Optimizing smartphone psychotherapy for depressive symptoms in patients with cancer: Multiphase optimization strategy using a decentralized multicenter randomized clinical trial (J-SUPPORT 2001 Study)

AIM

Patients with cancer experience various forms of psychological distress, including depressive symptoms, which can impact quality of life, elevate morbidity risk, and increase medical costs. Psychotherapy and pharmacotherapy are effective for reducing depressive symptoms among patients with cancer, but most patients prefer psychotherapy. This study aimed to develop an efficient and effective smartphone psychotherapy component to address depressive symptom.

METHODS

This was a decentralized, parallel-group, multicenter, open, individually randomized, fully factorial trial. Patients aged ≥20 years with cancer were randomized by the presence/absence of three cognitive-behavioral therapy (CBT) skills (behavioral activation [BA], assertiveness training [AT], and problem-solving [PS]) on a smartphone app. All participants received psychoeducation (PE). The primary outcome was change in the patient health questionnaire-9 (PHQ-9) total score between baseline and week 8. Secondary outcomes included anxiety.

RESULTS

In total, 359 participants were randomized. Primary outcome data at week 8 were obtained for 355 participants (99%). The week 8 PHQ-9 total score was significantly reduced from baseline for all participants by -1.41 points (95% confidence interval [CI] -1.89, -0.92), but between-group differences in change scores were not significant (BA: -0.04, 95% CI -0.75, 0.67; AT: -0.16, 95% CI -0.87, 0.55; PS: -0.19, 95% CI -0.90, 0.52).

CONCLUSION

As the presence of any of the three intervention components did not contribute to a significant additive reduction of depressive symptoms, we cannot make evidence-based recommendations regarding the use of specific smartphone psychotherapy.

Postoperative Adjuvant Anastrozole for 10 or 5 Years in Patients With Hormone Receptor-Positive Breast Cancer: AERAS, a Randomized Multicenter Open-Label Phase III Trial

PURPOSE

Treatment with an aromatase inhibitor for 5 years is the standard treatment for postmenopausal hormone receptor-positive breast cancer. We investigated the effects of extending this treatment to 10 years on disease-free survival (DFS).

PATIENTS AND METHODS

This prospective, randomized, multicenter open-label phase III study assessed the effect of extending anastrozole treatment for an additional 5 years in postmenopausal patients who were disease-free after treatment with either 5 years of anastrozole alone or 2-3 years of tamoxifen followed by 2-3 years of anastrozole. Patients were allocated randomly (1:1) to continue anastrozole for an additional 5 years or stop anastrozole. The primary end point was DFS, including breast cancer recurrence, second primary cancers, and death from any cause. This study is registered with University Hospital Medical Information Network, Japan (UMIN) clinical trials registry (UMIN000000818).

RESULTS

We enrolled 1,697 patients from 117 facilities between November 2007 and November 2012. Follow-up information was available for 1,593 patients (n = 787 in the continue group, n = 806 in the stop group), who were defined as the full analysis set, including 144 patients previously treated with tamoxifen and 259 patients who underwent breast-conserving surgery without irradiation. The 5-year DFS rates were 91% (95% CI, 89 to 93) in the continue group and 86% (95% CI, 83 to 88) in the stop group (hazard ratio, 0.61; 95% CI, 0.46 to 0.82; P < .0010). Notably, extended anastrozole treatment reduced the incidence of local recurrence (continue group, n = 10; stop group, n = 27) and second primary cancers (continue group, n = 27; stop group, n = 52). There was no significant difference in overall or distant DFS. Menopausal or bone-related all-grade adverse events were more frequent among patients in the continue group than those in the stop group, but the incidence of grade ≥3 adverse events was <1% in both groups.

CONCLUSION

Continuing adjuvant anastrozole for an additional 5 years after 5 years of initial treatment with anastrozole or tamoxifen followed by anastrozole was well tolerated and improved DFS. Although no difference in overall survival was observed as in other trials, extended anastrozole therapy could be one treatment choice in postmenopausal patients with hormone receptor-positive breast cancer.

Smartphone Psychotherapy Reduces Fear of Cancer Recurrence Among Breast Cancer Survivors: A Fully Decentralized Randomized Controlled Clinical Trial (J-SUPPORT 1703 Study)

PURPOSE

Fear of cancer recurrence (FCR) is a common distressing condition. We investigated the efficacy of smartphone problem-solving therapy and behavioral activation applications in breast cancer survivors.

METHODS

This was a decentralized randomized trial. Participants were disease-free breast cancer survivors age 20-49 years who were randomly assigned to the smartphone-based intervention or waitlist control. Both groups received treatment as usual. The control group could access the smartphone apps during weeks 8-24. The intervention comprised smartphone problem-solving therapy and behavioral activation apps. The primary end point was the Concerns About Recurrence Scale at week 8. Secondary outcomes included the Fear of Cancer Recurrence Inventory-Short Form (FCRI-SF), the Hospital Anxiety and Depression Scale (HADS), the Short-form Supportive Care Needs Survey (SCNS-SF34), and the Posttraumatic Growth Inventory at weeks 8 and 24 (trial registration: UMIN-CTR: UMIN000031140).

RESULTS

The intervention group included 223 participants, and the control group included 224 participants. Primary outcome data were obtained for 444 participants, and 213 participants in the intervention arm completed the week 24 assessment. The intervention group had statistically greater improvements than controls at week 8 on the Concerns About Recurrence Scale (difference -1.39; 95% CI, -1.93 to -0.85; P < .001), FCRI-SF (difference -1.65; 95% CI, -2.41 to -0.89; P < .001), HADS depression (difference -0.49; 95% CI, -0.98 to 0; P < .05), and SCNS-SF34 psychological domain (difference -1.49; 95% CI, -2.67 to -0.32; P < .05). These scores at week 24 were not statistically significant compared with week 8 although the HADS depression score at week 24 was significantly reduced (P = .03).

CONCLUSION

Novel smartphone psychotherapy offers a promising way to reduce FCR given the large number of survivors and a limited number of therapists to competently conduct psychotherapy.

A randomized study comparing docetaxel/cyclophosphamide (TC), 5-fluorouracil/epirubicin/cyclophosphamide (FEC) followed by TC, and TC followed by FEC for patients with hormone receptor-positive HER2-negative primary breast cancer

Purpose

Our primary objective was to determine the benefit/risk of anthracycline-free regimens by comparing docetaxel + cyclophosphamide (TC) alone, fluorouracil + epirubicin + cyclophosphamide (FEC) followed by TC, or TC followed by FEC as a primary treatment for patients with HR-positive, HER2-negative BC.

Methods

We randomized patients with stage I–III HR-positive HER2-negative, operable BC to receive either six cycles of TC (TC6), three cycles of FEC followed by three cycles of TC (FEC-TC), or three cycles of TC followed by three cycles of FEC (TC-FEC). The primary endpoint was the pathological response. Secondary endpoints included clinical response, type of surgical procedure, recurrence, death, and adverse events (by NCI-Common Terminology Criteria for Adverse Events v.3.0). We conducted all statistical analyses using SAS Version 9.2.

