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with cancer (20). As of 2015, the Center for Cancer Control and Information Services of the National Cancer Center collected and managed HBCR data from 427 cancer care hospitals designated by the Ministry of Health, Labor and Welfare (21). These data may cover more than 67% of all newly diagnosed cancer patients (20). The HBCR records information on newly encountered patients with malignant, intracranial borderline and benign tumors at the registering hospital. The recorded information includes (i) demographic characteristics, including the sex and date of birth, tumor site and histology codes according to the International Classification of Diseases for Oncology, third edition (ICD-O-3) (22); (ii) clinical and pathologic Tumor, node, metastasis (TNM) stage according to the Union for International Cancer Control (23); (iii) diagnosis date; and (iv) treatment details (20). After the registration, the National Cancer Center calls for the followed up data with health insurance claims data up to the end of the next year of diagnosis, which includes a maximum of 2 years from the date of diagnosis to monitor the quality and patterns of care nationwide. The health insurance claims database includes details regarding the care provided to each patient, including the health services and prescriptions provided, together with the corresponding dates (24). The National Cancer Center collects health insurance claims data from each hospital in a manner that is linkable with the HBCR.

Introduction Thymic epithelial tumors (TETs) are rarely occurring malignancies for which no standard treatment strategy (e.g. surgical resection, radiation therapy and chemotherapy and combinations thereof) has been established. Although the efficacy of primary surgical resection has been well-established for early-stage disease (1,2), no treatment has been established for advanced disease (3,4). Currently, the treatment for a TET is determined by each physician based on expert opinions and the results of small clinical trials (1,5–13). The rarity of these tumors has made it difficult to conduct phase III trials in such settings (2,14). The International Thymic Malignancy Interest Group has created a global database to record data from Japan (3,15), USA, Italy, Germany (4) and China (16,17). However, this database predominantly includes cases treated with surgical resection but not cases of unresectable advanced disease, especially those involving distant metastasis of thymic carcinoma. Additionally, the guidelines for TET published by the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) differ in several aspects (18,19). For example, the NCCN guideline describes 15 chemotherapy regimens, including second-line regimens, whereas the ESMO guideline describes only seven chemotherapy regimens and no second-line regimens. Therefore, this study aimed to investigate the current TET treatment situation in Japan.

ffer in several aspects (18,19). For example, the NCCN guideline describes 15 chemotherapy regimens, including second-line regimens, whereas the ESMO guideline describes only seven chemotherapy regimens and no second-line regimens. Therefore, this study aimed to investigate the current TET treatment situation in Japan. Materials and methods Data source This retrospective observational study was based on a nationwide Japanese database. The main purpose of the Hospital-based Cancer Registry (HBCR) is to evaluate and improve the quality of care for patients with cancer (20). As of 2015, the Center for Cancer Control and Information Services of the National Cancer Center collected and managed HBCR data from 427 cancer care hospitals designated by the Ministry of Health, Labor and Welfare (21). These data may cover more than 67% of all newly diagnosed cancer patients (20).

th insurance claims database includes details regarding the care provided to each patient, including the health services and prescriptions provided, together with the corresponding dates (24). The National Cancer Center collects health insurance claims data from each hospital in a manner that is linkable with the HBCR. We used the data for patients diagnosed from 2012 to 2014 who received treatment from hospitals that responded to the National Cancer Center call for data. We created a list of TET patients from the HBCR and analyzed the treatment patterns using information obtained from the health insurance claims database (20). These data were anonymized. Pathology and staging The database recorded pathology data that were evaluated according to the ICD-O-3 classification (25). HBCR recorded tumor site and histology codes based on the ICD-O-3. The definition of ‘not otherwise specified (NOS)’ in ICD-O-3 is the category that cannot be classified into any definite code in ICD-O-3. Cases involving surgery were evaluated using surgical specimens, whereas biopsy specimens were used for other cases. This classification method was based on the Summary Stage created by the California Tumor Registry Office and the Surveillance, Epidemiology and End Results plan developed by the National Cancer Institute (26). Tumors were classified as Stage 0: in situ, I: localized, II: regional lymph nodes, III: regional by direct extension with or without regional lymph node metastasis and IV: distant metastasis.

Tumor Registry Office and the Surveillance, Epidemiology and End Results plan developed by the National Cancer Institute (26). Tumors were classified as Stage 0: in situ, I: localized, II: regional lymph nodes, III: regional by direct extension with or without regional lymph node metastasis and IV: distant metastasis. Patient selection We extracted data on all patients diagnosed with thymoma or thymic carcinoma between 1 January 2012, and 31 December 2014 from the HBCR. The following codes were used for patient identification: (i) registered site on cancer, thymus (C37) and (ii) ICD-O-3 histology codes 8020, 8023, 8033, 8070, 8082, 8123, 8140, 8200, 8260, 8310, 8430, 8480, 8560, 8576, 8580–8585 and 8586 with a behavior code of 3 (i.e. malignant tumor). The data were limited to patients who were diagnosed and consequently treated at the same hospital. Patients who moved and initiated treatment at other hospitals were excluded. Hospital type The hospital types were generally identified with respect to institutional names. We categorized a hospital as a cancer center or university hospital, if that hospital has ‘cancer center’ or a university’s name, in the name of the institution, respectively. The others were categorized as municipal hospitals. Compliance rate It is defined as the proportion of regimens described in NCCN or ESMO guidelines to the total number of regimens.

Hospital type The hospital types were generally identified with respect to institutional names. We categorized a hospital as a cancer center or university hospital, if that hospital has ‘cancer center’ or a university’s name, in the name of the institution, respectively. The others were categorized as municipal hospitals. Compliance rate It is defined as the proportion of regimens described in NCCN or ESMO guidelines to the total number of regimens. Ethical consideration This study protocol and the use of the HBCR and health insurance claims database were approved by the Institutional Review Board and Data Use Committee at the National Cancer Center (Registration number: 2013-081; Approval date: 25 July 2013). The study was conducted in accordance with the principles of the Declaration of Helsinki (as revised in Fortaleza, Brazil in 2013). In publications analyzing the aforementioned data, the number of cases must be masked when <10, based on HBCR’s privacy policy. We categorized the group ‘<10’ as ‘1–3’, ‘4–6’ and ‘7–9’ without percentage. Statistical Analysis Differences between the groups were assessed using the chi-square test for categorical variables and the Mann–Whitney U test and Kruskal–Wallis test for continuous variables. All tests for significance were two-tailed, with an α-value of 0.05. The Stata® version 15.0 software (StataCorp, College Station, TX, USA) was used for all statistical analyses.

re assessed using the chi-square test for categorical variables and the Mann–Whitney U test and Kruskal–Wallis test for continuous variables. All tests for significance were two-tailed, with an α-value of 0.05. The Stata® version 15.0 software (StataCorp, College Station, TX, USA) was used for all statistical analyses. Results Patient characteristics A total of 1666 TET patients were diagnosed with thymoma or thymic carcinoma. After excluding patients who received treatment from other hospitals, 813 thymoma patients and 547 thymic carcinoma patients were included in the analysis (Fig. 1). Of the thymoma patients, 389 (47.8%) were male, and the median age at diagnosis was 63 years. Of the 466 patients with a known disease stage, 295 (63.3%) had stage I disease, among whom 283 (95.9%) underwent surgery as the primary treatment. Of the thymic carcinoma patients, 362 (66.2%) were male, a significantly higher frequency than that observed among thymoma cases (P < 0.01). The median age at diagnosis was 65 years; again, this was significantly higher than that of thymoma patients (P < 0.01) (Table 1).

.9%) underwent surgery as the primary treatment. Of the thymic carcinoma patients, 362 (66.2%) were male, a significantly higher frequency than that observed among thymoma cases (P < 0.01). The median age at diagnosis was 65 years; again, this was significantly higher than that of thymoma patients (P < 0.01) (Table 1). Figure 1. Flow chart of patient inclusion. Table 1 Patient characteristics Characteristic All patients (N = 1360) Thymoma (N = 813), N (%) or N (range) Thymic carcinoma (N = 547), N (%) or N (range) P-value Age in years: median (range) 63 (16–90) 65 (20–85) <0.01 Sex: number (%) Male 389 (47.8) 362 (66.2) <0.01 Female 424 (52.2) 185 (33.8) Hospital type: number (%) Municipal hospital 388 (47.7) 279 (51.0) 0.46 Cancer center 87 (10.7) 58 (10.6) University hospital 338 (41.6) 210 (38.4) Stage: number (%) I 295 (36.3) 89 (16.3) <0.01 II 2 (0.2) 6 (1.1) III 127 (15.6) 105 (19.2) IV 42 (8.3) 118 (21.6) No data 347 (42.6) 229 (41.9) WHO classification: number (%) A 54 (6.6) AB 162 (19.9) B1 154 (18.9) B2 174 (21.4) B3 121 (14.9) NOS 148 (18.2) Pathology of thymic cancer: number (%) Squamous cell carcinoma 282 (51.6) Adenocarcinoma 12 (2.2) Others 20 (3.7) Basaloid carcinoma 7–9 Mucoepidermoid carcinoma 7–9 Sarcomatoid carcinoma 1–3 Undifferentiated carcinoma 4–6 NOS 233 (42.6) WHO: World Health Organization, NOS: not otherwise specified.

14.9) NOS 148 (18.2) Pathology of thymic cancer: number (%) Squamous cell carcinoma 282 (51.6) Adenocarcinoma 12 (2.2) Others 20 (3.7) Basaloid carcinoma 7–9 Mucoepidermoid carcinoma 7–9 Sarcomatoid carcinoma 1–3 Undifferentiated carcinoma 4–6 NOS 233 (42.6) WHO: World Health Organization, NOS: not otherwise specified. Of the 318 patients with thymic carcinoma and a known disease stage, 223 (70.1%) had stage III or IV disease, indicating that this type of malignancy was significantly more frequently diagnosed at a later stage than thymoma (P < 0.01) (Table 1). Sixty-six (29.6%) patients with thymic carcinoma underwent surgery as the primary treatment, whereas 157 (70.4%) received radiotherapy or chemotherapy (Table 2).

age III or IV disease, indicating that this type of malignancy was significantly more frequently diagnosed at a later stage than thymoma (P < 0.01) (Table 1). Sixty-six (29.6%) patients with thymic carcinoma underwent surgery as the primary treatment, whereas 157 (70.4%) received radiotherapy or chemotherapy (Table 2). Table 2 Patient characteristics by initial treatment Characteristic Thymoma (813) Surgery (689), N (%) or N (range) Radiotherapy (21), N (%) or N (range) Chemotherapy (103), N (%) or N (range) P-value Age in years: median (range) 62 (16–87) 73 (43–90) 63 (23–81) <0.01 Sex: number (%) Male 317 (46.0) 8 (38.1) 64 (62.1) <0.01 Female 372 (54.0) 13 (61.9) 39 (37.9) Stage: number (%) I 283 (41.1) 1–3 9 (8.7) <0.01 II 2 (0.3) 0 0 III 90 (13.1) 4–6 33 (32.0) IV 15 (2.2) 4–6 21 (20.4) No data 299 (43.4) 7–9 40 (38.8) WHO classification: number (%) A 51 (7.4) 1–3 1–3 <0.01 AB 155 (22.5) 0 7–9 B1 140 (20.3) 1–3 11 (10.7) B2 150 (21.8) 4–6 19 (18.5) B3 97 (14.1) 4–6 19 (18.5) NOS 96 (13.9) 4–6 46 (44.7) Thymic carcinoma (547) Surgery (230) Radiotherapy (67) Chemotherapy (250) Age in years: median (range) 66 (20–85) 68 (36–85) 64 (22–84) <0.01 Sex: number (%) Male 141 (61.3) 46 (68.7) 175 (70.0) 0.12 Female 89 (38.7) 21 (31.3) 75 (30.0) Stage: number (%) I 70 (30.4) 7 (10.4) 12 (4.8) <0.01 II 3 (1.3) 1–3 2 (0.8) III 47 (20.4) 7–9 50 (20.0) IV 19 (8.3) 19 (28.4) 80 (32.0) No data 91 (39.6) 32 (47.8) 106 (42.4) Table 3 Regimens in patients with chemotherapy Thymoma (N = 135) Frequency N (%) Single agent 6 (4.4) AMR 1–3 GEMa 1–3 PEMa 1-3 Sirolimus 1–3 EPI 1–3 Platinum combination CDDP combination 75 (55.6) DXR + CPA+VCRb 37 (27.4) DXR 13 (9.6) Others 25 (18.5) DXR+CPAb 7-9 AMR 4-6 ETPa 4-6 DXR + ETP+VCRc 1-3 5-FU 1–3 S-1 1–3 VNR 1–3 CPT-11 1–3 CBDCA combination 54 (40.0) PTXb 47 (34.8) Others 7 (5.2) DOC 1–3 ETP 1–3 DXR 1–3 GEM 1–3 S-1 1–3 Compliance rate (%) 74.1 Thymic carcinoma (N = 316) Frequency N (%) Single agent 19 (6.0) S-1 7–9 DOC 4–6 AMR 1–3 PTXa 1-3 THP 1–3 Platinum combination CDDP combination 81 (25.6) DXR + CPA + VCRb 39 (12.3) ETPb 13 (4.1) Others 29 (9.2) DOC 7–9 CPT-11 4–6 DXR + CPAb 4-6 VNR 4-6 S-1 1–3 DXR + ETP + VCRc 1-3 DXR 1-3 5-FU 1–3 CBDCA combination 215 (68.0) PTXb 195 (61.7) Others 20 (6.3) GEM 7–9 S-1 4–6 DXR 4–6 ETP 1–3 DOC 1–3 Others DOC + nedaplatin 1–3 Compliance rate (%) 80.7 AMR: amurubicin, GEM: gemcitabine, PEM: pemetrexed, EPI: epirubicin, CDDP: cisplatin, DXR: doxorubicin, CPA: cyclophosphamide, VCR: vincristine, ETP: etoposide, 5-FU: fluo

combination 215 (68.0) PTXb 195 (61.7) Others 20 (6.3) GEM 7–9 S-1 4–6 DXR 4–6 ETP 1–3 DOC 1–3 Others DOC + nedaplatin 1–3 Compliance rate (%) 80.7 AMR: amurubicin, GEM: gemcitabine, PEM: pemetrexed, EPI: epirubicin, CDDP: cisplatin, DXR: doxorubicin, CPA: cyclophosphamide, VCR: vincristine, ETP: etoposide, 5-FU: fluo rouracil, S-1: tegafur/gimeracil/oteracil, VNR: vinorelbine, CBDCA: carboplatin, PTX: paclitaxel, DOC: docetaxel, THP: pirarubicin, NCCN: National Comprehensive Cancer Network, ESMO: European Society for Medical Oncology, CPT-11: irrinotecan. aRegimens described only in NCCN guidelines. bRegimens described in NCCN and ESMO guidelines. cRegimens described only in ESMO guidelines.

rouracil, S-1: tegafur/gimeracil/oteracil, VNR: vinorelbine, CBDCA: carboplatin, PTX: paclitaxel, DOC: docetaxel, THP: pirarubicin, NCCN: National Comprehensive Cancer Network, ESMO: European Society for Medical Oncology, CPT-11: irrinotecan. aRegimens described only in NCCN guidelines. bRegimens described in NCCN and ESMO guidelines. cRegimens described only in ESMO guidelines. Table 4 Regimens in patients with chemotherapy by hospital type Thymoma (N = 135) Municipal hospital (N = 68), N (%) Cancer center (N = 18), N (%) University hospital (N = 49), N (%) Monotherapy 4 (5.9) 2 (11.1) 0 AMR 1 (1.5) 1 (5.6) GEMa 1 (5.6) PEMa 1 (1.5) Sirolimus 1 (1.5) EPI 1 (1.5) CBDCA + PTXb 20 (29.4) 7–9 20 (40.8) CDDP + DXR + CPA + VCRb 17 (25.0) 1–3 18 (36.7) Others 27 (39.7) 7 (38.9) 11 (22.4) CDDP + DXR 10 (14.7) 1–3 1–3 CDDP + DXR + CPAb 4–6 1–3 CDDP + AMR 4–6 1–3 CDDP + ETPa 1–3 1–3 1–3 CDDP + DXR + ETP + VCRc 1–3 1–3 CDDP + 5-FU 1–3 CBDCA + DOC 1–3 1–3 CBDCA + ETP 1–3 CDDP + S-1 1–3 CDDP + VNR 1–3 CDDP + CPT-11 1–3 CBDCA + DXR 1–3 CBDCA + GEM 1–3 CBDCA + S-1 1–3 Compliance rate (%) 66.2 61.1 87.8 Thymic carcinoma (N = 316) Municipal hospital (N = 156) Cancer center (N = 30) University hospital (N = 130) Monotherapy 10 (6.4) 0 9 (6.9) S-1 4–6 4–6 DOC 1–3 1–3 AMR 1–3 PTXa 1–3 THP 1–3 CBDCA + PTXb 88 (56.4) 23 (76.7) 84 (64.6) CDDP + DXR + CPA + VCRb 22 (14.1) 1 (3.3) 16 (12.3) Others 36 (23.1) 6 (20.0) 21 (16.2) CDDP + ETPb 4–6 4–6 1–3 CDDP + DOC 4–6 CBDCA + GEM 4–6 1–3 CDDP + CPT-11 4–6 1–3 CBDCA + S-1 1–3 4–6 CDDP + DXR + CPAb 4-6 CDDP + VNR 1–3 1–3 CBDCA + DXR 1–3 1–3 CDDP + S-1 1–3 1–3 CBDCA + ETP 1–3 CDDP + DXR + ETP + VCRc 1–3 1–3 CDDP + DXR 1–3 4–6 CDDP + 5-FU 1–3 CBDCA + DOC 1–3 DOC + nedaplatin 1–3 Compliance rate (%) 78.8 100.0 78.4

4–6 1–3 CDDP + DOC 4–6 CBDCA + GEM 4–6 1–3 CDDP + CPT-11 4–6 1–3 CBDCA + S-1 1–3 4–6 CDDP + DXR + CPAb 4-6 CDDP + VNR 1–3 1–3 CBDCA + DXR 1–3 1–3 CDDP + S-1 1–3 1–3 CBDCA + ETP 1–3 CDDP + DXR + ETP + VCRc 1–3 1–3 CDDP + DXR 1–3 4–6 CDDP + 5-FU 1–3 CBDCA + DOC 1–3 DOC + nedaplatin 1–3 Compliance rate (%) 78.8 100.0 78.4 aRegimens described only in NCCN guidelines. bRegimens described in NCCN and ESMO guidelines. cRegimens described only in ESMO guidelines. Table 2 shows the patients’ backgrounds according to the initial treatment type. In both disease groups, patients receiving initial radiotherapy were significantly older than those receiving other treatments (P < 0.01). Most patients with stage I disease underwent initial surgery, whereas those with advanced-stage (III or IV) disease tended to receive initial radiotherapy or chemotherapy. Regarding thymoma pathology, patients with World Health Organization (WHO) classification A, AB and B1 disease underwent initial surgery, whereas those with higher cellular atypia and invasiveness (B2 and B3) tended to receive initial radiotherapy or chemotherapy. A significant difference in the rate of surgery was observed among thymoma patients with respect to hospital type but not among thymic carcinoma patients (Table S1). The rate of surgery was the lowest in cancer centers. In the operative method (open surgery or thoracoscopic surgery), no difference existed between both thymoma and thymic carcinoma patients (Table S2).

as observed among thymoma patients with respect to hospital type but not among thymic carcinoma patients (Table S1). The rate of surgery was the lowest in cancer centers. In the operative method (open surgery or thoracoscopic surgery), no difference existed between both thymoma and thymic carcinoma patients (Table S2). Treatment pattern Thymoma Of the 689 patients who underwent initial surgery, 549 (79.7%) did not receive subsequent treatment (Fig. 2). Furthermore, 124 patients did not undergo surgical resection, 103 (83.0%) patients received initial chemotherapy and 21 (16.9%) received initial radiotherapy. Of the patients who received initial chemotherapy, 29 (28.2%) did not receive further treatment, 17 (16.5%) underwent subsequent surgery and 57 (55.3%) received subsequent radiotherapy. Thirty-three (57.9%) of these patients subsequently underwent surgery. Seventeen patients underwent neoadjuvant chemotherapy. The regimens have been listed in Table S3. Additionally, five patients underwent radiotherapy before surgery.

16.5%) underwent subsequent surgery and 57 (55.3%) received subsequent radiotherapy. Thirty-three (57.9%) of these patients subsequently underwent surgery. Seventeen patients underwent neoadjuvant chemotherapy. The regimens have been listed in Table S3. Additionally, five patients underwent radiotherapy before surgery. Figure 2. (a) Treatment patterns in patients with thymoma. (b) Treatment patterns in patients with thymic carcinoma. Rx: treatment, XRT: radiation, Chemo: chemotherapy. Thymic carcinoma Of the 230 patients who underwent surgery, 106 (46.1%) did not receive subsequent treatment; this proportion was lower than that observed for thymoma patients (Fig. 2). Three hundred and seventeen patients did not undergo surgical resection. A total of 250 patients (78.9%) received initial chemotherapy, and 67 (21.1%) received initial radiotherapy. Of those who received initial chemotherapy, 94 (37.6%) did not receive further treatment, and 147 (58.8%) received subsequent radiotherapy. Eighty-three (56.5%) of the latter patients subsequently underwent surgery. Nine patients underwent neoadjuvant chemotherapy. The regimens have been listed in Table S3. In addition, four patients underwent radiotherapy before surgery.

did not receive further treatment, and 147 (58.8%) received subsequent radiotherapy. Eighty-three (56.5%) of the latter patients subsequently underwent surgery. Nine patients underwent neoadjuvant chemotherapy. The regimens have been listed in Table S3. In addition, four patients underwent radiotherapy before surgery. Chemotherapy regimens Thymoma A total of 135 thymoma patients received 21 chemotherapy regimens. Nearly all cases (129; 95.6%) received platinum combination regimens. The most commonly used regimens were carboplatin + paclitaxel (CBDCA + PTX), cisplatin + doxorubicin  + cyclophosphamide + vincristine (CDDP + DXR + CPA + VCR) and cisplatin + doxorubicin (CDDP + DXR). Amurubicin (AMR), gemcitabine (GEM), pemetrexed (PEM), sirolimus and epirubicin (EPI) monotherapies were used in a few cases. Overall, 74.1% of these chemotherapy regimens were described in the NCCN or ESMO guidelines (Table 3). According to hospital type, municipal hospitals used the highest number of regimens, whereas university hospitals did not use monotherapies. CBDCA + PTX was the most commonly used regimen across all hospital types. Cisplatin + amurubicin (CDDP + AMR) was used more frequently than CDDP + DXR + CPA + VCR only in cancer centers. Cancer centers had a compliance rate of 61.1%, which was the lowest across all hospital types (Table 4).

s did not use monotherapies. CBDCA + PTX was the most commonly used regimen across all hospital types. Cisplatin + amurubicin (CDDP + AMR) was used more frequently than CDDP + DXR + CPA + VCR only in cancer centers. Cancer centers had a compliance rate of 61.1%, which was the lowest across all hospital types (Table 4). Thymic carcinoma A total of 316 thymic carcinoma patients underwent 22 chemotherapy regimens. Most cases (296; 93.7%) were treated using platinum combination regimens. CBDCA + PTX (195; 61.7%) was the most commonly used regimen. Monotherapies, including tegafur/gimeracil/oteracil (S-1), docetaxel, AMR, PTX and pirarubicin (THP), were used in 19 (6.0%) cases. Overall, 80.7% of these regimens complied with the NCCN or ESMO guidelines (Table 3). According to hospital type, municipal hospitals used the greatest number of regimens, whereas cancer centers did not use monotherapies. Across all hospital types, CBDCA + PTX was the most commonly used regimen. CDDP + DXR + CPA + VCR was used in municipal and university hospitals, but rarely in cancer centers. Cisplatin + etoposide (CDDP + ETP) was more commonly used in cancer centers than in other hospital types. The compliance rate for cancer centers was 100.0%, which was the highest across all hospital types (Table 4).

en. CDDP + DXR + CPA + VCR was used in municipal and university hospitals, but rarely in cancer centers. Cisplatin + etoposide (CDDP + ETP) was more commonly used in cancer centers than in other hospital types. The compliance rate for cancer centers was 100.0%, which was the highest across all hospital types (Table 4). Discussion This study is the first to describe the real-world treatment patterns for TETs, based on data from an HBCR and a health insurance claims database. This analysis indicated that thymoma tended to be diagnosed at earlier stages and that the majority of patients (549; 67.5%) underwent primary surgery. CDDP + DXR + CPA + VCR was the most commonly used chemotherapy regimen for thymoma. According to a report from an Italian research group in 1990, this regimen, which has been used for more than two decades, has an overall response rate of 91.8% and a complete response rate of 43% (27). Notably, CBDCA + PTX was also frequently used for thymoma. However, the efficacy data associated with this regimen are limited when compared with the data for thymic carcinoma, with a reported overall response rate of 42.9% (28).

o decades, has an overall response rate of 91.8% and a complete response rate of 43% (27). Notably, CBDCA + PTX was also frequently used for thymoma. However, the efficacy data associated with this regimen are limited when compared with the data for thymic carcinoma, with a reported overall response rate of 42.9% (28). Thymic carcinoma tended to be diagnosed more frequently in advanced stages, and 106 (19.4%) affected patients underwent primary surgery, whereas 83 (15.2%) received initial chemotherapy and subsequent radiotherapy and surgery. The most commonly used regimen was CBDCA + PTX; however, these data were based on phase II trials conducted in 2011 and 2015, which reported an overall response rate of 21.7% (28,29). CDDP + DXR + CPA + VCR was also used for thymic carcinoma; however, data on the use of this regimen for thymic carcinoma are limited to retrospective analyses or small case series (30). The uses of AMR, irinotecan and nedaplatin (31), which were all developed in Japan, are unique to this country. Currently, the efficacy of CDDP + AMR for thymoma is being evaluated in a clinical trial by the West Japan Oncology Group 5509 L (UMIN000003933). The use of AMR for thymic carcinoma is based on the findings of a retrospective observational study (32). Notably, 13 of the 21 regimens used for thymoma (18,19) and 16 of the 22 regimens used for thymic carcinoma in this analysis were not described in the NCCN and ESMO guidelines.

ncology Group 5509 L (UMIN000003933). The use of AMR for thymic carcinoma is based on the findings of a retrospective observational study (32). Notably, 13 of the 21 regimens used for thymoma (18,19) and 16 of the 22 regimens used for thymic carcinoma in this analysis were not described in the NCCN and ESMO guidelines. An analysis by hospital type revealed several differences between cancer centers and other hospital types. Regimens comprising new drugs tended to be used more frequently in cancer centers. As shown in this study, most chemotherapy regimens used to treat TETs involved a combination of old and low-cost drugs. However, pharmaceutical companies have not conducted clinical trials intended to support the approval of old drugs for TETs. In Japan, drug approval can be obtained using a public knowledge-based application (33), which is based on the international use of a drug or the presence of sufficient medical literature to prove its safety and efficacy in the absence of a clinical trial. Although nationwide registry, insurance and efficacy data are all sources of domestic data, the associated analyses may provide useful information for public knowledge-based application. However, newer agents should be subjected to a prospective global clinical trial prior to approval. Global clinical trials for several new drugs, such as pembrolizumab, sunitinib and everolimus, are currently underway (34–37).

he associated analyses may provide useful information for public knowledge-based application. However, newer agents should be subjected to a prospective global clinical trial prior to approval. Global clinical trials for several new drugs, such as pembrolizumab, sunitinib and everolimus, are currently underway (34–37). Our study had several limitations. First, we lacked data on patient performance status and presence of comorbidities and therefore could not identify the main factor(s) associated with treatment decision-making. Variations in treatment choice may partially be due to the patients’ conditions. Second, the data were obtained only from hospitals where patients were diagnosed and started their treatment. If patients were transferred after the start of therapy or concurrently treated in other hospitals, the health services provided in the other hospitals were not included in the data. Third, the maximum follow-up period was 2 years, a relatively short period given the overall survival of patients with thymic tumors. When treatment was provided over an extended period, the data analyzed for these patients may have been assessed inaccurately in the results. Fourth, this was a descriptive study of voluntarily participating hospitals. Although the size of the data was larger than that of other prior studies assessing nonspecialized hospitals, nonparticipating hospitals might have different practice patterns. Fifth, the ICD-O-3 system includes the codes for thymoma of borderline malignancy, but they are not reportable to HBCR. Since tumors of the thymus are reportable to HBCR only when they are deemed malignant, it is possible that some thymomas diagnosed as borderline malignancies were not included in the HBCR. Nevertheless, the WHO classification of thymoma in the previous edition suggests that thymic tumors are automatically designed as malignant (38); in addition, the current version codes all thymoma as malignant (25). Sixth, pathology classification and stage included unknown or NOS data in many parts, which were excluded from the statistical analyses.

tion of thymoma in the previous edition suggests that thymic tumors are automatically designed as malignant (38); in addition, the current version codes all thymoma as malignant (25). Sixth, pathology classification and stage included unknown or NOS data in many parts, which were excluded from the statistical analyses. In conclusion, we analyzed the real-world treatment patterns associated with TETs in Japan. For rarely occurring cancers, such as TETs, analyses of nationwide registry, insurance, efficacy and prognostic data may contribute to the establishment of a standard treatment strategy. Supplementary Material Table_S1_hyz167 Click here for additional data file. Table_S2_hyz167 Click here for additional data file. Table_S3_hyz167 Click here for additional data file. Acknowledgements This study was supported by a National Cancer Center Research and Development Grant (grant number 28-A-21). Conflict of interest statement Dr Tamura received personal fees from Eli Lilly, Chugai, Ono, Taiho, KyowaKirin, Boehringer Ingelheim, Bristol-Myers Squibb, MSD and CMIC ShiftZero outside the submitted work. Dr Higashi reports grants and personal fees for committee attendance from the Ministry of Health, Labor and Welfare during the study.

t analyses according to histological type using OCR. The number of lung cancer incidence per year increased continuously because of the population aging. The main histological type of lung cancer switched from SQCC to ADC among men in 1990s. The declining trends for SQCC and SMCC continued in the updated present study. Smoking prevalence by birth-cohort among Japanese men was reported to have two peaks: around the 1925 birth-cohort and around the 1950 birth-cohort (11). In addition, there was a trough of smoking prevalence in 1930–40 birth-cohorts because of the limited cigarette supply just after World War II (11). In general, the trends in lung cancer incidence or mortality by birth-cohort were parallel to the trends in the smoking prevalence. Our results were consistent with the findings from previous studies, showing that lung cancer mortality and incidence rates among men in 1935–39 birth-cohorts were lower than the subsequent birth-cohorts (6–10). Since the smoking prevalence among Japanese men was declining after 1950s birth-cohorts, the appearance of declining trends of lung cancer incidence among men in 1955–59 birth-cohorts was an expected result.

