A retrospective study of the safety and efficacy of paclitaxel plus ramucirumab in patients with advanced or recurrent gastric cancer with ascites

Treatment outcomes of gemcitabine plus nab-paclitaxel in pancreatic cancer patients with malignant ascites

BACKGROUND

Gemcitabine plus nab-paclitaxel (GnP) therapy has been shown to improve the prognosis in patients with metastatic pancreatic cancer (PC); however, the efficacy and safety of GnP in PC patients with malignant ascites (MA) remains unknown.

METHODS

We retrospectively investigated PC patients with peritoneal dissemination who had received GnP as first-line chemotherapy at our institution between March 2015 and August 2021. The following patient data were reviewed: patient characteristics, overall survival (OS), progression-free survival (PFS), objective response rate (ORR), adverse events (AEs), and relative dose intensity (RDI). The severity of MA was categorized based on the CT findings as grade 1 (small), grade 2 (moderate), or grade 3 (massive).

RESULTS

A total of 189 patients were included; the study endpoints were compared between patients with each ascites grade and 41 patients without MA. The MA was classified as grade 1 in 85 patients, grade 2 in 41 patients, and grade 3 in 22 patients. In the patients with MA, the median OS, PFS and ORR were 11.2 months, 5.7 months and 24.3%, respectively. The OS and PFS decreased with increasing the severity of MA; in particular, patients with grade 2 and 3 showed a poorer prognosis. There were no differences in AEs, except for anorexia, or the RDI according to the severity of MA.

CONCLUSION

GnP showed moderate efficacy with manageable safety profile in PC patients with MA. However, PC patients with moderate to massive ascites still have a dismal prognosis, and further development of effective treatments is needed.

CA125 Kinetics as a Potential Biomarker for Peritoneal Metastasis Progression following Taxane-Plus-Ramucirumab Administration in Patients with Advanced Gastric Cancer

Currently, no established marker exists for predicting peritoneal metastasis progression during chemotherapy, although they are major interruptive factors in sequential chemotherapy in patients with advanced gastric cancer (AGC). This multicenter retrospective study was conducted from June 2015 to July 2019, analyzing 73 patients with AGC who underwent taxane-plus-ramucirumab (TAX/RAM) therapy and had their serum carbohydrate antigen 125 (CA125) concentrations measured. Of 31 patients with elevated CA125 levels above a cutoff of 35 U/mL, 25 (80.6%) had peritoneal metastasis. The CA125 concentrations before TAX/RAM treatment were associated with ascites burden. The overall survival was significantly shorter in the CA125-elevated group. CA125 kinetics, measured at a median of 28 days after chemotherapy, were associated with the ascites response (complete or partial response: -1.86%/day; stable disease: 0.28%/day; progressive disease: 2.33%/day). Progression-free survival in the CA125-increased group, defined by an increase of 0.0067%/day using receiver operating characteristic curve analysis, was significantly poorer among patients with peritoneal metastases. In conclusion, this study highlights that CA125 kinetics can serve as an early predictor for the progression of peritoneal metastasis during TAX/RAM treatment.

Effect of massive ascites on ramucirumab pharmacokinetics in patients with gastrointestinal cancers: a population pharmacokinetic analysis

PURPOSE

Considerable amounts of injected immunoglobulin G-based therapeutic monoclonal antibodies, such as ramucirumab, are distributed into ascites. This study aimed to examine the effect of massive ascites on ramucirumab pharmacokinetics in patients with gastrointestinal cancers.

METHODS

Population pharmacokinetic analysis of ramucirumab was performed using data on serum ramucirumab concentrations of 52 patients with gastrointestinal cancers, including 8 patients with massive ascites. The Bayesian method using the final population pharmacokinetic model was utilized to estimate trough ramucirumab concentrations after the first dose and at steady state.