Results

We enrolled 195 patients and analyzed data from 193 as the intention-to-treat population. Pathological complete response rates were numerically higher in the TC6 group than in the other groups (p = 0.321). The breast conservation rate was significantly higher in the TC6 group (73%) than in the other groups (FEC-TC 51%, TC-FEC 45%, p = 0.007). Adverse events with grade > 3 were not common in the treatment groups (p = 0.569). The overall and distant disease-free survivals were similar among the groups with median follow-up of 5.80 years.

Conclusions

Despite similar long-term efficacy and safety profile, the higher breast conservation rate in the TC6 group suggests that preoperative chemotherapy without an anthracycline may benefit patients with HR-positive HER2-negative BC.

Trial registration

UMIN000003283 https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000003873.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05590-w) contains supplementary material, which is available to authorized users.

Bi-weekly eribulin therapy for metastatic breast cancer: a multicenter phase II prospective study (JUST-STUDY)

Background

This study aimed to investigate whether schedule modification is safe and effective in patients intolerant to the standard eribulin dose and schedule.

Methods

Patients with metastatic breast cancer (MBC) treated with both anthracycline and taxane and ≤ 3 prior regimens of chemotherapy for MBC received eribulin at the standard dose and schedule (1.4 mg/m² on days 1 and 8 of a 21-day cycle) in the first cycle; change of dosing schedule (1.4 mg/m² on days 1 and 15 of a 28-day cycle) was determined by change in neutrophil count, platelet count, aspartate aminotransferase, alanine aminotransferase, total bilirubin, serum creatinine, and non-hematological toxicity on day 8 of the first cycle or day 1 of the second cycle. Clinical benefit rate (CBR; primary endpoint), time to treatment failure (TTF), overall survival (OS), and safety were evaluated.

Results

Of the 88 patients who were enrolled and received standard eribulin therapy in the first cycle, 42 patients were moved to the bi-weekly therapy group and 40 continued standard therapy. In the bi-weekly and standard therapy groups, mean relative dose intensity was 62.7 and 90.9%, CBR was 31.0 and 25.0%, median TTF was 81.5 and 75 days, and OS was 523 and 412 days, respectively. Neither group reported severe adverse events.

Conclusion

This is the first study to show that a bi-weekly eribulin schedule is tolerable and has comparable efficacy in patients intolerant to the standard eribulin schedule.

Clinical trial registration

University Hospital Medical Information Network (UMIN) Center (ID: UMIN 000008491).

Electronic supplementary material

The online version of this article (10.1007/s12282-018-0843-y) contains supplementary material, which is available to authorized users.

Conformationally-locked C-glycosides: tuning aglycone interactions for optimal chaperone behaviour in Gaucher fibroblasts

A series of conformationally locked C-glycosides based on the 3-aminopyrano[3,2-b]pyrrol-2(1H)-one (APP) scaffold has been synthesized.

Neoadjuvant Chemotherapy with or without Concurrent Hormone Therapy in Estrogen Receptor-Positive Breast Cancer: NACED-Randomized Multicenter Phase II Trial

Although in the neoadjuvant setting for estrogen receptor (ER)-positive breast cancers, chemotherapy or hormone therapy alone does not result in satisfactory tumor response, it is unknown whether concurrent chemo-endocrine therapy is superior to chemotherapy alone in clinical outcomes. We conducted a randomized phase II trial to test the responses of ER-positive patients to concurrent administration of chemo-endocrine therapy in the neoadjuvant setting. Women with stage II-III, ER-positive, invasive breast cancer (n=28) received paclitaxel followed by fluorouracil, epirubicin, cyclophosphamide (T-FEC) and were randomized to receive concurrent chemo-endocrine therapy consisting of goserelin administered subcutaneously for premenopausal women or an aromatase inhibitor for postmenopausal women. The primary endpoint was the pathological complete response (pCR) rate after neoadjuvant therapy. Twenty-eight patients were randomized. There were no significant differences in pCR rate between the concurrent group (12.5%;2/16) and the chemotherapy alone group (8.3%;1/12). Tumor size after therapy was significantly reduced in the concurrent therapy group (p=0.035), but not in the chemotherapy-alone group (p=0.622). Neoadjuvant chemotherapy with concurrent hormone therapy provided no significant improvement in pCR rate in ER-positive breast cancers. These preliminary results should be followed up by further studies.

Safety and efficacy of gemcitabine and trastuzumab in HER2-directed therapy pretreated patients with HER2-positive metastatic breast cancer: SBP-01 study

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Background: Prognosis of HER2-positive metastatic breast cancer (MBC) has been dramatically improved by trastuzumab (Tmab). More recently, newer anti-HER2 agents such as lapatinib, pertuzumab and T-DM1 have prolonged survival. Despite the efficacy of these drugs, most patients develop progressive disease during or after treatment, and alternative anti-HER2 agents plus chemotherapies are required in subsequent lines of treatment. However, there are few evidence on efficacy of Tmab-containing regimens after disease progression. Gemcitabine (GEM) is non-cross resistant to anthracycline and taxane. Preclinical studies have shown that the combination of Tmab and GEM has synergistic effect against HER2-positive breast cancer cell lines. SBP-01 study assessed the efficacy and safety of the combination of Tamb and GEM in patients with HER2-positive MBC previously treated with anti-HER2 therapy. Methods: SBP-01 study included patients treated with one or more anti-HER2 directed regimens for MBC. Patients were administered with GEM 1250 mg/m2 on days 1 and 8 of each 21-day cycle and Tmab 4mg/kg loading dose and then 2mg/kg weekly. The primary endpoint was objective response rate (ORR). Secondary endpoints included progression free survival (PFS), overall survival, and safety. Results: Between June 2011 and June 2014, 35 patients were enrolled. Patients had ER positive tumor (37.1%), a median of 2 metastatic organ sites, visceral metastasis (80.0%), prior (neo) adjuvant Tmab (22.9%) and a median of 2 prior chemotherapy regimens for MBC. Previous HER2-directed drugs included Tmab (94.3%), lapatinib (37.1%), T-DM1 (8.6%) and pertuzumab (2.9%). ORR was 22.9% (95% CI, 8.6%-36.8%). Median PFS was 146 days. Patients with stable disease response received a median of 7 cycles (6-28 cycles) of treatment. Grade3/4 leukopenia (20.0%) and neutropenia (48.6%) were observed. All non-hematological toxicities were less than grade3. Conclusions: The Combination Tmab and GEM is effective and well-tolerated regimen for patients previously treated with HER2-directed therapy, and appears to make disease stable for long time period. Clinical trial information: UMIN000005881.

A phase II study of metronomic paclitaxel/cyclophosphamide/capecitabine followed by 5-fluorouracil/epirubicin/cyclophosphamide as preoperative chemotherapy for triple-negative or low hormone receptor expressing/HER2-negative primary breast cancer

PURPOSE

Better treatments for triple-negative breast cancer (TNBC) are needed. To address this need, we studied the effects of preoperative metronomic paclitaxel/cyclophosphamide/capecitabine (mPCX) followed by 5-fluorouracil (FU)/epirubicin/cyclophosphamide (FEC) as preoperative chemotherapy in TNBC patients.

