Combination of irinotecan (CPT-11) plus oxaliplatin (L-OHP) as first-line treatment in locally advanced or metastatic gastric cancer: a multicentre phase II trial

Platelet-mimicking supramolecular nanomedicine with precisely integrated prodrugs for cascade amplification of synergistic chemotherapy

Camptothecin (CPT) and cisplatin (Pt) have shown synergistic effects on a variety of cancers during preclinical and clinical studies. However, the ratio of the two drugs often could not be precisely regulated in different delivery systems, which hinders the desired synergistic effect. In addition, the low delivery efficiency of the two drugs to the tumor further impedes the ideal therapeutic outcomes. Herein, we report that a platelet-mimicking supramolecular nanomedicine (SN) could precisely control of the ratio of CPT and Pt with a high tumor accumulation rate for cascade amplification of synergistic chemotherapy. The SN was fabricated via the host-guest interaction between cucurbit[7]uril conjugated hyaluronic acid (HA-CB[7]) and adamantane (ADA) respectively functionalized CPT- and Pt-based prodrugs. The ratio of CPT and Pt in the SN could be facilely regulated by simply controlling the loading ratio, based on the strong binding affinity between CB[7] and ADA, and SN60 with 60% CPT and 40% Pt showed the highest synergistic effects on 4T1 cells. To improve the tumor accumulation efficiency of SN, 5,6-dimethylxanthenone-4-acetic acid (DMXAA, a tumor vasculature-disruptive agent) was loaded into the optimized SN and then coated with platelet membrane to yield platelet-mimicking supramolecular nanomedicine (D@SN-P). D@SN-P could first passively accumulate in tumors owing to the enhanced permeability and retention (EPR) effect after intravenous administration. The initially release of DMXAA from D@SN-P could induce tumor vascular disruption, and the resultant epithelial collagen exposure around the disrupted tumor vasculature provided a target for further recruitment of platelet-mimicking SN, leading to cascade amplification of tumor accumulation with synergistic chemotherapy. Hence, this platelet-mimicking supramolecular nanomedicine presents a universal supramolecular strategy to finely regulate the ratio of loaded pro-drugs, and improve the accumulation efficiency to amplify chemotherapy via platelet-mimics.

Drug Self-Delivery Systems: Molecule Design, Construction Strategy, and Biological Application

Drug self-delivery systems (DSDSs) offer new ways to create novel drug delivery systems (DDSs). In typical DSDSs, therapeutic reagents are not considered passive cargos but active delivery agents of actionable targets. As an advanced drug delivery strategy, DSDSs with positive cooperativity of both free drugs and nanocarriers exhibit the clear merits of unprecedented drug-loading capacity, minimized systemic toxicity, and flexible preparation of nanoscale deliverables for passive targeted therapy. This review highlights the recent advances and future trends in DSDSs on the basis of two differently constructed structures: covalent and noncovalent bond-based DSDSs. Specifically, various chemical and architectural designs, fabrication strategies, and responsive and functional features are comprehensively discussed for these two types of DSDSs. In addition, additional comments on the current development status of DSDSs and the potential applications of their molecular designs are presented in the corresponding discussion. Finally, the promising potential of DSDSs in biological applications is revealed and the relationship between preliminary molecular design of DSDSs and therapeutic effects of subsequent DSDSs biological applications is clarified.

Supramolecular Drug-Drug Complex Vesicles Enable Sequential Drug Release for Enhanced Combination Therapy

Drug-drug self-delivery systems serving as both carriers and cargos have been explored as advanced combination chemotherapy strategies to overcome the limitations of the traditional single-drug chemotherapy. However, most known drug-drug self-delivery systems may cause a rapid increase in drug concentration when the single covalent bond is broken, thus leading to high toxicity to organs and low therapeutic efficiency against tumors. To address the above problem, in this study, a novel supramolecular drug-drug complex (SDDC) simultaneously containing both covalent and noncovalent bonds was proposed to realize the sequential release of two drugs in tumor cells for enhanced combination therapy. The SDDC could self-assemble into uniform bilayer supramolecular vesicles (SVs) with a remarkable drug loading capacity and stable drug transport. Notably, the SVs with controlled sequential release ability in tumor cells exhibited a superior synergistic effect and significantly improved therapeutic efficiency with reduced toxicity in in vivo antitumor activity and histological analyses in comparison to either individual free drugs or a mixture of two free drugs. Therefore, by combining the advantages of noncovalent interactions with the dynamic nature and stable covalent bonds, this study opens a new way for cancer therapy.

