FOLFIRI plus bevacizumab as second-line therapy in patients with metastatic colorectal cancer after first-line bevacizumab plus oxaliplatin-based therapy: the randomized phase III EAGLE study.

BACKGROUND: A targeted agent combined with chemotherapy is the standard treatment in patients with metastatic colorectal cancer (mCRC). The present phase III study was conducted to compare two doses of bevacizumab combined with irinotecan, 5-fluorouracil/leucovorin (FOLFIRI) in the second-line setting after first-line therapy with bevacizumab plus oxaliplatin-based therapy. PATIENTS AND METHODS: Patients were randomly assigned to receive FOLFIRI plus bevacizumab 5 or 10 mg/kg in 2-week cycles until disease progression. The primary end point was progression-free survival (PFS), and secondary end points included overall survival (OS), time to treatment failure (TTF), and safety. RESULTS: Three hundred and eighty-seven patients were randomized between September 2009 and January 2012 from 100 institutions in Japan. Baseline patient characteristics were well balanced between the two groups. Efficacy was evaluated in 369 patients (5 mg/kg, n = 181 and 10 mg/kg, n = 188). Safety was evaluated in 365 patients (5 mg/kg, n = 180 and 10 mg/kg, n = 185). The median PFS was 6.1 versus 6.4 months (hazard ratio, 0.95; 95% confidence interval [CI] 0.75-1.21; P = 0.676), and median TTF was 5.2 versus 5.2 months (hazard ratio, 1.01; 95% CI 0.81-1.25; P = 0.967), respectively, for the bevacizumab 5 and 10 mg/kg groups. Follow-up of OS is currently ongoing. Adverse events, including hypertension and hemorrhage, occurred at similar rates in both groups. CONCLUSION: Bevacizumab 10 mg/kg plus FOLFIRI as the second-line treatment did not prolong PFS compared with bevacizumab 5 mg/kg plus FOLFIRI in patients with mCRC. If bevacizumab is continued after first-line therapy in mCRC, a dose of 5 mg/kg is appropriate for use as second-line treatment. CLINICAL TRIAL IDENTIFIER: UMIN000002557.

Prevalence of Hoarseness and Its Association with Severity of Dysphagia in Patients with Sarcopenic Dysphagia.

OBJECTIVES: To investigate the prevalence of hoarseness and its association with the severity of dysphagia in patients with sarcopenic dysphagia. DESIGN: Cross-sectional study using the Japanese sarcopenic dysphagia database. SETTING: 19 hospitals including 9 acute care hospitals, 8 rehabilitation hospitals, 2 long-term care hospitals, and 1 home visit rehabilitation team. PARTICIPANTS: 287 patients with sarcopenic dysphagia, aged 20 years and older. MEASUREMENTS: Sarcopenic dysphagia was diagnosed using a reliable and validated diagnostic algorithm for the condition. The presence and characteristics of hoarseness classified as breathy, rough, asthenic, and strained were assessed. The prevalence of hoarseness and the relationship between hoarseness and Food Intake LEVEL Scale (FILS) were examined. Order logistic regression analysis adjusted for age, sex, naso-gastric tube, and handgrip strength was used to examine the relationship between hoarseness and FILS at baseline and at follow-up. RESULTS: The mean age was 83 ± 10 years. Seventy-four (26%) patients had hoarseness, while 32 (11%), 20 (7%), 22 (8%), and 0 (0%) patients had breathy, rough, asthenic, and strained hoarseness, respectively. Median FILS at the initial evaluation was 7 (interquartile range, 5-8). Hoarseness (ß=0.747, 95% confidence intervals= 0.229, 1.265, p=0.005), age, sex, naso-gastric tube, and handgrip strength were associated independently with baseline FILS, while hoarseness (ß=0.213, 95% confidence intervals= -0.324, 0.750, p=0.438) was not associated independently with the FILS at follow-up. CONCLUSIONS: Hoarseness was associated with the severity of dysphagia at baseline, however not a prognostic factor for sarcopenic dysphagia. Resistance training of swallowing and respiratory muscles and voice training as part of rehabilitation nutrition might be useful for treating sarcopenic dysphagia.

