Intravenous chemotherapy for resected gastric cancer: meta-analysis of randomized controlled trials

Meta-Analysis of the Effect of Dietary Care on Nausea and Vomiting in Oncology Chemotherapy Patients

Objective

To evaluate the effect of dietary care on chemotherapy-induced nausea and vomiting in oncology patients.

Methods

A retrospective analysis of digestive symptoms was conducted in cancer patients admitted to our hospital, who received chemotherapy, and corresponding effective dietary care countermeasures were adopted.

Results

After the nursing intervention, the incidence of digestive symptoms was significantly reduced, the quality of life was significantly improved (59.92 ± 6.57) vs. (37.95 ± 7.50), and the nursing satisfaction was significantly higher (91.67% vs. 69.44%), with statistically significant differences (P < 0.05). Meta-analysis showed that short-term (0 to 3 months) dietary care could alleviate nausea and vomiting symptoms in chemotherapy patients (P < 0.001) and improve the survival quality of oncology patients (P < 0.01). The effect of long-term (3–6 months) dietary care on the control of nausea and vomiting symptoms in chemotherapy patients was certain (P < 0.05), but the effect on the improvement of their quality of life (P > 0.05) was unclear.

Conclusion

Dietary care can alleviate the symptoms of nausea and vomiting in tumor chemotherapy patients and improve the quality of life of short-term chemotherapy tumor patients, so it can be recommended to strengthen the dietary management for tumor patients receiving chemotherapy. Patients receiving chemotherapy should be given corresponding dietary nutritional care according to their clinical symptoms in order to alleviate their adverse reactions, enhance their own immunity, and improve the prognosis of cancer patients.

Survival analysis of elderly patients over 65 years old with stage II/III gastric cancer treated with adjuvant chemotherapy after laparoscopic D2 gastrectomy: a retrospective cohort study

Background

The benefits of adjuvant chemotherapy for elderly patients with gastric cancer (GC) remain unknown because elderly patients are underrepresented in most clinical trials. This study aimed to evaluate the effectiveness and complications of adjuvant chemotherapy in patients > 65 years of age after laparoscopic D2 gastrectomy.

Methods

This was a single-center retrospective cohort study of elderly patients (> 65 years) with stage II/III GC who underwent curative laparoscopic D2 gastrectomy with R0 resection between 2004 and 2018. The adjuvant chemotherapy regimens included monotherapy (oral capecitabine) and doublet chemotherapy (oral capecitabine plus intravenous oxaliplatin [XELOX] or intravenous oxaliplatin, leucovorin, and 5-fluorouracil [FOLFOX]). The data were retrieved from a prospectively registered database maintained at the Department of General Surgery in Nanfang Hospital, China. The patients were divided as surgery alone and surgery plus adjuvant chemotherapy (chemo group). The overall survival (OS), disease-free survival (DFS), chemotherapy duration, and toxicity were examined.

Results

There were 270 patients included: 169 and 101 in the surgery and chemo groups, respectively. There were 10 (10/101) and six (6/101) patients with grade 3+ non-hematological and hematological adverse events. The 1−/3−/5-year OS rates of the surgery group were 72.9%/51.8%/48.3%, compared with 90.1%/66.4%/48.6% for the chemo group (log-rank test: P = 0.018). For stage III patients, the 1−/3−/5-year OS rates of the surgery group were 83.7%/40.7%/28.7%, compared with 89.9%/61.2%/43.6% for the chemo group (log-rank test: P = 0.015). Adjuvant chemotherapy was significantly associated with higher OS (HR = 0.568, 95%CI: 0.357–0.903, P = 0.017) and DFS (HR = 0.511, 95%CI: 0.322–0.811, P = 0.004) in stage III patients.

Conclusions

This study suggested that adjuvant chemotherapy significantly improves OS and DFS compared with surgery alone in elderly patients with stage III GC after D2 laparoscopic gastrectomy, with a tolerable adverse event profile.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07919-0.

Docetaxel, cisplatin, and 5-fluorouracil compared with epirubicin, cisplatin, and 5-fluorouracil regimen for advanced gastric cancer: A systematic review and meta-analysis

BACKGROUND

As the first-line regimens for the treatment of advanced gastric cancer, both docetaxel, cisplatin, and 5-fluorouracil (DCF) and epirubicin, cisplatin, and 5-fluorouracil (ECF) regimens are commonly used in clinical practice, but there is still controversy about which is better.

AIM

To compare the efficacy and safety of DCF and ECF regimens by conducting this meta-analysis.

METHODS

Computer searches in PubMed, EMBASE, Ovid MEDLINE, Science Direct, Web of Science, The Cochrane Library and Scopus were performed to find the clinical studies of all comparisons between DCF and ECF regimens. We used progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), and adverse effects (AEs) as endpoints for analysis.

RESULTS

Our meta-analysis included seven qualified studies involving a total of 598 patients. The pooled hazard ratios between the DCF and ECF groups were comparable in PFS (95%CI: 0.58-1.46, P = 0.73), OS (95%CI: 0.65-1.10, P = 0.21), and total AEs (95%CI: 0.93-1.29, P = 0.30). The DCF group was significantly better than the ECF group in terms of ORR (95%CI: 1.13-1.75, P = 0.002) and DCR (95%CI: 1.03-1.41, P = 0.02). However, the incidence rate of grade 3-4 AEs was also greater in the DCF group than in the ECF group (95%CI: 1.16-1.88, P = 0.002), especially for neutropenia and febrile neutropenia.

CONCLUSION

With better ORR and DCR values, the DCF regimen seems to be more suitable for advanced gastric cancer than the ECF regimen. However, the higher rate of AEs in the DCF group still needs to be noticed.

Adjuvant endocrine monotherapy for postmenopausal early breast cancer patients with hormone-receptor positive: a systemic review and network meta-analysis

BACKGROUND

In patients with hormone receptor-positive postmenopausal of early stage breast cancer, adjuvant endocrine monotherapies include letrozole, anastrozole, exemestane, toremifene and tamoxifen. But the optimum regimen remains controversial.

METHODS

PubMed, Cochrane Database and ClinicalTrials.gov were systematically reviewed of abstract for randomized-controlled trials (RCTs) to assess the efficacy of tamoxifen, letrozole, exemestane, anastrozle and toremifene for postmenopausal patients with hormone-receptor positive (HR+), who have not received prior therapy for early stage breast cancer. The outcomes were measured by disease-free survival (DFS) and overall survival (OS). We evaluated relative hazard ratios (HRs) for death of different therapies by combination hazard ratios for death of included trials. The SUCRA values were used to evaluate the rankings of efficacy for these monotherapies.

RESULTS

A total of fourteen studies including 19,517 patients in our research were absorbed and estimated. The superiority of efficacy for DFS were 5-year letrozole and 10-year tamoxifen (SUCRA values 0.743/0.657) in all comparisons. A more efficient SUCRA values for OS were 5-year Exemestane, 5-year letrozole and 10-year tamoxifen (0.756/0.677/0.669).