Gastric cancer pharmacogenetics: progress or old tripe?

Gastric cancer remains the second most frequent cause of cancer-related mortality. While surgery is traditionally the initial treatment for early-stage disease, the addition of chemotherapy has been shown to significantly increase overall survival and progression-free survival in advanced and metastatic stages of disease. However, despite the incorporation of newer chemotherapies and regimens into gastric cancer clinical trials, the response rate and median overall survival for treated patients has not significantly improved throughout the years; therefore, newer therapeutic approaches to improve upon the medication selection process are warranted. Treatment and dose selection based on patient factors, such as genetic variation, may provide a more rational and potentially more powerful means of personalizing chemotherapy. This review provides an update on the current status of pharmacogenetic studies regarding germline DNA mutations that may alter response to chemotherapeutic agents used to treat gastric cancer, including perspectives on clinical translation and future work.

[Comparison of the toxicities and efficacies of the combination chemotherapy regimens in advanced gastric cancer patients who achieved complete response after chemotherapy]

BACKGROUND/AIMS

We retrospectively analyzed comparative toxicities and efficacies of chemotherapy regimens in advanced gastric cancer (AGC) patients who achieved complete response (CR) after chemotherapy.

METHODS

We reviewed the medical records of 1,203 patients, who were pathologically diagnosed as AGC in a single center between January 2001 and October 2007. On the basis of the Response Evaluation Criteria in Solid Tumors, CR was evaluated with abdominal computed tomography. Toxicities were evaluated using the National Cancer Institute's common toxicity criteria before each chemotherapy cycle.

RESULTS

Among the 1,203 AGC patients enrolled in this study, 568 received chemotherapy and 635 received best supportive care. The major chemotherapy regimens were 5-fluorouracil, leucovorin and oxaliplatin (FOLFOX), docetaxel, cisplatin and 5-fluorouracil (DCF) and 5-fluorouracil, leucovorin and irinotecan (FOLFIRI). Among the 568 patients, 51 (9.0%) achieved CR (49 [8.6%] with FOLFOX [n=12], DCF [n=26], or FOLFIRI [n=11] and 2 [0.3%] with etoposide, leucovorin and 5-fluorouracil). For patients administered FOLFOX, DCF, and FOLFIRI, the median time to disease progression was 4 months (range, 1.8-59.5), 15 months (range, 2.9-31.2) and 10 months (range, 2.0-39.5), and the median survival times were 48 months (range, 5.9-74.0), 37 months (range, 14.0-86.0), and 30 months (range, 6.0-50.0), respectively. Grades 3-4 mucositis occurred mostly in patients administered DCF (n=8, 30.8%). Grades 3-4 leucopenia were observed in 1 (8.3%), 11 (42.3%), and 4 (36.4%) patients administered FOLFOX, DCF and FOLFIRI, respectively. No statistically significant differences were observed in the 3 regimens.

CONCLUSIONS

All 3 regimens (FOLFOX, DCF and FOLFIRI) were active and tolerable. Their efficacies and toxicities were not significantly different.

Effectiveness and safety of oxaliplatin compared to cisplatin for advanced, unresectable gastric cancer: a systematic review and meta-analysis

BACKGROUND

Cisplatin has been largely used in the treatment of advanced, unresectable gastric cancer, mainly in combinations with fluoropyrimidines and anthracyclines. Oxaliplatin has been shown to be at least as effective as cisplatin for this disease, but with less toxicity and a better tolerability profile, especially for older patients. We performed a systematic review of the literature to address and quantify differences in the efficacy and the safety between oxaliplatin and cisplatin for the treatment of this disease.

METHODS

The literature was searched for randomized controlled trials (RCTs) comparing oxaliplatin to cisplatin. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to analyze dichotomous variables. Hazard ratios (HRs) for progression and death were combined with an inverse variance method based on logarithmic conversion. A fixed effect model and Mantel-Haenszel's (M-H) method were used. Heterogeneity was tested with the Q test and the I (2) value. Sensitivity analyses were performed.

RESULTS

Three RCTs were identified, involving a total of 1294 patients. Oxaliplatin significantly improved progression-free survival (HR = 0.88, p = 0.02) and overall survival (HR = 0.88, p = 0.04). Moreover, it was associated with less neutropenia (OR = 0.53, p < 0.01) and fewer thromboembolic events (OR = 0.42, p < 0.01), but it was also associated with increased neurotoxicity (OR = 6.91, p < 0.01).

