Phase I/II study of S-1 combined with irinotecan for metastatic advanced gastric cancer.

A dose-escalation study of irinotecan (CPT-11) combined with S-1, an oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine, was performed to determine the maximum-tolerated dose (MTD), recommended dose (RD), dose-limiting toxicities (DLTs), and objective response rate (RR) in advanced gastric cancer (AGC). S-1 was administered orally at 80 mg m-2 day-1 from day 1 to 14 of a 28-day cycle and CPT-11 was given intravenously on day 1 and 8 at an initial dose of 70 mg m-2 day-1, stepping up to 100 mg m-2. The treatment was repeated every 4 weeks, unless disease progression was observed. In the phase I portion, the MTD of CPT-11 was presumed to be 100 mg m-2, because 66.6% of patients (two of three) developed DLTs. All three patients at the initial RD of CPT-11 (90 mg m-2) experienced grade 4 haematological or grade 3 nonhaematological toxicities at second course, followed by the dose reduction of CPT-11 from the third course. Considering safety and the ability to continue treatment, the final RD was determined to be 80 mg m-2. In the phase II portion, 42 patients including seven patients in the final RD phase I portion were evaluated. The median treatment course was five (range: 1-13). The incidences of severe (grade 3-4) haematological and nonhaematological toxicities were 19 and 10%, respectively, but all were manageable. The RR was 62% (26 of 42, 95% confidence interval: 47.2-76.6%), and the median survival time was 444 days. Our phase I/II trial showed S-1 combined with CPT-11 is effective for AGC and is well tolerated, with acceptable toxicity.

Thymidylate synthase predictive power is overcome by irinotecan combination therapy with S-1 for gastric cancer.

The predictive values of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) gene expressions were retrospectively evaluated in patients with gastric cancer treated by a regimen containing S-1. The study population consisted of 53 patients registered into different two phase II studies for metastatic gastric cancer; 27 patients treated by S-1-alone study: 26 patients treated with S-1 combined with irinotecan (CPT-11). TS and DPD gene expressions in primary tumours were measured by the real-time reverse transcription PCR method. There was no statistical difference in DPD gene expression in terms of response in cases treated with S-1 alone and those treated with S-1 plus CPT-11. TS mRNA of responding tumours was lower than that of nonresponding ones when treated with S-1 (P<0.005). In the S-1-alone group, taking TS cutoff as the median values, the response rate in the low TS group was 50%, but only 8% in the high TS group (P<0.05). Patients with low TS gene expression survived longer than those with high TS gene expression (P<0.0001). However, there was no statistically significant difference in response rate and survival between patients with low TS tumours and those with high TS tumours, when the cutoff was taken as the median value of TS gene expression in the group treated with S-1 plus CPT-11. In conclusion, treatment effects of S-1 monotherapy for gastric cancer were determined by the status of TS gene expression, regardless of DPD gene expression. TS predictive power was overcome by CPT-11 combination therapy with S-1.

Both gene expression for orotate phosphoribosyltransferase and its ratio to dihydropyrimidine dehydrogenase influence outcome following fluoropyrimidine-based chemotherapy for metastatic colorectal cancer.

Activation of 5-fluorouracil into its nucleotides requires phosphorylation by three pathways involving orotate phosphoribosyl-transferase (OPRT), uridine phosphorylase (UP), or thymidine phosphorylase (TP). In this study, we investigated the association between gene expressions of these three enzymes and antitumour effect. Gene expressions in primary colorectal tumours were analysed by a real-time reverse transcriptional-polymerase chain reaction method in 37 patients receiving oral treatment of tegafur-uracil and leucovorin for metastatic diseases. The median values of OPRT mRNA expressions were 1.39 and 0.85 for responding tumours and nonresponding tumours, respectively, showing a statistically significant difference (P=0.0008). Responding tumours had statistically lower expressions of TP mRNA than nonresponding tumours (P=0.006). However, there was no difference in UP mRNA expression between responding and nonresponding tumours. Patients with high OPRT (>/=1.0) gene expression survived longer than those with low OPRT (<1.0) expression. Dihydropyrimidine dehydrogenase (DPD) gene expressions were measured. Responding tumours had a statistically higher OPRT/DPD ratio than the nonresponding ones (P=0.003). When the median value of the OPRT/DPD ratio was selected as the cutoff value, patients with a high OPRT/DPD ratio survived statistically longer than those with a low ratio (P=0.0014). In conclusion, both the expression of OPRT gene and the OPRT/DPD ratio might be useful as predictive parameters for the efficacy of fluoropyrimidine-based chemotherapy for metastatic colorectal cancer.

