Adjuvant chemotherapy for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial

BACKGROUND

The discussion on the role of adjuvant chemotherapy for rectal cancer patients treated according to current guidelines is still ongoing. A multicentre, randomized phase III trial, PROCTOR-SCRIPT, was conducted to compare adjuvant chemotherapy with observation for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision (TME).

PATIENTS AND METHODS

The PROCTOR-SCRIPT trial recruited patients from 52 hospitals. Patients with histologically proven stage II or III rectal adenocarcinoma were randomly assigned (1:1) to observation or adjuvant chemotherapy after preoperative (chemo)radiotherapy and TME. Radiotherapy consisted of 5 × 5 Gy. Chemoradiotherapy consisted of 25 × 1.8-2 Gy combined with 5-FU-based chemotherapy. Adjuvant chemotherapy consisted of 5-FU/LV (PROCTOR) or eight courses capecitabine (SCRIPT). Randomization was based on permuted blocks of six, stratified according to centre, residual tumour, time between last irradiation and surgery, and preoperative treatment. The primary end point was overall survival.

RESULTS

Of 470 enrolled patients, 437 were eligible. The trial closed prematurely because of slow patient accrual. Patients were randomly assigned to observation (n = 221) or adjuvant chemotherapy (n = 216). After a median follow-up of 5.0 years, 5-year overall survival was 79.2% in the observation group and 80.4% in the chemotherapy group [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.62-1.39; P = 0.73]. The HR for disease-free survival was 0.80 (95% CI 0.60-1.07; P = 0.13). Five-year cumulative incidence for locoregional recurrences was 7.8% in both groups. Five-year cumulative incidence for distant recurrences was 38.5% and 34.7%, respectively (P = 0.39).

CONCLUSION

The PROCTOR-SCRIPT trial could not demonstrate a significant benefit of adjuvant chemotherapy with fluoropyrimidine monotherapy after preoperative (chemo)radiotherapy and TME on overall survival, disease-free survival, and recurrence rate. However, this trial did not complete planned accrual.

REGISTRATION NUMBER

Dutch Colorectal Cancer group, CKTO 2003-16, ISRCTN36266738.

Chronomodulated capecitabine in combination with short-time oxaliplatin: a Nordic phase II study of second-line therapy in patients with metastatic colorectal cancer after failure to irinotecan and 5-flourouracil

BACKGROUND

Oxaliplatin in combination with capecitabine prolongs survival in patients with metastatic colorectal cancer (mCRC). Chronomodulation might reduce toxicity and improve efficacy.

PATIENTS AND METHODS

A phase II study examining chronomodulated XELOX(30) (XELOX(30chron)): oxaliplatin: 130 mg/m(2) on day 1, as a 30-min infusion between 1 and 3 p.m. Capecitabine: total daily dose of 2000 mg/m(2), 20% of the dose between 7 and 9 a.m. and 80% of the dose between 6 and 8 p.m. in patients with mCRC resistant to irinotecan. Seventy-one patients were enrolled. Response rate was 18%; median progression-free survival 5.1 months and median overall survival (OS) 10.2 months. Platelet count and performance status were significantly correlated to OS in multivariate analyses. Neurotoxicity grade 2 and 3 was seen in 25% and 2% of patients, respectively, other grade 3 toxic effects were as follows: nausea 6%, vomiting 3%, diarrhoea 12% (3% experienced grade 4) and palmoplantart erytem 9%.

CONCLUSION

XELOX(30chron) is a convenient second-line regimen with efficacy and safety profile similar to other oxaliplatin schedules. To further investigate chronomodulated XELOX, we have started a Nordic randomised phase II study comparing XELOX(30) and XELOX(30chron) as first-line therapy in patients with mCRC.

High serum YKL-40, but not plasma VEGF and serum HER2, as a prognostic biomarker of short survival in patients with metastatic colorectal cancer

