Oxaliplatin in combination with infusional 5-fluorouracil and leucovorin every 2 weeks as first-line treatment in patients with advanced colorectal cancer: a phase II study

MT2A Promotes Oxaliplatin Resistance in Colorectal Cancer Cells

We aimed to understand the molecular mechanism underlying the incidence of Oxaliplatin resistance in colorectal cancer. The Oxaliplatin-resistant (OR) HT29 colorectal cell line was established by long-term exposure to Oxaliplatin. Cell viability and proliferation were determined by the 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyltetrazolium bromide and direct counting assays, respectively. Transcript level of metallothionein 2A (MT2A) was measured by real-time polymerase chain reaction. Protein levels of MT2A, BRCA1-associated RING domain 1 (BARD1), BRCA1, and β-actin were quantified by immunoblotting. Direct interaction between MT2A with BARD1 and BRCA1 was analyzed by co-immunoprecipitation. Colocalization between of MT2A and BARD1 was determined by immunofluorescence. MT2A was upregulated in OR cells at both transcript and protein levels. Knockdown of MT2A in HT29 OR cells improved sensitivity to Oxaliplatin, while ectopic overexpression of MT2A conferred HT29 cells relative resistance to Oxaliplatin. We further demonstrated that MT2A interacted with and positively regulated BARD1/BRCA1 in colorectal cancer cells. BARD1 overexpression partially restored the compromised Oxaliplatin resistance elicited by MT2A deficiency in terms of both cell proliferation and viability. Our data highlighted the critical contributions of MT2A-BARD1/BRCA1 in Oxaliplatin resistance in colorectal cancer cells.

Efficacy and safety of oxaliplatin-based regimen versus cisplatin-based regimen in the treatment of gastric cancer: a meta-analysis of randomized controlled trials

BACKGROUND

Cisplatin played an important role in the treatment of gastric cancer (GC). Oxaliplatin has been shown to be at least as effective as cisplatin for GC, with less toxicity and a better tolerability profile. We performed a meta-analysis to compare the efficacy and safety of oxaliplatin-based regimen versus cisplatin-based regimen in the treatment of GC.

METHODS

Databases of CNKI, CBM, VIP, Wanfang, PubMed, Embase, Cochrane Library were searched for eligible literatures from their establishments to November 2018. Randomized controlled trials that compared the efficacy and safety of oxaliplatin-based regimen with that of cisplatin-based regimen in the treatment of GC were included. Statistical analyses were calculated using RevMan 5.3 software.

RESULTS

Seven randomized controlled trials including 2297 patients were included. Compared with cisplatin-based regimen intervention in GC, oxaliplatin-based regimen treatment was able to significantly improve the partial response rate (OR = 1.26, 95% CI 1.07-1.49; p = 0.007), disease progression rate (OR = 0.41, 95% CI 0.25-0.66; p = 0.0002) and 1-year survival (OR = 1.25, 95% CI 1.00-1.56; p = 0.05). The toxicities of hematopoietic system were significantly higher in cisplatin-based regimen group (OR = 0.6, 95% CI 0.46-0.79; p = 0.0002), while oxaliplatin-based regimen group had higher neurosensory toxicity (OR = 2.21, 95% CI 1.52-3.21; p < 0.0001), In addition, gastrointestinal toxicity was similar between the two groups (OR = 1.01, 95% CI 0.5-2.01; p = 0.27).

CONCLUSIONS

Compared with cisplatin-based regimen, oxaliplatin-based regimen treatment has an obvious advantage in patients with GC with acceptable tolerance.

Neoadjuvant chemoradiation for locally advanced rectal cancer: a systematic review of the literature with network meta-analysis

Background

Neoadjuvant chemoradiotherapy (CRT) prior to surgery is a standard therapy for locally advanced rectal cancer, but the optimum regime is not conclusive. This meta-analysis evaluated various CRT regimens with regard to the rate of pathologic complete response (pCR) and toxic effects of grade ≥3.

Methods

The databases PubMed, Cochrane Library, and Embase were searched for randomized controlled trials (RCTs) that compared neoadjuvant CRT regimes for treating patients with locally advanced rectal cancer, published before 28 December 2017. The primary end points were pCR and toxic effects. A network meta-analysis was applied.

Results

Fourteen RCTs (with 5,599 participants) involving the following eight regimens were included: fluorouracil (5FU) alone, or 5FU with oxaliplatin (OXA), cisplatin, or irinotecan (CPT-11); capecitabine (CAP) alone, or CAP with OXA or CPT-11; and CPT-11 with combined tegafur, 5-chloro-2,4-dihydroxypyridine, and potassium oxonate. The rate of pCR associated with CAP + OXA was significantly higher compared with 5FU alone; there were no significant differences among the other regimens. The toxicity of 5FU + OXA or CAP + OXA was significantly worse than that of 5FU alone or CAP alone. CAP + OXA and CAP were ranked, respectively, the most and second most effective regimens in terms of pCR rate. 5FU alone and CAP alone likely had the lowest and second lowest toxicity, respectively.

