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Chan TH, Zhang JE, Pirmohamed M. DPYD genetic polymorphisms in non-European patients with severe fluoropyrimidine-related toxicity: a systematic review. Br J Cancer 2024; 131:498-514. [PMID: 38886557 PMCID: PMC11300675 DOI: 10.1038/s41416-024-02754-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Pre-treatment DPYD screening is mandated in the UK and EU to reduce the risk of severe and potentially fatal fluoropyrimidine-related toxicity. Four DPYD gene variants which are more prominently found in Europeans are tested. METHODS Our systematic review in patients of non-European ancestry followed PRISMA guidelines to identify relevant articles up to April 2023. Published in silico functional predictions and in vitro functional data were also extracted. We also undertook in silico prediction for all DPYD variants identified. RESULTS In 32 studies, published between 1998 and 2022, 53 DPYD variants were evaluated in patients from 12 countries encompassing 5 ethnic groups: African American, East Asian, Latin American, Middle Eastern, and South Asian. One of the 4 common European DPYD variants, c.1905+1G>A, is also present in South Asian, East Asian and Middle Eastern patients with severe fluoropyrimidine-related toxicity. There seems to be relatively strong evidence for the c.557A>G variant, which is found in individuals of African ancestry, but is not currently included in the UK genotyping panel. CONCLUSION Extending UK pre-treatment DPYD screening to include variants that are present in some non-European ancestry groups will improve patient safety and reduce race and health inequalities in ethnically diverse societies.
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Affiliation(s)
- Tsun Ho Chan
- Wolfson Centre for Personalised Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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2
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Cartwright BM, Corso JN, Lightner J, Whitted C, Torrenegra RD, Krishnan K, Palau VE. Achyrocline B (3,5 dihydroxy-6,7,8-trimethoxyflavone) synergizes with 5-fluorouracil allowing for dose reduction and reduced off-target toxicity in the treatment of colonic and pancreatic cancers. Biomed Pharmacother 2023; 167:115546. [PMID: 37741250 DOI: 10.1016/j.biopha.2023.115546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 09/25/2023] Open
Abstract
Surgically unresectable colorectal and pancreatic carcinomas have a high rate of mortality as current therapeutic options are limited. One common chemotherapeutic used to broadly treat both cancers is 5-flurouracil (5-Fu); however, treatment serves only to slow progression of the disease and comes with many side effects due to 5-Fu's intrinsic toxicity. Thus, strategies to decrease the dose of 5-Fu utilized therapeutically as well as reduce 5-Fu's off-target toxicity are paramount. Using cell models of colorectal and pancreatic cancers, we show that cotreatment with Achyrocline B (3,5 dihydroxy-6,7,8-trimethoxyflavone, AcB), a natural flavone from Achyrocline bogotensis, allows for four-fold reduction in 5-Fu dosage without loss of efficacy. We further show that the action of AcB is due to continued cell cycle progression despite 5-Fu pressure to synchronize at the G1/S threshold. In addition to AcB's effect on cancer cells, we found that AcB can directly reduce toxicity of 5-Fu in cells mimicking non-cancerous tissues. These in vitro results are then supported by xenograft modeling. AcB was shown to increase apoptosis in tumors leading to degeneration of the outer tumoral boundary. Furthermore, in 5-Fu treated animals it was found that AcB provided protection to the intestinal tract as indicated by preserved histological and immunohistochemical features. These results show promise for a new adjuvant therapy for colorectal and pancreatic carcinomas that not only reduces tumor progression, but more importantly has the potential to improve patient quality of life.
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Affiliation(s)
- Brian M Cartwright
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, 37614, United States; Department of Pathology, ETSU Quillen College of Medicine, Johnson City, TN, 37614, United States
| | - Jaclyn N Corso
- Department of Internal Medicine, ETSU Quillen College of Medicine, Johnson City, TN, 37614, United States
| | - Janet Lightner
- Department of Internal Medicine, ETSU Quillen College of Medicine, Johnson City, TN, 37614, United States
| | - Crystal Whitted
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, 37614, United States
| | - Ruben D Torrenegra
- Productos Naturales, Universidad de Ciencias Aplicadas y Ambientales, Bogota, Colombia
| | - Koyamangalath Krishnan
- Department of Internal Medicine, ETSU Quillen College of Medicine, Johnson City, TN, 37614, United States
| | - Victoria E Palau
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, 37614, United States; Productos Naturales, Universidad de Ciencias Aplicadas y Ambientales, Bogota, Colombia.
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3
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da Silva LC, Grando AP, de Baco LS, Hahn RZ, Ferreira Filho AF, Brucker N, Linden R, Antunes MV. Evaluation of dried blood spots as an alternative sampling strategy for 5-fluorouracil monitoring: From method development to clinical application. J Pharm Biomed Anal 2023; 235:115539. [PMID: 37517245 DOI: 10.1016/j.jpba.2023.115539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/01/2023]
Abstract
Therapeutic drug monitoring (TDM) of 5-Fluorouracil (5-FU) is strongly recommended because of its large inter-individual pharmacokinetic variability, narrow therapeutic window, and incidence of toxicity. However, there are several factors that limit the application of TDM in clinical settings. Considering the intrinsic advantages of dried microsamples, such as minimally invasive sampling, analyte stability, and cost-effective logistics, this study aimed to develop a method for the determination of 5-FU in dried blood spots (DBS) using ultra-high liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) and to evaluate its clinical application. Sample preparation was based on an aqueous extraction followed by protein precipitation. Separation was performed in an Acquity UPLC® HSS C18 (150 ×2.1 mm, 1.8 µm), and the mobile phases were water and acetonitrile with 0.5% acetic acid. The total run time was 5.5 min. The method was linear from 100 to 2000 ng/mL, precise (maximum CV% of 7.5%), and accurate (98.3-115.4%). The average recovery was 70%. Blood hematocrit had a minimal impact on the assay. DBS samples were stable for 21 days at 4, 25, and 45 °C. A total of 40 paired samples of plasma, capillary DBS, and venous DBS were analyzed. Median 5-FU concentrations were 444.7, 637.0, and 499.7 ng/mL for plasma, capillary DBS, and venous DBS, respectively. Capillary and plasma concentrations were significantly correlated (r > 0.90), but there was a lack of agreement between the methods, as capillary DBS levels were on average 146% of plasma. Venous DBS corresponded to 110% of the measured plasma concentrations, with a strong correlation (r > 0.97) and agreement between the methods. Our study is the first to report the use of DBS samples to quantify 5-FU. Further studies are needed to establish whether capillary samples can replace plasma.
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Affiliation(s)
- Laura C da Silva
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil; Toxicological Analysis Laboratory, Institute of Health Sciences, Feevale University, Novo Hamburgo, RS, Brazil.
| | - Ana P Grando
- Toxicological Analysis Laboratory, Institute of Health Sciences, Feevale University, Novo Hamburgo, RS, Brazil
| | | | - Roberta Z Hahn
- Toxicological Analysis Laboratory, Institute of Health Sciences, Feevale University, Novo Hamburgo, RS, Brazil
| | | | | | - Rafael Linden
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil; Toxicological Analysis Laboratory, Institute of Health Sciences, Feevale University, Novo Hamburgo, RS, Brazil
| | - Marina V Antunes
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil; Toxicological Analysis Laboratory, Institute of Health Sciences, Feevale University, Novo Hamburgo, RS, Brazil
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4
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Ruiz Sarrias O, Gónzalez Deza C, Rodríguez Rodríguez J, Arrizibita Iriarte O, Vizcay Atienza A, Zumárraga Lizundia T, Sayar Beristain O, Aldaz Pastor A. Predicting Severe Haematological Toxicity in Gastrointestinal Cancer Patients Undergoing 5-FU-Based Chemotherapy: A Bayesian Network Approach. Cancers (Basel) 2023; 15:4206. [PMID: 37686482 PMCID: PMC10486471 DOI: 10.3390/cancers15174206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Severe toxicity is reported in about 30% of gastrointestinal cancer patients receiving 5-Fluorouracil (5-FU)-based chemotherapy. To date, limited tools exist to identify at risk patients in this setting. The objective of this study was to address this need by designing a predictive model using a Bayesian network, a probabilistic graphical model offering robust, explainable predictions. METHODS We utilized a dataset of 267 gastrointestinal cancer patients, conducting preprocessing, and splitting it into TRAIN and TEST sets (80%:20% ratio). The RandomForest algorithm assessed variable importance based on MeanDecreaseGini coefficient. The bnlearn R library helped design a Bayesian network model using a 10-fold cross-validation on the TRAIN set and the aic-cg method for network structure optimization. The model's performance was gauged based on accuracy, sensitivity, and specificity, using cross-validation on the TRAIN set and independent validation on the TEST set. RESULTS The model demonstrated satisfactory performance with an average accuracy of 0.85 (±0.05) and 0.80 on TRAIN and TEST datasets, respectively. The sensitivity and specificity were 0.82 (±0.14) and 0.87 (±0.07) for the TRAIN dataset, and 0.71 and 0.83 for the TEST dataset, respectively. A user-friendly tool was developed for clinical implementation. CONCLUSIONS Despite several limitations, our Bayesian network model demonstrated a high level of accuracy in predicting the risk of developing severe haematological toxicity in gastrointestinal cancer patients receiving 5-FU-based chemotherapy. Future research should aim at model validation in larger cohorts of patients and different clinical settings.
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Affiliation(s)
- Oskitz Ruiz Sarrias
- Department of Mathematics and Statistic, NNBi, 31191 Esquiroz, Navarra, Spain; (O.R.S.)
| | - Cristina Gónzalez Deza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Javier Rodríguez Rodríguez
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | | | - Angel Vizcay Atienza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Teresa Zumárraga Lizundia
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
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5
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Hill C. Response to letter entitled: Re: Toxicities associated with chemotherapy regimens containing a fluoropyrimidine: A real-life evaluation in France. Eur J Cancer 2023; 189:112929. [PMID: 37327685 DOI: 10.1016/j.ejca.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Catherine Hill
- Institut Gustave Roussy, 14 rue Edouard Vaillant, 94800 Villejuif, France.
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6
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Schmitt A, Royer B, Boidot R, Berthier J, Ghiringhelli F. Case report: 5-Fluorouracil treatment in patient with an important partial DPD deficiency. Front Oncol 2023; 13:1187052. [PMID: 37409256 PMCID: PMC10319454 DOI: 10.3389/fonc.2023.1187052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Esophageal cancer is a cancer with poor prognosis and the standard 1st line treatment for metastatic or recurrent EC is systemic chemotherapy with doublet chemotherapy based on platinum and 5-fluorouracil (5-FU). However, 5-FU could be a source of severe treatment-related toxicities due to deficiency of dihydropyrimidine dehydrogenase (DPD). In this case report, a 74-year-old man with metastatic esophageal cancer was found to have partial DPD deficiency based on uracilemia measurements (about 90 ng/mL). Despite this, 5-FU was safely administered thanks to therapeutic drug monitoring (TDM). The case report highlights the importance of TDM in administering 5-FU to patients with partial DPD deficiency, as it allows individualized dosing and prevents severe toxicity.
