Assessment of Ramucirumab plus paclitaxel as switch maintenance versus continuation of first-line chemotherapy in patients with advanced HER-2 negative gastric or gastroesophageal junction cancers: the ARMANI phase III trial

The FJQR Has Synergistic Effect with Fluoropyrimidine in the Maintenance Treatment for HER-2 Negative Gastric Cancer

INTRODUCTION

Maintenance therapy aimed to strengthen the first-line chemotherapy and improve quality of life is needed for gastric cancer (GC). Currently, many clinical studies have confirmed the important role of fluoropyrimidine in the maintenance stage. Our team has created patented prescriptions "Fuzheng jiedu Quyu Method" recipe (FJQR), which was considered as an adjuvant therapeutic scheme (reduce toxicity and increase the efficacy of chemotherapy). This study aimed to evaluate the efficacy and safety of FJQR combined with fluoropyrimidine as a maintenance treatment in HER-2 negative GC patients.

METHODS

We performed the analysis of 129 patients with HER-2 negative GC who entered the maintenance stage in our hospital and Tianjin Cancer Hospital between January 2018 and December 2020. Out of the 129 eligible patients, 64 were categorized into the maintenance treatment group with FJQR+fluoropyrimidine, and 65 patients were assigned to the control group if they received fluoropyrimidine alone. Capecitabine was orally 1000mg/m2, Qd, half an hour after meals, and FGQR was 15g Bid after capecitabine. The primary endpoint was progression-free survival (PFS). The secondary endpoints were overall survival (OS), overall remission rate (ORR), quality of Life (QOL), TCM syndrome and safety.

RESULTS

The mPFS in the treatment group was significantly prolonged compared with the control group (6.3 vs. 5.0 months, p = 0.03), while the mOS was not substantially improved (11.4 vs. 10.5 months, p = 0.38). Gastrointestinal symptoms and pain became better in the treatment group. The number of distant metastatic organs, first-line chemotherapy cycles, and lymph node metastasis were independent risk predictors for PFS. Blood stasis syndrome may be the protective factor. In terms of safety, treatment-related adverse events (AEs) in the treatment group were relatively lighter, and the incidence of grade III-IV AEs could be significantly reduced.

CONCLUSION

FJQR and fluoropyrimidine have synergistic effects as maintenance treatment in HER-2 negative GC, with good efficacy and safety.

The Role of Angiogenesis Targeted Therapies in Metastatic Advanced Gastric Cancer: A Narrative Review

Since bevacizumab was first approved by the U.S. Food and Drug Administration as an anti-angiogenic therapy in 2004, angiogenesis-targeted therapy has been developed for various types of solid tumors. To date, ramucirumab and apatinib are clinically available as treatments for metastatic advanced gastric cancer (AGC). Ramucirumab demonstrated prolonged survival as second-line therapy of metastatic AGC in the RAINBOW and REGARD trials. However, neither ramucirumab extended survival in treatment-naïve patients with AGC in the RAINFALL or RAINSTORM trials nor bevacizumab in the AVAGAST and AVATAR trials. Apatinib demonstrated superior efficacy over the best supportive care in a Chinese phase III trial but not in an international phase III (ANGEL) trial. Currently, combination therapy of ramucirumab with irinotecan or FTD/TPI is being evaluated in the third-line setting, assessing the efficacy of continuous angiogenesis inhibition from second- to third-line therapy. Recently, the role of angiogenesis inhibition via immunomodulators is attractive to clinicians. Emerging results of several early-phase clinical trials indicated the promising antitumor activity of angiogenesis inhibition in combination with immune therapy. This review offers an overview of the history of clinical trials focused on anti-angiogenic for patients with AGC and presents future perspectives in this area.

The evolving strategies for the management of patients with metastatic gastric cancer: A narrative review and expert opinion

Gastric cancer (GC) is recognized as one of the most common deadly malignancies worldwide and about 40-50% of patients present at diagnosis with an unresectable disease due to a locally advanced or already metastatic condition. Recently, therapeutic options for management of metastatic GC (mGC) have been approved allowing a potential improvement of patient cancer treatment response and also an establishment of a continuum of care for this aggressive disease. This report is the result of a literature review by an expert panel. The aim of this document is to provide evidence, wherever it is lacking, to provide expert opinion directed at strategic management of mGC, and in particular aspect at practical management where appropriate guidelines are not available. Treatment landscape with new therapeutic strategies for third line and beyond, role of imaging, prognostic factors, symptoms, and markers as well as the importance of multidisciplinary approach particularly the nutritional aspects are discussed.

