A phase I/II study of oxaliplatin and paclitaxel in patients with non-resectable cancer of the oesophagus and adenocarcinoma of the gastro-oesophageal junction: a study of the Arbeitsgemeinschaft Internistische Onkologie

Potent molecular-targeted therapies for advanced esophageal squamous cell carcinoma

Esophageal cancer (EC) remains a public health concern with a high mortality and disease burden worldwide. Esophageal squamous cell carcinoma (ESCC) is a predominant histological subtype of EC that has unique etiology, molecular profiles, and clinicopathological features. Although systemic chemotherapy, including cytotoxic agents and immune checkpoint inhibitors, is the main therapeutic option for recurrent or metastatic ESCC patients, the clinical benefits are limited with poor prognosis. Personalized molecular-targeted therapies have been hampered due to the lack of robust treatment efficacy in clinical trials. Therefore, there is an urgent need to develop effective therapeutic strategies. In this review, we summarize the molecular profiles of ESCC based on the findings of pivotal comprehensive molecular analyses, highlighting potent therapeutic targets for establishing future precision medicine for ESCC patients, with the most recent results of clinical trials.

Development of chemotherapeutics for unresectable advanced esophageal cancer

INTRODUCTION

The prognosis of unresectable advanced esophageal squamous cell carcinoma (ESCC) has gradually improved due to efforts for the development of systemic chemotherapy or concurrent chemoradiotherapy.

AREAS COVERED

Chemotherapeutic agents such as cytotoxic agents, molecular-targeted agents, and immune checkpoint inhibitors, sometimes used with irradiation, lead in the treatment of unresectable advanced ESCC. Here, we review the latest treatment strategies for unresectable advanced ESCC and discuss future perspectives.

EXPERT OPINION

Immunotherapeutic agents will be part of the treatment of unresectable advanced ESCC in the near future. However, definitive predictive biomarkers to determine good patient candidates remain unclear for immunotherapy in patients with ESCC. Further research is warranted to identify those biomarkers working individually and in combination. Moreover, genome-based therapeutics enable individualized and patient-specific treatment. The development of molecular-targeted drugs against actionable or druggable genes is in progress.

Systemic treatment of advanced esophageal squamous cell carcinoma: chemotherapy, molecular-targeting therapy and immunotherapy

Systemic treatment of advanced esophageal squamous cell carcinoma (ESCC) mainly consists of cytotoxic agents, aiming to palliate symptoms and prolong survival. Cisplatin and 5-fluorouracil have been considered standard treatment for several decades. Efforts to develop more effective treatment have led to clinical trials testing triplet, irinotecan-based, oxaliplatin-based and paclitaxel-based regimens. Molecular-targeting agents, mainly anti-EGFR inhibitors including gefitinib, panitumumab and nimotuzumab, have been investigated; however, no molecular-targeting agents demonstrate the clinical utility in Phase 3 trials so far. Negative results from Phase 3 trials testing gefitinib and panitumumab suggest the importance of identifying predictive biomarkers of responses to molecular-targeting agents. On the basis of results from Phase 3 trials testing PD-1 inhibitors, nivolumab and pembrolizumab, are anticipated to be the standard treatment for patients with ESCC. Dual immune checkpoint inhibition and immunotherapy in combination with cytotoxic agents are under study. Recent advances in next-generation sequencing technologies provide comprehensive catalogues of genetic alterations in ESCC which may lead to therapeutic breakthroughs in a personalized manner. Here, we review the existing clinical data and discuss future perspectives with a focus on the systemic treatment of advanced ESCC.

Factors Predictive of Improved Outcomes With Multimodality Local Therapy After Palliative Chemotherapy for Stage IV Esophageal Cancer

OBJECTIVES

We reviewed survival outcomes and factors associated with improved outcomes for patients with stage IVB esophageal cancer who received multimodality therapy with initial chemotherapy followed by concurrent chemoradiation (CRT)±surgery.

METHODS

We retrospectively identified 96 patients with stage IVB esophageal carcinoma (with positive nonregional lymph nodes and/or distant organ metastasis) treated at a single institution with chemotherapy followed by concurrent CRT, with or without surgery. The Cox proportional hazard model was used to test associations between overall survival (OS), disease-free survival (DFS), locoregional relapse, distant metastasis-free survival, and potential predictive factors.

RESULTS

Median patient age at diagnosis was 59 years. The median OS time among all patients was 21.0 months, and 1-, 2-, and 5-year OS rates were 84.4%, 46.8%, and 17.9%, respectively; corresponding DFS time and rates were 8.1 months and 37%, 24.6%, and 24.6%, respectively. On multivariate analysis, factors that predicted improved OS with aggressive multimodal therapy included young age; lack of anorexia, fatigue at diagnosis; distant nodal metastasis without organ metastasis at diagnosis; and radiographic response to initial chemotherapy. A subset of 14 patients who had surgery after chemotherapy and concurrent CRT also had better median OS (not reached vs. 20 mo for 82 patients who did not receive surgery, P=0.001), DFS (14.6 vs. 5.9 mo, P=0.021), and distant metastasis-free survival (26.7 vs. 9.2 mo, P=0.042).