Association between Inflammation and Functional Outcome in Patients with Sarcopenic Dysphagia.

OBJECTIVES: This study aimed to investigate whether inflammation affects the outcome of swallowing ability to improve treatment for sarcopenic dysphagia. DESIGN: A retrospective observational cohort study was performed using data from the Japanese sarcopenic dysphagia database. SETTING: The database was constructed using data from 19 hospitals and one home visiting rehabilitation team. PARTICIPANTS: Patients with sarcopenic dysphagia with measurements of C-reactive protein (CRP) and serum albumin (Alb) were included. MEASUREMENTS: Patients were assigned to two groups using CRP, Alb, and the Japanese modified Glasgow Prognostic Score (mGPS). The Food Intake LEVEL Scale (FILS) was measured at the times of admission and follow-up (FILS follow-up) to assess swallowing function. RESULTS: A total of 197 patients were included. Mean or median values of each parameter were as follows: age: 83.8±8.7, Alb: 3.2 ± 0.6 g/dL, CRP: 8.0 [3.0, 29.0] mg/L, mGPS: 1 [1-2], FILS: 7 [6-8], FILS follow-up: 8 [7-8], and duration of follow-up: 57.0 [27.0, 85.0] days. The FILS score at follow-up was significantly lower in the high CRP group (≥ 5.0 mg/L) than in the low CRP group (< 5.0 mg/L) (p = 0.01). Further, the FILS score at follow-up was significantly lower in the high mGPS group (class; 2) than in the low mGPS group (class; 0 and 1) (p = 0.03). In the multiple linear regression analyses without FILS at baseline, CRP and mGPS were independent risk factors for FILS follow-up. When FILS at baseline was entered, CRP and mGPS were not an independent risk factors for FILS follow-up. CONCLUSIONS: Inflammation could modify the outcome of the patients with sarcopenic dysphagia. Inflammation may be an important risk factor in evaluating patients with sarcopenic dysphagia.

The Mass of Geniohyoid Muscle Is Associated with Maximum Tongue Pressure and Tongue Area in Patients with Sarcopenic Dysphagia.

OBJECTIVES: We investigated the associations about the mass of geniohyoid and tongue muscle and the maximum tongue pressure in patients with sarcopenic dysphagia using ultrasonography. DESIGN: Cross sectional study. SETTING: 5 hospitals including 3 acute and 2 rehabilitation hospitals and 1 older facility. PARTICIPANTS: 36 inpatients with sarcopenic dysphagia. MEASUREMENTS: Ultrasonography was performed for geniohyoid muscle and tongue. The area for geniohyoid and tongue muscles in sagittal plane and the mean brightness level (0-255) in the muscle area were calculated. Maximum tongue pressure as strength of swallowing muscle were investigated. Partial correlation coefficient and multiple regression analysis adjusting for age and sex were performed. RESULTS: The mean age was 81.1 ± 7.9. Men were 23. The mean BMI was 19.0 ± 4.1. The mean maximum tongue pressure was 21.3 ± 9.3 kPa. The mean cross sectional area for geniohyoid muscles was 140 ± 47 mm2. The mean brightness for geniohyoid muscle was 18.6 ± 9.0. The mean cross sectional area for tongue muscles was 1664.1 ± 386.0 mm2. The mean brightness for tongue muscles was 34.1 ± 10.6. There was a significant positive correlation between area of geniohyoid muscle and maximum tongue pressure (r = 0.38, p = 0.04). Geniohyoid muscle area was an explanatory factor for maximum tongue pressure (p = 0.012) and tongue muscle area (p = 0.031) in multivariate analysis. CONCLUSIONS: Geniohyoid muscle mass was an independent explanatory factor for maximum tongue pressure and tongue muscle mass.

Doxorubicin encapsulated in sterically stabilized liposomes is superior to free drug or drug-containing conventional liposomes at suppressing growth and metastases of human lung tumor xenografts.

