted agents. While EGFR-mediated signalling pathways have been well established, there is still a rather limited understanding of how intracellular protein-protein interactions, ubiquitination, endocytosis and subsequent degradation of EGFR contribute to the determination of sensitivity to EGFR targeting agents and are emerging areas of investigation. This review primarily focuses on the basic signal transduction pathways mediated through activated membrane bound and/or endosomal EGFR and emphasizes the need to co-target additional proteins that function either upstream or downstream of EGFR to improve cancer therapy.

First- and second-line therapy of metastatic colorectal cancer

In the USA, colorectal cancer is the fourth most prevalent cancer and is the second leading cause of cancer death after lung cancer. In 2006, 148,610 colorectal cancer cases are expected in the USA, with 55,170 deaths expected from this disease. After years of stagnation, the treatment of metastatic colorectal cancer has recently made dramatic advances. The previous standard of care, 5-fluorouracil, is the now the backbone of combination regimens with oxaliplatin or irinotecan. The addition of biological agents, such as the vascular endothelial growth factor inhibitor, bevacizumab, and the epidermal growth factor receptor inhibitors, cetuximab and panitumumab, have further enhanced the activity of conventional chemotherapy. These advances have increased the overall survival of advanced colorectal cancer patients, which was once 6 months with best supportive care, to over 2 years if all active agents are used in the course of the disease.

Effects of 5-fluorouracil adjuvant treatment of colon cancer

Since the late 1980s and early 1990s, 5-fluorouracil-based chemotherapy has been the standard adjuvant treatment for Stage III colon cancer. After the initial introduction of 5-fluorouracil in standard treatment protocols, several changes have been made based on results of randomized studies on various treatment regimens, including new cytotoxic agents. In Stage II patients, the role of adjuvant chemotherapy is debatable. However, there might be a role for adjuvant treatment in certain high-risk patients. Following a search of the Medline database, the results of randomized studies on 5-fluorouracil-based adjuvant therapy are reviewed, and future therapeutic options are discussed.

Chemotherapy for elderly patients with advanced colorectal carcinoma

There is an increasing need to redefine treatment strategies in elderly patients with advanced colorectal carcinoma since they constitute more than 50% of newly diagnosed patients. Taking into account that the vast majority of clinical trials in advanced colorectal carcinoma include patients up to 75 years old, it seems reasonable to consider those patients over 75 years as elderly. In general, 20% of patients have favorable factors (fewer than four liver nodules less than 5 cm in size) and are suitable for local treatments (surgery or local-ablative therapies). Additionally, 40% of patients have poor performance status or are severely disabled owing to geriatric syndromes and/or comorbid diseases (advanced stage) that preclude any treatment strategies. The remainder of patients (fit elderly patients not suitable for radical treatments) constitute the focus of this review.

[New prognostic and predictive factors in advanced colorectal cancer]

Cancer patients often show a clinical tendency to thromboembolic events. This tendency is due to tumor cell-related factors together with the damage of the vascular endothelial exerted by chemotherapy treatment. Gastrointestinal tumors especially contribute to these types of events. More recently, the implication of tumor angiogenesis in clotting/fibrynolisys and plasminogen systems activation has been addressed in cancer patients. Finally, some hemostasis and angiogenesis-related factors such as platelets, von Willebrand factor, fibrinogen, plasminogen activator inhibitor type-1, D dimer, and vascular endotelial growth factor have been highlighted as new potential response and survival predictors in colorectal cancer patients. In this review article, the current evidence supporting the use of these proteins in assessing prognosis in colorectal cancer patients is critically exposed and discussed.

