Sequential methotrexate and 5-fluorouracil therapy for gastric cancer patients with peritoneal dissemination: a retrospective study

Distribution of therapeutic monoclonal antibodies into ascites in advanced gastric cancer patients with peritoneal metastasis: case reports and literature review

BACKGROUND

Therapeutic monoclonal antibodies, including ramucirumab and nivolumab, are used to treat advanced gastric cancer (AGC). Malignant ascites is often accompanied by peritoneal metastasis in AGC patients. However, the distribution of therapeutic monoclonal antibodies into ascites has yet to be adequately investigated.

METHODS

We determined serum and ascites concentrations of ramucirumab or nivolumab and total IgG in three AGC patients with massive ascites. When serum and ascites samples were obtained on the same day, the ascites-to-serum ratio (A/S ratio) of the concentration of monoclonal antibodies was evaluated. The relationship between time after last infusion and the A/S ratio of therapeutic monoclonal antibodies was examined using 15 datasets from the present study and the literature.

RESULTS

Ramucirumab and nivolumab were detected in massive ascites at considerable amounts (A/S ratios of 0.24-0.35 for ramucirumab and 0.17-0.55 for nivolumab). A positive correlation was detected between the A/S ratios of the therapeutic monoclonal antibodies and the time after last infusion (r = 0.747). Removal of ascites using paracentesis eliminated at least 15.3%-30.3% and 5.2-27.4% of the injected ramucirumab and nivolumab, respectively. Endogenous IgG, as well as therapeutic monoclonal antibodies, were distributed into ascites; the A/S ratios for IgG were 0.22-0.45.

CONCLUSION

Our results suggest that therapeutic monoclonal antibodies, including ramucirumab and nivolumab, are distributed into massive ascites in AGC patients concomitantly with endogenous IgG. In these patients, retention of ascites and its removal may result in decreased systemic drug exposure to ramucirumab and nivolumab.

Real-World Data of Trifluridine/Tipiracil for Patients With Advanced Gastric Cancer: A Multi-Institutional Retrospective Study

Background:

A trial with trifluridine/tipiracil (FTD/TPI) versus placebo in patients with heavily pretreated metastatic gastric cancer showed that FTD/TPI is effective with manageable toxicity in these patients. However, real-world data on the effects of FTD/TPI in patients with advanced gastric cancer (AGC) are limited.

Methods:

We retrospectively collected and analyzed the clinicopathological data of patients with AGC who received FTD/TPI monotherapy at our institutions (Kobe City Medical Center General Hospital, Osaka Red Cross Hospital, Himeji Red Cross Hospital, and Kansai Medical University Hospital) between September 2019 and July 2021. Tumor responses were evaluated based on the Response Evaluation Criteria in Solid Tumors, version 1.1. Overall survival (OS) and progression-free survival were estimated using the Kaplan-Meier method.

Results:

A total of 53 patients were included in the study. The median age was 70 (range, 37-85) years; 39 patients (74%) were men; the numbers of patients with Eastern Cooperative Oncology Group performance status scores of 0, 1, and 2 were 10 (19%), 39 (74%), and 4 (8%), respectively; and 27 patients (51%) had diffuse-type histology. A total of 29 patients (56%) had ascites. Prior nivolumab therapy was administered to 49 patients (92%). The response rate and disease control rate (DCR) were 2% and 35%, respectively. The median progression-free survival was 2.4 months, and OS was 5.8 months. Patients with ascites exhibited significantly shorter OS (8.6 vs 4.7 months, P = .0291) than those without ascites, and DCR (54% vs 18%, P = .0055) was significantly worse in patients with ascites. There was no significant difference in the frequency of adverse events of grade 3 or higher between patients with and without ascites.

Conclusion:

In a real-world setting, FTD/TPI has similar effectiveness as late-line chemotherapy for patients with AGC, including those who previously had received nivolumab.

Retrospective analysis for the efficacy and safety of nivolumab in advanced gastric cancer patients according to ascites burden

BACKGROUND

Nivolumab is a standard later-line therapy for advanced gastric cancer (AGC). However, few reports exist about its efficacy and safety in patients with massive ascites.

METHODS

We retrospectively collected clinical data from 72 AGC patients who received nivolumab administration at least once from Oct 2017 to Feb 2019 and studied their clinical outcomes dividing into two groups: 50 patients with no or localized ascites in the pelvic cavity or liver surface (LAB: low ascites burden) and 22 patients with massive ascites (HAB: high ascites burden).