CONCLUSIONS

Clinically important differences exist between commonly prescribed different adjuvant endocrine monotherapy regimens for both efficacy and acceptability in favor of exemestane and letrozole. 10-year tamoxifen for early breast cancer patients is noninferior to 5-year anastrozle, and might be the best choice where aromatase inhibitors (AIs) are not easy to acquire.

Validity of studies suggesting postsurgical chemotherapy for resectable gastric cancer: critical appraisal of randomised trials

Background and aim

In 2013, Diaz-Nieto et al published a Cochrane review to summarise the impact of postsurgical chemotherapy versus surgery alone on survival for resectable gastric cancer. The authors concluded that postsurgical chemotherapy showed an improvement in overall survival. The aim of this article was to assess the validity of four studies included in the Cochrane review and to investigate the impact of an exclusion of these four studies on the result of the meta-analysis.

Methods

Overall survival was selected as endpoint of interest. Among the 34 included papers which analysed this endpoint, we identified the four publications which have the highest weights to influence the final result. The validity of these papers was analysed using the CONSORT (Consolidated Standards of Reporting Trials) checklist for randomised controlled trials. We performed a new meta-analysis without the four studies in order to assess their impact on the general result of the original meta-analysis.

Results

The analysed four studies revealed several inconsistencies: inappropriate answers were found in up to 77% of the items of the CONSORT checklist. Unclear or inadequate randomisation, missing blinded set-up, conflict of interest and lacking intention-to-treat analysis were the most common findings. When performing a meta-analysis excluding the four criticised studies, postsurgical chemotherapy still showed a significant improvement in overall survival. Even when excluding all single studies with a statistically significant outcome by themselves and performing a meta-analysis on the remaining 26 studies, the result remains statistically significant.

Conclusion

The four most powerful publications in the Cochrane review show substantial deficits. We suggest a more critical appraisal regarding the validity of single studies. However, after the exclusion of these four studies, the result of the meta-analysis did not change.

Adjuvant treatment combining cellular immunotherapy with chemotherapy improves the clinical outcome of patients with stage II/III gastric cancer

Postsurgical relapse remains a common issue for resectable gastric cancer (GC). Here, we investigated the efficacy and safety of an adjuvant treatment combining chemotherapy with cellular immunotherapy (CIT) using autologous natural killer cells, γδT cells, and cytokine-induced killer cells in the treatment of stage II/III GC. A pilot prospective cohort study was conducted in 169 patients with stage II/III GC who had undergone gastrectomy with D2 lymph node dissection. Patients were assigned into two groups according to the patient choice of treatment, including chemotherapy alone (chemo) or chemotherapy combined with CIT (chemo/CIT). Disease-free survival (DFS), overall survival (OS), and adverse events were evaluated. Univariate and multivariate Cox models were used to analyze the impact of chemo/CIT on DFS and OS. Kaplan-Meier analysis with the log-rank test was used to compare the clinical outcome between two groups. Three-year DFS rate was 60.6% and 74.7% (P = 0.036) and 3-year OS rate was 64.9% and 83% (P = 0.051) for the chemo and chemo/CIT group, respectively. TNM stage and chemo/CIT were independent prognostic factors for both DFS (for TNM stage, P < 0.001, hazard ratio [HR]: 5.599, 95% confidence interval [CI]: 2.791-11.232; for chemo/CIT, P = 0.013, HR: 0.478, 95% CI: 0.266-0.858) and OS (for TNM stage, P < 0.001, HR: 6.559, 95% CI: 2.903-14.817; for chemo/CIT, P = 0.04, HR: 0.506, 95% CI: 0.264-0.970). In subgroup analysis, 3-year DFS and OS rates of patients with stage III GC in the chemo/CIT group were significantly higher than those in the chemo group (38.4% vs. 57.1%, P = 0.038; and 45.9% vs. 76%, P = 0.06, respectively), while there was no significant difference between the two groups in patients with stage II GC. Only 15.9% of patients (10/63) in the chemo/CIT group had mild and manageable fever (grades 1 and 2), while no other side effects were observed. The adjuvant treatment combining chemotherapy with cellular immunotherapy is well tolerated and significantly improves the clinical outcome of patients with stage II/III GC, when compared with chemotherapy alone, therefore warrants further attention in treatment for relapsed GC after tumor resection.

Antibacterial Activity of Essential Oils and Their Isolated Constituents against Cariogenic Bacteria: A Systematic Review

Dental caries remains the most prevalent and costly oral infectious disease worldwide. Several methods have been employed to prevent this biofilm-dependent disease, including the use of essential oils (EOs). In this systematic review, we discuss the antibacterial activity of EOs and their isolated constituents in view of a potential applicability in novel dental formulations. Seven databases were systematically searched for clinical trials, in situ, in vivo and in vitro studies addressing the topic published up to date. Most of the knowledge in the literature is based on in vitro studies assessing the effects of EOs on caries-related streptococci (mainly Streptococcus mutans) and lactobacilli, and on a limited number of clinical trials. The most promising species with antibacterial potential against cariogenic bacteria are: Achillea ligustica, Baccharis dracunculifolia, Croton cajucara, Cryptomeria japonica, Coriandrum sativum, Eugenia caryophyllata, Lippia sidoides, Ocimum americanum, and Rosmarinus officinalis. In some cases, the major phytochemical compounds determine the biological properties of EOs. Menthol and eugenol were considered outstanding compounds demonstrating an antibacterial potential. Only L. sidoides mouthwash (1%) has shown clinical antimicrobial effects against oral pathogens thus far. This review suggests avenues for further non-clinical and clinical studies with the most promising EOs and their isolated constituents bioprospected worldwide.

Perioperative chemotherapy in locally advanced gastric cancer

Gastric cancer is one of the most common cancers and a main cause of cancer-related death worldwide, since the majority of patients suffering of this malignancy are usually faced with a poor prognosis due to diagnosis at later stages. In order to improve treatment outcomes, the association of surgery with chemo and/or radiotherapy (multimodal therapy) has become the standard treatment for locally advanced stages. However, despite several treatment options currently available for management of these tumors, perioperative chemotherapy has been mainly accepted for the comprehensive therapeutic strategy including an appropriated D2-gastrectomy. This manuscript presents a (nonsystematic) critical review about the use of perioperative chemotherapy, with a special focus on the drugs delivery.

Post-surgical chemotherapy versus surgery alone for resectable gastric cancer

BACKGROUND

For gastric cancer surgery is the mainstay treatment. Chemotherapy seems to improve the survival results. But chemotherapy is not a complication-free therapy and its role has been questioned by some trials.