Incidence and management of bevacizumab-related toxicities in colorectal cancer

Bevacizumab, a recombinant, humanised monoclonal antibody against vascular endothelial growth factor, when used in combination with intravenous 5-fluorouracil (5-FU)-based chemotherapy as first-line treatment of metastatic colorectal cancer (CRC) improves survival. In a randomised, placebo-controlled Phase III study, the addition of bevacizumab to irinotecan/5-FU/leucovorin (IFL) resulted in significant improvement in survival compared with IFL alone, which led to its approval for first-line use in CRC. Bevacizumab also demonstrates improved efficacy in combination with 5-FU/LV over chemotherapy alone when data were pooled from two randomised Phase II studies utilising bevacizumab with 5-FU/leucovorin, and also in a third treatment arm of bevacizumab/5-FU/LV of a randomised Phase III study. More recently, in the second-line setting, bevacizumab in combination with FOLFOX improved survival from 10.8 to 12.9 months in the ECOG 3200 trial. Clinical activity with the addition of bevacizumab to oxaliplatin and either 5-FU or capecitabine-based regimens has also been shown in TREE-2, and activity with the combination of bevacizumab and the EGFR inhibitor cetuximab has been documented in BOND-2. In this study, bevacizumab was generally well-tolerated with no unexpected toxicities when combined with cetuximab. A few toxicities were uniformly encountered in all of the above studies, in particular grade 3 medically-manageable hypertension (3 - 16%). In addition, other toxicities were haemorrhage (2 - 9.3%), gastrointestinal perforation (1.5%), arterial thromboembolism (3.8%), wound healing (1 - 2%) and proteinuria (1 - 2%). As bevacizumab is becoming widely used in general oncology practice, it is important to understand the toxicities which can arise and to develop practice guidelines for their management. This review addresses the toxicities noted in trials using bevacizumab for the treatment of CRC and provides recommendations for toxicity management.

Clinical and pathologic predictors of locoregional recurrence, distant metastasis, and overall survival in patients treated with chemoradiation and mesorectal excision for rectal cancer

OBJECTIVES

To identify predictive factors for locoregional recurrence (LR), distant metastasis (DM), and overall survival (OS) in patients treated with chemoradiation and surgery for rectal cancer.

METHODS

Between 1989 and 2001, 470 patients with rectal cancer were treated with preoperative (89%) or postoperative (11%) chemoradiation and mesorectal excision. Median radiation dose was 45 Gy; 97% received concurrent infusional 5-fluorouracil, and 65% received adjuvant chemotherapy. Median follow-up interval was 5.7 years.

RESULTS

The 5-year rates of freedom from LR, freedom from DM, and OS were 90%, 79%, and 80%, respectively. On univariate analysis, significant predictors of LR were female sex, clinical T stage, pathologic T and N stages, and positive radial margin. Significant univariate predictors of DM were circumferential extent of tumor, tumor immobility, lymphovascular invasion, perineural involvement, and pathologic T and N stages. Significant univariate predictors of lower OS were age, circumferential extent of tumor, shorter distance from anal verge, tumor size, tumor immobility, anal canal involvement, lymphovascular invasion, perineural involvement, positive radial margin, and pathologic T and N stages. On Cox multivariate analysis, female sex and pathologic T and N stages independently predicted for LR; pathologic T and N stages independently predicted for DM; and age, circumferential extent of tumor, positive radial margin, and pathologic T and N stages independently predicted for lower OS.

CONCLUSIONS

Pathologic T and N stages significantly predicted for all 3 end points (LR, DM and OS) on multivariate analysis. Investigations of more aggressive adjuvant chemotherapy appear warranted for pathologic stage T3/T4 or N1/2 rectal cancer.

[Targeted therapy in the treatment of solid tumors and in hematology-oncology. Advances and disappointments]

The development and clinical introduction of targeted therapies has resulted in significant progress for the treatment of malignant diseases. These forms of therapy supplement traditional methods of chemotherapy, radiation, and surgery. As new therapies increase the complexity of therapeutic options in oncology, the treatment costs steadily climb as well. Parameters need to be identified which will predict a response to new substances, and this effort is the subject of ongoing studies.

Pharmacogenetics of colorectal cancer

Colorectal cancer is one of the most common types of cancer in both men and women. Multiple chemotherapy combinations exist; however, there is currently no strategy for individualised therapy selection prior to treatment. Genetic polymorphisms in genes involved in the metabolism, transport or targets for the commonly used chemotherapy drugs (5-fluorouracil, irinotecan and oxaliplatin) have been described. Many require validation in large prospective trials before they can be used as markers for outcome and/or toxicity. This review describes the data available on polymorphisms in key genes that are associated with chemotherapy toxicity and response in colorectal cancer.

Clinical experience with anti-EGFR therapy

OBJECTIVES

To review clinical experience and studies with anti-EGFR therapies in metastatic CRC, SCCHN, and NSCLC. Case studies in each tumor type will also be outlined.

DATA SOURCES

Research articles and patient case histories.