BACKGROUND Lung cancer is the leading cause of cancer deaths in Japan, with 45 927 men and 17 307 women dying from lung cancer in 2006. To date, increase in the incidence rates of lung adenocarcinoma (ADC) and decrease in the incidence rates of squamous cell carcinoma (SQCC) and small cell carcinoma (SMCC) have been reported in Japan (1,2). The same trend has been reported in Western countries also (3–5). Some previous studies reported that there was a trough of lung cancer incidence or mortality in Japanese male 1935–39 birth-cohorts because of the limited cigarette supply just after World War II (6–10). Soda et al. (7) reported the birth-cohort analysis by histological type using Nagasaki Cancer Registry in 2000. However, this study was based on the small number of registered lung cancer cases and excluded the cases without histological diagnoses. In the present study, we updated the recent trends in lung cancer incidence by histological type and tried to clarify their characteristics by birth-cohort, using the data from Osaka Cancer Registry (OCR) with the large number of lung cancer incidence. MATERIALS AND METHODS OCR, which started in 1962, is the population-based cancer registry covering Osaka prefecture (population: 8.8 million, 2005 census). Using OCR data on lung cancer incidence (International Classification of Diseases 10th revision C33–C34) diagnosed between 1975 and 2003, we calculated the number of lung cancer incidence per year, age-adjusted rates and age-specific rates by birth-cohort according to histological type.

tion: 8.8 million, 2005 census). Using OCR data on lung cancer incidence (International Classification of Diseases 10th revision C33–C34) diagnosed between 1975 and 2003, we calculated the number of lung cancer incidence per year, age-adjusted rates and age-specific rates by birth-cohort according to histological type. Histological types were categorized into three major types: ADC (ICD-O: 8140, 8141, 8200, 8211, 8250, 8251, 8260, 8310, 8323, 8440, 8470, 8480, 8481 and 8490), SQCC (ICD-O: 8050, 8052 and 8070–8076), SMCC (ICD-O: 8041–8045) and the others. Incident years are divided into 5-year periods: 1975–78, 1979–83, 1989–93, 1994–98 and 1999–2003. Birth years were also divided into 5-year periods. The population data by age group in Osaka prefecture were obtained from the data of Population Census. For age-standardization, the Japanese model population in 1985 was used.

dent years are divided into 5-year periods: 1975–78, 1979–83, 1989–93, 1994–98 and 1999–2003. Birth years were also divided into 5-year periods. The population data by age group in Osaka prefecture were obtained from the data of Population Census. For age-standardization, the Japanese model population in 1985 was used. The data from OCR included the cases without specific histological diagnosis: a maximum of 60.4% in 1975–78 and a minimum of 31.4% in 1994–98. Based on the assumption that distributions of histological types in the same sex and age group were the same between those with and without a specific histological type, we compensated for the proportion of cases without a specific histological type. The detailed procedure was followed to the previous study (1); first, the sex-, age (5-year)- and incident year (or birth-cohort)-specific numbers of incidence were calculated for all histological types including the cases without histological diagnosis. Second, the sex-, age (10-year)- and incident year (or birth-cohort)-specific proportion of each histological type among the cases with histological diagnosis were calculated for three major histological types. Finally, the sex-, age (5-year)-, incident year (or birth-cohort)-specific number of incidence were multiplied by the corresponding sex-, age- and incident year (or birth-cohort)-specific proportion to approximate the number of incidence by histological type.

iagnosis were calculated for three major histological types. Finally, the sex-, age (5-year)-, incident year (or birth-cohort)-specific number of incidence were multiplied by the corresponding sex-, age- and incident year (or birth-cohort)-specific proportion to approximate the number of incidence by histological type. RESULTS Table 1 shows the trends in the number of lung cancer incidence per year according to histological type. Lung cancer incidence per year for all histological types among men and women increased consistently; from 1086 in 1975–78 to 3487 in 1999–2003 among men and from 395 in 1975–78 to 1482 in 1999–2003 among women. As for histological type, the number of ADC incidence has increased remarkably among men and women. The shift in main histological type among men occurred in the 1990s. Table 1. Trends in the number of lung cancer incidence per year according to histological type

RESULTS Table 1 shows the trends in the number of lung cancer incidence per year according to histological type. Lung cancer incidence per year for all histological types among men and women increased consistently; from 1086 in 1975–78 to 3487 in 1999–2003 among men and from 395 in 1975–78 to 1482 in 1999–2003 among women. As for histological type, the number of ADC incidence has increased remarkably among men and women. The shift in main histological type among men occurred in the 1990s. Table 1. Trends in the number of lung cancer incidence per year according to histological type Histological type Incident year 1975–78 1979–83 1984–88 1989–93 1994–98 1999–2003 Men Adenocarcinoma (%) 372 (34.2) 510 (35.7) 696 (35.5) 853 (35.8) 1191 (40.2) 1497 (42.9) Squamous cell carcinoma (%) 474 (43.6) 582 (40.8) 760 (38.8) 921 (38.6) 1086 (36.6) 1208 (34.7) Small cell carcinoma (%) 142 (13.0) 203 (14.2) 315 (16.1) 410 (17.2) 483 (16.3) 543 (15.6) Others (%) 99 (9.1) 132 (9.3) 189 (9.7) 200 (8.4) 204 (6.9) 239 (6.8) All histological types (%) 1086 (100) 1428 (100) 1961 (100) 2383 (100) 2964 (100) 3487 (100) Women Adenocarcinoma (%) 242 (61.2) 328 (60.2) 453 (58.7) 579 (60.3) 792 (64.8) 996 (67.2) Squamous cell carcinoma (%) 86 (21.9) 106 (19.5) 163 (21.2) 184 (19.2) 218 (17.9) 241 (16.3) Small cell carcinoma (%) 32 (8.0) 73 (13.3) 97 (12.5) 132 (13.7) 152 (12.5) 178 (12.0) Others (%) 35 (8.9) 38 (6.9) 59 (7.6) 65 (6.8) 60 (4.9) 66 (4.4) All histological types (%) 395 (100) 545 (100) 772 (100) 961 (100) 1223 (100) 1482 (100) Table 2 shows the trends in the age-adjusted rates according to the histological type. The age-adjusted rates for all histological types peaked in 1994–98 and recently leveled off among men, while those consistently increased among women. The rates for ADC consistently increased among men and women. In contrast, the rates for SQCC and SMCC peaked in 1989–93 among men, and decreased subsequently. Those rates for SQCC and SMCC peaked in 1984–88 and 1989–93, respectively, among women, and decreased subsequently.

le those consistently increased among women. The rates for ADC consistently increased among men and women. In contrast, the rates for SQCC and SMCC peaked in 1989–93 among men, and decreased subsequently. Those rates for SQCC and SMCC peaked in 1984–88 and 1989–93, respectively, among women, and decreased subsequently. Table 2. Trends in age-adjusted lung cancer incidence rates per 100 000 person-years according to histological type

le those consistently increased among women. The rates for ADC consistently increased among men and women. In contrast, the rates for SQCC and SMCC peaked in 1989–93 among men, and decreased subsequently. Those rates for SQCC and SMCC peaked in 1984–88 and 1989–93, respectively, among women, and decreased subsequently. Table 2. Trends in age-adjusted lung cancer incidence rates per 100 000 person-years according to histological type Histological type Incident year 1975–78 1979–83 1984–88 1989–93 1994–98 1999–2003 Men Adenocarcinoma 15.5 18.9 21.7 22.3 26.0 27.2 Squamous cell carcinoma 20.4 22.2 25.0 25.6 24.8 22.3 Small cell carcinoma 6.0 7.6 10.1 11.1 10.8 10.0 All histological types 46.2 53.7 62.9 64.7 66.5 64.3 Women Adenocarcinoma 7.9 9.2 10.5 11.3 13.1 13.8 Squamous cell carcinoma 2.8 3.0 3.8 3.5 3.4 3.1 Small cell carcinoma 1.0 2.0 2.3 2.5 2.4 2.3 All histological types 12.9 15.2 17.9 18.6 19.9 20.2 Fig. 1 shows the trends in the age-specific lung cancer incidence rates with 95% confidence interval by birth-cohort for all histological types. Among men, there was a trough in rates for all age groups in 1935–39 birth-cohorts, which was consistent with the previous findings (7,10). In the subsequent birth-cohorts, the rates increased for all age groups, but the declining tendency appeared in 1955–59 birth-cohorts. Among women, the trough in rates in 1935–39 birth-cohorts was not confirmed. The rates for aged ≥50 years increased gradually, while it seemed that the rates for aged <50 years turned to decrease or level off after 1950–54 birth-cohorts: however, these trends were unstable because of the wide confidence intervals due to the small number of incidence.

in 1935–39 birth-cohorts was not confirmed. The rates for aged ≥50 years increased gradually, while it seemed that the rates for aged <50 years turned to decrease or level off after 1950–54 birth-cohorts: however, these trends were unstable because of the wide confidence intervals due to the small number of incidence. Figure 1. Trends in age-group-specific lung cancer incidence rates with 95% confidence interval by birth-cohort for all histological types. Figs 2–4 show the trends in the age-specific incidence rates with 95% confidence interval by birth-cohort for ADC, SQCC and SMCC, respectively. The rates for ADC among men increased gradually for all age groups, but the declining tendency appeared in 1955–59 birth-cohorts. Furthermore, it seemed that there was a slight trough in rates in 1935–39 birth-cohorts, as well as findings in all histological types. The trends in ADC among women were almost similar with those in all histological types. The rates for SQCC among men peaked in 1910–14 birth-cohorts and decreased in the subsequent birth-cohorts. The trough in rates during 1935–39 birth-cohorts was not clear for SQCC among men. Trends in the rates for SQCC among women aged ≥65 years were similar with those among men. The trends in aged <65 years were, however, unclear because of the wide confidence interval. The rates for SMCC among men peaked around 1920s birth-cohorts and turned to slightly decrease or level off in the subsequent birth-cohorts. The rates for SMCC among women were unclear because of the wide confidence interval.

. The trends in aged <65 years were, however, unclear because of the wide confidence interval. The rates for SMCC among men peaked around 1920s birth-cohorts and turned to slightly decrease or level off in the subsequent birth-cohorts. The rates for SMCC among women were unclear because of the wide confidence interval. Figure 2. Trends in age-group-specific incidence rates with 95% confidence interval by birth-cohort for adenocarcinoma. Figure 3. Trends in age-group-specific incidence rates with 95% confidence interval by birth-cohort for squamous cell carcinoma. Figure 4. Trends in age-group-specific incidence rates with 95% confidence interval by birth-cohort for small cell carcinoma. DISCUSSION In the present study, we reported the population-based trends in lung cancer incidence including birth-cohort analyses according to histological type using OCR. The number of lung cancer incidence per year increased continuously because of the population aging. The main histological type of lung cancer switched from SQCC to ADC among men in 1990s. The declining trends for SQCC and SMCC continued in the updated present study.

lity and incidence rates among men in 1935–39 birth-cohorts were lower than the subsequent birth-cohorts (6–10). Since the smoking prevalence among Japanese men was declining after 1950s birth-cohorts, the appearance of declining trends of lung cancer incidence among men in 1955–59 birth-cohorts was an expected result. Classically, smoking behavior was considered to be more strongly associated with SQCC than with ADC. However, SQCC incidence rates by birth-cohort among men were not parallel to the smoking prevalence by birth-cohort. SQCC incidence rates among men after 1940–44 birth-cohorts leveled off, whereas the smoking prevalence among men after 1940–44 birth-cohorts increased. One reason would be the switching from non-filtered cigarettes to filtered cigarettes. Filtered cigarettes were considered to be associated with peripheral ADC because of the deep inhalation (3,12,13). According to the information from Japan Tobacco Inc., the switching from non-filtered cigarettes to filtered cigarettes occurred in the 1960s in Japan (14). The shift from SQCC to ADC among men in 1990s observed in the present study might have been the result of this shift in cigarette types.

deep inhalation (3,12,13). According to the information from Japan Tobacco Inc., the switching from non-filtered cigarettes to filtered cigarettes occurred in the 1960s in Japan (14). The shift from SQCC to ADC among men in 1990s observed in the present study might have been the result of this shift in cigarette types. The smoking prevalence by birth-cohort among women is continuously increasing after 1930s birth-cohorts (11). However, lung cancer incidence among women in 1950s birth-cohorts, particularly for ADC, seemed to be leveling off or decreasing. Marugame et al. (15) also reported the trends in lung cancer mortality by birth-cohort using the National Vital Statistics. In that study, lung cancer mortality trends appeared to be decreasing for female birth-cohorts born after 1960. Although our results were unstable because of the wide confidence intervals, those were not contradictory to this previous study. There is no clear explanation for these findings among younger Japanese women. There would be some factors other than active smoking for lung cancer incidence among them.

ts born after 1960. Although our results were unstable because of the wide confidence intervals, those were not contradictory to this previous study. There is no clear explanation for these findings among younger Japanese women. There would be some factors other than active smoking for lung cancer incidence among them. The present study has some limitations. First, there may be some missing cases in the OCR. The proportion of death certificate only for lung cancer in OCR was 19.3% in 1998–2002 (16). Therefore, lung cancer incidence may be under-estimated as a whole. Secondly, the trends by histological type among young women were unstable because of the small number of incidence; the number of lung cancer incidence among women aged <50 years per year was ∼80 cases in 2003. Finally, the data from OCR included many lung cancer cases without specific histological diagnoses. We had to use assumption in order to calculate the number of incidence according to histological type. The proportions of lung cancer cases without histological diagnoses for aged <80 years decreased between 1975–78 and 1999–2003; from 49.7 to 16.4% among aged 40–49 years, from 47.4 to 17.6% among aged 50–59 years, from 55.9 to 22.7% among aged 60–69 years and from 70.8 to 31.6% among aged 70–79 years, respectively. However, those for aged ≥80 years were still high: from 78.9 to 64.1%. Therefore, we require carefulness to interpret the findings, particularly for elderly.

ged 40–49 years, from 47.4 to 17.6% among aged 50–59 years, from 55.9 to 22.7% among aged 60–69 years and from 70.8 to 31.6% among aged 70–79 years, respectively. However, those for aged ≥80 years were still high: from 78.9 to 64.1%. Therefore, we require carefulness to interpret the findings, particularly for elderly. In conclusion, we reported recent trends in lung cancer incidence according to histological type. The increase in ADC incidence and the decrease in SQCC and SMCC incidence were confirmed. The trends in lung cancer incidence among young women in 1950s birth-cohorts, particularly for ADC, were not parallel to the smoking prevalence. We need careful monitoring of the trends in lung cancer incidence, particularly for ADC among young women. Funding Funding to pay the Open Access publication charges for this article was provided by ‘The Third-Term Comprehensive 10-Year Strategy for Cancer Control’, Ministry of Health, Labour and Welfare, Japan. Conflict of interest statement None declared. Acknowledgements We would like to thank Dr Akira Oshima, Cancer Patients Information Service, Osaka Medical Center for Cancer and Cardiovascular Disease, and Professor Hiroyasu Iso, Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine for their valuable comments. We also thank the staff at the Osaka Cancer Registry for data collection.

INTRODUCTION Ovarian cancer is the second most common gynecologic malignancy with 20 180 new cases and 15 310 deaths each year in women in the USA (1). The standard treatment for ovarian cancer consists of staging laparotomy, including maximal cytoreductive surgery and adjuvant chemotherapy using taxanes and platinum compounds.As a result of prospective trials by the Gynecologic Oncology Group (GOG) and European–Canadian investigators, paclitaxel and cisplatin became a more effective regimen in 1998 (2). However, carboplatin has been the preferred agent to cisplatin because gastrointestinal and neurological toxicities of carboplatin were appreciably lower than those of cisplatin in some studies, including the GOG protocol 158 (3). The number of cycles of intravenous adjuvant paclitaxel and carboplatin seems to be different according to the International Federation of Gynecology and Obstetrics (FIGO) criteria for ovarian cancer (4). Treatment with these drugs every 3 weeks for 3–6 cycles is recommended in patients with high-grade, high-risk stage I epithelial ovarian cancer. For those with advanced-stage epithelial ovarian cancer, intravenous adjuvant paclitaxel and carboplatin every 3 weeks for 6–8 cycles is recommended (5).

r ovarian cancer (4). Treatment with these drugs every 3 weeks for 3–6 cycles is recommended in patients with high-grade, high-risk stage I epithelial ovarian cancer. For those with advanced-stage epithelial ovarian cancer, intravenous adjuvant paclitaxel and carboplatin every 3 weeks for 6–8 cycles is recommended (5). Although ∼50% of patients with advanced-stage epithelial ovarian cancer achieve a first pathologic complete remission with the first treatment course, 90% of suboptimally debulked patients and 70% of optimally debulked patients relapse in 18–24 months. Improvement of survival should be approached by making primary adjuvant chemotherapy more effective or by applying consolidation therapy to patients with complete response after primary standard treatment (6).

course, 90% of suboptimally debulked patients and 70% of optimally debulked patients relapse in 18–24 months. Improvement of survival should be approached by making primary adjuvant chemotherapy more effective or by applying consolidation therapy to patients with complete response after primary standard treatment (6). Nevertheless, the role of consolidation chemotherapy is controversial in advanced-stage epithelial ovarian cancer patients with complete response after primary standard treatment. Some studies have shown that consolidation chemotherapy improves survival in patients with complete response to paclitaxel- and platinum-based chemotherapy (7,8). On the other hand, consolidation chemotherapy has been reported to be ineffective for patients with complete response and increases the incidence of chemotherapy-induced toxicities, including peripheral neuropathy (9,10). Furthermore, the role of consolidation chemotherapy has not yet been completely clarified because previous studies were performed with various methods of consolidation chemotherapy including different routes of administration (intravenous or intraperitoneal), different regimens of chemotherapy and concurrent radiation therapy. Therefore, this study was designed to evaluate the efficacy of three additional cycles of intravenous chemotherapy using paclitaxel/carboplatin as consolidation chemotherapy in patients with advanced-stage epithelial ovarian cancer who achieved complete response after six cycles of the same chemotherapy.

Nevertheless, the role of consolidation chemotherapy is controversial in advanced-stage epithelial ovarian cancer patients with complete response after primary standard treatment. Some studies have shown that consolidation chemotherapy improves survival in patients with complete response to paclitaxel- and platinum-based chemotherapy (7,8). On the other hand, consolidation chemotherapy has been reported to be ineffective for patients with complete response and increases the incidence of chemotherapy-induced toxicities, including peripheral neuropathy (9,10). Furthermore, the role of consolidation chemotherapy has not yet been completely clarified because previous studies were performed with various methods of consolidation chemotherapy including different routes of administration (intravenous or intraperitoneal), different regimens of chemotherapy and concurrent radiation therapy. Therefore, this study was designed to evaluate the efficacy of three additional cycles of intravenous chemotherapy using paclitaxel/carboplatin as consolidation chemotherapy in patients with advanced-stage epithelial ovarian cancer who achieved complete response after six cycles of the same chemotherapy. MATERIALS AND METHODS Patients All data of patients for this study were derived from a database of 477 patients who were diagnosed with epithelial ovarian cancer after staging laparotomy between January 1997 and March 2007. The inclusion criteria were as follows: patients with a histological confirmation of epithelial ovarian cancer; those who underwent staging laparotomy including maximal cytoreductive surgery; those treated with adjuvant paclitaxel and carboplatin chemotherapy for six or nine cycles; those with complete response after six cycles of paclitaxel and carboplatin chemotherapy; Eastern Co-operative Oncology Group performance states of 0 to 2; and those without any underlying diseases that may have affected survival. The current study was approved by the Institutional Review Board of Seoul National University Hospital. The requirement for informed consent was waived because of the retrospective nature of this study.

cology Group performance states of 0 to 2; and those without any underlying diseases that may have affected survival. The current study was approved by the Institutional Review Board of Seoul National University Hospital. The requirement for informed consent was waived because of the retrospective nature of this study. Patients were required to have adequate bone marrow, hepatic and renal function, defined as white blood cells ≥ 3000/mm3, absolute neutrophil counts ≥ 1500/mm3, platelet counts ≥ 75 000/mm3, hemoglobin levels ≥ 8.0 g/dl, serum bilirubin levels ≤ 1.8 mg/dl, serum transaminase levels ≤ 100 IU/l and serum creatinine levels ≤ 1.5 mg/dl. Optimal and suboptimal debulking surgeries were defined as a residual tumor ≤ 1 cm and >1 cm in maximal diameter, respectively. All patients were classified according to the FIGO criteria for ovarian cancer (4), and histological diagnosis was performed according to the World Health Organization (WHO) classification. All patients were then divided into two groups. Patients were similarly informed of their eligibility to receive three additional cycles of consolidation chemotherapy; patient consent to treatment was included in the medical records. Patients who then received three additional cycles after six cycles of primary adjuvant chemotherapy were included in Group 1, whereas patients treated with only six cycles of adjuvant chemotherapy were included in Group 2.

of consolidation chemotherapy; patient consent to treatment was included in the medical records. Patients who then received three additional cycles after six cycles of primary adjuvant chemotherapy were included in Group 1, whereas patients treated with only six cycles of adjuvant chemotherapy were included in Group 2. Chemotherapy All patients received intravenous adjuvant paclitaxel and carboplatin chemotherapy that started 2–3 weeks after surgery. The chemotherapeutic regimens consisted of paclitaxel (135 mg/m2 for a 24-h infusion period or 175 mg/m2 for a 3-h infusion period) and carboplatin (AUC 4.5 or 5). Chemotherapy was repeated every 3 weeks.

atients received intravenous adjuvant paclitaxel and carboplatin chemotherapy that started 2–3 weeks after surgery. The chemotherapeutic regimens consisted of paclitaxel (135 mg/m2 for a 24-h infusion period or 175 mg/m2 for a 3-h infusion period) and carboplatin (AUC 4.5 or 5). Chemotherapy was repeated every 3 weeks. Evaluation of Response, Definition of Survival and Toxicity Criteria Responses after six cycles of primary adjuvant chemotherapy were evaluated using appropriate imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), and serum CA-125 levels. Serum CA-125 levels were measured within 1 week before staging laparotomy and each cycle of primary adjuvant chemotherapy. They were measured using a radioimmunoassay kit (Fujirebio Diagnostics, Malvern, PA, USA) (11). The upper normal value of serum CA-125 was 37 U/ml. Since second-look laparotomy has been reported to be not associated with improvement in clinical outcomes (3), response to the chemotherapy was defined in relation to the difference between baseline and 4 weeks after the completion of chemotherapy according to the Response Evaluation Criteria in Solid Tumors (RECIST) and serum CA-125 levels (12,13). Therefore, a complete response was defined as the disappearance of all measurable diseases for at least 4 weeks and the normalization of serum CA-125 levels after five cycles of the chemotherapy.

tion of chemotherapy according to the Response Evaluation Criteria in Solid Tumors (RECIST) and serum CA-125 levels (12,13). Therefore, a complete response was defined as the disappearance of all measurable diseases for at least 4 weeks and the normalization of serum CA-125 levels after five cycles of the chemotherapy. Disease-free survival (DFS) was defined as the time that elapsed from the date after the completion of primary adjuvant chemotherapy to the date of clinically proven recurrence. Overall survival (OS) was calculated as the time from the date of staging laparotomy to the date of cancer-related death or the end of study. Hematological toxicities due to chemotherapy were coded according to the National Cancer Common Toxicity Criteria (NCI-CTC), version 2.0 (14). Statistical Analysis Clinical prognostic factors affecting DFS and OS were identified by the use of Cox's proportional hazard analysis. DFS and OS between the two groups were evaluated using the Kaplan–Meier method with the log-rank test. Clinical characteristics and hematological toxicities were analysed using the Student's t-test and chi-square test. Statistical analyses were performed using SPSS software (Version 12.0; SPSS Inc, Chicago, IL, USA). A value of P< 0.05 was considered statistically significant.