OBJECTIVES

To determine whether post-surgical chemotherapy should be used routinely in resectable gastric cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (July 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing post-surgical chemotherapy versus surgery alone for resectable gastric cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using the RevMan analysis software. We calculated the hazard ratio (HR) with 95% confidence interval (CI) based on intention-to-treat or available case analysis.

MAIN RESULTS

The authors identified 34 studies (7824 patients) reporting overall survival (OS) and only 15 reporting disease free survival (DFS) as well. Post-surgical chemotherapy showed an improvement in OS (HR 0.85; 95% CI 0.80 to 0.90) and an improvement in DFS (HR 0.79; 95% CI 0.72 to 0.87), although all the trials had a high risk of bias.The planned analysis of quality of life, return to work, and number of hospital admissions was impossible to complete as the outcome data for the analysis were not available from any trials.

AUTHORS' CONCLUSIONS

Post-surgical chemotherapy should be used routinely for resectable gastric cancer where possible. Further RCTs are needed to determine the role at each stage of disease.

Can adjuvant chemoradiotherapy replace extended lymph node dissection in gastric cancer?

Surgical resection remains the essential part in the curative treatment of gastric cancer. However, with surgery only, long-term survival is poor (5-year survival <25 % in Europe). Randomized studies, which compared limited (D1) lymph node dissection with more extended (D2) resections in the Western world, failed to show a survival benefit for more extensive surgery. A substantial increase in survival was found with perioperative chemotherapy in the MAGIC study. In addition, the SWOG/Intergroup 0116 study showed that postoperative chemoradiotherapy (CRT) prolonged 5-year overall survival compared to surgery only. However, it has been argued that surgical undertreatment undermined survival in this trial. In a randomized Korean study, patients with advanced stage gastric cancer who received postoperative CRT had better outcome after a D2 dissection. At our institute phase I-II studies with adjuvant cisplatin and capecitabine-based CRT have been performed in over 120 patients with resected gastric cancer. Retrospective comparison of patients treated in these studies with those that had surgery only in the D1D2 study, demonstrated that postoperative CRT was associated with better outcome, especially after D1 or a R1 resection. For daily practice, it remains unclear whether patients after optimal (D2) gastric surgery will benefit from postoperative CRT. This is currently being tested in prospective randomized phase III trials (CRITICS; TOPGEAR).

Docetaxel, cisplatin and fluorouracil (DCF) regimen compared with non-taxane-containing palliative chemotherapy for gastric carcinoma: a systematic review and meta-analysis

BACKGROUND

Gastric carcinoma (GC) is one of the highest cancer-mortality diseases with a high incidence rate in Asia. For surgically unfit but medically fit patients, palliative chemotherapy is the main treatment. The chemotherapy regimen of docetaxel, cisplatin and 5-fluorouracil (DCF) has been used to treat the advanced stage or metastatic GC. It is necessary to compare effectiveness and toxicities of DCF regimen with non-taxane-containing palliative chemotherapy for GC.

METHODS

PubMed, EmBase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure databases were searched to select relative randomized controlled trials (RCTs) comparing DCF to non-taxane-containing chemotherapy for patients with palliatively resected, unresectable, recurrent or metastatic GC. Primary outcome measures were 1-year and 2-year overall survival (OS) rates. Secondary outcome measures were median survival time (MST), median time to progression (TTP), response rate and toxicities.

RESULTS

Twelve RCTs were eligible and 1089 patients were analyzed totally (549 in DCF and 540 in control). DCF regimen increased partial response rate (38.8% vs 27.9%, p = 0.0003) and reduced progressive disease rate (18.9% vs 33.3%, p = 0.0005) compared to control regimen. Significant improvement of 2-year OS rate was found in DCF regimen (RR = 2.03, p = 0.006), but not of 1-year OS rate (RR = 1.22, p = 0.08). MST was significantly prolonged by DCF regimen (p = 0.039), but not median TTP (p = 0.054). Both 1-year OS rate and median TTP had a trend of prolongation by DCF regimen. Chemotherapy-related mortality was comparable (RR = 1.23, p = 0.49) in both regimens. In grade I-IV toxicities, DCF regimen showed a major raise of febrile neutropenia (RR = 2.33, p<0.0001) and minor raises of leucopenia (RR = 1.25, p<0.00001), neutropenia (RR = 1.19, p<0.00001), and diarrhea (RR = 1.59, p<0.00001), while in other toxicities there were no significant differences.

CONCLUSION

DCF regimen has better response than non-taxane containing regimen and could potentially improve the survival outcomes. The chemotherapy-related toxicity of DCF regimen is acceptable to some extent.

Neoadjuvant or adjuvant therapy for resectable gastric cancer: a systematic review and practice guideline for North America

BACKGROUND

Gastric cancer is a global health problem accounting for 10% of all new cancer cases and 12% of all cancer deaths worldwide. Many clinical trials and meta-analyses have explored the value of neoadjuvant or adjuvant chemotherapy and radiation therapy in gastric cancer; however, these studies have produced conflicting results. The purpose of this guidance document was to determine whether patients with resectable gastric cancer should receive neoadjuvant or adjuvant therapy in addition to surgery. Outcomes of interest were overall survival, disease-free survival, and adverse events.

METHODS

A systematic review was undertaken to inform recommendations regarding neoadjuvant and adjuvant therapy in resectable gastric cancer in Ontario, Canada. MEDLINE and EMBASE databases, as well as American Society of Clinical Oncology (ASCO) annual meeting proceedings and American Society for Therapeutic Radiology and Oncology (ASTRO) proceedings were systematically searched from 2002 to 2010. Oral fluoropyrimidine trials were excluded owing to the unavailability of these agents in North America.

RESULTS

Overall, 22 randomized controlled trials (RCTs), 13 meta-analyses, and two secondary analyses were included. The systematic review informed the development of a clinical practice guideline with the following recommendations. Postoperative 5-fluorouracil-based chemoradiotherapy based on the Macdonald approach or perioperative ECF (epirubicin, cisplatin, fluorouracil) chemotherapy based on the Cunningham/MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) approach are both acceptable standards of care in North America. Choice of treatment should be made on a case-by-case basis. Adjuvant chemotherapy is a reasonable option for those patients for whom the Macdonald and MAGIC protocols are contraindicated. All patients with resectable gastric cancer should undergo a pretreatment multidisciplinary assessment to determine the best plan of care.

CONCLUSIONS

Overall survival in patients with resectable gastric cancer is significantly improved with the use of either postoperative chemoradiation (Macdonald approach) or perioperative ECF (MAGIC protocol).

Quality of care indicators for the surgical treatment of gastric cancer: a systematic review

BACKGROUND

Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer.

METHODS

A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators.

RESULTS

A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection.

CONCLUSIONS

Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.