RESULTS

Median overall survival (OS) was 5.3 months (95% CI 3.4-7.3) in the LAB group and 2.5 months (95% CI 0.0-5.0) in the HAB group. Multivariate Cox regression analysis for OS revealed blood neutrophil-to-lymphocyte ratio (hazard ratio 0.40, 95% CI 0.20-0.83, p = 0.013) as an independent prognostic factor. Response rates in the patients with measurable lesions were 16% (7/43) and 8% (1/12) in the LAB and HAB groups, respectively. Ascites decreased or disappeared in 6 HAB patients (27%) and these responders had a prolonged OS of median 9.7 months (95% CI 3.6-15.8). The median time to ascites response was 1.3 months (95% CI 0.8-1.9). These responders have lower neutrophil-to-lymphocyte ratios than 5.0 at the start of nivolumab. Immune-related adverse events occurred in 23% of HAB and 18% of LAB patients.

CONCLUSIONS

Nivolumab could improve massive ascites and confer survival benefit for some AGC patients. Considering a similar incidence of immune-related adverse events, it would be a recommended treatment option for AGC with massive ascites.

Evaluation and treatment of malignant ascites secondary to gastric cancer

Malignant ascites affects approximately 10% of patients with gastric cancer (GC), and poses significant difficulties for both patients and clinicians. In addition to the dismal general condition of affected patients and the diversity of associated complications such as jaundice and ileus, problems in assessing scattered tumors have hampered the expansion of clinical trials for this condition. However, the accumulation of reported studies is starting to indicate that the weak response to treatment in GC patients with malignant ascites is more relevant to their poor prognosis rather than to the ascites volume at diagnosis. Therefore, precise assessment of initial state of ascites, repetitive evaluation of treatment efficacy, selection of suitable treatment, and swift transition to other treatment options as needed are paramount to maximizing patient benefit. Accurately determining ascites volume is the crucial first step in clinically treating a patient with malignant ascites. Ultrasonography is commonly used to identify the existence of ascites, and several methods have been proposed to estimate ascites volume. Reportedly, the sum of the depth of ascites at five points (named “five-point method”) on three panels of computed tomography images is well correlated to the actual ascites volume and/or abdominal girth. This method is already suited to repetitive assessment due to its convenience compared to the conventional volume rendering method. Meanwhile, a new concept, “Clinical Benefit Response in GC (CBR-GC)”, was recently introduced to measure the efficacy of chemotherapy for malignant ascites of GC. CBR-GC is a simple and reliable patient-oriented evaluation system based on changes in performance status and ascites, and is expected to become an important clinical endpoint in future clinical trials. The principal of treatment for GC patients with ascites is palliation and prevention of ascites-related symptoms. The treatment options are various, including a standard treatment based on the available guidelines, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), laparoscopic HIPEC alone, intravenous chemotherapy, intraperitoneal chemotherapy, and molecular targeting therapy. Although each treatment option is valid, further research is imperative to establish the optimal choice for each patient.

Pilot study of a combination of S-1 and paclitaxel for patients with peritoneal metastasis from gastric cancer

BACKGROUND

This pilot study was carried out to evaluate the efficacy of chemotherapy for patients with peritoneal dissemination from gastric cancer or positive lavage cytology diagnosed by staging laparoscopy.

METHODS

Sixteen patients were enrolled. Paclitaxel was administered at 120 mg/m(2) on day 1 and S-1 was administered orally at 80 mg/m(2) for 14 consecutive days, followed by a 1-week rest, as one course. After five courses of this therapy, the primary gastric tumors were evaluated and second-look laparoscopy was performed for patients showing partial response or stable disease with clinical benefit.

RESULTS

Partial response or stable disease with clinical benefit was confirmed in seven and five patients, respectively, and these patients underwent second-look laparoscopy. No viable cancer cells were detected on cytopathological investigation during second-look laparoscopy in 9 patients who underwent surgical treatment. The intent-to-treat response rate for gastric tumor was 44% and the rate of disappearance of peritoneal metastasis was 38% (6 cases) at surgery. The median survival time was 555 days. Leucopenia of grade 3 and neutropenia of grade 3 were recognized in two and three patients, respectively.

CONCLUSION

This chemotherapy regimen may be an acceptable option for patients with peritoneal dissemination. We plan to study this regimen further in gastric cancer patients with peritoneal dissemination.

