A phase II study of S-1 monotherapy administered for 2 weeks of a 3-week cycle in advanced gastric cancer patients with poor performance status

The relationship between the number of examined lymph nodes and the efficacy of chemotherapy for gastric cancer

BACKGROUND

The purpose of this research was to investigate the relationship between the number of examined lymph nodes (eLNs) and the prognosis.

METHODS

A retrospective examination of reports and studies carried out at two institutions was conducted. According to TNM stages, the relationship between the number of eLNs and the prognosis was analyzed.

RESULTS

The 5-year disease-specific survival (DSS) of all enrolled patients was 66.3%. A multivariate analysis showed the type of gastrectomy, histologic type, perineural invasion, pT stage, pN stage, chemotherapy and eLNs to be independent prognostic markers. Additionally, with the exception of patients with stage I disease, the 5-year DSS of patients who had < 25 eLNs removed had a higher risk of having a worst prognosis compared to patients who had ≥ 25 eLNs removed. Through this study, a hypothetical TNM staging system was obtained for predicting the prognosis according to the number of eLNs. Chemotherapy was able to improve the prognosis of patients with stage III and < 25 eLNs in stage II.

CONCLUSIONS

Extended lymphadenectomy with a new goal of dissecting 25 LNs for the evaluation of stage II-III cancer cases is recommended. Our hypothetical TNM staging system may be able to stratify the risk more accurately compared to the current AJCC 8th system. Chemotherapy can improve the prognosis in advanced gastric cancer, but its benefit may be affected by the surgical quality.

Should S-1 be better than capecitabine for patients with advanced gastric cancer in Asia? A systematic review and meta-analysis

Background

S-1 or capecitabine (Cap) containing treatment is an increasingly used strategy in patients with advanced gastric cancer in Asia. It is unclear whether there is sufficient evidence to support which regimen is better.

Methods

A systematic review of retrospective studies and randomized controlled trials (RCTs) comparing S-1 with Cap containing treatment in advanced gastric cancer patients was performed. Embase, PubMed, ClinicalTrials.gov, Cochrane Library, and reference lists were searched from inception until August 2018 for relevant studies. Outcomes of interest included 1-year overall survival (OS), 1-year progression-free survival (PFS), objective response rate (ORR), and adverse events. Meta-analyses of the random events were performed. We also performed sensitivity analysis to examine whether the results of the meta-analyses were robust.

Results

A total of 770 subjects from six RCTs and two retrospective studies in Asia were analyzed. Compared with S-1, Cap containing treatment had better ORR (overall risk ratio =0.85, 95% CI: 0.72, 0.99, I ²=0%, P=0.043) and higher incidence of all-grade hand-foot syndrome (HFS) (overall risk ratio =0.29, 95% CI: 0.20, 0.40, I ²=0%, P<0.001) and neutropenia (overall risk ratio =0.85, 95% CI: 0.73, 0.99, I ²=0%, P=0.039). But there was no statistical difference in 1-year PFS, 1-year OS, incidence of other all-grade or grade 3-4 adverse events between S-1 and Cap containing arms (P>0.05). We found no publication bias in this review.

Conclusion

This systematic review showed that for Asian patients, Cap shows superiority in ORR but not 1-year OS or PFS, and it will increase the risk of all-grade HFS and neutropenia. Until now, S-1 containing treatment might be a better choice for advanced gastric cancer patients. But more high-quality RCTs are needed to confirm these results.

Survival effect of supportive care services for Turkish patients with metastatic gastric cancer

BACKGROUND

Gastric cancer is the second most common cause of cancer- related deaths worldwide and ranks 11th or 14th among all deaths. Patients with advanced disease require supportive care along with the medical and/ or surgical treatment.

AIM

To assess the need for palliative care for patients with advanced tumours along with standard clinical therapy.

MATERIALS AND METHODS

Eighty-four patients with metastatic (stage 4) gastric cancer, including both patients who had received surgical treatment or not , were followed up in Bagcilar Training and Research Hospital, Division of Medical Oncology between 2011 and 2014. They were categorised as supportive care (-) (Group 1, n=37) and (+) groups (Group 2, n=47) and evaluated retrospectively.