Treatment of resectable gastric cancer

Stomach cancer is one of the most common cancers worldwide, despite its declining overall incidence. Although there are differences in incidence, etiology and pathological factors, most studies do not separately analyze cardia and noncardia gastric cancer. Surgery is the only potentially curative treatment for advanced, resectable gastric cancer, but locoregional relapse rate is high with a consequently poor prognosis. To improve survival, several preoperative and postoperative treatment strategies have been investigated. Whereas perioperative chemotherapy and postoperative chemoradiation (CRT) are considered standard therapy in the Western world, in Asia postoperative monochemotherapy with S-1 is often used. Several other therapeutic options, although generally not accepted as standard treatment, are postoperative combination chemotherapy, hyperthermic intraperitoneal chemotherapy and preoperative radiotherapy and CRT. Postoperative combination chemotherapy does show a statistically significant but clinically equivocal survival advantage in several meta-analyses. Hyperthermic intraperitoneal chemotherapy is mainly performed in Asia and is associated with a higher postoperative complication rate. Based on the currently available data, the use of postoperative radiotherapy alone and the use of intraoperative radiotherapy should not be advised in the treatment of resectable gastric cancer. Western randomized trials on gastric cancer are often hampered by slow or incomplete accrual. Reduction of toxicity for preoperative and especially postoperative treatment is essential for the ongoing improvement of gastric cancer care.

HIF-1alpha is an unfavorable determinant of relapse in gastric cancer patients who underwent curative surgery followed by adjuvant 5-FU chemotherapy

Among several chemotherapeutic agents, 5-fluorouracil (5-FU) has been widely used as a key drug in adjuvant chemotherapy for gastric cancer. However, no reliable marker, which predicts the response to 5-FU in an adjuvant setting, has been identified. Hypoxia-induced drug resistance, via upregulation of HIF-1alpha, is a major obstacle in the development of effective cancer therapy. However, few clinical studies have so far assessed the relationship between the HIF-1alpha expression and the chemo-resistance of gastric cancer patients in an adjuvant setting. We established 2 HIF-1alpha knockdown gastric cancer cell lines in order to clarify the role of HIF-1alpha in chemo-resistance against 5-FU. Furthermore, expression of HIF-1alpha was immunohistochemically assessed in 91 resected specimens. Sixty-four of 91 patients received 5-FU adjuvant chemotherapy after surgery. HIF-1alpha expression was associated with the significantly shorter relapse-free survival and disease-specific survival in the 64 patients of adjuvant group (p = 0.026, 0.014, respectively), but not in the 27 of surgery group. Multivariate analysis showed that HIF-1alpha was an independent risk factor for relapse in 64 patients in the adjuvant group (p = 0.029). In conclusion, the current study confirmed, for the first time that HIF-1alpha expression is an independent risk factor for relapse in high-risk gastric cancer patients who underwent curative surgery followed by adjuvant 5-FU chemotherapy. A favorable effect of 5-FU might therefore be expected in patients that do not express HIF-1alpha, whereas, other types of chemotherapy or additional treatments, such as HIF-1alpha inhibitors, should be considered in patients that do express HIF-1alpha.

R0 resection in the treatment of gastric cancer: Room for improvement

Gastric carcinoma is one of the most frequent malignancies in the world and its clinical behavior especially depends on the metastatic potential of the tumor. In particular, lymphatic metastasis is one of the main predictors of tumor recurrence and survival, and current pathological staging systems reflect the concept that lymphatic spread is the most relevant prognostic factor in patients undergoing curative resection. This is compounded by the observation that two-thirds of gastric cancer in the Western world presents at an advanced stage, with lymph node metastasis at diagnosis. All current therapeutic efforts in gastric cancer are directed toward individualization of therapeutic protocols, tailoring the extent of resection and the administration of preoperative and postoperative treatment. The goals of all these strategies are to improve prognosis towards the achievement of a curative resection (R0 resection) with minimal morbidity and mortality, and better postoperative quality of life.

Adjuvant FOLFOX-4 in patients with radically resected gastric cancer: Tolerability and prognostic factors

The aim of the present study was to evaluate the toxicity and efficacy of the FOLFOX-4 regimen as adjuvant chemotherapy in patients with gastric cancer after radical surgery. Fifty-four patients (1 stage Ib, 6 stage II, 22 stage IIIa, 14 stage IIIb and 11 stage IV) received 8-12 cycles of FOLFOX-4 (oxaliplatin 85 mg/m(2), Day 1; leucovorin 100 mg/m(2) i.v., Days 1 and 2; 5-fluorouracil 400 mg/m(2) i.v. bolus, Days 1 and 2 and 600 mg/m(2) in 22 h i.v. continuous infusion, Days 1 and 2; every 14 days). Toxicity was recorded at each cycle according to the National Cancer Institute Common Toxicity Criteria. Disease-free (DFS) and overall survival (OS) were calculated according to the Kaplan-Meier method. Thirty-eight patients (70.4%) completed the prescribed number of cycles of chemotherapy. The toxicity was mild. Grade 3-4 neutropenia occurred in 57% of patients, thrombocytopenia and anemia in 2% of cases. Peripheral neuropathy was experienced by 46% of the patients (grade 4 in 2% of cases). Five patients experienced grade 3 gastrointestinal toxicity. After a median follow-up of 33.1 months, 17 patients relapsed and 17 succumbed to the disease. The mean observed DFS and OS were 49.7 months (range 40.7-58.8) and 57.9 months (range 49.6-66.2), respectively. At univariate analysis, females and patients who had received <8 cycles of chemotherapy had a significantly worse probability of DFS and OS. The Cox model showed gender to be independent of the factors affecting DFS. Adjuvant FOLFOX-4 is feasible and well-tolerated in patients radically resected for gastric cancer. Receiving <4 months of adjuvant FOLFOX-4 could be detrimental to prognosis.

Meta-analysis of adjuvant chemotherapy after radical surgery for advanced gastric cancer

BACKGROUND

There is no consensus of opinion about postoperative adjuvant chemotherapy after radical surgery for advanced gastric cancer. This is a meta-analysis of the published results of relevant randomized clinical trials (RCTs).

METHODS

Electronic databases from January 1998 to December 2007 were searched and 12 RCTs were selected. These included a total of 3809 patients. The hazard ratio (HR) for overall survival was calculated.

RESULTS

The pooled HR for overall survival was 0.78 (95 per cent confidence interval 0.71 to 0.85) in favour of chemotherapy. Subgroup analysis showed that the advantage of chemotherapy was not influenced by depth of tumour infiltration, status of lymph node metastasis, type of lymphadenectomy, geographical distribution of patients or route of drug administration.

CONCLUSIONS

Postoperative chemotherapy can improve overall survival after radical surgery for gastric cancer; there is no standardized chemotherapy regimen. Japanese-style D2 radical surgery plus oral 5-fluorouracil appears an effective treatment at present.