CONCLUSIONS

Our results support the existence of a small but significant survival benefit of oxaliplatin over cisplatin. Oxaliplatin is associated with less toxicity and better tolerability, especially in older patients and when used in two-drug, bi-weekly regimens.

Hypersensitivity reactions associated with platinum antineoplastic agents: a systematic review

Platinum-containing chemotherapy agents (cisplatin, carboplatin, oxaliplatin) have been approved in the first-line setting of numerous malignancies, such as ovarian, bladder, head and neck, colorectal, and lung cancer. Their extensive use over the last decade has led to a significant increase in the incidence of hypersensitivity reactions, which are defined as unforeseen reactions whose signs and symptoms cannot be explained by the known toxicity of these drugs. Skin rash, flushing, abdominal cramping, itchy palms, and back pain are common symptoms. Cardiovascular and respiratory complications can prove fatal. Multiple pathogenetic mechanisms have been suggested. Hypersensitivity usually appears after multiple infusions, suggesting type I allergic reactions; however, other types of hypersensitivity also seem to be implicated. Several management options are available to treating physicians: discontinuation of chemotherapy, premedication, prolonging of infusion duration, desensitization protocols, and replacement with a different platinum compound after performing skin tests that rule out cross-reactions among platinum agents.

A phase II study of S-1 and oxaliplatin (SOx) combination chemotherapy as a first-line therapy for patients with advanced gastric cancer

BACKGROUND

Palliative chemotherapy has been shown to have a survival benefit for patients with recurrent or metastatic gastric cancer. 5-fluorouracil (5-FU) and cisplatin have been widely used in a variety of combinations. We conducted a phase II study of combination chemotherapy with new agents, S-1 and oxaliplatin (SOx), in advanced gastric cancer patients in an effort to evaluate the efficacy and toxicity of this regimen.

METHOD

Histologically confirmed recurrent or metastatic gastric cancer were treated by the oral administration of S-1 80 mg/m(2)/day on days 1-28, and oxaliplatin 85 mg/m(2) administered as a 90-min intravenous infusion on days 1, 15, and 29. Treatment courses were repeated every 6 weeks. Patients received a maximum of four cycles.

RESULTS

From Feb 2006 to May 2008, 41 patients were enrolled in this study. The ratio of males to females was 28 to 13. The median patient age was 61 years (range, 36-74 years), and 85.4% (35/41) of the patients had a performance status (ECOG) of 1. The median number of chemotherapy cycles administered was 3 (range, 1-4). According to the results of our Intent-to-Treat analysis, 22 patients (53.7%) achieved a partial response (95% CI, 38-70%). 15 patients (36.6%) evidenced a stable disease, and 1 patient (2.4%) progressed during the course of the treatment. 3 patients were lost to follow-up prior to evaluation. The median time to progression and overall survival time were 4.6 months (95% CI, 3.4-5.8 months) and 7.8 months (95% CI, 6.9-8.7 months) from the start of the chemotherapy, respectively. A total of 114 cycles were assessed for toxicity. The major hematologic toxicities included grade 2 anemia (41.2%), grade 1-2 neutropenia (28.1%), and grade 1 thrombocytopenia (23.7%). Only 1 cycle of neutropenic fever occurred. The non-hematological toxicities observed were grade 3 vomiting (12.2%) and grade 3 diarrhea (4.9%). No treatment-related deaths occurred in our patient population during the study period.

CONCLUSION

The SOx regimen evidenced a relatively high response rate and was well tolerated as a first-line therapy for advanced gastric cancer.

A phase II study of irinotecan with biweekly, low dose leucovorin and bolus and continuous infusion 5-fluorouracil (modified FOLFIRI) as first line therapy for patients with recurrent or metastatic gastric cancer

BACKGROUND

To determine the activity and toxicities of a low-dose leucovorin plus 5-fluorouracil (5-FU) regimen, combined with irinotecan and administered every 2 weeks (modified FOLFIRI), as a first-line therapy for patients with advanced gastric cancer.

METHOD

Patients were treated with cycles of 150 mg/m irinotecan on day 1 plus 50 mg of LV, followed by a 400 mg/m 5-FU bolus and a 22-hour continuous infusion of 600 mg/m 5-FU on days 1 and 2.