RESULTS

Population pharmacokinetic analysis revealed that massive ascites as well as body weight were influencing factors for ramucirumab clearance. The estimated ramucirumab clearance was significantly higher in patients with massive ascites than in those with no/mild ascites (0.020 ± 0.004 versus 0.013 ± 0.004 L/h, P < 0.001). The estimated trough ramucirumab concentrations were significantly lower in patients with massive ascites than in those with no/mild ascites after the first dose (26.4 ± 6.8 versus 36.1 ± 7.1 μg/mL, P < 0.001) and at steady state (41.4 ± 16.3 versus 65.9 ± 18.0 μg/mL, P < 0.001).

CONCLUSION

In the present study, the presence of massive ascites affected the pharmacokinetics of ramucirumab in patients with gastrointestinal cancers. Our results suggest that dose optimization of ramucirumab may be necessary in patients with massive ascites due to higher ramucirumab clearance.

Correlation Between Tumor Response and Survival Outcomes in Patients with Advanced Gastric Cancer Receiving Ramucirumab and Paclitaxel as Second-Line Therapy

BACKGROUND

Gastric cancer (GC) is one of the leading causes of cancer-related death worldwide. The first-line treatment for GC is a combination of platinum and fluoropyrimidine-based therapy. Based on the positive results of RAINBOW and REGARD trials, ramucirumab either alone or in combination with paclitaxel has proved to be a safe and active option for second-line treatment in GC patients.

MATERIAL AND METHODS

Advanced GC patients who received a 28-day cycles of ramucirumab and paclitaxel until disease progression or unacceptable toxicity were evaluated. Eligible patients had ECOG PS ≤ 1 and adequate organ function. Baseline characteristics were assessed for progression-free survival (PFS) and overall survival (OS). The Kaplan-Meier method and Cox proportional-hazards regression models were used for survival analyses.

RESULTS

In our single institution experience, we included a total of 67 patients. A median OS of 8 months and a median PFS of 4 months, were recorded. In patients experiencing an initial partial response (PR), we observed a significant association between tumor response and survival outcomes (OS and PFS). The OS and PFS were 15 and 11 months in patients who experienced PR compared to 8 and 4 months in patients without PR (p = 0.02; p = 0.04).

CONCLUSION

Treatment with ramucirumab plus paclitaxel yielded the highest overall response rate reported to date for patients with previously treated advanced GC. In our experience, the initial tumor response is associated with a greater survival benefit which could be further improved by the identification of biomarkers predicting response.

Xiaoaiping improves the general state of rats with malignant ascites secondary to gastric cancer by blocking the TGF-β1 signaling pathway

OBJECTIVE

To investigate the effect of Xiaoaiping on the general state of rats with malignant ascites secondary to gastric cancer by blocking the transforming growth factor-β1 (TGF-β1) signaling pathway.

METHODS

Fifty healthy Wistar rats were randomly divided into 5 groups, with 10 rats in each group. After successful modeling, 0.2 g/(20 g∙d), 0.4 g/(20 g∙d) and 0.8 g/(20 g∙d) of Xiaoaiping injections were administrated at the low dose group (LDG), medium dose group (MDG) and high dose group (HDG), respectively. The model group (MG) was injected intraperitoneally with the same amount of sterile normal saline for 8 d. Rats in the control group (CG) were healthy without any treatment. The general states (mental state, dietary habits, reactions and body shape) of rats in each group were observed. The abdominal circumference, platelet (PLT) count, white blood cell (WBC) count, serum ferritin (SF), ascites volume, cell survival rate, and expression levels of TGF-β1 signaling pathway (TGF-β1, Smad2) were compared among the groups.