Sequential chemotherapy with methotrexate and 5-fluorouracil for chemotherapy-naive advanced gastric cancer with disseminated intravascular coagulation at initial diagnosis

PURPOSE

Advanced gastric cancer (AGC) rarely presents with disseminated intravascular coagulation (DIC) at the time of diagnosis before treatment with no current standard chemotherapy (CTx) regimen. However the prognosis is extremely poor without CTx. We investigated the effectiveness of sequential CTx with methotrexate and 5-fluorouracil (MF) in chemotherapy-naive AGC patients with DIC.

METHODS

We retrospectively examined AGC patients who received first-line CTx and selected those who were diagnosed with DIC before starting CTx to investigate clinical characteristics and responses.

RESULTS

From July 1999 to January 2007, 1,365 patients with unresectable or recurrent AGC received first-line CTx at the National Cancer Center Hospital in Tokyo, Japan. DIC was diagnosed in 22 (1.6%) patients (16 men and 6 women; median age, 56 years) and the performance status of all the patients was 1/2/3 = 9/10/3. Nineteen patients (86%) had histologically diffuse-type adenocarcinoma and 18 (82%) had bone metastasis. Patients received sequential MF every week until progressive disease was confirmed, with DIC improving in 17 (77%) patients. The median time-to-treatment failure for AGC and overall survival were 98 days [95% confidence interval (CI), range 50-146 days] and 154 days (95% CI, range 126-180 days), respectively. Grade 3 or greater toxicities consisted of neutropenia (4 patients, 18%), anemia (9 patients, 40%), thrombocytopenia (4 patients, 18%), and bilirubinemia (1 patient, 5%).

CONCLUSIONS

MF was an effective and well-tolerated regimen for improving DIC in chemotherapy-naive AGC patients with DIC; however, the prognosis of the patients remained poor even with improved DIC parameters.

Efficacy of sequential methotrexate and 5-fluorouracil (MTX/5FU) in improving oral intake in patients with advanced gastric cancer with severe peritoneal dissemination

BACKGROUND

Although peritoneal dissemination of gastric cancer is common and often causes deterioration of the patient's condition and quality of life (QOL), these patients are usually excluded from clinical trials. We retrospectively investigated the clinical benefit and toxicity of sequential methotrexate and 5-fluorouracil (MTX/5FU) therapy for patients with peritoneal dissemination.

METHODS

The subjects were 31 patients with severe peritoneal dissemination of gastric cancer who were treated with MTX/5FU. The treatment schedule comprised weekly administration of MTX (100 mg/m(2)) followed by 5FU (600 mg/m(2)). Leucovorin (10 mg/m(2)) was administered six times, every 6 h, starting 24 h after MTX administration.

RESULTS

The median survival time was 255 days, and the median progression-free survival was 127 days. Of the 21 patients with measurable lesions, 4 (19%) patients achieved a partial response. Ascites volume decreased markedly in 14 (54%) of the 26 patients with ascites. Seventeen patients had adequate oral intake, but the other 14 patients had required nutritional support before treatment. The median dripinfusion free survival was 100 days in the former 17 patients, and oral intake improved in 3 (21%) of the latter 14 patients. Grade 3 or 4 neutropenia was observed in 26% of the patients and anemia was observed in 45%. The grade 3 nonhematological toxicities were vomiting (6%) and fatigue (10%). Early death, within 30 days of the last administration of MTX/5FU, occurred due to disease progression in 2 patients, but there were no treatment-related deaths.

CONCLUSION

MTX/5FU chemotherapy may be effective in treating peritoneal dissemination of gastric cancer and might improve the patient's condition in terms of reducing ascites and improving oral intake.

Phase II study of weekly paclitaxel by one-hour infusion for advanced gastric cancer

PURPOSE

A phase clinical II trial was conducted to determine the antitumor activity and toxicity of weekly paclitaxel administered to patients with advanced gastric cancer.

METHODS

Sixty-eight patients with advanced gastric cancer and performance status 0-2 were treated with 80 mg/m2 paclitaxel over 1 h following a short course of premedication with dexamethasone, diphenhydramine, and ranitidine administered 30 min prior to the delivery of the paclitaxel. In principle, the treatment was repeated weekly for three courses, followed by a 1-week rest.

RESULTS

Objective responses were observed in 12 of 68 patients (17.6%; 95% confidence interval: 9.5%-28.8%). Two of fourteen (14.2%) patients with no prior chemotherapy and 10 of 54 (18.5%) patients previously treated for metastatic disease developed a partial response. The median therapeutic duration and the median survival time were 96 days and 222 days, respectively. In 212 (85.5%) of 248 total cycles, the original dose of 80 mg/m2 of paclitaxel was administered and was well tolerated. Fourteen of 68 patients (20.1%) experienced grade 3 or 4 neutropenia. Grade 1 or 2 peripheral neuropathy occurred in 10 patients (14.7%).