RESULTS

The median patient age was 55 years (range, 29-75 years), and 77% (34/44) of the patients had a performance status (Eastern Cooperative Oncology Group) of 0 or 1. Of the 44 patients evaluated for their tumor response, 3 patients (6.8%) and 14 patients (31.8%) achieved a complete and partial response, respectively, with an overall response rate of 38.6% (95% confidence interval, 23.7%-53.6%). 13 patients (29.6%) evidenced a stable disease, and 14 patients (31.8%) progressed during the course of the treatment. The median time to progression and overall survival time were 4.9 months (range, 0.9-22.8 months) and 10.3 months (range, 1.2-29.0 months) from the start of the chemotherapy, respectively. A total of 293 cycles were assessed for toxicity. The major hematologic toxicities included grade 1 to 2 anemia (27.6%), neutropenia (48.8%), and grade 3 to 4 neutropenia (12.6%). There were 7 cycles of neutropenic fever. Nonhematological toxicities were observed grade 3 vomiting (6.8%), grade 3 diarrhea (4.5%), and grade 3 mucositis (2.3%). We noted no treatment-related deaths.

CONCLUSIONS

The modified FOLFIRI regimen-lowering of irinotecan and LV doses-is a safe and feasible regimen as a first-line therapy for patients with recurrent or metastatic gastric cancer.

A general review of the role of irinotecan (CPT11) in the treatment of gastric cancer

BACKGROUND

The prognosis of gastric tumor is generally poor because most tumors are diagnosed at an advanced stage. Chemotherapy has a proven palliative role in advanced gastric cancer and several combination regimens were explored in the last 10 yr. Nevertheless, none of them showed a convincing improvement resulting in an enhancement of response rate and overall survival without discrimination of the quality of life. Irinotecan (CPT11) has been evaluated in multiple trials alone or in combined therapy with promising results and good tolerance. Thus, a review of the importance and impact of CPT11 in this indication is detailed.

METHODS

This article reviews the evidence for the use of CPT11 in the treatment of gastric cancer based on a computerized MEDLINE search of literature published until August 2006 leading to a total of 91 publications.

RESULTS

CPT11 was frequently used and showed a good response rate varying from 14% to 23% as single agent and 45% to 70% in combination with a median time to progression of 3 mo in single agent and 4-6 mo in combination, and median overall survival of approx 7 mo in single agent and up to 10.58 mo in combination.

CONCLUSION

The overall response of irinotecan-based chemotherapy in advanced gastric cancer was shown to be as effective as other combined chemotherapy. The hematological and digestive toxicity were tolerable and mild, especially in weekly regimen. Thus, irinotecan-based chemotherapy should be considered as one of the preferred choices in front line chemotherapy in advanced gastric cancer.

Pharmacogenetics and stomach cancer: an update

Although new drugs and association regimens have been used in recent years, the chemotherapeutic outcome for gastric cancer is still poor and improvement in patient survival is not satisfactory. Pharmacogenetics could represent a useful approach to optimize chemotherapeutic treatments in order to identify individuals that are true candidates for clinical benefits from therapy, avoiding the development of severe side effects. The most recent update regarding gastric cancer pharmacogenetics highlights a prominent role of genetic polymorphisms of thymidylate synthase and glutathione S-transferase in the pharmacological treatment with commonly used drugs, such as 5-fluorouracil and platinum derivatives. In order to validate the genetic markers, further larger scale and controlled studies are required. A future challenge is represented by the introduction of targeted therapy in gastric cancer treatment, with the potential emerging tool of pharmacogenetic impact on this field.

Updated efficacy and toxicity analysis of irinotecan and oxaliplatin (IROX) : intergroup trial N9741 in first-line treatment of metastatic colorectal cancer

BACKGROUND

Efficacy and toxicity of oxaliplatin (Eloxatin; Sanofi-Aventis, Paris, France) combined with irinotecan (IROX) were examined in 383 patients enrolled on the IROX arm of Intergroup Study N9741.

METHODS

This IROX regimen was oxaliplatin 85 mg/m(2) and irinotecan 200 mg/m(2) administered every 3 weeks. The relation between adverse events on IROX to selected characteristics was analyzed. Time to progression (TTP), response rate, and overall survival for patients treated with IROX compared with patients treated with oxaliplatin with 5- fluorouracil (FOLFOX) were updated in this article.

