Phase I study of neoadjuvant chemoradiotherapy with S-1 and oxaliplatin in patients with locally advanced gastric cancer

Preoperative Chemotherapy for Gastric Cancer: Personal Interventions and Precision Medicine

In spite of the declining incidence of gastric cancer (GC) in recent years, the mortality rate is still high. The asymptomatic nature and nonspecific clinical manifestations combined with the lack of efficient screening programs delay the diagnosis of GC. Therefore, the prevalence of advanced gastric cancer (AGC) has prompted the need for aggressive and intensive treatment options. Among the various treatment options for AGC, surgery is still the mainstay. However, the efficacy of surgery alone is not established. Results from multiple randomized controlled trials suggest that preoperative chemotherapy is promising intervention for the treatment and management of AGC. The main objective of neoadjuvant chemotherapy is to downstage or control micrometastasis in resectable tumor before surgery. On the other hand, conversion chemotherapy refers to surgical treatment aiming at R0 resection after chemotherapy for originally nonresectable or marginally resectable tumors. Nevertheless, preoperative chemoradiotherapy is considered beneficial for AGC patients. Over the last few decades, the combination of chemotherapy and targeted therapy prior to surgery demonstrated great results for the treatment of AGC. The rapid developments in genomics and proteomics have heralded the era of precision medicine. The combination of preoperative chemotherapy and precision medicine may enhance survival in AGC patients.

Neoadjuvant therapy for gastric cancer: current evidence and future directions

Although surgical resection remains the only potentially curative treatment for gastric cancer (GC), poor long-term outcomes with resection alone compel a multimodality approach to this disease. Multimodality strategies vary widely; while adjuvant approaches are typically favored in Asia and the United States (USA), a growing body of evidence supports neoadjuvant and/or perioperative strategies in locally advanced tumors. Neoadjuvant approaches are particularly attractive given the morbidity associated with surgical management of GC and the substantial risk of omission of adjuvant therapy. The specific advantages of chemoradiotherapy (CRT) compared to chemotherapy have not been well defined, particularly in the preoperative setting and trials aimed at determining the optimal elements and sequencing of therapy are underway. Future studies will also define the role of targeted and biologic therapies.

Gastric Perforation in a Patient Receiving Neoadjuvant Chemoradiotherapy

Perioperative chemoradiotherapy is considered to be one of the standards of care for early-stage gastric cancer, especially when it involves the esophagogastric junction or greater curvature. To date, there are no reported cases of gastrointestinal perforation in the literature, including many major clinical trials of adjuvant or neoadjuvant chemoradiotherapy for gastric cancer. It is important to recognize and manage this rare, but fatal complication in a timely manner. We report one case of gastrointestinal perforation in a gastric cancer patient undergoing neoadjuvant chemoradiotherapy with 5-fluorouracil and oxaliplatin. A 75-year-old man was diagnosed with stage IV gastric cancer (T4N1M0). We started neoadjuvant chemoradiotherapy with 5-fluorouracil and oxaliplatin. After he finished the first cycle, the patient presented to emergency room with severe abdominal pain of sudden onset. Computed tomography showed moderate pneumoperitoneum and perihepatic fluid. The patient expired 6 hours after he presented to emergency room.

Phase I study of postoperative radiotherapy concurrent with S-1 in patients with gastric cancer

Postoperative chemoradiotherapy (CRT) with concurrent 5-fluorouracil is the standard care for gastric cancer patients after curative surgery. The previous studies revealed that the subgroup of patients with high recurrence risk would benefit most from adjuvant CRT. S-1, a novel oral fluorouracil, has showed very effective in metastatic gastric cancer and became the standard option for gastric cancer with D2 dissection. The safety and dosage of S-1 combined with postoperative radiotherapy have not yet been evaluated. This study is to determine the maximum tolerate dose (MTD) and dose-limiting toxicity (DLT) of S-1 given concurrently with postoperative high-dose radiotherapy in gastric cancer. Patients with more advanced stage (pT4 and/or pN+) after R0 resection were recruited. Eligible patients received one cycle standard SOX (S-1 plus oxaliplatin) chemotherapy, then S-1 monotherapy with concurrent radiotherapy for 6 weeks, followed by additional three cycles of SOX. During the concurrent CRT, S-1 was administered on every radiotherapy treatment day according to a predefined dose-escalation schedule. Radiotherapy (3D-RT or IMRT) was given to a total dose of 50.4 Gy in 28 fractions. DLT was defined as grade 3 or 4 hematologic and non-hematologic toxicity. From March 2011 to October 2012, 21 patients were enrolled at five dose levels: 40 (n = 3), 50 (n = 3), 60 (n = 6), 70 (n = 6) and 80 mg/m(2)/day (n = 3). D2-dissection was performed in 18 patients (85.7 %) and 15 patients (71.4 %) had stage III disease. The most common dose-related toxicity was anorexia, nausea and vomiting, fatigue and leucopenia. DLT was occurred in one patient at 60 mg/m(2)/day (grade 3 fatigue), one patient at 70 mg/m(2)/day (grade 3 vomiting and anorexia), two patients at 80 mg/m(2)/day (one with grade 3 vomiting and anorexia; another with grade 3 febrile leucopenia). Four patients did not complete CRT as planned. Overall, this phase I study demonstrated that postoperative CRT with daily S-1 was feasible in gastric cancer and the MTD of S-1 concurrent with radiotherapy was 70 mg/m(2)/day. This S-1-based postoperative CRT will be investigated in a multicenter phase III study in West China.