METHODS

Forty primary TNBC patients received four cycles of metronomic paclitaxel (80 mg/m(2) on Days 1, 8, and 15), cyclophosphamide (50 mg/body daily), and capecitabine (1,200 mg/m(2) daily), followed by four cycles of 5-FU (500 mg/m(2)), epirubicin (100 mg/m(2)), and cyclophosphamide (500 mg/m(2)) every 3 weeks. The primary end point was the pathological complete response (pCR) rate.

RESULTS

Forty patients formed the intent-to-treat population. The median dose intensities of paclitaxel, cyclophosphamide, and capecitabine were 89.7, 92.1, and 89.8%, respectively. Five patients discontinued mPCX and two discontinued FEC, primarily because of adverse events, resulting in a per-protocol population (PPS) of 33 patients. The pCR (ypT0/Tis ypN0) rate was 47.5% (19/40) in the intent-to-treat population and 54.5% (18/33) in the PPS. The clinical response rates were 36/40 (90.0%) and 31/33 (93.9%) in the intent-to-treat and PPS, respectively. The breast conservation rate was 72.7% (24/33), and 5/13 patients underwent partial resection instead of pre-planned total mastectomy. Grade 3-4 adverse events included neutropenia (35%), leukopenia (25%), and hand-foot syndrome (8%).

CONCLUSIONS

Metronomic PCX followed by FEC chemotherapy was associated with a high pCR rate and low toxicity in TNBC patients. Further studies of this regimen in larger numbers of patients are warranted.

Estrogen receptor (ER) mRNA expression and molecular subtype distribution in ER-negative/progesterone receptor-positive breast cancers

We examined estrogen receptor (ER) mRNA expression and molecular subtypes in stage I-III breast cancers that are progesterone receptor (PR) positive but ER and HER2 negative by immunohistochemistry (IHC) or fluorescent in situ hybridization. The ER, PR, and HER2 status was determined by IHC as part of routine clinical assessment (N = 501). Gene expression profiling was done with the Affymetrix U133A gene chip. We compared expressions of ESR1 and MKI67 mRNA, distribution of molecular subtypes by the PAM50 classifier, the sensitivity to endocrine therapy index, and the DLDA30 chemotherapy response predictor signature among ER/PR-positive (n = 223), ER-positive/PR-negative (n = 73), ER-negative/PR-positive (n = 20), and triple-negative (n = 185) cancers. All patients received neoadjuvant chemotherapy with an anthracycline and taxane and had adjuvant endocrine therapy only if ER or PR > 10 % positive. ESR1 expression was high in 25 % of ER-negative/PR-positive, in 79 % of ER-positive/PR-negative, in 96 % of ER/PR-positive, and in 12 % of triple-negative cancers by IHC. The average MKI67 expression was significantly higher in the ER-negative/PR-positive and triple-negative cohorts. Among the ER-negative/PR-positive patients, 15 % were luminal A, 5 % were Luminal B, and 65 % were basal like. The relapse-free survival rate of ER-negative/PR-positive patients was equivalent to ER-positive cancers and better than the triple-negative cohort. Only 20-25 % of the ER-negative/PR-positive tumors show molecular features of ER-positive cancers. In this rare subset of patients (i) a second RNA-based assessment may help identifying the minority of ESR1 mRNA-positive, luminal-type cancers and (ii) the safest clinical approach may be to consider both adjuvant endocrine and chemotherapy.

Abstract P3-14-05: Randomized phase II study of preoperative docetaxel and cyclophosphamide-containing chemotherapy for luminal-type breast cancer

Background: We compared and evaluated three 6-cycle, docetaxel and cyclophosphamide (TC)-containing chemotherapy regimens in a multicenter randomized phase II study. The main aim was to investigate whether anthracyclines are needed or can be omitted, and whether the order of chemotherapy is important, for treating luminal-type breast cancer.

Methods: We recruited patients (pts) with ER-positive, HER2-negative breast cancer aged 20–70 years, and histo-pathologically invasive breast cancer (T1c-3, N0-1, M0), T≤7cm. Pts were randomized to 3 groups for the following treatments: 6 cycles of TC; 3 cycles of 5-FU/epirubicin/cyclophosphamide (FEC) followed by 3 cycles of TC (FEC-TC); and 3 cycles of TC followed by 3 cycles of FEC (TC-FEC). TC treatment consisted of administration of docetaxel at 75 mg/m2 and cyclophosphamide at 600 mg/m2 once every 3 weeks. FEC treatment consisted of administration of 5-FU at 500 mg/m2, epirubicin at 100 mg/m2, and cyclophosphamide at 500 mg/m2 once every 3 weeks. We aimed to enroll 65 pts per group based on an expected pCR rate among regimens of adding 10% at a threshold of 9%. The primary endpoint was pathological complete response (pCR) rate. Secondary endpoints were overall response rate (ORR), breast conservation rate and safety.

Results: A total of 195 pts (median age, 49.5 years (range, 26–69); median tumor size, 32.8 mm (range, 9–82); 91 pts with N(+) (51%)) were enrolled and randomized as follows: FEC-TC (n = 65), TC-FEC (n = 63), and TC group (n = 67). There were no differences in backgrounds among groups. Both the intention-to-treat population and the safety analysis set included 65, 63 and 65 pts in these groups, respectively. The 6-cycle treatment completion rates were 96.9%, 96.8% and 84.6%, respectively. pCR, defined as yT0/isyN0, was achieved by 9.2% of pts in the FEC-TC group, 8.1% in the TC-FEC group, and 15.9% in the TC group (p = 0.321). A quasi pCR in breast (yT0/is and near pCR) was achieved by 13.9%, 14.5%, and 17.5%, respectively. These responses did not differ among the 3 groups. ORRs, assessed by MRI or CT, were 75.8% (CR: 12.9%), 75% (CR: 5%), and 82.2% (CR: 17.9%) in the FEC-TC, TC-FEC and TC groups, respectively. Breast conservation rates were 50.8%, 45.2%, and 73.0%, respectively.Adverse events of Grade≥3 were observed in 20.0%, 27.0%, and 20.3% of pts in the FEC-TC, TC-FEC, and TC groups, respectively, with no significant differences. Febrile neutropenia was observed in 17.2%, 21.0%, and 11.3%, respectively, but in most cases it was managed sufficiently on an outpatient basis. Of 28, 27 and 23 pts in these groups in whom mastectomy was planned, 9 (32%), 5 (19%), and 10 (44%) were successfully converted to undergo breast-conserving surgery. Of 37, 35 and 40 pts in the FEC-TC, TC-FEC and TC groups in whom breast-conserving surgery was planned, 13 (35%), 12 (34%), and 4 (10%) underwent mastectomy.

Conclusion: Six cycles of TC had therapeutic effects and safety equivalent to FEC-TC and TC-FEC. The 3 treatment groups showed similar pCR rates, although the breast conservation rate was significantly higher in the TC group than in the other 2 groups. It may be possible to conduct preoperative chemotherapy for pts with ER-positive breast cancer without using an anthracycline.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-05.