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Affiliation(s)
- Antonin Schmitt
- Pharmacy Department, Centre Georges-François Leclerc, Dijon, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1231, University of Burgundy Franche-Comté, Dijon, France
| | - Bernard Royer
- Pharmacology and Toxicology Laboratory, Besançon University Hospital, Dijon, France
| | - Romain Boidot
- Unit of Molecular Biology, Centre Georges-François Leclerc, Institut de Chimie Moléculaire de l'Université de Bourgogne (ICMUB) Unité Mixte de Recherche (UMR) Centre National de la Recherche Scientifique (CNRS) 6302, Dijon, France
| | - Joseph Berthier
- Pharmacology and Toxicology Laboratory, Dijon University Hospital, Dijon, France
| | - François Ghiringhelli
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1231, University of Burgundy Franche-Comté, Dijon, France
- Medical Oncology Department, Centre Georges-François Leclerc, Dijon, France
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7
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Gmeiner WH. A narrative review of genetic factors affecting fluoropyrimidine toxicity. PRECISION CANCER MEDICINE 2021; 4:38. [PMID: 34901834 PMCID: PMC8664072 DOI: 10.21037/pcm-21-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our objective is to document progress in developing personalized therapy with fluoropyrimidine drugs (FPs) to improve outcomes for cancer patients and to identify areas requiring further investigation. BACKGROUND FPs including 5-fluorouracil (5-FU), are among the most widely used drugs for treating colorectal cancer (CRC) and other gastrointestinal (GI) malignancies. While FPs confer a survival benefit for CRC patients, serious systemic toxicities, including neutropenia, occur in ~30% of patients with lethality in 0.5-1% of patients. While serious systemic toxicities may occur in any patient, patients with polymorphisms in DPYD, which encodes the rate-limiting enzyme for pyrimidine degradation are at very high risk. Other genetic factors affecting risk for 5-FU toxicity, including miR-27a, are under investigation. METHODS Literature used to inform the text of this article was selected from PubMed.gov from the National Library of Medicine while regulatory documents were identified via Google search. CONCLUSIONS Clinical studies to date have validated four DPYD polymorphisms (DPYD*2A, DPYD*13, c.2846A>T, HapB3) associated with serious toxicities in patients treated with 5-FU. Genetic screening for these is being implemented in the Netherlands and the UK and has been shown to be a cost-effective way to improve outcomes. Factors other than DPYD polymorphisms (e.g., miR-27a, TYMS, ENOSF1, p53) also affect 5-FU toxicity. Functional testing for deficient pyrimidine catabolism {defined as [U] >16 ng/mL or [UH2]:[U] <10} is being implemented in France and has demonstrated utility in identifying patients with elevated risk for 5-FU toxicity. Therapeutic drug monitoring (TDM) from plasma levels of 5-FU during first cycle treatment also is being used to improve outcomes and pharmacokinetic-based dosing is being used to increase the percent of patients within optimal area under the curve (AUC) (18-28 mg*h/L) values. Patients maintained in the optimal AUC range experienced significantly reduced systemic toxicities. As understanding the genetic basis for increased risk of 5-FU toxicity becomes more refined, the development of functional-based methods to optimize treatment is likely to become more widespread.
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Affiliation(s)
- William H Gmeiner
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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8
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Bikiewicz A, Banach M, von Haehling S, Maciejewski M, Bielecka‐Dabrowa A. Adjuvant breast cancer treatments cardiotoxicity and modern methods of detection and prevention of cardiac complications. ESC Heart Fail 2021; 8:2397-2418. [PMID: 33955207 PMCID: PMC8318493 DOI: 10.1002/ehf2.13365] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/24/2022] Open
Abstract
The most common cancer diagnosis in female population is breast cancer, which affects every year about 2.0 million women worldwide. In recent years, significant progress has been made in oncological therapy, in systemic treatment, and in radiotherapy of breast cancer. Unfortunately, the improvement in the effectiveness of oncological treatment and prolonging patients' life span is associated with more frequent occurrence of organ complications, which are side effects of this treatment. Current recommendations suggest a periodic monitoring of the cardiovascular system in course of oncological treatment. The monitoring includes the assessment of occurrence of risk factors for cardiovascular diseases in combination with the evaluation of the left ventricular systolic function using echocardiography and electrocardiography as well as with the analysis of the concentration of cardiac biomarkers. The aim of this review was critical assessment of the breast cancer therapy cardiotoxicity and the analysis of methods its detections. The new cardio-specific biomarkers in serum, the development of modern imaging techniques (Global Longitudinal Strain and Three-Dimensional Left Ventricular Ejection Fraction) and genotyping, and especially their combined use, may become a useful tool for identifying patients at risk of developing cardiotoxicity, who require further cardiovascular monitoring or cardioprotective therapy.
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Affiliation(s)
- Agata Bikiewicz
- Heart Failure Unit, Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research Institute (PMMHRI)Rzgowska 281/289Lodz93‐338Poland
- Department of Hypertension, Chair of Nephrology and HypertensionMedical University of LodzLodzPoland
| | - Maciej Banach
- Heart Failure Unit, Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research Institute (PMMHRI)Rzgowska 281/289Lodz93‐338Poland
- Department of Hypertension, Chair of Nephrology and HypertensionMedical University of LodzLodzPoland
| | - Stephan von Haehling
- Department of Cardiology and Pneumology and German Center for Cardiovascular Research (DZHK), partner site GöttingenUniversity Medical Center Göttingen (UMG)GöttingenGermany
| | - Marek Maciejewski
- Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research Institute (PMMHRI)LodzPoland
| | - Agata Bielecka‐Dabrowa
- Heart Failure Unit, Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research Institute (PMMHRI)Rzgowska 281/289Lodz93‐338Poland
- Department of Hypertension, Chair of Nephrology and HypertensionMedical University of LodzLodzPoland
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Dolat M, Macaire P, Goirand F, Vincent J, Hennequin A, Palmier R, Bengrine-Lefevre L, Ghiringhelli F, Royer B, Schmitt A. Association of 5-FU Therapeutic Drug Monitoring to DPD Phenotype Assessment May Reduce 5-FU Under-Exposure. Pharmaceuticals (Basel) 2020; 13:ph13110416. [PMID: 33238487 PMCID: PMC7700344 DOI: 10.3390/ph13110416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 12/27/2022] Open
Abstract
In order to limit 5-fluorouracil (5-FU) toxicity, some health agencies recommend evaluating dihydropyrimidine dehydrogenase (DPD) deficiency before any 5-FU treatment introduction. In our study, we investigated relationships between 5-FU clearance and markers of DPD activity such as uracilemia (U), dihydrouracilemia (UH2)/U ratio, or genotype of the gene encoding DPD (DPYD). All patients with gastrointestinal cancers who received 5-FU-based regimens form March 2018 to June 2020 were included in our study. They routinely benefited of a pre-therapeutic DPYD genotyping and phenotyping. During 5-FU infusion, blood samples were collected to measure 5-FU steady-state concentration in order to adapt 5-FU doses at the following cycles. A total of 169 patients were included. Median age was 68 (40–88) years and main primary tumor sites were colorectal (40.8%) and pancreas (31.4%), metastatic in 76.3%. 5-FU was given as part of FOLFIRINOX (44.4%), simplified FOLFOX-6 (26.6%), or docetaxel/FOLFOX-4 (10.6%). Regarding DPD activity, median U and UH2/U were, respectively, 10.8 ng/mL and 10.1, and almost 15% harbored a heterozygous mutation. On the range of measured U and UH2/U, no correlation was observed with 5-FU clearance. Moreover, in patients with U < 16 ng/mL, 5-FU exposure was higher than in other patients, and most of them benefited of dose increase following 5-FU therapeutic drug monitoring (TDM). If recent guidelines recommend decreasing 5-FU dose in patients harboring U ≥ 16 ng/mL, our study highlights that those patients are at risk of under-exposure and that 5-FU TDM should be conducted in order to avoid loss of efficacy.
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Affiliation(s)
- Marine Dolat
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Pauline Macaire
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
| | - Françoise Goirand
- Laboratoire de Pharmacologie/Toxicologie, CHU de Dijon, 21000 Dijon, France;
| | - Julie Vincent
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Audrey Hennequin
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Rémi Palmier
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - Leïla Bengrine-Lefevre
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
| | - François Ghiringhelli
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
| | - Bernard Royer
- Laboratoire de Pharmacologie Clinique, CHU Jean-Minjoz, 3, Boulevard Alexandre-Fleming, 25030 Besançon, France;
- INSERM, EFS BFC, UMR1098, Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Université Bourgogne Franche-Comté, 25000 Besançon, France
| | - Antonin Schmitt
- Centre Georges-François Leclerc, 21000 Dijon, France; (M.D.); (P.M.); (J.V.); (A.H.); (R.P.); (L.B.-L.); (F.G.)
- INSERM U1231, University of Burgundy Franche-Comté, 21000 Dijon, France
- Correspondence:
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10
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Ding W, Zhang H, Mei G. Synergistic antitumor activity of DHA and JQ1 in colorectal carcinoma. Eur J Pharmacol 2020; 885:173500. [PMID: 32861663 DOI: 10.1016/j.ejphar.2020.173500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/19/2022]
Abstract
Colon cancer is still a major disease plaguing humans. In this study, we evaluated the synergistic antitumor effects of the combination of BRD4 inhibitor JQ1 and docosahexaenoic acid (DHA) in colon cancer. We demonstrated that simultaneous exposure to JQ1 and DHA resulted in strong synergistic antiproliferative and proapoptotic effects related to inhibition of expression of c-Myc and activation of NF-κB in colon cancer cell lines. At the same time, the synergetic anticancer effect had been confirmed in vivo. For in vivo experiments, JQ1 and DHA resulted in more significant tumor growth inhibition (53.7%) in a human colon cancer HCT116 xenograft model, comparing with the moderate inhibition in JQ1-treated (31.9%) or DHA-treated groups (20.3%). Because DHA is the predominant component of fish oil, our data suggest that this nontoxic dietary supplement could be administered with BRD4 inhibitor during therapy for CRC, which lay an important foundation for the development of therapeutic regimens for CRC.