Study on the Application Value of Concurrent Chemoradiotherapy and Clinical Nursing Pathway for Postoperative Patients with Esophageal Cancer

Backgrounds

To observe the value of concurrent chemoradiotherapy and clinical nursing pathway for postoperative patients with esophageal cancer (EC).

Methods

A total of 88 postoperative EC patients were divided into the radiotherapy group (RG group, 44 cases) and the chemoradiotherapy group (CRG group, 44 cases). The RG group received single three-dimensional conformal radiotherapy+clinical nursing pathway, and the CRG group was combined with chemotherapy on this basis. The 5-year overall survival rate, progression-free survival rate, pathological remission and survival rate, lymph node metastasis and survival rate, quality of life analysis, tumor-related factor level, and incidence of adverse reactions were compared between the two groups.

Results

The overall survival rates at 1, 3, and 5 years were 93.18%, 56.82%, and 50.0% in the CRG group and 86.36%, 52.27%, and 43.18% in the RG group, respectively. The 5-year progression-free survival rate of the CRG group was 60.87%, which was clearly higher than that of the RG group (33.33%). The 1-, 3-, and 5-year overall survival rates of pCR and NpCR patients were 90.48%, 80.95%, and 61.90% and 89.55%, 44.78%, and 38.81%, respectively. The overall 1-year, 3-year, and 5-year survival rates were 81.08%, 37.84, and 24.32% and 96.08%, 66.67%, and 62.75% in patients with lymph node metastasis and nonlymph node metastasis, respectively, with statistical significant differences. The emotional function, physical function, cough, pain, and eating difficulty in the CRG group were better than those in the RG group. After treatment, serum CEA, SCC, CYFRA21-1, and CA199 levels in the CRG group were obviously downregulated compared with those in the RG group. There was no obvious difference in the incidence of adverse reactions between the CRG group and the RG group.

Conclusion

Single radiotherapy and concurrent chemoradiotherapy can be used as effective means in the treatment of EC. Moreover, the quality of life and survival time of the concurrent chemoradiotherapy group were dramatically better than those of the single radiotherapy group, and the antitumor ability of the concurrent chemoradiotherapy group was stronger.

Tumor vessel normalization and immunotherapy in gastric cancer

Gastric cancer (GC) is a common malignant tumor, and patients with GC have a low survival rate due to limited effective treatment methods. Angiogenesis and immune evasion are two key processes in GC progression, and they act synergistically to promote tumor progression. Tumor vascular normalization has been shown to improve the efficacy of cancer immunotherapy, which in turn may be improved through enhanced immune stimulation. Therefore, it may be interesting to identify synergies between immunomodulatory agents and anti-angiogenic therapies in GC. This strategy aims to normalize the tumor microenvironment through the action of the anti-vascular endothelial growth factor while stimulating the immune response through immunotherapy and prolonging the survival of GC patients.

Prognostic significance of excision repair cross complementation group 1 rs2298881 in patients with gastric cancer receiving platinum-based chemotherapy: A PRISMA-compliant meta-analysis

BACKGROUND

Gastric cancer (GC) is a strong cause of global cancer mortality. Nucleotide excision repair (NER) can modulate platinum-based chemotherapeutic efficacy by removing drug-produced DNA damage. Some studies have found a link between excision repair cross complementation group 1 (ERCC1) rs2298881, one gene in NER pathway, and response to chemotherapy. However, the results have been disputed.

METHODS

We conducted a meta-analysis to reevaluate the association between polymorphisms of NER gene (ERCC1 rs2298881) and the clinical outcomes in gastric cancer patients receiving platinum-based chemotherapy. Searching PubMed, Web of Science, EMBASE, Google Scholar, and China National Knowledge Infrastructure, 2 independent searchers found all pertinent literatures up to May 1, 2021. We enrolled studies according to consistent selection criteria, extracted and vitrified data. Crude odds ratios (ORs) and hazard ratios (HRs) with 95% confidence interval (CI) were applied to evaluate the effect of ERCC1 rs2298881 on patients treated by platinum-based chemotherapy.