Phase II study of neoadjuvant chemotherapy with a metronomic regimen of paclitaxel + cyclophosphamide + capecitabine followed by 5-fluorouracil + epirubicin + cyclophosphamide in operable triple-negative breast cancer (JBCRG-13 study)

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Background: Triple-negative breast cancer (TNBC) is generally associated with a poor prognosis. Combination therapy with anthracyclines and taxanes is widely used as preoperative systemic chemotherapy (PST), but pathological complete response (pCR) rate is ≤50%. We conducted metronomic PST in TNBC patients. Methods: Patients had primary breast cancer (T1C-3N0M0 or T1-3N1M0) with low ER expression (<10%) diagnosed with either a triple-negative or HER2-negative invasive tumor. They received 4 cycles of a metronomic PCX regimen followed by 4 cycles of 5-fluorouracil (500 mg/m2, q3w) + epirubicin (100 mg/m2, q3w) + cyclophosphamide (500 mg/m2, q3w) (FEC regimen). The metronomic PCX regimen includes weekly administration of paclitaxel (80 mg/m2; days 1, 8, 15), cyclophosphamide (50 mg/body; po, days 1-21) and capecitabine (1200 mg/m2; po, daily), with one cycle set to 21 days. Primary endpoint was pCR rate. Results: Between March 2010 and September 2011, 41 patients were enrolled and 40 patients were treated. Characteristics of these 40 pts (ITT population) were: median age 52 years (range, 33-69), median tumor size 23.7 mm (range, 3.5-82), N(+) in 16 pts (40%), and estrogen receptor weakly positive (ER;1-9%) in 7 pts (17.5%). Median dose intensity for paclitaxel, cyclophosphamide and capecitabine was 89.7%, 92.1% and 89.8%, respectively. Five pts requested discontinuation of PST during PCX and 2 during FEC, primarily due to adverse events, leaving a per protocol population of 33 pts. pCR (ypT0/Tis ypN0) rate was 54.5% (18/33). 22 pts achieved CR, and ORR was 93.9% (95% CI, 79.8-99.3) as assessed by MRI or CT. Breast conservation rate was 72.7% (24/33), and 5 of 13 pts changed to partial resection from pre-planned total mastectomy. Grade 3-4 adverse events were neutropenia (35%), febrile neutropenia (25%), leucopenia (25%), and hand-foot syndrome (7.5%). There was no SAE report, and most pts completed treatment as outpatients. Conclusions: Metronomic PCX followed by FEC provided a high pCR rate and was manageable as PST in patients with TNBC. Clinical trial information: UMIN000003570.

Analysis of health-related quality of life during neoadjuvant endocrine therapy with letrozole in postmenopausal breast cancer patients: N-SAS BC06 trial

6588

Background: The impact of neoadjuvant endocrine therapy (NET) on health-related QOL (HRQOL) has not been clarified yet. N-SAS BC 06 is a multicenter study in postmenopausal patients with hormone-sensitive primary breast cancer, two-staged (preoperative and postoperative) enrollment, and intervention. It includes a randomized controlled study of patients responding to NET, which is designed to compare chemotherapy followed by endocrine therapy, with endocrine therapy alone, as postoperative adjuvant therapy. The primary endpoint is DFS, and the secondary endpoints include adverse events, HRQOL and health economic evaluation. This report presents the planned analysis of HRQOL during 6 months of NET. Methods: The target sample size was 850 patients of whom the first 500 enrolled patients were included in HRQOL evaluation. Subjects were assessed at enrollment, and at 1 and 4 months after starting NET, using FACT-G (General), B (Breast), ES (Endocrine Symptoms) and HADS (Hospital Anxiety and Depression Scale). Results: Mean age was 63 years, mean BMI was 23.9. Results of clinical efficacy were as follows: CR: 2%; PR: 44.3%; SD: 48%; and PD: 5.7%. The questionnaire response rates at enrollment, and at 1 and 4 months were 93%, 90% and 82%, respectively, quite a high response rate. The mean scores at enrollment, and at 1 and 4 months were as follows: FACT-G: 82.9; 83.4; 82.7, FACT-B TOI (Trail outcome index): 68.3; 69.5; 68.9; ES subscale: 61.2; 60.1; 59.7 and HADS score: 10.4; 8.9; 8.8 respectively. There were no significant changes in the FACT-G or B-TOI over time, while the social domain score, ES subscale, decreased significantly (worse social well-being and ES). In the ES analysis by item, symptoms such as hot flash showed a greater decrease. HADS scores deceased significantly (improved anxiety and depression), and emotional domain scores increased significantly (better emotional well-being) at 1 month and 4 months after NET. Conclusions: NET had no impact on the overall HRQOL scores, but the anxiety and depression observed at enrollment had improved by 1 month after therapy. To our best knowledge, this is the first report of HRQOL during NET. Clinical trial information: 000001090.

Efficacy of goserelin plus anastrozole in premenopausal women with advanced or recurrent breast cancer refractory to an LH-RH analogue with tamoxifen: results of the JMTO BC08-01 phase II trial

The aim of the present study was to assess the efficacy and tolerability of a luteinizing hormone-releasing hormone (LH-RH) analogue plus an aromatase inhibitor following failure to respond to standard LH-RH analogue plus tamoxifen (TAM) in premenopausal patients. Premenopausal women with estrogen receptor (ER)-positive and/or progesterone-receptor positive, advanced or recurrent breast cancer refractory to an LH-RH analogue plus TAM received goserelin (GOS) in conjunction with anastrozole (ANA). The primary endpoint was the objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), clinical benefit rate (CBR) and safety. Between September 2008 and November 2010, 37 patients were enrolled. Thirty-five patients (94.6%) had ER-positive tumors, and 36 (97.3%) had human epidermal growth factor receptor (HER) 2-negative tumors. Thirty-six (97.3%) had measurable lesions and 1 (2.7%) had only bone metastasis. The ORR was 18.9% [95% confidence interval (CI), 8.0–35.2%], the CBR was 62.2% (95% CI, 44.8–77.5%) and the median PFS was 7.3 months. Eight patients had adverse drug reactions but none resulted in discontinuation of treatment. GOS plus ANA is a safe effective treatment for premenopausal women with hormone receptor-positive, recurrent or advanced breast cancer. The treatment may become viable treatment in the future, particularly when TAM is ineffective or contraindicated. Further studies and discussion are warranted.

Abstract P4-01-05: Utility of Preoperative Routine MRI and PET/CT in Breast Cancer Staging vs. Surgical Staging

Background: Staging of breast cancer is one of the most important factors in determining treatment options. The aim of this study is to assess the utility of routine magnetic resonance imaging (MRI) and positron emission tomography and computed tomography (PET/CT) in preoperative breast cancer staging.