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Affiliation(s)
- Wanjing Ding
- Institute of Marine Biology& Pharmacology, Ocean College, Zhejiang University, Zhoushan, Zhejiang, 316021, China.
| | - Haojian Zhang
- Institute of Marine Biology& Pharmacology, Ocean College, Zhejiang University, Zhoushan, Zhejiang, 316021, China
| | - Guangming Mei
- Marine Fishery Research Institute of Zhejiang Province, Zhoushan, Zhejiang, 316021, China
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11
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Capitain O, Seegers V, Metges JP, Faroux R, Stampfli C, Ferec M, Budnik TM, Senellart H, Rossi V, Blouin N, Dauvé J, Campone M. Comparison of 4 Screening Methods for Detecting Fluoropyrimidine Toxicity Risk: Identification of the Most Effective, Cost-Efficient Method to Save Lives. Dose Response 2020; 18:1559325820951367. [PMID: 32973417 PMCID: PMC7493257 DOI: 10.1177/1559325820951367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 01/07/2023] Open
Abstract
Background Fluoropyrimidines (FPs) carry around 20% risk of G3-5 toxicity and 0.2-1% risk of death, due to dihydropyrimidine dehydrogenase (DPD) deficiency. Several screening approaches exist for predicting toxicity, however there is ongoing debate over which method is best. This study compares 4 screening approaches. Method 472 patients treated for colorectal, head-and-neck, breast, or pancreatic cancers, who had not been tested pre-treatment for FP toxicity risk, were screened using: DPYD genotyping (G); phenotyping via plasma Uracil (U); phenotyping via plasma-dihydrouracil/uracil ratio (UH2/U); and a Multi-Parametric Method (MPM) using genotype, phenotype, and epigenetic data. Performance was compared, particularly the inability to detect at-risk patients (false negatives). Results False negative rates for detecting G5 toxicity risk were 51.2%, 19.5%, 9.8% and 2.4%, for G, U, UH2/U and MPM, respectively. False negative rates for detecting G4-5 toxicity risk were 59.8%, 36.1%, 21.3% and 4.7%, respectively. MPM demonstrated significantly (p < 0.001) better prediction performance. Conclusion MPM is the most effective method for limiting G4-5 toxicity. Its systematic implementation is cost-effective and significantly improves the risk-benefit ratio of FP-treatment. The use of MPM, rather than G or U testing, would avoid nearly 8,000 FP-related deaths per year globally (500 in France), and spare hundreds of thousands from G4 toxicity.
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Affiliation(s)
| | | | | | - Roger Faroux
- CH Départemental Vendée La Roche sur Yon, France
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12
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5-Fluorouracil Response Prediction and Blood Level-Guided Therapy in Oncology: Existing Evidence Fundamentally Supports Instigation. Ther Drug Monit 2020; 42:660-664. [PMID: 32649488 DOI: 10.1097/ftd.0000000000000788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
5-Fluorouracil (5-FU) response prediction and therapeutic drug monitoring (TDM) are required to minimize toxicity while preserving efficacy. Conventional 5-FU dose normalization uses body surface area. It is characterized by up to 100-fold interindividual variability of pharmacokinetic (PK) parameters, and typically >50% of patients have plasma 5-FU concentrations outside the optimal range. This underscores the need for a different dose rationalization paradigm, hence there is a case for 5-FU TDM. An association between 5-FU PK parameters and efficacy/toxicity has been established. It is believed that 5-FU response is enhanced and toxicity is reduced by PK management of its dosing. The area under the concentration-time curve is the most relevant PK parameter associated with 5-FU efficacy/toxicity, and optimal therapeutic windows have been proposed. Currently, there is no universally applied a priori test for predicting 5-FU response and identifying individuals with an elevated risk of toxicity. The following two-step strategy: prediction of response/toxicity and TDM for subsequent doses seems plausible. Approximately 80% of 5-FU is degraded in a three-step sequential metabolic pathway. Dihydropyrimidine dehydrogenase (DPD) is the initial and rate-limiting enzyme. Its deficiency can cause toxicity with standard 5-FU doses. DPD also metabolizes uracil (U) into 5,6-dihydrouracil (UH2). The UH2/U ratio is an index of DPD activity and a credible biomarker of response and toxicity. This article outlines the UH2/U ratio as a parameter for 5-FU response/toxicity prediction and highlights key studies emphasizing the value of 5-FU TDM. Broad application of 5-FU response/toxicity prediction and blood level-guided therapy remains unmet, despite ever-increasing clinical interest. Considered collectively, existing evidence is compelling and fundamentally supports universal instigation of response/toxicity prediction and TDM.
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13
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Scagliarini A, Mathey A, Aires V, Delmas D. Xanthohumol, a Prenylated Flavonoid from Hops, Induces DNA Damages in Colorectal Cancer Cells and Sensitizes SW480 Cells to the SN38 Chemotherapeutic Agent. Cells 2020; 9:E932. [PMID: 32290112 PMCID: PMC7226974 DOI: 10.3390/cells9040932] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/26/2020] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
In spite of chemotherapy and systematic screening for people at risk, the mortality rate of colorectal cancer (CRC) remains consistently high, with 600,000 deaths per year. This low success rate in the treatment of CRC results from many failures associated with high resistance and the risk of metastasis. Therefore, in response to these therapeutic failures, new strategies have been under development for several years aimed at increasing the effect of anticancer compounds and/or at reducing their secondary effects on normal cells, thus enabling the host to better withstand chemotherapy. This study highlights that xanthohumol (Xn) concentrations under the IC50 values were able to induce apoptosis and to enhance the DNA-damage response (DDR). We demonstrate for the first time that Xn exerts its anticancer activity in models of colon cancer through activation of the ataxia telangiectasia mutated (ATM) pathway. Subsequently, the ability of Xn to restore DNA damage in CRC cells can sensitize them to anticancer agents such as SN38 (7-ethyl-10-hydroxycamptothecin) used in chemotherapy.
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Affiliation(s)
- Alessandra Scagliarini
- Université de Bourgogne Franche-Comté, F-21000 Dijon, France; (A.S.); (A.M.); (V.A.)
- INSERM Research Center U1231—Cancer and Adaptive Immune Response Team, Bioactive Molecules and Health Research Group, F-21000 Dijon, France
| | - Aline Mathey
- Université de Bourgogne Franche-Comté, F-21000 Dijon, France; (A.S.); (A.M.); (V.A.)
- INSERM Research Center U1231—Cancer and Adaptive Immune Response Team, Bioactive Molecules and Health Research Group, F-21000 Dijon, France
| | - Virginie Aires
- Université de Bourgogne Franche-Comté, F-21000 Dijon, France; (A.S.); (A.M.); (V.A.)
- INSERM Research Center U1231—Cancer and Adaptive Immune Response Team, Bioactive Molecules and Health Research Group, F-21000 Dijon, France
| | - Dominique Delmas
- Université de Bourgogne Franche-Comté, F-21000 Dijon, France; (A.S.); (A.M.); (V.A.)
- INSERM Research Center U1231—Cancer and Adaptive Immune Response Team, Bioactive Molecules and Health Research Group, F-21000 Dijon, France
- Centre Anticancéreux Georges François Leclerc, F-21000 Dijon, France
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14
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Khan N, Jajeh F, Eberhardt EL, Miller DD, Albrecht DM, Van Doorn R, Hruby MD, Maresh ME, Clipson L, Mukhtar H, Halberg RB. Fisetin and 5-fluorouracil: Effective combination for PIK3CA-mutant colorectal cancer. Int J Cancer 2019; 145:3022-3032. [PMID: 31018249 DOI: 10.1002/ijc.32367] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 12/16/2022]
Abstract
The normal colon epithelium is transformed into its neoplastic counterpart through a series of genetic alterations in driver genes including activating mutations in PIK3CA. Treatment often involves surgery followed by 5-fluorouracil (5-FU) based therapy, which has limited efficiency and serious side effects. We sought to determine whether fisetin, a dietary flavonoid, alone or in combination with 5-FU affected tumorigenesis in the mammalian intestine. We first determined the effect of fisetin, 5-FU or their combination on PIK3CA-mutant and PIK3CA wild-type colon cancer cells by assessing cell viability, colony formation, apoptosis and effects on PI3K/AKT/mTOR signaling. Treatment of PIK3CA-mutant cells with fisetin and 5-FU reduced the expression of PI3K, phosphorylation of AKT, mTOR, its target proteins, constituents of mTOR signaling complex and this treatment increased the phosphorylation of AMPKα. We then determined whether fisetin and 5-FU together or singly affected tumorigenesis in ApcMin/+ mice that also express constitutively active PI3K in the distal small intestine and colon. Tumor incidence was markedly lower in fisetin-treated FC1 3K1 ApcMin/+ mice that also express constitutively active PI3K in distal small intestine and colon, as compared to control animals, indicating that fisetin is a strong preventive agent. In addition, the combination of fisetin and 5-FU also reduced the total number of intestinal tumors. Fisetin could be used as a preventive agent plus an adjuvant with 5-FU for the treatment of PIK3CA-mutant colorectal cancer.
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Affiliation(s)
- Naghma Khan
- Department of Dermatology, University of Wisconsin-Madison, Madison, WI.,University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Farah Jajeh
- Department of Dermatology, University of Wisconsin-Madison, Madison, WI
| | - Emily L Eberhardt
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Devon D Miller
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Dawn M Albrecht
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Rachel Van Doorn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Melissa D Hruby
- Department of Dermatology, University of Wisconsin-Madison, Madison, WI
| | - Morgan E Maresh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Linda Clipson
- Department of Oncology, McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI
| | - Hasan Mukhtar
- Department of Dermatology, University of Wisconsin-Madison, Madison, WI.,University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Richard B Halberg
- University of Wisconsin Carbone Cancer Center, Madison, WI.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin-Madison, Madison, WI.,Department of Oncology, McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI
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15
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Macaire P, Morawska K, Vincent J, Quipourt V, Marilier S, Ghiringhelli F, Bengrine-Lefevre L, Schmitt A. Therapeutic drug monitoring as a tool to optimize 5-FU-based chemotherapy in gastrointestinal cancer patients older than 75 years. Eur J Cancer 2019; 111:116-125. [PMID: 30849685 DOI: 10.1016/j.ejca.2019.01.102] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
AIMS Most clinical trials exclude elderly people, leading to a limited understanding of the benefit-to-risk ratio in this population. Despite existing data regarding the oncological management of elderly receiving fluorouracil (5-FU)-based regimen, our objective was to investigate 5-FU exposure/toxicity relationship in patients ≥75 years and compare the effectiveness of 5-FU therapeutic drug monitoring between elderly and younger patients. METHODS Hundred fifty-four patients (31 of whom are older than 75 years) with gastrointestinal cancers, who were to receive 5-FU-based regimens, were included in our study. At cycle 1 (C1), the 5-FU dose was calculated using patient's body surface area, then a blood sample was drawn to measure 5-FU concentration and 5-FU dose was adjusted at the subsequent cycles based on C1 concentration. Assessments of toxicity were performed at the beginning of every cycle. RESULTS Seventy-one percent of elderly patients required dose adjustments after C1, compared with 50% for younger patients. Percentages of patients within 5-FU area under the curve range at cycle 2 were 64% and 68%, respectively, for elderly and younger patients. The proportion of elderly patients experiencing severe toxicities fell from 15% at C1 to only 5% at cycle 3. CONCLUSION Pharmacokinetic-guided 5-FU-dosing algorithm, leading to an improved tolerability while remaining within therapeutic concentration range, is even more valuable for patients older than 75 years than in younger patients.