RESULTS

PLT and WBC counts in the MG were lower than those in the CG. Ascites volume, tumor cell survival rate, and SF in the MG were higher than those in the LDG, MDG and HDG (P<0.05). Thymus index in the LDG, MDG and HDG were significantly higher than that in the MG (P<0.05). There was no significant difference in the spleen indices among the groups (P>0.05). The kidney index, serum creatinine and urea nitrogen levels in LDG, MDG and HDG were significantly lower than those of MG (P<0.05). The LDG, MDG and HDG exhibited significantly higher peripheral blood CD4+ cells and CD4+/CD8+, and lower CD8+ level, as compared with the MG (P<0.05). The levels of serum interferon γ (IFN-γ), interleukin (IL)-1α, IL-1β, IL-2, IL-4 and tumor necrosis factor-α (TNF-α) in the LDG, MDG and HDG were higher than those in the MG (P<0.05). The ascites volume and tumor cell survival rate were decreased sequentially in the LDG, MDG and HDG (P<0.05). The MG had higher mRNA levels of TGF-β1 and Smad2 than the CG (P<0.05). No statistically significant difference was found in TGF-β1 and Smad2 between the LDG and MG (P>0.05).

CONCLUSION

Xiaoaiping could significantly reduce the ascites volume in rats with gastric cancer, inhibit the production of tumor cells in the abdominal cavity, and improve the general state of rats in a dose-dependent manner. The mechanism may be related to the down-regulation of the mRNA level of TGF-β1 and Smad2.

How May Ramucirumab Help Improve Treatment Outcome for Patients with Gastrointestinal Cancers?

GI cancers are characterized by high recurrence rates and a dismal prognosis and there is an urgent need for new therapeutic approaches. This is a narrative review designed to provide a summary of the efficacy as measured by overall survival, progression free survival, and safety data from phase 3 randomized controlled GI clinical trials of ramucirumab including those from important pre-specified patient subgroups and evidence from real clinical practice worldwide. Quality of life (QOL) is discussed where data are available. Our aim was to summarize the efficacy and safety of ramucirumab in the treatment of GI cancers using these existing published data with a view to demonstrating how ramucirumab may help improve treatment outcome for patients with GI cancers. The data indicate that ramucirumab is efficacious, safe, and tolerable across the intent-to-treat patient populations as a whole and across several pre-specified subgroups, even those whose disease is traditionally more difficult to treat. Furthermore, survival outcomes observed in real-world clinical practice demonstrate similar data from phase 3 clinical trials even in patients with complications, suggesting that the benefits of ramucirumab translate in actual clinical practice.

Trastuzumab-based palliative chemotherapy for HER2-positive gastric cancer: a single-center real-world data

Background

Since the results of the ToGA trial were published, trastuzumab-based chemotherapy has been used as the standard first-line treatment for HER2-positive recurrent or primary metastatic gastric cancer (RPMGC). However, the real-world data has been rarely reported. Therefore, we investigated the outcomes of trastuzumab-based chemotherapy in a single center.

Methods

This study analyzed the real-world data of 47 patients with HER2-positive RPMGC treated with trastuzumab-based chemotherapy in a single institution.

Results

With the median follow-up duration of 18.8 months in survivors, the median overall survival (OS) and progression-free survival were 12.8 and 6.9 months, respectively, and the overall response rate was 64%. Eastern Cooperative Oncology Group performance status 2 and massive amount of ascites were independent poor prognostic factors for OS, while surgical resection before or after chemotherapy was associated with favorable OS, in multivariate analysis. In addition, 5 patients who underwent conversion surgery after chemotherapy demonstrated an encouraging median OS of 30.8 months, all with R0 resection.

Conclusions

Trastuzumab-based chemotherapy in patients with HER2-positive RPMGC in the real world demonstrated outcomes almost comparable to those of the ToGA trial. Moreover, conversion surgery can be actively considered in fit patients with a favorable response after trastuzumab-based chemotherapy.

Retrospective cohort study of nanoparticle albumin-bound paclitaxel plus ramucirumab versus paclitaxel plus ramucirumab as second-line treatment in patients with advanced gastric cancer

BACKGROUND

Nanoparticle albumin-bound paclitaxel (nab-PTX) has shown non-inferiority to paclitaxel (PTX) as second-line therapy for advanced gastric cancer (AGC) with fewer infusion-related reactions. The efficacy and safety of nab-PTX plus ramucirumab (RAM) was reported in a phase II trial; however, there is no randomized trial comparing this regimen with PTX plus RAM in patients with AGC. This retrospective study aimed to investigate the efficacy and safety of nab-PTX plus RAM versus PTX plus RAM in patients with AGC.