RESULTS

Demographic characteristics of the patients were as follows: mean age, Group 1, 65.2±10.5 years, Group 2,63.7±11.3 years; male/female ratio, Group 1, 21/16, Group 2, 28/19; distribution of Eastern Cooperative Oncology Group (ECOG) performance scores of 0 and 1, Group 1, ECOG 0 (n=9) and 1 (n=14), Group 2, ECOG 0 (34) and 1 (n=13) (p<0.0001); patients receiving second-line, Group 1 (n=7) and Group 2 (n=22) (p<0.008) or third - line chemotherapy,Group 2 (n=6) (p<0.02); mortality rates, Group 1, (n=28; 75.6%) and Group 2 (n=30; 63.8%); progression-free survival (PFS) rates, Group 1, 17.4±6 weeks, Group 2, 28.3±16.2 weeks; statistically significant overall survival rates, Group 1, 20.8±8.2 weeks and Group 2, 28.3 ± 162 weeks (p<0.01).

CONCLUSIONS

The supportive care team (medical oncologist, general surgeon, internal medicine specialist, algologist, psychiatrist and radiologist) can play a role in the treatment of metastatic gastric tumours, with improvements shown in terms of the performance status of cases, eligibility of patients to be on chemotherapy programmes for longer duration and overall survival rates in Turkey.

Geographic differences in approach to advanced gastric cancer: Is there a standard approach?

Gastric cancer is one of the leading causes of cancer related deaths worldwide. Regional differences in gastric cancer are evident between Asian and Western societies with respect to etiology, prevalence, clinicopathologic features as well as treatment pattern of the disease. For patients with advanced gastric cancer (AGC), chemotherapy has been found to improve survival and quality of life compared to best supportive care alone. But contrast to other tumors such as colon or pancreatic cancer, there are regional differences in outcome in gastric cancer. Various geographic/ethnic, biology and treatment strategies may contribute to these differences. In the first line setting, cisplatin and fluoropyrimidine based therapies remain the backbone of treatment for advanced gastric cancer in Asian and Western patients, although there is preference for S1 in Asia and 5FU in the West. A third agent may be added in patients with good performance status. Recent trials from Asia and Europe demonstrate an advantage for second line chemotherapy. Irinotecan and taxanes are the most commonly used agents. The introduction of trastuzumab into the frontline therapy of AGC has ushered the age of targeted therapy and personalized medicine in this disease. In this article, we will review the various first and second line chemotherapy regimens in AGC, taking into account regional differences including potential biomarkers.

Complete response of liver metastasis of gastric cancer treated by s-1 chemoradiotherapy: a case report

This paper presents a case of suspected liver metastasis of gastric cancer and a virtual complete response to S-1 chemoradiotherapy. A 69-year-old man underwent distal gastrectomy for gastric cancer in 2008. Multiple liver metastases occurred in 2009. He underwent 15 courses of S-1 therapy and radiation therapy (37.5 Gy). Abdominal computed tomography showed virtual complete disappearance of liver metastasis after chemoradiotherapy. Hence, this case was interpreted as a complete response. No sign of recurrence was noted 18 months after complete response was confirmed. S-1 chemoradiotherapy is likely to be effective in treating patients with liver metastases of gastric cancer.

First-line single-agent chemotherapy for patients with recurrent or metastatic gastric cancer with poor performance status

Combination chemotherapy is a standard treatment approach in advanced gastric cancer. However, combination chemotherapy for advanced gastric cancer is often associated with severe treatment-related toxicities and most oncologists are reluctant to perform combination chemotherapy in patients with a poor clinical condition. We retrospectively investigated the efficacy and tolerability of single-agent chemotherapy in patients with recurrent or metastatic gastric cancer with poor performance status (PS). We reviewed advanced gastric adenocarcinoma patients who received first-line single-agent palliative chemotherapy due to poor PS between June 2006 and December 2010. A total of 125 patients with Eastern Cooperative Oncology Group (ECOG) PS 2-3, whose general condition did not allow combination chemotherapy, were enrolled. Four single agents were used: TS-1 (n=63), paclitaxel (n=42), irinotecan (n=15) and capecitabine (n=5). The median age was 66 years, with a range of 25-81 years. The percent response rate and rate of stable disease (SD) were 19.2 and 35.2%, respectively, giving a disease control rate of 54.4%. The median progression-free survival (PFS) was 3.9 months (95% CI, 2.73-5.06). The median overall survival (OS) was 9.1 months (95% CI, 7.70-10.56) with a 1-year survival rate of 31.2%. Multivariate analysis demonstrated that the independent prognostic factors for OS were chemotherapy regimen (capecitabine) [reference: TS-1, hazard ratio (HR), 5.00; 95% CI, 1.81-13.81; P=0.002], no second-line chemotherapy (HR, 2.3; 95% CI, 1.48-3.57; P=0.001), bone metastasis (HR, 2.73; 95% CI, 1.22-6.09; P=0.014), ECOG PS 3 (HR, 38.10; 95% CI, 13.72-105.78; P=0.001), Glasgow prognostic score (GPS) ≥1 (HR, 1.88; 95% CI, 1.24-2.85; P=0.003) and chemotherapy response [SD + progressive disease (PD) + not evaluable (NE); HR, 2.37; 95% CI, 1.39-4.05; P=0.002)]. First-line single-agent palliative chemotherapy demonstrated a relatively good clinical efficacy for recurrent or metastatic gastric cancer patients with poor PS.