RESULTS

By the data gathered from 6 independent studies, 1940 cases diagnosed with gastric cancer and treated with chemotherapy were included, containing 1208 Good-Responders and 732 Poor-Responders. With a comprehensive meta-analysis, we found that the patients with ERCC1 rs2298881A allele had a worse response to chemotherapy than those who with rs2298881C allele under allelic model (A vs C), with the pooled OR of 0.780 (95% CI: 0.611-0.996, P = .046). And our analysis indicated that AA genotype was associated with unfavorable overall survival (HR = 1.540, 95% CI = 1.106-2.144, P = .011) compared with CC genotype.

CONCLUSIONS

ERCC1 rs2298881 is suggested as a marker of clinical outcome in gastric cancer patients treated by platinum-based chemotherapy.

Maintenance in gastric cancer: New life for an old issue?

The interest in maintenance therapy for patients with advanced cancers has been rapidly growing. Maintenance therapy is a useful strategy that may strengthen results of induction therapy thus extending survival and preserving the quality of life (QoL) with less toxicity. Maintenance also represents a suitable setting to investigate novel agents. The value of maintenance therapy after first-line chemotherapy has been well established in several solid tumours, such as colorectal, lung, breast, and ovarian cancer in which it is largely adopted. To date, there is no established role for maintenance therapy following first-line chemotherapy for advanced gastric cancer (GC). This review summarizes the current knowledge regarding maintenance strategies in advanced GC exploring cytotoxic agents, biologic agents and immunotherapy. We also critically review new issues to optimize randomized clinical trials for maintenance therapies and suggest clinical consideration to guide a personalized approach in daily clinical practice for this setting.

Current Perspectives on Taxanes: Focus on Their Bioactivity, Delivery and Combination Therapy

Taxanes, mainly paclitaxel and docetaxel, the microtubule stabilizers, have been well known for being the first-line therapy for breast cancer for more than the last thirty years. Moreover, they have been also used for the treatment of ovarian, hormone-refractory prostate, head and neck, and non-small cell lung carcinomas. Even though paclitaxel and docetaxel significantly enhance the overall survival rate of cancer patients, there are some limitations of their use, such as very poor water solubility and the occurrence of severe side effects. However, this is what pushes the research on these microtubule-stabilizing agents further and yields novel taxane derivatives with significantly improved properties. Therefore, this review article brings recent advances reported in taxane research mainly in the last two years. We focused especially on recent methods of taxane isolation, their mechanism of action, development of their novel derivatives, formulations, and improved tumor-targeted drug delivery. Since cancer cell chemoresistance can be an unsurpassable hurdle in taxane administration, a significant part of this review article has been also devoted to combination therapy of taxanes in cancer treatment. Last but not least, we summarize ongoing clinical trials on these compounds and bring a perspective of advancements in this field.

Beyond the Guidelines: The Grey Zones of the Management of Gastric Cancer. Consensus Statements from the Gastric Cancer Italian Network (GAIN)

BACKGROUND

Management of gastric and gastroesophageal junction (GEJ) adenocarcinoma remains challenging, because of the heterogeneity in tumor biology within the upper gastrointestinal tract. Daily clinical practice is full of grey areas regarding the complexity of diagnostic, staging, and therapeutic procedures. The aim of this paper is to provide a guide for clinicians facing challenging situations in routine practice, taking a multidisciplinary consensus approach based on available literature.

METHODS

The GAIN (GAstric cancer Italian Network) group was established with the aims of reviewing literature evidence, discussing key issues in prevention, diagnosis, and management of gastric and GEJ adenocarcinoma, and offering a summary of statements. A Delphi consensus method was used to obtain opinions from the expert panel of specialists.

RESULTS

Forty-nine clinical questions were identified in six areas of interest: role of multidisciplinary team; risk factors; diagnosis; management of early gastric cancer and multimodal approach to localized gastric cancer; treatment of elderly patients with locally advanced resectable disease; and treatment of locally advanced and metastatic cancer.

CONCLUSIONS

The statements presented may guide clinicians in practical management of this disease.