Preoperative chemoradiotherapy in locally advanced gastric cancer, a phase I/II feasibility and efficacy study

OBJECTIVES

This study was initiated to investigate the feasibility and efficacy of preoperative radiotherapy with weekly paclitaxel and carboplatin in locally advanced gastric cancer.

METHODS

In a prospective study, patients with locally advanced gastric cancer stage IB-IV(M0) were treated with chemoradiotherapy followed by surgery 4-6 weeks after the last irradiation. Chemoradiotherapy consisted of radiation to a total dose of 45 Gy given in 25 fractions of 1.8 Gy, combined with concurrent weekly carboplatin and paclitaxel.

RESULTS

Between December 2007 and January 2012, 25 patients with cT3 (64%) or cT4 (36%) gastric cancer were included. One patient discontinued concurrent chemotherapy in the 4th week due to toxicity, but completed radiotherapy. Another patient discontinued chemoradiotherapy after the 3rd week due to progressive disease. Grade III adverse events of chemoradiotherapy were: gastrointestinal 12%, haematological 12% and other 8%. All patients, except one who developed progressive disease, were operated. Surgical complications were: general/infectious 48%, anastomotic leakage 12%, and bowel perforation 8%. Postoperative mortality was 4%. Microscopically radical resection rate was 72%. Pathological complete response rate was 16% and near complete response rate 24%.

CONCLUSIONS

In this study, preoperative chemoradiotherapy for patients with locally advanced gastric cancer was associated with manageable toxicity and encouraging pathological response rates.

Is postoperative adjuvant chemoradiotherapy efficacious and safe for gastric cancer patients with D2 lymphadenectomy? A meta-analysis of the literature

BACKGROUND

Adjuvant chemoradiotherapy (CRT) for patients with gastric cancer after D2 lymphadenectomy remains controversial. The objective of the present meta-analysis was to analyze efficacy and safety of postoperative CRT and establish a consensus on whether it is suitable for the patients.

METHODS

We searched PubMed, Ovid, Cochrane, and Web of Science. Statistical analysis was carried out by STATA version 12.0 software. The quality of evidence was assessed by Jadad and the Newcastle-Ottawa quality assessment scale.

RESULTS

Six studies involving 2135 patients were included for the meta-analysis. The results showed that, compared with non-CRT, postoperative adjuvant CRT was associated with a significant improvement in 5-year overall survival (OS) (HR = 0.79, 95% CI 0.68-0.92, P = 0.002) and 5-year relapse-free survival (RFS) (HR = 0.81, 95% CI 0.70-0.93, P = 0.004). However, there were no differences in distant metastasis (RR = 0.93, 95% CI 0.82-1.06, P = 0.304) and treatment-related toxicity between the two groups.

CONCLUSIONS

From the results of our study, postoperative adjuvant CRT may be associated with longer 5-year OS and 5-year RFS in patients with D2 lymphadenectomy, but might not improve 5-year disease-free survival compared to non-CRT. Methodologically high-quality comparative studies are needed for further evaluation.

S-1 plus oxaliplatin vs. S-1 as first-line treatment in patients with previously untreated advanced gastric cancer: a randomized phase II study

This randomized phase II study was performed to compare the efficacy and safety of oxaliplatin combined with S-1 (OXS regimen) with S-1 alone in the management of advanced gastric cancer (AGC). Ninety-four patients were 1:1 randomly assigned to S-1 on days 1-14 of a 3-week cycle or S-1 on days 1-14 plus oxaliplatin (130 mg/m(2) i.v.) on day 1 of the 3-week cycle. S-1 was orally administered in a fixed quantity according to body surface area. The median survival time with OXS versus S-1 monotherapy was 14·0 versus 11·0 months (P = 0·03), progression-free survival was 6·5 versus 4·0 months (P = 0·02), and the 1-year survival rate was 63·8% versus 48·9%, respectively. The response rate was significantly higher for OXS than for S-1 monotherapy (51·1% vs. 27·7%, P = 0·03). OXS was well tolerated with no treatment-related death. In conclusion, the OXS regimen evidenced a relatively high efficacy and was well tolerated as a first-line therapy for AGC patients.

Role of salvage radiotherapy for regional lymph node recurrence after radical surgery in advanced gastric cancer

PURPOSE

To evaluate the role of salvage radiotherapy (RT) for the treatment of regional lymph node recurrence (RLNR) after radical surgery in advanced gastric cancer.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 26 patients who underwent salvage treatment after diagnosis of RLNR between 2006 and 2011. Patients with peritoneal seeding or distant metastasis were excluded. Eighteen patients received RT with or without chemotherapy and the other 8 did chemotherapy only without RT. A three-dimensional conformal RT was performed with median dose of 56 Gy (range, 44 to 60 Gy). Sixteen patients had fluoropyrimidine-based chemotherapy, 5 did taxane-based chemotherapy, and irinotecan was applied in 4.

RESULTS

With a median follow-up of 20 months (range, 5 to 57 months), median overall survival (OS) and progression-free survival (PFS) after diagnosis of RLNR were 29 months and 12 months in the entire patients, respectively. Radiotherapy (p = 0.007) and disease-free interval (p = 0.033) were statistically significant factors for OS in multivariate analysis. Median OS was 36 months in patients who received RT and 16 months in those who did not. Furthermore, delivery of RT (p < 0.001), complete remission after salvage treatment (p = 0.040) and performance status (p = 0.023) were associated with a significantly better PFS. Gastrointestinal toxicities from RT were mild in most patients.

CONCLUSION

Salvage RT combined with systemic chemotherapy may be an effective treatment managing RLNR from advanced gastric cancer.