Kaplan–Meier method with the log-rank test. Clinical characteristics and hematological toxicities were analysed using the Student's t-test and chi-square test. Statistical analyses were performed using SPSS software (Version 12.0; SPSS Inc, Chicago, IL, USA). A value of P< 0.05 was considered statistically significant. RESULTS Patients Characteristics A total of 94 patients with a median age of 52 years (range, 24–79 years) were enrolled in the current study. Among all patients, 57 were included in Group 1 and 37 in Group 2. Clinicopathologic characteristics of the two groups are summarized in Table 1. Sixty-two (66.0%) patients were in menopause. According to the FIGO criteria for ovarian cancer, two (2.1%) patients were in Stage IIIa, 11 (11.7%) in Stage IIIb, 73 (77.7%) in Stage IIIc and 8 (8.5%) in Stage IV. Tumor grade was G1 in 9 (9.6%), G2 in 17 (18.1%) and G3 in 68 (72.3%) of all patients. Histologically, 77 (81.9%) tumors were diagnosed as serous carcinoma, nine (9.6%) as endometrioid carcinoma, five (5.3%) as clear cell carcinoma, one (1.1%) as undifferentiated carcinoma and two (2.1%) as mixed serous and undifferentiated carcinoma. Table 1. Clinicopathologic characteristics of Groups 1 (nine cycles) and 2 (six cycles)

RESULTS Patients Characteristics A total of 94 patients with a median age of 52 years (range, 24–79 years) were enrolled in the current study. Among all patients, 57 were included in Group 1 and 37 in Group 2. Clinicopathologic characteristics of the two groups are summarized in Table 1. Sixty-two (66.0%) patients were in menopause. According to the FIGO criteria for ovarian cancer, two (2.1%) patients were in Stage IIIa, 11 (11.7%) in Stage IIIb, 73 (77.7%) in Stage IIIc and 8 (8.5%) in Stage IV. Tumor grade was G1 in 9 (9.6%), G2 in 17 (18.1%) and G3 in 68 (72.3%) of all patients. Histologically, 77 (81.9%) tumors were diagnosed as serous carcinoma, nine (9.6%) as endometrioid carcinoma, five (5.3%) as clear cell carcinoma, one (1.1%) as undifferentiated carcinoma and two (2.1%) as mixed serous and undifferentiated carcinoma. Table 1. Clinicopathologic characteristics of Groups 1 (nine cycles) and 2 (six cycles) Characteristics Group 1 (n = 57) Group 2 (n = 37) P value Age (mean ± SD, year) 51.0 ± 9.7 56.3 ± 10.1 0.012 Menopause (n, %) 36 (63.2) 26 (70.3) 0.477 FIGO stage (n, %) 0.078 IIIa–b 5 (8.8) 8 (21.6) IIIc–IV 52 (91.2) 29 (78.4) Grade (n, %) 0.188 1 8 (14.0) 1 (2.7) 2 10 (17.5) 7 (18.9) 3 39 (68.4) 29 (78.4) Pathology (n, %) 0.473 Serous 48 (84.2) 29 (78.4) Non-serous* 9 (15.8) 8 (21.6) Residual tumor (n, %) 0.083 ≤1 cm 25 (43.9) 23 (62.2) >1 cm 32 (56.1) 14 (37.8) Lymph node involvement (n, %) 0.475 Yes 23 (40.4) 8 (21.6) No 15 (26.3) 8 (21.6) Imaging study for the diagnosis of complete response (n, %) 0.598 CT 36 (63.2) 27 (73.0) MRI 5 (8.8) 2 (5.4) PET-CT 16 (28.1) 8 (21.6) Serum CA-125 levels after six cycles of chemotherapy (median with range, U/ml) 8 (5, 37) 7 (5, 36) 0.689 *Non-serous: endometrioid adenocarcinoma (nine cases), clear cell carcinoma (five cases), undifferentiated adenocarcinoma (one case), mixed serous and undifferentiated adenocarcinoma (two cases).

16 (28.1) 8 (21.6) Serum CA-125 levels after six cycles of chemotherapy (median with range, U/ml) 8 (5, 37) 7 (5, 36) 0.689 *Non-serous: endometrioid adenocarcinoma (nine cases), clear cell carcinoma (five cases), undifferentiated adenocarcinoma (one case), mixed serous and undifferentiated adenocarcinoma (two cases). CT, computed tomography; FIGO, International Federation of Gynecology and Obstetrics; MRI, magnetic resonance imaging; PET, position emission tomography; SD, standard deviation. The median value of serum CA-125 levels before surgery and after six cycles of primary adjuvant chemotherapy were 765 U/ml (range, 21–300 000 U/ml) and 8 U/ml (range, 5–37 U/ml), respectively. Pelvic or para-aortic lymph node sampling or dissection was performed on 54 (57.4%) of all patients, and lymph node metastasis was identified in 31 (57.4%). Among all patients, 48 (51.1%) and 46 (48.9%) patients were classified into optimal and suboptimal groups, respectively. CT was performed in 63 (67.0%) patients, MRI in 7 (7.5%) and PET scan in 24 (25.5%) for the diagnosis of complete response. When clinical characteristics between the two groups were compared using the Student's t-test and chi-square test, there was a significant difference only in age (P = 0.012) (Table 1).

spectively. CT was performed in 63 (67.0%) patients, MRI in 7 (7.5%) and PET scan in 24 (25.5%) for the diagnosis of complete response. When clinical characteristics between the two groups were compared using the Student's t-test and chi-square test, there was a significant difference only in age (P = 0.012) (Table 1). Evaluation of Survival and Toxicity The median DFS and OS of all patients was 22 months (range, 1–96 months) and 74 months (range, 6–100 months), respectively. The median DFS in Groups 1 and 2 was 15 and 22 months, respectively (P = 0.703) (Fig. 1). We calculated mean OS in the two groups because Group 2 did not reach median OS. The mean OS in Groups 1 and 2 was 69 and 73 months, respectively (P = 0.891) (Fig. 2). On multivariate Cox's proportional hazard analysis, consolidation chemotherapy was not a prognostic factor for DFS although optimal debulking surgery and lower value of serum CA-125 levels after six cycles of primary adjuvant chemotherapy were independent prognostic factors improving DFS (P < 0.05) (Table 2). However, there was no independent prognostic factor for OS (P > 0.05). Figure 1. Kaplan–Meier analysis with the log-rank test of disease-free survival (DFS) between groups 1 (9 cycles) and 2 (6 cycles) (median DFS: 15 versus 22 months, P = 0.703). Figure 2. Kaplan–Meier analysis with the log-rank test of overall survival (OS) between groups 1 (9 cycles) and 2 (6 cycles) (mean OS: 69 versus 73 months, P = 0.891).

Figure 1. Kaplan–Meier analysis with the log-rank test of disease-free survival (DFS) between groups 1 (9 cycles) and 2 (6 cycles) (median DFS: 15 versus 22 months, P = 0.703). Figure 2. Kaplan–Meier analysis with the log-rank test of overall survival (OS) between groups 1 (9 cycles) and 2 (6 cycles) (mean OS: 69 versus 73 months, P = 0.891). Table 2. Multivariate Cox's proportional hazard analysis for clinical prognostic factors affecting disease-free survival (DFS) of patients with complete response after six cycles of primary adjuvant paclitaxel and carboplatin following staging laparotomy in advanced-stage epithelial ovarian cancer Characteristics Hazard ratio 95% confidence interval P value Age (year) <50 Reference ≥50 1.319 0.538–3.231 0.545 FIGO stage IIIa–b Reference IIIc–IV 0.420 0.063–2.803 0.370 Grade 1 Reference 2 1.706 0.277–10.514 0.565 3 2.691 0.564–12.850 0.214 Histology Serous Reference Non-serous* 2.241 0.577–8.699 0.243 Primary adjuvant chemotherapy (cycles) 6 Reference 9 0.631 0.121–3.292 0.585 Residual tumor (cm) ≤1 Reference >1 6.195 1.631–23.528 0.007 Lymph node involvement No Reference Yes 1.895 0.591–6.074 0.282 Serum CA-125 levels after six cycles of primary adjuvant chemotherapy 1.127 1.045–1.217 0.002 *Non-serous: endometrioid adenocarcinoma (nine cases), clear cell carcinoma (five cases), undifferentiated adenocarcinoma (one case), mixed serous and undifferentiated adenocarcinoma (two cases).

ce Yes 1.895 0.591–6.074 0.282 Serum CA-125 levels after six cycles of primary adjuvant chemotherapy 1.127 1.045–1.217 0.002 *Non-serous: endometrioid adenocarcinoma (nine cases), clear cell carcinoma (five cases), undifferentiated adenocarcinoma (one case), mixed serous and undifferentiated adenocarcinoma (two cases). When chemotherapy-induced hematological toxicities were compared between the two groups, Grade 3 or 4 leukopenia was more common in patients who were treated with consolidation chemotherapy than in those who were not (50.9 versus 21.6%, P = 0.004) (Table 3). Table 3. Chemotherapy-induced hematological toxicities between Groups 1 (nine cycles) and 2 (six cycles)

When chemotherapy-induced hematological toxicities were compared between the two groups, Grade 3 or 4 leukopenia was more common in patients who were treated with consolidation chemotherapy than in those who were not (50.9 versus 21.6%, P = 0.004) (Table 3). Table 3. Chemotherapy-induced hematological toxicities between Groups 1 (nine cycles) and 2 (six cycles) Chemotherapy-induced hematologic toxicity Group 1 (n = 57) Group 2 (n = 37) P value Anemia (n, %) 0.973 Grade 0–2 49 (86.0) 31 (83.8) Grade 3–4 8 (14.0) 6 (16.2) Leukopenia (n, %) 0.004 Grade 0–2 28 (49.1) 29 (79.4) Grade 3–4 29 (50.9) 8 (21.6) Neutropenia (n, %) 0.396 Grade 0–2 8 (14.0) 9 (24.3) Grade 3–4 49 (86.0) 28 (75.7) Thrombocytopenia (n, %) 0.628 Grade 0–2 55 (96.5) 34 (91.9) Grade 3–4 2 (3.5) 3 (8.1) DISCUSSION The aim of the current study was to evaluate the efficacy of three additional cycles as consolidation therapy for advanced-stage epithelial ovarian cancer patients with complete response after six cycles of adjuvant paclitaxel and carboplatin chemotherapy after staging laparotomy. Consolidation chemotherapy using paclitaxel/carboplatin may be inefficient and relatively toxic to advanced-stage epithelial ovarian cancer patients with complete response to six cycles of the same chemotherapy after surgery. The current study included some limitations as follows: first, the recommendation of additional chemotherapy in complete responders' after six cycles of adjuvant paclitaxel/carboplatin chemotherapy was different depending upon the physician because the role of consolidation chemotherapy has been controversial in previous studies. Thus, patients were classified into two groups based upon patient consent to additional consolidation chemotherapy; all patients were similarly informed of their eligibility for additional chemotherapy but classification was based upon the individual patient's decision. Secondly, the number of serous-type epithelial ovarian cancer is relatively higher than that suggested in a previous report (52.4%) although serous type is known to be the most frequent in epithelial ovarian cancer (15). Thirdly, different imaging studies (CT, MRI or PET) were used for the evaluation of complete response. However, there was no significant difference in the distribution of selected types of imaging studies, and survival was not affected by the type of imaging studies between the two groups (P > 0.05), which minimized the bias in the current study.

tudies (CT, MRI or PET) were used for the evaluation of complete response. However, there was no significant difference in the distribution of selected types of imaging studies, and survival was not affected by the type of imaging studies between the two groups (P > 0.05), which minimized the bias in the current study. The reason why consolidation chemotherapy has been important for the management of epithelial ovarian cancer is that most clinicians expect that extending treatment beyond the standard six cycles of chemotherapy can improve survival in epithelial ovarian cancer. Thus, various methods have been developed, which consist of different regimens using paclitaxel or platinum agents (8,16,17), second-line chemotherapy (18,19), intraperitoneal chemotherapy (20,21), high-dose chemotherapy with hematopoietic support (22) and whole abdominal radiotherapy (23).

n epithelial ovarian cancer. Thus, various methods have been developed, which consist of different regimens using paclitaxel or platinum agents (8,16,17), second-line chemotherapy (18,19), intraperitoneal chemotherapy (20,21), high-dose chemotherapy with hematopoietic support (22) and whole abdominal radiotherapy (23). Nevertheless, no randomized trial with regard to consolidation chemotherapy has provided a statistically significant improvement in OS although a small number of phase II studies have suggested improved outcomes (24,25). The only randomized trial with the evidence of clinical benefit was reported by the Southwest Oncology Group/GOG study of ovarian cancer patients receiving 3 versus 12 additional cycles of intravenous paclitaxel following a complete response to platinum and paclitaxel chemotherapy. The study showed a progression-free survival (PFS) advantage of 28 versus 21 months in favor of the 12-cycle arm (hazard ratio = 2.31; 95% confidence interval = 1.08–4.94; P = 0.005). Although survival data were not available because of its early termination by the data safety monitoring committee, there was no difference in OS between the treatment arms as of the date of study closure (17).

21 months in favor of the 12-cycle arm (hazard ratio = 2.31; 95% confidence interval = 1.08–4.94; P = 0.005). Although survival data were not available because of its early termination by the data safety monitoring committee, there was no difference in OS between the treatment arms as of the date of study closure (17). The current study demonstrated that consolidation chemotherapy using three additional cycles comprised the best regimen (intravenous paclitaxel and carboplatin), as primary adjuvant chemotherapy did not improve DFS and OS in patients with advanced-stage epithelial ovarian cancer, but who achieved complete response after six cycles of the same regimen, supporting the results of previous reports with regard to the uselessness of consolidation chemotherapy. In a similar study, three cycle consolidation chemotherapy with paclitaxel and platinum-based chemotherapy did not provide a favorable outcome in epithelial ovarian cancer patients with complete response (26).

imen, supporting the results of previous reports with regard to the uselessness of consolidation chemotherapy. In a similar study, three cycle consolidation chemotherapy with paclitaxel and platinum-based chemotherapy did not provide a favorable outcome in epithelial ovarian cancer patients with complete response (26). Moreover, consolidation chemotherapy may increase toxicities in patients with complete response after primary standard therapy. Consolidation chemotherapy using weekly paclitaxel increased the risk for the development of severe peripheral neuropathy when it was administered for 3–12 cycles (9). Three additional cycles of paclitaxel- and platinum-based chemotherapy increased Grade 3 or 4 toxicities in patients with complete response after primary treatment although it was statistically insignificant (26). In the current study, there was a significant increase of Grade 3 or 4 leukopenia in patients who underwent consolidation chemotherapy (P = 0.004). In conclusion, prolonged use of the preferred chemotherapeutic regimen using paclitaxel and carboplatin may not improve survival in patients with advanced-stage epithelial ovarian cancer who achieved complete response after six cycles of the same chemotherapy, and may increase hematological toxicities, such as Grade 3 or 4 leukopenia. Funding Funding to pay the Open Access publication charges for this article was provided by the corresponding author, Dr Noh-Hyun Park. Conflict of interest statement None declared.

INTRODUCTION Approximately 8000 cases of ovarian cancer are newly diagnosed in Japan and more than 4000 women die of this disease (1). From an embryologic perspective, epithelial ovarian carcinoma, primary carcinoma of fallopian tube and peritoneal carcinoma are generally recognized as a similar disease group, which is known as Müllerian carcinoma. In patients with primary carcinoma of the fallopian tube and peritoneal carcinoma, the experience with chemotherapeutic agents is largely limited to case reports and small studies due to the rarity of disease type (2,3). However, the overall experience closely parallels that of ovarian cancer, so treatment of primary carcinoma of the fallopian tube and peritoneal carcinoma is conducted according to that of ovarian cancer (2,3). Advanced epithelial ovarian cancer is a highly chemosensitive solid tumour with response rates to first-line chemotherapy of ∼80%. The majority of patients, however, eventually relapse and treatment with second-line agents becomes necessary. Furthermore, patients with recurrent ovarian cancer ultimately die of chemoresistant disease. Therefore, it is very important to recognize recurrent ovarian cancer therapy as palliative therapy and therapeutic agents are required to show efficacy as well as favourable toxicity profile. However, there are not many drugs approved in Japan for ovarian carcinoma, or recommended by the Japanese clinical practice guideline for as second-line treatment except platinum, taxane and irinotecan.

py as palliative therapy and therapeutic agents are required to show efficacy as well as favourable toxicity profile. However, there are not many drugs approved in Japan for ovarian carcinoma, or recommended by the Japanese clinical practice guideline for as second-line treatment except platinum, taxane and irinotecan. Pegylated liposomal doxorubicin (PLD) is a formulation of doxorubicin hydrochloride encapsulated in long circulating STEALTH® liposomes and formulated for intravenous administration. STEALTH® liposomes have liquid membranes coated with polyethylene glycol, which attracts water and renders resistance to mononuclear phagocytosis (4). The liposome's small diameter (∼100 nm) and their persistence in the circulation allow their penetration into altered and often compromised, leaky tumour vasculature with entry into the interstitial space in malignant tissues (5). Therefore, pegylated liposomes are suitable for prolonged delivery of doxorubicin and have a prolonged circulation time (6,7). At these tumour sites, the accumulating liposomes gradually break down, releasing doxorubicin to the surrounding tumour cells (8,9). PLD has been designed to enhance the efficacy and to reduce the toxicities of doxorubicin such as myelosuppression, alopecia and cardiotoxicity by altering the plasma pharmacokinetics and tissue distribution of the drug.

lating liposomes gradually break down, releasing doxorubicin to the surrounding tumour cells (8,9). PLD has been designed to enhance the efficacy and to reduce the toxicities of doxorubicin such as myelosuppression, alopecia and cardiotoxicity by altering the plasma pharmacokinetics and tissue distribution of the drug. Based on the data from the Phases II and III clinical trials in Europe and the USA, it is evident that PLD possesses promising activity and a favourable toxicity profile in the second-line treatment of ovarian cancer (10–15). Currently, PLD is provided as one of the standard treatment options in recurrent ovarian cancer treatment guidelines (16–18). The result of the Phase I clinical trial in Japan was reported (19). In that study, recommended PLD dose was evaluated in 15 Japanese patients with solid tumours and resulted in 50 mg/m2 every 4 weeks. In addition, one partial response (PR) and one normalization of CA125 were observed among six ovarian cancer patients enrolled in that study, and further trials with Japanese ovarian cancer patients were encouraged. Based on the result from a Phase I clinical trial in Japan, we conducted the Phase II clinical trial of PLD in patients with recurrent or relapsed Müllerian carcinoma (epithelial ovarian carcinoma, primary carcinoma of fallopian tube, peritoneal carcinoma) having a therapeutic history of platinum-based chemotherapy.

The result of the Phase I clinical trial in Japan was reported (19). In that study, recommended PLD dose was evaluated in 15 Japanese patients with solid tumours and resulted in 50 mg/m2 every 4 weeks. In addition, one partial response (PR) and one normalization of CA125 were observed among six ovarian cancer patients enrolled in that study, and further trials with Japanese ovarian cancer patients were encouraged. Based on the result from a Phase I clinical trial in Japan, we conducted the Phase II clinical trial of PLD in patients with recurrent or relapsed Müllerian carcinoma (epithelial ovarian carcinoma, primary carcinoma of fallopian tube, peritoneal carcinoma) having a therapeutic history of platinum-based chemotherapy. We conducted a multicentre, non-randomized, open-label study to evaluate efficacy and safety of a PLD 50 mg/m2 every 4-week regimen in Japanese patients with Müllerian carcinoma who had previously been treated with platinum-based chemotherapy.

Based on the result from a Phase I clinical trial in Japan, we conducted the Phase II clinical trial of PLD in patients with recurrent or relapsed Müllerian carcinoma (epithelial ovarian carcinoma, primary carcinoma of fallopian tube, peritoneal carcinoma) having a therapeutic history of platinum-based chemotherapy. We conducted a multicentre, non-randomized, open-label study to evaluate efficacy and safety of a PLD 50 mg/m2 every 4-week regimen in Japanese patients with Müllerian carcinoma who had previously been treated with platinum-based chemotherapy. PATIENT AND METHODS Study Design This study was a multicentre non-randomized, open-label trial to evaluate efficacy and safety of PLD in Japanese patients with Müllerian carcinoma previously treated with platinum-based chemotherapy. The primary endpoint was the best overall response (response rate) and secondary endpoints included adverse events and adverse drug reactions (incidence, severity, seriousness and causality), time to response and duration of response. The final evaluation of the antitumour effect was performed by the independent radiological review committee. The study protocol was approved by the institutional review board at each site. This study was conducted based on ethical principles in the Declaration of Helsinki and in compliance with Good Clinical Practice.

The final evaluation of the antitumour effect was performed by the independent radiological review committee. The study protocol was approved by the institutional review board at each site. This study was conducted based on ethical principles in the Declaration of Helsinki and in compliance with Good Clinical Practice. Patients This study included patients who met all the following inclusion criteria: (i) having histological confirmation of Müllerian carcinoma (epithelial ovarian carcinoma, primary fallopian tube carcinoma and peritoneal carcinoma); (ii) receiving first-line platinum-based chemotherapy and who would receive PLD as a second-line therapy if time to progression was within 12 months from the date of final administration of platinum therapy, excluding patients whose best response to first-line platinum-based chemotherapy was progressive disease (PD), or who received PLD as a third-line therapy; (iii) receiving 1 or 2 regimens with prior chemotherapy; (iv) having measurable lesions that conformed to the Response Evaluation Criteria in Solid Tumours (RECIST) criteria; (v) ECOG performance status (PS) grade of 0–2; (vi) adequate functions of principal organs, defined by white blood cell (WBC) counts 3.0 × 103–12.0 × 103/mm3, neutrophil counts not less than 1.5 × 103/mm3, haemoglobin not less than 9.0 g/dl, platelet count not less than 10.0 × 104/mm3, serum AST, ALT and AP not more than 2.5 times the institutional upper limit of normal, total bilirubin not more than the institutional upper limit of normal, serum creatinine not more than 1.5 times the institutional upper limit of normal, left ventricular ejection fraction (LVEF) not less than 50%, electrocardiography (ECG) normal or minor change without symptoms that required any therapeutic intervention, and no evidence of cardiac disorder or Class I in New York Heart Association (NYHA) functional classification; (vii) no colony stimulating factor (CSF) agent or blood transfusion received within 2 weeks before the date of blood tests for screening; (viii) no previous treatment with hormonal agents, oral antimetabolic or immunotherapeutic agents for at least 2 weeks, with nitrosourea or mitomycin C at least 6 weeks, or with surgical therapy, radiation therapy or other chemotherapy for 4 weeks or more; (ix) abilities to stay in hospital for 4 consecutive weeks from the initial administration of PLD; (x) survival expectancy 3 months or longer; (xi) 20–79 of age years at enrolment in the trial; and (xii) received an explan

t 6 weeks, or with surgical therapy, radiation therapy or other chemotherapy for 4 weeks or more; (ix) abilities to stay in hospital for 4 consecutive weeks from the initial administration of PLD; (x) survival expectancy 3 months or longer; (xi) 20–79 of age years at enrolment in the trial; and (xii) received an explan ation of this trial from the physicians with written informed consent forms and other relevant information and freely provided informed consent before the trial. Patients who met any of the following exclusion criteria were excluded from the trial: (i) requiring drainage of pericardial fluid; (ii) having experienced myocardial infarction or angina attack within 90 days before the start of trial; (iii) receiving prior therapy with anthracycline (total anthracycline dose of more than 250 mg/m2 as doxorubicin); and (iv) having known hypersensitivity to doxorubicin or any component of PLD. Medication PLD was intravenously administered to each subject at a dose of 50 mg/m2 as doxorubicin hydrochloride on Day 1 of each cycle, followed by a treatment-free interval of 28 days including Day 1. This was repeated for at least two cycles if the subject did not meet the withdrawal criteria. PLD was administered at a rate of 1.0 mg/min from the start of infusion to completion, using an infusion pump in consideration of risks of development of infusion-related reactions. PLD was used by diluting with 250 ml of 5% glucose injection for a dose of less than 90 mg as doxorubicin hydrochloride or with 500 ml for a dose of 90 mg or more as doxorubicin hydrochloride.

start of infusion to completion, using an infusion pump in consideration of risks of development of infusion-related reactions. PLD was used by diluting with 250 ml of 5% glucose injection for a dose of less than 90 mg as doxorubicin hydrochloride or with 500 ml for a dose of 90 mg or more as doxorubicin hydrochloride. After administration, PLD would be discontinued in subjects who met any of the following withdrawal criteria: (i) desiring to discontinue the study treatment or withdrawing consent; (ii) having LVEF decreased to less than 45% after administration of PLD or decreased by 20% or more than baseline; (iii) having no possibility for a subsequent cycle to be started within 6 weeks from the planned injection date because of adverse reactions or after 8 weeks for hand-foot syndrome (HFS) or stomatitis; (iv) having bilirubin increased to 3.0 mg/dl or more; (v) requiring a repeated reduction in the dose; (vi) the anticipated total dose of anthracycline antibiotics including PLD would exceed 500 mg/m2 as doxorubicin hydrochloride (including doses from prior chemotherapy and pre/postoperative treatment); (vii) being judged by the physician to have difficulties continuing the trial due to serious (or significant) adverse events; (viii) being assessed to have difficulty continuing the trial due to concurrent illnesses (e.g. complications); (ix) having obvious progression of the underlying disease or development of new lesions (PD); (x) having any of the exclusion criteria which was discovered after enrolment; and (xi) being judged as unfavourable to continue the trial by the physician.

ontinuing the trial due to concurrent illnesses (e.g. complications); (ix) having obvious progression of the underlying disease or development of new lesions (PD); (x) having any of the exclusion criteria which was discovered after enrolment; and (xi) being judged as unfavourable to continue the trial by the physician. Prior to administration of the study drug in the next cycle, all the subjects were confirmed to meet all the following criteria: (i) HFS or stomatitis ≤Grade 1; (ii) neutrophil counts ≥1.5 × 103/mm3; (iii) WBC counts ≥3.0 × 103/mm3; (iv) platelet counts ≥7.5 × 104/mm3; (v) bilirubin ≤1.5 mg/dl; and (vi) other adverse drug reactions ≤ Grade 2 (excluding fatigue, nausea, vomiting, anorexia, hypokalemia, hyponatremia and lymphopenia). If any of these criteria was not met, the scheduled administration of the study drug for the next cycle would be delayed for 2 weeks at the maximum. If any of the above criteria was still not met after a 2-week delay from the scheduled initial date of each cycle, the trial for the subjects would be discontinued. In case Grade 2 HFS or stomatitis was observed at 6 weeks from the initial date of each cycle, the scheduled administration of the test drug for the next cycle would be delayed for 2 weeks. As a result, when the subjects met all the above criteria, the next cycle would be started. Even if the subjects met all the criteria, the scheduled initial date could be delayed for a maximum of 2 weeks at the investigator's discretion.

d administration of the test drug for the next cycle would be delayed for 2 weeks. As a result, when the subjects met all the above criteria, the next cycle would be started. Even if the subjects met all the criteria, the scheduled initial date could be delayed for a maximum of 2 weeks at the investigator's discretion. As the subjects met any of the following dose reduction criteria, the previous dose would be reduced by 25% (37.5 mg/m2) for the next cycle: (i) HFS or stomatitis ≥ Grade 3; (ii) neutrophil count <500/mm3 or WBC count <1000/mm3 that was maintained for at least 7 days; (iii) neutrophil counts <1000/mm3 with 38.0°C or higher fever; (iv) platelet reduction <2.5 × 104/mm3; (v) other adverse drug reactions ≥ Grade 3 (excluding fatigue, nausea, vomiting, anorexia, hypokalemia, hyponatremia, lymphopenia and other adverse events associated with infusion-related reactions); and (vi) the physician judged that the dose should be decreased. Dose reduction was permitted only once, and it was prohibited to increase the dose after the dose was reduced. If a further dose reduction was required after the dose was reduced, the trial for the subject would be discontinued. Administration of CSF was admitted when patients met any of the following criteria: (i) neutrophil counts <1000/mm3 with fever (≥38°C); (ii) neutrophil counts <500/mm3; (iii) experience of either (i) or (ii) in the prior cycle and neutrophil counts <1000/mm3 in the following cycle.