CONCLUSION

Weekly paclitaxel therapy is an active and safe treatment for advanced gastric cancer.

Intraperitoneal administration of paclitaxel and oral S-1 for a patient with peritoneal dissemination and hydronephrosis due to advanced gastric cancer

We report a patient with type 3 gastric cancer with peritoneal dissemination and hydronephrosis who was successfully treated with intraperitoneal infusion of paclitaxel and oral administration of S-1. He was diagnosed with unresectable gastric cancer with severe peritoneal dissemination by staging laparoscopy. We selected combined chemotherapy with both paclitaxel and S-1. Paclitaxel at 60 mg/m(2) was administered intraperitoneally on days 1 and 8, and S-1 at 100 mg/body was administered orally for 14 days, followed by 7 days' rest, as one course. After five courses, primary tumor reduction was confirmed and no cancer cells were detected on pathocytological investigation at second-look laparoscopy. The patient underwent total gastrectomy with lymph node dissection. He died from liver metastasis 29 months after the initial treatment, but he had not suffered from peritoneal metastases and had kept a good quality of life (QOL) since that treatment. This chemotherapy can be applied as one of the promising candidates for the treatment of patients with peritoneal metastasis of gastric cancer.

Feasibility study of postoperative intraperitoneal hyperthermochemotherapy by radiofrequency capacitive heating system for advanced gastric cancer with peritoneal seeding

BACKGROUND

Gastric carcinoma patients with peritoneal dissemination have an extremely poor prognosis. Attempting to improve regional control and decrease the risk of complications related to hyperthermic chemotherapy, we applied a new treatment modality using a combination of gastrectomy with postoperative intraperitoneal hyperthermo-chemotherapy (PIHC) using Thermotron RF-8. The purpose of this study was to evaluate the feasibility of PIHC in advanced gastric carcinoma patients with peritoneal seeding.

PATIENTS AND METHODS

Between March 2002 and April 2006, 20 gastric carcinoma patients with peritoneal dissemination were allocated to two groups in the patient's selection. The PIHC group (10 patients) received a 60-min PIHC with a cisplatin dose of 80 mg/m2 two weeks after surgery, and the control group (10 patients) received surgery alone. Thermotron RF-8 is a heating device that can raise temperatures in both superficial and deep-seated tumours using 8 MHz radiofrequency electromagnetic waves as a source of heat.

RESULTS

No patients in either group had life-threatening complications. The most frequent nonhaematologic toxicity (grade 3) was nausea. The one-, two-, and three-year cumulative survival rates for the PIHC group were 60%, 48%, and 36%, respectively, whereas those for the control group were 40%, 10%, and 0%, respectively. The survival rates for the PIHC group were significantly higher than those for the control group.

CONCLUSION

Although this study was conducted non-randomly with a small number of patients, the PIHC group had a higher survival rate and better prognosis compared with the control group.

A phase II study of combined chemotherapy with methotrexate, 5-fluorouracil, and low-dose cisplatin (MFP) for histologically diffuse-type advanced and recurrent gastric cancer (KDOG9501)

BACKGROUND

Histologically diffuse-type gastric cancer is well known to have a poor prognosis and is often complicated with abdominal and pleural effusions. We evaluated the efficacy of a low dose of cisplatin combined with methotrexate and 5-fluorouracil (MFP therapy) in diffuse-type advanced gastric cancer.

METHODS

The study group comprised 47 patients. Patients with pleural effusion or ascites were actively enrolled. Methotrexate (30 mg/m(2) per day) plus 5-fluorouracil (600 mg/m(2) per day) was administered on days 1 and 8. Cisplatin (6 mg/m(2) per day) was given daily for 14 days after which there was 14 day's rest. Calcium leucovorin (15 mg) was administered after methotrexate.

RESULTS

The overall response rate was 38.3%. Ascites disappeared or decreased in 15 of 23 patients (disappeared in 9). Pleural effusion disappeared or decreased in 6 of 8 patients (disappeared in 4). Of the 21 patients with poor oral intake at study entry, 15 (71.4%) were able to orally ingest food. Hematologic toxicity of grade 3 or higher comprised leukopenia in 10 patients (21.3%) and neutropenia in 9 (19.1%). Nonhematologic toxicity included anorexia and nausea/vomiting, in 1 patient each (2.1%). The median survival time was 211 days.