CONCLUSION

Several phase II/III trials have shown the activity of anti-EGFR therapy in CRC, SCCHN, and NSCLC. Treatment confers substantial clinical benefit with improved symptoms, particularly in previously treated patients. Toxicity of anti-EGFR therapies is generally manageable and non-overlapping with other treatment options, including chemotherapy and radiotherapy.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to further advance our understanding of anti-EGFR therapies and continue to encourage patient enrollment in ongoing trials of anti-EGFR therapy.

Targeting tyrosine kinases in cancer: the second wave

One of the most exciting developments in cancer research in recent years has been the clinical validation of molecularly targeted drugs that inhibit the action of pathogenic tyrosine kinases. Treatment of appropriately selected patients with these drugs can alter the natural history of their disease and improve survival. The clinical validation of these "first-generation" tyrosine kinase inhibitors has been the prelude to a second wave of advances in molecular targeting that is expected to further change the way we classify and treat cancer. Efforts are now being directed at identifying the tumor subtypes and patients who will benefit the most from these drugs. In addition, new compounds that circumvent acquired resistance to the first-generation tyrosine kinase inhibitors are being tested in patients with refractory disease. Agents directed against new molecular targets are also being explored.

Common side effects of anti-EGFR therapy: acneform rash

OBJECTIVES

To review the general toxicity profile of EGFR-targeted therapies and the management of the most common side effect, skin toxicity.

DATA SOURCES

Research articles.

CONCLUSION

The most common side effect of anti-EGFR therapy is skin toxicity, which is generally mild to moderate, but may be severe in up to 18% of patients. Appearance of more severe rash has been correlated with better treatment outcomes. Skin toxicity is generally manageable with standard topical or systemic antibiotics and anti-inflammatory agents. Rash does not warrant treatment discontinuation; however, when using TKIs, the combination of rash and severe diarrhea may require treatment cessation.

IMPLICATIONS FOR NURSING PRACTICE

Patients and nurses need to be well informed about the expected side effects of anti-EGFR therapy and appropriate management techniques. Patient education prior to beginning therapy and proactive intervention at the first signs of skin toxicity are key to successful management.

Role of receptor tyrosine kinases in gastric cancer: New targets for a selective therapy

Receptor tyrosine kinases (RTKs) such as the epidermal growth factor receptor family participate in several steps of tumor formation including proliferation and metastatic spread. Several known RTKs are upregulated in gastric cancer being prime targets of a tailored therapy. Only preliminary data exist, however, on the use of the currently clinically available drugs such as trastuzumab, cetuximab, bevacizumab, gefitinib, erlotinib, and imatinib in the setting of gastric cancer. Preclinical data suggest a potential benefit of their use, especially in combination with “conventional” cytostatic therapy. This review summarizes the current knowledge about their use in cancer therapy as well as new approaches and drugs to optimize treatment success.

Towards therapeutic vaccines for colorectal carcinoma: a review of clinical trials

Colorectal carcinoma is a leading cause of cancer-related mortality. Despite the introduction of new cytotoxic drugs, improved surgical and radiotherapeutic techniques, a large proportion of colorectal carcinomas remain incurable. New targeted therapeutic strategies, including immunotherapy, are being explored as complementary treatments. Recent advances in immunology and molecular biology have opened new avenues for the clinical testing of rationally designed vaccination strategies against cancer. The present report reviews the results of therapeutic vaccine trials in colorectal carcinoma, published mainly in the past 6 years. Tumor-associated antigens (self-antigens) have been targeted by therapeutic vaccination in more than 2000 colorectal carcinoma patients. The results demonstrate that tumor antigen-specific immune responses are reproducibly induced; that is, tolerance can be reversed, without the induction of serious adverse events or autoimmune disorders. No long-term autoimmune side effects have been observed after a minimum follow-up of 4 years in over 700 patients. Over 1300 colorectal carcinoma patients with minimal residual disease have been enrolled in randomized controlled Phase II/III trials using autologous tumor cell vaccines. A significantly improved overall survival was noted for Stages I-IV colorectal carcinoma patients utilizing Newcastle-disease virus as an adjuvant. Autologous tumor cells mixed with bacillus Calmette-Guerin (BCG) were of significant clinical benefit for patients with Stage II colon cancer. Results of randomized controlled trials targeting Ep-CAM have shown clinical benefit in subgroups of patients. Several new generation vaccines have demonstrated excellent safety profile and immunogenicity. Some studies have also demonstrated a statistically significant correlation between the induced immune response and prolonged overall survival, which should be confirmed in enlarged trials. Although it is unlikely that active specific immunotherapy will provide a standard complementary therapeutic approach for colorectal carcinoma in the near future, the results so far are encouraging. Randomized controlled vaccine trials targeting molecularly defined tumor antigens are warranted, particularly in colon carcinoma with minimal residual disease.