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Affiliation(s)
- Pauline Macaire
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France; INSERM U1231, University of Burgundy Franche-Comté, 7 Bd Jeanne d'Arc, 21000 Dijon, France
| | - Katarzyna Morawska
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France
| | - Julie Vincent
- Medical Oncology Deparment, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France
| | - Valérie Quipourt
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, 21079 Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, 21079 Dijon, France
| | - Sophie Marilier
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, 21079 Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, 21079 Dijon, France
| | - François Ghiringhelli
- INSERM U1231, University of Burgundy Franche-Comté, 7 Bd Jeanne d'Arc, 21000 Dijon, France; Medical Oncology Deparment, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France
| | - Leila Bengrine-Lefevre
- Medical Oncology Deparment, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France
| | - Antonin Schmitt
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr. Marion, 21000 Dijon, France; INSERM U1231, University of Burgundy Franche-Comté, 7 Bd Jeanne d'Arc, 21000 Dijon, France.
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16
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Goirand F, Lemaitre F, Launay M, Tron C, Chatelut E, Boyer JC, Bardou M, Schmitt A. How can we best monitor 5-FU administration to maximize benefit to risk ratio? Expert Opin Drug Metab Toxicol 2018; 14:1303-1313. [PMID: 30451549 DOI: 10.1080/17425255.2018.1550484] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION 5-Fluorouracil (5-FU) is currently used as a chemotherapy in several cancers such as head-and-neck (H&N) and colorectal cancers. 5-FU dosing is traditionally based on body surface area (BSA), but this strategy is usually associated with severe toxicities. 5-FU is mainly catabolized by dihydropyrimidine dehydrogenase (DPD), and 5-FU dosage adaptation according to DPD status at the first cycle of treatment is now recommended. To further optimize 5-FU-based chemotherapy, a body of evidences justifies therapeutic drug monitoring (TDM). Areas covered: 5-FU pharmacokinetics, relationships between pharmacokinetics and efficacy or toxicity of 5-FU, proofs of interest of 5-FU TDM and its practical considerations are discussed. Expert opinion: BSA-adjusted 5-FU administration is associated with a large inter-individual variability, and according to this strategy, many patients experience under- or overexposure. Moreover, relationships between 5-FU area under the curve (AUC) and its toxicity or efficacy have been demonstrated, at least in patients with colorectal or H&N cancers. 5-FU therapeutic index has been validated and algorithms of 5-FU dosage adaptation according to its AUC are now available. Advances in pre-analytical and analytical steps of 5-FU TDM make its use feasible in clinical practice. Thus, there are consistent evidences to recommend 5-FU TDM in patients with advanced colorectal or H&N cancers.
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Affiliation(s)
- Françoise Goirand
- a Centre Hospitalo-Universitaire de Dijon-Bourgogne , Dijon , France
| | - Florian Lemaitre
- b Service de Pharmacologie Clinique , Laboratoire de Pharmacologie Expérimentale et Clinique, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université Rennes 1 , Rennes , France
| | - Manon Launay
- c Service de Pharmacologie, Hôpital Européen Georges Pompidou , Laboratoire de Pharmacologie et de Toxicologie , Paris , France
| | - Camille Tron
- b Service de Pharmacologie Clinique , Laboratoire de Pharmacologie Expérimentale et Clinique, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université Rennes 1 , Rennes , France
| | - Etienne Chatelut
- d Institut Claudius-Regaud et Centre de Recherches en Cancérologie de Toulouse , IUCT - Oncopole , Toulouse , France
| | - Jean-Christophe Boyer
- e Laboratoire de Biochimie et Biologie Moléculaire , CHU de Nîmes Carémeau , Nîmes , France
| | - Marc Bardou
- f Centre d'Investigations Cliniques 1432, Module Plurithématique , CHU Dijon-Bourgogne, Hôpital François Mitterrand , Dijon , France
| | - Antonin Schmitt
- g Service Pharmacie , Centre Georges-François Leclerc , Dijon , France
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17
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Lemaitre F, Goirand F, Launay M, Chatelut E, Boyer JC, Evrard A, Paludetto MN, Guilhaumou R, Ciccolini J, Schmitt A. [5-fluorouracil therapeutic drug monitoring: Update and recommendations of the STP-PT group of the SFPT and the GPCO-Unicancer]. Bull Cancer 2018; 105:790-803. [PMID: 30103904 DOI: 10.1016/j.bulcan.2018.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Despite being 60-years old now, 5-FU remains the backbone of numerous regimen to treat a variety of solid tumors such as breast, head-and-neck and digestive cancers either in neo-adjuvant, adjuvant or metastatic settings. Standard 5-FU usually claims 15-40% of severe toxicities and up to 1% of toxic-death. Numerous studies show a stiff relationship between 5-FU exposure and toxicity or efficacy. In addition, 5-FU pharmacokinetics is highly variable between patients. Indeed, 80% of the 5-FU dose is catabolized in the liver by dihydropyrimidine dehydrogenase (DPD) into inactive compounds. It is now well established that DPD deficiency could lead to severe toxicities and, thus, require dose reduction in deficient patients. However, despite dosage adaptation based on DPD status, some patients may still experience under- or over-exposure, leading to inefficacy or major toxicity. The "Suivi thérapeutique pharmacologique et personnalisation des traitements" (STP-PT) group of the "Société française de pharmacologie et de thérapeutique" (SFPT) and the "Groupe de pharmacologie clinique oncologique" (GPCO)-Unicancer, based on the latest and most up-to-date literature data, recommend the implementation of 5-FU Therapeutic Drug Monitoring in order to ensure an adequate 5-FU exposure.
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Affiliation(s)
- Florian Lemaitre
- Université Rennes 1, CHU de Rennes, centre d'investigation clinique Inserm 1414, service de pharmacologie clinique, laboratoire de pharmacologie expérimentale et clinique, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - Françoise Goirand
- Centre hospitalo-universitaire de Dijon-Bourgogne, 5, boulevard Jeanne-d'Arc, 21000 Dijon, France
| | - Manon Launay
- Hôpital européen Georges-Pompidou, laboratoire de pharmacologie et de toxicologie, service de pharmacologie, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - Etienne Chatelut
- Institut Claudius-Regaud et centre de recherches en cancérologie de Toulouse, IUCT - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - Jean-Christophe Boyer
- CHU de Nîmes Carémeau, laboratoire de biochimie et biologie moléculaire, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
| | - Alexandre Evrard
- CHU de Nîmes Carémeau, laboratoire de biochimie et biologie moléculaire, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
| | - Marie-Noelle Paludetto
- Institut Claudius-Regaud et centre de recherches en cancérologie de Toulouse, IUCT - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse, France
| | - Romain Guilhaumou
- AP-HM, CHU Timone, service de pharmacologie clinique et pharmacovigilance, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Joseph Ciccolini
- AP-HM, CHU Timone, SMARTc CRCM UMR Inserm U1068, laboratoire de pharmacocinétique clinique, 265, rue St-Pierre, 13385 Marseille, France
| | - Antonin Schmitt
- Centre Georges-François-Leclerc, service pharmacie, 1, rue Pr.-Marion, 21000 Dijon, France.
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18
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Morawska K, Goirand F, Marceau L, Devaux M, Cueff A, Bertaut A, Vincent J, Bengrine-Lefevre L, Ghiringhelli F, Schmitt A. 5-FU therapeutic drug monitoring as a valuable option to reduce toxicity in patients with gastrointestinal cancer. Oncotarget 2018; 9:11559-11571. [PMID: 29545919 PMCID: PMC5837758 DOI: 10.18632/oncotarget.24338] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022] Open
Abstract
Aims 5-FU is used as the main backbone of chemotherapy regimens for patients with colorectal and other gastrointestinal cancers. Despite development of new strategies that allowed enhancing clinical effectiveness and tolerability of 5-FU, 10-30% of patients treated with 5-FU-based regimens experience severe treatment-related toxicity. In our study, we evaluated the 5-FU exposure-toxicity relationship and investigated the efficacy of PK-guided dosing in increasing tolerability of 5-FU-based chemotherapy. Results 50.7% of patients required dose adjustments after cycle 1. Percentage of patients within 5-FU AUC range was 49.3%, 66.9%, 61.0% at cycle 1, 2 and 3 respectively (p = 0.002 cycle 1 vs cycle 2). At all 3 cycles, lower incidences of grade I/II toxicities were observed for patients below or within range compared with those above range (19.4% vs 41.3%, p < 0.001 respectively). Conclusions Our analysis confirms that the use of BSA-guided dosing results in highly variable 5-FU exposure and strongly suggests that PK-guided dosing can improve tolerability of 5-FU based chemotherapy in patients with gastrointestinal cancers, thus supporting 5-FU therapeutic drug monitoring. Methods 155 patients with gastrointestinal cancers, who were to receive 5-FU-based regimens were included in our study. At cycle 1, the 5-FU dose was calculated using patient's Body Surface Area (BSA) method. A blood sample was drawn on Day 2 to measure 5-FU concentration. At cycle 2, the 5-FU dose was adjusted using a PK-guided dosing strategy targeting a plasma AUC range of 18-28 mg·h/L, based on cycle 1 concentration. Assessments of toxicity was performed at the beginning of every cycle.
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Affiliation(s)
| | - Françoise Goirand
- Laboratoire de Pharmacologie/Toxicologie, CHU de Dijon, Dijon, France.,INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
| | | | | | - Adèle Cueff
- Centre Georges-François Leclerc, Dijon, France
| | - Aurélie Bertaut
- Centre Georges-François Leclerc, Dijon, France.,INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
| | | | | | - François Ghiringhelli
- Centre Georges-François Leclerc, Dijon, France.,INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
| | - Antonin Schmitt
- Centre Georges-François Leclerc, Dijon, France.,INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
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Quaranta S, Thomas F. Pharmacogénétique des médicaments anticancéreux : état des connaissances et des pratiques – recommandations du Réseau national de pharmacogénétique (RNPGx). Therapie 2017; 72:193-204. [DOI: 10.1016/j.therap.2016.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/02/2016] [Indexed: 11/26/2022]
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20
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Quaranta S, Thomas F. Pharmacogenetics of anti-cancer drugs: State of the art and implementation - recommendations of the French National Network of Pharmacogenetics. Therapie 2017; 72:205-215. [PMID: 28262261 DOI: 10.1016/j.therap.2017.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/02/2016] [Indexed: 12/27/2022]
Abstract
Individualized treatment is of special importance in oncology because the drugs used for chemotherapy have a very narrow therapeutic index. Pharmacogenetics may contribute substantially to clinical routine for optimizing cancer treatment to limit toxic effects while maintaining efficacy. This review presents the usefulness of pharmacogenetic tests for some key applications: dihydropyrimidine dehydrogenase (DPYD) genotyping for fluoropyrimidine (5-fluorouracil, capecitabine), UDP glucuronosylstransferase (UGT1A1) for irinotecan and thiopurine S-methyltransferase (TPMT) for thiopurine drugs. Depending on the level of evidence, the French National Network of Pharmacogenetics (RNPGx) has issued three levels of recommendations for these pharmacogenetic tests: essential, advisable, and potentially useful. Other applications, for which the level of evidence is still discussed, will be evoked in the final section of this review.
