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Kamal MV, Rao M, Damerla RR, Pai A, Sharan K, Palod A, Shetty PS, Usman N, Kumar NAN. A Mechanistic Review of Methotrexate and Celecoxib as a Potential Metronomic Chemotherapy for Oral Squamous Cell Carcinoma. Cancer Invest 2023; 41:144-154. [PMID: 36269850 DOI: 10.1080/07357907.2022.2139840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The combination of low-dose methotrexate and celecoxib as metronomic chemotherapy (MCT) is a novel therapy, believed to act by modulating the immune response, inhibiting angiogenesis and its cytotoxic action, though the exact mechanism of action is unclear. Clinically, MCT was found to be very effective in delaying tumor progression in patients with head and neck squamous cell carcinoma in both curative and palliative settings. This review was aimed to give a brief insight into the mechanism of action and potential molecular alterations of MCT in the treatment of oral cancers taking into consideration the various in vivo and in vitro studies.
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Affiliation(s)
- Mehta Vedant Kamal
- Department of Surgical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Rama Rao Damerla
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Ananth Pai
- Department of Medical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Krishan Sharan
- Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Akhil Palod
- Department of Surgical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Preethi S Shetty
- Department of Surgical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Nawaz Usman
- Department of Surgical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Naveena A N Kumar
- Department of Surgical Oncology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
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Oral metronomic chemotherapy after definitive chemoradiation in esophageal squamous cell carcinoma: a randomized clinical trial. Esophagus 2022; 19:670-682. [PMID: 35614161 DOI: 10.1007/s10388-022-00923-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Improving outcomes in locally advanced esophageal/GEJ squamous cell cancer (SCC) is an unmet need. We investigated the addition of oral metronomic chemotherapy (OMC) following definitive chemoradiotherapy (CRT). MATERIALS AND METHODS This was a randomized open-label integrated phase II/III study in patients with SCC of esophagus/GEJ following definitive CRT who had no radiologic evidence of progression, and no endoscopically detected disease. Randomization was 1:1 to OMC (celecoxib 200 mg twice daily and methotrexate 15 mg/m2 weekly) for 12 months or observation. The primary endpoint for the phase II portion was progression-free survival (PFS); secondary endpoints were overall survival (OS) and toxicity. P ≤ 0.2 for PFS was required to proceed to phase III. RESULTS Between Jan 2016 and Dec 2019, we enrolled 151 patients for the phase II portion, 75 to OMC and 76 to observation. The tumor originated in the upper thoracic esophagus in 79% patients. Concurrent CRT consisted of median 63 Gy in a median of 35 fractions; concurrent chemotherapy was weekly paclitaxel + carboplatin in 91%. OMC was started at a median of 2.6 months (IQR 2.3-2.8) from CRT completion. Grade 3 or higher toxicities occurred in 18 patients (24%) in the OMC arm and 9 (12%) in the observation arm; P = 0.071. Median PFS was 25 months (95% CI, 17-58) in the OMC arm and was not attained [NA] (95% CI, 25-NA) in the observation arm; HR, 1.51, 95% CI, 1-2; P = 0.073. Median OS was 36 months (95% CI, 23-NA) in the OMC arm, and not attained (95% CI, NA-NA) in the observation arm; HR, 1.77; 95% CI, 1-2.9; P = 0.023. CONCLUSION Oral metronomic methotrexate and celecoxib in patients who have not progressed radiologically and have no endoscopic evidence of disease following radical CRT for locally advanced esophageal/GEJ SCC does not improve outcomes and may lower survival. [Funded by the TMC-Research Administration Council (TRAC); CHROME study (CHemoRadiotherapy followed by Oral Metronomic therapy in Esophageal cancer); ctri.nic.in number: CTRI/2015/09/006204]. TRIAL REGISTRATION NUMBER CTRI/2015/09/006204.
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Barreto SG. Young-Onset Pancreatobiliary Cancers—Whereto from Here? Indian J Surg 2022. [DOI: 10.1007/s12262-022-03533-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AbstractThis Invited Editorial towards the Special Issue on Hepatobiliary and Pancreatic Surgery highlights the global problem of young-onset cancers. The paucity of data on young-onset pancreatobiliary cancers is presented in the context of its relevance to India (and its large component of adults in the at-risk age group for these cancers). In the face of limited information on the underlying cause of young-onset cancers, the author draws attention to evidence from colorectal cancer. The readers are encouraged to develop collaborative efforts in India to address answers to much needed questions on the management of young-onset pancreatobiliary cancers, some of which are listed in this Editorial.