METHODS

This study included patients with AGC who received nab-PTX plus RAM from September 2017 to January 2019 or PTX plus RAM from June 2015 to August 2017 as second-line chemotherapy in our hospital.

RESULTS

A total of 113 and 138 patients who received nab-PTX plus RAM and PTX plus RAM, respectively, were analyzed. Median progression-free survival (PFS) was 3.9 months (95% confidence interval [CI]: 3.4-4.3) in the nab-PTX plus RAM group and 3.9 months (95% CI: 3.1-4.7) in the PTX plus RAM group (hazard ratio [HR]: 1.08; 95% CI: 0.83-1.40; P = 0.573). Median overall survival (OS) was 10.9 months (95% CI: 9.3-12.7) in the nab-PTX plus RAM group and 10.3 months (95% CI: 8.5-12.0) in the PTX plus RAM group (hazard ratio: 0.82; 95% CI: 0.61-1.10; P = 0.188). In patients with moderate/massive ascites, favorable outcomes for progression-free survival were observed in the nab-PTX plus RAM group compared with the PTX plus RAM group. Although anemia and fatigue (any grade) were more frequent in the nab-PTX plus RAM group, discontinuation of study treatment was not increased in the nab-PTX plus RAM group. There was no occurrence of hypersensitivity reaction in the nab-PTX plus RAM group, while two patients (1.4%) experienced grade 3 hypersensitivity reactions in the PTX plus RAM group.

CONCLUSIONS

The combination of nab-PTX plus RAM showed a similar efficacy and safety profile to PTX plus RAM as second-line treatment for patients with AGC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Second-line chemotherapy using taxane in patients with advanced gastric cancer who presented with severe peritoneal metastasis: a multicenter retrospective study

BACKGROUND

Individuals with advanced gastric cancer (AGC) who present with severe peritoneal metastasis (SPM) have poor prognosis. This study aimed to evaluate efficacy and safety of second-line treatment for patients with such condition.

METHODS

This retrospective study included patients receiving taxane-based second-line chemotherapy at three Japanese institutions between 2010 and 2016. Patients with AGC who present with SPM were included if they had massive ascites and/or inadequate oral intake requiring intravenous nutritional support.

RESULTS

In this study, 43 (40%) of 108 patients had an Eastern Cooperative Oncology Group Performance Status score ≥ 2, and the median serum albumin level of the patients was 3.3 g/dL. Ramucirumab was used in combination with paclitaxel in 21 patients. The median overall survival (OS) and progression-free survival (PFS) were 5.1 and 2.8 months, respectively. Inadequate oral intake was considered a negative prognostic factor of both OS and PFS in the multivariate analysis. Three treatment-related deaths were observed, which include those attributed to febrile neutropenia, gastrointestinal perforation, and pneumonitis. Common grade ≥ 3 adverse events were neutropenia (35%), leukopenia (30%), anemia (24%), and anorexia (16%). We observed febrile neutropenia in 8% and gastrointestinal perforation in 4% of patients, and such conditions were dominantly observed in patients with inadequate oral intake.

CONCLUSION

Taxane-based second-line chemotherapy was effective and safe for patients with AGC who present with SPM. Attention must be provided when treating patients with inadequate oral intake as they are likely to have short prognosis and serious toxicities.