Liposomes containing polyethylene glycol-derivatized phospholipids are able to evade the reticuloendothelial system and thereby remain in circulation for prolonged periods. We report here that doxorubicin encapsulated in these sterically stabilized liposomes (S-DOX) suppresses the growth of established human lung tumor xenografts in severe combined immunodeficient (SCID) mice and inhibits the spontaneous metastases of these tumors. The enhanced therapeutic efficacy of S-DOX compared to free doxorubicin was demonstrated in two independent human/mouse models. In the first model, S-DOX inhibited the growth of a human non-small cell lung tumor xenograft established orthotopically in the lungs of SCID mice. Treatment of these mice with S-DOX, but not with free drug, suppressed the growth of the tumor in the lung, prevented metastasis from the lung, and enhanced survival percentage. In another model, the human lung tumor is engrafted into gonadal fat pad of SCID mice. Human tumor xenografts grow floridly in this site of engraftment, and the tumor spreads from this primary site into the peritoneal cavity and subsequently reaches the liver and lung. In this model, free drug suppressed the growth of the primary tumor but had no effect upon the subsequent spread of the tumor into the peritoneal cavity, liver, and lung. In contrast, treatment of the tumor-bearing mice with S-DOX (but not with doxorubicin in conventional liposomes) suppressed the tumor spread to the peritoneal cavity, completely arrested metastasis to the liver and lung, and suppressed the growth of the primary tumor xenograft. This report provides the first evidence that antitumor drugs delivered by sterically stabilized liposomes can arrest the metastasis of human tumor xenografts.

Activation of p38 mitogen-activated protein kinase mediates thyroid hormone-stimulated osteocalcin synthesis in osteoblasts.

It is well known that thyroid hormone modulates osteoblast cell function. We have previously shown that triiodothyronine (T(3)) activates p44/p42 mitogen-activated protein (MAP) kinase, which limits T(3)-induced alkaline phosphatase activity in osteoblast-like MC3T3-E1 cells. In the present study, we investigated whether p44/p42 MAP kinase or p38 MAP kinase is involved in the thyroid hormone-stimulated osteocalcin synthesis in these cells. T(3) markedly induced the phosphorylation of p38 MAP kinase in addition to p44/p42 MAP kinase. PD98059 and U0126, inhibitors of the upstream kinase that activates p44/p42 MAP kinase, had little effect on the T(3)-induced synthesis of osteocalcin. On the contrary, the T(3)-induced osteocalcin synthesis was significantly reduced by SB203580 and PD169316, inhibitors of p38 MAP kinase. SB203580, PD169316 or PD98059 suppressed the T(3)-phosphorylation of myelin basic protein. T(3)-induced osteocalcin synthesis was significantly reduced by SB203580 or PD169316 also in primary cultured mouse osteoblasts. These results strongly suggest that p38 MAP kinase but not p44/p42 MAP kinase takes part in the thyroid hormone-stimulated osteocalcin synthesis in osteoblasts.

Enhancement by hyperthermia of the in vivo antitumour effect of doxorubicin hydrochloride (DOX) and buthionine sulfoximine (BSO)-hydroxyapatite (HAP) complex.

We have developed a new type of drug delivery system (DDS) comprising a complex of porous hydroxyapatite (HAP) with the anticancer drug doxorubicin hydrochloride (DOX) and the glutathione inhibitor buthionine sulfoximine (BSO) (DOX and BSO-HAP complex). We then studied the antitumour effect of DOX and BSO-HAP combined with 44 degrees C hyperthermia for 40 min. It was found that in mice this combined treatment suppressed the growth of sarcoma 180 in terms of tumour volume to 36% in comparison viith mice given plain HAP, and was more effective than HAP + hyperthermia or DOX- and BSO-HAP. These results were also confirmed by histological observation.

Hydroxyapatite beads containing Doxorubicin hydrochloride (dox) and buthionine sulfoximine (bso) - a new anticancer drug design for local treatment with multiple-drugs.