Conclusion

Among the currently available CRT regimens for locally advanced rectal cancer, this meta-analysis indicated that CAP + OXA provides the superior clinical results. Adding OXA to 5FU or CAP significantly increases toxicity.

Capecitabine plus oxaliplatin compared with 5-fluorouracil plus oxaliplatin in metastatic colorectal cancer: Meta-analysis of randomized controlled trials

The aim of this study was to evaluate the curative effects and safety of capecitabine plus oxaliplatin compared with 5-fluorouracil (5-FU) plus oxaliplatin in patients with metastatic colorectal cancer (MCRC). We searched the Cochrane Central register of Controlled Trials (CENTRAL), PubMed, Ovid, ScienceDirect, EBSCO, EMBASE and conference proceedings for eligible trials. A meta-analysis was performed using Review Manager 5.0. A total of 3,603 cancer patients from 7 trials were analyzed, and the baseline patient characteristics were comparable in all studies. Curative effect outcomes including complete response (CR) (OR=0.78; 95% CI 0.47-1.31; p=0.35), partial response (PR) (OR=0.81; 95% CI 0.65-1.00; p=0.05) and the overall response rate (ORR) (OR=0.85; 95% CI 0.71-1.02; p=0.08) showed similar curative effects between the capecitabine plus oxaliplatin group and the 5-FU plus oxaliplatin group. Moreover, the median overall survival (OS) and progression-free survival (PFS) had no statistically significant differences. Regarding safety, hand-foot syndrome was more frequently observed in the capecitabine plus oxaliplatin group (OR=2.71; 95% CI 2.04-3.61; p<0.00001), while stomatitis and neutropenia were reversed. Other toxic effects had no statistically significant differences between the two groups. Our results showed that capecitabine plus oxaliplatin had similar curative effects to 5-FU plus oxaliplatin, however, it was safer in patients with MCRC.

Oxaliplatin-Induced Haemolytic Anaemia: A Case Report

Oxaliplatin plus 5Fluorouracil (5FU) and leucovorin (LV) is the standard treatment of metastatic colorectal cancer (CRC). We describe a rare clinical case of acute renal failure probably oxaliplatin-related at one day from the end of the palliative treatment. A 36 year-old woman developed a stage I CRC. Five months later a liver lesion was detected and treated with FOLFOX4 schedule. Because of progression the patient underwent surgery and she repeated the Oxaliplatin-based therapy for more than one cycle. After many months of therapy, on the second day, the patient noticed urine discoloration. Immediate urinanalysis demonstrated haemoglobinuria. The patient's complete blood count exhibited signs consistent with acute hemolysis, neutrophilic leucocytosis, thrombocytopenia and acute renal failure. She was treated with blood transfusion and hemodialysis and she was managed conservatively with monitored intravenous hydration and loop diuretics. The patient gradually recovered and the results of successive hematological and biochemical tests confirmed the improvement of her condition but a cardiologic evaluation showed a iatrogenic depressed systolic function (ejection fraction of 40%).

Effect of the Cdk-inhibitor roscovitine on mouse hematopoietic progenitors in vivo and in vitro

