Phase II Trial Using a Combination of Oxaliplatin, Capecitabine, and Celecoxib with Concurrent Radiation for Newly Diagnosed Resectable Rectal Cancer

LESSONS LEARNED

Colorectal cancers exhibit a high level of cyclooxygenase-2 (COX-2) expression with strong preclinical rationale for improved clinical outcomes with COX-2 inhibition. Celecoxib is a COX-2 inhibitor and we have shown that it can be safely combined with capecitabine and oxaliplatin as part of neoadjuvant treatment with radiation therapy (RT) in rectal cancer.There was a significant improvement in skin toxicity with this combination as compared with historical data. Considering the field has moved on to single-agent capecitabine, we believe future trials with capecitabine and celecoxib hold potential.

BACKGROUND

Improved survival is seen among patients with rectal cancer who achieve pathologic complete response (pCR) after neoadjuvant therapy. Cyclooxygenase-2 (COX-2) expression is increased in gastrointestinal malignancies and it may serve as a target to enhance pathologic response. A trial combining chemoradiation and COX-2 inhibition was conducted to evaluate the pCR rate, surgical outcomes, survival, and treatment toxicity.

METHODS

Patients with resectable (T3-4, N1-2) rectal cancer within 12 cm of the anal verge were included in this phase II clinical trial. The neoadjuvant treatment consisted of capecitabine 850 mg/m² b.i.d. Monday through Friday for 5 weeks, weekly oxaliplatin 50 mg/m² intravenous (IV), celecoxib 200 mg b.i.d. daily, along with concurrent 45 gray radiation therapy in 25 fractions.

RESULTS

Thirty-two patients were included in the final analysis. The primary endpoint was pCR: 31% (95% confidence interval [CI]: 16%-50%). Secondary endpoints were surgical downstaging (SD): 75% (95% CI: 57%-89%) and sphincter-sparing surgery (SSS): 56% (95% CI: 38%-74%). Common grade >3 toxicities were diarrhea and abnormal liver function tests (9% each). Grade 0 and 1 toxicities included radiation dermatitis (59% and 34%, respectively) and proctitis (63% and 28%, respectively). At 3 years, disease-free survival and overall survival (OS) were 84% (95% CI: 65%-93%) and 94% (95% CI: 77%-98%), respectively.

CONCLUSION

Chemoradiation with celecoxib in rectal cancer was well tolerated and demonstrated high rates of pCR, SD, and SSS. Improvement in skin toxicity (34% grade 1 and no grade 3/4) as compared with historical results (43%-78% grade 3/4) seems to be a significant improvement with addition of celecoxib to neoadjuvant chemotherapy.

Improved survival with combination oxaliplatin, irinotecan, cetuximab for metastatic pancreatic cancer

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Background: For metastatic pancreatic cancer, no combination chemotherapy has been shown to improve survival significantly in comparison to single agent gemcitabine. A novel combination with oxaliplatin 60 mg/m2, irinotecan 90 mg/m2, cetuximab 250 mg/m2 (OIC) given every two weeks appears to produce a high rate of radiographic response. Since our reporting (ASCO 2007 GI Conference), we continue to see a high rate of clinical and radiographic responses (50% by Recist Criteria). We therefore decided to look carefully on the survival data of OIC versus control (mainly gemcitabine single agent or in combination with other agents). Methods: We retrospective reviewed patients seen from 10/2002 to 10/2006 with diagnosis of metastatic pancreatic cancer. The survival duration was calculated from the date of diagnosis to the date of death. We included only patients whose dates of death could be confirmed with death certificates. Results: A total of 37 patients were identified. 11 of those were in the OIC arm and 26 were treated with other regimens (17 with gemcitabine-based regimens, 9 with either capecitabine or 5-FU-based regimens) that function as control. The range of survival duration was 4 - 28 months for OIC arm and 1 - 28 months for the control. Median survival was 10 months for the OIC arm versus 5 months for the control. Conclusions: OIC regimen produces a high rate of tumor response and may have a survival advantage with this retrospective analysis. We believe it is a regimen deserves further evaluation.