Advances in the treatment of locally advanced non-nasopharyngeal squamous cell carcinoma of the head and neck region

Over the past decade important advances have been made in the treatment of locally advanced squamous cell carcinoma of the head and neck (SCCHN). Traditionally, chemotherapy has been incorporated in the treatment of SCCHN either before local treatment as induction, concomitantly with radiation, or following local treatment as adjuvant therapy. A number of randomized trials and meta-analyses have demonstrated that induction chemotherapy (usually based on the combination of cisplatin and 5-d continuous infusion of fluorouracil) followed by local treatment or concomitant chemoradiotherapy (CCRT) each prolongs survival and results in organ preservation in a significant number of patients. Survival rates appear to be higher when CCRT with cisplatin is used. Furthermore, accelerated fractionation radiation regimens have shown improved local control rates in randomized trials. Recently, new therapeutic strategies such as induction chemotherapy followed by CCRT or the incorporation of newer agents such as taxanes are under intense investigation and preliminary results are promising. Advances in molecular biology have led to the elucidation of molecular mechanisms that initiate and maintain the malignant phenotype in SCCHN. The identification of molecular targets has revolutionized our approach to cancer therapy and resulted in the introduction of novel targeted therapies. Cyclin-dependent kinases, the tumor suppressor p53 gene, and epidermal growth factor receptor are some of the molecular targets of such therapies in patients with SCCHN.

Novel kinase inhibitors in renal cell carcinoma: progressive development of static agents

The rapidly expanding knowledge regarding neoplastic diseases is providing a plethora of new targets for drug discovery and development as exemplified by recent data in renal cell carcinoma. The initial experience with molecularly "targeted" agents has demonstrated that development of the newer non-cytotoxic agents will provide unique challenges requiring modification of many traditional drug development concepts and methods. We discuss recently reported data from a few renal cell carcinoma trials with putative cytostatic agents and highlight issues that need to be addressed for efficient development of cytostatic agents during various phases of clinical development.

Targeting of solid tumors and blood malignancies by antibody-based therapies — EGFR-pathway as an example

A well-coordinated interaction between extracellular signals and intracellular response forms the basis of life within multicellular organisms, with growth factors playing a crucial role in these interactions. Discoveries in recent years have shown that components of the Epidermal Growth Factor (EGF) signaling system have frequently been used by cancer cells to autonomously provide survival and proliferation signals. The main focus of this review is the ErbB epidermal growth factor receptor (EGFR) family of receptor tyrosine kinases including ErbB1/EGFR, ErbB2/HER2/neu, ErbB3/HER3, and ErbB4/HER4 as therapeutic targets. Since the ErbB receptor family regulates cell proliferation through the Ras-mitogen-activated protein kinase (RAS/MAPK) pathway, and cell survival and transformation through the phosphatidylinositol 3-kinase (PI3K/AKT) pathway, pharmacological targeting of these pathways is also discussed. We will also address the clinical studies that have been conducted to evaluate antibody-based therapies mostly on solid tumors and hematologic malignancies.

Economic impact of simplified de Gramont regimen in first-line therapy in metastatic colorectal cancer