RESULTS

Grade >or=3 gastrointestinal and hematologic toxicities were common with 39% patients experiencing neutropenia, 28% diarrhea, and 21% vomiting. Patients ages >70 years experienced higher rates of grade >or=3 toxicity, with significantly higher rates of grade >or=3 hematologic toxicities (P = .02). Long-term toxicity was uncommon, and nearly all cases of grade >or=3 neurotoxicity resolved within 10 months. Fifty-two percent of patients required dose reductions for adverse events, and 26% experienced 119 hospitalizations related to complications of treatment or their disease, with 5 treatment-related deaths. This analysis confirmed prior findings that FOLFOX is superior to IROX in terms of response rate (43% vs 36%, p = 0.002), TTP (9.2 months vs 6.7 months, P < .0001), and overall survival (19.5 months vs 17.3 months, P = .0001).

CONCLUSIONS

IROX was found to be less active than FOLFOX but with a similar toxicity profile except in patients ages >70 years. Although IROX may be considered in patients intolerant of 5-FU or in patients known to have a dihydropyrimidine dehydrogenase (DPD) deficiency, it should be used with caution in older patients.

A phase II study of oxaliplatin with low dose leucovorin and bolus and continuous infusion 5-fluorouracil (modified FOLFOX-4) as first line therapy for patients with advanced gastric cancer

To determine the activity and toxicities of a low dose leucovorin (ldLV) plus fluorouracil (5-FU) regimen, combined with oxaliplatin administered fortnightly (modified FOLFOX-4), as a first-line therapy for patients with advanced gastric cancer. Patients were treated with cycles of oxaliplatin 85 mg/m2 on day 1 plus LV 20 mg/m2, followed by 5-FU a 400 mg/m2 bolus and a 22 hour continuous infusion of 600 mg/m2 5-FU on days 1 - 2 every two week intervals. Forty-five patients were enrolled in this study. Forty-two patients were assessable for response. One of the 42 patients demonstrated complete response, and 20 partial responses, and overall response rate of 50%. The median time to progression and overall survival time were 7.7 months (95% CI: 3.6 - 11.9 months) and 11.2 months (95% CI: 9.1 - 13.3 months), respectively. Major hematologic toxicities included grade 1 - 2 anemia (39.7%), neutropenia (30.4%) and grade 3 - 4 neutropenia (10.9%). Twelve cycles were associated with neutropenic fever. The most common non-hematological toxicities were grade 2 nausea/vomiting (20%). There was no treatment related death. The modified FOLFOX-4 regimen was found to be a safe and effective first line therapy in advanced gastric cancer.

Irinotecan, docetaxel and oxaliplatin combination in metastatic gastric or gastroesophageal junction adenocarcinoma

This phase II study was designed to evaluate the activity and safety of a combination of irinotecan, docetaxel and oxaliplatin in metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma. Forty patients with measurable distant metastasis received irinotecan 150 mg m(-2) and docetaxel 60 mg m(-2) on day 1, and oxaliplatin 85 mg m(-2) on day 2. Cycles were repeated every 3 weeks. The primary end point was to demonstrate a 50% improvement in time-to-progression (TTP) over historical controls. All patients were evaluable. Median TTP was 6.5 months (95% confidence interval (CI) 5.6-7.4), the overall response rate was 50% (95% CI 35-65%) and the median overall survival was 11.5 months (95% CI 8.7-14.3). Grade 3/4 neutropaenia occurred in 47.5% of patients. There were four episodes of febrile neutropaenia in three patients. Other non-haematological grade 3 toxicities included diarrhoea in four patients (10%), vomiting in three patients (7.5%) and mucositis in two patients (5%). The irinotecan, docetaxel and oxaliplatin combination chemotherapy is an active and well-tolerated novel regimen for treating metastatic gastric or GEJ adenocarcinoma and deserves further evaluation in randomised trials and in combination with molecular targeting agents.

Chemotherapy for advanced gastric cancer: across the years for a standard of care

Chemotherapy is of crucial importance in advanced gastric cancer patients, in order to obtain palliation of symptoms and improve survival. The most extensively studied drugs as single agents are 5-fluorouracil, cisplatin, doxorubicin, epirubicin, mitomycin C and etoposide. Newer chemotherapeutic agents include the taxanes (docetaxel and paclitaxel), oral fluoropyrimidines (capecitabine and S-1), oxaliplatin and irinotecan. Randomised trials comparing monotherapy with combination regimens have consistently shown increased response rates in favour of combination regimens, whereas only marginally improved survival rates were usually found. Several combination therapies have been developed and have been examined in Phase III trials. However, in most cases, they have failed to demonstrate a survival advantage over the reference arm. There is no internationally accepted standard of care, and uncertainty remains regarding the choice of the optimal chemotherapy regimen. The objective of this article is to review the present literature available on major Phase II - III clinical trials, in which patients suffering from advanced gastric cancer were treated with cytotoxic chemotherapy.