No significant financial relationships to disclose.

Combination of irinotecan, oxaliplatin and cetuximab for patients with metastatic pancreatic cancer

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Background: Gemcitabine-based chemotherapy is considered standard approach for patients with metastatic pancreatic cancer but the results remain unsatisfactory with survival averaging about 6 to 10 months. Cell line study indicates more than 90% of pancreatic cancer cells express EGFR receptor. We therefore explore the use of non-gemcitabine-containing regimen and add an EGFR inhibitor. Method: We initiated a regimen with irinotecan 120 mg/m2, oxaliplatin 85 mg/m2, and cetuximab 400 mg/m2 first dose followed by 250 mg/m2 for all subsequent doses delivered every 14 days for patients with metastatic pancreatic cancer. Results: From 1/2005 to 12/2005, a total of 5 patients were treated. Two males and three females, age 59 to 78. Three presented with metastatic disease. One had Whipple’s procedure then had disease recur 2 months post-surgery. One had locally advanced disease and progressed 10 months after concurrent chemoradiation. Grade III/IV neutropenia, anemia developed in 1/5 patients. Grade III/IV diarrhea and nausea/vomiting developed in 3/5 patients. Grade III/IV fatigue, anorexia developed in 4/5 patients. The non-hematologic toxicity was the main reason for dose reduction. 4 had CT scan for response evaluation. The fifth patient completed first cycle of treatment on 1/3/2006 and had CA19–9 dropped from 15,900 to 9,398 u/ml (40% decline). By CT scan, partial response rate is 75% as shown in the table. So far, two patients have died, 5 and 10 months since initiating treatment, one from recurrent hepatic abscess and one from fungus infection. Conclusions: This combination delivered every other week appears promising for patients with metastatic pancreatic cancer. The planned phase II trial will adopt a lower dose approach with irinotecan 90 mg/m2, oxaliplatin 60 mg/m2, and cetuximab 250 mg/m2. [Table: see text]

No significant financial relationships to disclose.

Combination irinotecan, capecitabine and celecoxib in patients with advanced biliary cancers

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Background: Patients with metastatic biliary cancers continue to face a very grim prognosis with no effective chemotherapy. Median survival is around 6–9 months. Irinotecan and capecitabine have modest activity against cholangiocarcinoma. Cyclooxygenase-2 (COX-2) enzyme expression is reported in many human cholangiocarcinoma cell line studies and is linked to tumor cell resistance to chemotherapy-induced apoptosis. We hypothesized that adding a COX-2 inhibitor would improve the therapeutic benefits in patients with biliary tumors. Methods: From 9/2003 to 2/2005, a total of 12 patients were treated with a combination regimen, delivered at a cycle interval of 21 days, that consisted of 120 mg/m2 irinotecan given intravenously over 60 minutes on day 1, 1500 mg/m2/day capecitabine taken orally in divided doses on days 1–14 and 400 mg/day celecoxib taken orally in divided doses on days 1–21. Results: A total of 117 treatments were administered to the 12 patients (9 females and 3 males; median age, 56 years; 10 cholangiocarcinoma and 2 gallbladder cancer). Based on the tumor marker CA19–9, 7 of the patients had a partial response (7/12, 58%). Of the seven patients for which sequential CT evaluation was available, the partial response rate was 43% (3/7) and two additional patients had stable disease. The median progression-free survival was 13 months and the median overall survival was 17 months. We encountered grade II neutropenia and anemia (2/12 each, 17%) and grade I diarrhea and hand-foot syndrome (33% and 7%, respectively). Conclusions: These data suggest that the combination of irinotecan, capecitabine and celecoxib is an effective palliative regimen for patients with metastatic biliary cancers. Further development of this regimen is severely hindered by the potential cardiovascular risk associated with long-term use of COX-2 inhibitor.

No significant financial relationships to disclose.

Effects of inhaled tumour necrosis factor alpha in subjects with mild asthma

BACKGROUND

Inhaled tumour necrosis factor alpha (TNF alpha) has previously been shown to induce airway neutrophilia and increased airway reactivity in normal subjects. It was hypothesised that a similar challenge would increase airway reactivity in those with mild asthma, but that the inflammatory profile may differ.