Association of ERBB2 gene status with histopathological parameters and disease-specific survival in gastric carcinoma patients

The clinical significance of ERBB2 amplification/overexpression in gastric cancer remains unclear. In this study, we evaluated the ERBB2 status in 463 gastric carcinomas using immunohistochemistry (IHC) and fluorescence in situ hybridisation (FISH), and compared the findings with histopathological characteristics and with disease-specific survival. ERBB2 overexpression (2+ and 3+) and amplification (ratio ERBB2/CEP17⩾2) were found in 43 (9.3%) and 38 (8.2%) gastric carcinomas, respectively. Perfect IHC/FISH correlation was found for the 19 cases scored as 0 (all negative by FISH), and also for the 25 cases scored as 3+ (all positive by FISH). One out of six carcinomas scored as 1+ and 12 out of 18 carcinomas scored as 2+ were positive by FISH. ERBB2 amplification was associated with gastric carcinomas of intestinal type (P=0.007) and with an expansive growth pattern (P=0.021). ERBB2 amplification was detected in both histological components of two mixed carcinomas, indicating a common clonal origin. A statistically significant association was found between ERBB2 amplification and worse survival in patients with expansive gastric carcinomas (P=0.011). We conclude that ERBB2 status may have clinical significance in subsets of gastric cancer patients, and that further studies are warranted to evaluate whether patients whose gastric carcinomas present ERBB2 amplification/overexpression may benefit from therapy targeting this surface receptor.

Four consecutive multicenter phase II trials of adjuvant chemoradiation in patients with completely resected high-risk gastric cancer: the experience of the German AIO/ARO/CAO group

PURPOSE

Feasibility and efficacy of four different adjuvant radiochemotherapy regimens in patients with completely resected gastric cancer were evaluated in consecutive cooperative phase II trials using different 5-fluorouracil (5-FU)-based combination chemotherapies (CTX) and 5-FU-enhanced radiotherapy.

METHODS

Between 2000 and 2005, 157 patients with completely resected gastric adenocarcinoma were included. The study design was based on two cycles of CTX and irradiation with 45 Gy plus concomitant 5-FU 225 mg/m(2) per 24 h between these two cycles. CTX cycles consisted of 5-FU, folinic acid (FA), cisplatin plus paclitaxel (FLPP); 5-FU, FA and cisplatin (FLP); 5-FU, FA and irinotecan (FLI); or 5-FU, cisplatin plus docetaxel (FPD).

RESULTS

Median follow-up for all four trials was 18 months (range, 1-64) without significant difference between the four regimens: FLPP 30 months (2-46+), FLP 18 months (1-64+), FLI 15 months (1-26), FPD 10 months (5-19+). Treatment associated toxicity was tolerable and did not differ significantly between the four CTX regimens. Across all patients grade (3/4), toxicities during the first cycle/chemoradiation/second cycle consisted of leukocytopenia 4%/2%/30%, anorexia 5%/10%/6%, diarrhea 6%/1%/3%, nausea 2%/7%/2%. Early death occurred in one patient due to Pneumocystis carinii pneumonia. Median progression free survival was 23 months for FLPP, 18 months for FLP, 14 months for FLI, 9 months for FPD (not significant). One-year-overall survival rates were 95% for FLPP, 82% for FLP, 94% for FLI, 86% for FPD.

CONCLUSION

Adjuvant radiochemotherapy in patients with gastric cancer can be safely given continuous infusion of 5-FU at 225 mg/m(2) per day. In addition, a variety of 5-FU-based multiagent chemotherapy regimen with defined activity in gastric cancer appears both safe and effective when given prior and after radiochemotherapy in this setting.

The role of postoperative adjuvant chemotherapy following curative resection for gastric cancer: a meta-analysis

To evaluate the effect of adjuvant chemotherapy on survival rates after curative resection of gastric cancer, MEDLINE (1969-2006), EMBASE (1974-2006), bibliographies, and review articles were searched for relevant articles. The meta-analysis was finally based on 15 trials that included 3212 patients. RR for death in the treated group was 0.90 (95% CI, 0.84-0.96) (P = 0.0010). Little or no significant benefits were suggested in subgroup analyses between different population and regimens either. Postoperative adjuvant chemotherapy for gastric cancer confers slightly significant benefits compared to the surgery only group. The prognoses after surgery may differ among various population groups or because of different regimens.

Pharmacotherapy for oesophagogastric cancer

Gastric cancer is the seventh and oesophageal cancer the ninth most common cancer in the UK, and >50% of patients present with locally advanced or metastatic disease. The incidence of oesophageal and oesophagogastric junctional tumours is increasing, making these important disease entities to understand and research. Despite improvements in surgical and peri-operative supportive care, 3-year overall survival with surgery alone for resectable disease is still poor. Outcomes in localised oesophageal cancer are improved with pre-operative chemotherapy, and in gastric cancer with peri-operative treatment or post-operative chemoradiotherapy. Oesophageal squamous cell carcinoma can be treated with definitive chemoradiotherapy as an alternative to surgery. While survival in patients presenting with metastatic disease is improved with the addition of systemic chemotherapy, median survival remains <1 year. Patients who are otherwise fit can be offered chemotherapy and this is superior to best supportive care. Regimens including a platinum and an anthracycline agent are favoured by the results of randomised trials. No standard second-line therapy has emerged. New research into taxanes has shown promising anti-cancer activity, and novel areas of investigation include incorporation of agents targeting vascular endothelial growth factor or epidermal growth factor receptor into standard regimens. This review focuses on the clinical trial evidence that dictates the optimal management of localised and advanced oesophagogastric cancer, focusing on pharmacotherapy. We examine areas of current research and highlight future therapeutic directions.

Advances in the treatment of patients with gastric adenocarcinoma

Despite a decline in its incidence in the Western world, gastric cancer (GC) remains the fourth most frequent cancer diagnosis worldwide and is, after lung cancer, the second leading cause of death from a malignant disease globally. Based on the published literature, treatment guidelines and reports from international meetings, we here review the current treatment options for GC and discuss insights and perspectives from the latest clinical studies. The management of GC in the early stages of the disease is based on an optimal surgical resection of the primary tumor and the regional lymph nodes. However, less than one third of patients have a resectable disease at diagnosis and among those operated, more than half are not cured by surgery alone, due to a high rate of relapse. Thus, for the majority of patients, systemic cytotoxic therapy, and sometimes radiotherapy, is a treatment option both as an adjunct to surgery and in the palliative setting. Adjuvant chemotherapy offers only a marginal benefit and has not become a standard of care in the West. In North America, adjuvant chemoradiation is broadly used, shown to significantly improve overall survival, albeit with the cost of high toxicity. Furthermore, a recently reported study from the United Kingdom demonstrated a significant disease-free and survival benefit by the use of perioperative combination chemotherapy. Several chemotherapeutic agents have been tested as a palliative therapy in advanced GC including 5- fluorouracil (5-FU), oral pyrimidines, platinum derivatives, anthracyclines, taxanes and camptothecans. It is now accepted that chemotherapy is better than best supportive care only and that 5-FU based combinations are more effective than monotherapy. However, the response rates have generally been moderate and there is no consensus on the optimal combination of cytotoxic agents and the potential role of more recently developed "targeted therapies".