CONCLUSIONS

Aggressive local therapy with radiation and potentially surgery after initial palliative chemotherapy can improve prognosis for a select group of patients with stage IVB esophageal cancer.

Paclitaxel-based regimens as first-line treatment in advanced gastric cancer

The aim of this study was to evaluate the efficacy and safety of paclitaxel-based regimens as first-line treatments in advanced gastric cancer. We reviewed 397 previously untreated patients with advanced gastric cancer, who non-randomly received one of three paclitaxel-based regimens: paclitaxel plus fluorouracil/leucovorin (PF), paclitaxel plus oxaliplatin (PO), and paclitaxel plus oxaliplatin plus fluorouracil/leucovorin (POF) between January 2003 and December 2010. The PF, PO, and POF response rates were 47.13, 52.08, and 63.78%, respectively. Overall survivals (OS) were 11.2, 11.7, and 11.7 months, respectively. Progression-free survivals (PFS) were 6.6, 7.2, and 7.1 months, respectively. Leucopenia was higher on the triplet regimen than the doublet regimens. The paclitaxel-based regimens appeared to be effective in patients with advanced gastric cancer. The triplet regimen produced a higher response rate than either doublet regimen with more side effects, while survivals were similar among all three treatments.

Sunitinib plus paclitaxel in patients with advanced esophageal cancer: a phase II study from the Hoosier Oncology Group

The combination of sunitinb (37.5 mg orally daily) + paclitaxel (90 mg/m intravenously on days 1, 8, 15 every 4 weeks) was examined in patients with advanced esophageal or gastroesophageal junction cancer, and progression-free survival (PFS) was compared to that of historical controls. The end points included response rate, overall survival, and toxicities. Twenty-eight patients were enrolled at six centers. Median age was 59.5 years. The 24-week PFS rate was 25% (90% confidence interval [CI], 12-42%). Three (11%) of 23 evaluable patients had a response (1 complete response and 2 partial response) (90% CI, 3-25%). Median overall survival was 228 days (90% CI, 140-283 days). Grade 3/4 toxicities included leukopenia/neutropenia (25%), anemia (18%), fatigue (11%), and hemorrhage (11%). There were four grade 5 toxicities including upper gastrointestinal hemorrhage (n = 2), gastrointestinal/esophageal fistula (n = 1), and unexplained death (n = 1). In our study, we found that sunitinib + paclitaxel in patients with advanced esophageal or gastroesophageal junction cancer had a 24-week PFS no better than the PFS of historical controls. The combination also had a high rate of serious toxicities and will not be pursued.

The pivotal role of intracellular calcium in oxaliplatin-induced inhibition of neurite outgrowth but not cell death in differentiated PC12 cells

The antineoplastic efficacy of oxaliplatin, a widely used anticancer drug, is restricted by its adverse effects such as peripheral neuropathy. Infusing a combination of calcium gluconate and magnesium sulfate (Ca/Mg) suppresses the acute neurotoxic side effects of oxaliplatin, although the mechanism is unclear. To elucidate the molecular mechanisms of oxaliplatin-induced neurotoxicity and the effects of Ca/Mg against this toxicity, we examined the effect of Ca/Mg on oxaliplatin-induced inhibition of neurite outgrowth in PC12 cells, a commonly used neuronal cell model. Oxaliplatin and oxalate suppressed nerve growth factor (NGF)-induced neurite outgrowth and reduced the NGF-mediated increase in the intracellular calcium concentration [Ca(2+)](i). A calcium-chelating agent, BAPTA/AM, also exhibited similar inhibitory effects on neurite outgrowth and [Ca(2+)](i). The addition of Ca/Mg attenuated these inhibitions induced by oxaliplatin and oxalate. The NGF-induced upregulation of growth-associated protein-43 (GAP-43) was suppressed by oxaliplatin and oxalate. Oxaliplatin, but not oxalate, suppressed NGF-stimulated extracellular signal-regulated kinase activation, and this inhibition was not affected by Ca/Mg. Ca/Mg did not modify the oxaliplatin-induced loss of cell viability or apoptosis in PC12 or HCT-116 cells, a human colorectal cancer cell line. These results suggest that the inhibition of neurite outgrowth but not tumor cell death induced by oxaliplatin is partly associated with reductions in [Ca(2+)](i) and GAP-43 expression, and this inhibition was suppressed by the addition of Ca/Mg. Therefore, it may be assumed that Ca/Mg is useful for protecting against oxaliplatin-induced neurotoxicity without reducing the antitumor activity of oxaliplatin.