Patients and methods: We examined 616 consecutive patients, who were newly-diagnosed with operable primary breast cancer less than 3 cm, at our institution between 2009 and 2011. They all underwent MRI and PET/CT to assign the clinical stage by TNM classification. Tumor size was measured by contrast MRI examinations and node status and metastases were evaluated on PET/CT. We examined their clinical and pathological T and N status retrospectively to assess the utility and concordance rate of preoperative imaging studies. Patients with tumors more than 3 cm were excluded from this study, since preoperative systemic therapy is the standard therapeutic strategy for those patients.

Results: The concordance rate of T status was 79.9% in clinical T1 patients (366/458) and 55.6% in clinical T2 patients (88/158). The concordance rate of N status was 83.8% in clinical N0 patients (495/591) and 60.0% in clinical N1 patients (15/25). As a result, the concordance rate of clinical stage was 66.5% in clinical stage I patients (296/445) and 55.0% in clinical stage II patients (94/171). In addition, 43 patients were diagnosed as contrary breast cancer by MRI (7.5%) and 31 contrary breast cancer (5.4%) and 12 other malignant disease (1.9%) were found by PET/CT.

Conclusions: MRI and PET/CT are valuable tools to provide information on tumor size, lymph node involvement, distant metastases and other occult primary disease. Preoperative routine MRI and PET/CT studies have a substantial impact on patients with operable primary breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-05.

Abstract P1-14-12: Response to neoadjuvant chemotherapy and prognosis of primary breast cancer according to intrinsic subtype

Background: Response to neoadjuvant chemotherapy of primary breast cancer differs across intrinsic subtypes and is considered as a useful surrogate indicator for prognostic prediction, while some subtype populations seems to take different course.

Methods: We classified 364 primary breast cancer patients, who received neoadjuvant chemotherapy after 2002 at our institute, to 5 intrinsic subtype groups; Luminal A type (LA), Luminal B type (LB), Luminal Her2 type (LH), Her2 type (Her2) and triple negative (TN), according to hormonal sensitivity, Her2 status, and cancer proliferation. We evaluated their pathological response to neoadjuvant chemotherapy by response criteria of Japanese Breast Cancer Society. Pathological complete response (pCR) is defined as Necrosis or disappearance of invasive cancer of breast in this study, approving residual non-invasive component of breast or axillary lymph node metastasis. We also examined disease free survival (DFS) and overall survival (OS) by each subtypes statistically, using Kaplan-Meier method and Log-rank test.

Results: Number of patients in each subtype were as follows; LA: 141 patients, LB: 41 patients, LH: 38 patients, Her2: 54 patients, and TN: 90 patients. Surveillance period is 4–105 months (median: 37 months). Most of cases in all subtypes received both anthracycline and taxane. 27 cases in LH (71.1%) and 48 cases in Her2 (88.9%) were treated with trastzumab. 7 cases in LA (5.0%), 4 cases in LB (9.8%), 9 cases in LH (23.7%), 31 cases in Her2 (57.4%), and 26 cases in TN (28.9%) achieved pCR. pCR rate was significantly high in Her2 and TN (p &lt; 0.05). LA, LB, LH showed no significant differences in DFS and OS between pCR group and non-pCR group (LA; DFS p = 0.929 OS p = 0.663, LB; DFS p = 0.189 OS p = 0.552, LH; DFS p = 0.508 OS p = 0.691). In Her2 group, pCR group tended to show better prognosis, but there were no significant differences (Her2; DFS p = 0.107, OS p = 0.343). In TN group, pCR group showed significantly better prognosis (TN; DFS p = 0.046, OS p = 0.040), which indicates the correlation between response to neoadjuvant chemotherapy and prognosis.

Conclusion: Our results indicate the correlation between response to neoadjuvant chemotherapy and prognosis in TN breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-12.

Abstract P1-14-08: A prospective multicenter randomized phase II neo-adjuvant study of 5-fluorouracil, epirubicin and cyclophosphamide (FEC) followed by docetaxel, cyclophosphamide and trastuzumab (TCH) versus TCH followed by FEC versus TCH alone, in patients (pts) with operable HER2 positive breast cancer: JBCRG-10 study

Background: The current standard treatment of primary systemic therapy (PST) in HER2 positive breast cancer is anthracyclines (A) and/or taxanes combined with trastuzumab (H) which demonstrates high pathological complete response (pCR). The pCR is considered as a predictive marker of prognosis although results are slightly different depending on the hormone receptor status. We conducted a randomized phase II study to examine sequence of treatments and necessity of A in the treatments using TCH to improve outcome and reduce cardiac toxicity in Japanese HER2 positive pts.

Methods: Pts were treated with FEC (5FU 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2) and/or TCH (docetaxel 75 mg/m2, cyclophosphamide 600 mg/m2, H 6 mg/kg, loading by 8 mg) in 3 groups: 4 cycles of FEC followed by 4 cycles of TCH (A-TCH); 4 cycles of TCH followed by 4 cycles of FEC (TCH-A) or 6 cycles of TCH. An unplanned interim analysis was conducted due to one death by interstitial lung disease (ILD) in the A-TCH after completion of 8 cycles. The pCR results suggested A containing regimens did not exceed benefit from the current standard regimen. The study was continued by limiting allocation only to the TCH group considering efficacy and safety. The primary endpoint was pCR and secondary endpoints were overall response rate (ORR) and safety.

Results: A total of 103 pts were enrolled between Sep. 2009 and Sep. 2011; 21 pts in the A-TCH, 22 pts in the TCH-A and 60 pts in the TCH including pts enrolled after termination of random allocation. Characteristics of the 103 pts were; median age of 54 (range, 33–70), median tumor size of 35 mm (range, 12–80), 42 pts with N(+) (40.8%) and 62 ER positive pts (60.2%). Characteristics of pts in the TCH were; median age of 54.5 (range, 33–67), median tumor size of 35.5 mm (range, 12–80), 25 pts with N(+) (41.7%) and 34 ER positive pts (56.7%). No major difference was reported between groups treated with or without A. Per protocol population was 59 pts in the TCH and its pCR rate was 45.8% (95% CI, 32.2–59.3: ER negative, 61.5%; ER positive, 33.3%). ORR was 86.4% assessed by MRI or CT. Although it is an exploratory analysis, the pCR rate of A containing regimens was 39.0% (ER negative, 57.1%; ER positive, 29.6%). Adverse events ≥grade 3 were reported in 50 pts (48.5%). Reported ILD was in 5 pts (A-TCH, 1; TCH-A, 1; TCH, 3). The mean left ventricular ejection fraction (LVEF) decreased from 70.0% to 69.0% after treatment (A-TCH, 65.9%; TCH-A, 70.4%; TCH, 69.0%). Decrease of LVEF in the A-TCH was significant (p &lt; 0.01).

Conclusion: The pCR rate of the TCH group was similar to previous reports on A including regimens. Although ILD had been occurred during the treatment containing the TCH, no other new safety issues were reported. We were not able to conclude preferable sequence of A and T since statistical power was not sufficient. However, the result of LVEF suggested TCH followed by A or TCH were preferable. Six cycles of TCH could be one of treatment options as a PST in HER2 positive breast cancer to exclude A. (UMIN000002365)

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-08.