The cost of chemotherapy has dramatically increased in advanced colorectal cancer patients, and the schedule of fluorouracil administration appears to be a determining factor. This retrospective study compared direct medical costs related to two different de Gramont schedules (standard vs. simplified) given in first-line chemotherapy with oxaliplatin or irinotecan. This cost-minimization analysis was performed from the French Health System perspective. Consecutive unselected patients treated in first-line therapy by LV5FU2 de Gramont with oxaliplatin (Folfox regimen) or with irinotecan (Folfiri regimen) were enrolled. Hospital and outpatient resources related to chemotherapy and adverse events were collected from 1999 to 2004 in 87 patients. Overall cost was reduced in the simplified regimen. The major factor which explained cost saving was the lower need for admissions for chemotherapy. Amount of cost saving depended on the method for assessing hospital stay. In patients treated by the Folfox regimen the per diem and DRG methods found cost savings of Euro 1,997 and Euro 5,982 according to studied schedules; in patients treated by Folfiri regimen cost savings of Euro 4,773 and Euro 7,274 were observed, respectively. In addition, travel costs were also reduced by simplified regimens. The robustness of our results was showed by one-way sensitivity analyses. These findings demonstrate that the simplified de Gramont schedule reduces costs of current first-line chemotherapy in advanced colorectal cancer. Interestingly, our study showed several differences in costs between two costing approaches of hospital stay: average per diem and DRG costs. These results suggested that standard regimen may be considered a profitable strategy from the hospital perspective. The opposition between health system perspective and hospital perspective is worth examining and may affect daily practices. In conclusion, our study shows that the simplified de Gramont schedule in combination with oxaliplatin or irinotecan is an attractive option from the French Health System perspective. This safe and less costly regimen must compared to alternative options such as oral fluoropyrimidines.

Retrospective Study of Capecitabine and Celecoxib In Metastatic Colorectal Cancer

OBJECTIVE

COX-2 activation may mediate capecitabine induced toxicities, eg, hand-foot syndrome (HFS) and colorectal cancer progression, both of which may be improved by concurrent celecoxib.

PATIENTS AND METHODS

From October 2000 to December 2003, 66 patients with metastatic colorectal cancer received concurrent capecitabine at 1000 mg/m/d b.i.d. and celecoxib at 200 mg b.i.d. (XCEL). Twenty-four patients were chemo-naive, 42 patients were second-line; while 34 had XCEL with radiation.

RESULTS

The median duration of XCEL was 7.2 months (range, 1.5-38 months). Ninety percent of Grade 2/3 HFS (17%) occurred after 6 months and incidence of grade 3/4 diarrheas was 8%. The overall response rate was 38% (95% confidence interval [CI], 26-51%), with 11 patients (17%) achieving complete responses and 2 patients (3%) with near complete responses. Six patients (9%) become resectable after sustaining treatment response. The median progression-free survival (PFS) and overall survival (OS) was 8.3 months (95% CI, 7.0-11.0 months) and 22 months (95% CI, 17.8-31.5 months), respectively. Improved median PFS of 14.5 months (P = 0.0001) and OS of 31.5 months (P = 0.005) were noted in patients with normal lactate dehydrogenase (LDH) levels (n = 37) than patients with high levels of LDH (n = 29).

CONCLUSIONS

XCEL integrating radiation may improve response rate and survival and reduce toxicities, notably HFS for patients with metastatic colorectal cancer, leading to a randomized phase III study.

The treatment of hepatic metastases in colorectal carcinoma

Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.

Kutane Nebenwirkungen einer EGF-Rezeptor-Blockade und deren Management

The receptor of the epidermal growth factor (EGF-receptor) plays a role in the pathogenesis of many human carcinomas. Recent strategies in anti-tumor therapy target the EGF-receptor, e.g., by the EGF-receptor blocking monoclonal antibody cetuximab or by small molecules inhibiting the tyrosine kinase activity of the EGF-receptor, such as gefitinib and erlotinib. The EGF-receptor is also expressed in normal human skin; in clinical trials with different EGF-receptor inhibitors, cutaneous side effects were common. We report on cutaneous side effects of EGF-receptor blockade, in particular acneiform lesions, xerosis and paronychia, and discuss their management.

Efectos cutáneos de los inhibidores del receptor del factor de crecimiento epidérmico

Epidermal growth factor receptor (EGFR) inhibitors are a new group of drugs used in the treatment of several malignancies. Three molecules are approved at the moment: gefitinib and erlotinib for the treatment of non-small-cell lung cancer, and cetuximab for colorectal cancer. These drugs originate cutaneous side effects with a high frequency: acneiform rashes, paronychia and generalized xerodermia. In this paper we review these common side effects and how to manage them.

Adjuvant therapy for stage II colorectal cancer: Who and with what?