As the subjects met any of the following dose reduction criteria, the previous dose would be reduced by 25% (37.5 mg/m2) for the next cycle: (i) HFS or stomatitis ≥ Grade 3; (ii) neutrophil count <500/mm3 or WBC count <1000/mm3 that was maintained for at least 7 days; (iii) neutrophil counts <1000/mm3 with 38.0°C or higher fever; (iv) platelet reduction <2.5 × 104/mm3; (v) other adverse drug reactions ≥ Grade 3 (excluding fatigue, nausea, vomiting, anorexia, hypokalemia, hyponatremia, lymphopenia and other adverse events associated with infusion-related reactions); and (vi) the physician judged that the dose should be decreased. Dose reduction was permitted only once, and it was prohibited to increase the dose after the dose was reduced. If a further dose reduction was required after the dose was reduced, the trial for the subject would be discontinued. Administration of CSF was admitted when patients met any of the following criteria: (i) neutrophil counts <1000/mm3 with fever (≥38°C); (ii) neutrophil counts <500/mm3; (iii) experience of either (i) or (ii) in the prior cycle and neutrophil counts <1000/mm3 in the following cycle. Evaluation of Response and Safety Tumour response evaluation was performed according to the RECIST guidelines. Confirmed duration of stable disease (SD) was defined as the duration of 8 consecutive weeks or longer after the start of administration. Severity of adverse events was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) Version 3.0.

Evaluation of Response and Safety Tumour response evaluation was performed according to the RECIST guidelines. Confirmed duration of stable disease (SD) was defined as the duration of 8 consecutive weeks or longer after the start of administration. Severity of adverse events was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) Version 3.0. Sample Size and Statistical Analysis Among the subjects enrolled in this trial, those who received platinum-based chemotherapy as the first-line chemotherapy and experienced disease progression between 6 and 12 months after the completion of the platinum regimen were classified as the platinum-sensitive group, and those who had progression during the first-line chemotherapy, received platinum-based chemotherapy as the first-line chemotherapy and experienced progression less than 6 months after the completion of the platinum regimen, or who would receive PLD as a third-line therapy were classified as the platinum-resistant group. A sample size to produce the expected response rate of 30 and 15% for the platinum-sensitive and platinum-resistant groups, respectively, with the threshold response rate of 5%, a significance level of 5% and power of 80% was determined to be 80 patients in total (20 and 60 patients for the platinum-sensitive and platinum-resistant groups, respectively).

d response rate of 30 and 15% for the platinum-sensitive and platinum-resistant groups, respectively, with the threshold response rate of 5%, a significance level of 5% and power of 80% was determined to be 80 patients in total (20 and 60 patients for the platinum-sensitive and platinum-resistant groups, respectively). For the response evaluation, statistical analysis was performed based on the evaluation for the full analysis set (FAS) by the independent radiological review committee. The primary endpoint was the response rate, the proportion of patients with complete response (CR) or PR in the response analysis set, and the point estimate and two-sided 95% confidence interval (CI) were calculated. The secondary endpoints included the duration of overall response, time to response and time to progression, and the progression-free survival was analysed using the Kaplan–Meier method, and descriptive statistics (median, minimum and maximum) were calculated. The safety of PLD was evaluated for all the subjects treated with PLD. Statistical analyses were performed using the SAS System for Windows release 8.02.

o progression, and the progression-free survival was analysed using the Kaplan–Meier method, and descriptive statistics (median, minimum and maximum) were calculated. The safety of PLD was evaluated for all the subjects treated with PLD. Statistical analyses were performed using the SAS System for Windows release 8.02. RESULT Demographics and baseline characteristics of patients are shown in Table 1. Seventy-four patients were enrolled into the trial between January and December 2005, and 73 patients (11 for the platinum-sensitive group and 62 for the platinum-resistant group), excluding one patient who was confirmed to be ineligible after enrolment, were eligible for the trial, and defined as the FAS. All 74 patients who received PLD were defined as the safety analysis set. Although the targeted number of patients for the platinum-sensitive group was 20, only 11 patients were enrolled. That was because the study was closed at the end of 2005 when the patient enrolment in the platinum-resistant group reached the target number due to slow enrolment. Table 1. Demographics and baseline characteristics of patients

RESULT Demographics and baseline characteristics of patients are shown in Table 1. Seventy-four patients were enrolled into the trial between January and December 2005, and 73 patients (11 for the platinum-sensitive group and 62 for the platinum-resistant group), excluding one patient who was confirmed to be ineligible after enrolment, were eligible for the trial, and defined as the FAS. All 74 patients who received PLD were defined as the safety analysis set. Although the targeted number of patients for the platinum-sensitive group was 20, only 11 patients were enrolled. That was because the study was closed at the end of 2005 when the patient enrolment in the platinum-resistant group reached the target number due to slow enrolment. Table 1. Demographics and baseline characteristics of patients Characteristics Total (n = 74) Platinum sensitive (n = 11) Platinum resistant (n = 63) Age, years Median (range) 57.0 (32–76) 55.0 (40–72) 58.0 (32–76) Primary cancer (%) Epithelial ovarian carcinoma 62 (83.8) 11 (100.0) 51 (81.0) Peritoneal carcinoma 12 (16.2) 0 (0.0) 12 (19.0) Tumour histology (%) Serous 49 (66.2) 6 (54.5) 43 (68.3) Endometrioid 8 (10.8) 3 (27.3) 5 (7.9) Clear cell 8 (10.8) 1 (9.1) 7 (11.1) Mucinous 1 (1.4) 0 (0.0) 1 (1.6) Other 8 (10.8) 1 (9.1) 7 (11.1) Initial FIGO stage (%) I 7 (9.5) 1 (9.1) 6 (9.5) II 1 (1.4) 1 (9.1) 0 (0.0) III 50 (67.6) 6 (54.5) 44 (69.8) IV 16 (21.6) 3 (27.3) 13 (20.6) Previous chemotherapy (%) 1 regimen 23 (31.1) 11 (100.0) 12 (19.0) 2 regimen 50 (67.6) 0 (0.0) 50 (79.4) 3 regimen 1 (1.4) 0 (0.0) 1 (1.6) Previous chemotherapy with antracycline (%) Yes 3 (4.1) 0 (0.0) 3 (4.8) No 71 (95.9) 11 (100.0) 60 (95.2) Platinum-free interval (days) Median (range) 263 (28–2792) 315 (216–441) 235 (28–2792) CA-125 at baseline (U/ml) Median (range) 243.6 (5.8–7809.8) 192.1 (22.2–808.0) 261.0 (5.8–7809.8) FIGO, Federation Internationale de Gynecologie et d'Obstetrique.

line (%) Yes 3 (4.1) 0 (0.0) 3 (4.8) No 71 (95.9) 11 (100.0) 60 (95.2) Platinum-free interval (days) Median (range) 263 (28–2792) 315 (216–441) 235 (28–2792) CA-125 at baseline (U/ml) Median (range) 243.6 (5.8–7809.8) 192.1 (22.2–808.0) 261.0 (5.8–7809.8) FIGO, Federation Internationale de Gynecologie et d'Obstetrique. The median of patients' age was 57.0 years (range, 32–76). Among 74 patients enrolled, 62 had epithelial ovarian carcinoma and 12 had peritoneal carcinoma. Histological, 49 patients had serous carcinoma, eight had endometrioid carcinoma, eight had clear cell carcinoma, one had mucinous carcinoma and eight had other types of carcinoma. All 74 patients had received first-line chemotherapy including platinum regimen, 70 (94.6%) had also received taxanes as the first-line chemotherapy, and only three had received anthracycline in the prior chemotherapy. A total of 334 cycles of PLD was administered to 74 patients, and the median number of cycles administered was 4.0 (range, 1–10 cycles). Administration of PLD was completed or discontinued in all 74 patients before statistical analysis. The dose of PLD was reduced to 37.5 mg/m2 in 26 of 74 patients (35.1%). The scheduled administration of PLD was delayed in 49 of 74 patients (66.2%) and in 154 of 334 cycles (46.1%).

istered was 4.0 (range, 1–10 cycles). Administration of PLD was completed or discontinued in all 74 patients before statistical analysis. The dose of PLD was reduced to 37.5 mg/m2 in 26 of 74 patients (35.1%). The scheduled administration of PLD was delayed in 49 of 74 patients (66.2%) and in 154 of 334 cycles (46.1%). Response The antitumour effect (best overall response) and response rate are shown in Table 2. The best overall response in 73 patients of FAS was CR in two patients, PR in 14, SD in 28, PD in 27 and not evaluable (NE) in two patients. The response rate was 21.9% (16 of 73) (95% CI: 13.1–33.1%). The response rate (two-sided 95% CI) by patient group was 27.3% (3 of 11) (95% CI: 6.0–61.0%) in the platinum-sensitive group and 21.0% (13 of 62) (95% CI: 11.7–33.2%) in the platinum-resistant group. The proportion of patients with CR, PR or SD was 60.3% (44 of 73) in FAS, and 54.5% (6 of 11) in the platinum-sensitive group and 61.3% (38 of 62) in the platinum-resistant group. Table 2. Response rate Total Platinum sensitive Platinum resistant Number of patients 73 11 62 Best overall response: n (%) CR 2 (2.7) 0 (0.0) 2 (3.2) PR 14 (19.2) 3 (27.3) 11 (17.7) SD 28 (38.4) 3 (27.3) 25 (40.3) PD 27 (37.0) 4 (36.4) 23 (37.1) NE 2 (2.7) 1 (9.1) 1 (1.6) Response rate n (%) (95% CI) 16 (21.9) (13.1–33.1) 3 (27.3) (6.0–61.0) 13 (21.0) (11.7–33.2) CR, complete response; PR, partial response; SD, stable disease; PD, progression disease; NE, not evaluable; 95% CI, confidence interval.

D 28 (38.4) 3 (27.3) 25 (40.3) PD 27 (37.0) 4 (36.4) 23 (37.1) NE 2 (2.7) 1 (9.1) 1 (1.6) Response rate n (%) (95% CI) 16 (21.9) (13.1–33.1) 3 (27.3) (6.0–61.0) 13 (21.0) (11.7–33.2) CR, complete response; PR, partial response; SD, stable disease; PD, progression disease; NE, not evaluable; 95% CI, confidence interval. The results from subgroup analysis sets by platinum-free interval were as follows. In a subgroup analysis set where patients received PLD as a second-line therapy, the response rate by platinum-free intervals was 8.3% (1 of 12) and 27.3% (3 of 11) in patients with the platinum-free interval of within 6 months and of 6–12 months, respectively. In another subgroup analysis set where patients received PLD as a third-line therapy, the response rate was 7.1% (1 of 14), 15.4% (2 of 13) and 36.8% (7 of 19) in patients with the platinum-free interval of within 6 months, of 6–12 months and more than 12 months, respectively. The response rate by histological type was 29.2% (14 of 48) and 25.0% (2 of 8) in patients with serous carcinoma and with endometrioid carcinoma, respectively. In patients with clear cell carcinoma, SD was observed in two of eight patients, and the time to progression in the two patients was 350+ and 87+ days, respectively. In patients with mucinous carcinoma, SD was observed in one of one patient and the time to progression was 135+ days. The median and range of the duration of response, time to response and time to progression are shown in Table 3. Table 3. Time to response, duration of response and time to progression

The response rate by histological type was 29.2% (14 of 48) and 25.0% (2 of 8) in patients with serous carcinoma and with endometrioid carcinoma, respectively. In patients with clear cell carcinoma, SD was observed in two of eight patients, and the time to progression in the two patients was 350+ and 87+ days, respectively. In patients with mucinous carcinoma, SD was observed in one of one patient and the time to progression was 135+ days. The median and range of the duration of response, time to response and time to progression are shown in Table 3. Table 3. Time to response, duration of response and time to progression Total Platinum sensitive Platinum resistant Number of patients 73 11 62 Time to response (day) Patient (%)a 16 (21.9) 3 (27.3) 13 (21.0) Median (range) 54.0 (20–162) 56.0 (54–59) 52.0 (20–162) Duration of response (day) Patient (%)a 16 (21.9) 3 (27.3) 13 (21.0) Median (range) 149.0 (56–309) − (92–159) 149.0 (56–309) Withdrawal (%) 11 (68.8) 2 (66.7) 9 (69.2) Time to progression (day) Patient (%)b 71 (97.3) 10 (90.9) 61 (98.4) Median (range) 166.0 (14–358) 159.0 (16–217) 168.0 (14–358) Withdrawal (%) 30 (42.3) 4 (40.0) 26 (42.6) aResponder only. bExcluded two patients due to unable calculation for time to progression. The median time to response (CR or PR) was 54.0 days. The median time to response was 56.0 days in the platinum-sensitive group and 52.0 days in the platinum-resistant group.

Total Platinum sensitive Platinum resistant Number of patients 73 11 62 Time to response (day) Patient (%)a 16 (21.9) 3 (27.3) 13 (21.0) Median (range) 54.0 (20–162) 56.0 (54–59) 52.0 (20–162) Duration of response (day) Patient (%)a 16 (21.9) 3 (27.3) 13 (21.0) Median (range) 149.0 (56–309) − (92–159) 149.0 (56–309) Withdrawal (%) 11 (68.8) 2 (66.7) 9 (69.2) Time to progression (day) Patient (%)b 71 (97.3) 10 (90.9) 61 (98.4) Median (range) 166.0 (14–358) 159.0 (16–217) 168.0 (14–358) Withdrawal (%) 30 (42.3) 4 (40.0) 26 (42.6) aResponder only. bExcluded two patients due to unable calculation for time to progression. The median time to response (CR or PR) was 54.0 days. The median time to response was 56.0 days in the platinum-sensitive group and 52.0 days in the platinum-resistant group. The median duration of overall response was 149.0 days. The median duration of overall response in the platinum-resistant group was 149.0 days, however, that in the platinum-sensitive group could not be calculated. The Kaplan–Meier curve for time to progression is shown in Fig. 1. The median time to progression was 166.0 days: 159.0 days in the platinum-sensitive group and 168.0 days in the platinum-resistant group. The median survival could not be calculated. Figure 1. Kaplan–Meier estimates of time to progression. Safety Adverse drug reactions were reported from all 74 patients treated with PLD. The major adverse drug reactions observed in the study are shown in Table 4. Table 4. Grades 3 and 4 adverse drug reactions

The median duration of overall response was 149.0 days. The median duration of overall response in the platinum-resistant group was 149.0 days, however, that in the platinum-sensitive group could not be calculated. The Kaplan–Meier curve for time to progression is shown in Fig. 1. The median time to progression was 166.0 days: 159.0 days in the platinum-sensitive group and 168.0 days in the platinum-resistant group. The median survival could not be calculated. Figure 1. Kaplan–Meier estimates of time to progression. Safety Adverse drug reactions were reported from all 74 patients treated with PLD. The major adverse drug reactions observed in the study are shown in Table 4. Table 4. Grades 3 and 4 adverse drug reactions Adverse Reaction (MedDRA/J Ver9.0) Number of patients (n = 74) Grade 1 (%) Grade 2 (%) Grade 3 (%) Grade 4 (%) Neutropenia 8 (10.8) 11 (14.9) 23 (31.1) 27 (36.5) Lymphocytopenia 15 (20.3) 16 (21.6) 29 (39.2) 6 (8.1) Leukopenia 5 (6.8) 20 (27.0) 39 (52.7) 5 (6.8) Haemoglobin decreased 23 (31.1) 27 (36.5) 11 (14.9) 2 (2.7) Thrombocytopenia 27 (36.5) 13 (17.6) 4 (5.4) 1 (1.4) Deep vein thrombosis 0 (0) 0 (0) 0 (0) 1 (1.4) Hand-foot syndrome 20 (27.0) 26 (35.1) 12 (16.2) 0 (0) Stomatitis 29 (39.2) 22 (29.7) 6 (8.1) 0 (0) Erythropenia 42 (56.8) 11 (14.9) 3 (4.1) 0 (0) Nausea 37 (50.0) 6 (8.1) 2 (2.7) 0 (0) ALT (GPT) increased 16 (21.6) 1 (1.4) 2 (2.7) 0 (0) Blood potassium decreased 10 (13.5) 0 (0) 2 (2.7) 0 (0) Febrile neutropenia 0 (0) 0 (0) 2 (2.7) 0 (0) Rash 17 (23.0) 19 (25.7) 1 (1.4) 0 (0) Fatigue 28 (37.8) 5 (6.8) 1 (1.4) 0 (0) Vomiting 11 (14.9) 5 (6.8) 1 (1.4) 0 (0) γ-GTP increased 13 (17.6) 4 (5.4) 1 (1.4) 0 (0) Diarrhoea 12 (16.2) 4 (5.4) 1 (1.4) 0 (0) AST (GOT) increased 18 (24.3) 2 (2.7) 1 (1.4) 0 (0) Upper respiratory tract infection 0 (0) 2 (2.7) 1 (1.4) 0 (0) Blood sodium decreased 15 (20.3) 0 (0) 1 (1.4) 0 (0) Small intestinal obstruction 0 (0) 0 (0) 1 (1.4) 0 (0) Herpes zoster 0 (0) 0 (0) 1 (1.4) 0 (0) Infection 0 (0) 0 (0) 1 (1.4) 0 (0) Glucose tolerance impaired 0 (0) 0 (0) 1 (1.4) 0 (0) The most common Grade 3 or 4 adverse reactions were due to haematological toxicity: neutropenia in 50 patients (67.6%), leukopenia in 44 (52.7%), lymphopenia in 35 (47.3%), decreased haemoglobin in 13 (17.6%), thrombocytopenia in five (6.8%) and erythropenia in three patients (4.1%). The median time to nadir for neutrophils, WBCs, haemoglobin and platelets from the start of administration in the first cycle was 21.0 days, 21.0, 15.0 and 22.0 days, respectively. The median time to recovery to the level at which the administration of PLD in the next cycle was permitted was 7.0–8.0 days for any haematological event.

to nadir for neutrophils, WBCs, haemoglobin and platelets from the start of administration in the first cycle was 21.0 days, 21.0, 15.0 and 22.0 days, respectively. The median time to recovery to the level at which the administration of PLD in the next cycle was permitted was 7.0–8.0 days for any haematological event. Grade 3 or 4 adverse drug reactions due to non-haematological toxicity included: HFS in 12 patients (16.2%), stomatitis in six (8.1%), febrile neutropenia, nausea, ALT (GPT) increased and blood potassium decreased in two each (2.7%) and deep venous thrombosis rash, herpes zoster, infection, upper respiratory tract infection, impaired glucose tolerance, diarrhoea, small intestinal obstruction, vomiting, fatigue, AST (GOT) increased, decreased blood sodium and increased γ-GTP in one each (1.4%). Only deep venous thrombosis was Grade 4. The median time to occurrence of HFS, rash and stomatitis from the start of administration was 34.0 days (2.0 cycles), 33.0 days (2.0 cycles) and 16.0 days (1.0 cycle), respectively. The median time to the Grade 2, 3 or 4 adverse reactions (Grade 3 or 4 for rash), which required delay of next administration, was 64.5 (3.0 cycles), 84.0 (3.0 cycles) and 43.0 (2.0 cycles), respectively and the median duration for those reactions was 15.0, 8.0 and 8.0 days, respectively.

ays (1.0 cycle), respectively. The median time to the Grade 2, 3 or 4 adverse reactions (Grade 3 or 4 for rash), which required delay of next administration, was 64.5 (3.0 cycles), 84.0 (3.0 cycles) and 43.0 (2.0 cycles), respectively and the median duration for those reactions was 15.0, 8.0 and 8.0 days, respectively. Infusion-related reactions were seen in 14 patients (18.9%) only during the first cycle. Serious reactions were not seen. Of these patients, one patient had Grade 2 events and other patients had Grade 1 events. Symptoms associated with infusion-related reactions included hot flushes, facial flushing and hot feeling. These symptoms were restored on the day of occurrence or the following day. PLD was discontinued in one patient who had nausea, low back pain, chest tightness and facial flushing as Grade 2 infusion-related reactions. These symptoms were rapidly restored by supportive care with drip infusion of physiological saline. Although slowdown in the PLD infusion rate was required in two patients, the other 11 patients completed the infusion without any intervention. Among 14 patients with infusion-related reactions, 11 patients received the next cycle without recurrence of infusion-related reactions. Cardiac toxicity was seen in 17 of 74 patients (23.0%), all of which were Grade 1. Increase in the incidence of cardiac toxicity associated with accumulation of PLD was not observed. Alopecia was seen in 18 patients (24.3%), which was Grade 1 in all of them.

Infusion-related reactions were seen in 14 patients (18.9%) only during the first cycle. Serious reactions were not seen. Of these patients, one patient had Grade 2 events and other patients had Grade 1 events. Symptoms associated with infusion-related reactions included hot flushes, facial flushing and hot feeling. These symptoms were restored on the day of occurrence or the following day. PLD was discontinued in one patient who had nausea, low back pain, chest tightness and facial flushing as Grade 2 infusion-related reactions. These symptoms were rapidly restored by supportive care with drip infusion of physiological saline. Although slowdown in the PLD infusion rate was required in two patients, the other 11 patients completed the infusion without any intervention. Among 14 patients with infusion-related reactions, 11 patients received the next cycle without recurrence of infusion-related reactions. Cardiac toxicity was seen in 17 of 74 patients (23.0%), all of which were Grade 1. Increase in the incidence of cardiac toxicity associated with accumulation of PLD was not observed. Alopecia was seen in 18 patients (24.3%), which was Grade 1 in all of them. There was no death due to adverse events reported during the trial period. Fourteen serious adverse reactions were seen in 11 patients (14.9%): two events each of nausea, HFS, small intestinal obstruction and stomatitis; and one event each of neutropenia, leukopenia, vomiting, pneumonitis, deep venous thrombosis and anorexia.

as no death due to adverse events reported during the trial period. Fourteen serious adverse reactions were seen in 11 patients (14.9%): two events each of nausea, HFS, small intestinal obstruction and stomatitis; and one event each of neutropenia, leukopenia, vomiting, pneumonitis, deep venous thrombosis and anorexia. PLD was discontinued due to adverse reactions in 16 (21.6%). Common adverse reactions that required the discontinuation of PLD included: decreased haemoglobin in six patients (8.1%), leukopenia in four (5.4%) and HFS and neutropenia in three each (4.1%). The PLD dose was reduced in 24 patients (32.4%) due to adverse drug reactions such as HFS in 10 patients (13.5%), decreased haemoglobin and stomatitis in five each (6.8%) and neutropenia in three patients (4.1%). Administration of PLD was delayed in 49 patients (66.2%) in 111 cycles of 334 cycles due to adverse reactions mainly including leukopenia in 68 cycles (20.4%), neutropenia in 56 cycles (16.8%), HFS in 40 cycles (12.0%) and stomatitis in eight cycles (2.4%). DISCUSSION We evaluated the efficacy and safety of PLD in Japanese patients with Müllerian carcinoma (epithelial ovarian carcinoma, primary fallopian tube carcinoma and peritoneal carcinoma) previously treated with platinum-based chemotherapy.

PLD was discontinued due to adverse reactions in 16 (21.6%). Common adverse reactions that required the discontinuation of PLD included: decreased haemoglobin in six patients (8.1%), leukopenia in four (5.4%) and HFS and neutropenia in three each (4.1%). The PLD dose was reduced in 24 patients (32.4%) due to adverse drug reactions such as HFS in 10 patients (13.5%), decreased haemoglobin and stomatitis in five each (6.8%) and neutropenia in three patients (4.1%). Administration of PLD was delayed in 49 patients (66.2%) in 111 cycles of 334 cycles due to adverse reactions mainly including leukopenia in 68 cycles (20.4%), neutropenia in 56 cycles (16.8%), HFS in 40 cycles (12.0%) and stomatitis in eight cycles (2.4%). DISCUSSION We evaluated the efficacy and safety of PLD in Japanese patients with Müllerian carcinoma (epithelial ovarian carcinoma, primary fallopian tube carcinoma and peritoneal carcinoma) previously treated with platinum-based chemotherapy. Currently, platinum and taxane therapies are used for the standard first-line chemotherapy for treatment of ovarian carcinoma, though the results of Phase III clinical trials conducted in the US and Europe demonstrated the effectiveness of PLD, gemcitabine and topotecan in patients resistant to these drugs (13,14,20). However, these drugs have not been approved and the results from prospective studies of their use in patients with ovarian carcinoma previously treated with platinum and taxane therapy have not been reported in Japan. Our study was intended to provide the outcome in patients who had recurrent Müllerian carcinoma after the standard first-line chemotherapy (90% of patients in our study had received first-line chemotherapy with platinum and taxane).

ma previously treated with platinum and taxane therapy have not been reported in Japan. Our study was intended to provide the outcome in patients who had recurrent Müllerian carcinoma after the standard first-line chemotherapy (90% of patients in our study had received first-line chemotherapy with platinum and taxane). In this trial, the response rate was 21.9% (95% CI: 13.1–33.1%) for all patients in FAS. The response rate in the platinum-sensitive and platinum-resistant groups was 27.3% (95% CI: 6.0–61.0%) and 21.0% (95% CI: 11.7–33.2%), respectively. Better response was obtained in patients with longer platinum-free interval when PLD was administered as second- or third-line chemotherapy. Clinical studies conducted in the US and Europe showed that the response rate of PLD was 28.4% in the platinum-sensitive group and 6.5–18.3% in the platinum-resistant group (11,12,13). These response rates were similar to those obtained in our trial. Common adverse reactions reported in this study were haematological toxicities (leukopenia, neutropenia and decreased haemoglobin), HFS and stomatitis. The median time to nadir for WBC, neutrophils and haemoglobin after the start of administration of PLD was 15–22 days, and the median time to recovery to baseline after reaching the nadir was 7–8 days. Repeated cycles did not lead to worsening the events. Most patients could receive PLD continually by concomitant use of G-CSF and dose modification, such as dose reduction and delay of next administration.

stration of PLD was 15–22 days, and the median time to recovery to baseline after reaching the nadir was 7–8 days. Repeated cycles did not lead to worsening the events. Most patients could receive PLD continually by concomitant use of G-CSF and dose modification, such as dose reduction and delay of next administration. In the previous Phase III study (13), HFS and stomatitis occurred in 49% (Grade 3 or higher: 23%) and 40% (Grade 3 or higher: 8%) of patients, respectively. Although these toxicities were seen in 78.3 and 77.0% of patients in our study, only 16.2 and 8.1% of patients experienced Grade 3 or higher toxicities, respectively. Most patients could continually receive PLD treatment by dose modification of PLD and supportive care, and the patients discontinued due to toxicities were few. Infusion-related reaction that is known as toxicity specific to PLD was seen in 14 patients (18.9%) during the first cycle, all of which were resolved on the day of the occurrence or the following day. The second cycle was administered in 11 of 14 patients with infusion-related reactions. No recurrence of infusion-related reactions was seen in all 11 patients. It is important to use PLD with close attention to the condition of patients at the first administration of PLD. Infusion-related reaction is related to the initial infusion rate of PLD. It has been reported that decreasing the infusion rate reduces the risk of the infusion-related reaction (21).

en in all 11 patients. It is important to use PLD with close attention to the condition of patients at the first administration of PLD. Infusion-related reaction is related to the initial infusion rate of PLD. It has been reported that decreasing the infusion rate reduces the risk of the infusion-related reaction (21). It has been reported that cardiac toxicity, which is a significant problem with the use of conventional doxorubicin, associated with PLD is mild (22). Also in this trial, all cardiac toxicities observed were Grade 1, and had no effect on continuation of the trial. Furthermore, no patients experienced Grade 2 or higher alopecia, and Grade 3 or higher gastrointestinal toxicities were rarely seen in our trial. These toxicities are frequently induced by treatment of conventional doxorubicin. These results suggest that toxicity of PLD is manageable by dose modification of PLD and supportive care.