Achieving sequential therapy in advanced gastric cancer: the importance of appropriate patient management for the elderly and/or those with ascites

Treatment options for patients with advanced gastric cancer (AGC) are limited. One approach to improving survival in patients with AGC is to optimize the available agents via sequential therapy. However, clinical trial reports of first-line chemotherapy indicate that elderly patients and patients with massive ascites are less likely to receive subsequent lines of therapy. In addition, clinical trials of second- and third-line chemotherapy generally exclude these two patient populations because they are likely to have poor performance status and additional issues that are difficult to manage. Good patient management is likely to be key to the successful use of sequential therapy in these two patient populations by minimizing adverse effects to allow patients to derive benefit from the additional treatment. This narrative review summarizes the available information on AGC treatment and patient management in elderly patients and patients with massive ascites. The available data suggest that elderly patients benefit from chemotherapy; however, monitoring toxicity is essential to avoid chemotherapy-related toxicities. Important aspects of patient management for elderly patients include symptom monitoring, nutritional support, and fall prevention. The available data for patients with massive ascites show limited success for a range of treatment approaches, including systemic chemotherapy. The management of ascites is also challenging, with no clear guidance on the preferred strategies. To address these gaps in knowledge, future clinical trials should incorporate more inclusive eligibility criteria to enroll populations of patients with AGC that are more reflective of the real-world population with respect to age, complications, and overall health status.

Metastasectomy Improves the Survival of Gastric Cancer Patients with Krukenberg Tumors: A Retrospective Analysis of 182 patients

Purpose

There is no consensus regarding whether metastasectomy in gastric cancer patients with Krukenberg tumors (KTs) is associated with survival benefits. The aim of this study was to evaluate the treatment of KTs of gastric origin in a large series of patients and to identify prognostic factors affecting survival.

Patients and Methods

All patients who were diagnosed with gastric cancer and ovarian metastases in a single medical center between January 2006 and December 2016 were identified and included. The patients were divided into two groups according to treatment modality: a metastasectomy group and a nonmetastasectomy group. Clinicopathological features and overall survival (OS) were compared between the groups.

Results

In total, 182 patients were identified; 94 patients presented with synchronous KTs, and 88 developed metachronous KTs during follow-up. OS was significantly longer in the metastasectomy group than in the nonmetastasectomy group among those with synchronous (14.0 months vs 8.0 months; p = 0.001) and metachronous (14 months vs 8 months; p = 0.018) KTs. Multivariate analysis indicated that metastasectomy (hazard ratio [HR] 0.537; 95% confidence interval [CI] 0.344-0.839; p = 0.006), ascites (HR 1.523; 95% CI 1.058-2.193; p = 0.024), linitis plastica (HR 1.995; 95% CI 1.115-3.571; p = 0.020), and systemic chemotherapy (HR 0.456; 95% CI 0.280-0.742; p = 0.002) were independent predictors of OS.

Conclusion

Metastasectomy combined with systemic chemotherapy should be performed in gastric cancer patients with synchronous or metachronous KTs. Metastasectomy, systemic therapy, linitis plastica, and ascites are prognostic factors for OS. Further prospective randomized studies are needed.

Treatment of Metastatic or High-Risk Solid Cancer Patients by Targeting the Immune System and/or Tumor Burden: Six Cases Reports

This article summarizes the histories of six patients with different solid tumors treated with a new strategy based on tumor burden reduction and immune evasion as potential targets. All six patients were at a high risk of relapse and were likely to have a minimal residual disease following conventional therapy: biochemical recurrence (BCR) following radical prostatectomy (RP) (two prostate cancers patients), removal of distant metastases (one colorectal and one breast cancer), and complete response (CR) of distant metastases to conventional therapy (one breast cancer and one esophageal–gastric junction cancer). Four of the patients, two after RP and BCR, one after removal of a single pulmonary metastasis from breast cancer, and one after CR to chemotherapy of peritoneal metastases and ascites from an esophageal–gastric junction primary cancer, regularly received cycles of a new drug schedule with the aim of inhibiting immune suppression (IT). In these four patients, preliminary laboratory tests of peripheral blood suggested an interleukin (IL)-2/IL-12 mediated stimulation of cellular immune response with a concomitant decrease in vascular endothelial growth factor (VEGF) immune suppression. The fifth case was a breast cancer patient with distant metastases in CR, while receiving beta-interferon and interleukin-2 in addition to conventional hormone therapy. To date, all five patients are alive and doing well and they have been unexpectedly disease-free for 201 and 78 months following BCR, 28 months following the removal of a single pulmonary metastases, 32 months following CR to chemotherapy of peritoneal metastases and ascites, and 140 months following diagnosis of multiple bone metastases, respectively. The sixth patient, who had colorectal cancer and multiple synchronous liver metastases and underwent nine surgical interventions for metastatic disease, although not disease-free, is doing well 98 months after primary surgery. Our six cases reports can be interpreted with the hypothesis that immune manipulation and/or a concomitant low tumor burden favored their clinical outcome.