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Karn A, Khaddar S, Agrawal A, Kapoor A. Exceptional response to oral metronomic chemotherapy in a rare case of sinonasal mucosal melanoma. Ecancermedicalscience 2021; 15:1287. [PMID: 34824610 PMCID: PMC8580597 DOI: 10.3332/ecancer.2021.1287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 11/30/2022] Open
Abstract
Sinonasal mucosal melanoma is a rare malignancy with limited treatment options and a poor prognosis. They are usually diagnosed at an advanced stage owing to their late and nonspecific clinical presentation. Here we present a case of relapsed refractory unresectable malignant melanoma involving the right nasal cavity managed with Oral Metronomic Chemotherapy (OMCT). A 75-year-old male patient was diagnosed with unresectable malignant melanoma involving the right nasal cavity and showed radiological progression after initial management with four cycles of Dacarbazine. He was then shifted to OMCT (Cyclophosphamide, Celecoxib and Tamoxifen), as immunotherapy could not be given due to financial constraints, on which he showed approximately 40% reduction in tumour size after 6 months. This result can have important clinical implications in resource constrained settings, where the use of immunotherapy is limited by great financial burden.
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Affiliation(s)
- Anukul Karn
- Department of Medical Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India 221005
| | - Satvik Khaddar
- Department of Medical Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India 221005
| | - Amit Agrawal
- Department of Medical Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India 221005
| | - Akhil Kapoor
- Department of Medical Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India 221005
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Scharovsky OG, Rico MJ, Mainetti LE, Perroud HA, Rozados VR. Achievements and challenges in the use of metronomics for the treatment of breast cancer. Biochem Pharmacol 2020; 175:113909. [DOI: 10.1016/j.bcp.2020.113909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/09/2020] [Indexed: 12/17/2022]
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Patil VM, Noronha V, Joshi A, Dhumal S, Mahimkar M, Bhattacharjee A, Gota V, Pandey M, Menon N, Mahajan A, Sable N, Kumar S, Nawale K, Mukadam S, Solanki B, Das S, Simha V, Abraham G, Chandrasekharan A, Talreja V, DSouza H, Srinivas S, Kashyap L, Banavali S, Prabhash K. Phase I/II Study of Palliative Triple Metronomic Chemotherapy in Platinum-Refractory/Early-Failure Oral Cancer. J Clin Oncol 2019; 37:3032-3041. [PMID: 31539316 DOI: 10.1200/jco.19.01076] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Platinum-resistant oral cancer has a dismal outcome with limited treatment options. We conducted a phase I/II study to identify the optimal biologic dose (OBD) of methotrexate when given along with erlotinib and celecoxib and to assess the efficacy of this three-drug regimen in advanced oral cancer. METHODS Patients with platinum-resistant or early-failure squamous cell carcinoma of the oral cavity were eligible for this study. They were orally administered erlotinib 150 mg once per day, celecoxib 200 mg twice per day, and methotrexate per week. The primary end point of phase I was to determine the OBD of methotrexate, and that of phase II was to determine the 3-month progression-free survival. The OBD of methotrexate was determined on the basis of the clinical benefit rate at 2 months and circulating endothelial cell level at day 8, using a de-escalation model. Pharmacokinetic evaluation was performed during phase I. Phase II consisted of an expansion cohort of 76 patients. RESULTS Fifteen patients were recruited in phase I, and 9 mg/m2 methotrexate was identified as the OBD. A total of 91 patients were recruited, and the median follow-up was 6.8 months (range, 0 to 16.8 months). The 3-month progression-free survival rate was 71.1% (95% CI, 60.5% to 79.3%), the 6-month overall survival rate was 61.2% (95% CI, 49.2% to 67.8%), and the response rate was 42.9% (95% CI, 33.2% to 53.1%; n = 39). The mean Functional Assessment of Cancer Therapy-Head and Neck Trial Outcome Index score at day 8 was improved by 6.1 units (standard deviation, 13.6 units) and was maintained around this magnitude ( P = .001). CONCLUSION Triple oral metronomic chemotherapy with erlotinib, methotrexate, and celecoxib is efficacious in platinum-refractory oral cavity cancers and represents a new therapeutic option in patients with poor prognosis.