It has been reported that cardiac toxicity, which is a significant problem with the use of conventional doxorubicin, associated with PLD is mild (22). Also in this trial, all cardiac toxicities observed were Grade 1, and had no effect on continuation of the trial. Furthermore, no patients experienced Grade 2 or higher alopecia, and Grade 3 or higher gastrointestinal toxicities were rarely seen in our trial. These toxicities are frequently induced by treatment of conventional doxorubicin. These results suggest that toxicity of PLD is manageable by dose modification of PLD and supportive care. Most patients with ovarian carcinoma exhibited response to first-line chemotherapy, however, the incidence of recurrence is high and prognosis is poor. It might be important to recognize that the chemotherapy would be palliative treatment for treatment of recurrent ovarian carcinoma. PLD has a safety profile that is different from that of platinum and taxanes, which are used for the standard first-line chemotherapy. PLD has a low risk of enhancing cumulative toxicities (haematological toxicity or neurotoxicity) associated with first-line chemotherapy. PLD is expected to have a beneficial effect against disease progression as the proportion of patients with CR, PR or SD and time to progression were 60.3% and 166 days (median). Furthermore, PLD might make it easy to provide long-term outpatient chemotherapy since PLD would reduce a patient burden by dosing once every 4 weeks.

xpected to have a beneficial effect against disease progression as the proportion of patients with CR, PR or SD and time to progression were 60.3% and 166 days (median). Furthermore, PLD might make it easy to provide long-term outpatient chemotherapy since PLD would reduce a patient burden by dosing once every 4 weeks. In conclusion, this trial demonstrated that PLD (50 mg/m2 every 4 weeks) was expected to have antitumour effect in Japanese patients with Müllerian carcinoma previously treated with platinum-based chemotherapy and that toxicities associated with PLD are manageable by dose modification and supportive care. In the USA and Europe, combination chemotherapy with PLD and platinum has recently been investigated in the platinum-sensitive group where PLD is considered to be more effective (23,24,25). It is desirable to investigate the optimal regimen of the combination therapy in Japan. Funding Funding to pay the Open Access publication charges for this article was provided by Janssen Pharmaceutical K.K. Conflict of interest statement None declared.

In conclusion, this trial demonstrated that PLD (50 mg/m2 every 4 weeks) was expected to have antitumour effect in Japanese patients with Müllerian carcinoma previously treated with platinum-based chemotherapy and that toxicities associated with PLD are manageable by dose modification and supportive care. In the USA and Europe, combination chemotherapy with PLD and platinum has recently been investigated in the platinum-sensitive group where PLD is considered to be more effective (23,24,25). It is desirable to investigate the optimal regimen of the combination therapy in Japan. Funding Funding to pay the Open Access publication charges for this article was provided by Janssen Pharmaceutical K.K. Conflict of interest statement None declared. Acknowledgements The authors extend special thanks to Dr N. Saijo (National Cancer Center Hospital East, Chiba), Dr S. Isonishi (Jikei University School of Medicine, Tokyo), Dr H. Katabuchi (Kumamoto University, Kumamoto), Dr T. Koyama (Kyoto University, Kyoto), Dr K. Miyagawa (National Cancer Center Hospital, Tokyo), Dr H. Watanabe (National Cancer Center Hospital, Tokyo), Dr K Hasegawa (Inamino Hospital, Hyogo), Dr Y. Matsumura (National Cancer Center Research Institute East, Chiba), Dr T. Tamura (National Cancer Center Hospital, Tokyo) and Dr Y. Ohashi (University of Tokyo, Tokyo) for careful review of the protocol and the clinical data in this study.

INTRODUCTION Lung cancer is the most common malignancy in many countries and it has become the number one cause of cancer death in Korea, surpassing gastric cancer (1,2). Majority of lung cancer patients has non-small cell type, in which surgical resection is still the mainstay of the curative treatment (2). However, the prognosis of patients with non-small cell lung cancer (NSCLC) is still poor despite surgical treatment (2,3). Recently, several phase III trials demonstrated improved survival with adjuvant chemotherapy, especially in patients with Stage II or III disease (4–7). Therefore, the determination of parameters that may identify those patients who would benefit from adjuvant chemotherapy, and those who would not, has strong clinical implications. Apoptosis-related proteins are important candidates for such parameters, because apoptosis is the predominant mechanism in which chemotherapy and radiotherapy kill the cancer cells (8). Among several proteins involved in apoptosis, the fine interplay between the anti-apoptotic members of the Bcl-2 family and the death-promoting members such as Bax and p53 has been suggested as the most important process (8). BH3-only proteins or p53 directly or indirectly activate the Bax protein, which permeabilizes the mitochondrial outer membrane, leading to the activation of downstream apoptosis signaling pathways (8,9). In addition, galectin-3, which belongs to a family of the galactoside-binding protein-3, and is structurally and functionally similar to Bcl-2, is known to protect cells from apoptosis by various stimuli (10). Therefore, genetic defects in these proteins may not only result in intrinsic biologic aggressiveness, but also lead to resistance to the cytotoxic effects of chemotherapy and radiotherapy (8,11–13). We evaluated the prognostic significance of apoptosis-related proteins p53, Bax and galectin-3 in NSCLC patients treated with surgical resection with or without adjuvant treatment.

sult in intrinsic biologic aggressiveness, but also lead to resistance to the cytotoxic effects of chemotherapy and radiotherapy (8,11–13). We evaluated the prognostic significance of apoptosis-related proteins p53, Bax and galectin-3 in NSCLC patients treated with surgical resection with or without adjuvant treatment. PATIENTS AND METHODS Patients Two hundred and five patients who underwent resection of primary NSCLC at Ajou University Medical Center between September 1996 and December 2002 were eligible to be included in this retrospective study. Patients with a history of cancer from a non-pulmonary origin were included if the disease was cured. Exclusion criteria included patients with history of previous lung cancer, a Stage IV disease and those treated preoperatively with either chemotherapy or radiotherapy. Before operation, each patient underwent the following staging procedures: chest radiography, chest computed tomography (CT) scan and hematologic and biochemical profiles. The American Joint Committee on Cancer staging was used for post-operative pathologic staging of the patients (14). This research protocol was approved by the Institutional Review Board of the Ajou University Medical Center, Suwon, Korea.

hy, chest computed tomography (CT) scan and hematologic and biochemical profiles. The American Joint Committee on Cancer staging was used for post-operative pathologic staging of the patients (14). This research protocol was approved by the Institutional Review Board of the Ajou University Medical Center, Suwon, Korea. Chemotherapy In the majority of patients in Stage II or III, adjuvant chemotherapy was performed according to the discretion of physicians. Although adjuvant chemotherapy regimens were not uniformly applied, all, except three, patients received cisplatin-based chemotherapy (gemcitabine, tegracil and gemcitabine/carboplatin, respectively). The most commonly administered regimen (24 patients) consisted of two cycles of etoposide/cisplatin chemotherapy followed by concurrent chemoradiotherapy with cisplatin. In this regimen, etoposide 100 mg/m2/day (Days 1–3) and cisplatin 20 mg/m2/day (Days 1–4) were administered every 3 weeks, while concurrent chemoradiotherapy consisted of radiotherapy with cisplatin 20 mg/m2/day for 4 days during Weeks 1 and 4 of radiotherapy.

py followed by concurrent chemoradiotherapy with cisplatin. In this regimen, etoposide 100 mg/m2/day (Days 1–3) and cisplatin 20 mg/m2/day (Days 1–4) were administered every 3 weeks, while concurrent chemoradiotherapy consisted of radiotherapy with cisplatin 20 mg/m2/day for 4 days during Weeks 1 and 4 of radiotherapy. Radiotherapy Radiotherapy was performed using 6- or 15-MV LINAC (CLINAC 2100CD, Varian Medical Systems, Palo Alto, CA, USA). Patients were treated with multiple portals, and a conformal isodose plan was created. The target volume was the bronchial stump, and ipsilateral hilar and mediastinal lymph nodes with a 1–2 cm margin. The primary tumor bed was included when there was chest wall invasion. The radiation dose to target volume was 50.4 Gy in 27–30 fractions, 5 days/week when corrections for inhomogeneity were not made. After inhomogeneity corrections were made, radiation of 54–60 Gy in 27–30 fractions were delivered to the target volume. Boost radiation of 10–15 Gy was required when the tumor cells were on the resection margins. The dose to the spinal cord did not exceed 45 Gy. Evaluation The patients were followed with chest radiography either with or without chest CT scan every 3 months for 2 years, then every 6 months for 3 years and yearly thereafter.

Radiotherapy Radiotherapy was performed using 6- or 15-MV LINAC (CLINAC 2100CD, Varian Medical Systems, Palo Alto, CA, USA). Patients were treated with multiple portals, and a conformal isodose plan was created. The target volume was the bronchial stump, and ipsilateral hilar and mediastinal lymph nodes with a 1–2 cm margin. The primary tumor bed was included when there was chest wall invasion. The radiation dose to target volume was 50.4 Gy in 27–30 fractions, 5 days/week when corrections for inhomogeneity were not made. After inhomogeneity corrections were made, radiation of 54–60 Gy in 27–30 fractions were delivered to the target volume. Boost radiation of 10–15 Gy was required when the tumor cells were on the resection margins. The dose to the spinal cord did not exceed 45 Gy. Evaluation The patients were followed with chest radiography either with or without chest CT scan every 3 months for 2 years, then every 6 months for 3 years and yearly thereafter. Construction of Tissue Microarray and Immunohistochemical Staining for Apoptosis-Related Proteins Two representative areas were taken of all cases from paraffin tissue blocks after reviewing the hematoxylin–eosin-stained slides of the primary tumor. A total of 410 core tissue biopsies (diameter, 1.0 mm) were taken and arrayed into three new recipient paraffin blocks. Five-micrometer sections of these tissue array blocks were then cut, placed on charged poly-l-lysine–coated slides and used for immunohistochemical analysis.

eosin-stained slides of the primary tumor. A total of 410 core tissue biopsies (diameter, 1.0 mm) were taken and arrayed into three new recipient paraffin blocks. Five-micrometer sections of these tissue array blocks were then cut, placed on charged poly-l-lysine–coated slides and used for immunohistochemical analysis. Sections from the tissue array were deparaffinized in xylene and were rehydrated in graded alcohol and water. Endogenous peroxidase activity was blocked by treatment with 3% hydrogen peroxide for 10 min. Sections were treated with a protein-blocking solution and then with primary antibodies, including mouse anti-human monoclonal antibodies against p53 (DO-7, dilution 1:20) and galectin-3 (NCL-GAL3, dilution 1:100) (Novocastra Laboratories Ltd, Newcastle upon Tyne, UK), and rabbit anti-human polyclonal antibody against Bax (dilution 1:1000, DAKO, Carpinteria, CA, USA), for 1 h at room temperature. After rinsing several times in phosphate-buffered saline, the sections were incubated in biotinylated secondary antibody. Bound antibodies were detected by the streptavidin–biotin method with a Cap-Plus detection kit (Zymed Laboratories Inc, San Francisco, CA, USA). Slides were rinsed in phosphate-buffered saline, exposed to diaminobenzidine and counterstained with Mayer’s hematoxylin. The negative controls for these proteins were made by omitting the primary antibody during the process of immunohistochemical staining. For positive controls of p53 and Bax, a tissue section of colon adenocarcinoma known to have high expression of p53 and lymphocytes in the germinal center were used, respectively, while a tissue section of the tonsil was used as the positive control for galectin-3.

dy during the process of immunohistochemical staining. For positive controls of p53 and Bax, a tissue section of colon adenocarcinoma known to have high expression of p53 and lymphocytes in the germinal center were used, respectively, while a tissue section of the tonsil was used as the positive control for galectin-3. The slides were examined independently by two observers (JHH, JHK) blinded to both clinical and pathologic data. Expression of the apoptosis-related proteins was quantified using a visual grading system based on the extent of staining (percentage of positive tumor cells) (graded on a scale of 0–3; 0, 0–25%; 1, 26–50%; 2, 51–75%; 3, >75%) for p53, and the intensity of staining (graded on a scale of 0–3; 0, no staining; 1, weak staining; 2, moderate staining; 3, strong staining) for Bax and galectin-3, respectively. There was close agreement (>90%) in the evaluation of apoptosis-related proteins between both investigators. In case of disagreement, final grading was determined by consensus. Expression of apoptosis-related proteins was classified into high (Grade 2, 3) and low (Grade 0, 1) expressions (Fig. 1). Figure 1. Immunohistochemical staining of apoptosis-related proteins in non-small cell lung cancer (×400). (A) High expression of Bax: cytoplasmic staining (Grade 3 in the intensity). (B) Low expression of Bax (Grade 1 in the intensity). (C) High expression of p53: nuclear staining (Grade 3 in the extent). (D) High expression of galectin-3: cytoplasmic staining (Grade 3 in the intensity).

non-small cell lung cancer (×400). (A) High expression of Bax: cytoplasmic staining (Grade 3 in the intensity). (B) Low expression of Bax (Grade 1 in the intensity). (C) High expression of p53: nuclear staining (Grade 3 in the extent). (D) High expression of galectin-3: cytoplasmic staining (Grade 3 in the intensity). Statistical Analysis Disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan–Meier method (15). DFS was defined as the time from the day of operation to a documented day of recurrence, development of a second primary cancer or death from any other cause. Data on patients who did not experience recurrence were censored at the last follow-up. OS was defined as the time from the day of operation to the time of death; data on survivors were censored at the last follow-up. The differences between the survival curves were tested using the log-rank test and the Wilcoxon test. The Cox proportional-hazards regression model was used to determine the joint effects of several variables on survival (16). The comparison of clinicopathologic characteristics was evaluated with the Fisher’s exact test. All statistical analyses were performed two-sided, with SPSS for Windows 12.0 software.

coxon test. The Cox proportional-hazards regression model was used to determine the joint effects of several variables on survival (16). The comparison of clinicopathologic characteristics was evaluated with the Fisher’s exact test. All statistical analyses were performed two-sided, with SPSS for Windows 12.0 software. RESULTS Patient Characteristics The median age of 205 patients with NSCLC was 63 years (range: 30–78), and the median longest diameter of the primary tumor was 3.9 cm (1.2–12). Twenty-six patients (13%) were in Stage IA, 71 (35%) in IB, 7 (3%) in IIA, 39 (19%) in IIB, 45 (22%) in IIIA and 17 (8%) in IIIB. One hundred and fifty-eight male patients (99%) and seven female patients (16%) had a history of smoking (current or previous smoker). In terms of histologic type, 98% of patients with squamous cell carcinoma had a history of smoking, while 63% of adenocarcinoma patients and 74% of patients with other histologic types were current or previous smokers. Other clinicopathologic characteristics of the patients are listed in Table 1. Table 1. Expression of Bax and clinicopathologic characteristics

RESULTS Patient Characteristics The median age of 205 patients with NSCLC was 63 years (range: 30–78), and the median longest diameter of the primary tumor was 3.9 cm (1.2–12). Twenty-six patients (13%) were in Stage IA, 71 (35%) in IB, 7 (3%) in IIA, 39 (19%) in IIB, 45 (22%) in IIIA and 17 (8%) in IIIB. One hundred and fifty-eight male patients (99%) and seven female patients (16%) had a history of smoking (current or previous smoker). In terms of histologic type, 98% of patients with squamous cell carcinoma had a history of smoking, while 63% of adenocarcinoma patients and 74% of patients with other histologic types were current or previous smokers. Other clinicopathologic characteristics of the patients are listed in Table 1. Table 1. Expression of Bax and clinicopathologic characteristics Low Bax (%) High Bax (%) P valuea Gender Female 22 (14) 23 (48) <0.0001 Male 135 (86) 25 (52) Age ≤63b 84 (54) 28 (58) 0.621 >63 73 (46) 20 (42) History of smoking Yes 140 (89) 25 (52) <0.0001 No 17 (11) 23 (48) Operation Lobectomyc 100 (64) 39 (81) 0.023 Pneumonectomy 57 (36) 9 (19) Histologic types Squamous 89 (57) 7 (15) <0.0001 Adeno 54 (34) 36 (75) Adenosquamous 7 (4) 5 (10) Othersd 7 (4) 0 (0) Tumor size (cm) ≤3.9e 76 (48) 29 (60) 0.187 >3.9 81 (52) 19 (40) Stagef I 72 (46) 25 (52) 0.658 II 38 (24) 8 (17) IIIA 35 (22) 10 (21) IIIB 12 (8) 5 (10) Resection margin Negative 140 (89) 45 (94) 0.420 Positive 17 (11) 3 (6) Adjuvant treatment No 89 (57) 28 (58) 0.773 Chemotherapy 7 (4) 1 (2) Chemoradiotherapy 44 (28) 12 (25) Radiotherapy 17 (11) 7 (15) Expression of p53 Low 89 (57) 35 (73) 0.063 High 68 (43) 13 (27) Expression of galectin-3 Low 88 (56) 12 (25) <0.0001 High 69 (44) 36 (75) aFisher’s exact test. bMedian age. cIncluding two patients with wedge resection. dIncluding five patients with large cell carcinoma, one with mucoepidermoid carcinoma and one with carcinosarcoma. eMedian longest diameter of primary tumor. fPost-operative pathologic staging.

88 (56) 12 (25) <0.0001 High 69 (44) 36 (75) aFisher’s exact test. bMedian age. cIncluding two patients with wedge resection. dIncluding five patients with large cell carcinoma, one with mucoepidermoid carcinoma and one with carcinosarcoma. eMedian longest diameter of primary tumor. fPost-operative pathologic staging. Association of Expression of Apoptosis-Related Proteins with Clinicopathologic Characteristics High expressions of Bax, p53 and galectin-3 were observed in 48 (23%), 81 (40%) and 105 (51%) patients, respectively. High expression of p53 was associated with male gender (P = 0.024), history of smoking (P = 0.002), post-pneumonectomy status (P = 0.046) and squamous cell histology (P = 0.033). In addition, high expression of galectin-3 correlated with no smoking history (P = 0.023), post-lobectomy status (P = 0.011), adenocarcinoma (P < 0.0001) and negative resection margin (P = 0.018). Low expression of Bax was significantly associated with male gender (P < 0.0001), history of smoking (P < 0.0001), squamous cell histology (P < 0.0001) and low expression of galectin-3 (P < 0.0001) (Table 1). In terms of subtypes of adenocarcinoma, high expression of Bax showed a trend of correlation with bronchioloalveloar carcinoma (P = 0.094) (Table 2). Table 2. Relationship between the expression of apoptosis-related proteins and subtypes of adenocarcinoma

Association of Expression of Apoptosis-Related Proteins with Clinicopathologic Characteristics High expressions of Bax, p53 and galectin-3 were observed in 48 (23%), 81 (40%) and 105 (51%) patients, respectively. High expression of p53 was associated with male gender (P = 0.024), history of smoking (P = 0.002), post-pneumonectomy status (P = 0.046) and squamous cell histology (P = 0.033). In addition, high expression of galectin-3 correlated with no smoking history (P = 0.023), post-lobectomy status (P = 0.011), adenocarcinoma (P < 0.0001) and negative resection margin (P = 0.018). Low expression of Bax was significantly associated with male gender (P < 0.0001), history of smoking (P < 0.0001), squamous cell histology (P < 0.0001) and low expression of galectin-3 (P < 0.0001) (Table 1). In terms of subtypes of adenocarcinoma, high expression of Bax showed a trend of correlation with bronchioloalveloar carcinoma (P = 0.094) (Table 2). Table 2. Relationship between the expression of apoptosis-related proteins and subtypes of adenocarcinoma Subtype Bax p53 Galectin-3 Low (%) High (%) P valuea Low (%) High (%) P valuea Low (%) High (%) P valuea Acinar 38 (70) 22 (61) 0.094 42 (67) 18 (67) 0.093 21 (78) 39 (62) 0.622 BAC 6 (11) 10 (28) 12 (19) 4 (15) 3 (11) 13 (21) Papillary 3 (6) 3 (8) 6 (10) 0 (0) 1 (4) 5 (8) Solidb 7 (13) 1 (3) 3 (5) 5 (19) 2 (7) 6 (10) BAC, Bronchioloalveolar carcinoma. aFisher’s exact test. bIncluding one patient with signet-ring adenocarcinoma.

38 (70) 22 (61) 0.094 42 (67) 18 (67) 0.093 21 (78) 39 (62) 0.622 BAC 6 (11) 10 (28) 12 (19) 4 (15) 3 (11) 13 (21) Papillary 3 (6) 3 (8) 6 (10) 0 (0) 1 (4) 5 (8) Solidb 7 (13) 1 (3) 3 (5) 5 (19) 2 (7) 6 (10) BAC, Bronchioloalveolar carcinoma. aFisher’s exact test. bIncluding one patient with signet-ring adenocarcinoma. Association of Expression of Apoptosis-Related Proteins with Patient Outcome The median follow-up duration of surviving patients was 79 months (range: 35–149 months), and one patient with recurrence was lost during follow-up because the patient immigrated to another country. At the time of analysis, 132 of 205 patients (64%) had died, while 14 patients with either recurrence (11 patients) or second primary cancer (three patients) were alive. Seven patients who died of post-operative complication were excluded from further survival analysis. Five-year DFS and OS of total patients were 37 and 46%, respectively (Fig. 2). High expressions of p53 and galectin-3 were not associated with poor DFS or OS (Table 3). Moreover, there was no significant correlation between low expression of Bax and outcome of patients (Fig. 3 and Table 3). However, in patients with non-squamous histology (108 patients), low expression of Bax was a significant independent predictor of poor DFS (P = 0.017) and OS (P = 0.037) in multivariate analysis (Fig. 4 and Table 4). In addition, in patients with Stage II or III, low expression of Bax significantly correlated with poor DFS (P = 0.004) (Table 5). It was also the most significant independent prognostic factor second only to a large primary tumor size in Stage II or III patients with non-squamous histology (P = 0.001 for DFS, P = 0.013 for OS) in multivariate analysis as well as in univariate analysis (Fig. 5 and Table 6).

ted with poor DFS (P = 0.004) (Table 5). It was also the most significant independent prognostic factor second only to a large primary tumor size in Stage II or III patients with non-squamous histology (P = 0.001 for DFS, P = 0.013 for OS) in multivariate analysis as well as in univariate analysis (Fig. 5 and Table 6). Figure 2. Disease-free and overall survival of resected non-small cell lung cancer patients. Figure 3. Disease-free survival (A) and overall survival (B) of resected non-small cell lung cancer patients according to the expression of Bax (P value was obtained using the Wilcoxon test). Figure 4. Disease-free survival (A) and overall survival (B) of non-small cell lung cancer patients with non-squamous histology according to the expression of Bax (P value was obtained using the Wilcoxon test). Figure 5. Disease-free survival (A) and overall survival (B) of non-small cell lung cancer patients in Stage II or III with non-squamous histology according to the expression of Bax (P value was obtained using the Wilcoxon test). Table 3. Disease-free and overall survival of the patients according to various characteristicsa

Figure 5. Disease-free survival (A) and overall survival (B) of non-small cell lung cancer patients in Stage II or III with non-squamous histology according to the expression of Bax (P value was obtained using the Wilcoxon test). Table 3. Disease-free and overall survival of the patients according to various characteristicsa Characteristics Number of patients 5-year disease-free survival (%) P valueb 5-year overall survival (%) P valueb Gender Female 45 42 0.623 55 0.327 Male 153 36 44 Age ≤63c 111 38 0.875 47 0.648 >63 87 36 46 History of smoking Yes 158 34 0.230 43 0.080 No 40 50 59 Operation Lobectomyd 138 37 0.419 49 0.063 Pneumonectomy 60 37 42 Histologic type Squamous 90 40 0.687 46 0.746 Non-squamous 108 35 46 Tumor size (cm) ≤3.9e 103 44 0.019 52 0.026 >3.9 95 29 41 Stagef I 95 51 <0.0001 59 <0.0001 II 45 33 44 IIIA 44 20 29 IIIB 14 7 21 Resection margin Negative 181 38 0.155 49 0.037 Positive 17 24 24 Expression of Bax Low 151 35 0.381g 45 0.247h High 47 45 53 Expression of p53 Low 121 38 0.579 48 0.566 High 77 36 44 Expression of galectin-3 Low 96 34 0.237 42 0.157 High 102 40 50 aExcluding seven patients who died of post-operative complication. bLog-rank test. cMedian age. dIncluding wedge resection. eMedian longest diameter of primary tumor. fPost-operative pathologic staging. gP = 0.103 according to the Wilcoxon test. hP = 0.057 according to the Wilcoxon test. Table 4. Multivariate analysis of disease-free survival and overall survival in non-squamous histology (n = 108)a

Characteristics Number of patients 5-year disease-free survival (%) P valueb 5-year overall survival (%) P valueb Gender Female 45 42 0.623 55 0.327 Male 153 36 44 Age ≤63c 111 38 0.875 47 0.648 >63 87 36 46 History of smoking Yes 158 34 0.230 43 0.080 No 40 50 59 Operation Lobectomyd 138 37 0.419 49 0.063 Pneumonectomy 60 37 42 Histologic type Squamous 90 40 0.687 46 0.746 Non-squamous 108 35 46 Tumor size (cm) ≤3.9e 103 44 0.019 52 0.026 >3.9 95 29 41 Stagef I 95 51 <0.0001 59 <0.0001 II 45 33 44 IIIA 44 20 29 IIIB 14 7 21 Resection margin Negative 181 38 0.155 49 0.037 Positive 17 24 24 Expression of Bax Low 151 35 0.381g 45 0.247h High 47 45 53 Expression of p53 Low 121 38 0.579 48 0.566 High 77 36 44 Expression of galectin-3 Low 96 34 0.237 42 0.157 High 102 40 50 aExcluding seven patients who died of post-operative complication. bLog-rank test. cMedian age. dIncluding wedge resection. eMedian longest diameter of primary tumor. fPost-operative pathologic staging. gP = 0.103 according to the Wilcoxon test. hP = 0.057 according to the Wilcoxon test. Table 4. Multivariate analysis of disease-free survival and overall survival in non-squamous histology (n = 108)a Prognostic factors Disease-free survival Overall survival HR 95% CI P valueb HR 95% CI P valueb Operation Lobectomyc 1.00 1.00 Pneumonectomy 1.41 0.77–2.62 0.269 2.63 1.45–4.79 0.002 Tumor size (cm) ≤3.9d 1.00 1.00 >3.9 2.14 1.33–3.45 0.002 1.53 0.90–2.61 0.118 Stagee I 1.00 1.00 II 2.65 1.42–4.96 0.002 1.93 0.97–3.85 0.062 IIIA 3.76 2.09–6.77 <0.0001 2.58 1.40–4.76 0.002 IIIB 5.23 2.08–13.11 <0.0001 3.52 1.44–8.62 0.006 Expression of Bax High 1.00 1.00 Low 1.87 1.12–3.14 0.017 1.79 1.04–3.08 0.037 HR, hazard ratio; CI, confidence interval. aExcluding one patient who died of post-operative complication. bCox proportional-hazards regression model. cIncluding wedge resection. dMedian longest diameter of primary tumor. ePost-operative pathologic staging.