Phase II and UGT1A1 genotype study of irinotecan dose escalation as salvage therapy for advanced gastric cancer

Background:

To assess the efficacy and safety of individualised dose optimisation of irinotecan monotherapy as salvage treatment for advanced gastric cancer (AGC).

Methods:

A total of 43 patients were enrolled. Intravenous irinotecan (350 mg m⁻²) was administered every 3 weeks. The dose was increased (425 mg m⁻² and 500 mg m⁻²) or decreased (250 mg m⁻²) depending on patient tolerance. UGT1A1 genotypes were determined by direct sequencing of genomic DNA extracted from peripheral blood.

Results:

A total of 183 cycles of irinotecan were administered, with a median of four cycles per patient. The overall response rate was 9.3%, and the disease control rate was 62.8%. Median time to disease progression was 2.8 months, and median overall survival was 8.0 months. Grade 3–4 neutropenia was the most common toxicity (53.5%), and febrile neutropenia was the least common toxicity (4.6%). Compared with defective allele groups, UGT1A1 *1/*1 was associated with a lower incidence of grade 3–4 neutropenia during the first cycle (P=0.018).

Conclusion:

Individualised irinotecan dose escalation based on patient tolerance was not associated with increased toxicity and shows modest activity as salvage chemotherapy for AGC. The role of UGT1A1 genotype in clinical toxicity requires further evaluation.

A Case of Advanced Gastric Cancer with Poor Performance Status Which Improved by Chemotherapy

Introduction

The prognosis of advanced gastric cancer patients, especially those with poor performance status (PS), is generally dismally poor. Patients with PS 3–4 are usually ineligible for participation in clinical studies and are managed with only best supportive care. Case Report: A 63-year-old male with advanced gastric cancer was admitted to our hospital. His PS was markedly impaired (Eastern Cooperative Oncology Group PS 4), with dyspnea secondary to lymphangitis, pleuritis and pericarditis). He also had bilateral leg paralysis due to multiple bone metastases. He was treated with chemotherapy using 5-fluorouracil and leucovorin for 14 days with pericardial drainage followed by intrapericardial infusion of cisplatin. He was also treated with radiotherapy for bone metastasis. The patient required 5 l/min oxygen therapy at the start of chemotherapy, but his dyspnea was improved by day 14 and he no longer required supplemental oxygen therapy. His leg paralysis also improved with the radiation therapy. His PS was significantly improved with this multimodal treatment modality, and he was ultimately discharged with chemotherapy with oral fluoropyrimidine.

Conclusion

This case suggests that multimodal therapy including chemotherapy may be beneficial in advanced gastric cancer patients even in the setting of poor PS. Further study might be required to confirm the benefit of chemotherapy in this patient population.

Chemotherapy for patients with advanced gastric cancer with performance status 2

METHODS

We retrospectively analyzed 657 patients with advanced gastric cancer who received first-line chemotherapy. Baseline patient characteristics and treatment results were compared between Eastern Cooperative Oncology Group performance status (PS) 0-1 and PS 2 patients.

RESULTS

Prior to beginning first-line chemotherapy, 513, 112, and 32 patients were PS 0-1, PS 2, and PS 3-4, respectively. Patients with massive ascites (42% vs. 3%; P < .001) or inability to eat (39% vs. 4%; P < .001) were more likely to be PS 2 than PS 0-1. Significantly fewer PS 2 patients received first-line chemotherapy regimens containing oral agents (40% vs. 77%; P < .001) or combination chemotherapy (19% vs. 40%; P < .001) compared to PS 0-1 patients. Median survival time was significantly shorter in PS 2 patients (5.8 vs. 13.9 months; P < .001). Multivariate survival analysis revealed that use of oral agents was associated with a better prognosis in PS 0-1 patients (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.59-0.97, P = .03), while it was associated with poorer survival in PS 2 patients (HR 1.52, 95% CI 1.0-2.3, P = .046).