Expression of pyrimidine nucleoside phosphorylase (PyNPase) in colorectal cancer.

BACKGROUND: We investigated the expression of PyNPase both in cancer cells and in stroma cells to clarify the correlation between PyNPase expression and the prognosis of patients with colorectal cancer. METHODS: Using immunohistochemical staining with an anti-PyNPase antibody, the PyNPase expression in tissues from 114 patients with stage II or III colorectal cancer was examined. From the correlation between PyNPase expression and the clinicopathological findings, the prognosis for survival was analyzed. RESULTS: The expression of PyNPase was classified as negative or positive on the basis of staining. No relationship between PyNPase expression and any of the clinicopathological findings was identified. However, a relationship was observed regarding positive staining between cancer cells and stroma cells. The prognosis of patients with positive staining in both cancer cells and stroma was worse than that of other patients. In multivariate analyses, expression in cancer cells was the strongest predictor of prognosis. CONCLUSIONS: PyNPase expression appears to be a relevant factor for predicting the prognosis of colorectal cancer.

Depth of invasion parallels increased cyclooxygenase-2 levels in patients with gastric carcinoma.

BACKGROUND: Nonsteroidal anti-inflammatory drugs may reduce the incidence of intestinal carcinoma, presumably through inhibition of cyclooxygenase-2 (COX-2). The authors correlated tumor expression of COX-2 with clinicopathologic features in tissues from patients with gastric carcinoma. METHODS: Thirty-three surgical specimens, including carcinomas and corresponding noncancerous mucosa, were sampled. Reverse transcription-polymerase chain reaction analysis was performed concomitantly for COX-1 and COX-2. A COX-2 index was determined from the band density ratio of COX-2 to constitutively expressed COX-1. Immunohistochemical staining with COX-2 antibody and routine histologic assessment were performed in the same specimens. RESULTS: The COX-2 index in gastric carcinoma was significantly higher than in normal mucosa (3.4 +/- 0.7 vs. 2.2 +/- 0.7; P < 0.05). COX-2 indices were significantly higher in gastric carcinoma tissues with deep invasion; indices for pT1, pT2, pT3, and pT4 carcinomas were 0.8 +/- 0.3, 2.8 +/- 0.5, 4.3 +/- 1.0, and 8.8 +/- 5.5, respectively (P < 0.05). Immunohistochemistry demonstrated COX-2 protein diffusely in the cytoplasm of tumor cells but not in surrounding stroma or in noncancerous mucosa. CONCLUSIONS: COX-2 mRNA expression in gastric carcinoma tissue is correlated closely with depth of invasion, indicating that COX-2 is involved in the growth of gastric carcinoma.

Is lymphadenectomy needed for all submucosal gastric cancers?

OBJECTIVE: To find out if it is feasible to extend the indication for local resection of submucosal gastric cancer without increasing the risk of lymph node metastases. DESIGN: Retrospective study. SETTING: University hospital, Japan. SUBJECTS: 104 patients with gastric cancer confined to the submucosal layer who underwent conventional gastrectomy with lymphadenectomy. INTERVENTIONS: The risk of nodal metastases was analysed retrospectively depending on the depth of submucosal invasion, size of the tumour, and other clinicopathological findings. MAIN OUTCOME MEASURES: The degree of submucosal invasion, size of the tumour, and incidence of lymph node metastasis. RESULTS: 15/104 patients (14%) had lymph node metastases. No patient in whom submucosal invasion was less than 500 microm or tumour was less than 15 mm in diameter developed lymph node metastases. Fewer patients had lymphatic permeation (37/89) and venous involvement (21/89) in the group without lymph node metastases. CONCLUSION: These data seem to support the hypothesis that early, minimally invasive, gastric cancer measuring < 15 mm in diameter could be treated by endoscopic mucosal or local resection, and gastrectomy with lymphadenectomy might be unnecessary.

Thymidylate synthase gene expression in primary colorectal cancer and metastatic sites.

Thymidylate synthase (TS) expression has been identified as an important predictor of response to 5-fluorouracil (5-FU). However, there is relatively little information on the heterogeneity of TS mRNA expression between primary and metastatic tumors, as well as differential expression of TS mRNA in metastatic sites. In this study, TS mRNA expression was measured in primary colorectal cancer tumors and various metastatic tumors. The median TS/glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA ratio was 0.98 in primary tumors, 0.70 in liver metastases, 1.92 in lymph node metastases, and 3.42 in pulmonary metastases. A significantly higher expression of TS mRNA was observed in pulmonary and lymph node metastases compared with their respective primary tumors. In contrast, TS mRNA expression in hepatic metastases was significantly lower than in primary tumors. Similar results were observed in tumors obtained from the same patient. These results may explain the difference in the clinical response to 5-FU-based chemotherapy between various metastatic sites. The discordant TS expression between primary and metastatic tumors is a critical factor that must be taken into account when TS is being used as a predictive biomarker for the antitumor effect of 5-FU-based chemotherapy.