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Noronha V, Patil VM, Joshi A, Chougule A, Banavali S, Prabhash K. Potential role of metronomic chemotherapy in the treatment of esophageal and gastroesophageal cancer. Cancer Lett 2017; 400:267-275. [PMID: 28109908 DOI: 10.1016/j.canlet.2017.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/25/2022]
Abstract
Patients with esophagogastric cancer have poor prognoses in spite of the best available therapies. Patients are debilitated and may not tolerate, or may progress, on standard cytotoxic chemotherapy regimens. Metronomic chemotherapy is an attractive treatment option due to its very low reported toxicity, modest efficacy, low cost and ease of administration. Capecitabine is the most common drug used in metronomic scheduling; other drugs include cyclophosphamide and paclitaxel. Dosing of capecitabine can range from 1000 mg orally daily for 4 weeks on and 1 week off to a continuous dosing schedule of 1500 mg orally daily. Reported toxicities, including neutropenia, mucositis and hand-foot syndrome, occur in <10% of patients. As there is a lack of well-conducted, randomized clinical trials evaluating the role of metronomic chemotherapy in esophagogastric cancer, it cannot be recommended as the standard of care; however, it can be considered to be a therapeutic option, especially in elderly patients with relapsed disease for whom other therapeutic options are limited.
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Affiliation(s)
- Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vijay M Patil
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anuradha Chougule
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shripad Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India.
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Abstract
Patients in advanced stages of illness trajectories with local and widespread musculoskeletal incurable malignancies, either treatment naive or having recurrence are referred to the palliative care clinic to relieve various disease-related symptoms and to improve the quality of life. Palliative care is a specialized medicine that offers treatment to the disease-specific symptoms, places emphasis on the psychosocial and spiritual aspects of life and help the patients and their family to cope with advance stage cancer in a stronger and reasonable way. The overall outcome of musculoskeletal malignancies has improved with the advent of multidisciplinary management. Even then these tumors do relapse and leads to organ failures and disease-specific deaths in children and young adults in productive age group thus requiring an integrated approach to improve the supportive/palliative care needs in end-stage disease. In this article, we would like to discuss the spectrum of presentation of advanced musculoskeletal malignancies, skeletal metastasis, and their management.
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Affiliation(s)
- Ashish Gulia
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Suman Byregowda
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Pankaj Kumar Panda
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
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Pandey A, Abhay D, Sunny J, Vikas O, Vijay P, Rajeshri K, Netaji P, Sudeep G, Banavali SD. Outcomes of advanced epithelial ovarian cancer with integration of metronomic chemotherapy: An Indian rural cancer centre experience. South Asian J Cancer 2016; 5:59-62. [PMID: 27275448 PMCID: PMC4873697 DOI: 10.4103/2278-330x.181627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Paclitaxel-platinum and optimal cytoreductive surgery are the standard of care for ovarian carcinoma. Poor socioeconomic profile and therapeutic constraints in rural India poses a therapeutic challenge. AIM To evaluate outcomes of epithelial ovarian carcinoma. OBJECTIVES To calculate disease-free survival (DFS), overall survival (OS), and factors affecting outcomes. MATERIALS AND METHODS Data of patients diagnosed as ovarian carcinoma registered between March 2009 and March 2014 were retrieved. Demographic profile, chemotherapy and response, surgery, and disease progression were collected. Patients who underwent surgery or completed three cycles of chemotherapy were selected. Kaplan-Meir survival was used to determine disease-free and OS. Log-rank test used to evaluate factors affecting outcome. RESULTS Median follow-up is 26 months. 93/102 patients (91%) underwent cytoreductive surgery, of which 37 had primary cytoreduction (40%) while 56 had interval cytoreduction. 21/93 (23%), 57/93 (61%), and 15/93 (16%) patients were operated by local surgeons, surgeons of our hospital, and trained oncosurgeons, respectively. Induction paclitaxel-platinum was used in 35/63 (56%) patients while 28/63 patients (44%) received neoadjuvant metronomic chemotherapy. Median DFS and OS are 17 and 54 months respectively while 3 year OS of 66%. Median DFS of patients operated by oncosurgeons versus local surgeons were 22 months versus 15 months (P = 0.01), OS was 54 versus 26 months (P = 0.01).40/88 (45%) patients received maintenance metronomic therapy after adjuvant chemotherapy with median of 6 months (range 2-18 months). Patients receiving metronomic maintenance had better DFS, 18 months versus 15 months (P = 0.69). CONCLUSION Induction therapy in ovarian carcinoma helps in selecting patients for cytoreductive surgery. Outcomes are better if operated by trained oncosurgeons. Maintenance metronomic has potential to delay disease progression.