The role of adjuvant chemotherapy for patients with stage II colon adenocarcinoma remains controversial. The high surgical cure rate for patients with "low-risk" stage II colon cancer, ranging from 75% to 80%, and the available clinical trials and meta-analyses provide conflicting recommendations for or against adjuvant chemotherapy for this group of patients. For fit "high-risk" stage II patients with clinical obstruction or perforation at presentation, in which the 5-year survival rate is 60% to 70%, there is little controversy, as these patients are routinely treated with adjuvant chemotherapy. Other potential high-risk factors, including high histologic grade, microsatellite instability, and loss of 18q, have yet to be validated in prospective trials. Patients with fewer than 12 regional lymph nodes identified in the surgical specimen have a statistically unclear risk of lymph node involvement. These patients may have stage III disease and should receive adjuvant therapy. The decision to use adjuvant chemotherapy to treat low-risk stage II colon cancer patients (no obstruction or perforation) should be an informed decision weighing the magnitude of a net 2% to 5% survival benefit, a 0.5% to 1.0% risk of mortality with chemotherapy in addition to 6 months of chemotherapy-related toxicities, other coexisting patient morbidities, and the anticipated life expectancy of each patient. As adjuvant chemotherapy is therapy addressing local or metastatic microscopic disease, and the effectiveness of systemic and biologically targeted therapy for advanced macroscopic colon cancer continues to improve rapidly, it remains to be determined by clinical trials whether therapies including newer agents such as cetuximab and bevacizumab administered in the adjuvant setting may affect survival for stage II cancer patients.

Prognostic significance of epidermal growth factor receptor expression in colon cancer patients undergoing curative surgery

BACKGROUND

To investigate the role of epidermal growth factor receptor (EGFR) expression as a prognostic marker for prediction of cancer behavior and clinical outcomes in colon cancer patients undergoing potentially curative surgery.

METHODS

EGFR determination using a commercially available immunohistochemistry kit was performed in tissues from 149 colon cancer patients receiving primary surgical treatment and in 25 normal colon mucosa specimens from noncancer patients. EGFR positivity was correlated in univariate and multivariate analyses with disease recurrence and survival. In addition, p27, p53, and vascular endothelial growth factor expression were assessed by immunohistochemistry in 104 patients and correlated with EGFR tumor expression and clinical outcome.

RESULTS

EGFR expression was detected in approximately one third of colon cancer patients (53 of 149; 35.6%). In 126 curatively treated patients, EGFR expression was correlated with disease recurrence and worse survival in both univariate and multivariate analyses. In a multivariate model for predicting recurrence and survival, Dukes' staging, p27, and EGFR expression were the only independent covariates. In particular, in Dukes' A and B patients the 5-year survival probability was 96% for EGFR-negative and high p27 expression cases and was 30.7% for EGFR-positive and low p27 expression cases.

CONCLUSIONS

EGFR expression was an independent prognostic indicator of disease recurrence and poor survival in colon cancer patients undergoing curative surgery. In the context of novel therapeutic options such as molecularly targeted therapies, these findings suggest that anti-EGFR drugs could be evaluated in the adjuvant treatment of EGFR-positive colon cancer patients.

Targeting growth factors and angiogenesis; using small molecules in malignancy

Targeted biologic therapy for cancer has evolved from the laboratory to active clinical protocols and applied clinical practice in selected patients. Major targets include epidermal growth factor, and vascular endothelial growth factor receptors which are commonly expressed in gastro-intestinal cancers head & neck and lung cancers, and to some degree breast and gynecologic malignancy. Down stream signal transduction pathway inhibition of B-raf and N-ras mutations are examined in melanoma. New approaches involving re-packaging of chemotherapeutic agents are being exemplified in the nanoparticle formulation of paclitaxel which provides increased access to endothelial and tumor cells with potential enhanced therapeutic efficacy compared to the conventional version solubilized in a cremophor.

Cetuximab: an epidermal growth factor receptor monoclonal antibody for the treatment of colorectal cancer

BACKGROUND

Cetuximab is a recombinant human/mouse chimeric epidermal growth factor receptor (EGFR) monoclonal antibody. It was approved by the US Food and Drug Administration in February 2004 to be used in combination with irinotecan for the treatment of EGFR-expressing, metastatic colorectal cancer in patients who had failed to improve with irinotecan-based chemotherapy. Cetuximab was also approved for administration as a single agent in the treatment of patients with EGFR-expressing, metastatic colorectal cancer who are intolerant to irinotecan-based chemotherapy.