Docetaxel and oxaliplatin combination in second-line treatment of patients with advanced gastric cancer

BACKGROUND

In advanced gastric cancer few data are available on the efficacy or safety of new drug combination regimens after progression following first-line chemotherapy.

METHODS

Patients with histologically confirmed advanced gastric cancer and Eastern Cooperative Oncology Group (ECOG) performance status (PS) less than 2, progressing after first-line chemotherapy, were eligible. Patients were treated with docetaxel 75 mg/m(2) on day 1 and oxaliplatin 80 mg/m(2) on day 2, every 3 weeks, until progression or unacceptable toxicity.

RESULTS

Between May 2002 and April 2005, 38 patients were enrolled. Men accounted for 73.7% of the patients and the median age was 59 years. The primary tumor was not resected in 47.4% of the patients; the peritoneum was the most frequent metastatic site (60.5%). The first-line treatment was cisplatin, epirubicin, and infusional 5-fluorouracil (ECF) in 81.5% of the patients and cisplatin and infusional 5-fluorouracil (CF) in 15.7%. The median number of cycles was 4.3. The treatment was well tolerated, with no toxic deaths. National Cancer Institute (NCI) grade III-IV neutropenia was frequent (26.3%), but no febrile neutropenia was reported. Severe asthenia (15.7%) and severe nausea (15.7%) required dose reductions in 2 patients and treatment discontinuation in another. The overall response rate was 10.5%, and 18 patients (47.3%) experienced disease stabilization (7 of them with significant clinical benefit). Median time to progression was 4.0 months (range, 2-8 months) and median overall survival was 8.1 months (range, 3-26 months). Thirteen patients (34.2%) also received third-line chemotherapy, with an irinotecan-containing regimen, and their median overall survival was higher than that of the other patients (16.3 vs 6.0 months)

CONCLUSION

The combination of oxaliplatin and docetaxel shows only marginal activity as second-line treatment, but it has a good tolerability profile. This suggests that there is room for optimizing the schedule as well as for planning sequential treatments in gastric cancer.

Reflections on adjuvant treatment of gastric cancer

Gastric cancer constitutes a significant health problem in the world due to its high incidence in certain geographical areas. The basic treatment of this tumor in its localized stages is surgery. Unfortunately, survival is less than 5 years, despite radical surgery. Radical and extensive surgery has proved to be crucial to survival, although there is no agreement on the need for reaching the nodes until there is more than 3 cm of tumor. However, even with the most extensive surgery, survival does not reach more than approximately 35% at 5 years, if we consider all the localized stages. Adjuvant treatment is therefore necessary for this neoplasm. The role of post-operative chemotherapy, as that of radiochemotherapy, is not well established and there is no standard. However, there is relative evidence of the benefit of adjuvant treatment in some chemotherapy studies and in combination with radiotherapy, so that it is an option for treatment in these patients.

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

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

Review of capecitabine as oral treatment of gastric, gastroesophageal, and esophageal cancers

Capecitabine is a novel, orally administered fluoropyrimidine carbamate that has been approved for adjuvant treatment in patients with Stage III colon cancer, first-line metastatic colorectal cancer, and metastatic breast cancer, both as a single agent (for patients who are resistant to paclitaxel and anthracyclines) and in combination with docetaxel (after failure on anthracycline-based therapy). Capecitabine is being investigated in Phase I and II trials for the treatment of gastric, gastroesophageal, and esophageal cancers, primarily in the first-line metastatic setting but also in the adjuvant setting. The MEDLINE data base was searched for English-language clinical trials that were published from 1996 through October 2005 along with relevant abstracts that were presented at the American Society of Clinical Oncology and at meetings of the European Cancer Conference and the European Society of Medical Oncology. The most frequently investigated combinations were capecitabine with docetaxel, paclitaxel, cisplatin, or oxaliplatin, and capecitabine also has been combined with irinotecan. These therapies have yielded efficacy data that compare favorably with data from Phase III trials of parenteral 5-fluorouracil (5-FU) in the first-line metastatic setting, and they mostly are well tolerated. Capecitabine, when combined in doses <1250 mg/m(2) twice daily, consistently resulted in a lower frequency of Grade 3 or 4 toxic effects. Capecitabine, as a representative of oral fluoropymidine, is a promising agent in gastroesophageal cancers. Although some Phase III trials are completed, additional Phase III trials of capecitabine-based combinations that compare its efficacy and safety with parenteral 5-FU-based combinations, in both first-line metastatic and adjuvant settings, would be important.

Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG

BACKGROUND

In patients who underwent radical resection for gastric cancer, we investigate the relative efficacy of combined 5-fluorouracil+adriamycin or epirubicin and methotrexate with leucovorin rescue (FAMTX or FEMTX) compared with a control arm.

PATIENTS AND METHODS

This report is a prospective combined analysis of two randomized clinical trials conducted on patients who underwent radical resection for histologically proven adenocarcinoma of the stomach or esophago-gastric junction. Three hundred and ninety-seven untreated patients, 206 from 23 European Organization for Research and Treatment of Cancer (EORTC) institutions and 191 from 16 International Collaborative Cancer Group (ICCG) institutions, were randomized. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and the treatments were compared for these end-points by means of the log-rank test, retrospectively stratified by trial.

RESULTS

In a planned combined analysis of the two trials, no significant differences were found between the treatment and control arms for either DFS (hazards ratio: 0.98, P=0.87) or OS (hazards ratio: 0.98, P=0.86). The 5-year OS was 43% in the treatment arm and 44% in the control arm and the 5-year DFS was 41% and 42%, respectively.

CONCLUSION

Neither FAMTX nor FEMTX can be advocated as adjuvant treatment in patients who undergo resection for gastric cancer.

Gastric cancer

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.

Perioperative adjunctive treatment in the management of operable gastric cancer

Outcome in the management of clinically resectable gastric carcinoma has been disappointing, at least in Western populations, despite increasingly radical surgery and extensive experience with adjunctive perioperative treatment with innumerable single and combined modality regimens. The United States Intergroup Study, a prospective, randomized, controlled trial of adjuvant chemoradiation, demonstrated significant improvement in disease-free and overall survival. Consequently, this regimen of postoperative fluoruracil plus leucovorin and locoregional radiation has been incorporated into current clinical practice. In hopes of further improving cure rates, many other regimens are under investigation, including the efficacy of neoadjuvant therapy alone, combined neoadjuvant and adjuvant therapy, and adjuvant therapy alone. In these clinical trials, therapeutic agents are prescribed alone or in multimodal regimens and include systemic chemotherapy, intraperitoneal (IP) chemotherapy with or without hyperthermia, intraoperative radiotherapy (IORT), and postoperative external beam irradiation. Several molecular markers have been identified, which seem to predict that a given tumor may be effective or resistant to a drug, raising the possibility of customized chemotherapy regimens. Preclinical studies suggest potential efficacy of angiogenesis inhibitors, monoclonal antibodies, and antisense agents.