14517

Purpose: To evaluate the prognostic value of plasma VEGF, serum YKL-40 and HER2 before, during and after chemotherapy in patients with their first manifestation of metastatic colorectal cancer (mCRC). Patients and Methods: Prospective, longitudinal study of 105 patients (60 men and 45 women, median age 65, range 36–79 years, PS 0–2) from 7 centers referred with their first manifestation of mCRC. The patients were treated with Oxaliplatin 130 mg/m2 day 1 and Capecitabine 2000 mg/m2 days 1–14 every 3 weeks. Median follow-up was 1.8 years. 92 patients had progression and 62 died. The biomarkers were determined by ELISAs. Results: Pretreatment plasma VEGF (median 90 ng/l, range 3–2622, 37% had high level >137 ng/l) and serum YKL-40 (102 μg/l, 28–692, 40% had higher level than the age-corrected 95th percentile in healthy individuals) were significantly (p<0.001) elevated in the patients compared to normal levels. Serum HER2 was not elevated (7.90 μg/l, 3.6–92, 6% had high level >15 μg/l). Pretreatment serum YKL-40 was higher in patients who died compared to those alive (115 vs. 75 μg/l, p=0.004). No differences in plasma VEGF (97 vs. 85 ng/l, p=0.27) and serum HER2 (8.0 vs. 7.4 μg/l, p=0.16) were found. Univariate Cox analysis showed that plasma VEGF and serum HER2 before treatment or during follow-up could not predict progression-free and overall survival. Pretreatment serum YKL-40 (log transformed, scored as a continuous variable) was in a univariate analysis a prognostic biomarker of overall survival (HR=1.8, 95% CI: 1.3–2.6, p=0.0006), but not of progression- free survival (p=0.81). Multivariate Cox analysis (age, sex, number of organs with metastasis, pretreatment serum YKL-40 (continuous variable)) showed that serum YKL-40 (HR=1.8, 95% CI: 1.3–2.6, p=0.001) and possible the number of organs with metastasis (p=0.06) were independent predictors of overall survival. During follow-up, a high serum YKL-40 (log transformed continuous variable and landmark time) predicted shorter time to progression (HR=1.5, 95% CI 1.1–2.1, p=0.01) and overall survival (HR=1.7, 95% CI 1.2–2.4, p=0.005). Conclusion: Serum YKL-40 is a prognostic biomarker of overall survival and during follow-up also of progression-free survival in patients with mCRC.

No significant financial relationships to disclose.

Short-time infusion of oxaliplatin in combination with capecitabine (XELOX30) as second-line therapy in patients with advanced colorectal cancer after failure to irinotecan and 5-fluorouracil

BACKGROUND

The efficacy of oxaliplatin combined with capecitabine (XELOX) as second-line therapy in patients with advanced colorectal cancer (ACRC) resistant to irinotecan is not well established. Oxaliplatin induces acute, cold-induced neuropathy in most patients. The incidence is claimed to be infusion rate-dependent and therefore a 2-h infusion is recommended.

PATIENTS AND METHODS

For practical and economic reasons, but also for patient's convenience, we performed a phase II study to examine XELOX30 (capecitabine 1000 mg/m2 orally twice daily on days 1-14 and oxaliplatin 130 mg/m2 as a 30 min infusion on day 1) in patients with ACRC resistant to irinotecan. In addition the pharmacokinetics of oxaliplatin was studied.

RESULTS

From November 2002 to September 2003, 70 patients with ACRC were treated with XELOX30. Median age was 62 (range 33-74 years) years and median performance status was 1 (range 0-2). The median number of courses was four (range 1-12) and median cumulative dose of oxaliplatin was 530 (range 125-1560) mg/m2. The response rate was 17% (95% CI 10-23), median time to progression (TTP) was 5.4 months (95% CI 4.6-6.4) and median survival 9.5 months (95% CI 8.5-11.2). White blood cell count (WBC) and performance status were significantly correlated to TTP. Neurotoxicity was moderate: grade 1 56%, grade 2 17% and grade 3 6%. Other grade 3 toxicities were nausea/vomiting 9%, diarrhoea 14% and PPE 8%. The maximum blood concentration and total body clearance of oxaliplatin was higher than previously reported in studies examining 2-h infusions, but the volume of distribution and terminal half-life was in close agreement with previous results.

CONCLUSION

XELOX30 is a very convenient second-line regimen in ACRC with an activity and safety profile similar to other oxaliplatin schedules.

Radiation therapy in the management of brain metastases from breast cancer

A retrospective analysis of 99 patients treated at Radiumhemmet, Karolinska Hospital 1979-1990 with palliative radiotherapy for brain metastases from breast cancer was performed. A relief of symptoms was obtained in 45% of patients. Median time from diagnosis of breast cancer until CNS metastases was 33 months. Median survival time with CNS metastases after diagnosis was 5 months. Prognostic indicators for survival were studied. Patients operated for a singular brain metastasis and irradiated postoperatively had a mean survival of 21 months while patients with multiple brain metastases and meningeal spread displayed a short median survival. Extracranial disease status influenced prognosis significantly. Radiation dose (CRE) did not correlate with survival.

The Ras farnesylation inhibitor BZA-5B increases the resistance to cisplatin in a human melanoma cell line

Ras proteins have been implicated in transducing cellular responses to DNA damaging agents. We used BZA-5B, an inhibitor of Ras-farnesylation, to examine the role of Ras in cellular sensitivity to cisplatin. A human melanoma cell line (224) with a Gln61Arg mutation in N-ras was used for these studies. We report that BZA-5B treated cells show an increased resistance to cisplatin. BZA-5B treatment decreased the number of cells showing in situ DNA fragmentation and increased cell viability and clonogenic survival after cisplatin treatment. Further experiments showed that cisplatin induction of the immediate early genes c-jun and p21cip1 was not affected by BZA-5B. Finally, we show that cisplatin causes only weak activation of Jun N-terminal kinase (JNK) in a human melanoma cell line. We conclude that inhibition of Ras function decreases the sensitivity of human melanoma cells to cisplatin-induced cell death.