UFT plus leucovorin for metastatic colorectal cancer: Japanese experience.

In the United States and Europe, the combination of oral UFT plus leucovorin has been reported to produce objective responses and survival rates similar to those achieved with standard intravenous 5-fluorouracil plus leucovorin in patients with metastatic colorectal cancer, with reduced toxicity. However, because knowledge and experience with UFT plus leucovorin are relatively limited in Japan, we conducted a phase II study to evaluate the safety and efficacy of this combination in Japanese patients with metastatic colorectal cancer. For the purposes of this study, 20 patients received oral UFT 400 mg/m2/day in two divided doses (q 12 h) and a 5-mg tablet of leucovorin (q 8 h). Treatment was administered for 5 days, followed by a 2-day rest period, for a 28-day cycle. There were six partial responses (30%) and one complete response (5%) (overall response rate, 35%; 95% confidence interval, 14.1% to 55.9%). Greater efficacy of UFT plus leucovorin was demonstrated in patients with lung metastases, with a response rate of 63% (five of eight patients). Patients received a median of 4.5 courses (range, 2 to 12) of therapy. The median duration of survival was 228+ days (range, 81 to 540; six patients remain alive). Grade 3 or 4 toxicities occurred in three patients: diarrhea in two and mucositis in one. No toxicity-related hospitalization was reported. In summary, this combination showed promising activity and an acceptable toxicity profile in the treatment of Japanese patients with metastatic colorectal cancer.

Assessment of intestinal viability using a non-contact laser tissue blood flowmeter.

BACKGROUND: Intraoperative assessment of small intestinal viability following ischemic insult from arterial occlusion has remained difficult. The purpose of the present study was to assess the applicability of non-contact tissue blood flowmeter (NCLBF) with regard to intraoperative assessment of intestinal viability. METHODS: Using the ischemia-reperfusion model of rabbits, the relationship between the records of NCLBF, pulse oximetry (PO), and histological grade and the comparison of accuracy of intestinal viability among NCLBF, PO, and fluorescein (FL) were examined. RESULTS: There was a significant relationship between NCLBF and the histological grade (coefficient-0.80, P <0.0001); however, PO was not related. The accuracy and sensitivity of bowel viability of NCLBF (76%, 88%) were better than those of PO (58%, 23%) and FL (48%, 4%), respectively (P <0.001). CONCLUSIONS: NCLBF is useful to assess intestinal viability, suggesting the possibility of clinical use.

[Chemoradiotherapy with low-dose cisplatin and 5-FU for advanced esophageal cancer].

We evaluated the efficacy of chemoradiotherapy (CRT) for advanced esophageal cancer, from the view point of response. The relationship between chemo-radiosensitivity and dihydropyridine dehydrogenase (DPD), thymidylate synthase (TS), and p53 was investigated immunohistochemically. Thirteen patients with inoperable advanced esophageal cancer were involved in this study. CDDP of 10 mg/m2/day and 5-FU of 335 mg/m2/day were infused intravenously (day 1-5, day 15-19). Radiation was delivered concomitantly at a total dose of 30 Gy. Expressions of p53, DPD and TS were detected using immunohistology in the biopsy samples taken before CRT from 8 patients. Partial response was observed in 8 cases, no change in 4 cases, and progressive disease in one case. The overall response rate was 62%. The reduction rate was higher in tumors positive for p53 expression than in negative ones. The same was true for DPD and TS. The Treatment effect was more precisely predicted by combination of p53, DPD and TS. CRT with low-dose CDDP + 5-FU chemotherapy was effective and combination with p53, DPD, and TS might be a predictive marker for CRT in patients with advanced esophageal cancer.

Expression of apolipoprotein B-100 in isolated human small intestine epithelium.