OBJECTIVE

This article reviews the role of cetuximab, an EGFR monoclonal antibody, in the treatment of colorectal cancer.

METHODS

A MEDLINE search was conducted of articles published from 1976 to the present using the terms cetuximab, C225, IMC-C225, colon cancer, colorectal cancer, monoclonal therapy, and target therapy. Abstracts presented at the American Society of Clinical Oncology annual meetings from 2000 to 2004 and the 2004 Gastrointestinal Cancers Symposium were reviewed and included as applicable.

RESULTS

In a Phase III trial, cetuximab was administered to 329 patients with colorectal cancer who were irinotecan refractory and/or had failed to respond to oxaliplatin treatment. Partial response was achieved in 10.8% of patients who received cetuximab monotherapy and 22.9% of patients who received cetuximab plus irinotecan therapy (P = 0.007). The overall response rate in 2 Phase II trials using the conventional dosing regimen of cetuximab to treat EGFR-expressing, metastatic colorectal cancer that was refractory to irinotecan therapy ranged from 9% to 12%. The drug was well tolerated with proper administration precautions. The most common adverse events reported included acnelike rash and hypersensitivity reaction. The positive correlation of the incidence of skin reactions to response rates and median survival is one aspect that warrants further investigation in terms of its use as a response predictor. Unfortunately, the role of immunohistochemistry for EGFR expression continues to be a poor predictor of patients who may benefit from cetuximab. Clinical studies are ongoing of cetuximab in combination with radiation therapy and/or platinum in patients with squamous cell head and neck cancer, as well as cetuximab in combination with various antineoplastic agents in the treatment of non-small cell lung cancer and pancreatic cancer.

CONCLUSIONS

Cetuximab has shown considerable activity-both as monotherapy and in combination with chemotherapy-in the treatment of metastatic colorectal cancer that is resistant to chemotherapy. The future of cetuximab lies in its use in combination with antineoplastic agents and/or radiation therapy in the treatment of colorectal cancer, head and neck cancer, non-small cell lung cancer, and pancreatic cancer. The lack of a predictive marker that would allow clinicians to select patients who are most likely to benefit from cetuximab therapy, especially taking into consideration the high costs of this medication, remains a challenge.

Evolution in the treatment of metastatic colorectal carcinoma of the liver

Metastatic colorectal cancer to the liver is associated with a uniform poor prognosis without treatment. Advances in therapy over the past decades have now allowed surgical resections of the liver to occur with a low morbidity and mortality. Improvements in chemotherapy regimes have paralleled technical improvements and now allow a new group of patients to become eligible for surgical resection. This chapter will review the recent advances in surgical and chemotherapeutic regimes in metastatic colorectal cancer to the liver.

Comparison of two antibodies for immunohistochemical evaluation of epidermal growth factor receptor expression in colorectal carcinomas, adenomas, and normal mucosa

BACKGROUND

Immunohistochemical staining for epidermal growth factor receptor (EGFR) has been used as a criterion for the selection of patients with colon cancer for anti-EGFR therapy. Two antibodies, the PharmDx kit and the 31G7 clone, are used commonly for immunohistochemistry by various laboratories. No comparative studies on the performance of these 2 antibodies are available.

METHODS

EGFR status was evaluated in 744 tissue microarray core samples from primary and metastatic colorectal carcinomas, colorectal adenomas, and normal colorectal mucosa with both the PharmDx kit and the clone 31G7 monoclonal antibodies. The stains were compared for staining intensity by using an automated image-analysis system. The intensity of positive staining (brown color) was measured on a scale from 0 to 255. The staining intensity also was scored manually as 0, 1 +, 2 +, and 3 +.

RESULTS

Statistically, the median staining intensities scored by the automated system between the 2 antibodies did not differ significantly, although, within each category of samples (normal, adenoma, carcinoma, and metastases), the PharmDx antibody staining was slightly more intense than the clone 31G7 antibody staining. There was a linear correlation between automated image-analysis and manual scoring categories. The median automated image-analysis intensity scores for the 4 manual scoring categories with the PharmDx kit were as follows: 0 staining, 67.5; 1 + staining, 75.5; 2 + staining, 89.6; and 3 + staining, 106.0. The median automated image-analysis intensity scores for the 4 manual scoring categories with the clone 31G7 antibody were as follows: 0 staining, 71.3; 1 + staining, 73.6; 2 + staining, 84.6; and 3 + staining, 99.1. The classification of tumors as EGFR-negative (0 staining) or positive (1 +, 2 +, or 3 + staining) was concordant in 151 of 160 carcinomas (94.4%) with 2 antibodies using manual scoring. Five samples (3%) that scored 1 + with the PharmDx kit antibody scored 0 with the clone 31G7 antibody; whereas 4 samples (2.5%) that scored 1 + with the clone 31G7 antibody scored 0 with the PharmDx kit antibody.