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Affiliation(s)
- Avinash Pandey
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India; Department of Medical Oncology, BKLWH, Dervan, Chiplun, Ratnagiri, Maharashtra, India
| | - Desai Abhay
- Department of Surgical Oncology, BKLWH, Dervan, Chiplun, Ratnagiri, Maharashtra, India
| | - Jandyal Sunny
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ostwal Vikas
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Patil Vijay
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kulkarni Rajeshri
- Department of Pathology, BKLWH, Dervan, Chiplun, Ratnagiri, Maharashtra, India
| | - Patil Netaji
- Department of Radiodiagnosis, BKLWH, Dervan, Chiplun, Ratnagiri, Maharashtra, India
| | - Gupta Sudeep
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Parikh PM, Hingmire SS, Deshmukh CD. Selected current data on metronomic therapy (and its promise) from India. South Asian J Cancer 2016; 5:37-47. [PMID: 27275444 PMCID: PMC4873693 DOI: 10.4103/2278-330x.181623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- P M Parikh
- Department of Precision Oncology, Asian Cancer Institute, Sion East, Mumbai, Maharashtra, India
| | - S S Hingmire
- Department of Oncology, Deenanath Mangeshkar Hospital, Erandwane, Pune, Maharashtra, India
| | - C D Deshmukh
- Department of Oncology, Deenanath Mangeshkar Hospital, Erandwane, Pune, Maharashtra, India
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Reece DE, Trieu Y, Masih-Khan E, Atenafu EG, Chen C, Prica A, Tiedemann R, Trudel S, Kukreti V. Cyclophosphamide and Bortezomib With Prednisone or Dexamethasone for the Treatment of Relapsed and Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:387-94. [PMID: 27349765 DOI: 10.1016/j.clml.2016.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Cyclophosphamide, bortezomib, and prednisone (CyBorP) is a highly effective, well-tolerated regimen in relapsed/refractory multiple myeloma. CyBorP, originally developed at our center to include weekly bortezomib (Bor) and alternate-day prednisone (P), was recently modified so that weekly dexamethasone (D) replaced prednisone. PATIENTS AND METHODS To assess the effectiveness and tolerability of CyBorP/D in real-world practice, we identified 96 relapsed/refractory patients who received ≥ 1 28-day cycle of CyBorP/D, consisting of cyclophosphamide 300 mg/m(2) (days 1, 8, 15, and 22), Bor 1.0 to 1.5 mg/m(2) (days 1, 8, and 15), and either P 50 to 100 mg on alternate days or D 20 to 40 mg weekly between 2007 and 2013. RESULTS Sixty-six (69%) patients achieved ≥ partial response: 16 with clinical complete response and 25 with very good partial response; 22 others had stable disease. Progression-free and overall survival for all patients were 16.2 months (95% confidence interval [CI], 7.7-20.1 months) and 26.3 months (95% CI, 21.6-81.2 months), respectively. Although 26 patients had prior Bor exposure, there was no difference in progression-free or overall survival versus Bor-naive patients. CONCLUSION Toxicities with CyBorP/D were generally mild and manageable. New onset peripheral neuropathy was seen in 13 cases; 9 of 26 patients with pre-existing peripheral neuropathy developed worsening symptoms. No second primary malignancies were observed.
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Affiliation(s)
- Donna E Reece
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Young Trieu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Esther Masih-Khan
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christine Chen
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Anca Prica
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rodger Tiedemann
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Suzanne Trudel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vishal Kukreti
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Patil VM, Noronha V, Joshi A, Pinninti R, Dhumal S, Bhattacharjee A, Prabhash K. Metronomic chemotherapy in platinum-insensitive failures and/or early failures postmultimodality management in oral cancers. Indian J Med Paediatr Oncol 2016; 36:161-5. [PMID: 26855524 PMCID: PMC4743183 DOI: 10.4103/0971-5851.166725] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Oral cancer patients with platinum-resistant disease and or early failures have limited treatment options. This analysis was planned to study the efficacy of metronomic chemotherapy in this group of patients. MATERIALS AND METHODS This was a retrospective analysis of oral cancer patients who had squamous cell carcinoma and had an early failure and/or platinum-insensitive failure. Early failure was defined as a failure either within 1-month of adjuvant radiotherapy or within 6 months of chemoradiation (CTRT). A sample size of 100 patients was selected for this study. If ≥39 of 100 patients would have survived at 6 months with metronomic chemotherapy, then additional studies would be warranted. RESULTS The ECOG PS was 0-1 in 92 patients and 2 in 8 patients. The subsite of primary was buccal mucosa in 38 patients (38%), anterior two-third tongue (oral tongue) in 51 patients (51%), and alveolus in 11 patients (11%). The median estimated overall survival was 110 days (95% confidence interval [CI]: 85-134 days). The proportion of patients surviving at 6 months was 26.4% (95% CI: 17.9-35.6). CONCLUSION Metronomic combination of methotrexate and celecoxib failed to meet its prespecified efficacy limit and should not be used in these patients as routine.