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Affiliation(s)
- Sylvie Quaranta
- Service de pharmacocinétique et toxicologie, laboratoire de biologie médicale, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France
| | - Fabienne Thomas
- Institut Claudius-Regaud, CRCT, Université de Toulouse, Inserm, UPS, 31059 Toulouse, France; GPCO-Unicancer, 101, rue de Tolbiac, 75013 Paris, France.
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21
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Ma WW, Saif MW, El‐Rayes BF, Fakih MG, Cartwright TH, Posey JA, King TR, von Borstel RW, Bamat MK. Emergency use of uridine triacetate for the prevention and treatment of life-threatening 5-fluorouracil and capecitabine toxicity. Cancer 2017; 123:345-356. [PMID: 27622829 PMCID: PMC5248610 DOI: 10.1002/cncr.30321] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/03/2016] [Accepted: 08/08/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Increased susceptibility to 5-fluorouracil (5-FU)/capecitabine can lead to rapidly occurring toxicity caused by impaired clearance, dihydropyrimidine dehydrogenase deficiency, and other genetic variations in the enzymes that metabolize 5-FU. Life-threatening 5-FU overdoses occur because of infusion pump errors, dosage miscalculations, and accidental or suicidal ingestion of capecitabine. Uridine triacetate (Vistogard) was approved in 2015 for adult and pediatric patients who exhibit early-onset severe or life-threatening 5-FU/capecitabine toxicities or present with an overdose. Uridine triacetate delivers high concentrations of uridine, which competes with toxic 5-FU metabolites. METHODS In 2 open-label clinical studies, patients who presented with a 5-FU/capecitabine overdose or an early onset of severe toxicities were treated. Patients received uridine triacetate as soon as possible (most within the first 96 hours after 5-FU/capecitabine). Outcomes included survival, resumption of chemotherapy, and safety. Their survival was compared with the survival of a historical cohort of overdose patients who received only supportive care. RESULTS A total of 137 of 142 overdose patients (96%) treated with uridine triacetate survived and had a rapid reversal of severe acute cardiotoxicity and neurotoxicity; in addition, mucositis and leukopenia were prevented, or the patients recovered from them. In the historical cohort, 21 of 25 patients (84%) died. Among the 141 uridine triacetate-treated overdose patients with a diagnosis of cancer (the noncancer patients included 6 intentional or accidental pediatric overdoses), 53 resumed chemotherapy in < 30 days (median time after 5-FU, 19.6 days), and this indicated a rapid recovery from toxicity. Adverse reactions in patients receiving uridine triacetate included vomiting (8.1%), nausea (4.6%), and diarrhea (3.5%). CONCLUSIONS In these studies, uridine triacetate was a safe and effective lifesaving antidote for capecitabine and 5-FU overexposure, and it facilitated the rapid resumption of chemotherapy. Cancer 2017;123:345-356. © 2016 American Cancer Society.
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Affiliation(s)
- Wen Wee Ma
- Department of OncologyMayo ClinicRochesterMinnesota
| | | | - Bassel F. El‐Rayes
- Department of Hematology and Oncology, Winship Cancer InstituteEmory UniversityAtlantaGeorgia
| | - Marwan G. Fakih
- Department of Medical OncologyCity of Hope Medical CenterDuarteCalifornia
| | | | - James A. Posey
- Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvania
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Ison G, Beaver JA, McGuinn WD, Palmby TR, Dinin J, Charlab R, Marathe A, Jin R, Liu Q, Chen XH, Ysern X, Stephens O, Bai G, Wang Y, Dorff SE, Cheng J, Tang S, Sridhara R, Pierce W, McKee AE, Ibrahim A, Kim G, Pazdur R. FDA Approval: Uridine Triacetate for the Treatment of Patients Following Fluorouracil or Capecitabine Overdose or Exhibiting Early-Onset Severe Toxicities Following Administration of These Drugs. Clin Cancer Res 2016; 22:4545-9. [PMID: 27401247 DOI: 10.1158/1078-0432.ccr-16-0638] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/10/2016] [Indexed: 01/24/2023]
Abstract
On December 11, 2015, the FDA approved uridine triacetate (VISTOGARD; Wellstat Therapeutics Corporation) for the emergency treatment of adult and pediatric patients following a fluorouracil or capecitabine overdose regardless of the presence of symptoms, and of those who exhibit early-onset, severe, or life-threatening toxicity affecting the cardiac or central nervous system, and/or early onset, unusually severe adverse reactions (e.g., gastrointestinal toxicity and/or neutropenia) within 96 hours following the end of fluorouracil or capecitabine administration. Uridine triacetate is not recommended for the nonemergent treatment of adverse reactions associated with fluorouracil or capecitabine because it may diminish the efficacy of these drugs, and the safety and efficacy of uridine triacetate initiated more than 96 hours following the end of administration of these drugs has not been established. The approval is based on data from two single-arm, open-label, expanded-access trials in 135 patients receiving uridine triacetate (10 g or 6.2 g/m(2) orally every 6 hours for 20 doses) for fluorouracil or capecitabine overdose, or who exhibited severe or life-threatening toxicities within 96 hours following the end of fluorouracil or capecitabine administration. Ninety-six percent of patients met the major efficacy outcome measure, which was survival at 30 days or survival until the resumption of chemotherapy, if prior to 30 days. The most common adverse reactions were vomiting, nausea, and diarrhea. This article summarizes the FDA review of this New Drug Application, the data supporting approval of uridine triacetate, and the unique regulatory situations encountered by this approval. Clin Cancer Res; 22(18); 4545-49. ©2016 AACR.
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Affiliation(s)
- Gwynn Ison
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland.
| | - Julia A Beaver
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - W David McGuinn
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Todd R Palmby
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Jeannette Dinin
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Rosane Charlab
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Anshu Marathe
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Runyan Jin
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Qi Liu
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Xiao Hong Chen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Xavier Ysern
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Olen Stephens
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Ge Bai
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Yaning Wang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Sarah E Dorff
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Joyce Cheng
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Shenghui Tang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Rajeshwari Sridhara
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - William Pierce
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Amy E McKee
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Amna Ibrahim
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Geoffrey Kim
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Richard Pazdur
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
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Meulendijks D, Henricks LM, Sonke GS, Deenen MJ, Froehlich TK, Amstutz U, Largiadèr CR, Jennings BA, Marinaki AM, Sanderson JD, Kleibl Z, Kleiblova P, Schwab M, Zanger UM, Palles C, Tomlinson I, Gross E, van Kuilenburg ABP, Punt CJA, Koopman M, Beijnen JH, Cats A, Schellens JHM. Clinical relevance of DPYD variants c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity: a systematic review and meta-analysis of individual patient data. Lancet Oncol 2015; 16:1639-50. [PMID: 26603945 DOI: 10.1016/s1470-2045(15)00286-7] [Citation(s) in RCA: 247] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/26/2015] [Accepted: 08/28/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The best-known cause of intolerance to fluoropyrimidines is dihydropyrimidine dehydrogenase (DPD) deficiency, which can result from deleterious polymorphisms in the gene encoding DPD (DPYD), including DPYD*2A and c.2846A>T. Three other variants-DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A-have been associated with DPD deficiency, but no definitive evidence for the clinical validity of these variants is available. The primary objective of this systematic review and meta-analysis was to assess the clinical validity of c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity. METHODS We did a systematic review of the literature published before Dec 17, 2014, to identify cohort studies investigating associations between DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A and severe (grade ≥3) fluoropyrimidine-associated toxicity in patients treated with fluoropyrimidines (fluorouracil, capecitabine, or tegafur-uracil as single agents, in combination with other anticancer drugs, or with radiotherapy). Individual patient data were retrieved and analysed in a multivariable analysis to obtain an adjusted relative risk (RR). Effect estimates were pooled by use of a random-effects meta-analysis. The threshold for significance was set at a p value of less than 0·0167 (Bonferroni correction). FINDINGS 7365 patients from eight studies were included in the meta-analysis. DPYD c.1679T>G was significantly associated with fluoropyrimidine-associated toxicity (adjusted RR 4·40, 95% CI 2·08-9·30, p<0·0001), as was c.1236G>A/HapB3 (1·59, 1·29-1·97, p<0·0001). The association between c.1601G>A and fluoropyrimidine-associated toxicity was not significant (adjusted RR 1·52, 95% CI 0·86-2·70, p=0·15). Analysis of individual types of toxicity showed consistent associations of c.1679T>G and c.1236G>A/HapB3 with gastrointestinal toxicity (adjusted RR 5·72, 95% CI 1·40-23·33, p=0·015; and 2·04, 1·49-2·78, p<0·0001, respectively) and haematological toxicity (adjusted RR 9·76, 95% CI 3·03-31·48, p=0·00014; and 2·07, 1·17-3·68, p=0·013, respectively), but not with hand-foot syndrome. DPYD*2A and c.2846A>T were also significantly associated with severe fluoropyrimidine-associated toxicity (adjusted RR 2·85, 95% CI 1·75-4·62, p<0·0001; and 3·02, 2·22-4·10, p<0·0001, respectively). INTERPRETATION DPYD variants c.1679T>G and c.1236G>A/HapB3 are clinically relevant predictors of fluoropyrimidine-associated toxicity. Upfront screening for these variants, in addition to the established variants DPYD*2A and c.2846A>T, is recommended to improve the safety of patients with cancer treated with fluoropyrimidines. FUNDING None.
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Affiliation(s)
- Didier Meulendijks
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Linda M Henricks
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Gabe S Sonke
- Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tanja K Froehlich
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ursula Amstutz
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | | | | | - Zdenek Kleibl
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Petra Kleiblova
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrich M Zanger
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; University of Tuebingen, Tuebingen, Germany
| | - Claire Palles
- Molecular and Population Genetics Laboratory and Oxford NIHR Biomedical Research Centre, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Ian Tomlinson
- Molecular and Population Genetics Laboratory and Oxford NIHR Biomedical Research Centre, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Eva Gross
- Department of Gynecology and Obstetrics, Technische Universität München, Munich, Germany
| | - André B P van Kuilenburg
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands.