Gastric adenocarcinoma: review and considerations for future directions

OBJECTIVE

This update reviews the epidemiology and surgical management, and the controversies of gastric adenocarcinoma. We provide the relevance of outcome data to surgical decision-making and discuss the application of gene-expression analysis to clinical practice.

SUMMARY BACKGROUND DATA

Gastric cancer mortality rates have remained relatively unchanged over the past 30 years, and gastric cancer continues to be one of the leading causes of cancer-related death. Well-conducted studies have stimulated changes to surgical decision-making and technique. Microarray studies linked to predictive outcome models are poised to advance our understanding of the biologic behavior of gastric cancer and improve surgical management and outcome.

METHODS

We performed a review of the English gastric adenocarcinoma medical literature (1980-2003). This review included epidemiology, pathology and staging, surgical management, issues and controversies in management, prognostic variables, and the application of outcome models to gastric cancer. The results of DNA microarray analysis in various cancers and its predictive abilities in gastric cancer are considered.

RESULTS

Prognostic studies have provided valuable data to better the understanding of gastric cancer. These studies have contributed to improved surgical technique, more accurate pathologic characterization, and the identification of clinically useful prognostic markers. The application of microarray analysis linked to predictive models will provide a molecular understanding of the biology driving gastric cancer.

CONCLUSIONS

Predictive models generate important information allowing a logical evolution in the surgical and pathologic understanding and therapy for gastric cancer. However, a greater understanding of the molecular changes associated with gastric cancer is needed to guide surgical and medical therapy.

Stable transfection of extrinsic Smac gene enhances apoptosis-inducing effects of chemotherapeutic drugs on gastric cancer cells

AIM: To explore the feasibility of enhancing apoptosis-inducing effects of chemotherapeutic drugs on human gastric cancer cells by stable transfection of extrinsic Smac gene.

METHODS: After Smac gene was transferred into gastric cancer cell line MKN-45, subclone cells were obtained by persistent G₄₁₈ selection. Cellular Smac gene expression was determined by RT-PCR and Western blotting. After treatment with mitomycin (MMC) as an apoptotic inducer, in vitro cell growth activities were investigated by trypan blue-staining method and MTT colorimetry. Cell apoptosis and its rates were determined by electronic microscopy, annexin V-FITC and propidium iodide staining flow cytometry. Cellular caspase-3 protein expression and its activities were assayed by Western blotting and colorimetry.

RESULTS: When compared with MKN-45 cells, the selected subclone cell line MKN-45/Smac had significantly higher Smac mRNA (3.12±0.21 vs 0.82±0.14, t = 7.52, P<0.01) and protein levels (4.02±0.24 vs 0.98±0.11, t = 8.32, P<0.01). After treatment with 10 μg/mL MMC for 6-24 h, growth inhibition rate of MKN-45/Smac (15.8±1.2-54.8±2.9%) was significantly higher than that of MKN-45 (5.8±0.4- 24.0±1.5%, t = 6.42, P<0.01). Partial MKN-45/Smac cancer cells presented characteristic morphological changes of apoptosis under the electronic microscope with an apoptosis rate of 36.4±2.1%, which was significantly higher than that of MKN-45 (15.2±0.8%, t = 9.25, P<0.01). Compared with MKN-45, caspase-3 expression levels in MKN-45/Smac were improved significantly (3.39±0.42 vs 0.96±0.14, t = 8.63, P<0.01), while its activities were 3.25 times as many as those of MKN-45 (0.364±0.010 vs 0.112±0.007, t = 6.34, P<0.01).

CONCLUSION: Stable transfection of extrinsic Smac gene and its over-expression in gastric cancer cell line can significantly enhance cellular caspase-3 expression and activities, ameliorate apoptosis-inducing effects of mitomycin C on cancer cells, which is a novel strategy to improve chemotherapeutic effects on gastric cancer.

Randomized multicenter phase II trial of a biweekly regimen of fluorouracil and leucovorin (LV5FU2), LV5FU2 plus cisplatin, or LV5FU2 plus irinotecan in patients with previously untreated metastatic gastric cancer: a Federation Francophone de Cancerologie Digestive Group Study--FFCD 9803

PURPOSE

To determine the efficacy and safety of a biweekly regimen of leucovorin (LV) plus fluorouracil (FU) alone or in combination with cisplatin or irinotecan in patients with previously untreated metastatic gastric adenocarcinoma and to select the best arm for a phase III study.

PATIENTS AND METHODS

One hundred thirty-six patients (two were ineligible) were enrolled onto the randomized multicenter phase II trial. Patients received LV 200 mg/m(2) (2-hour infusion) followed by FU 400 mg/m(2) (bolus) and FU 600 mg/m(2) (22-hour continuous infusion) on days 1 and 2 every 14 days (LV5FU2; arm A), LV5FU2 plus cisplatin 50 mg/m(2) (1-hour infusion) on day 1 or 2 (arm B), or LV5FU2 plus irinotecan 180 mg/m(2) (2-hour infusion) on day 1 (arm C).

RESULTS

The overall response rates, which were confirmed by an independent expert panel, were 13% (95% CI, 3.4% to 23.3%), 27% (95% CI, 14.1% to 40.4%), and 40% (95% CI, 25.7% to 54.3%) for arms A, B, and C, respectively. Median progression-free survival and overall survival times were 3.2 months (95% CI, 1.8 to 4.6 months) and 6.8 months (95% CI, 2.6 to 11.1 months) with LV5FU2, respectively; 4.9 months (95% CI, 3.5 to 6.3 months) and 9.5 months (95% CI, 6.9 to 12.2 months) with LV5FU2-cisplatin, respectively; and 6.9 months (95% CI, 5.5 to 8.3 months) and 11.3 months (95% CI, 9.3 to 13.3 months) with LV5FU2-irinotecan, respectively.

CONCLUSION

Of the three regimens tested, the combination of LV5FU2-irinotecan is the most promising and will be assessed in a phase III trial.

An inhibitor of p53 protects intestinal epithelial cells against apoptosis induced by hyperthermic chemotherapy

AIM: To investigate the effect of PFT-a (p53 inhibitor, PFT-a) on apoptosis and apoptosis-associated gene expression in intestinal epithelial cells (IECs) induced by hyperthermic chemotherapy.