Prognostic significance of malignant ascites in gastric cancer patients with peritoneal metastasis: A systemic review and meta-analysis

BACKGROUND

Recent evidence indicates that malignant ascites may be associated with the high malignancy and poor prognosis of gastric cancer (GC) with peritoneal metastasis (PM), but no robust consensus has been reached until now.

AIM

To evaluate the prognostic significance of malignant ascites in GC patients with PM.

METHODS

Two independent authors conducted database searches. The searches were performed in the EMBASE, PubMed, and Cochrane Library databases, and the terms used to search included stomach neoplasms, GC, ascites, peritoneal effusion, survival, and survival analysis. Outcomes included overall survival and hazard ratios with 95% confidence intervals (CIs). Three pairs of comparisons for measuring survival were made: (1) Patients with ascites vs those without ascites; (2) Patients with massive ascites vs those with mild to moderate ascites; and (3) Patients with massive ascites vs those with no to moderate ascites.

RESULTS

Fourteen articles including fifteen studies were considered in the final analysis. Among them, nine studies assessed the difference in prognosis between patients with and without malignant ascites. A pooled HR of 1.63 (95%CI: 1.47-1.82, P < 0.00001) indicated that GC patients with malignant ascites had a relatively poor prognosis compared to patients without ascites. We also found that the prognosis of GC patients with malignant ascites was related to the volume of ascites in the six other studies.

CONCLUSION

GC patients with malignant ascites tend to have a worse prognosis, and the volume of ascites has an impact on GC outcomes.

Weight loss and body mass index in advanced gastric cancer patients treated with second-line ramucirumab: a real-life multicentre study

AIMS AND METHODS

This multicenter retrospective study aims to evaluate the correlations between Body Weight Loss (BWL), Body Mass Index (BMI) and clinical outcomes (ORR, PFS, and OS) of advanced gastric cancer (aGC) patients treated with second-line ramucirumab-based therapy in a "real-life" setting.

RESULTS

From December 2014 to October 2018, 101 consecutive aGC patients progressed to a first-line chemotherapy were treated with ramucirumab alone (10.9%) or in combination with paclitaxel (89.1%). Median BMI was 21.2 kg/m2 and mBWL since first-line treatment commencement was 4.5%. Among 53 patients who underwent primary tumor resection (PTR), 73.6% experienced BWL, while 26.4% did not experience BWL (p = 0.0429). Patients who underwent PTR had a significantly higher probability of experiencing BWL (yes vs no) [OR = 2.35 (95% CI 1.02-5.42), p = 0.0439]. Among the 89 evaluable patients, ORR was 26.9% (95% CI 17.2-40.1). At a median follow-up of 17.3 months, mPFS was 5.4 months (95% CI 3.6-6.8) and mOS was 8.7 months (95% CI 7.3-11.9). In the multivariate analysis, only ECOG-PS and BMI were confirmed independent predictors for shorter PFS [HR = 1.69 (95% CI 1.01-2.82), p = 0.04] [HR = 1.97 (95% CI 1.12-3.46), p = 0.01] and OS [HR = 1.69 (95% CI 1.01-2.83), p = 0.04] [HR = 2.08 (95% CI 1.17-3.70), p = 0.01].

CONCLUSION

Efficacy of ramucirumab is confirmed in this "real-life" analysis. BWL seems not to have correlations with clinical outcomes in these patients, while BMI and ECOG-PS remain major prognostic factors. A possible explanation for the lack of prognostic effect of BWL might be the proportion of patients subjected to PTR in this series (52.5%).