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Launay M, Dahan L, Duval M, Rodallec A, Milano G, Duluc M, Lacarelle B, Ciccolini J, Seitz JF. Beating the odds: efficacy and toxicity of dihydropyrimidine dehydrogenase-driven adaptive dosing of 5-FU in patients with digestive cancer. Br J Clin Pharmacol 2015; 81:124-30. [PMID: 26392323 DOI: 10.1111/bcp.12790] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/07/2015] [Accepted: 09/20/2015] [Indexed: 12/26/2022] Open
Abstract
AIMS 5-FU is the backbone of most regimens in digestive oncology. Administration of standard 5-FU leads to 15-30% of severe side effects, and lethal toxicities are regularly reported with fluoropyrimidine drugs. Dihydropyrimidine dehydrogenase (DPD) deficiency is a pharmacogenetic syndrome responsible for most cases of life-threatening toxicities upon 5-FU intake, and pre-treatment checking for DPD status should help to reduce both incidence and severity of side effects through adaptive dosing strategies. METHODS We have used a simple method for rapidly establishing the DPD phenotype of patients with cancer and used it prospectively in 59 routine patients treated with 5-FU-based therapy for digestive cancers. No patient with total DPD deficiency was found but 23% of patients exhibited poor metabolizer phenotype, and one patient was phenotyped as profoundly deficient. Consequently, 5-FU doses in poor metabolizer patients were cut by an average 35% as compared with non deficient patients (2390 ± 1225 mg vs. 3653 ± 1371 mg, P < 0.003, t-test). RESULTS Despite this marked reduction in 5-FU dosing, similar efficacy was achieved in the two subsets (clinical benefit: 40 vs. 43%, stable disease: 40 vs. 37%, progressive disease: 20% in both subsets, P = 0.893, Pearson's chi-square). No difference in toxicities was observed (P = 0.104, Fisher's exact test). Overall, only 3% of early severe toxicities were recorded, a value markedly lower than the 15-30% ones usually reported with 5-FU. CONCLUSIONS This feasibility study shows how simplified DPD-based adaptive dosing of 5-FU can reduce sharply the incidence of treatment-related severe toxicities while maintaining efficacy as part of routine clinical practice in digestive oncology.
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Affiliation(s)
- Manon Launay
- Laboratoire de Pharmacocinétique La Timone University Hospital of Marseille, Marseille
| | - Laetitia Dahan
- Digestive Oncology Unit, La Timone University Hospital of Marseille, Marseille
| | - Manon Duval
- Laboratoire de Pharmacocinétique La Timone University Hospital of Marseille, Marseille
| | - Anne Rodallec
- Laboratoire de Pharmacocinétique La Timone University Hospital of Marseille, Marseille
| | - Gérard Milano
- Oncopharmacology Unit, Centre Antoine Lacassagne, Nice
| | - Muriel Duluc
- Digestive Oncology Unit, La Timone University Hospital of Marseille, Marseille
| | - Bruno Lacarelle
- Laboratoire de Pharmacocinétique La Timone University Hospital of Marseille, Marseille.,SMARTc Unit, U911 Cro2 Aix-Marseille Univ., Marseille, France
| | - Joseph Ciccolini
- Laboratoire de Pharmacocinétique La Timone University Hospital of Marseille, Marseille.,SMARTc Unit, U911 Cro2 Aix-Marseille Univ., Marseille, France
| | - Jean-Francois Seitz
- Digestive Oncology Unit, La Timone University Hospital of Marseille, Marseille
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Kalsi T, Babic-Illman G, Fields P, Hughes S, Maisey N, Ross P, Wang Y, Harari D. The impact of low-grade toxicity in older people with cancer undergoing chemotherapy. Br J Cancer 2014; 111:2224-8. [PMID: 25268369 PMCID: PMC4264435 DOI: 10.1038/bjc.2014.496] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/24/2014] [Accepted: 08/16/2014] [Indexed: 12/27/2022] Open
Abstract
Background: Significant toxicity in chemotherapy trials is usually defined as grade ⩾3. In clinical practice, however, multiple lower grade toxicities are often considered meaningful. The purpose of this observational cohort study was to identify which level of toxicity triggers treatment modification and early discontinuation of chemotherapy in older people. Methods: Patients aged 65+ were recruited in a central London hospital. A total of 108 patients were recruited at the start of new chemotherapy treatment between October 2010 and July 2012. Results: Mean age was 72.1±5 years, median 72 and range 65–86 years. Of the patients, 50.9% (55) were male with gastrointestinal (49), gynaecological (18), lung (15) and other cancers (26). Chemotherapy was palliative in 59.3% (64/108), curative/ neoadjuvant/adjuvant in the others. Mean number of cycles completed was 4.2±3. Treatment modifications due to toxicity occurred in 60 (55.6%) patients, 35% (21/60) of whom had no greater than grade 2 toxicity. Early treatment discontinuation because of toxicity occurred in 23 patients (21.3%), 39.1% (9/23) of whom had no greater than grade 2 toxicity. Conclusions: Many older patients did not complete treatment as planned. Treatment was modified/discontinued even for one or two low-grade toxicities. Further work is required to clarify whether low-grade toxicity has a greater clinical impact in older people, or whether clinicians have a lower threshold for modifying/discontinuing treatment in older people.
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Affiliation(s)
- T Kalsi
- 1] POPS-GOLD, Department of Ageing & Health, Ground floor Bermondsey Wing, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK [2] Division of Health and Social Care Research, King's College London, Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - G Babic-Illman
- POPS-GOLD, Department of Ageing & Health, Ground floor Bermondsey Wing, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - P Fields
- Department of Haematology, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - S Hughes
- Department of Clinical Oncology, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - N Maisey
- Department of Medical Oncology, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - P Ross
- Department of Medical Oncology, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Y Wang
- Division of Health and Social Care Research, King's College London, Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - D Harari
- 1] POPS-GOLD, Department of Ageing & Health, Ground floor Bermondsey Wing, Guys Hospital, Guys & St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK [2] Division of Health and Social Care Research, King's College London, Capital House, 42 Weston Street, London, SE1 3QD, UK
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Potential of dihydropyrimidine dehydrogenase genotypes in personalizing 5-fluorouracil therapy among colorectal cancer patients. Ther Drug Monit 2014; 35:624-30. [PMID: 23942539 DOI: 10.1097/ftd.0b013e318290acd2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) is a pyrimidine catabolic enzyme involved in the initial and rate-limiting step of the catabolic pathway of toxic metabolites of 5-fluorouracil (5-FU). Several studies have reported that deficiency of DPD and polymorphisms of its gene are related to 5-FU toxicities and death. Association between serum concentration of 5-FU and its related toxicity has also been previously demonstrated. Hence, this study aims to understand the role of DPYD variants in serum level of 5-FU and the risk of developing toxicity to prevent adverse reactions and maximize therapy outcome for personalized medicine. METHODS A total of 26 patients comprising 3 different ethnic groups (Malay, Chinese, and Indian) diagnosed with colorectal cancer and treated with 5-FU chemotherapy regimen from local hospital were recruited. Polymerase chain reaction and denaturing high-performance liquid chromatography methods were developed to screen polymorphisms of DPYD gene. High-performance liquid chromatography-based quantification assay was developed to measure the serum concentration of 5-FU among these patients. RESULTS Patients with DPYD genotypes of deficient enzyme activity had higher median serum levels of 5-FU compared with normal DPD group (median, 11.51 mcg/mL; 95% confidence interval, 10.18-16.11 versus median, 0.83 mcg/mL; 95% confidence interval, 0.55-5.90, Mann-Whitney U test; P = 0.010). Patients with neutropenia (n = 11) had significantly higher serum concentrations of 5-FU as compared with those with normal white blood cell count (n = 15) (Mann-Whitney U test, P = 0.031). Combined regression analysis showed that the predictive power of DPYD*5 (rs1801159) and 1896 T>C (rs17376848) for serum concentrations of 5-FU in the studied group was 36.6% (P = 0.04). Similarly, DPYD*5 and 1896 T>C accounted for 29.9% of the occurrences of neutropenia (analysis of variance, P = 0.017). CONCLUSIONS This study revealed that DPYD*5 (rs1801159) and 1896 T>C (rs17376848) are potentially useful predictive markers of patients' responses to 5-FU chemotherapy. Pharmacogenotyping is therefore recommended to guide dosing of 5-FU and prevent neutropenia.
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Garg MB, Lincz LF, Adler K, Scorgie FE, Ackland SP, Sakoff JA. Predicting 5-fluorouracil toxicity in colorectal cancer patients from peripheral blood cell telomere length: a multivariate analysis. Br J Cancer 2012; 107:1525-33. [PMID: 22990653 PMCID: PMC3493765 DOI: 10.1038/bjc.2012.421] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Identifying various pretreatment factors that predict chemotherapy-induced toxicity in colorectal cancer (CRC) patients undergoing treatment for their disease is crucial to optimising patient care. METHODS Seventy-three patients received adjuvant 5-fluorouracil (5FU)/leucovorin using either the Mayo Clinic (n=42) or a weekly schedule (n=31) and evaluated for clinical toxicity. Pretreatment blood analysis included measures of plasma uracil and dihydrouracil, peripheral blood mononuclear cell (PBMNC) telomere length (TL), standard biochemistry and cell differential analysis. On the first day of treatment 5FU-pharmacokinetic variables of area under the curve, half life and clearance were also measured. These variables together with age and gender were used in univariate and multivariate analysis as predictors of clinical toxicity. RESULTS For the Mayo schedule the primary toxicities were neutropenia (69%), mucositis (58%) and leukopenia (46%), with 70% of patients presenting with haematological toxicity ≥grade 1 (neutropenia and/or leukopenia). Multivariate analysis showed that haematological toxicity was predicted by short TL, high platelet lymphocyte ratio (PLR) and low neutrophil count (R(2)=0.38, P<0.0006), whereas mucositis was predicted by age, TL and PLR (R(2)=0.34, P<0.001). For the weekly schedule diarrhoea predominated (16%), with female gender as the only predictive factor. Although measures of uracil metabolism correlated well with 5FU metabolism (r=0.45-0.49), they did not indicate abnormal pyrimidine metabolism in this cohort and not surprisingly failed to predict for 5FU toxicity. CONCLUSION Short TL of PBMNC and an increased PLR were strong predictors of mucositis and haematological toxicity in CRC patients undergoing 5FU treatment in the adjuvant setting.