CONCLUSION

MFP therapy is useful for the management of diffuse-type inoperable and recurrent gastric cancer, even in patients with conditions such as pleural effusion, ascites, or lymphangitis carcinomatosa who have a poor prognosis or cannot eat solid food.

Efficacy of S-1 for patients with peritoneal metastasis of gastric cancer

BACKGROUND

This study was designed to examine the efficacy and compliance of S-1 for the patients with peritoneal metastasis of gastric cancer.

METHODS

Sixteen consecutive patients with peritoneal metastasis of gastric cancer were treated with S-1. Their survival was compared with that of the historical control group (25 patients). Thymidylate synthase, dihydropyrimidine dehydrogenase, thymidine phosphorylase and orotate phosphoribosyl transferase mRNA expression in the tumor were evaluated.

RESULTS

The median survival time of S-1-treated patients was 550 days, which was significantly longer than that of the historical control group (215 days). We elucidated some factors to prolong the survival of the patients treated with S-1 for peritoneal metastasis: peritoneal metastasis without other distant metastases, the combination of S-1 treatment and gastrectomy, and low expression of thymidine phosphorylase mRNA in primary tumors.

CONCLUSIONS

S-1 showed a surprisingly long-term survival with minimum toxicity in patients with peritoneal metastasis of gastric cancer.

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for advanced gastric cancer

Peritoneal carcinomatosis is a common and universally fatal sequelae of gastric carcinoma. Treatment of peritoneal carcinomatosis from appendiceal and colorectal sources with intraperitoneal hyperthermic chemotherapy (IPHC) combined with aggressive cytoreductive surgery has been shown to be effective. There are few data on this treatment modality for carcinoma of the stomach. This study evaluates cytoreductive surgery and IPHC with peritoneal carcinomatosis from gastric carcinoma. Thirty-four patients with peritoneal carcinomatosis due to gastric carcinoma underwent gastric resection with cytoreductive surgery followed by IPHC with mitomycin C. A control group consisting of 40 contemporaneous patients, who underwent radical gastrectomy without extended nodal resection, was identified through the tumor registry. Despite more advanced disease in the IPHC group compared to the control group (P < 0.001), overall survival in the two groups was similar. Proportional-hazards regression analysis shows that only resection status is significantly correlated with improved survival (P=0.0068). Within the IPHC group, patients who underwent an R0/R1 resection had increased survival times (11.2 vs. 3.3 months, P=0.015) vs. those who underwent R2 resection. The group who had an R0/R1 resection had 1- and 2-year survival rates of 45% and 45% compared to 16% and 8%, respectively, in the R2 group. Cytoreductive surgery and IPHC is a modality with limited potential for the treatment of peritoneal carcinomatosis from gastric carcinoma. Careful patient selection for this procedure is imperative, and patients in whom an R0/R1 resection can be achieved are the best candidates.

Efficacy and safety profile of S-1 in patients with metastatic gastric cancer in clinical practice: results from a post-marketing survey

BACKGROUND

S-1(TS-1), a novel oral fluoropyrimidine, has been commercially available for gastric cancer in Japan. A nationwide post-marketing survey for safety was carried out after its approval. The aim of this analysis was to evaluate the efficacy and safety profile of this agent in clinical practice for patients with advanced gastric cancer registered in the postmarketing survey from our institution.

METHODS

Between April 1999 and April 2000, a total of 51 chemo-naive patients were registered in the survey from the National Cancer Center Hospital East. S-1 was administered at 80 mg/m2/day for 4 weeks, followed by a 2-week rest, repeated every 6 weeks until disease progression, unacceptable toxicity, or the patient's refusal.

RESULTS

Of the 51 patients, 41 (80%) fulfilled the criteria of the guidelines determined by the company as appropriate patients for the drug administration. The median number of treatment courses was five. Toxicities were generally mild: grade 3 or 4 toxicities were seen in 10% or fewer patients, and no treatment-related deaths occurred. In the 47 patients with evaluable lesions, there were 2 complete responses and 18 partial responses, with a response rate of 43%. With a minimum follow-up of 2 years, median survival time and 2-year survival were 11.1 months and 33%, respectively. The majority of the 17 2-year survivors had diffuse-type histology and peritoneal metastasis and achieved an objective response.

CONCLUSION

S-1 appears to be safe and highly active, with favorable longterm survival in patients with metastatic gastric cancer, particularly in those with diffuse-type histology and peritoneal metastasis.