Myelosuppression is one the most frequent side effects of chemotherapy. New agents that more selectively target cancer cells have been developed in attempt to improve the effects and to decrease the side effects of cancer treatment. Roscovitine is a purine analogue and cyclin-dependent kinase inhibitor. Several studies have shown its cytotoxic effect in cancer cell lines in vitro and in xenograft models in vivo. In this study, we investigated the effect of roscovitine on hematopoietic progenitors in vitro and in vivo in mice. The clonogenic capacity of hematopoietic progenitors was studied using burst-forming unit-erythroid (BFU-E), colony-forming unit granulocyte, macrophage (CFU-GM) and colony-forming unit granulocyte, erythroid, macrophage, megakaryocyte (CFU-GEMM). In vitro, bone marrow cells were exposed to roscovitine (25-250 microM) in Iscove's modified Dulbecco's media for 4 h or to roscovitine (1-100 microM) in MethoCult media for 12 days. No effect on colony formation was observed after exposure to roscovitine for 4 h; however, concentration- and cell type-dependent effects were observed after 12 days. Roscovitine in concentration of 100 microM inhibited the growth of all types of colonies, while lower concentrations have shown differential effect on hematopoietic progenitors. The most sensitive were CFU-GEMM, followed by BFU-E and then CFU-GM. In vivo, mice were treated with single dose of roscovitine (50, 100 or 250 mg/kg) and the effect on bone marrow was studied on day 1, 3, 6, 9 or 12 after the treatment. In the second part of experiment, the mice were treated with roscovitine 350 mg/kg/day divided into two daily doses for 4 days. The bone marrow was examined on day 1 and 5 after the last dose of roscovitine. On day 1, BFU-E decreased to less than 50% of the controls (P = 0.019). No decrease in BFU-E formation was observed on day 5. No significant effect was observed on CFU-GM and CFU-GEMM growth after the treatment with multiple doses of roscovitine. Single doses of roscovitine or dimethylsulfoxide did not affect the colony formation. We also studied the distribution of roscovitine to the bone marrow after a dose of 50 mg/kg was administered intraperitoneally. Only 1.5% of the drug was detected in the bone marrow. Thus, the roscovitine effect on hematopoietic progenitors in bone marrow in vivo is only transient. One reason may be that only a small fraction of roscovitine reaches the bone marrow. Another explanation may be the short half-life observed for roscovitine that might not allow enough cell exposure to the drug. However, the toxicity of roscovitine to hematopoietic progenitors in vitro is within the same exposure range as cytotoxicity to cancer cells. Thus, precaution should be taken in clinical trials, especially when combinations with myelosuppressive cytostatics are used.

Phase II study of oxaliplatin, 5-fluorouracil, and leucovorin in relapsed or metastatic colorectal cancer as second line therapy

PURPOSE

The purpose of the study was to assess the efficacy and safety of biweekly oxaliplatin in combination with leucovorin (LV)-modulated bolus plus infusion of 5-fluorouracil (5-FU) in patients with relapsed or metastatic colorectal cancer (CRC) as a second line therapy.

MATERIALS AND METHODS

Between November 2002 and October 2005, 26 patients with histologically confirmed relapsed or metastatic CRC were enrolled. All patients were previously treated with irinotecan-based combination chemotherapy. The chemotherapy regimen consisted of oxaliplatin 85 mg/m(2) on day 1; LV 200 mg/m(2) on days 1 and 2; and 5-FU 400 mg/m(2) bolus IV with 600 mg/m(2) with a 22-hour infusion on days 1 and 2 every 2 weeks.

RESULTS

The median age of the 26 patients was 50.5 years (range, 31 approximately 72). Their metastatic sites included: the liver (42.3%), peritoneum (26.9%), lung (23.1%) and ovary (7.7%). Twenty five patients were evaluated for their response. Four patients achieved partial responses and 15 patients had stable disease. The overall response rate was 16% (95% confidence interval; 1.7 approximately 30.3%). The median follow-up duration for the surviving patients was 7.4 months (range, 2.08 approximately 21.2). Median overall survival (OS) and 1-year OS rates were 16.7 months and 63.9%, respectively. The most common hematological toxicities were: NCI grade I/II leucopenia (49.3%), grade I/II neutropenia (41%) and grade I/II anemia (65.2%). The main non-hematological toxicities were: grade I/II peripheral neuropathy (16.1% and 21.5%, respectively) and nausea/vomiting (23.6%/18.5%). There was no life-threatening toxicity.

CONCLUSION

The oxaliplatin, 5-FU and LV combination chemotherapy, scheduled as a biweekly protocol, was effective and well tolerated in the treatment of relapsed or metastatic colorectal cancer patients as second line chemotherapy.

A phase 1 and pharmacokinetic study of gemcitabine and oxaliplatin in patients with solid tumors

PURPOSE

This dose escalation study aimed to determine the recommended doses, toxicity and pharmacokinetics of oxaliplatin and gemcitabine given on days 1 and 8 every 21 days. This schedule may maximize dose intensity of both drugs with acceptable or reduced toxicity.

PATIENT AND METHODS

Eligible patients had solid malignancies, no more than two prior courses of chemotherapy, ECOG performance status 0-2, neurotoxicity < or = NCI-CTC grade 1 and adequate organ function. Dose escalation commenced at oxaliplatin 40 mg/m(2) and gemcitabine 750 mg/m(2), both given on days 1 and 8 every 21 days, and reached oxaliplatin 80 mg/m(2) and gemcitabine 1,500 mg/m(2). The two highest dose levels were each expanded to six patients to gain additional toxicity data.

RESULTS

There were no dose limiting toxicities related to treatment and an MTD was not reached. Five patients (24%) had grade 3 neutropenia, without associated infection, and seven patients (33%) had grade 3/4 thrombocytopenia. Neurotoxicity was mild and no worse than grade 1. Two patients with mesothelioma (10%) had partial responses and 11 patients (52%) had disease stabilization. No pharmacokinetic interaction between oxaliplatin and gemcitabine was detected. Dose intensity was maximal at level 4 (oxaliplatin 70 mg/m(2) and gemcitabine 1,250 mg/m(2)).