Doxorubicin hydrochloride (DOX) and buthionine sulfoximine (BSO) were adsorbed on to a drug-carrier, hydroxyapatite (HAP), to form a DOX and BSO-HAP complex. The time-course of the release of these drugs from the complex into phosphate-buffered saline (PBS) was measured photometrically at 37-degrees-C in vitro. After 3 h of incubation, almost all the BSO in the DOX and BSO-HAP complex was released into the PBS, whereas 48.7% of the DOX was released during this period. DOX was released continuously over 10 h of incubation, the rate of release being 7.3%h of the total amount released. Both DOX and BSO were eluted from the DOX and BSO-HAP complex over the first 3 h of incubation. From the 4 h of incubation, only DOX was released, indicating a slow-release property of the complex. The DOX and BSO-HAP complex developed in this study may in future have an in vivo application. It is possible that intracellular glutathione could be depleted first by the rapidly released BSO and that DNA strand breaks could then be intensified by the slowly released DOX. Therefore, this complex has potential as a new drug delivery system (DDS) in cancer chemotherapy.

Antitumor effects of Doxorubicin hydrochloride (dox) and buthionine sulfoximine (bso)-hydroxyapatite (hap) complex on transplanted tumors in-vivo.

We prepared hydroxyapatite (HAP) beads containing doxorubicin hydrochloride (DOX) and buthionine sulfoximine (BSO), as a DOX and BSO-HAP complex. When the complex was implanted into mice bearing sarcoma 180 tumor, the antitumor effect of the complex was intensified 1.5-fold, as assessed using tumor volume, on day 27 as compared with that of a complex of DOX-HAP only. Therefore, we concluded that the antitumor effect of the DOX and BSO-HAP complex was increased through depletion of the intracellular radical scavenger glutathione (GSH) by released BSO and subsequently free radicals produced by released DOX.

Potential applicability of clinical hyperthermia using a Thermotron-RF8 as assessed from thermal distribution in an agar phantom containing hydroxyapatite.

We have already reported the antitumour effect of hydroxyapatite (HAP) containing anticancer drugs. In this study, we found an increased temperature effect around HAP particle(s) in an agar phantom in comparison with other areas when a Thermotron-RF8 (RF generator) was used for heating. Furthermore, it was revealed that the quantity of doxorubicin hydrochloride (DOX) released from HAP containing the drug (DOX-HAP complex) was increased by raising the temperature. These results indicated that the antitumor effect of the DOX-HAP complex + hyperthermia system was greater than that of either the DOX-HAP complex or hyperthermia system alone.

Change of temperature in mouse tumour tissue immersed in a water bath at 44 degrees C.

We investigated the change in temperature in tumour and normal tissues of mice when immersed in a water bath at 44.0 degrees C as part of a series of studies of hyperthermia. The right hind legs of the mice bearing the experimental tumour sarcoma 180 were immersed in the water bath, and measurements were performed using the multi-thermocouple thermosensor from a radiofrequency (RF) generator every 24 sec with a precision of 0.1 degrees C. The temperature in all tumour tissues exceeded 43.0 degrees C only at 1 min 24 sec after immersion of the limbs. The rise in temperature then reached a plateau phase, and was maintained around 44.0 degrees C. However, we found that the temperature of the normal tissue was about 0.6 degrees C lower than that of the tumour tissue or the tissue around the tumour at the plateau phase.

Detection of peritoneal micrometastases by reverse transcriptase-polymerase chain reaction targeting carcinoembryonic antigen and cytokeratin 20 in colon cancer patients.

Peritoneal recurrence after curative resection of malignant tumor with negative cytology is considered to be caused by microscopic dissemination of the exfoliated cancer cells from primary tumors to serosal surfaces at the time of operation, not detectable with conventional diagnostic tools. We applied the reverse transcriptase-polymerase chain reaction (RT-PCR) for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK 20) to detect micrometastatic foci in the peritoneal cavity of colon cancer patients. Cytological samples taken by peritoneal lavage from a series of 79 colon cancer patients were analyzed microscopically, for CEA levels, and by RT-PCR analysis using nested primers for CEA and CK 20. Cases with both CEA and CK 20 signals were defined as PCR-positive. This RT-PCR method proved both sensitive (1 tumor cell/10(6) non-tumor cells on preparation of serial colorectal cancer cell dilutions) and specific (no false positive results, 0/23 tested in our control experiment). Intraperitoneal micrometastatic cells were detected in peritoneal lavage 7.6% by cytology, 17.7% by CEA levels, and 24.1% by RT-PCR (significantly higher than by cytology: p=0.0046). RT-PCR detection rate increased in parallel with pathological depth of tumor invasion, and also a pathological stage-dependence was suggested according to the tumor-node-metastasis classification of the International Union Against Cancer. Our results suggest that CEA and CK 20 mRNA identification by RT-PCR appeared to be reliable and may be useful for early diagnosis in peritoneal dissemination of colon cancer.