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Affiliation(s)
- Vijay M Patil
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rakesh Pinninti
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sachin Dhumal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Atanu Bhattacharjee
- Division of Clinical Research and Biostatistics, Malabar Cancer Centre, Kerala, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Wu J, Waxman DJ. Metronomic cyclophosphamide eradicates large implanted GL261 gliomas by activating antitumor Cd8 + T-cell responses and immune memory. Oncoimmunology 2015; 4:e1005521. [PMID: 26137402 PMCID: PMC4485826 DOI: 10.1080/2162402x.2015.1005521] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/02/2015] [Accepted: 01/06/2015] [Indexed: 11/13/2022] Open
Abstract
Cancer chemotherapy using cytotoxic drugs can induce immunogenic tumor cell death; however, dosing regimens and schedules that enable single-agent chemotherapy to induce adaptive immune-dependent ablation of large, established tumors with activation of long-term immune memory have not been identified. Here, we investigate this issue in a syngeneic, implanted GL261 glioma model in immune-competent mice given cyclophosphamide on a 6-day repeating metronomic schedule. Two cycles of metronomic cyclophosphamide treatment induced sustained upregulation of tumor-associated CD8+ cytotoxic T lymphocyte (CTL) cells, natural killer (NK) cells, macrophages, and other immune cells. Expression of CTL- and NK–cell-shared effectors peaked on Day 6, and then declined by Day 9 after the second cyclophosphamide injection and correlated inversely with the expression of the regulatory T cell (Treg) marker Foxp3. Sustained tumor regression leading to tumor ablation was achieved after several cyclophosphamide treatment cycles. Tumor ablation required CD8+ T cells, as shown by immunodepletion studies, and was associated with immunity to re-challenge with GL261 glioma cells, but not B16-F10 melanoma or Lewis lung carcinoma cells. Rejection of GL261 tumor re-challenge was associated with elevated CTLs in blood and increased CTL infiltration in tumors, consistent with the induction of long-term, specific CD8+ T-cell anti-GL261 tumor memory. Co-depletion of CD8+ T cells and NK cells did not inhibit tumor regression beyond CD8+ T-cell depletion alone, suggesting that the metronomic cyclophosphamide-activated NK cells function via CD8a+ T cells. Taken together, these findings provide proof-of-concept that single-agent chemotherapy delivered on an optimized metronomic schedule can eradicate large, established tumors and induce long-term immune memory.