Intérêt de la chronothérapie dans le traitement pluridisciplinaire des cancers de l'œsophage et de l'estomac

The authors evaluated the impact of a chronotherapy with 5-FU, folinic acid and carboplatine (chronomodulated infusions by ambulatory pumps; 5/21 days) for the management of oesophagus (52 cases) and gastric (56 cases) cancer patients. The overall tolerance of treatment was gauged excellent (grade 3-4; % patients: mucitis: 11-23%; leucopenia 6-19%; thrombopenia 18-50%; almost no digestive disturbances nor alopecia). Also tumor outcome was considered interesting with major responses rate in 61% (gastric) to 79% (oesophagus) of patients. The median survival of oesophageal cancer was limited to 9.2 months; the one of disseminated gastric cancer was 12.7 months but 72% of curatively resected patients were alive at 5+ years.

Docetaxel in the treatment of gastric cancer

Docetaxel is part of the standard chemotherapy in breast, non-small cell lung cancer and androgen-independent metastatic prostate cancer and has recently been approved for advanced gastric cancer. It demonstrated promising single-agent efficacy in gastric cancer and was therefore investigated in different combination regimens. The combination of docetaxel with 5-fluorouracil (5-FU), capecitabine, irinotecan or cisplatin demonstrated high efficacy. The triple combination of docetaxel/cisplatin and 5-FU (DCF) was investigated in randomized Phase II trials and a randomized Phase III study (TAX325). In TAX325, DCF demonstrated superiority in terms of time to tumor progression, response rate and survival against a cisplatin/5-FU combination. Docetaxel was therefore approved for advanced gastric cancer by the US FDA and the European Agency for the Evaluation of Medicinal Products and will evolve as an integral part of routine combination regimens against gastric cancer. This review will discuss and interpret the different Phase II and III trials of docetaxel in gastric cancer.

Prevention of irinotecan associated diarrhea by intestinal alkalization. A pilot study in gastrointestinal cancer patients

AIM AND BACKGROUND

Intestinal alkalization could prevent irinotecan associated diarrhea modulating some chemical equilibria between irinotecan metabolites. The aim of this study was to evaluate the efficacy of this procedure in advanced gastrointestinal cancer patients (GICP).

MATERIALS AND METHOD

In this prospective study advanced GICP, receiving irinotecan based chemotherapy regimens, were well trained to add sodium bicarbonate to the water intake in order to accomplish intestinal alkalization.

RESULTS

A total of twenty four advanced GICP were enrolled. Grade III-IV diarrhea has been observed in four patients (16%), some of whom had several risk factors for diarrhea. Only one out of seventeen colorectal cancer patients, receiving the irinotecan combination as first line therapy, had grade III-IV diarrhea. No side effects of the procedure have been appreciated.

CONCLUSIONS

Intestinal alkalization may be effective as a preventive treatment for irinotecan associated diarrhea in chemotherapy regimens used in GICP. This procedure deserves further investigation.

Recent developments in the systemic therapy of advanced gastroesophageal malignancies

Cancers of the upper gastrointestinal tract are a common cause of worldwide morbidity and mortality. The prognosis for patients with these cancers remains poor and only a minority of patients are cured. Systemic therapy has been used to treat patients with advanced disease but outcomes have not improved dramatically in the past few decades. Newer, more effective agents are desperately needed, and agents such as the taxanes (docetaxel and paclitaxel), irinotecan, oxaliplatin and capecitabine have recently shown some promise. In addition, molecularly targeted, non-cytotoxic therapies are being evaluated with the hope of improving the available therapeutic options. This article reviews the current clinical data regarding systemic therapy for patients with advanced upper gastrointestinal malignancies.