Apolipoprotein B-48 (apoB48) is synthesized in the small intestine and becomes a component of chylomicrons (CM). Apolipoprotein B-100 (apoB100) is synthesized in liver and becomes a component of both very low density lipoprotein (VLDL) and low density lipoprotein (LDL). To evaluate whether apoB100 is present in the human small intestine, we performed immunohistochemical staining using anti-apoB100 monoclonal antibody (mAb). Jejunal samples stained positive and the granular staining was noted in the supranuclear region of epithelial cells. We also identified apoB100 expression in the epithelial cells by immunoblotting and dot-blotting of PCR-amplified cDNA. In order to exclude submucosal stroma contaminated with blood, we used isolated epithelium from human small intestine obtained by a crypt isolation technique. The results indicate that not only apoB48, but also apoB100 are expressed in human small intestine epithelium. The expression of apoB100 suggests that the dietary VLDL may be synthesized in human small intestine epithelium and converted into LDL, which might play an important role in atherosclerosis.

Distinction of differentiated type early gastric carcinoma with gastric type mucin expression.

BACKGROUND: Intestinal and diffuse gastric carcinomas differ in morphology and growth behavior. Differentiated type gastric carcinoma (DGC), which corresponds roughly with the intestinal type of Lauren, can demonstrate phenotypic properties associated with mucin expression and brush border. However, their clinical significance is controversial. A classification based on mucin phenotype and brush border was performed to determine the clinicopathologic diversity of DGCs in their early stage. METHODS: A total of 120 specimens from 116 DGC patients with definite submucosal invasion were evaluated both macroscopically and histologically. All sections were examined immunohistochemically with human gastric mucin, Muc-2, and CD10 and with mucin histochemically with paradoxical concanavalin A staining and high iron Diamine-Alcian Blue. They were classified into gastric type (G-type), intestinal type (I-type), mixed gastric and intestinal type (M-type), or null type (N-type) phenotypes. The immunoreactivity of E-cadherin and beta-catenin also was investigated to determine the correlation between mucin phenotype and clinicopathologic factors. RESULTS: The G-type phenotype was found to be in contrast to I-type: G-type was an independent factor associated with lymph node metastasis. Significant correlations were observed between the G-type phenotype and the complex type carcinoma found that was histologically: lymphatic invasion, lymph node metastasis, and the abnormal expression of E-cadherin. A significant difference in the proportion of mucin phenotypes between papillary type and tubular type carcinoma was observed. G-type was found to be the predominant phenotype in papillary carcinoma in contrast to tubular carcinoma. CONCLUSIONS: The G-type mucin phenotype and papillary adenocarcinoma should be distinguished from other types of DGCs because of their increased malignant potential in the incipient phase of invasion and metastasis. The significance of G-type and papillary adenocarcinoma should be reflected in the treatment of patients with early stage DGCs, including endoscopic mucosal resection.

Alterations and hypermethylation of the p14(ARF) gene in gastric cancer.

p14(ARF), generated through an alternative splicing process that replaces the first exon, 1alpha, of p16(INK4a) with exon 1beta, located >15 kb upstream of exon 1alpha, has been shown to function as a growth suppressor. We examined 11 gastric cancer cell lines for mRNA expression, homozygous deletion, mutation, and promoter methylation of the p14(ARF) gene. No mRNA expression was detected in 5 of the 7 diffuse-type cell lines. All intestinal cell lines displayed normal levels of expression except for one with a low level of expression. Of the 5 cell lines without expression, 3 (MKN45, NUGC-2, and NUGC-4) and 1 (KATO III) displayed homozygous deletion and methylation of the p14(ARF) gene, respectively. No mutation was found in the whole coding region of the p14(ARF) gene in 8 cell lines without homozygous deletion. Our results indicate that the p14(ARF) gene is more frequently inactivated by homozygous deletion or methylation in diffuse-type gastric cancer cell lines (5/7, 71.4%) than in intestinal ones (0/4, P = 0.022). When we also analyzed 62 primary gastric cancers for the methylation status of the p14(ARF) promoter region, the methylation frequency tended to be higher in diffuse-type gastric cancers (15/33, 45.5%) than in intestinal ones (7/28, 25%). Thus, p14(ARF) alterations might be involved in diffuse-type gastric carcinogenesis.

[Familial gastric cancer].

Literature on familial gastric cancer was reviewed from the stand point of genetic and clinico-pathological aspects. Germline mutations of the E-cadherin gene were found in about one quarter of diffuse type cases of familial gastric cancer in kindreds of New Zealand and Europe, while the E-cadherin gene may not be responsible for most Japanese familial gastric cancer cases. It is likely that mismatch repair genes are not major causative genes for familial gastric cancer. Additional studies are necessary to elucidate the nature of familial gastric cancer including that of intestinal type. Prophylactic gastrectomy is effective in preventing gastric carcinoma, but it is not generally recommended at present for all E-cadherin mutation carriers in Japan.

Ultrasound-guided core needle biopsy for breast cancer: preliminary report.