x High 1.00 1.00 Low 1.87 1.12–3.14 0.017 1.79 1.04–3.08 0.037 HR, hazard ratio; CI, confidence interval. aExcluding one patient who died of post-operative complication. bCox proportional-hazards regression model. cIncluding wedge resection. dMedian longest diameter of primary tumor. ePost-operative pathologic staging. Table 5. Multivariate analysis of disease-free survival and overall survival in Stages II and III (n = 103)a Prognostic factors Disease-free survival Overall survival HR 95% CI P valueb HR 95% CI P valueb Age ≤62c 1.00 1.00 >62 1.40 0.84–2.34 0.202 2.06 1.21–3.53 0.008 Histologic type Squamous 1.00 1.00 Non-squamous 2.84 1.65–4.89 <0.0001 1.75 0.99–3.07 0.052 Tumor size (cm) ≤3.9d 1.00 1.00 >3.9 2.00 1.26–3.20 0.004 1.94 1.18–3.19 0.009 Stagee II 1.00 1.00 IIIA 1.51 0.91–2.49 0.110 1.66 0.96–2.86 0.069 IIIB 1.83 0.93–3.57 0.079 2.29 1.15–4.56 0.019 Resection margin Negative 1.00 1.00 Positive 2.07 1.04–4.13 0.039 2.21 1.10–4.44 0.026 Chemotherapy Yes 1.00 1.00 No 1.55 0.98–2.45 0.061 1.47 0.89–2.45 0.136 Expression of Bax High 1.00 1.00 Low 2.51 1.35–4.66 0.004 1.77 0.92–3.40 0.086 aExcluding five patients who died of post-operative complication. bCox proportional-hazards regression model. cMedian age. dMedian longest diameter of primary tumor. ePost-operative pathologic staging. Table 6. Multivariate analysis of disease-free survival and overall survival in Stages II and III with non-squamous histology (n = 48)a

Prognostic factors Disease-free survival Overall survival HR 95% CI P valueb HR 95% CI P valueb Age ≤62c 1.00 1.00 >62 1.40 0.84–2.34 0.202 2.06 1.21–3.53 0.008 Histologic type Squamous 1.00 1.00 Non-squamous 2.84 1.65–4.89 <0.0001 1.75 0.99–3.07 0.052 Tumor size (cm) ≤3.9d 1.00 1.00 >3.9 2.00 1.26–3.20 0.004 1.94 1.18–3.19 0.009 Stagee II 1.00 1.00 IIIA 1.51 0.91–2.49 0.110 1.66 0.96–2.86 0.069 IIIB 1.83 0.93–3.57 0.079 2.29 1.15–4.56 0.019 Resection margin Negative 1.00 1.00 Positive 2.07 1.04–4.13 0.039 2.21 1.10–4.44 0.026 Chemotherapy Yes 1.00 1.00 No 1.55 0.98–2.45 0.061 1.47 0.89–2.45 0.136 Expression of Bax High 1.00 1.00 Low 2.51 1.35–4.66 0.004 1.77 0.92–3.40 0.086 aExcluding five patients who died of post-operative complication. bCox proportional-hazards regression model. cMedian age. dMedian longest diameter of primary tumor. ePost-operative pathologic staging. Table 6. Multivariate analysis of disease-free survival and overall survival in Stages II and III with non-squamous histology (n = 48)a Prognostic factors Disease-free survival Overall survival HR 95% CI P valueb HR 95% CI P valueb Operation Lobectomy 1.00 1.00 Pneumonectomy 1.45 0.67–3.13 0.347 2.36 1.11–4.99 0.025 Tumor sizec (cm) ≤3.9 1.00 1.00 >3.9 4.12 2.01–8.43 <0.0001 2.69 1.25–5.83 0.012 Staged II 1.00 1.00 III 1.41 0.74–2.68 0.291 1.42 0.62–3.27 0.407 Expression of Bax High 1.00 1.00 Low 3.05 1.56–5.97 0.001 2.34 1.20–4.56 0.013 aExcluding one patient who died of post-operative complication. bCox proportional-hazards regression model. cMedian longest diameter of primary tumor. dPost-operative pathologic staging.

.00 1.00 III 1.41 0.74–2.68 0.291 1.42 0.62–3.27 0.407 Expression of Bax High 1.00 1.00 Low 3.05 1.56–5.97 0.001 2.34 1.20–4.56 0.013 aExcluding one patient who died of post-operative complication. bCox proportional-hazards regression model. cMedian longest diameter of primary tumor. dPost-operative pathologic staging. DISCUSSION We evaluated the expression of p53, Bax and galectin-3 under the assumption that abnormalities in these apoptosis-related proteins may be associated with poor outcome in patients with NSCLC treated with surgical resection either with or without adjuvant treatment. The most frequently investigated apoptosis-related protein in NSCLC is p53 (11,12,17–22). Although a meta-analysis demonstrated the association of abnormal p53 status with poor prognosis of resected NSCLC, the prognostic significance of p53 still remains controversial (11,12,17–22). Among the reports regarding the role of galectin-3 in NSCLC, one study with only Stage II patients showed the association of high expression of galectin-3 with poor outcome (23–25). The results of the present study showed that high expression of galectin-3 was frequently found in adenocarcinoma, which is consistent with results reported in a previous study (25). In addition, high expressions of p53 and galectin-3 were not associated with poor outcome in patients with resected NSCLC.

tcome (23–25). The results of the present study showed that high expression of galectin-3 was frequently found in adenocarcinoma, which is consistent with results reported in a previous study (25). In addition, high expressions of p53 and galectin-3 were not associated with poor outcome in patients with resected NSCLC. The most important finding of the current study was the prognostic significance of the low expression of Bax in patients with resected NSCLC, having non-squamous histology or locally advanced disease (Stages II and III), although it did not predict poor outcome in the entire group of patients. In the present study, the frequency of low expression of Bax was very high (94%) in squamous cell carcinoma. Previous studies also revealed the association of low expression of Bax with squamous cell carcinoma in NSCLC (19,26). Therefore, Bax seems to be of little value as a prognostic indicator in NSCLC patients with squamous cell histology. On the other hand, in adenocarcinoma, the high expression of Bax demonstrated a trend of correlation with the bronchioloalveolar subtype, which has relatively higher prevalence in non-smokers and females (27). The mechanism of extremely high frequency of low expression of Bax in squamous cell carcinoma remains to be determined. Considering that almost all squamous cell carcinoma patients had a history of smoking and there was a strong correlation between smoking history and low expression of Bax even in adenocarcinoma in the present study (P = 0.014, data not shown), there is a possibility that smoking might cause the change in the expression of Bax. However, further study is essential to prove this speculation. Recently, Tanaka et al. (28) reported relevant results, which showed that Bax inhibitor-1 gene expression in adenocarcinoma was higher in patients with a bronchioloalveolar component and low smoking index. Since high expression of Bax in adenocarcinoma demonstrated similar significant association with bronchioloalvelolar subtype and no history of smoking in the present study, further investigation of the relationship between Bax and the Bax inhibitor-1 may provide valuable information for better understanding of the role of Bax in NSCLC.

sion of Bax in adenocarcinoma demonstrated similar significant association with bronchioloalvelolar subtype and no history of smoking in the present study, further investigation of the relationship between Bax and the Bax inhibitor-1 may provide valuable information for better understanding of the role of Bax in NSCLC. To our knowledge, this study is the largest research project that has investigated the role of Bax in NSCLC. Unlike for p53 or Bcl-2, there are fewer studies that discuss the prognostic significance of Bax in NSCLC (11,12,19–22,29–31). In addition, only one study that investigated 61 patients in a predominantly advanced stage (Stage IV, 54%) demonstrated the correlation between a low expression of Bax and poor outcome (29).

. Unlike for p53 or Bcl-2, there are fewer studies that discuss the prognostic significance of Bax in NSCLC (11,12,19–22,29–31). In addition, only one study that investigated 61 patients in a predominantly advanced stage (Stage IV, 54%) demonstrated the correlation between a low expression of Bax and poor outcome (29). The poor outcome of patients with low expression of Bax may be attributed to the intrinsic aggressiveness of the tumor (11,32). The prognostic value of low expression of Bax was more significant in patients with non-squamous histology, which had relatively lower proportion of current or previous smokers compared with squamous cell carcinoma in the present study. In addition, there was a very strong association between smoking history and low expression of Bax in patients with non-squamous histology (P < 0.0001, data not shown). These findings suggest the possibility that more extensive genetic damage such as low expression of Bax caused by smoking may result in intrinsic aggressiveness of the tumor, leading to poor outcome. On the other hand, we may suppose that resistance to adjuvant chemotherapy or radiotherapy in tumors with low expression of Bax may be the cause of poor prognosis, based on the results of the present study, which demonstrated that the low expression of Bax predicted poor DFS in Stages II or III when adjuvant treatments were commonly given (80% of patients) (8,11–13).

to adjuvant chemotherapy or radiotherapy in tumors with low expression of Bax may be the cause of poor prognosis, based on the results of the present study, which demonstrated that the low expression of Bax predicted poor DFS in Stages II or III when adjuvant treatments were commonly given (80% of patients) (8,11–13). The present study has several potential limitations. First, this is a retrospective analysis from a single institution with patients’ cohort within a relatively long period of time. Second, adjuvant chemotherapy was individualized according to the discretion of the treating oncologists, which resulted in rather heterogeneous chemotherapy regimens, although cisplatin was included in almost all. Third, the low expression of Bax did not demonstrate prognostic significance in the entire study population.

ond, adjuvant chemotherapy was individualized according to the discretion of the treating oncologists, which resulted in rather heterogeneous chemotherapy regimens, although cisplatin was included in almost all. Third, the low expression of Bax did not demonstrate prognostic significance in the entire study population. The association of low expression of Bax with poor DFS in Stages II or III has a clinical relevance, because adjuvant chemotherapy has recently been established as a standard of care for resected Stage II or III NSCLC, and the majority of patients in these stages in the current study received adjuvant chemotherapy either with or without radiotherapy (62%) (2,4–7). In Stage II or III patients with non-squamous histology, the 5-year OS of patients with low expression of Bax was significantly lower compared with that of high expression (22 versus 43%, P = 0.012, Wilcoxon test), while low expression of Bax was one of the significant independent predictors of poor prognosis in multivariate analysis. Therefore, the present study suggests that locally advanced (Stage II or III) non-squamous NSCLC patients with low expression of Bax may require more effective adjuvant treatment or an intensified follow-up.

expression of Bax was one of the significant independent predictors of poor prognosis in multivariate analysis. Therefore, the present study suggests that locally advanced (Stage II or III) non-squamous NSCLC patients with low expression of Bax may require more effective adjuvant treatment or an intensified follow-up. In conclusion, low expression of Bax was significantly associated with the poor outcome in patients with non-squamous NSCLC. If the prognostic significance of low expression of Bax is validated by further prospective studies with larger numbers of patients, a relatively simple immunohistochemical staining of surgical specimens for the Bax protein may provide valuable information to the oncologist for selecting effective adjuvant treatments or follow-up strategies. Funding Ajou University Medical Center, Suwon, Korea. Funding to pay the Open Access publication charges for this article was provided by Ajou University Medical Center. Acknowledgements The authors are grateful to Geum Sook Jeong for administrative assistance in preparing and submitting the manuscript. We would also like to thank Joo Yeon Kim for proofreading the manuscript.

INTRODUCTION The human epidermal growth factor receptor (HER) family consists of four tyrosine kinase receptors: HER1/ErbB-1 [epidermal growth factor receptor (EGFR)], HER2/ErbB-2/Neu, HER3/ErbB-3 and HER4/ErbB-4 (1). These receptors are highly expressed in many solid tumor types, including lung (2), breast (3), ovarian (4), colorectal (5) and prostate (6). They also play an important role in the proliferation, differentiation, motility, adhesion, protection from apoptosis and transformation of tumor cells (1,7,8). Receptor dimerization is essential for HER pathway activation, leading to phosphorylation and downstream signal transduction (1). Unlike HER1, HER3 and HER4, HER2 is considered to be an orphan receptor: no direct ligand for HER2 has been discovered. HER2 assumes an open conformation, with its dimerization domain permanently exposed for interaction with other ligand-activated HER receptors (9). HER2 is the preferred partner for dimer formation, and pre-clinical studies have demonstrated that HER2-containing heterodimers are the most mitogenic and have the highest transformation potential of all the HER complexes (1,10,11).

main permanently exposed for interaction with other ligand-activated HER receptors (9). HER2 is the preferred partner for dimer formation, and pre-clinical studies have demonstrated that HER2-containing heterodimers are the most mitogenic and have the highest transformation potential of all the HER complexes (1,10,11). Pertuzumab (rhuMAb 2C4, RO4368451) is a recombinant, humanized monoclonal antibody that targets an epitope within the HER2 dimerization domain (12,13). Pertuzumab inhibits the formation of the HER2 heterodimer, independent of HER2 expression levels, and its binding site does not overlap with the epitope on HER2 that is recognized by trastuzumab (Herceptin) (14,15). Pertuzumab has demonstrated growth inhibition in ovarian, lung, breast and prostate tumor cells without HER2 overexpression (15). In the initial US Phase I study, the dose of pertuzumab was escalated from 0.5 to 15 mg/kg. The majority of adverse events were of Grades 1–2 severity and included asthenia, vomiting, nausea, abdominal pain, rash, diarrhea, pain and anemia. A Grade 3 gastrointestinal hemorrhage was observed at the 15 mg/kg dose level and this was determined as a dose-limiting toxicity (DLT); however, the maximum tolerated dose (MTD) was not reached up to the dose level of 15 mg/kg. Two out of 21 patients, one with ovarian cancer and the other with pancreatic islet cell carcinoma, achieved a partial response (16).

observed at the 15 mg/kg dose level and this was determined as a dose-limiting toxicity (DLT); however, the maximum tolerated dose (MTD) was not reached up to the dose level of 15 mg/kg. Two out of 21 patients, one with ovarian cancer and the other with pancreatic islet cell carcinoma, achieved a partial response (16). In light of these promising pre-clinical and clinical findings, we conducted a Phase I study of pertuzumab in Japanese patients with solid tumors. The objectives of this study were to determine the toxicity, pharmacokinetics and anti-tumor activities of pertuzumab.

observed at the 15 mg/kg dose level and this was determined as a dose-limiting toxicity (DLT); however, the maximum tolerated dose (MTD) was not reached up to the dose level of 15 mg/kg. Two out of 21 patients, one with ovarian cancer and the other with pancreatic islet cell carcinoma, achieved a partial response (16). In light of these promising pre-clinical and clinical findings, we conducted a Phase I study of pertuzumab in Japanese patients with solid tumors. The objectives of this study were to determine the toxicity, pharmacokinetics and anti-tumor activities of pertuzumab. PATIENTS AND METHODS Patient Eligibility Patients were eligible if they had histologically or cytologically confirmed malignant solid tumors that were resistant to standard therapies, or for which there was no effective treatment. HER2 status was not used in the selection process, except for those patients with breast cancer. Eligibility criteria were: age 20–74 years; Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1; life expectancy >12 weeks; no previous chemotherapy, radiation therapy or surgery within 4 weeks before treatment with pertuzumab (6 weeks for previous treatment with nitrosoureas or mitomycin); adequate bone marrow (absolute neutrophil count ≥1500/mm3, platelet count ≥75 000/mm3 and hemoglobin level ≥9.0 g/dl), hepatic [serum total bilirubin ≤1.5 mg/dl, aspartate amino transferase (AST) ≤80 IU/l, alanine amine transferase (ALT) ≤80 IU/l and alkaline phosphatase (ALP) ≤1400 IU/l], renal (serum creatinine ≤1.3 mg/dl), coagulation [prothrombin time international normalized ratio (PT-INR) <1.3, activated partial thromboplastin time (APTT) <60 s], pulmonary [arterial oxygen pressure (PaO2) ≥70 torr], and cardiac [left ventricular ejection fraction (LVEF) ≥50% by echocardiography] functions. Exclusion criteria included: pregnancy or lactation; symptomatic brain metastasis; HER2-positive breast cancer by fluorescence in situ hybridization; previous treatment with antibody agents for HER receptors; a history of hypersensitivity reactions to any drug; pleural effusion and ascites that required drainage; cumulative doxorubicin dose of ≥360 mg/m2 given prior to study; hepatitis B or C or HIV; and serious pre-existing medical conditions such as uncontrolled infections, hypertension, hypercalcemia, diabetes, severe heart disease or psychogenic disorders.

ns to any drug; pleural effusion and ascites that required drainage; cumulative doxorubicin dose of ≥360 mg/m2 given prior to study; hepatitis B or C or HIV; and serious pre-existing medical conditions such as uncontrolled infections, hypertension, hypercalcemia, diabetes, severe heart disease or psychogenic disorders. Written informed consent was obtained from all patients. The study was approved by the institutional review board at the National Cancer Center, and conducted in accordance with Japanese Good Clinical Practice (GCP) guidelines. Drug Administration and Dose Escalation Procedure Pertuzumab (rhuMAb 2C4, RO4368451) was supplied by Chugai Pharmaceutical Co. Ltd (Tokyo, Japan). Each 10 ml vial contained approximately 175 mg pertuzumab formulated in 10 mmol/l l-histidine (pH 6.0), 240 mmol/l sucrose and 0.02% polysorbate 20. Pertuzumab was diluted in 250 ml saline immediately prior to administration. The calculated dose was administered by a 90 min intravenous infusion at the initial cycle of treatment, and repeated every 3 weeks. No prophylactic pre-medication to reduce hypersensitivity reaction was given. If no hypersensitivity reaction (related to pertuzumab administration) was observed, administration was shortened to a 30 min infusion after the second treatment cycle.

s infusion at the initial cycle of treatment, and repeated every 3 weeks. No prophylactic pre-medication to reduce hypersensitivity reaction was given. If no hypersensitivity reaction (related to pertuzumab administration) was observed, administration was shortened to a 30 min infusion after the second treatment cycle. The starting dose was 5 mg/kg, with subsequent dose escalations to 10, 15, 20 and 25 mg/kg. The upper dose of 25 mg/kg was set based on the serum trough level estimation of efficacy in pre-clinical models (25 µg/ml) with the aim of exploring the safety range in Japanese patients considering the differences in body weight between patients from western countries and those from Japan. At least three patients were entered at each dose level. Three additional patients were entered at the same dose, if a DLT was observed in one of the initial three patients. The MTD was defined as the dose level at which two of three to six patients experienced DLT. DLT was defined as: Grade 4 hematological toxicities; Grade 3 or 4 non-hematological toxicities except for AST/ALT and serum creatinine elevations; AST/ALT elevations >150 IU/l; or serum creatinine elevation >2.0 mg/dl.

tients. The MTD was defined as the dose level at which two of three to six patients experienced DLT. DLT was defined as: Grade 4 hematological toxicities; Grade 3 or 4 non-hematological toxicities except for AST/ALT and serum creatinine elevations; AST/ALT elevations >150 IU/l; or serum creatinine elevation >2.0 mg/dl. Pre-treatment Assessment and Follow-up Studies Complete clinical assessments, including physical examination, ECOG PS, blood pressure, weight, chest X-ray, ECG, echocardiography and routine laboratory tests, were performed for all patients before study entry and prior to each treatment cycle. Routine laboratory tests included complete blood count and differential testing of electrolytes, urea nitrogen, serum creatinine, serum total protein, serum albumin, glucose, total bilirubin, AST, ALT, ALP, lactic dehydrogenase, gamma-glutamyl transferase, PaO2, adequate tumor markers, PT-INR, APTT and urinalysis. With the exception of PaO2 and tumor markers, these laboratory tests were repeated on Days 1, 8, 22, 29 and 42, and then every 3 weeks. PaO2 was assessed on an as needed basis. Tumor markers were assessed on alternate treatment cycles (cycles 1 and 3). Anti-pertuzumab antibody was assessed before each treatment cycle. Toxicities were evaluated according to the National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 2.0. Tumor responses were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria (17).

Pre-treatment Assessment and Follow-up Studies Complete clinical assessments, including physical examination, ECOG PS, blood pressure, weight, chest X-ray, ECG, echocardiography and routine laboratory tests, were performed for all patients before study entry and prior to each treatment cycle. Routine laboratory tests included complete blood count and differential testing of electrolytes, urea nitrogen, serum creatinine, serum total protein, serum albumin, glucose, total bilirubin, AST, ALT, ALP, lactic dehydrogenase, gamma-glutamyl transferase, PaO2, adequate tumor markers, PT-INR, APTT and urinalysis. With the exception of PaO2 and tumor markers, these laboratory tests were repeated on Days 1, 8, 22, 29 and 42, and then every 3 weeks. PaO2 was assessed on an as needed basis. Tumor markers were assessed on alternate treatment cycles (cycles 1 and 3). Anti-pertuzumab antibody was assessed before each treatment cycle. Toxicities were evaluated according to the National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 2.0. Tumor responses were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria (17). Pharmacokinetics Pharmacokinetic evaluation was performed in all patients. Venous blood samples (5 ml) were taken and immediately centrifuged at 1500 rpm for 10 min. Serum was aliquoted and stored at −70°C or less in polyethylene tubes until analysis. Pharmacokinetic sampling points in the initial treatment cycle were before infusion, at the end of infusion, after 1.5, 4 and 8 h, and at 8, 15 and 22 days after completion of infusion. In the second treatment cycle, sampling points were before infusion, at the end of infusion, at 4 and 8 h, and at 8 and 22 days. For the third cycle, pharmacokinetic samples were taken before infusion, at the end of infusion, and 8 and 22 days after treatment.

8 h, and at 8, 15 and 22 days after completion of infusion. In the second treatment cycle, sampling points were before infusion, at the end of infusion, at 4 and 8 h, and at 8 and 22 days. For the third cycle, pharmacokinetic samples were taken before infusion, at the end of infusion, and 8 and 22 days after treatment. The concentration of pertuzumab in serum was measured by receptor-binding enzyme-linked immunosorbent assay using p185HER2 extracellular domain to capture pertuzumab. Bound pertuzumab was detected with mouse anti-human Fc-horseradish peroxidase (Jackson ImmunoResearch Laboratories Inc., West Grove, PA, USA), and tetramethyl benzidine (KPI Inc., Gaithersburg, MD, USA) was used as the substrate for color development to quantify serum pertuzumab against a known standard curve. The minimum quantifiable concentration was 0.025 µg/ml. Analyzed pharmacokinetic parameters included the maximum plasma drug concentration (Cmax), area under the plasma drug concentration–time curve (AUC), distribution volume at steady state (Vdss), terminal half-life, mean residence time (MRT) and clearance (CL). These data were analyzed by two-compartmental method analysis using the WinNonlin software program version 4.1 (Pharsight Corporation, CA, USA).

Cmax), area under the plasma drug concentration–time curve (AUC), distribution volume at steady state (Vdss), terminal half-life, mean residence time (MRT) and clearance (CL). These data were analyzed by two-compartmental method analysis using the WinNonlin software program version 4.1 (Pharsight Corporation, CA, USA). RESULTS Patient Characteristics Eighteen patients (11 males and 7 females; ECOG PS 0 or 1) were entered in the study. Patient characteristics are shown in Table 1. Median age and body weight were 57 (range 38–66) years and 57.9 (42.9–73.5) kg, respectively. Non-small-cell lung cancer (NSCLC) was the predominant tumor type. Thirteen patients had received surgical resection for primary tumors, 18 had received prior chemotherapy and 8 had ≥4 prior treatment regimens. A total of 32 cycles of pertuzumab were administered, and the median number of cycles administered per patient was 2 (range 1–4). All 18 patients were included in the toxicity evaluation and 15 patients met the RECIST criteria. Three patients were not evaluable for efficacy because they did not meet RECIST criteria for adequate measurable lesions. Table 1. Patient characteristics Characteristics No. of patients Total no. of patients 18 Male/female 11/7 ECOG performance status 0 5 1 13 Tumor type NSCLC 7 Rectum 3 Stomach 2 Ovary 2 Breast 1 Esophagus 1 Germ cell 1 Primary unknown 1 Prior treatment Surgery 13 Radiotherapy 6 Chemotherapy 18 ECOG, Eastern Cooperative Oncology Group; NSCLC, non-small-cell lung cancer.

. of patients Total no. of patients 18 Male/female 11/7 ECOG performance status 0 5 1 13 Tumor type NSCLC 7 Rectum 3 Stomach 2 Ovary 2 Breast 1 Esophagus 1 Germ cell 1 Primary unknown 1 Prior treatment Surgery 13 Radiotherapy 6 Chemotherapy 18 ECOG, Eastern Cooperative Oncology Group; NSCLC, non-small-cell lung cancer. Safety and Tolerability The main toxicities seen in all cycles of treatment are shown in Table 2. The majority of toxicities were mild (Grades 1–2) in severity, and diarrhea, rash, brain natriuretic peptide (BNP) increase and lymphopenia were the most frequent toxicities seen. Table 2. Major toxicities in all cycles Pertuzumab dose (mg/kg) 5 10 15 20 25 Total % No. of patients 3 3 3 3 6 NCI-CTC grade 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 Diarrhea 2 0 3 0 3 0 2 0 1 0 11 61.1 Rash 3 0 2 0 1 0 0 0 3 0 9 50.0 BNP increase 2 0 0 0 2 0 1 0 4 0 9 50.0 Lymphopenia 1 0 0 0 1 1 2 0 1 1 7 38.9 Anemia 1 0 1 0 0 0 1 0 2 0 5 27.8 Leukocytosis 2 0 1 0 1 0 1 0 0 0 5 27.8 Hyperglycemia 0 0 2 0 2 0 0 0 1 0 5 27.8 Neutropenia 2 0 1 0 1 0 0 0 0 0 4 22.2 Leukopenia 1 0 0 0 0 0 2 0 1 0 4 22.2 Nausea 2 0 0 0 0 0 0 0 1 0 3 16.7 Stomatitis 0 0 0 0 1 0 0 0 2 0 3 16.7 Asthenia 1 0 0 0 1 0 1 0 0 0 3 16.7 Gamma-GTP increase 0 0 0 0 0 0 0 0 1 1a 2 11.1 HSR 0 0 0 0 0 0 0 0 2 0 2 11.1 BNP, brain natriuretic peptide; Gamma-GTP, gamma-glutamyl transpeptidase; HSR, hypersensitivity reaction; NCI-CTC, National Cancer Institute Common Toxicity Criteria. aDose-limiting toxicity.