A comparison of the prognostic significance between the number of metastatic lymph nodes and nodal stage in gastric carcinoma.

BACKGROUND/AIMS: To clarify what staging system of lymph node metastasis is suitable for evaluating prognosis of gastric cancer patients. METHODOLOGY: We analyzed the survival 5 years after operation of 186 advanced gastric cancer patients who underwent potentially curative gastric resection. The following 3 systems were compared using multivariate analyses by the logistic regression model. Nodal status in pathology was classified as follows: (a) nodal stage according to the General Rules for the Gastric Cancer Study of the Japanese Research Society for Gastric Cancer (the Japanese Rules), (b) number of metastatic nodes according to the new UICC staging system (the TNM system), (c) number of metastatic nodes in n1 group of the Japanese Rules (the new classification). RESULTS: The TNM system revealed better results than the nodal stage in sensitivity and -2 log likelihood. The new classification revealed the best result among the 3 systems in sensitivity, specificity, accuracy and -2 log likelihood. CONCLUSIONS: The TNM system is a better prognostic factor than the nodal stage in the Japanese Rules, and the new classification is the best prognostic factor of the above 3 systems in potentially curative advanced gastric cancer patients. Furthermore, the new classification might be useful in comparing data between some facilities.

Metastases in fatty liver: appearance on conventional spin-echo, fast-spin-echo, and echo-planar T2-weighted MR images.

A 71-year-old woman with liver metastases from colon adenocarcinoma in a severe fatty liver underwent T2-weighted MR imaging with conventional spin-echo (CSE), breath-hold fast-SE (BH-fast-SE), respiratory-triggered fast-SE (RT-fast-SE), and multishot SE echo-planar (SE-EP) techniques. CSE and SE-EP T2-weighted images showed the metastases as areas of high signal intensity. In contrast, RT-fast-SE and BH-fast-SE images showed them as areas of low signal intensity. Metastatic tumors in severe fatty liver can be shown as low signal-intensity areas with T2-weighted MR imaging using fast-SE sequences without use of the fat-suppression technique.

Diffuse calcification in gastric cancer.

The progressive expansion of calcification into the wall of the stomach and peritoneal metastatic foci was observed in a 31-year-old female with Borrmann type 4 calcified advanced gastric cancer. Despite treatment with systemic lentinan, uracil tegaful and mitomycin C, together with intraperitoneal injections of mitomycin C, OK-432 and prednisolone, the patient died 27 months after first presentation. The case provided a useful means of studying the mechanism of calcification.

Evaluation of angiographically assisted spiral CT in surgical cases of hepatocellular carcinoma considering recurrent cases.

Between June 1993 and July 1996, computed tomography during arterial portgraphy (CTAP) was performed on 22 patients with hepatocellular carcinoma (HCC) and liver cirrhosis before surgery. In 17 out of 22 patients, CT hepatic arteriography (CTA) was combined with CTAP. All 22 patients underwent definitive surgery. In 16 patients in which CTA was successfully performed, 20 HCC nodules and 28 pseudolesions were detected. The pseudolesions were depicted larger in size with CTA than with CTAP, formed a variety of shapes, and were enhanced homogeneously, while HCC nodules were depicted larger with CTAP than with CTA, formed a round or wedge shape, and were sometimes enhanced heterogeneously. Recurrence was diagnosed in 9 of 22 patients. Five recurrent lesions in 4 patients were already revealed by pre-operative CTAP. CTA was performed in only 1 of 5 lesions. The diagnostic accuracy for HCC significantly improves by recognizing by recognizing pseudolesions with CTA and CTAP.