Is ramucirumab and paclitaxel therapy beneficial for second-line treatment of metastatic gastric or junctional adenocarcinoma for patients with ascites? Analysis of RAINBOW phase 3 trial data

Purpose

Second-line treatment with ramucirumab-paclitaxel has demonstrated statistically significant and clinically meaningful survival outcomes compared to paclitaxel-alone in patients with advanced gastric cancer (HR=0.807, 95% CI 0.678–0.962; P=0.017). Post hoc, exploratory analyses of RAINBOW patient data were performed to examine whether ascites impacted the efficacy and safety of ramucirumab-paclitaxel.

Patients and methods

Patients were placed in with- or without-ascites subgroups based on baseline information collected on case report forms. The Kaplan–Meier method was used to estimate median progression-free survival (PFS) and overall survival (OS) of the ascites subgroups. HR and 95% CI were calculated using the Cox proportional hazards model. Survival distributions within the two arms in each ascites subgroup were compared using the log-rank test.

Results

There were 36% of RAINBOW trial patients (237/665) that had ascites at baseline (with-ascites subgroup); 64% of patients (428/665) had no baseline ascites (without-ascites subgroup). Most baseline characteristics were balanced. The with-ascites subgroup had a higher percentage of patients with peritoneal metastases (91% vs 23%) as expected. Overall survival for the with-ascites subgroup was worse than for the without-ascites subgroup (median OS for placebo-treated patients: 5.2 vs 8.5 months, respectively). However, OS treatment effects did not seem to differ significantly among patients with ascites (OS stratified HR=0.864, 95% CI=0.644–1.161; P=0.3362) vs those without ascites (OS stratified HR=0.745, 95% CI=0.593–0.936; P=0.0115). Similar results were observed for PFS. Ramucirumab treatment was associated with a greater incidence of all-grade vomiting for the with-ascites subgroup vs the without-ascites subgroup (ramucirumab arm: 39.2% vs 18.8%; placebo arm: 23.3% vs 19.5%, respectively). The incidence of adverse events of special interest was not elevated among the ramucirumab-treated ascites subgroup over the without-ascites subgroup.

Conclusion

The benefit/risk profile of ramucirumab-paclitaxel remains favorable in patients with ascites and is consistent with the findings of the RAINBOW trial.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Gastric Cancer Patients with Peritoneal Metastasis (PM): Results of a Single-Center Experience and Register Study

PURPOSE

Gastric cancer (GC) patients with peritoneal metastasis (PM) have poor prognosis. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in combination with systemic chemotherapy is a novel treatment option for patients in stage IV of the disease.

MATERIALS AND METHODS

Between November 2015 and June 2018, prospective data collection was performed in 24 patients with GC and PM (median age, 57; range, 44-75 years). These patients underwent 46 PIPAC procedures with a median number of 2 interventions per patient (range, 1-6). A laparoscopic access was used and a combined therapy of cisplatin and doxorubicin aerosol was administered.

RESULTS

The median peritoneal carcinomatosis index before the 1st PIPAC was 14 (range, 2-36), and the median ascites volume in patients before the 1st PIPAC was 100 mL (range, 0-6 mL, 300 mL). Eleven patients, who received 2 or more PIPAC procedures, had decreased and stable volumes of ascites, while only 3 patients displayed increasing volume of ascites. The median overall survival was 121 days (range, 66-625 days) after the 1st PIPAC procedure, while 8 patients who received more than 3 PIPAC procedures had a median survival of 450 days (range, 206-481 days) (P=0.0376).

CONCLUSIONS

Our data show that PIPAC is safe and well tolerated, and that the production of ascites can be controlled by PIPAC in GC patients. Patients, who received 2 or more PIPAC procedures, reported a stable overall quality of life. Further studies are required to document the significance of PIPAC as a palliative multimodal therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03100708.