BACKGROUND: Ultrasound-guided automated percutaneous core needle biopsy (US-CNB) for breast tumors has been introduced into clinical practice, but it has not yet been used routinely. We evaluated its usefulness, especially in terms of histological accuracy. METHODS: Thirty-one consecutive patients underwent mammography followed by breast biopsy with the automated core needle biopsy device. RESULTS: Mammography was highly suggestive of malignancy or suspicious abnormalities in 17 cases whose histological findings from US-CNB specimens were invasive ductal carcinoma without exception. The other 14 cases with benign or probably benign mammography findings showed no malignancy histologically in the US-CNB specimens. In cases of malignancy, the accuracy rates of histological findings for the specimens obtained by US-CNB were 94.1% in histological type, 100% in direct infiltration, 82.4% in lymphatic infiltration, 82.4% in venous infiltration, 94.1% in histological grading and 82.4% in intraductal spread. CONCLUSION: US-CNB was useful for making reliable preoperative histopathological diagnosis and may substitute fine needle aspiration biopsy and surgical biopsy.

Follicular gastritis associated with Helicobacter pylori.

In order to understand the pathogenesis of gastric lymphoma, we investigated the association of H.pylori infection with lymphoid follicular hyperplasia. Eighty-four gastric specimens removed for gastroduodenal ulcer were histologically examined. The distribution and prevalence of H. pylori, neutrophilic and lymphocytic infiltration, mucosal atrophy, intestinal metaplasia, and lymphoid follicles were scored. The lymphoid follicles were more frequently observed in H.pylori positive cases. They indicated a positive correlation with the score of H. pylori. When follicular gastritis (FG) was defined as a case in which the secondary lymphoid follicles (Lf2) numbered two or more per one centimeter of mucosa in the pyloric gland area of the lesser curvature, twenty specimens out of the 84 (24%) fit that definition. All of the FG cases were H.pylori positive, and they displayed high H. pylori scores. It was supposed that most FG cases would ultimately lead to atrophic gastritis, whereas H.pylori would gradationally decrease or disappear in accordance with the aging and progression of intestinal metaplasia. The histological features of the FG cases, however, were similar to the background mucosal state of early-stage MALT-type gastric lymphoma. We may conclude that H. pylori infection is one cause of the FG, which may be a high-risk condition that gives rise to MALT-type gastric lymphoma.

[Dihydropyrimidine dehydrogenase gene expression in patients with hepatic metastases from colorectal cancer].

Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme for 5-FU catabolism. Recently, much interest has been taken in the relation between the antitumor effect of 5-FU and DPD expression in gastrointestinal cancers. In this study, we compared DPD mRNA of 11 hepatic metastatic foci with that of 50 primary foci in colorectal cancer patients. DPD mRNA levels in hepatic metastatic foci were significantly higher than those in primary foci (median DPD/GAPDH ratio 0.79 vs 0.44, p = 0.035). Even in 6 cases available to compare DPD mRNA expression in matched primary and metastatic foci, the same significant difference was obtained (median DPD/GAPDH ratio 0.80 vs 0.36, p = 0.028). Our results suggested that the efficacy of intra-arterial infusion for metastatic liver tumor is mainly due to the fact that the high concentration of 5-FU is enough to overcome the high clearance of 5-FU, which is caused by DPD.

Relationship between intratumoral dihydropyrimidine dehydrogenase activity and gene expression in human colorectal cancer.

Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme for 5-fluorouracil catabolism. In this study, both the enzymatic activity and mRNA level of DPD were estimated in the tumor tissue and adjacent normal mucosa of 51 patients with colorectal cancer. Although no significant difference in enzymatic activity was observed between tumor tissue and normal mucosa (70.4 and 70.7 pmol/min/mg protein, respectively), the mRNA level in normal mucosa was significantly higher than that in tumor tissue (1.37 and 0.39, respectively; P<0.01). A linear relationship was noted between DPD activity and the DPD mRNA level in cancerous tissue (r(s) = 0.714, P<0.001). Thus, the DPD mRNA level as determined by reverse transcription-PCR can be used to indicate the DPD activity of colorectal cancers.

Infrequent germ-line mutation of the E-cadherin gene in Japanese familial gastric cancer kindreds.

Germ-line mutation of the E-cadherin gene was reported in familial gastric cancer (FGC) kindreds from New Zealand. Therefore, we analyzed all of the exons of E-cadherin by PCR-single-strand conformational polymorphism analysis in 16 patients from 14 Japanese FGC kindreds. However, no germ-line mutation was detected, suggesting that a predisposition to FGCs by E-cadherin gene mutation is infrequent in Japanese cases.