Polymorphisms of glutathione S-transferases (GST) and thymidylate synthase (TS)--novel predictors for response and survival in gastric cancer patients

To evaluate the predictive value of a panel of gene polymorphisms involved in metabolism of 5-FU and cisplatin on clinical outcome in advanced gastric cancer patients. A total of 52 patients were enrolled in this study. DNA was extracted from paraffin-embedded tumour specimen. Genotypes were determined using PCR-RFLP. Median survival time was 6.0 months (95% CI 3.9;8.1). Overall response rate was 26%. Patients possessing the glutathione S-transferase P1-105 Valine/Valine (GSTP1-105VV) genotype showed a response rate of 67% compared to 21% in patients harbouring at least one GSTP1-105 Isoleucine (GSTP1-105I) allele (P=0.038). GSTP1-105VV patients demonstrated a significant superior median survival time of 15.0 months (95% CI 7.8;22.0) compared to 6.0 months (95% CI 5.1;7.0) in patients with at least one GSTP1-105I allele (P=0.037). Patients possessing a favourable thymidylate synthase (TS) genotype (2R/2R, 2R/3RC, 3RC/3RC) experienced a superior survival time of 10.2 months (95% CI 5.1;15.3) compared to 6.0 months (95% CI 5.0;7.0) in patients with unfavourable TS genotypes (P=0.099). Patients harbouring the GSTP1-105II genotype and one of the unfavourable TS genotypes showed an inferior median survival time of 6.0 months (95% CI 3.9;8.1) compared to 11 months (95% CI 6,23;15,77) in patients with either GSTP1-105VV or a favourable TS genotype (P=0.044). Testing for TS and GSTP1 polymorphisms may allow identification of gastric cancer patients who will benefit from 5-FU/cisplatin chemotherapy, sparing others the side effects of this chemotherapy.

The emerging role of oxaliplatin in the treatment of gastric cancer

Gastric cancer is often diagnosed in locally advanced or metastatic stages and, therefore, of poor prognosis. Many controversies exist about surgery, neoadjuvant, adjuvant and palliative treatments of gastric cancer. So we need to explore a variety of novel management options including the use of new agents and new combinations. Some of these agents include oral fluoropyrimidine, irinotecan, docetaxel and oxaliplatin. Oxaliplatin is a diaminocyclohexane-platinum compound that is significantly different from cisplatin and carboplatin with respect to its activity and toxicity. Oxaliplatin is an alkylating agent inhibiting DNA replication by forming adducts between two adjacent guanines or guanine and adenine molecules. However, the adducts of oxaliplatin appear to be more effective than cisplatin adducts in regard to the inhibition of DNA synthesis. In contrast to cisplatin, oxaliplatin has demonstrated efficacy alone and in combination with 5-fluorouracil in advanced colorectal cancer. Many studies are ongoing to test the combination in noncolorectal gastrointestinal tumors and other malignancies. This review focuses on the increasing amount of data concerning the clinical activity of oxaliplatin-based regimens in advanced gastric cancer.

Evolving chemotherapy for advanced gastric cancer

Gastric cancer is the fourth most commonly diagnosed cancer and is the second leading cause of cancer death worldwide. More than 50% of patients undergo surgery, but even after a curative resection, 60% of patients relapse locally or with distant metastases. Despite the fact that many advances have occurred in the management of gastric cancer, it continues to carry a poor prognosis, amplifying the importance of palliative chemotherapy. When compared with best supportive care alone, combination chemotherapy yields a significant advantage in the management of advanced gastric cancer. However, no single regimen has emerged or been accepted as clearly superior over another. Numerous phase II studies have demonstrated promising results with newer agents including irinotecan, docetaxel, capecitabine, S-1, and oxaliplatin. Recently reported phase III results with these agents now demonstrate positive developments in the treatment options for patients with advanced gastric cancer.

In vitro detection of cross-resistant and non-cross-resistant agents with fluorouracil for patients with colorectal cancer

BACKGROUND

Fluorouracil-based chemotherapy, such as that with 5-fluorouracil (5-FU)/leucovorin, is standard as first-line chemotherapy for advanced colorectal cancer (CRC) in Japan. However, the best agent for second-line chemotherapy after fluorouracil failure is yet to be determined. This study was undertaken to find an appropriate agent for second-line chemotherapy.

METHODS

Seventy-five tumor specimens from CRC patients with no prior chemotherapy were obtained operatively and their chemosensitivity to five anticancer agents; i.e., 5-FU, mitomycin C (MMC), cisplatin, docetaxel, and an active metabolite of irinotecan (SN-38), was analyzed in an in vitro chemosensitivity test. In this method, the degree of chemosensitivity was expressed as the percent T/C ratio, where T was the total volume of the tumor colonies in the treated group and C was that of the control group. Pearson's correlation coefficients were used to assess the relationship between two agents.