CONCLUSIONS

The EGFR expression results obtained by immunohistochemistry using both the EGFR PharmaDx kit and the 31G7 clone were comparable. Either antibody may be used for immunohistochemical detection of EGFR in colorectal carcinomas. In addition, manual scoring had an excellent correlation with automated scoring.

A Phase 2 trial of the liposomal DACH platinum L-NDDP in patients with therapy-refractory advanced colorectal cancer

PURPOSE

L-NDDP (Aroplatin) is a liposomal formulation of cis-bis-neodecanoato-trans-R,R-1,2-diaminocyclohexane platinum (II), a structural analogue of oxaliplatin. In a Phase 1 trial, the maximum tolerated dose (MTD) of L-NDDP was 312.5 mg/m2 with myelosuppression as dose limiting toxicity (DLT). We conducted a Phase 2 trial of L-NDDP in patients (pts) with advanced colorectal cancer (CRC) refractory to 5-fluorouracil/leucovorin or capecitabine and irinotecan to investigate the anti-tumor response of L-NDDP and to further characterize its toxicity profile in this population.

METHODS

L-NDDP was administered intravenously, once every 28 days. The starting dose was 300 mg/m2, with possible intra-patient dose escalation in the absence of grade 2 or higher drug-related toxicity. Patients were treated until disease progression or unacceptable toxicity. Of 20 eligible patients all were evaluable for toxicity and 18 were evaluable for response. Hematologic toxicities included anemia (grades 1-4) in 20% of pts and leucopenia, neutropenia and thrombocytopenia (grade 1/2) in 5% of patients each. Common non-hematologic toxicities included nausea (75%), vomiting (60%), and fatigue (70%), reversible infusion reactions (chest/back pain or shortness of breath; 40%), transient transaminase elevations (35%) and hyperbilirubinemia (20%). Grade 3-4 toxicities included infusion reaction (20%), vomiting (15%), fatigue (15%), anemia (10%) and ALT/AST elevation (5/15%). Peripheral neuropathy (grade 1/2) was seen in 15% of pts. One of 18 pts had a confirmed PR (5.6%), three (16.7%) had stable disease (> or =3 months) and 14 pts progressed. L-NDDP was well tolerated in this group of refractory patients and demonstrated evidence of anti-tumor activity.

CONCLUSION

Further studies of L-NDDP, preferably in combination with other agents such as fluoropyrimidines, are warranted.

Inhibition of bone-derived insulin-like growth factors by a ligand-specific antibody suppresses the growth of human multiple myeloma in the human adult bone explanted in NOD/SCID mouse

Multiple myeloma (MM) is a fatal disease that affects plasma cells. Patients with MM have 1 or more osteolytic lesions in their bone tissues, where insulin-like growth factors (IGFs; IGF-I and IGF-II) are mainly stored. The role of bone-derived IGFs in the development of MM has not been extensively studied because reliable animal models are lacking. We established an animal model using a human MM cell line, RPMI8226, in nonobese diabetic/severe-combined immunodeficient (NOD/SCID) mice implanted with human adult bone (HAB) fragments. Treatment with an anti-human IGF-neutralizing monoclonal antibody, KM1468, inhibited the IGF-I-stimulated phosphorylation of type-I IGF receptors (IGF-IR) in RPMI8226 cells and the activation of the downstream PI3-K/Akt signaling pathway in vitro. KM1468 inhibited IGF-I-mediated RPMI8226 cell growth in a dose-dependent manner. In the NOD/SCID-HAB model, treatment with KM1468 significantly inhibited the growth of RPMI8226 cells (p<0.02). These results indicated that the growth of MM cells was predominantly stimulated not by serum-derived IGFs, but by bone-derived IGFs. Furthermore, the targeting of bone-derived IGFs, using a neutralizing antibody, may offer a new therapeutic strategy for MM.