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Affiliation(s)
- M B Garg
- Department of Medical Oncology, Calvary Mater Newcastle Hospital, Hunter Regional Mail Centre, Locked Bag No 7, Waratah, NSW 2310, Australia
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Blau L, Menegon RF, Ferreira EI, Ferreira AG, Boffo EF, Tavares LA, Heleno VCG, Chung MC. Synthesis and total 1H- and 13C-NMR assignment of cephem derivatives for use in ADEPT approaches. Molecules 2008; 13:841-54. [PMID: 18463586 PMCID: PMC6245275 DOI: 10.3390/molecules13040841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 04/06/2008] [Accepted: 04/07/2007] [Indexed: 12/05/2022] Open
Abstract
We report the synthesis and total NMR characterization of 5-thia-1-azabicyclo-[4.2.0]oct-2-ene-2-carboxylic acid-3-[[[(4’’-nitrophenoxy)carbonyl]oxy]-methyl]-8-oxo-7-[(2-thienyloxoacetyl)amino]-diphenylmethyl ester-5-dioxide (5), a new cephalosporin derivative. This compound can be used as the carrier of a wide range of drugs containing an amino group. The preparation of the intermediate product, 5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid-3-[methyl 4-(6-methoxyquinolin-8-ylamino)pentylcarbamate]-8-oxo-7-[(2-thienyloxoacetyl)amino]-diphenylmethyl ester-5-dioxide (6), as well as the synthesis of the antimalarial primaquine prodrug 5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid-3-[methyl 4-(6-methoxyquinolin-8-ylamino)pentylcarbamate]-8-oxo-7-[(2-thienyloxoacetyl)amino]- 5-dioxide (7) are also described, together with their total 1H- and 13C-NMR assignments.
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Affiliation(s)
- Lorena Blau
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista, CP 502 - 14801-902, Araraquara, SP, Brazil.
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Roque VMN, Forones NM. [Evaluation of the toxicity and quality of life in patients with colorectal cancer treated with chemotherapy]. ARQUIVOS DE GASTROENTEROLOGIA 2007; 43:94-101. [PMID: 17119662 DOI: 10.1590/s0004-28032006000200007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 10/27/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND The colorectal cancer is the fourth cause of cancer in Brazil and 5-fluorouracil is the drug most commonly used in the adjuvant or palliative treatment of this disease. AIM - Evaluating in patients with colorectal cancer and chemotherapy, the toxicity and the quality of life. PATIENTS AND METHODS From March 2001 and May 2003, 45 patients treated with colorectal cancer treated with 5-fluourouracil and folinic acid were followed closely during six cycles. The gastrointestinal and hematologic toxicity was analysed making use of the chart "Recommendations for the Graduation of Acute and Subacute Toxicity". After the end of each cycle of chemotherapy, the results were registered according to the respectives degrees that vary from 0 to 4. The quality of life was researched through the WHOQOL bref (World Health Organization Quality of Life) questionary that consists of 26 questions and 4 domains: physical, psychological, social relations and environmental, in the beginning, on the 3rd and 6th cycles of treatment. RESULTS Among the 45 patients, 28 were male, the average age was 58.4 years old (from 34 to 79 years old). According to the International Union Against Cancer classification, 34 patients (75.6%) had tumors stage II or III and 11 had tumors stage IV (24.4%), 64.4% were in the colon. In 57.7% the chemotherapy was adjuvant and in the others palliative. The toxicities more commonly found were nauseas (42%), diarrhea (38%), and neutropenia (15.7%). There was no significant difference among the degrees of toxicity in the different cycles as well as among the patients in adjuvant or palliative treatment. Significant alterations was found among the quality of life in the physical and psychological domains when the 1st and the 2nd or the 1st and the 3rd application of the test were done. Alterations of the quality of life were also found in the social domain when the first evaluation was compared with the last one. There was no difference between the quality of life and the treatment.
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Affiliation(s)
- Vanessa Maria Nunes Roque
- Setor de Oncologia, Disciplina de Gastroenterologia, Departamento de Medicina, Universidade Federal de São Paulo, UNIFESP, SP
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Lichtman SM, Wildiers H, Chatelut E, Steer C, Budman D, Morrison VA, Tranchand B, Shapira I, Aapro M. International Society of Geriatric Oncology Chemotherapy Taskforce: evaluation of chemotherapy in older patients--an analysis of the medical literature. J Clin Oncol 2007; 25:1832-43. [PMID: 17488981 DOI: 10.1200/jco.2007.10.6583] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The elderly comprise the majority of patients with cancer and are the recipients of the greatest amount of chemotherapy. Unfortunately, there is a lack of data to make evidence-based decisions with regard to chemotherapy. This is due to the minimal participation of older patients in clinical trials and that trials have not systematically evaluated chemotherapy. This article reviews the available information with regard to chemotherapy and aging provided by a task force of the International Society of Geriatric Oncology (SIOG). Due to the lack of prospective data, the conclusions and recommendations made are a consensus of the participants. Extrapolation of data from younger to older patients is necessary, particularly to those patients older than 80 years, for which data is almost entirely lacking. The classes of drugs reviewed include alkylators, antimetabolites, anthracyclines, taxanes, camptothecins, and epipodophyllotoxins. Clinical trials need to incorporate an analysis of chemotherapy in terms of the pharmacokinetic and pharmacodynamic effects of aging. In addition, data already accumulated need to be reanalyzed by age to aid in the management of the older cancer patient.
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Affiliation(s)
- Stuart M Lichtman
- Memorial Sloan-Kettering Cancer Center, Commack, New York 11725, USA.
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Jensen SA, Vilmar A, Sørensen JB. Adjuvant chemotherapy in elderly patients (>or=75 yr) completely resected for colon cancer stage III compared to younger patients: toxicity and prognosis. Med Oncol 2007; 23:521-31. [PMID: 17303911 DOI: 10.1385/mo:23:4:521] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Revised: 11/30/1999] [Accepted: 03/28/2006] [Indexed: 12/27/2022]
Abstract
PURPOSE To compare benefits and risks to adjuvant chemotherapy following complete resection of node-positive colon cancer stage III for patients aged >or=75 yr and younger. METHOD A retrospective study compared recurrence-free and overall survival, toxicity, and dose intensity of adjuvant bolus 5-FU according to the Mayo regimen chemotherapy in consecutive patients aged 19-74 (n=203) and >or=75 yr (n=24). RESULTS The estimated 5-yr proportional survival rates were 0.65 for patients age less than 75 yr compared to 0.65 (p=0.96) for elderly. The frequencies of anemia (0%), thrombocytopenia (0%), leukopenia (4%), infection (8%), vomiting (0%), mucositis (17%), diarrhea (13%) CTC grade 3 or 4 toxicity in elderly patients were not significantly different from that in younger patients (p > 0.05). Significantly more elderly (8%) had a decline in performance status to grade 3 or 4, as compared to younger patients (4%) (p=0.002). 5-FU dose reduction was necessary for significantly more elderly (51%) as compared to younger patients (28%) (p=0.02), and fewer elderly (54%) completed the scheduled six treatment courses as compared to younger patients (82%) (p=0.05). CONCLUSIONS Adjuvant 5-FU chemotherapy should be considered for elderly patients aged >or=75 yr in good performance at high risk of recurrence of colon carcinoma after resection.
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Fadda G, Campus G, Lugliè P. Risk factors for oral mucositis in paediatric oncology patients receiving alkylant chemotherapy. BMC Oral Health 2006; 6:13. [PMID: 17049085 PMCID: PMC1629008 DOI: 10.1186/1472-6831-6-13] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Accepted: 10/18/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We describe the risk indicators for oral mucositis (OM) in paediatric oncology patients hospitalised in the Institut Gustave Roussy (Villejuif-Paris) and treated with alkylant chemotherapy with autologous peripheral blood progenitor cells. METHODS The sample was selected using PIGAS software. Three groups of subjects received different chemotherapy regimens: A. Melphalan, B. Busulfan and C. other alkylant protocols. The degree of mucositis was recorded by CTC version 2.0 (Common Toxicity Criteria). Descriptive statistics were performed. The association between mucositis and risk indicator variables was tested using a chi2 test. The association between case status and covariates was tested using unconditional logistic regression analysis. RESULTS Of the 337 children enrolled, 241 showed mucositis (group 1) and 96 did not show mucositis (group 2) during alkylant chemotherapy. There was a higher prevalence of male patients in both groups. The three different chemotherapy regimen groups are correlated with the appearance of oral mucositis (chi2 = 22.42, p < 0.01). Weight loss was higher in group 1 (chi2 = 6.31, p = 0.01). The duration of aplasia was lower in the Busulfan protocol (7.5 days) than in the Melphalan group (9.3 days) or the other regimens (8.6 days). The use of Bufulfan was directly associated with case status (presence of oral mucositis): odds ratio [OR] = 2.1 and confidence interval [95%CI] = 1.3-3.0. Also, occurrences of germinal tumours and secondary bacterial infections were directly linked with case status: [OR] = 1.4 and 1.8, confidence interval [95%CI] = 1.2 - 1.7 and 1.1 - 2.5, respectively. CONCLUSION The presence of OM was associated with the three different chemotherapy regimens considered; in particularly patients treated with Busulfan had the highest prevalence.
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Affiliation(s)
- Giulia Fadda
- Dental Institute, University of Sassari, Viale San Pietro 43/c I-07100 Sassari, Italy
- Institut Gustave Roussy, Paris, France
| | - Guglielmo Campus
- Dental Institute, University of Sassari, Viale San Pietro 43/c I-07100 Sassari, Italy
| | - PierFranca Lugliè
- Dental Institute, University of Sassari, Viale San Pietro 43/c I-07100 Sassari, Italy
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Smalley SR, Benedetti JK, Williamson SK, Robertson JM, Estes NC, Maher T, Fisher B, Rich TA, Martenson JA, Kugler JW, Benson AB, Haller DG, Mayer RJ, Atkins JN, Cripps C, Pedersen J, Periman PO, Tanaka MS, Leichman CG, Macdonald JS. Phase III trial of fluorouracil-based chemotherapy regimens plus radiotherapy in postoperative adjuvant rectal cancer: GI INT 0144. J Clin Oncol 2006; 24:3542-7. [PMID: 16877719 DOI: 10.1200/jco.2005.04.9544] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Adjuvant chemoradiotherapy after or before resection of high-risk rectal cancer improves overall survival (OS) and pelvic control. We studied three postoperative fluorouracil (FU) radiochemotherapy regimens. PATIENTS AND METHODS After resection of T3-4, N0, M0 or T1-4, N1, 2M0 rectal adenocarcinoma, 1,917 patients were randomly assigned to arm 1, with bolus FU in two 5-day cycles every 28 days before and after radiotherapy (XRT) plus FU via protracted venous infusion (PVI) 225 mg/m2/d during XRT; arm 2 (PVI-only arm), with PVI 42 days before and 56 days after XRT + PVI; or arm 3 (bolus-only arm), with bolus FU + leucovorin (LV) in two 5-day cycles before and after XRT, plus bolus FU + LV (levamisole was administered each cycle before and after XRT). Patients were stratified by operation type, T and N stage, and time from surgery. RESULTS Median follow-up was 5.7 years. Lethal toxicity was less than 1%, with grade 3 to 4 hematologic toxicity in 49% to 55% of the bolus arms versus 4% in the PVI arm. No disease-free survival (DFS) or OS difference was detected (3-year DFS, 67% to 69% and 3-year OS, 81% to 83% in all arms). Locoregional failure (LRF) at first relapse was 8% in arm 1, 4.6% in arm 2, and 7% in arm 3. LRF in T1-2, N1-2, and T3, N0-2 primaries who received low anterior resection (those most suitable for primary resection) was 5% in arm 1, 3% in arm 2, and 5% in arm 3. CONCLUSION All arms provide similar relapse-free survival and OS, with different toxicity profiles and central catheter requirements. LRF with postoperative therapy is low, justifying initial resection for T1-2, N0-2 and T3, and N0-2 anterior resection candidates.
