Fixed-dose rate infusion and standard rate infusion of gemcitabine in patients with advanced non-small-cell lung cancer: a meta-analysis of six trials. Cancer Chemother Pharmacol. 2012;70:861-873. [PMID: 23053260 DOI: 10.1007/s00280-012-1974-z]

Optimized Dosing: The Next Step in Precision Medicine in Non-Small-Cell Lung Cancer

In oncology, and especially in the treatment of non-small-cell lung cancer (NSCLC), dose optimization is often a neglected part of precision medicine. Many drugs are still being administered in "one dose fits all" regimens or based on parameters that are often only minor determinants for systemic exposure. These dosing approaches often introduce additional pharmacokinetic variability and do not add to treatment outcomes. Fortunately, pharmacological knowledge is increasing, providing valuable information regarding the potential of, for example, therapeutic drug monitoring. This article focuses on the evidence for the most promising and easily implemented optimized dosing approaches for the small-molecule inhibitors, chemotherapeutic agents, and monoclonal antibodies as treatment options currently approved for NSCLC. Despite limitations such as investigations having been conducted in oncological diseases other than NSCLC or the retrospective origin of many analyses, an alternative dosing regimen could be beneficial for treatment outcomes, prescriber convenience, or financial burden on healthcare systems. This review of the literature provides recommendations on the implementation of dose optimization and advice regarding promising strategies that deserve further research in NSCLC.

Risk Factors for Gemcitabine-Induced Vascular Pain in Patients With Pancreatic Cancer

BACKGROUND

Peripheral intravenous injection of gemcitabine often causes vascular pain; however, preventive measures have not yet been established.

OBJECTIVES

This study focused on identifying predictive factors for gemcitabine-induced vascular pain.

METHODS

We retrospectively analyzed risk factors for developing vascular pain in patients with pancreatic cancer receiving gemcitabine infusions at our institution. Infusions were divided into groups according to presence or absence of vascular pain symptoms, and variables were compared. Odds ratios for risk factors were calculated using logistic regression analyses.

RESULTS

Overall, 272 patients with pancreatic cancer were subjected to 725 gemcitabine infusions, and of these, 18.4% (n = 50) experienced vascular pain. There were significant differences in the gemcitabine dose (P = 0.025), dose of gemcitabine/body surface area (BSA; P = 0.004), concentration of gemcitabine (P = 0.025), and hot pack use (P = 0.011) between the vascular pain and no vascular pain groups. Multivariable analyses indicated that gemcitabine dose/BSA and lack of hot pack use were risk factors for developing vascular pain. Moreover, on administration of a higher dosage (>930 mg/m²), the incidence of vascular pain in patients using a hot pack (6.7%) was significantly lower than that in patients not provided a hot pack (16.2%).

CONCLUSIONS AND RELEVANCE

High gemcitabine dosages and lack of hot pack use were predictive factors for gemcitabine-induced vascular pain in patients with pancreatic cancer. Patients receiving gemcitabine treatment should apply a hot pack to the injection site. Scrupulous clinical attention is required for patients presenting with these risk factors to improve pain management.

Meta-analysis of gemcitabine in brief versus prolonged low-dose infusion for advanced non-small cell lung cancer

Objective

To evaluate the efficacy and safety of gemcitabine (GEM) at 30 min standard-dose infusion (30 min-SDI) compared with prolonged low-dose infusion (P-LDI) in patients with advanced non-small-cell lung cancer (NSCLC).

Methods

Electronic databases including Pubmed, EMbase, Cochrane Library, CNKI, CBM, and VIP were searched using keywords “GEM”, “P-LDI”, and “NSCLC”. Review Manager 5.3 was used to perform the meta-analysis. Primary endpoints were overall response rate (ORR) and 1-year survival rate (1-year SR). Secondary endpoints were grade 3/4 hematotoxicity and nausea/vomiting. In association. GRADE quality of evidence system was used to assess the results of meta-analysis.

Results

Six randomized controlled trials (RCTs) with a total of 637 patients were included and no statistical heterogeneity was found among the studies. The results showed that P-LDI was superior in ORR (RD = 0.09, 95% CI: 0.02 to 0.16, P = 0.02), but had a similar 1-year SR (RD = 0.05, 95% CI: -0.02 to 0.12, P = 0.18) as compared with 30 min-SDI. For grade 3/4 adverse events, there was no significant difference in anemia (RD = 0.02, 95% CI: -0.01 to 0.04, P = 0.27) and nausea/vomiting (RD = 0.01, 95% CI: -0.04 to 0.06, P = 0.64) between the two treatments. However, patients with P-LDI experienced less leukopenia (RD = -0.08, 95% CI: -0.15 to -0.01, P = 0.03) and thrombocytopenia ((RD = -0.05, 95% CI: -0.09 to –0.01, P = 0.006). The GRADE profile showed that the included RCTs had low quality of evidences.

Conclusion

P-LDI was superior in terms of ORR, experienced less grade 3/4 thrombocytopenia and leukopenia compared with 30 min-SDI, and could be a viable treatment option for advanced NSCLC. However, the results need to be further verified by high quality trials and large samples owing to the low quality of evidences.