CONCLUSIONS

This schedule allows oxaliplatin and gemcitabine to be delivered at the full dose intensity of each drug with excellent tolerability and predictable pharmacokinetics. The recommended doses for phase II studies are oxaliplatin 70 mg/m(2) and gemcitabine 1,250 mg/m(2) on days 1 and 8 every 21 days.

Colorectal cancer in the elderly: is palliative chemotherapy of value?

Colorectal cancer is a disease of the elderly, with 70% of patients being aged 65 years or older. In Western countries, the total number of elderly patients with this disease is expected to further increase in the future. Since the incidence of adverse physical or socioeconomic conditions in the elderly is higher than in younger patients, a thorough assessment of the patient's suitability for therapy should be performed before a decision is made. Using a Comprehensive Geriatric Assessment (CGA) to subdivide the population of elderly cancer patients into three groups can help to guide treatment decisions. Both in the adjuvant and in the palliative setting, there are sufficient data supporting the use of fluorouracil-based chemotherapy in fit elderly patients who can tolerate cytotoxic treatment. Systemic chemotherapy has been shown to effectively reduce mortality in the adjuvant situation and to be of clinical benefit for patients with metastatic disease in terms of longer survival, control of symptoms and quality of life. In recent years, new substances such as oxaliplatin or irinotecan have shown significant activity in the treatment of patients with metastatic colorectal cancer. However, information on how to guide the use of these new drugs in elderly patients is still lacking. Limited data from clinical trials indicate treatment efficacy in selected elderly patients comparable to that observed in younger patients, with overall manageable toxicity. Clearly, further clinical trials in elderly patients with colorectal cancer are necessary as well as the incorporation of aspects of geriatric medicine into the teaching programme of medical oncologists.

Hypersensitivity and idiosyncratic reactions to oxaliplatin

BACKGROUND

Oxaliplatin is a third-generation platinum analog that is used to treat a variety of solid tumors, particularly colorectal carcinoma. Patients may develop hypersensitivity reactions, although this complication occurs infrequently.

METHODS

Three patients developed hypersensitivity reactions to oxaliplatin while undergoing treatment on a Phase I trial of oxaliplatin and capecitabine. An Entrez PUBMED search was performed to identify other cases.

RESULTS

Two patients experienced the abrupt onset of erythema alone or with pruritus during the 9th and 11th infusions of oxaliplatin, whereas the other patient developed fever and mild dyspnea a few hours after the 9th oxaliplatin infusion. All 3 patients were rechallenged successfully for at least 1 additional oxaliplatin infusion by using oral dexamethasone, 20 mg orally, 6 and 12 hours before the administration of oxaliplatin and by administering intravenously 125 mg of solumedrol, 50 mg of diphenhydramine, and 50 mg of cimetidine 30 minutes before oxaliplatin. The literature review suggests two distinct patterns of reactions: classic hypersensitivity (as experienced by the first two patients) and idiosyncratic reactions (as experienced by the third patient).

CONCLUSIONS

Patients who develop mild to moderate hypersensitivity to oxaliplatin may be pretreated with steroids and antagonists of Type 1 and 2 histamine receptors, whereas patients who develop severe reactions are unlikely to tolerate further therapy.

Perspectives on the role of sequential or combination chemotherapy for first-line and salvage therapy in advanced colorectal cancer

Metastatic colorectal cancer is a major cause of cancer-related mortality. Surgical resection of all known metastatic disease can be curative in selected patients. The majority of patients, however, require the consideration of systemic chemotherapy as optimal palliative treatment for their diseases. Using new effective chemotherapeutic agents such as irinotecan and oxaliplatin has resulted in a clear and clinically significant improvement in survival for patients with metastatic colorectal cancer. The optimal sequences and combinations of these agents as initial and salvage chemotherapy along with 5-fluorouracil (5-FU) and leucovorin are controversial. It seems clear that it is important for all patients to have access to all 3 drugs at some point in their therapy for optimal results. Recent randomized trials of first-line chemotherapy for metastatic colorectal cancer in which patients were likely to have access to all 3 effective drugs demonstrated median survivals of 18-20 months. This compares favorably to median survivals of approximately 12 months for patients treated with 5-FU-based regimens alone prior to the availability of effective salvage therapy. A small but meaningful number of patients might develop resectable disease with curative intent as the result of significant tumor response to combination chemotherapy. Herein, we review recent developments in combination and sequential chemotherapy for metastatic colorectal cancer and the implications for the optimal treatment in these patients.