A multicenter phase II trial of the LH-RH analogue and an aromatase inhibitor combination in premenopausal patients with advanced or recurrent breast cancer refractory to an LH-RH analogue with tamoxifen: JMTO BC08-01

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Background: The aim was to provide an endocrine therapy option against advanced (ABC) or recurrent breast cancer (RBC) in premenopausal women. We conducted an exploratory phase II trial in combination with an LH-RH analogue (LH-RHa) and an aromatase inhibitor (AI) to assess the efficacy and tolerability after failure of standard LH-RHa plus tamoxifen (TAM). Methods: Premenopausal patients (pts) with ER+ and/or PgR+ ABC or RBC refractory to LH-RHa + TAM were treated with LH-RHa (goserelin: GOS) and AI (anastrozole: ANA). The primary endpoint was an objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), clinical benefit rate (CBR) based on RECIST, and safety assessed using CTCAE ver. 3.0. Pts with only bone legions were assessed using the criteria by Japanese Breast Cancer Society (14th Ed.). Local assessment (CR, PR or long SD of 24 weeks or longer) was confirmed independently by two radiologists. Results: Between September 2008 and November 2010, 37 pts were enrolled at 10 clinical institutions in Japan. Eleven had recurrence either during, or within one year after the end of adjuvant GOS + TAM (including GOS + TAM followed by only TAM). The disease progressed in 26 women during GOS + TAM. Mean age and BMI were 43.5 years and 22.2 kg/m2, respectively. Thirty-five pts (94.6%) were ER+, and 36 pts (97.3%) were HER2- (one with unknown HER2 status). Non-endocrine treatment included chemotherapy (20 pts; 54%) and radiation therapy (13 pts; 35%). The viscera, soft tissue, and bones were treated in 17, 15 and 14 pts, respectively. Pts with both measurable lesions and bone metastasis, measurable lesions only, and only bone metastasis were 21 (57%), 15 (41%) and 1 (2%), respectively. ORR was 18.9% (95%CI: 8.0-35.2%, 1 CR and 6 PR cases), CBR 62.2% (23 pts, 95%CI: 44.8-77.5%), and median PFS was 7.2 months. Eight pts (21.6%) had adverse events, but none resulted in treatment discontinuation. GOS + ANA was well tolerated. Conclusions: LH-RHa (GOS) + ANA can be a subsequent endocrine treatment for premenopausal pts with ABC or RBC after failure of GOS + TAM.

Immunohistochemical study of nuclear factor-κB expression in esophageal squamous cell carcinoma: prognostic significance and sensitivity to treatment with 5-FU

Nuclear factor-κB (NF-κB) is expressed in many types of cancers. It has been suggested that the expression of NF-κB is associated with poor prognosis and resistance to chemoradiation therapies. This study evaluated the relationship between the expression of NF-κB and the prognosis and sensitivity of esophageal squamous cell carcinoma (ESCC) to chemotherapy. One hundred and nine ESCC specimens, from patients who had undergone radical esophagectomy, were divided into two groups depending on the expression of NF-κB. Surgical data and prognosis were compared between the two groups. NF-κB-positive tumors were detected in 61.5% of the cases. In 69 patients with stage II and III disease, 41 patients who were NF-κB-positive showed poor survival. The sensitivity of esophageal squamous cell carcinoma cell lines to 5-fluorouracil (5-FU) was analyzed by their NF-κB expression, and the effect of 5-FU was evaluated on the proliferation and activity of two cell lines of cultured ESCCs expressing NF-κB. ESCCs with activated NF-κB had poor sensitivity to 5-FU. These results suggest that the increased expression of NF-κB is associated with poor prognosis in patients with ESCC. NF-κB may be a target for ESCC therapy because of its selective expression in this type of cancer.

Transcriptional activation of the anchoring protein SAP97 by heat shock factor (HSF)-1 stabilizes K(v) 1.5 channels in HL-1 cells

BACKGROUND AND PURPOSE

The expression of voltage-dependent K⁺ channels (K_v) 1.5 is regulated by members of the heat shock protein (Hsp) family. We examined whether the heat shock transcription factor 1 (HSF-1) and its inducer geranylgeranylacetone (GGA) could affect the expression of K_v1.5 channels and its anchoring protein, synapse associated protein 97 (SAP97).

EXPERIMENTAL APPROACH

Transfected mouse atrial cardiomyocytes (HL-1 cells) and COS7 cells were subjected to luciferase reporter gene assay and whole-cell patch clamp. Protein and mRNA extracts were subjected to Western blot and quantitative real-time polymerase chain reaction.

KEY RESULTS

Heat shock of HL-1 cells induced expression of Hsp70, HSF-1, SAP97 and K_v1.5 proteins. These effects were reproduced by wild-type HSF-1. Both heat shock and expression of HSF-1, but not the R71G mutant, increased the SAP97 mRNA level. Small interfering RNA (siRNA) against SAP97 abolished HSF-1-induced increase of K_v1.5 and SAP97 proteins. A luciferase reporter gene assay revealed that the SAP97 promoter region (from −919 to −740) that contains heat shock elements (HSEs) was required for this induction. Suppression of SIRT1 function either by nicotinamide or siRNA decreased the level of SAP97 mRNA. SIRT1 activation by resveratrol had opposing effects. A treatment of the cells with GGA increased the level of SAP97 mRNA, K_v1.5 proteins and I_Kur current, which could be modified with either resveratrol or nicotinamide.

CONCLUSIONS AND IMPLICATIONS

HSF-1 induced transcription of SAP97 through SIRT1-dependent interaction with HSEs; the increase in SAP97 resulted in stabilization of K_v1.5 channels. These effects were mimicked by GGA.

Radiofrequency ablation of early breast cancer followed by delayed surgical resection--a promising alternative to breast-conserving surgery

To examine the radiofrequency ablation (RFA) reliability in early breast cancer, we performed RFA followed by delayed surgical resection on 41 patients with invasive or non-invasive breast carcinoma less than 2 cm. MRI scans were obtained before ablation and resection. Excised specimens were examined pathologically by haematoxylin-eosin and nicotinamide adenine dinucleotide-diaphorase staining. 40 patients completed 1 RFA session, which was sufficient to achieve complete tumour cell death. Overall complete ablation rate was 87.8% (36/41). There were no treatment-related complications other than that of a superficial burn in 1 case. After RFA, the tumour was no longer enhanced on MRI in 25/26 (96.2%) cases. Residual cancer, which was suspected on MRI in 1 case, was confirmed pathologically. MRI could be an applicable modality to evaluate therapeutic effect. RFA could be an alternate local treatment option to breast-conserving surgery for early breast cancer.