METHODS: Primary cultured IECs were divided into control(CON), hyperthermic chemotherapy (HTC) and PFT-a plus hyperthermic chemotherapy group (PFT-a, HTC). IECs in HTC group were treated with hyperthermic (43 ℃) cisplatin (terminal concentration 10 mg/L) for 30 min. IECs in PFT-a, HTC group were treated with different dosages (10, 20, 30, 40 mmol/L) of PFT-a 4 h before treated the same as those in HTC group. The rate of apoptosis was detected using flow cytometry after double staining of annexin V-FITC and PI. The expression of p53 and Bax protein were detected by Western blotting, and the level of bax mRNA expression was detected using semi-quantitative RT-PCR.

RESULTS: PFT-a reduced apoptotic rate of IECs in a dose-dependant manner, from (14.83 ±1.51%) at the concentration of 10mmol/L to (3.75±0.33%) at 40 mmol/L, which were significantly lower than the rate in HCT group(27.03 ±2.07%, P <0.01). The ratio of p53 in the nucleus and cytoplasm was 13.22:1 in HCT group. However, the ratio in PFT-a, HTC group decreased from 0.8:1 at the concentration of 10 mmol/L to 0.4:1 at 40 mmol/L, which were significantly lower than that in HCT group. Hyperthermic chemotherapy upregulated the levels of bax mRNA (128.85±2.38) and protein (14.29 ±0.43) in IECs, whereas PFT-a significantly reduced (P <0.01) those levels in a dose-dependant manner, from 106.98±3.75 (mRNA) and 5.79±0.24 (protein) at the concentration of 10 mmol/L to 4.79±0.31 (mRNA) and 1.36±0.09 (protein) at 40 mmol/L respectively.

CONCLUSION: PFT-a effectively inhibits apoptosis of IECs induced by hyperthermic chemotherapy. The mechanisms may relate to its effect on changing the nuclear translocation of p53and inhibiting the expression of bax gene.

MAPK signal transduction and apoptosis of human gastric carcinoma cells induced by liposomes of survivin antisense oligonucleotide

AIM: To study the relation of mitogen-activated protein kinase (MAPK) signal transduction and apoptosis of human gastric carcinoma cells HS-746T induced by liposomes of survivin antisense oligonucleotide (ASODN).

METHODS: Survivin ASODN was designed and synthesised to transfect human gastric carcinoma cells HS-746T. The cultured cells were divided into 6 groups: vacuity control group, liposome and sense oligonucleotide (SODN) group, 100, 200 and 400 nmoL/L ASODN group and P38MAPK, extracellular signal-regulated kinase 1/2 (ERK1/2) inhibitor groups. Apoptotic index (AI) and proliferative index (PI) were examined by flow cytometry after transfection 2, 4, 8, 12, 24 and 48 h. RT-PCR, immunocytochemical stain, Western blot, immuno-precipitation and kinase activity assay were used to detect protein expression and activity of P38MAPK, ERK1/2, survivin and survivin mRNA after transfection.

RESULTS: Expression of ERK1/2 and P38MAPK has not significantly different among vacuity control group, liposomes group and SODN group. The apoptotic cells increased in anisoconcentration survivin ASODN groups and AI was higher than that of other control group. Apoptotic cells decreased in P38MAPK inhibitor group while increased in ERK1/2. The protein and mRNA expression of survivin decreased when transfection concentration was increased. The phosphorylated and nonphosphorylated ERK1/ 2 showed a dose-and time-dependent decrease whereas protein level of p38MAPK remained unchanged, but activity increased.

CONCLUSION: Survivin ASODN can induce apoptosis of human gastric carcinoma cells in vitro though MAPK signal transduction including activating apoptosis-related signal P38MAPK and suppressing proliferation-related signal ERK1/2.

Clinical efficacy and mechanism of oxaliplatin in treating human gastric carcinoma

AIM

To evaluate the therapeutic effect of oxaliplatin on human gastric carcinoma and to explore the mechanisms.

METHODS

22 cases of stage IV gastric carcinoma patients received 4-6 (mean 4.6) cycles of first line combined chemotherapy with oxaliplatin (oxaliplatin 85 mg/m², ivgtt, 1 h, d 1; leukovorin 200 mg/m², iv, gtt, 1 h, d 1-5; 5-FU 300 mg/m², iv, d 1-2; 5-FU, continuously iv, gtt, 48 h; 1 cycle/2w). Response rate, progression-free survival (PFS), total survival time, toxic side effects were evaluated. The inhibitory effect of oxaliplatin on human gastric cell line SGC-7901 was calculated by MTT and IC50 was measured. Flow cytometry and TUNEL were applied to evaluate the apoptosis of cell line induced by the drug. The expression of caspase-3 mRNA was detected by RT-PCR.

RESULTS

Total response (complete and partial) occurred in 9 (40.9%) patients. Mean PFS was 4.2 months and mean total survival time was 7.2 months. Cumulative neurotoxicity (all grade I-II), vomiting and diarrhea, myelosuppression appeared in 93.5%, 20%, 32.9% of the patients, respectively. Apoptosis index was elevated after incubating with 1 mmol/L oxaliplatin for 30 min, but without statistic significance (P>0.05), but was much higher both by flowcytometry and TUNEL with statistical significance (P<0.05) after incubating with 1 mmol/L oxaliplatin for 2 days. Caspase-3 mRNA expression was elevated in oxaliplatin treated cells and correlated with apoptosis induced by the drug.

CONCLUSION

Oxaliplatin is effective and well-tolerated on human advanced gastric carcinoma. Oxaliplatin could significantly inhibit the growth of human gastric cell line SGC-7901, inducing caspase-3 mRNA expression and cell apoptosis.

Screening and identification of mimotope of gastric cancer associated antigen MGb1-Ag

AIM: Using a monoclonal antibody against gastric cancer antigen named MGb1 to screen a phage-displayed random peptide library fused with coat protein pIII in order to get some information on mimotopes.

METHODS: Through affinity enrichment and ELISA screening, positive clones of phages were amplified. 10 phage clones were selected after three rounds of biopanning and the ability of specific binding of the positive phage clones to MGb1-Ab were detected by ELISA assay (DNA sequencing was performed and the amino acid sequences were deduced) By blocking test, specificity of the mimic phage epitopes was identified.

RESULTS: There were approximately 200 times of enrichment about the titer of bound phages after three rounds of biopanning procedures. DNA of 10 phage clones after the third biopanning was assayed and the result showed that the positive clones had a specific binding activity to MGb1-Ab and a weak ability of binding to control mAb or to mouse IgG. DNA sequencing of 10 phage clones was performed and the amino acid sequences were deduced. According to the homology of the amino acid sequences of the displayed peptides, most of the phage clones had motifs of H(x)Q or L(x)S. And these 10 phage clones could also partly inhibit the binding of MGb1-Ab to gastric cancer cell KATO-III. The percentage of blocking was from (21.0 ± 1.6)% to (39.0 ± 2.7)%.

CONCLUSION: Motifs of H(x)Q and L(x)S selected and identified show a high homology in the mimic epitopes of gastric cancer associated antigen. There may be one or more clones which can act as candidates of tumor vaccines.

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