METHODS

Ten mild asthmatic subjects were recruited on the basis of clinical asthma and either a sensitivity to methacholine within the range defined for asthma or a 20% improvement in forced expiratory volume (FEV(1)) after 200 micro g salbutamol. Subjects inhaled either vehicle control or 60 ng recombinant human (rh)TNF alpha and were studied at baseline, 6, 24, and 48 hours later. Variables included spirometric parameters, methacholine provocative concentration causing a 20% fall in FEV(1) (PC(20)), induced sputum differential cell count, relative sputum level of mRNA of interleukins (IL)-4, IL-5, IL-9, IL-14, IL-15 and TNF alpha, and the exhaled gaseous markers of inflammation, nitric oxide and carbon monoxide.

RESULTS

PC(20) showed an increase in sensitivity after TNF alpha compared with control (p<0.01). The mean percentage of neutrophils increased at 24-48 hours (24 hour control: 1.1 (95% CI 0.4 to 2.7) v 9.2 (95% CI 3.5 to 14.9), p<0.05), and there was also a rise in eosinophils (p=0.05). Relative levels of sputum mRNA suggested a rise in expression of TNF alpha, IL-14, and IL-15, but no change in IL-4 and IL-5. Spirometric parameters and exhaled gases showed no significant change.

CONCLUSION

The increase in airway responsiveness and sputum inflammatory cell influx in response to rhTNF alpha indicates that TNF alpha may contribute to the airway inflammation that characterises asthma.

Surgical therapy of pancreatic cancer

Surgical resection remains the only curative modality for pancreatic cancer. Improvements in surgical technique have greatly reduced the morbidity and mortality from pancreatic resection. These results clearly justify the use of pancreatic resection for localized and resectable pancreatic cancer. New surgical techniques such as laparoscopy can aid in the proper selection of candidates for curative resection. Integration of surgery with more effective treatments to prevent systemic relapse are needed to further improve survival.

Correlates of response to IL-2 therapy in patients treated for metastatic renal cancer and melanoma

PURPOSE

We evaluated the characteristics of patients with metastatic renal cancer or metastatic melanoma prior to and during treatment with bolus intravenous interleukin-2 to define prognostic indicators of subsequent response to therapy.

PATIENTS AND METHODS

A consecutive series of 509 patients with progressive metastatic cancer were treated with intravenous interleukin-2 from September 1985 to July 1993. Pretreatment demographic characteristics, treatment history, results of laboratory tests, and metastatic sites of disease were evaluated. The amount of interleukin-2 administered, toxicity, and changes in laboratory test results were recorded for the first course of therapy. Subsequent objective response to therapy and survival were determined and used to evaluate pretreatment and treatment characteristics that acted as prognostic indicators of response.

RESULTS

At the end of the study, 22.6% of patients with renal cancer and 16.3% of patients with melanoma experienced an objective response to interleukin-2 therapy. Patients with renal cancer responded more frequently if they had not previously failed other immunotherapies. Also, renal cancer patients who achieved an objective response had a more profound thrombocytopenia during the first cycle of therapy. Patients with melanoma responded more frequently to interleukin-2 therapy when metastases were confined to subcutaneous tissue. In addition, responding patients with melanoma received more interleukin-2 in their first course and exhibited a more profound lymphocytosis 7 to 11 days after initiating therapy than did nonresponders.

CONCLUSIONS

Renal cancer and melanoma displayed separate prognostic indicators with respect to response from interleukin-2 therapy. Although significant correlates to response were identified, there was much variability and a reliable predictive model of response to therapy could not be formulated based on these results.

Goal-directed therapy with dopexamine, dobutamine, and volume expansion: effects of systemic oxygen transport on hepatic ultrastructure in porcine sepsis

OBJECTIVES

Can the hepatic structural deterioration that occurs during peritonitis be attenuated by increasing cardiac output and oxygen consumption (VO2)? Do the agents used to achieve these increases have any characteristic affects on these hepatic structural changes?