No. of patients 3 3 3 3 6 NCI-CTC grade 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 1, 2 ≥3 Diarrhea 2 0 3 0 3 0 2 0 1 0 11 61.1 Rash 3 0 2 0 1 0 0 0 3 0 9 50.0 BNP increase 2 0 0 0 2 0 1 0 4 0 9 50.0 Lymphopenia 1 0 0 0 1 1 2 0 1 1 7 38.9 Anemia 1 0 1 0 0 0 1 0 2 0 5 27.8 Leukocytosis 2 0 1 0 1 0 1 0 0 0 5 27.8 Hyperglycemia 0 0 2 0 2 0 0 0 1 0 5 27.8 Neutropenia 2 0 1 0 1 0 0 0 0 0 4 22.2 Leukopenia 1 0 0 0 0 0 2 0 1 0 4 22.2 Nausea 2 0 0 0 0 0 0 0 1 0 3 16.7 Stomatitis 0 0 0 0 1 0 0 0 2 0 3 16.7 Asthenia 1 0 0 0 1 0 1 0 0 0 3 16.7 Gamma-GTP increase 0 0 0 0 0 0 0 0 1 1a 2 11.1 HSR 0 0 0 0 0 0 0 0 2 0 2 11.1 BNP, brain natriuretic peptide; Gamma-GTP, gamma-glutamyl transpeptidase; HSR, hypersensitivity reaction; NCI-CTC, National Cancer Institute Common Toxicity Criteria. aDose-limiting toxicity. Diarrhea was observed in 11 (61.1%) of 18 patients; 10 of these were defined as Grade 1, and 1 was Grade 2. The onset of diarrhea was within 1 week of treatment and resolved on treatment with a Lactobacillus preparation. No watery diarrhea was observed and treatment with loperamide was not required. Rash was experienced by 9 (50%) of 18 patients, 6 of which were defined as Grade 1 and 3 as Grade 2, and mostly consisted of acne and seborrhea. The onset of these skin toxicities generally occurred within 7–14 days of the initial treatment cycle, persisting for 1–2 weeks and almost asymptomatic with no medication required.

was experienced by 9 (50%) of 18 patients, 6 of which were defined as Grade 1 and 3 as Grade 2, and mostly consisted of acne and seborrhea. The onset of these skin toxicities generally occurred within 7–14 days of the initial treatment cycle, persisting for 1–2 weeks and almost asymptomatic with no medication required. BNP increase and lymphopenia were observed in nine (50%) and seven (38.9%) patients, respectively. The largest elevation of BNP was 119.5 pg/ml in the 20 mg/kg cohort, but this patient was asymptomatic. No cardiac dysfunction (assessed by troponin-T, ECG and echocardiography) was observed among any patients. Lymphopenia was also asymptomatic, and the severity appeared to be dose-related. Hypersensitivity reactions were observed in two patients immediately following pertuzumab administration: one experienced Grade 1 fever and the other had Grade 2 fever. Both resolved without medication. No other hypersensitivity symptoms, such as dyspnea, bronchospasm, hypotension or tachycardia, were observed. One patient at the 25 mg/kg dose level had a Grade 3 gamma-glutamyl transpeptidase (gamma-GTP) increase. This patient was a 57-year-old man, with ECOG PS 1, who was diagnosed with advanced gastric cancer with multiple liver metastases. The Grade 3 gamma-GTP increase was observed on the third day of pertuzumab treatment, but it was asymptomatic and resolved without medication. It was considered to be a DLT according to the DLT definition.

a 57-year-old man, with ECOG PS 1, who was diagnosed with advanced gastric cancer with multiple liver metastases. The Grade 3 gamma-GTP increase was observed on the third day of pertuzumab treatment, but it was asymptomatic and resolved without medication. It was considered to be a DLT according to the DLT definition. Up to the 25 mg/kg dose level, one DLT (Grade 3 gamma-GTP increase at a dose of 25 mg/kg) was observed. Other toxicities were considered acceptable. Therefore, the MTD was not reached, and the acceptable tolerability of pertuzumab doses up to 25 mg/kg was confirmed. Anti-tumor Activity Fifteen of 18 patients were evaluable for anti-tumor response. Two patients had stable disease (one rectal cancer and one NSCLC), and 13 had progressive disease. There was limited evidence of anti-tumor activity in this study; therefore, a relationship between pertuzumab dose and anti-tumor response could not be determined. Pharmacokinetics Serum sampling for pharmacokinetic analysis was performed in all 18 patients in the initial cycle of treatment. In subsequent cycles, samples from only 9 of 18 patients were available for pharmacokinetic analysis; the other 9 patients were withdrawn due to disease progression. The pharmacokinetic profile of pertuzumab is summarized in Table 3, and trough concentrations of subsequent cycles are summarized in Table 4. Also, the mean serum concentration–time profiles of pertuzumab are illustrated in Fig. 1. Figure 1. Mean serum concentration–time profiles of pertuzumab. Table 3. Pharmacokinetic parameters

Pharmacokinetics Serum sampling for pharmacokinetic analysis was performed in all 18 patients in the initial cycle of treatment. In subsequent cycles, samples from only 9 of 18 patients were available for pharmacokinetic analysis; the other 9 patients were withdrawn due to disease progression. The pharmacokinetic profile of pertuzumab is summarized in Table 3, and trough concentrations of subsequent cycles are summarized in Table 4. Also, the mean serum concentration–time profiles of pertuzumab are illustrated in Fig. 1. Figure 1. Mean serum concentration–time profiles of pertuzumab. Table 3. Pharmacokinetic parameters Dose (mg/kg) No. of patients Cmax (mg/ml) AUC (day*mg/ml) CL (ml/day/kg) Vc (ml/kg) Vdss (ml/kg) MRT (days) t1/2 initial (h) t1/2 terminal (days) 5 3 105 ± 14.2 928 ± 162 5.51 ± 1.03 46.0 ± 6.54 88.5 ± 14.5 16.3 ± 2.89 7.17 ± 4.47 11.5 ± 1.95 10 3 178 ± 31.1 2190 ± 813 4.95 ± 1.60 56.0 ± 9.12 95.1 ± 15.3 20.0 ± 3.83 13.6 ± 7.89 14.3 ± 2.66 15 3 314 ± 65.1 4220 ± 2090 4.24 ± 2.17 48.6 ± 11.1 96.3 ± 32.5 24.7 ± 7.32 26.5 ± 10.7 18.2 ± 5.17 20 3 334 ± 62.4 3870 ± 576 5.25 ± 0.848 57.7 ± 8.22 85.6 ± 6.70 16.7 ± 3.59 5.02 ± 5.22 11.7 ± 2.61 25 6 495 ± 91.8 6490 ± 2090 4.30 ± 1.72 50.4 ± 12.7 92.4 ± 15.2 24.2 ± 9.37 11.6 ± 9.81 17.3 ± 6.97 Values are mean ± SD. AUC, area under plasma drug concentration–time curve; CL, clearance; Cmax, maximum plasma drug concentration; MRT, mean residence time; t1/2, half-life; Vc, distribution volume of the central compartment; Vdss, distribution volume at steady state. Table 4. Trough concentration ratio of subsequent cycles

Dose (mg/kg) No. of patients Cmax (mg/ml) AUC (day*mg/ml) CL (ml/day/kg) Vc (ml/kg) Vdss (ml/kg) MRT (days) t1/2 initial (h) t1/2 terminal (days) 5 3 105 ± 14.2 928 ± 162 5.51 ± 1.03 46.0 ± 6.54 88.5 ± 14.5 16.3 ± 2.89 7.17 ± 4.47 11.5 ± 1.95 10 3 178 ± 31.1 2190 ± 813 4.95 ± 1.60 56.0 ± 9.12 95.1 ± 15.3 20.0 ± 3.83 13.6 ± 7.89 14.3 ± 2.66 15 3 314 ± 65.1 4220 ± 2090 4.24 ± 2.17 48.6 ± 11.1 96.3 ± 32.5 24.7 ± 7.32 26.5 ± 10.7 18.2 ± 5.17 20 3 334 ± 62.4 3870 ± 576 5.25 ± 0.848 57.7 ± 8.22 85.6 ± 6.70 16.7 ± 3.59 5.02 ± 5.22 11.7 ± 2.61 25 6 495 ± 91.8 6490 ± 2090 4.30 ± 1.72 50.4 ± 12.7 92.4 ± 15.2 24.2 ± 9.37 11.6 ± 9.81 17.3 ± 6.97 Values are mean ± SD. AUC, area under plasma drug concentration–time curve; CL, clearance; Cmax, maximum plasma drug concentration; MRT, mean residence time; t1/2, half-life; Vc, distribution volume of the central compartment; Vdss, distribution volume at steady state. Table 4. Trough concentration ratio of subsequent cycles Dose (mg/kg) No. of cycles No. of patients Mean Standard deviation CV (%) Median Min Max 5 2 2 1.43 0.610 42.6 1.43 1.00 1.86 3 2 2.29 0.0427 1.9 2.29 2.26 2.32 10 2 1 1.72 — — 1.72 1.72 1.72 15 2 1 1.43 — — 1.43 1.43 1.43 20 2 1 1.76 — — 1.76 1.76 1.76 25 2 4 1.88 0.0805 4.3 1.86 1.81 2.00 3 1 2.31 — — 2.31 2.31 2.31 CV, coefficient of variation.

. of patients Mean Standard deviation CV (%) Median Min Max 5 2 2 1.43 0.610 42.6 1.43 1.00 1.86 3 2 2.29 0.0427 1.9 2.29 2.26 2.32 10 2 1 1.72 — — 1.72 1.72 1.72 15 2 1 1.43 — — 1.43 1.43 1.43 20 2 1 1.76 — — 1.76 1.76 1.76 25 2 4 1.88 0.0805 4.3 1.86 1.81 2.00 3 1 2.31 — — 2.31 2.31 2.31 CV, coefficient of variation. The concentration–time profile of pertuzumab was biphasic, with mean initial half-life and terminal half-life of 11.6 h and 17.3 days at the 25 mg/kg dose level, respectively. Vdss and CL showed moderate inter-individual variability and the mean ± SD values (CV%) for Vdss and CL were 92.4 ± 15.2 (16.5 CV%) ml/kg and 4.30 ± 1.72 (40.1 CV%) ml/day/kg, respectively. At doses of 5–25 mg/kg, CL, Vdss, the distribution volume of the central compartment (Vc) and the terminal half-life did not change with dose. The peak serum concentration (Cmax) and the AUC increased proportionally with the dose of pertuzumab (r = 0.914 and r = 0.808, respectively), suggesting linear pharmacokinetics within the dose range in this study.

e distribution volume of the central compartment (Vc) and the terminal half-life did not change with dose. The peak serum concentration (Cmax) and the AUC increased proportionally with the dose of pertuzumab (r = 0.914 and r = 0.808, respectively), suggesting linear pharmacokinetics within the dose range in this study. DISCUSSION Pertuzumab is a humanized monoclonal antibody that inhibits dimerization of HER2 with other ligand-activated HER kinases. At the start of this study, the pertuzumab study with a flat dose (i.e. unadjusted by body weight) was also in preliminary stages in western countries. Its planned higher dose (1050 mg/person) was based on the highest pertuzumab dose in the US Phase I study (15 mg/kg) and a median body weight of approximately 70 kg. As the body weight of Japanese patients was expected to be lower than US patients, it was thought that this study needed to determine the safety range of pertuzumab doses of more than 15 mg/kg in this population. Although one DLT was observed at the 25 mg/kg dose level, pertuzumab was generally well tolerated and the MTD of pertuzumab was not reached up to a dose level of 25 mg/kg.

than US patients, it was thought that this study needed to determine the safety range of pertuzumab doses of more than 15 mg/kg in this population. Although one DLT was observed at the 25 mg/kg dose level, pertuzumab was generally well tolerated and the MTD of pertuzumab was not reached up to a dose level of 25 mg/kg. The most frequent toxicities observed were diarrhea, rash, BNP increase and lymphopenia. The most frequent adverse event was diarrhea (61.1%), which was generally consistent with findings from the initial Phase I study in the USA (43%) (16), though higher than that observed with other humanized antibodies (trastuzumab, bevacizumab and cetuximab: <10%) (18–23). However, severity was generally mild (10 of 11 cases were Grade 1) and intensive supportive treatment such as loperamide was not required. The precise mechanism of the diarrhea observed has not been determined, but it was considered that pertuzumab was tolerable in Japanese patients. Rash was experienced by 50% of patients, mostly consisting of acne and seborrhea. The profile of rash was similar to that seen in the US study (16). As pertuzumab inhibits heterodimerization of HER1/HER2, this rash was considered as possibly related to treatment. However, all these events were mild in severity and it was thought that pertuzumab-related rash was milder than the reported skin disorders due to EGFR inhibition with cetuximab (22–24).

the US study (16). As pertuzumab inhibits heterodimerization of HER1/HER2, this rash was considered as possibly related to treatment. However, all these events were mild in severity and it was thought that pertuzumab-related rash was milder than the reported skin disorders due to EGFR inhibition with cetuximab (22–24). Hypersensitivity reactions were observed in two (11.1%) patients. These reactions were transient fever and headache and resolved immediately without medication. Furthermore, no anti-pertuzumab antibody production was observed. Therefore, the administration of pertuzumab could be considered as safe as other humanized monoclonal antibodies, such as bevacizumab and cetuximab. Following prior experience with trastuzumab (25), cardiotoxicity was closely monitored throughout this study. A BNP increase was observed in 50% of patients; however, no clinically significant cardiotoxicity or other laboratory abnormalities, such as troponin-T increase and LVEF decrease, were observed. A DLT (Grade 3 gamma-GTP increase) was observed in one patient at the 25 mg/kg dose level. This resolved without medication. As pertuzumab is not metabolized by the liver, the causality could not be considered as definite. Routine measurement of gamma-GTP levels was not included in the initial study design, so the frequency of such increases is unknown. Routine assessment of gamma-GTP levels should be considered for future studies.

dication. As pertuzumab is not metabolized by the liver, the causality could not be considered as definite. Routine measurement of gamma-GTP levels was not included in the initial study design, so the frequency of such increases is unknown. Routine assessment of gamma-GTP levels should be considered for future studies. The pharmacokinetic profile of pertuzumab revealed moderate inter-individual variability and linear pharmacokinetics. The mean terminal half-life at the 25 mg/kg dose level was 17.3 days, and the concentration–time profile was similar to that of other monoclonal antibodies such as trastuzumab (25.5 days) and bevacizumab (18.4 days). The observed pharmacokinetic profile was similar to that seen in the US Phase I study (16). The variability of pertuzumab steady-state trough serum concentrations and exposure after fixed, body-weight-based, or body-surface area (BSA)-based dosing in cancer patients had previously been examined (26), and demonstrated the feasibility of administration using flat dosing in specific patients such as ovarian or breast cancer patients.

tuzumab steady-state trough serum concentrations and exposure after fixed, body-weight-based, or body-surface area (BSA)-based dosing in cancer patients had previously been examined (26), and demonstrated the feasibility of administration using flat dosing in specific patients such as ovarian or breast cancer patients. In this Phase I study, the safe range of pertuzumab dosing in Japanese patients was determined to be up to 25 mg/kg. This dose level was higher than that determined in the US Phase I study (15 mg/kg). However, the median body weight of enrolled patients in this study was 57.9 kg, compared with a median body weight of 69.0 kg for patients in the US study. Considering the results from these studies and the respective patient body weights, it is thought that this pertuzumab dose range may apply for common dose settings such as a flat dose in further studies. In conclusion, the MTD of pertuzumab was not reached up to a dose of 25 mg/kg and acceptable tolerability was confirmed. Although an objective anti-tumor effect was not observed in this study, the profile of pertuzumab is unique and encouraging, and further investigation with flat doses and in combination with other cytotoxic or molecular-targeted drugs for various tumor types is warranted. Funding This study was supported by Chugai Pharmaceutical Co. Ltd. Funding to Pay the Open Access publication charges for this article was provided by Chugai Pharmaceutical Co., Ltd. Conflict of interest statement None declared.

INTRODUCTION According to the Japanese Classification of Esophageal Cancer by the Japan Esophageal Society, T1 esophageal tumors defined by the TNM system (6th edition) is further divided into T1a (mucosal) and T1b (submucosal) tumors by the Japanese Classification of Esophageal Cancer (1). Endoscopic mucosal resection (EMR) is usually indicated for T1a tumor, whereas the standard treatment for T1b tumors has been a surgical resection with adequate lymph node dissection in Japan because of the high incidence of lymph node metastasis (∼40%) (2). However, surgical resection often deteriorates patient's general condition. Some patients with clinical T1b esophageal cancer are over-treated by surgery with a result of pathological T1a tumor, because the accuracy of diagnosis of T1b esophageal cancer is not high. Recent advance in techniques of EMR including endoscopic submucosal dissection (ESD) enables us to remove the clinical T1b tumor and gives us accurate diagnosis of depth of invasion. However, the patients with T1b are at risk of lymph node metastasis (3) and therefore EMR alone cannot be considered as curative.

INTRODUCTION According to the Japanese Classification of Esophageal Cancer by the Japan Esophageal Society, T1 esophageal tumors defined by the TNM system (6th edition) is further divided into T1a (mucosal) and T1b (submucosal) tumors by the Japanese Classification of Esophageal Cancer (1). Endoscopic mucosal resection (EMR) is usually indicated for T1a tumor, whereas the standard treatment for T1b tumors has been a surgical resection with adequate lymph node dissection in Japan because of the high incidence of lymph node metastasis (∼40%) (2). However, surgical resection often deteriorates patient's general condition. Some patients with clinical T1b esophageal cancer are over-treated by surgery with a result of pathological T1a tumor, because the accuracy of diagnosis of T1b esophageal cancer is not high. Recent advance in techniques of EMR including endoscopic submucosal dissection (ESD) enables us to remove the clinical T1b tumor and gives us accurate diagnosis of depth of invasion. However, the patients with T1b are at risk of lymph node metastasis (3) and therefore EMR alone cannot be considered as curative. Chemoradiotherapy is one of the effective modalities for both early and advanced esophageal tumors. Since chemoradiotherapy is less toxic than surgical resection, the usefulness has been tested in several clinical trials (4,5). In Japan, a Phase II trial (JCOG9708) was conducted to evaluate the efficacy and the safety of concurrent chemoradiotherapy using 5-fluoraouracil (5-FU) plus cisplatin (CDDP) for T1 tumors (6). However, 22% of patients showed minor relapses that needed to be removed by endoscopic treatment. We have therefore conducted a pilot study of EMR followed by chemoradiotherapy and have reported promising results (7). Thus, the Japan Clinical Oncology Group initiated this multi-institutional Phase II trial (JCOG0508) to evaluate the efficacy and the safety of combined treatment of EMR and chemoradiotherapy for clinical stage I (cT1bN0) esophageal cancer.

y of EMR followed by chemoradiotherapy and have reported promising results (7). Thus, the Japan Clinical Oncology Group initiated this multi-institutional Phase II trial (JCOG0508) to evaluate the efficacy and the safety of combined treatment of EMR and chemoradiotherapy for clinical stage I (cT1bN0) esophageal cancer. The Protocol Review Committee of JCOG approved the protocol in October 2006 and the study was activated in December 2006. JCOG0508 PROTOCOL Purpose The aim of this study is to evaluate the efficacy and the safety of combined treatment of EMR and chemoradiotherapy for clinical stage I (T1b) esophageal cancer. Study Setting The study is a multi-institutional (20 centers), single-arm Phase II trial. Resources This study is supported by the Grants-in-Aid for Cancer Research (17S-3, 17S-5, 20S-3, 20S-6) and Health and Labour Sciences Research Grant for Clinical Cancer Research (17-12) from the Ministry of Health, Labour and Welfare, Japan. Endpoints The primary endpoint is 3-year overall survival (OS) in pT1b cases with negative resection margin (comment 4). The secondary endpoints are 3-year OS and progression-free survival (PFS) in all eligible cases, OS in pT1a-MM (muscularis mucosa) cases with negative resection margin, complications of EMR and adverse events of chemoradiotherapy.

is 3-year overall survival (OS) in pT1b cases with negative resection margin (comment 4). The secondary endpoints are 3-year OS and progression-free survival (PFS) in all eligible cases, OS in pT1a-MM (muscularis mucosa) cases with negative resection margin, complications of EMR and adverse events of chemoradiotherapy. In this trial, resection margin is diagnosed from endoscopic findings immediately after mucosal resection for horizontal margin and from pathological findings for vertical margin. OS is defined as the time from registration to death from any cause, and it is censored at the last contact day for living patient. PFS is defined as the time from registration to either the first event of progression or death from any cause, and it is censored at the latest day when patient is alive without progression.

is defined as the time from registration to death from any cause, and it is censored at the last contact day for living patient. PFS is defined as the time from registration to either the first event of progression or death from any cause, and it is censored at the latest day when patient is alive without progression. Inclusion Criteria Patients are included in this trial if they meet all of the following criteria: (i) histologically proven squamous cell carcinoma of the esophagus by endoscopic biopsy, (ii) tumors located within the thoracic esophagus, (iii) depth of tumor invasion is diagnosed as T1b by endoscopy and endoscopic ultrasonography, (iv) the number of multiple intra-esophageal tumors is less than three, and the depths of invasion of them are diagnosed as cT1a-EP (carcinoma in situ) or cT1a-LPM (tumor invades lamina propria mucosa), (v) clinically node-negative (cN0) and no metastasis to other organs (cM0), (vi) size of main tumor is ≤5 cm, and circularity of esophageal lumen is less than three-fourths, (vii) no ulcerative lesion in the tumors, (viii) no intra-esophageal metastasis, (ix) no prior treatment of chemotherapy or radiation therapy against any other malignancies, except for previous curative EMR for pT1 esophageal cancer, (x) aged between 20 and 75 years old, (xi) performance status of 0 or 1, (xii) sufficient organ functions and (xiii) written informed consent.

a-esophageal metastasis, (ix) no prior treatment of chemotherapy or radiation therapy against any other malignancies, except for previous curative EMR for pT1 esophageal cancer, (x) aged between 20 and 75 years old, (xi) performance status of 0 or 1, (xii) sufficient organ functions and (xiii) written informed consent. Exclusion Criteria Patients are excluded if they meet any of the following criteria: (i) iodine allergy, (ii) enable to discontinue anticoagulant or antiplatelet medications, (iii) synchronous or metachronous (within 5 years) malignancy other than carcinoma in situ, (iv) pregnant or breast-feeding women, (v) severe mental disease, (vi) systemic administration of corticosteroids, (vii) HBs antigen positive, (viii) active bacterial or fungous infection, (ix) concurrent unstable angina or myocardial infarction within 3 months before registration, (x) unstable hypertension, (xi) diabetes mellitus, uncontrolled or controlled with insulin, or (xii) interstitial pneumonia, lung fibrosis or severe emphysema. Registration After confirming the inclusion/exclusion criteria by telephoning or faxing the JCOG Data Center, the patients are registered into this JCOG0508 trial.

Exclusion Criteria Patients are excluded if they meet any of the following criteria: (i) iodine allergy, (ii) enable to discontinue anticoagulant or antiplatelet medications, (iii) synchronous or metachronous (within 5 years) malignancy other than carcinoma in situ, (iv) pregnant or breast-feeding women, (v) severe mental disease, (vi) systemic administration of corticosteroids, (vii) HBs antigen positive, (viii) active bacterial or fungous infection, (ix) concurrent unstable angina or myocardial infarction within 3 months before registration, (x) unstable hypertension, (xi) diabetes mellitus, uncontrolled or controlled with insulin, or (xii) interstitial pneumonia, lung fibrosis or severe emphysema. Registration After confirming the inclusion/exclusion criteria by telephoning or faxing the JCOG Data Center, the patients are registered into this JCOG0508 trial. Quality Control of EMR Twenty institutions among the Gastrointestinal Oncology Study Group of the JCOG participate in this trial. All participating physicians have agreed to the technical details for EMR. For quality control of EMR technique and endoscopic diagnosis, we perform central review of the photographs in all patients at the semi-annual investigators meeting. Regarding an ESD procedure, we permit it only for expert physicians who have significant experiences in ESD and EMR, and they are registered by the primary investigator (M.M.). The minimum request for ESD permission is the experience of EMR ≥ 50 and ESD ≥ 10 for esophageal carcinoma, ESD ≥ 50 for gastric cancer and perforation rate ≤2% in total.

we permit it only for expert physicians who have significant experiences in ESD and EMR, and they are registered by the primary investigator (M.M.). The minimum request for ESD permission is the experience of EMR ≥ 50 and ESD ≥ 10 for esophageal carcinoma, ESD ≥ 50 for gastric cancer and perforation rate ≤2% in total. Treatment Methods Endoscopic Mucosal Resection EMR is performed against esophageal tumors within 30 days from registration. The technical methods of EMR approved in this trial are a two-channel method, a cap method or an esophageal endoscopic mucosal resection-tube method (8). Only the registered physicians are allowed to perform ESD in this trial. After EMR, it should be confirmed endoscopically that no iodine-unstained area is left. Physicians need to take pictures before and after EMR and submit them to the primary investigator for quality control of EMR technique and endoscopic diagnosis. Chemoradiotherapy In cases of pT1a tumor with negative resection margin and no vascular invasion, no additional treatment after EMR is given. In other cases, chemoradiotherapy was started at 29–70 days after EMR. The chemotherapy regimen is continuous 5-FU (700 mg/m2/day, days 1–4 and 29–32) and CDDP (70 mg/m2/day, days 1 and 29). The dose of radiotherapy is 41.4 Gy/23 Fr/5 weeks (5 days/week) for cases with negative resection margin and 50.4 Gy/28 Fr/5 weeks (5 days/week) with boost on the primary site for the case with positive resection margin, respectively.

uous 5-FU (700 mg/m2/day, days 1–4 and 29–32) and CDDP (70 mg/m2/day, days 1 and 29). The dose of radiotherapy is 41.4 Gy/23 Fr/5 weeks (5 days/week) for cases with negative resection margin and 50.4 Gy/28 Fr/5 weeks (5 days/week) with boost on the primary site for the case with positive resection margin, respectively. Follow-up Patients are followed with blood tests, upper gastrointestinal endoscopy and computed tomography at least every 4 months for 3 years. Study Design and Statistical Methods This trial determines the efficacy and the safety of combined treatment of EMR and chemoradiotherapy for cT1b esophageal cancer in terms of 3-year OS. Additionally, 3-year OS in all eligible patients are evaluated as the most important secondary endpoint. The sample size is 82 for pT1b cases with negative resection margin with the power of 90%. In case this hypothesis rejected, the secondary hypothesis for all eligible patients can be tested using hierarchical method keeping trial-wise α error nominal level, one-sided 5%, with the power of 80%. To test the hypothesis, 3-year OS estimated by Kaplan–Meier method and its confidence interval by Greenwood’s formula is used. The total number of registered patients is estimated as 137, because the proportion of pT1b cases with margin-negative among all eligible patients is predicted as ∼60%. This study was registered with UMIN-CTR [www.umin.ac.jp/ctr/], identification number UMIN000000553.

Study Design and Statistical Methods This trial determines the efficacy and the safety of combined treatment of EMR and chemoradiotherapy for cT1b esophageal cancer in terms of 3-year OS. Additionally, 3-year OS in all eligible patients are evaluated as the most important secondary endpoint. The sample size is 82 for pT1b cases with negative resection margin with the power of 90%. In case this hypothesis rejected, the secondary hypothesis for all eligible patients can be tested using hierarchical method keeping trial-wise α error nominal level, one-sided 5%, with the power of 80%. To test the hypothesis, 3-year OS estimated by Kaplan–Meier method and its confidence interval by Greenwood’s formula is used. The total number of registered patients is estimated as 137, because the proportion of pT1b cases with margin-negative among all eligible patients is predicted as ∼60%. This study was registered with UMIN-CTR [www.umin.ac.jp/ctr/], identification number UMIN000000553. Interim Analysis and Monitoring Interim analysis is not planned. If the number of cases with treatment-related death, severe (Grade 4) bleeding or severe (Grade 4) perforation reaches seven, the registration will be suspended unless the JCOG Data and Safety Monitoring Committee approves to continue this trial. The JCOG Data Center is responsible for data management, central monitoring and statistical analysis. This center also provides semi-annual monitoring reports, each of which is submitted to and reviewed by the JCOG Data and Safety Monitoring Committee on demand of the JCOG Data Center. None of physicians administering the interventions are involved in the data analysis. For quality assurance, site-visit audits, not for a specific study basis but for the study group basis, are done by the JCOG Audit Committee.

reviewed by the JCOG Data and Safety Monitoring Committee on demand of the JCOG Data Center. None of physicians administering the interventions are involved in the data analysis. For quality assurance, site-visit audits, not for a specific study basis but for the study group basis, are done by the JCOG Audit Committee. Funding This study was supported by a grant from the Ministry of Health and Welfare of Japan (H20-Ganrinsho-Ippan-015). Conflict of interest statement None declared. Acknowledgements The authors thank Dr Seiichiro Yamamoto and Mr Taro Shibata for statistical study design, and Dr Kenichi Nakamura for valuable comments to the manuscript. Appendix The initially participating hospitals are as follows: Iwate Prefectural Central Hospital, Ibaragi Prefectural Central Hospital, Tochigi Cancer Center Hospital, National Cancer Center Hospital East, National Cancer Center Hospital, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Showa University Hospital, Cancer Institute Ariake Hospital, Kitasato University East Hospital, Kanagawa Cancer Center Hospital, Ishikawa Prefectural Central Hospital, Saku Central Hospital, Shizuoka Cancer Center Hospital, Aichi Cancer Center Central Hospital, Kyoto University Hospital, Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka City Medical Center, and Osaka Medical College Hospital.