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Affiliation(s)
- Stephen R Smalley
- Kansas City Community Clinical Oncology Program (CCOP), Kansas City, KS, USA
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Klimm B, Reineke T, Haverkamp H, Behringer K, Eich HT, Josting A, Pfistner B, Diehl V, Engert A. Role of hematotoxicity and sex in patients with Hodgkin's lymphoma: an analysis from the German Hodgkin Study Group. J Clin Oncol 2005; 23:8003-11. [PMID: 16204002 DOI: 10.1200/jco.2005.205.60] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Several scores have described sex as a prognostic factor in patients with Hodgkin's lymphoma (HL). However, little is known how sex-specific factors influence treatment outcome. We systematically investigated sex differences with regard to pretreatment characteristics and therapy-related variables, and examined their influence on the outcome of HL patients. PATIENTS AND METHODS This analysis comprises 4,626 HL patients of all prognostic risk groups who were enrolled onto the multicenter studies HD4 to HD9 of the German Hodgkin Study Group. At 5.5 years, 2,050 female and 2,576 male patients were analyzed. RESULTS Male and female patients had similar prognostic factors. There was more acute chemotherapy-related hematotoxicity in women, especially more severe leucopenia (WHO grade 3/4, 69.9% female and 55.2% male; P < .0001). Importantly, this did not translate into more infections. Female patients had similar response rates but fewer relapses and deaths, leading to a significantly better freedom from treatment failure (FFTF; at 66 months, 81% female [95% CI, 79% to 82%] and 74% male [95% CI, 72% to 76%]). Severe leucopenia during chemotherapy was strongly associated with better FFTF, both for males and females. In addition, when only those patients who developed severe leucopenia within the first two cycles of chemotherapy were included, the factor maintained its protective role. CONCLUSION The protective role of severe leucopenia suggests the testing of a more individualized therapy. In future trials, this therapy may be tailored in a response-adapted manner depending on the individual toxicity profile within the first cycles.
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Affiliation(s)
- Beate Klimm
- First Department of Internal Medicine, University Hospital Cologne, Germany
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Ricke J, Hildebrandt B, Miersch A, Nicolaou A, Warschewske G, Teichgräber U, Lopez Hänninen E, Riess H, Felix R. Hepatic Arterial Port Systems for Treatment of Liver Metastases: Factors Affecting Patency and Adverse Events. J Vasc Interv Radiol 2004; 15:825-33. [PMID: 15297586 DOI: 10.1097/01.rvi.0000136992.96374.60] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess the outcome of interventional hepatic arterial port placement in a prospective phase II trial. MATERIALS AND METHODS One-hundred five consecutive patients were included in this study. Primary endpoint was port patency; secondary endpoints were complications, toxicity, response, and progression free and overall survival. Seventy-eight patients presented with liver metastasis only, 6 patients had additional minor extrahepatic disease, and 21 patients had no evidence of disease after liver resection, laser-induced thermotherapy, or computed tomography (CT)-guided interstitial brachytherapy of liver metastasis. Exclusive access route was the femoral artery. Subgroup analysis compared either 4-F catheters (n = 58) to 2.2-F (n = 33) and 2.7-F (n = 20) microcatheters or different strategies in anatomic variants of the celiac branch: neglect (n = 10) or embolization of minor hepatic feeders (n = 11), splenic arterial port (n = 8), double port (n = 7). RESULTS Technical success was 99%. Assisted port patency after 6 months was 93%. Complications demanding port revisions were significantly lower in patients receiving 4-F versus 2.2-F and 2.7-F systems (P <.001), with disconnection as the major problem with use of microcatheters. Hepatic artery thrombosis occurred in 10 patients (9%), with successful lysis in two patients. With use of 4-F and 2.2-F catheters, there was no difference with respect to catheter occlusion or hepatic thrombosis. No differences were noted in complications or outcome applying four different strategies in celiac branch variants. In a subgroup of patients receiving folinic acid/5-fluorouracil (170 mg/600 mg; 10% dose escalation per cycle) for 5 days every 4 weeks only 15% experienced Grade 3 toxicity. Patients with liver metastasis and salvage therapy demonstrated progression-free survival of 63% after 6 months and a median survival of 16 months. CONCLUSION Interventional placement of hepatic arterial port systems may overcome frequent hepatic arterial chemotherapy failures as encountered in all published major trials on hepatic arterial infusion.
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Affiliation(s)
- Jens Ricke
- Department of Radiology, Charité Campus Virchow-Klinikum, Humboldt-University, Augustenburgerplatz 1, 13353 Berlin, Germany.
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Robien K, Schubert MM, Bruemmer B, Lloid ME, Potter JD, Ulrich CM. Predictors of oral mucositis in patients receiving hematopoietic cell transplants for chronic myelogenous leukemia. J Clin Oncol 2004; 22:1268-75. [PMID: 15051775 DOI: 10.1200/jco.2004.05.147] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Oral mucositis is a nearly universal and often severe complication following hematopoietic cell transplantation (HCT). The objective of this study was to evaluate factors predicting oral mucositis severity among 133 patients undergoing allogeneic HCT for chronic myelogenous leukemia. PATIENTS AND METHODS All patients were transplanted between 1992 and 1999, were >or= 18 years of age, received either cyclophosphamide/total-body irradiation (TBI) or busulfan/cyclophosphamide conditioning regimens, and received four doses of methotrexate for graft-versus-host disease prophylaxis post-transplant. Oral mucositis was measured by a trained examiner every 2 to 3 days using the Oral Mucositis Index (OMI). Multiple linear regression analysis was used to identify predictors of mean OMI during days 6 to 12, 1 to 18, and the maximum OMI score between days 1 to 18. RESULTS TBI containing conditioning regimens, body mass index >or= 25, and methylenetetrahydrofolate reductase 677 TT genotype were found to be predictive of higher mean OMI scores (P <.05). Pretransplant multivitamin supplement use was associated with lower mean OMI scores compared to those who did not use supplements. Smoking status, race, pretransplant treatment with interferon-alfa or hydroxyurea, and patient/donor ABO compatibility were not associated with mean OMI scores. CONCLUSION Patients who are scheduled to receive conditioning regimens containing TBI, have a pretransplant body mass index >or= 25, or carry the methylenetetrahydrofolate reductase 677 TT genotype should be considered at greater risk of developing oral mucositis following HCT. Future studies should investigate whether multivitamin supplementation before HCT could reduce mucositis severity.
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Affiliation(s)
- Kim Robien
- Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004; 12:699-714. [PMID: 14762987 DOI: 10.1002/pds.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Chemotherapy and radiotherapy, whilst highly effective in the treatment of neoplasia, can also cause damage to healthy tissue. In particular, the alimentary tract may be badly affected. Severe inflammation, lesioning and ulceration can occur. Patients may experience intense pain, nausea and gastro-enteritis. They are also highly susceptible to infection. The disorder (mucositis) is a dose-limiting toxicity of therapy and affects around 500 000 patients world-wide annually. Oral and intestinal mucositis is multi-factorial in nature. The disruption or loss of rapidly dividing epithelial progenitor cells is a trigger for the onset of the disorder. However, the actual dysfunction that manifests and its severity and duration are greatly influenced by changes in other cell populations, immune responses and the effects of oral/gut flora. This complexity has hampered the development of effective palliative or preventative measures. Recent studies have concentrated on the use of bioactive/growth factors, hormones or interleukins to modify epithelial metabolism and reduce the susceptibility of the tract to mucositis. Some of these treatments appear to have considerable potential and are at present under clinical evaluation. This overview deals with the cellular changes and host responses that may lead to the development of mucositis of the oral cavity and gastrointestinal tract, and the potential of existing and novel palliative measures to limit or prevent the disorder. Presently available treatments do not prevent mucositis, but can limit its severity if used in combination. Poor oral health and existing epithelial damage predispose patients to mucositis. The elimination of dental problems or the minimization of existing damage to the alimentary tract, prior to the commencement of therapy, lowers their susceptibility. Measures that reduce the flora of the tract, before therapy, can also be helpful. Increased production of free radicals and the induction of inflammation are early events in the onset of mucositis. Prophylactic administration of scavengers or anti-inflammatories can partially counteract or limit some of these therapy-mediated effects, as can the use of cryotherapy. The regular use of mouthwashes, mouth coatings, antibiotics and analgesics is essential, prior to and during loss and ablation of the epithelial layer. Granulocyte-macrophage colony-stimulating factor/granulocyte colony-stimulating factor or the use of laser light therapy may aid restitution and repair. Glutamine supplements may be beneficial in the repair/recovery phase.
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Affiliation(s)
- M Duncan
- Rowett Research Institute, Bucksburn, Aberdeen, UK
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Abstract
AIM: To analyse the prognostic factors in 165 colorectal patients aged ≥ 70.
METHODS: One hundred and sixty-five elderly patients with colorectal cancer diagnosed by histology were entered into the retrospective study between 1994 and 2001. Patients were given optimal operation alone, chemotherapy after operation, or chemotherapy alone according to tumor stage, histology, physical strength, and co-morbid problems. Survival rate was calculated by Kaplan-Meier method, and compared with meaningful variances by Log-rank method. Prognostic factors were analyzed by Cox regression.
RESULTS: The 1, 2, 3, 4, 5 year survival rate (all-cause mortality) was 87.76%, 65.96%, 52.05%, 42.77%, 40.51%, respectively. The mean survival time was 41.89 ± 2.33 months (95%CI: 37.33-46.45 months), and the median survival time was 37 months. Univariate analysis showed that factors such as age, nodal metastasis, treatment method, Duke’s stage, gross findings, kind of histology, and degree of differentiation had influences on the survival rate. Multivariate analysis showed that factors such as treatment method, Duke’s stage, kind of histology and degree of differentiation were independent prognostic factors.
CONCLUSION: This study suggests that the prognosis of elderly colorectal cancer patients is influenced by several factors. Most of elderly patients can endure surgery and/or chemotherapy, and have a long-time survival and good quality of life.
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Affiliation(s)
- Ke-Jun Nan
- Department of Oncology, First Hospital of Xi'an Jiaotong University, 1 Jiankang Xilu, Xi'an 710061, Shaanxi Province, China
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