Apatinib in Combination with S-1 as First-Line Treatment in Patients with Advanced Metastatic Gastric Cancer: Results from an Open, Exploratory, Single-Arm, Phase II Trial

Lessons Learned

Apatinib combined with S‐1 was not superior to other chemotherapy regimens as first‐line therapy for advanced gastric cancer.

There was a tendency for patients with lymph node metastasis to have prolonged median progression‐free survival and median overall survival, compared with patients with liver metastasis.

Background

The best choice of first‐line chemotherapy regimen for patients with metastatic gastric cancer is still debated. We combined apatinib and S‐1 as a new first‐line therapy to treat advanced gastric cancer. The efficacy and safety of the combination were assessed, with the goal of determining the most appropriate subgroup of patients who could benefit from this new regimen.

Methods

This study was an open, exploratory single‐arm, phase II trial. Enrolled patients received apatinib plus S‐1 treatment (apatinib, 500 mg, once a day [qd], days 1–21; S‐1, 40 mg/m², bid, days 1–14). The primary endpoints were progression‐free survival (PFS) and safety of this new regimen. Next‐generation sequencing was used to explore potential biomarkers.

Results

A total of 30 patients were enrolled. The median progression‐free survival (mPFS) was 4.21 months (95% confidence interval [CI], 2.29–6.13 months). The median overall survival (mOS) was 7.49 months (95% CI, 4.81–10.17 months). Patients with lymph node metastasis had prolonged mPFS and mOS when compared with those with liver metastasis (mPFS, 4.21 vs. 1.84 months; mOS, 8.21 vs. 6.31 months, p = .08). The most common grade 3 to 4 adverse events were abdominal pain, dizziness, and diarrhea. Gene mutation profiles between the two subgroups were significantly different.

Conclusion

Apatinib combined with S‐1 was not superior to other chemotherapy regimens as first‐line therapy for advanced gastric cancer. Toxicity was consistent with known profiles when given as monotherapy. There was a tendency toward prolonged mPFS and mOS in patients with lymph node metastasis compared with patients with liver metastasis, which could support the need to design a future clinical trial with a better defined patient population.

Maintenance treatment in advanced HER2-negative gastric cancer

Survival for patients with advanced gastric cancer (GC) remains poor. Systemic chemotherapy which has reached a plateau stays the standard first-line (1L) treatment for advanced human epidermal growth-factor receptor 2 (HER2)-negative GC. To maximize the benefit of 1L treatment, the concept of maintenance treatment is constantly being explored. In advanced HER2-negative GC, current clinical guidelines do not recommend a standard maintenance therapy strategy. In addition to the monotherapy maintenance with fluorouracil after 4-6 cycles of 1L chemotherapy, some agents that are active against novel targets have been evaluated in clinical trials for maintenance treatment. Whereas most of these trials do not reach their primary endpoints, they open new horizons for the 1L treatment of advanced HER2-negative GC. Therefore, we reviewed the clinical trials in the field of maintenance treatment in advanced HER2-negative GC and discussed some of the problems in clinical trials.

Molecular mechanisms of synergistic action of Ramucirumab and Paclitaxel in Gastric Cancers cell lines

Ramucirumab is approved both as monotherapy and in combination with Paclitaxel for advanced gastric cancer in patients with disease progression after chemotherapy. In tumor cells, the VEGFA-VEGFR2 binding activates autocrine survival and migration signaling in angiogenesis independent manner. The present in vitro study investigated the effects of single and combined treatments with Ramucirumab and Paclitaxel on cell growth and migration highlighting the mechanisms underlying the interaction between the two drugs in gastric cancer cells. Cell growth and motility were investigated in human gastric cancer cell lines characterized by different tumorigenicity. The inhibitory effect on cell growth exerted by both drugs was potentiated by their combination and was synergistic. Ramucirumab was able to enhance the inhibitory effect exerted by Paclitaxel on cell cycle progression. A synergistic action was also observed in the expression of proteins crucial for cell motility, microtubule organization and epithelial-mesenchymal transition. Furthermore, synergistic inhibition of VEGFR2 expression was obtained by the drug combination. These findings highlighted the importance of the combined treatment to strongly inhibit all the main molecules of both PI3K/Akt/mTOR and MAPK pathways thus preventing possible reactivations due to cross-talk phenomena. The combined treatment with Ramucirumab seems to be a promising option to overcome the Paclitaxel resistance.