[Scotomatous defects in the central visual field, associated with pituitary tumor--a case report (author's transl)].

A rare case which showed scotomatous defects in the left central visual field was presented. A 51 year-old man was admitted to our clinic because of the visual deterioration. In neuroradiological examinations the left carotid angiography showed elevation of both A1 portions and CT suggested pituitary tumor. On February 5, 1980 radical operation was carried out, in which it was confirmed that part of the optic nerve was concave and split longitudinally with a compression of the pituitary adenoma. Postoperative course was uneventful and recovery from the defects in the central visual field was quickly. In this case longitudinal splitting of unilateral optic nerve, caused by gradual compression of supra- or parasellar tumor, was considered as one cause of scotomatous defects in the central visual field. In addition, visual status of forty six cases of pituitary adenoma which had been operated at our clinic during the past fourteen years was analysed both pre- and post-operatively, compared with the case described above.

[Significance in gene expression of matrix metalloproteinase-9, urokinase-type plasminogen activator and tissue inhibitor of metalloproteinase for metastases of gastric and/or colo-rectal cancer].

In order to clarify the role of matrix metalloproteinase-9 (MMP-9), urokinase-type plasminogen activator (uPA) and tissue inhibitor of metalloproteinase (TIMP) in metastases of gastroenterological cancer, their gene expression in the primary lesions on 47 gastric or 48 colorectal cancer patients was examined by RT-PCR method. 1) The expression of MMP-9, uPA, and TIMP was observed in 55.3%, 66.0% and 87.2% of gastric cancer and in 54.2%, 70.8%, and 89.6% of colorectal cancer, respectively. 2) In the cases with either peritoneal dissemination or lymph node metastases, the incidence of gene expression of MMP-9 was significantly higher in comparison to the cases without those metastases. The same result was observed as for uPA. 3) In the cases with liver metastases, the incidence of gene expression of MMP-9 was significantly higher in comparison to the cases without liver metastasis. The same result was observed as for uPA. The above results indicate that MMP-9 and uPA might play important roles in the peritoneal and lymph node metastases in gastric cancer and in liver metastasis in colorectal cancer. Therefore the investigation of their gene expression in the primary lesions of cancer could be one of the useful methods for the prediction of metastasis, leading to the best decision as to the treatment.

[Recent progress in biological therapies for cancer].

After approval of national health insurance for non-specific immunomodulation such as OK-432 (1978) and PSK (1980), lentinan, SPG, bestatin and dried BCG vaccine have been tried. Including cytokines such as IL-2, IL-12, IFN, TNF or monoclonal antibodies, they have been widely used as biological response modifiers (BRM). Progress in BRM therapy may be broken down into the first 10 years as development, the next 10 years as disappointment and the most recent 5 years as dream-like progress owing to molecular biological techniques. An interdisciplinary approach has been taken by the Japanese Research Society for Surgical Cancer Immunology, founded in 1980, and the Japanese Society of BRM founded in 1988. Many investigations have been performed on issues such as the clinical evaluation or criteria for responder cases, host immunocompetency, post-operative adjuvant immuno-chemotherapy, locoregional immunotherapy, cytokine therapy, adoptive immunotherapy, and tumor specific immunotherapy. Attention has also focused on malignant tumor injury, surgical stress, the advantages or disadvantages of splenectomy, and discussions of the current status and future prospects in the next century for new BRM therapy.

[A recurrent case of esophageal cancer in which metastatic skin tumor disappeared after local injection of activated lymphocytes with tumor-pulsed dendritic cells].

We examined the effect of activated lymphocytes stimulated with tumor-pulsed dendritic cells (DC-K), and found that such stimulation enhanced the cytotoxity of the activated lymphocytes. Furthermore, in applying DC-K to a recurrent case of esophageal cancer, the skin tumors disappeared after local injection of DC-K. The only adverse effect of this treatment was pyrexia. Although no general effect was observed, the local effect was satisfactory. This suggests that DC-K might be useful for local treatment or postoperative adjuvant therapy.