RESULTS

Fifty-eight specimens (colon, 28; rectum, 30) were successfully analyzed. Positive correlations with 5-FU chemosensitivity were verified for the chemosensitivity of MMC, cisplatin, and docetaxel. No correlation with 5-FU chemosensitivity was verified for SN-38 chemosensitivity. Although the functional mechanism of each of the agents differs from that of 5-FU, with the exception of irinotecan, they all had a spectrum closely similar to the 5-FU spectrum.

CONCLUSION

Only irinotecan exhibited a spectrum independent of that of 5-FU, thus indicating that it could be an appropriate agent for second-line chemotherapy after fluorouracil failure.

Chemotherapy for gastric cancer

Metastatic gastric cancer remains a non-curative disease. Palliative chemotherapy has been demonstrated to prolong survival without quality of life compromise. Many single-agents and combinations have been confirmed to be active in the treatment of metastatic disease. Objective response rates ranged from 10-30% for single-agent therapy and 30-60% for polychemotherapy. Results of phase II and III studies are reviewed in this paper as well as the potential efficacy of new drugs. For patients with localized disease, the role of adjuvant and neoadjuvant chemotherapy and radiation therapy is discussed. Most studies on adjuvant chemotherapy failed to demonstrate a survival advantage, and therefore, it is not considered as standard treatment in most centres. Adjuvant immunochemotherapy has been developed fundamentally in Korea and Japan. A meta-analysis of phase III trials with OK-432 suggested that immunochemotherapy may improve survival of patients with curatively resected gastric cancer. Based on the results of US Intergroup 0116 study, postoperative chemoradiation has been accepted as standard care in patients with resected gastric cancer in North America. However, the results are somewhat confounded by the fact that patients underwent less than a recommended D1 lymph node dissection and the pattern of recurrence suggested a positive effect derived from local radiotherapy without any effect on micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation therapy remains experimental, but several phase II studies are showing promising results. Phase III trials are needed.

Chemotherapy for advanced gastric cancer: slow but further progress

Gastric cancer remains a significant problem in terms of global health, and is the most common cancer in Korea. Surgery is the only potentially curative treatment for localized gastric cancer, but most cases present at an advanced stage. Randomized trials have demonstrated that chemotherapy for advanced gastric cancer improves the quality of life and extends survival, by 4 approximately 6 months, compared with best supportive care alone. Single agents with a proven activity in a first-line setting include 5-fluorouracil (5-FU), doxorubicin, mitomycin C, cisplatin, taxanes (docetaxel and paclitaxel) and oral fluoropyrimidines (capecitabine and TS-1). Based on the results from several large scale randomized trials, FP (5-FU/cisplatin) and ECF (epirubicin/cisplatin/5-FU) combinations are the most widely used regimen against advanced gastric cancer. Phase II studies of the FP and ECF combination reported a 40~51% response rate in previously untreated patients, and this regimen also produced a significantly higher response rate than the FAM (5-FU/doxorubicin/mitomycin) and FAMTX (5-FU/doxorubicin/methotrexate) regimens, respectively. However, significant treatment related-toxicities and discomfort were reported from ECF, which prevents this combination from becoming the standard treatment regimen. While no one combination chemotherapy regimen is accepted as the standard for advanced gastric cancer, FP is currently considered a suitable reference regimen worldwide. New agents, such as taxane, irinotecan and oxaliplatin, combined with old agents, such as cisplatin and 5-FU, are currently under evaluation to further improve treatment outcomes. Also, oral 5-FU prodrugs are replacing the cumbersome 5-FU long-term infusion due to its convenience and superior toxicity profile. However, the low complete response rate and short response duration are still the main obstacles in the chemotherapy for gastric cancer. Only large scale comparative clinical trials will give clues to improve the results of gastric cancer treatments.

Recent developments in chemotherapy of advanced gastric cancer

Approximately 1 million individuals develop gastric cancer every year and the mortality of gastric cancer is only second to lung cancer. The poor prognosis is caused by late diagnosis of most cancers in advanced stages and the limited therapeutic options in these stages. Apart from the elucidation of underlying molecular and genetic changes in the development and progression of gastric cancers, the development of new treatment strategies is critical for the improvement of the treatment and prognosis of these patients. In this review we have summarized and critically assessed recent studies dealing with the chemotherapy of advanced gastric cancer. While the efficacy of most treatment regimens is only limited, new developments may indicate that treatment with chemotherapy may confer some benefit in the future.