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Key Words
- B6, C57BL/6 mouse strain
- CD8+ T cells
- CPA, cyclophosphamide
- CPA-90 and CPA-140, metronomic CPA scheduling at 90 and 140 mg CPA/kg body weight, respectively, repeated every 6 days
- CTL, cytotoxic T lymphocyte
- FACS, fluorescence-activated cell sorting
- GL261 glioma
- LLC, Lewis lung carcinoma
- MDSC, myeloid-derived suppressor cells
- MTD, maximum-tolerated dose
- NK cell, natural killer cell
- NK cells
- PEB, phosphate-EDTA buffer
- chemoimmunotherapy
- chemotherapy
- cyclophosphamide
- drug scheduling
- glioblastoma
- immune memory
- metronomic chemotherapy
- qPCR, quantitative real-time polymerase chain reaction
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Affiliation(s)
- Junjie Wu
- Division of Cell and Molecular Biology; Department of Biology and Graduate Program in Molecular and Translational Medicine; Boston University ; Boston, MA USA
| | - David J Waxman
- Division of Cell and Molecular Biology; Department of Biology and Graduate Program in Molecular and Translational Medicine; Boston University ; Boston, MA USA
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Hao YB, Yi SY, Ruan J, Zhao L, Nan KJ. New insights into metronomic chemotherapy-induced immunoregulation. Cancer Lett 2014; 354:220-6. [DOI: 10.1016/j.canlet.2014.08.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 08/17/2014] [Accepted: 08/20/2014] [Indexed: 12/15/2022]
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Reece DE, Masih-Khan E, Atenafu EG, Jimenez-Zepeda VH, Anglin P, Chen C, Kukreti V, Mikhael JR, Trudel S. Phase I-II trial of oral cyclophosphamide, prednisone and lenalidomide for the treatment of patients with relapsed and refractory multiple myeloma. Br J Haematol 2014; 168:46-54. [PMID: 25146584 DOI: 10.1111/bjh.13100] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022]
Abstract
This single institution, open label Phase I-II dose escalation trial evaluated the safety and efficacy of the combination of lenalidomide (Revlimid®), cyclophosphamide and prednisone (CPR) in patients with relapsed/refractory multiple myeloma. The maximal administered dose of CPR consisted of cyclophosphamide 300 mg/m(2) on day 1, 8, and 15, lenalidomide 25 mg on d 1-21 and prednisone 100 mg every other day in a 28-d cycle. Between November 2007 and June 2009, 32 patients were entered in cohorts of three at three dose levels. The median age was 64 years, 59% were male, with a median two prior regimens. Responding patients could stay on treatment until progression. The full-dose CPR regimen produced no dose-limiting toxicity and was delivered for a median of 16 months (3·5-65 months) with acceptable safety and tolerance. The overall response rate (≥ partial response) was 94% at a median follow up of 28 months. The median progression-free survival was 16·1 months [95% confidence interval (CI); 10·9-22·5 months], while the median overall survival was 27·6 months (95% CI; 16·8-36·6 months). Only the beta-2 microglobulin level at protocol entry correlated with a better survival (P = 0·047). These observations compare favourably with other 2- and 3- drug combinations for relapsed/refractory myeloma, and suggest that CPR should be evaluated further in the setting of relapsed/refractory disease, or in newly diagnosed patients.
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Affiliation(s)
- Donna E Reece
- Department of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Wu J, Waxman DJ. Metronomic cyclophosphamide schedule-dependence of innate immune cell recruitment and tumor regression in an implanted glioma model. Cancer Lett 2014; 353:272-80. [PMID: 25069038 DOI: 10.1016/j.canlet.2014.07.033] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/17/2014] [Accepted: 07/19/2014] [Indexed: 01/13/2023]
Abstract
Metronomic cyclophosphamide (CPA) treatment activates robust innate anti-tumor immunity and induces major regression of large, implanted brain tumor xenografts when administered on an intermittent, every 6-day schedule, but not on a daily low-dose or a maximum-tolerated dose CPA schedule. Here, we used an implanted GL261 glioma model to compare five intermittent metronomic CPA schedules to elucidate the kinetics and schedule dependence of innate immune cell recruitment and tumor regression. Tumor-recruited natural killer cells induced by two every 6-day treatment cycles were significantly ablated 1 day after a third CPA treatment, but largely recovered several days later. Natural killer and other tumor-infiltrating innate immune cells peaked 12 days after the last CPA treatment on the every 6-day schedule, suggesting that drug-free intervals longer than 6 days may show increased efficacy. Metronomic CPA treatments spaced 9 or 12 days apart, or on an alternating 6 and 9 day schedule, induced extensive tumor regression, similar to the 6-day schedule; however, the tumor-infiltrating natural killer cell responses were not sustained, leading to rapid resumption of tumor growth after day 24, despite ongoing metronomic CPA treatment. Increasing the CPA dose prolonged the period of tumor regression on the every 9-day schedule, but natural killer cell activation was markedly decreased. Thus, while several intermittent metronomic CPA treatment schedules can activate innate immune cell recruitment leading to major tumor regression, sustained immune and anti-tumor responses are only achieved on the 6-day schedule. However, even with this schedule, some tumors eventually relapse, indicating a need for further improvements in this immunogenic metronomic therapy.
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Affiliation(s)
- Junjie Wu
- Division of Cell and Molecular Biology, Department of Biology, Boston University, 5 Cummington Mall, Boston, MA 02215, USA
| | - David J Waxman
- Division of Cell and Molecular Biology, Department of Biology, Boston University, 5 Cummington Mall, Boston, MA 02215, USA.
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