CONCLUSION

Advanced gastric cancer patients with PS 2 not only had a poorer prognosis but also differed in several baseline characteristics compared to PS 0-1 patients. These results indicate that additional clinical trials that specifically target gastric cancer patients with PS 2 may be required to evaluate optimal treatment regimens for this patient population.

Is there a role for second-line chemotherapy in advanced gastric cancer?

Gastric cancer remains one of the most common forms of cancer worldwide. Unfortunately, most patients will present with advanced-stage disease, and will therefore need palliative chemotherapy. Some chemotherapy regimens have been well established as first-line therapy, and have been shown to increase survival; however, almost all patients with metastatic gastric cancer will develop progressive disease after first-line therapy. With the availability of several active chemotherapy drugs, many patients who retain a good performance status after the initial treatment remain good candidates for additional therapy; however, no standard approach for second-line therapy exists. Many small, phase 2 trials have been done and the findings are variable. No data from randomised-controlled trials suggest a benefit of second-line chemotherapy compared with supportive care alone. We review the published data concerning the use of chemotherapy in the second-line setting for the treatment of advanced gastric cancer.

Phase II study of S-1 monotherapy in paclitaxel- and cisplatin-refractory gastric cancer

PURPOSE

S-1 is a fourth-generation oral fluoropyrimidine that was developed to mimic the effects achieved with protracted continuous infusion of 5-fluorouracil (5-FU). This phase II study evaluated the efficacy and safety of S-1 salvage chemotherapy in patients with paclitaxel- and cisplatin-refractory gastric cancer. The primary end point was progression-free survival; secondary end points were overall survival, safety, and clinical benefit.

METHODS

Patients were eligible for the study if they had histologically documented gastric adenocarcinoma previously treated with paclitaxel and cisplatin, age > or = 18 years, Eastern Clinical Oncology Group performance status < or =2, adequate organ function, and no evidence of gastrointestinal obstruction or passage disturbance. Patients were treated with a dose of S-1 based on body surface area (BSA) as follows: BSA < 1.25 m(2), 80 mg/day; 1.25 < or = BSA < 1.5 m(2), 100 mg/day; BSA > or= 1.5 m(2), 120 mg/day. The total dose was divided in two and administered twice daily for 4 weeks followed by a 2-week rest period.

RESULTS

Of the 53 patients enrolled in this study, 49 were evaluable. A total of 190 chemotherapy cycles were administered, and the median number of cycles was 2. Five patients (9.4%) had a partial response, and 18 (34%) had stable disease. Median progression-free survival and overall survival were 4.9 and 10.4 months, respectively. Grade 3/4 hematological toxicities included neutropenia in six patients (11%) but no cases of febrile neutropenia were found. Most of the non-hematological toxicities were diarrhea, asthenia, and mucositis, but none reached grade 3 or grade 4 in severity. Improvement of pain was observed in 17 patients (32.1%).

CONCLUSIONS

S-1 monotherapy provides active and safe salvage chemotherapy for patients with advanced gastric cancer who have been previously treated with paclitaxel and cisplatin.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer

BACKGROUND

A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy.

METHODS

Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy.

RESULTS

Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months.

CONCLUSIONS

Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

Phase I dose-escalating study of S-1 in combination with oxaliplatin for patients with advanced and/or metastatic colorectal cancer

The purpose of this study was to determine the optimal dose of oxaliplatin, when combined with a fixed dose of S-1 (40 mg/m twice daily on days 1-14) on a 3-week schedule, for patients with advanced and/or metastatic colorectal cancer. Patients were required to have a histologically proven advanced or metastatic colorectal cancer for which they had received no previous chemotherapy. Oxaliplatin was administered intravenously on day 1 every 3 weeks. Patients were divided into two groups to receive two doses of oxaliplatin - 100 mg/m or 130 mg/m. Ten patients were enrolled in the study between March 2006 and July 2006, and were followed up until 50% of the patients progressed. All patients were evaluated for chemotherapy-related toxicity. The maximum tolerated dose was not reached during the first course. One of six patients experienced grade 3 thrombocytopenia at dose level 2 of oxaliplatin. Nonhematological toxicity was mild and tolerable. During the full course of treatment, complete response was achieved in two of the nine evaluated patients and partial response was achieved in one patient. The remaining six patients achieved stable disease during first two courses of therapy, and four patients remained stable at the time of the last follow-up. The median time to progression-free survival was 8.3 months. When combined with a fixed dose of S-1 80 mg/m, oxaliplatin administered at a dose of 130 mg/m is tolerable and recommended for phase II study.