DESIGN

Randomized, prospective, observational animal study.

SETTING

Research laboratory of a university medical school.

SUBJECTS

Twenty-five Middle White adolescent pigs, weighing 25 to 30 kg, divided into five groups.

INTERVENTIONS

A thermodilution flotation catheter was advanced into the pulmonary artery. Additional catheters were inserted into the jugular, portal, and hepatic veins, and into the femoral artery. Ultrasound flow probes were placed around the portal vein and the hepatic artery. A metabolic cart was attached to the ventilator. Baseline measurements were made and cardiac output was increased by > 25% by administering either dobutamine (10 micrograms/min), dopexamine (10 micrograms/kg/min), or colloid. A control group had its cardiac output maintained at its baseline value. Peritonitis was induced in the four groups by contamination with cecal content and maintained for 6 hrs. Hepatic tissue was then removed for ultrastructural analysis and the animals were killed.

MEASUREMENTS AND MAIN RESULTS

Before infection, cardiac output, VO2, and hepatic blood flow were increased in the three treatment groups. In the dobutamine and dopexamine groups, oxygen delivery increased, but decreased in the volume group. Mean arterial pressure increased in the dobutamine and dopexamine groups, but in the volume group, mean arterial pressure was maintained. Six hours after infection, cardiac output and VO2 had further increased in the dobutamine and volume groups, but both variables had decreased in the dopexamine group. After infection in the control group, cardiac output had decreased, although oxygen delivery and VO2 increased. There were no significant differences between hepatic hemodynamic or oxygen transport variables in any of the groups during the infection period. Hepatic ultrastructure was well maintained in the dopexamine group, while considerable deterioration was seen in the volume and control groups. In the dobutamine group, hepatic deterioration was greater than in the other three groups.

CONCLUSIONS

Increasing cardiac output and VO2 before and during infection was only protective when dopexamine was administered. Dobutamine infusion was associated with greater hepatic deterioration than that effect seen in either the control or volume groups.

Thyroid dysfunction in 281 patients with metastatic melanoma or renal carcinoma treated with interleukin-2 alone

The purpose of this prospective study was to determine the incidence of thyroid dysfunction in cancer patients receiving immunotherapy with interleukin-2 (IL-2) alone, and to assess the relationship of hypothyroidism to clinical response. A cohort of 281 consecutive patients with metastatic melanoma or renal carcinoma were treated with IL-2 alone from July 1, 1989 until June 30, 1993. The majority (n = 216) received high-dose IL-2 and the remainder (n = 65) received low-dose therapy. Thyroid function was measured before, during, and after immunotherapy. Forty-one percent of initially euthyroid patients developed thyroid dysfunction after starting high-dose IL-2-alone therapy. The most common abnormality was hypothyroidism, occurring in 35% of patients, although moderate or severe hypothyroidism requiring thyroid hormone replacement occurred in 9% of patients. Hypothyroidism was related to duration of IL-2 therapy and was not associated with clinical response. Hyperthyroidism developed in 7% of previously euthyroid patients receiving high-dose IL-2. Overall, the incidence of thyroid dysfunction was similar in the high- and low-dose IL-2 regimens. In conclusion, thyroid dysfunction is a common sequela of IL-2 therapy. Thyroid function should be measured routinely in cancer patients receiving IL-2-based treatment. It is recommended that thyroid hormone replacement be given to patients with moderate or severe hypothyroidism.

Effect of nitroglycerin ointment placement on the severity of headache and flushing in patients with cardiac disease

Fifty-six patients with cardiac disease participated in a study to determine the effect of site placement on patient reports of headache and flushing after topical nitroglycerin ointment placement. Nitroglycerin was placed on the upper arm, chest, and pelvis in random order. Approximately 30 minutes after application, patients were asked to evaluate their headache and flushing using a visual analogue scale. No significant difference in the severity of side effects was found when the three sites were compared by multivariate analysis of variance with repeated measures. The clinical practice of instructing patients to vary the site placement of nitroglycerin ointment to avoid side effects was not supported.