[Catamenial pneumothorax with breast cancer treated successfully by goserelin acetate]

A 47-year-old woman with 4 episodes of right pneumothorax related to onset of menstruation was reported. A month ago, she was undergone breast conserving resection for breast cancer. She had recurrent right pneumothorax a month later and operation was performed. Thoracoscopy revealed the presence of multiple fenestrations in the right diaphragm. Thoracoscopic partial resection of the diaphragm was performed. Histopathological findings of the lesion showed spindle cells with hemosiderosis. Immunohistochemistry showed that spindle cells were estrogen receptor (ER) positive and progesterone receptor (PgR) positive, compatible with endometriosis. She was treated by tamoxifen and goserelin acetate for breast cancer and endometriosis. Two years later, gonadotropin releasing hormone (GnRH) analogue was converted from goserelin acetate to leuprorelin acetate. She was diagnosed as having recurrence of right pneumothorax 17 months later and was treated with a chest tube. Additionally, GnRH analogue was re-converted to goserelin acetate. Since then, she has been asymptomatic free for 18 months. A catamenial pneumothorax is rare disease with difficulty of diagnosis and treatment We herein report a case of the disease that was treated successfully by goserelin acetate.

[Clinical effect of Vinorelbine monotherapy in 18 cases of advanced or metastatic breast cancer]

We analyzed the efficacy and safety of Vinorelbine monotherapy in 18 patients with advanced or metastatic breast cancer between May 2006 and July 2007, retrospectively. The outcomes were PR in 4 cases, long-term SD in 1, SD in 5, and PD in 8. The overall response rate was 22.2%(4/18), and a clinical benefit was shown in 27.8%(5/18). The median time to progression(TTP)was 138 days. Major adverse events were leukopenia(72.2%), neutropenia(77.8%) and superficial phlebitis(58.8%). These results suggest that Vinorelbine was a safe and effective agent.

Pharmacokinetic analysis of factors determining elimination pathways for sulfate and glucuronide metabolites of xenobiotics. iii: mechanisms for sinusoidal efflux of 4-methylumbelliferone sulfate

1. To elucidate the mechanisms involved in the sinusoidal efflux of sulfate and glucuronide metabolites of 4-methylumbelliferone (4MU), isolated rat liver perfusion studies were performed under several conditions. 2. The effect of sodium azide on the hepatic handling of both conjugates was examined. The net sinusoidal efflux clearance (CL(eff)) based on the unbound concentration in the liver did not change for 4MU glucuronide (4MUG) or significantly increase for 4MU sulfate (4MUS), suggesting that the sinusoidal efflux of both conjugates is not mediated by the transport systems dependent on adenosine triphosphate. 3. Under Cl(-)-depleted conditions, the CL(eff) of 4MUG significantly decreased, but the saturation of its sinusoidal efflux rather than the transport system dependent on Cl(-) might be involved because the hepatic concentration of 4MUG was extensively higher than that of the control study due to the extremely attenuated biliary excretion. The CL(eff) of 4MUS also significantly decreased, but its hepatic concentration was not different from that in the control study, suggesting that the transport system using Cl(-) is involved in the sinusoidal efflux of 4MUS. 4. The effect of glutathione was examined. CL(eff) of 4MUG was not affected by the additional glutathione, but CL(eff) of 4MUS decreased significantly, suggesting that some transport system sensitive to glutathione is involved in the sinusoidal efflux of 4MUS, but not of 4MUG. 5. Transporters such as Oatp1, Oatp2 and/or Npt1 might be involved in the sinusoidal efflux of 4MUS, but 4MUG is secreted from the sinusoidal membrane via the systems that are totally different from those for 4MUS.

[Prediction of response to primary systemic chemotherapy involving weekly paclitaxel followed by FEC 100 for advanced breast cancer]

To predict the response to primary systemic chemotherapy (PSC) involving weekly paclitaxel (PTX) followed by FEC100, we analyzed the therapeutic effects of PSC on 58 cases of stage II - III advanced breast cancer, 2 cases of PD, 4 cases of suspension due to adverse events, and 52 successful cases (89.7%). As for clinical effect, CR was observed in 12 cases (23.1%) and PR in 33 cases (63.5%) and for histological effects, grade 3 (pCR) was observed in 7 cases (13.5%) and grade 2 in 13 cases (25.0%). At the time of completion of 4 courses of PTX, SD was observed in 34 out of 52 cases, but the number of SD decreased to 28 cases on completion of 8 courses of PTX, to 19 cases on completion of 12 courses of PTX, and to 7 cases on completion of 4 courses of FEC. In examining the 7 cases of pCR in whom the histological effect was observed, 3 cases of SD were observed on completion of 4 courses of PTX and 2 cases on completion of 8 courses of PTX. Unless PD is observed during the course of PSC, continuation of therapy would be indicated because of the delayed response.

[A case of progressive gastric carcinoma accompanied by disseminated carcinomatosis of bone marrow due to bone metastasis with DIC recovery by joint administration of 5-FU and paclitaxel]

A 54-year-old male visited our hospital with the chief complaint of anorexia. Based on various tests, a diagnosis of scirrhous gastric carcinoma accompanied by bone metastasis and liver metastasis was made. As DIC developed following hospital admission, 5-FU and PTX therapy (5-FU at 600 mg/m(2), 24-hour continuous infusion, day 1-5 and PTX at 80 mg/m(2), iv, day 8, 15, 22) were administered. Although primary foci, bone metastasis, and liver metastasis were observed by image diagnostic procedures, recovery from DIC was achieved. 5-FU+PTX therapy is considered to be effective for DIC due to bone metastasis of gastric carcinoma.

Prevalence of hepatitis C virus infection in cases of B-cell lymphoma in Japan

AIMS

To determine the prevalence of hepatitis C virus (HCV) infection in B-cell lymphoma in Japan. HCV infection and type II (monoclonal IgM) cryoglobulinaemia (CG) may be involved in the pathogenesis of low-grade B-cell lymphoma (ML) in southern Europe.

METHODS AND RESULTS

Forty-five (11.3%) of 400 B-cell ML cases were HCV antibody (Ab) positive, which was significantly (P < 0.01) higher than the blood donors (2.5%). Among them, 28 diffuse large B-cell lymphoma (DLBCL) cases were included. In the primary sites, 10 (47.6%) of 21 splenic DLBCL and seven (23.3%) of 30 gastric DLBCL were HCV Ab positive, which were significantly (P < 0.05) higher than the myeloma cases (4.9%). HCV infection was rarely (4.2%) detected in 24 lymphoplasmacytic and salivary gland low-grade B-cell ML cases. Type II CG was detected in one myeloma case (3.5%) of 29 HCV+ B-cell ML. By real-time polymerase chain reaction, HCV RNA was detected in fresh tumour tissues of all 11 B-cell ML cases examined. Lymphoma cells were positive for the envelope HCV non-structural (NS)3 and envelope (E2) proteins in six of eight examined B-cell ML cases.

CONCLUSIONS

The rare incidence of type II CG is characteristic of Japanese HCV+ ML patients and may influence the low incidence of low-grade B-cell ML. HCV infection may play a role in lymphomagenesis of splenic and gastric DLBCL.