Chemical Constituents of Mangifera indica and Their Antiausterity Activity against the PANC-1 Human Pancreatic Cancer Cell Line

Human pancreatic cancer cell lines such as PANC-1 have an altered metabolism, enabiling them to tolerate and survive under extreme conditions of nutrient starvation. The search for candidates that inhibit their viability during nutrition starvation represents a novel antiausterity strategy in anticancer drug discovery. A methanol extract of the bark of Mangifera indica was found to inhibit the survival of PANC-1 human pancreatic cancer cells preferentially under nutrient-deprived conditions with a PC50 value of 15.5 μg/mL, without apparent toxicity, in normal nutrient-rich conditions. Chemical investigation on this bioactive extract led to the isolation of 19 compounds (1-19), including two new cycloartane-type triterpenes, mangiferolate A (1) and mangiferolate B (2). The structures of 1 and 2 were determined by NMR spectroscopic analysis. Among the isolated compounds, mangiferolate B (2) and isoambolic acid (12) exhibited potent preferential cytotoxicity against PANC-1 human pancreatic cancer cells under the nutrition-deprived condition with PC50 values of 11.0 and 4.8 μM, respectively.

Gemcitabine fixed-dose rate infusion for the treatment of pancreatic carcinoma: a meta-analysis of randomized controlled trials

Background

Pre-clinical evidence shows that fixed dose rate (FDR) infusion of gemcitabine could optimize plasma concentration of gemcitabine, while the clinical efficacy and toxicity of FDR infusion of gemcitabine in advanced pancreatic carcinoma has not been systematically investigated. Thus, this meta-analysis was designed to ascertain this issue.

Methods

Databases of EMBASE, PubMed, and Cochrane Library were searched for eligible randomized controlled trials (RCTs). RCTs comparing FDR and standard 30-min infusion of gemcitabine in advanced pancreatic carcinoma were included. The primary endpoints were treatment efficacy (overall response rate, 1-year survival rate, median survival, and time to treatment failure) and toxicities were secondary endpoints (neutropenia, thrombocytopenia, anemia, and vomiting). Relative risks or mean differences and corresponding 95% confidence intervals (CIs) were calculated.

Result

After careful and rigorous selection, 3 eligible RCTs including 764 patients of advanced pancreatic adenocarcinoma were included in this meta-analysis. For treatment efficacy, FDR gemcitabine provided significantly longer median survival over standard gemcitabine (Mean Difference = 1.24 months, 95% CI: 0.39-2.09), while there was no statistical difference in other endpoints of treatment efficacy. For toxicities, patients with FDR gemcitabine experienced significantly more grade 3/4 hematological toxicities than those received standard gemcitabine (neutropenia, thrombocytopenia, and anemia), while there was no difference for vomiting.

Conclusion

Compared with standard 30-min infusion, FDR gemcitabine provide longer median survival, but increased the risk of hematological toxicities for patients with advanced pancreatic adenocarcinoma.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_214

Electronic supplementary material

The online version of this article (doi:10.1186/s13000-014-0214-8) contains supplementary material, which is available to authorized users.

Inhibition of arachidonic acid metabolism to decrease pancreatic cancer cell proliferation

AIM: To investigate the effect of inhibition of arachidonic acid metabolism on proliferation of pancreatic cancer cells.

METHODS: Cultured pancreatic cancer SW1990 cells were treated with different concentrations of MK886, celecoxib, or MK886 + celecoxib. After treatment, the expression of leukotriene B4 receptor 1 (BLT1) and vascular endothelial growth factor (VEGF) mRNAs was detected by semi-quantitative RT-PCR and the expression of phosphorylated extracellular regulated protein (p-Erk) was measured by Western blot.

RESULTS: Treatment with MK886 significantly decreased the expression of BLT1 and VEGF mRNAs (P < 0.01 for both) and p-Erk (P < 0.05). Treatment with celecoxib did not alter the expression of BLT1 mRNA and decreased the expression of VEGF mRNA compared with untreated cells (P < 0.01), but increased the expression of p-Erk compared with the MK886 group (P < 0.01). Treatment with MK886 and celecoxib significantly decreased the expression of BLT1 and VEGF mRNAs (P < 0.01 for both), but did not alter the expression of p-Erk.

CONCLUSION: Both two pathways of arachidonic acid metabolism are associated with pancreatic cancer cell proliferation, with the pathway involving 5-lipoxygenase being more important.

(+)-Grandifloracin, an antiausterity agent, induces autophagic PANC-1 pancreatic cancer cell death

Human pancreatic tumors are known to be highly resistant to nutrient starvation, and this prolongs their survival in the hypovascular (austere) tumor microenvironment. Agents that retard this tolerance to nutrient starvation represent a novel antiausterity strategy in anticancer drug discovery. (+)-Grandifloracin (GF), isolated from Uvaria dac, has shown preferential toxicity to PANC-1 human pancreatic cancer cells under nutrient starvation, with a PC₅₀ value of 14.5 μM. However, the underlying mechanism is not clear. In this study, GF was found to preferentially induce PANC-1 cell death in a nutrient-deprived medium via hyperactivation of autophagy, as evidenced by a dramatic upregulation of microtubule-associated protein 1 light chain 3. No change was observed in expression of the caspase-3 and Bcl-2 apoptosis marker proteins. GF was also found to strongly inhibit the activation of Akt, a key regulator of cancer cell survival and proliferation. Because pancreatic tumors are highly resistant to current therapies that induce apoptosis, the alternative cell death mechanism exhibited by GF provides a novel therapeutic insight into antiausterity drug candidates.