Enhancement of topical delivery of drugs via direct penetration by reducing blood flow rate in skin

The purpose of this work was to investigate the effect of blood flow in the skin on the direct penetration of topically applied drugs into the muscular layer, and to show that the skin blood flow could also be one of the important factors determining the direct penetration of drugs to the muscular layer. In vivo percutaneous absorption study was performed for antipyrine, salicylic acid or diclofenac by using rats with tape-stripped skin. Phenylephrine, which is well known to reduce the local blood flow by vasoconstrictor action, was topically applied to decrease the local blood flow in the skin. The concentrations of drugs in viable skin and muscle, and the local blood flow in the skin under the applied and the contralateral sites were determined to evaluate the effect of the local blood flow on the delivery of topically applied drugs into the muscular layer. Dose dependency for the effect of phenylephrine was, first of all, investigated for antipyrine in the range from 0.4 to 10 micromol. The distribution of antipyrine into the viable skin and muscular layer 2 h after topical application significantly increased, but the effect of phenylephrine was saturated around 2 micromol and the dose-dependent profiles for both tissues were almost superimposed. On the other hand, the fraction dose absorbed, plasma concentration and concentrations in viable skin and muscular layer under the contralateral site showed the decreasing tendency and the saturation of the effect around 2 micromol. To confirm the effect of phenylephrine on the local blood flow in the skin, the skin blood flow was measured 2 h after topical application of 2 micromol phenylephrine, and the significant decrease in the blood flow was recognized. In vivo percutaneous absorption studies were performed for salicylic acid and diclofenac, too. Extensive enhancement of penetration into the viable skin and muscular layer was observed for both drugs, although total absorption from the donor cell showed the decreasing tendency. In conclusion, direct penetration of drugs applied topically is enhanced by reducing the local blood flow in the skin, which would be a possible approach to improve the local delivery of drugs applied topically.

[Evaluation of multimodality therapy for synchronous liver metastases of gastric cancer]

We evaluated the significance of multimodality therapy for cases of liver metastases of gastric cancer. Accumulated survival rate and median survival time were analyzed for twenty cases of such gastric cancer. Survival rates of H1+H2 group and hepatic resection (HR) group were higher than that of H3 group and non-HR group. MST of HR group and hepatic arterial infusion (HAI) group were longer than that of non-HR group and non-HAI group. Survival rate of HAI group was higher than that of non-HAI group among eleven cases of HR group. On the other hand, survival rate of HR group was higher than that of non-HR group among eleven cases of HAI group. These results suggested that HAI chemotherapy after hepatic resection for gastric cancer patients with synchronous liver metastasis would improve prognosis.

[The significance of low-dose CDDP intraperitoneal administration for cases of peritoneal dissemination of gastric cancer]

We examined the significance of low-dose cisplatinum (CDDP) intraperitoneal administration for cases of peritoneal dissemination of gastric cancer. Sixty-eight cases of gastric cancer, diagnosed as P1 or CY1 in the gastrectomy operation that was carried out during the period between January 1994 and December 2001, were studied based on accumulated survival rate and mean survival time (MST). Ten milligram of CDDP was weekly administrated intraperitoneally through an infusion port. A two-week interval was taken after the eight-week administration. This group, the CDDP intraperitoneal administration group, was statistically superior both in the accumulated survival rate and MST. These results suggested that the low-dose CDDP intraperitoneal administration would contribute to improved prognosis of such gastric cancers as P1 or CY1.

[Effects of repeated intraperitoneal CDDP chemotherapy for the prevention of T3 and T4 gastric cancer]

We studied the significance of repeated intraperitoneal CDDP administration, as adjuvant chemotherapy, for the prevention of T3 and T4 gastric cancer. Fifty-two patients who had been operated as Curability B were divided into the following two groups, and the data on survival rate, median survival time and interval of "free of recurrence" were accumulated and analyzed. Group A consisted of nineteen patients treated with intraperitoneal CDDP administration and oral anticancer drugs. Group B were treated with systemic chemotherapy. Group A was superior to Group B in comparing the analyzed data. These results suggested that repeated intraperitoneal CDDP chemotherapy for the prevention of T3 and T4 advanced gastric cancer would improve survival rate.

Pharmacokinetic analysis of factors determining elimination pathways for sulfate and glucuronide metabolites of xenobiotics II: Studies with isolated perfused rat liver

1. To elucidate the determining factors for elimination pathways of sulfate and glucuronide metabolites of xenobiotics, a single-pass perfusion of 4-methylumbelliferone (4MU) or p-nitrophenol (pNP) was performed with an isolated rat liver preparation. 2. Without bovine serum albumin in the perfusion system, clearance calculated based on the unbound concentration in the liver clearly showed that the net efflux clearances (CLeff) of sulfates from the sinusoidal membrane were much higher than those of glucuronides and that the biliary excretion clearances (CLb) of glucuronides were approximately two times larger than those of sulfates. 3. The ratios of CLeff to CLb were much higher for sulfates than those for glucuronides. The bile-oriented elimination of glucuronides or sinusoidal efflux-oriented elimination of sulfates was observed even using the perfusate including 3% bovine serum albumin, but the sinusoidal efflux of sulfates was extensively enhanced by bovine serum albumin in the perfusate. The mechanisms behind this stimulatory effect remain to be elucidated. 4. For both compounds, CLb of glucuronide was comparable with CLb of sulfate, meaning that CLb is not responsible for the biliary excretion of glucuronides at extensively higher rate than sulfates. 5. Higher concentration of glucuronides in the liver, partly caused by much lower CLeff of glucuronides than that of sulfates, is likely responsible for the bile-oriented excretion of glucuronides. The extensive sinusoidal efflux of sulfates, leading to the urine-oriented excretion, is attributed to the substantially higher CLeff than CLb. 6. In conclusion, the sinusoidal efflux is an important factor for determining elimination pathways of both sulfates and glucuronides, although further studies are needed to clarify the mechanisms of the sinusoidal efflux.

Uptake of rosuvastatin by isolated rat hepatocytes: comparison with pravastatin

1. The liver is the target organ for the lipid-regulating effect of rosuvastatin, a new 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, and liver-selective uptake of this drug is therefore a desirable property. The uptake kinetics of rosuvastatin were investigated and compared with those of pravastatin using isolated rat hepatocytes. 2. Uptake for both drugs involved both active transport and passive diffusion processes. The Michaelis constant (K(m)) of uptake rate for rosuvastatin (9.17 micro M) was approximately half that for pravastatin (16.5 micro M). However, the maximum uptake rate (V(max)) and carrier-mediated uptake clearance (V(max)/K(m)) of rosuvastatin were significantly (p < 0.01) greater than those of pravastatin, and a larger contribution of carrier-mediated uptake clearance to total uptake clearance was shown for rosuvastatin (contribution ratio 0.903 versus pravastatin 0.654). 3. Sodium and chloride ions did not play a significant role in the uptake of rosuvastatin and pravastatin, but the uptake of both drugs was inhibited both by depletion of cellular ATP and by organic anions such as bromosulfophthalein. 4. Rosuvastatin competitively inhibited the uptake of pravastatin, with an inhibition constant (K(i)) (2.75 micro M) relatively similar to its K(m). 5. The results suggest that an organic anion transport protein is the main mediator of the hepatic uptake of rosuvastatin and pravastatin, which occurs in an ATP-dependent manner. Our results indicated that rosuvastatin was taken up by the hepatocytes via the same transport systems as pravastatin, but with a greater affinity and efficiency than pravastatin.