INTRODUCTION Germ cell tumors (GCTs), mainly presenting as testicular cancer, are relatively rare neoplasms that account for 0.8% of all cancers in males (1). However, GCTs are the most common malignancy among men aged 15–44 years old (2). GCTs have been considered to be curable malignancies, even in the advanced stage, since the introduction of cisplatin (3). Because GCTs occur in young patients, improvement of the prognosis has caused a new clinical problem. Disease recurrence is often found after even more than 5 years (4), and there is no consensus on how long we should follow up patients with periodic examinations. The occurrence of a second primary malignancy is also clinically significant, because chemotherapy and radiotherapy may increase the risk for such an onset after a long-term duration (5). Little is known about second malignant neoplasms in Japanese men who become free of testicular cancer. This is partly because Japanese men have a much lower incidence of the disease than Caucasian men (6), and thus each institute has a limited number of patients. In this study, we reviewed long-term oncological outcomes in patients with GCT receiving treatment at our hospital and assessed the occurrence of late recurrence and second malignant neoplasms.

INTRODUCTION Germ cell tumors (GCTs), mainly presenting as testicular cancer, are relatively rare neoplasms that account for 0.8% of all cancers in males (1). However, GCTs are the most common malignancy among men aged 15–44 years old (2). GCTs have been considered to be curable malignancies, even in the advanced stage, since the introduction of cisplatin (3). Because GCTs occur in young patients, improvement of the prognosis has caused a new clinical problem. Disease recurrence is often found after even more than 5 years (4), and there is no consensus on how long we should follow up patients with periodic examinations. The occurrence of a second primary malignancy is also clinically significant, because chemotherapy and radiotherapy may increase the risk for such an onset after a long-term duration (5). Little is known about second malignant neoplasms in Japanese men who become free of testicular cancer. This is partly because Japanese men have a much lower incidence of the disease than Caucasian men (6), and thus each institute has a limited number of patients. In this study, we reviewed long-term oncological outcomes in patients with GCT receiving treatment at our hospital and assessed the occurrence of late recurrence and second malignant neoplasms. PATIENTS AND METHODS This retrospective study included 139 males with newly diagnosed GCTs of the testis or extragonadal origin treated at our hospital between 1980 and 2005. These patients underwent single or combined treatments including surgery, radiation and chemotherapy according to the extent of the disease. All patients were diagnosed by histological examination of the primary or metastatic site, except for one patient with a disease of mediastinal origin, in whom non-seminomatous GCT (NSGCT) was presumed to be due to elevated serum α-fetoprotein and human choriogonadotropin. Clinical stage was determined based on the 1997 version of the UICC tumor stage classification (7). All of the patients with metastatic disease received platinum-agent-based chemotherapy and, if indicated, subsequent surgical resection of the residual mass. The exception was patients with pure seminoma having a solitary metastatic mass in an abdominal lymph node <5 cm in diameter who underwent radiation therapy or chemotherapy for the metastasis. Selected patients with organ-confined disease in the early 1980s received prophylactic treatment such as chemotherapy, retroperitoneal lymph node dissection (RPLND) or radiation therapy.

tary metastatic mass in an abdominal lymph node <5 cm in diameter who underwent radiation therapy or chemotherapy for the metastasis. Selected patients with organ-confined disease in the early 1980s received prophylactic treatment such as chemotherapy, retroperitoneal lymph node dissection (RPLND) or radiation therapy. Although follow-up intervals depended on the stage of the disease, the evaluation was basically done as follows. In the first 2 years, the follow-up consisted of measurement of tumor markers such as AFP, HCG, and HCG-β every 1–2 months. A complete blood count, blood chemistry and computed tomography (CT) of lung and abdomen were done every 3 months. In the next 3–5 years, tumor markers, complete blood counts and blood chemistry were evaluated every 3–6 months. CT was done every 3–12 months, depending on the stage of the disease and follow-up period. After 6–10 years, we followed patients semi-annually or annually with tumor markers, complete blood counts and blood chemistry evaluations. CT was done if clinically indicated. After 10 years, patients were followed up annually with the clinical examinations described above if needed.

the disease and follow-up period. After 6–10 years, we followed patients semi-annually or annually with tumor markers, complete blood counts and blood chemistry evaluations. CT was done if clinically indicated. After 10 years, patients were followed up annually with the clinical examinations described above if needed. Late recurrence and the occurrence of second malignancy were reviewed. The recurrence was defined as that with an initial histological diagnosis of testicular or extragonadal GCT and recurrence of disease >2 years after the initial successful treatment. Metachronous GCTs that arose from the contralateral testis were excluded from late recurrence. Progression-free survival (PFS) and cause-specific survival (CSS) were estimated by the Kaplan–Meier method.

agnosis of testicular or extragonadal GCT and recurrence of disease >2 years after the initial successful treatment. Metachronous GCTs that arose from the contralateral testis were excluded from late recurrence. Progression-free survival (PFS) and cause-specific survival (CSS) were estimated by the Kaplan–Meier method. RESULTS The patients' characteristics are shown in Table 1. The mean age was 32.5 years and they were followed up for a median period of nearly 6 years. The median follow-up period of current survivors was 7.4 years, with a mean period of 8.6 years. Extragonadal GCTs were found in four patients, three with retroperitoneal disease and one with a mediastinal one. Histological examination revealed pure seminoma in 38.1% of the patients and tumors including a non-seminomatous component in 61.9%. For metastatic lesions, 2 patients received radiation therapy alone and 66 had chemotherapy with or without surgical treatment. Both radiation and chemotherapy were given to three patients. As the first-line regimen, PVB (cisplatin + vinblastine + bleomycin) was used from 1980 to 1990, whereas BEP (bleomycin + etoposide + cisplatin) was used after 1990. Table 1. Patients' characteristics

RESULTS The patients' characteristics are shown in Table 1. The mean age was 32.5 years and they were followed up for a median period of nearly 6 years. The median follow-up period of current survivors was 7.4 years, with a mean period of 8.6 years. Extragonadal GCTs were found in four patients, three with retroperitoneal disease and one with a mediastinal one. Histological examination revealed pure seminoma in 38.1% of the patients and tumors including a non-seminomatous component in 61.9%. For metastatic lesions, 2 patients received radiation therapy alone and 66 had chemotherapy with or without surgical treatment. Both radiation and chemotherapy were given to three patients. As the first-line regimen, PVB (cisplatin + vinblastine + bleomycin) was used from 1980 to 1990, whereas BEP (bleomycin + etoposide + cisplatin) was used after 1990. Table 1. Patients' characteristics No. of patients 139 Mean age: years (range) 32.5 (15–56) Median follow-up period: months (range) 75.5 (2.4–304) Primary site (n) Testis (right/left) 135 (68/67) (97.1%) Retroperitoneal 3 (2.2%) Mediastinum 1 (0.7%) Histology (n) Seminoma 53 (38.1%) Clinical stage I 41 II 9 III 3 Non-seminomatous germ cell tumor 86 (61.9%) Clinical stage I 30 II 20 III 36 Treatment added to orchiectomy (n) None 25 Radiation only 38 Chemotherapy only 16 Radiation + chemotherapy 2 Chemotherapy + surgical resection of metastatic site 54 RPLND only 4 Chemotherapy regimen (n) PVB 27 BEP/EP 63 VIP 19 VeIP 2 High-dose ICE + autologous HCT 11 TIP/TIN 6 Irinotecan + nedaplatin 5 RPLND, retroperitoneal lymph node dissection; PVB, cisplatin + vinblastine + bleomycin; BEP, bleomycin + etoposide + cisplatin; VIP, etoposide + ifosphamide + cisplatin; VeIP, vinblastine + ifosphamide + cisplatin; ICE, ifosphamide + carboplatin + etoposide; HCT, hematopoietic cell transplantation; TIP, paclitaxel + ifosphamide + cisplatin; TIN, paclitaxel + ifosphamide + nedaplatin.

blastine + bleomycin; BEP, bleomycin + etoposide + cisplatin; VIP, etoposide + ifosphamide + cisplatin; VeIP, vinblastine + ifosphamide + cisplatin; ICE, ifosphamide + carboplatin + etoposide; HCT, hematopoietic cell transplantation; TIP, paclitaxel + ifosphamide + cisplatin; TIN, paclitaxel + ifosphamide + nedaplatin. In the early 1980s, some patients received combination chemotherapy with cisplatin, vinblastine, peplomycin and adriamycin as the first-line treatment. Various chemotherapeutic regimens were used as the second- or third-line treatment as shown in Table 1. A combination of paclitaxel and irinotecan was introduced in 2003. Details of management for advanced disease will be reported elsewhere. Disease-free status was achieved in 92.1% of the patients by the initially planned treatment. Of them, however, 12.2% developed recurrent disease and a GCT appeared in the contralateral testis in 1.4%. On the other hand, 11 (7.9%) patients never became free from the disease. Finally, 11 (7.9%) patients died of the primary disease. Four patients died of chemotherapy-related complications. Life-threatening second malignant disease developed in three patients who had undergone chemotherapy for GCTs (Table 2). Details of their clinical courses are discussed below. Table 2. Outcome of patients

Disease-free status was achieved in 92.1% of the patients by the initially planned treatment. Of them, however, 12.2% developed recurrent disease and a GCT appeared in the contralateral testis in 1.4%. On the other hand, 11 (7.9%) patients never became free from the disease. Finally, 11 (7.9%) patients died of the primary disease. Four patients died of chemotherapy-related complications. Life-threatening second malignant disease developed in three patients who had undergone chemotherapy for GCTs (Table 2). Details of their clinical courses are discussed below. Table 2. Outcome of patients Total no. 139 Disease-free after the initially planned treatment 128 (92.1%) Disease recurrence 17 (12.2%) Median time to recurrence: months (range) 8 (1.1–84) Metachronous appearance in contralateral testis 2 (1.4%) Disease remaining after the initially planned treatment 11 (7.9%) Alive without disease 117 (84.2%) Alive with disease 3 (2.2%) Died of the primary disease 11 (7.9%) Died of chemotherapy-related complications 4 (2.9%) Died of second malignant disease 3 (2.2%) Died of disease other than germ cell tumor 4 (2.9%) Figure 1 presents the PFS of patients with seminoma and that of those with NSGCTs. One patient with seminoma and 9 with NSGCTs were never free of the disease after the initially planned treatments and all of these 10 were excluded from the analysis of PFS. Stage I disease had worse 5- and 10-year PFS than Stage II disease due to the difference in the recurrence rate. However, CSS was excellent in Stage I disease for both types of histology (Fig. 2).

ever free of the disease after the initially planned treatments and all of these 10 were excluded from the analysis of PFS. Stage I disease had worse 5- and 10-year PFS than Stage II disease due to the difference in the recurrence rate. However, CSS was excellent in Stage I disease for both types of histology (Fig. 2). Figure 1. (A) Progression-free survival (PFS) of 52 patients with seminoma. (B) PFS of 77 patients with non-seminomatous germ cell tumors (NSGCTs). Figure 2. (A) Cause-specific survival (CSS) of 53 patients with seminoma. (B) CSS of 86 patients with NSGCTs. Late recurrence was seen in five patients (3.6%), including three with Stage I NSGCT, one with Stage I seminoma and one with Stage III NSGCT (Table 3). Interestingly, one patient with Stage I NSGCT developed abdominal lymph node metastasis 7 years after the primary tumor resection. Treatments consisting of chemotherapy and mass resection were successful for the recurrent disease in all patients. Table 3. Patients with late recurrence after initial treatment

Late recurrence was seen in five patients (3.6%), including three with Stage I NSGCT, one with Stage I seminoma and one with Stage III NSGCT (Table 3). Interestingly, one patient with Stage I NSGCT developed abdominal lymph node metastasis 7 years after the primary tumor resection. Treatments consisting of chemotherapy and mass resection were successful for the recurrent disease in all patients. Table 3. Patients with late recurrence after initial treatment Stage Histology Initial treatment added to radical orchiectomy Time to relapse (months) Site of relapse Tumor markers at relapse (AFP/HCG-β) Outcome Period after the treatment for recurrent disease (months) I E + T + S None 26 RPLN, lung 24.9/1.5 NED 65 I S None 46 Dura mater 1.2/0.1 NED 105 I T + S None 84 RPLN 465/0.2 NED 5 I E + T RPLND 25 RPLN 69.0/5.0 NED 196 IIIB2 E + Y + C + T Chemotherapy + tumor resection 59 Mediastinum 1085/69.0 NED 115 AFP, α-fetoprotein; HCG-β, human chorionic gonadotropin-β subunit; E, embryonal carcinoma; T, teratoma; S, seminoma; RPLN, retroperitoneal lymph nodes; NED, no evidence of disease; Y, yolk sac tumor; C, choriocarcinoma. HCG was not examined at the time of relapse in these cases.

section 59 Mediastinum 1085/69.0 NED 115 AFP, α-fetoprotein; HCG-β, human chorionic gonadotropin-β subunit; E, embryonal carcinoma; T, teratoma; S, seminoma; RPLN, retroperitoneal lymph nodes; NED, no evidence of disease; Y, yolk sac tumor; C, choriocarcinoma. HCG was not examined at the time of relapse in these cases. Patients who developed a second primary malignant disease after the treatment for GCTs are shown in Table 4. They received chemotherapy before 1985. In three patients who developed hematologic neoplasms, two had seminoma in the primary lesion and had undergone prophylactic or therapeutic radiation therapy. All three patients had a history of chemotherapy with a regimen containing cisplatin for the original and recurrent disease, whereas etoposide was administered to one patient. There was another patient who developed renal cell carcinoma (RCC) 20 years after the initial treatment for testicular cancer. He received orchiectomy and RPLND for Stage I disease. After the initial treatment, lung metastasis was found 1.5 years later. He received combination chemotherapy consisting of cisplatin, vinblastine, peplomycin and adriamycin. He underwent a nephrectomy for RCC and is now the only survivor among those who had a second primary malignancy. Table 4. Patients developing secondary primary malignant neoplasms

Patients who developed a second primary malignant disease after the treatment for GCTs are shown in Table 4. They received chemotherapy before 1985. In three patients who developed hematologic neoplasms, two had seminoma in the primary lesion and had undergone prophylactic or therapeutic radiation therapy. All three patients had a history of chemotherapy with a regimen containing cisplatin for the original and recurrent disease, whereas etoposide was administered to one patient. There was another patient who developed renal cell carcinoma (RCC) 20 years after the initial treatment for testicular cancer. He received orchiectomy and RPLND for Stage I disease. After the initial treatment, lung metastasis was found 1.5 years later. He received combination chemotherapy consisting of cisplatin, vinblastine, peplomycin and adriamycin. He underwent a nephrectomy for RCC and is now the only survivor among those who had a second primary malignancy. Table 4. Patients developing secondary primary malignant neoplasms Stage Histology Prior treatment for GCT Chemotherapeutic regimen Time to onset (months) Second neoplasms Hematological neoplasm I S RPLND + chemotherapy + radiation CDDP/VBL/PEP/ADM 186 Leukemia IIA S RPLND + chemotherapy + radiation CDDP/VBL/PEP/ADM 62 MDS IIA E, T Chemotherapy CDDP/etoposide/BLM 47 MDS Non-hematological neoplasm I E RPLND,a chemotherapyb CDDP/VBL/PEP/ADM 240 RCC GCT, germ cell tumor; CDDP, cisplatin; VBL, vinblastine; PEP, peplomycin; ADM, adriamycin; MDS; myelodysplastic syndrome; BLM, bleomycin; RCC; renal cell carcinoma.

ation CDDP/VBL/PEP/ADM 62 MDS IIA E, T Chemotherapy CDDP/etoposide/BLM 47 MDS Non-hematological neoplasm I E RPLND,a chemotherapyb CDDP/VBL/PEP/ADM 240 RCC GCT, germ cell tumor; CDDP, cisplatin; VBL, vinblastine; PEP, peplomycin; ADM, adriamycin; MDS; myelodysplastic syndrome; BLM, bleomycin; RCC; renal cell carcinoma. aDone the initial treatment together with radical orchiectomy. bDone for recurrence disease in the lung. DISCUSSION In this study, we reviewed the outcomes of patients with GCTs since the introduction of cisplatin. Multimodal treatments consisting of surgical resection, radiation and chemotherapy provided excellent oncological outcomes in patients with clinical stage I and II diseases, as other investigators reported (8). However, the result of treatment for the systemic disseminated disease is still unsatisfactory (9), although details of our results were not fully reported in this manuscript. Only a few years have passed since the newer anti-cancer agents such as paclitaxel and irinotecan began to be employed. Therefore, further observation is needed to evaluate the long-term efficacy of these drugs.

ase is still unsatisfactory (9), although details of our results were not fully reported in this manuscript. Only a few years have passed since the newer anti-cancer agents such as paclitaxel and irinotecan began to be employed. Therefore, further observation is needed to evaluate the long-term efficacy of these drugs. The incidence of late recurrence was 3.6%, which was similar to those in other reports (10). Most patients who developed late recurrence had Stage I disease with surveillance after tumor resection, and relapse >5 years after the diagnosis of GCT may be rare in patients with advanced disease who receive chemotherapy and become free of the disease. These results suggest the efficacy of adjuvant chemotherapy to prevent disease recurrence in some patients with Stage I disease. However, the use of chemotherapeutic agents entails a risk of de novo primary malignancy, as discussed below (11). In addition, all of our patients with late recurrence successfully obtained freedom from disease by chemotherapy with residual mass resection. Taking these findings and the incidence of late recurrence into consideration, adjuvant chemotherapy may not always be necessary for Stage I GCT patients, except those with a high risk for disease recurrence (12), as long as they receive close follow-up (13,14). Oldenburg et al. (15) reported that RPLND might be effective to prevent late relapse in Stage I GCT. However, because of its invasiveness and low incidence of relapse, it is controversial whether RPLND should be performed. Similar to adjuvant chemotherapy, if close follow-up can be done, immediate RPLND may not be necessary in Stage I disease.

orted that RPLND might be effective to prevent late relapse in Stage I GCT. However, because of its invasiveness and low incidence of relapse, it is controversial whether RPLND should be performed. Similar to adjuvant chemotherapy, if close follow-up can be done, immediate RPLND may not be necessary in Stage I disease. Some anti-cancer agents have potential oncogenicity. Topoisomerase II inhibitors increase the risk for secondary leukemia arising in 2 or 3 years (16), with a relative risk of 15–25% (5). However, our leukemic patient had not been administrated etoposide. Moreover, the onset was too late for topoisomerase II-specific leukemia. Travis et al. (17) reported that both radiation therapy and chemotherapy promoted the risk for leukemia in long-term survivors. Even in our cases, the combined therapy might affect the development of leukemia after a long duration. On the other hand, alkylating agent-related myelodysplastic syndrome and acute myeloid leukemia often occur 5–7 years after the administration (18). Our two cases presented its typical course. In this study, one patient developed secondary solid organ malignancy. Its frequency was extremely rare, although if the follow-up period were to be prolonged, solid organ malignancy might increase. Treatment-related solid organ cancers have developed 20 years after radiation therapy and chemotherapy (19). Thus, further follow-up might detect secondary solid organ malignancies in our series.

frequency was extremely rare, although if the follow-up period were to be prolonged, solid organ malignancy might increase. Treatment-related solid organ cancers have developed 20 years after radiation therapy and chemotherapy (19). Thus, further follow-up might detect secondary solid organ malignancies in our series. There is no consensus on the duration of periodic follow-up for GCT patients. As shown in this study, some patients probably develop relapse of the disease >5 years after the initial diagnosis (20). We successfully detected and managed all patients with late relapse in the follow-up periods. Patients who are diagnosed as having a late recurrence after presentation of the recurrence-related symptoms have a tendency to have poorer prognoses (21,22). When we take this into consideration, follow-up for at least 10 years may be preferable (15). Since long-term survivors who undergo chemotherapy and/or radiation therapy have a high risk for second malignancy, we should carefully follow them to detect the disease. Follow-up >10 years may be needed. However, periodical examinations cannot always detect a second malignant disease. In addition, the clinical efficacy of early detection of second malignancy is still unknown, because the disease tends to be refractory to treatment. Further investigation is needed to establish the management procedure for a second malignant disease. Conflict of interest statement None declared.

Recurrence or metastasis of cancer has usually been considered to occur in the last stage of the patient's life. From this perspective, even if only one site of recurrence or metastasis is present, the cancer can be seeded throughout the body hematogenously, meaning that local therapy cannot eradicate all cancer cells. Systemic chemotherapy can then only prolong life, rather than achieving cure. However, Hellman and Weichselbaum proposed an alternative notion in 1995, bringing about a paradigm shift in the conceptualization of cancer metastasis or cancer recurrence. This new notion is that of oligometastases (1). OLIGOMETASTASES Oligometastases is the state in which the patient shows distant relapse in only a limited number of regions. Local therapy such as surgery, radiotherapy and radiofrequency ablation for the relapsed sites could thus improve patient's survival. The state of oligometastases (Fig. 1) represents an important concept, but one important problem remains to be solved. Oligometastases did not eliminate the uncontrolled primary site with several distant metastases. Then, all metastatic sites were thoroughly treated with local therapy, which did not lead to disappearance of all gross tumors and not might have achieved cure. As the primary site was not or could not be treated with local therapy, the primary site would exacerbate sooner. Figure 1. This is a schema of oligometastases. Schema 1 shows one distant metastasis/recurrence with a primary lesion. Schema 2 shows two distant metastases/recurrences with a primary lesion.

OLIGOMETASTASES Oligometastases is the state in which the patient shows distant relapse in only a limited number of regions. Local therapy such as surgery, radiotherapy and radiofrequency ablation for the relapsed sites could thus improve patient's survival. The state of oligometastases (Fig. 1) represents an important concept, but one important problem remains to be solved. Oligometastases did not eliminate the uncontrolled primary site with several distant metastases. Then, all metastatic sites were thoroughly treated with local therapy, which did not lead to disappearance of all gross tumors and not might have achieved cure. As the primary site was not or could not be treated with local therapy, the primary site would exacerbate sooner. Figure 1. This is a schema of oligometastases. Schema 1 shows one distant metastasis/recurrence with a primary lesion. Schema 2 shows two distant metastases/recurrences with a primary lesion. OLIGO-RECURRENCE Niibe et al. (2–4) proposed the new notion of oligo-recurrence to overcome these problems. Oligo-recurrence is a notion similar to oligometastases. However, the conditions of oligo-recurrence are: (i) one to several distant metastases/recurrences (usually one) in one to several organs (usually one); (ii) primary site of the cancer controlled; (iii) one to several distant metastases/recurrences can be treated with local therapy; and (iv) no other distant metastases/recurrences other than those in (iii). This state of oligo-recurrence is shown in Fig. 2 and the differences between oligometastasis and oligo-recurrence are listed in Table 1. In the state of oligo-recurrence, recurrent or metastatic sites with a controlled primary lesion were treated with local therapy, meaning that all gross recurrent or metastatic sites could be treated using local therapy.

n in Fig. 2 and the differences between oligometastasis and oligo-recurrence are listed in Table 1. In the state of oligo-recurrence, recurrent or metastatic sites with a controlled primary lesion were treated with local therapy, meaning that all gross recurrent or metastatic sites could be treated using local therapy. Figure 2. This is a schema of oligo-recurrence. Schema 1 shows one distant metastasis/recurrence with a controlled primary lesion. Schema 2 shows two distant metastases/recurrences with a controlled primary lesion. The biggest difference between oligometastases and oligo-recurrences lies in the uncontrolled or controlled primary lesion. Oligo-recurrence requires a controlled primary lesion. Table 1. Oligometastases and oligo-recurrence

Figure 2. This is a schema of oligo-recurrence. Schema 1 shows one distant metastasis/recurrence with a controlled primary lesion. Schema 2 shows two distant metastases/recurrences with a controlled primary lesion. The biggest difference between oligometastases and oligo-recurrences lies in the uncontrolled or controlled primary lesion. Oligo-recurrence requires a controlled primary lesion. Table 1. Oligometastases and oligo-recurrence Oligometastases Oligo-recurrence Reference Hellman and Weichselbaum (1) Niibe et al. (2,3,4) Primary lesion Uncontrolled/controlled Controlled No. of distant/metastases/recurrences One to several One to several (one is better) SYSTEMIC THERAPY AND LOCAL THERAPY Improvement of systemic chemotherapy including molecular-targeted therapy has allowed micrometastases to be almost completely absent clinically. Theoretically, if several gross metastatic or recurrent sites could be eradiated by local therapy, these patients could be cured with concomitant systemic chemotherapy. Punglia et al. (5) reported that if systemic therapy improved, the role of local therapy would improve and proposed a figure for this correlation. Here, a new figure of the correlation between local therapy and systemic therapy is proposed (Fig. 3), showing that the role of local therapy is initially increasingly important as systemic therapy improves, depending on the sigmoid curve. The current status of cancer therapy lies in the range between 0 and A. However, in the future, extreme improvements in systemic therapy will decrease the importance of local therapy, because cancers will be diminished by systemic therapy alone such as intravenous anti-cancer drug infusion or oral anti-cancer drugs. All cancerous lesions including gross tumors and microinvasive tumors could be eradicated with systemic therapy alone. This desirable state is shown as B in Fig. 3. In the present status (range: 0–A in Fig. 3), systemic therapy is not yet powerful enough that local therapy is not required for eradication, particularly for gross tumor.

sions including gross tumors and microinvasive tumors could be eradicated with systemic therapy alone. This desirable state is shown as B in Fig. 3. In the present status (range: 0–A in Fig. 3), systemic therapy is not yet powerful enough that local therapy is not required for eradication, particularly for gross tumor. Figure 3. This shows correlations between systemic and local therapies. Until point A, the role of local therapy increases as systemic therapy improves. However, after point A, the role of local therapy decreases as systemic therapy improves, as all cancerous lesions can be cured by systemic therapy at point B. BRAIN TUMOR This section and the following four sections focus on organ-specific oligometastases and oligo-recurrence. First, oligometastases and oligo-recurrence of brain metastatic tumors are described.

Figure 3. This shows correlations between systemic and local therapies. Until point A, the role of local therapy increases as systemic therapy improves. However, after point A, the role of local therapy decreases as systemic therapy improves, as all cancerous lesions can be cured by systemic therapy at point B. BRAIN TUMOR This section and the following four sections focus on organ-specific oligometastases and oligo-recurrence. First, oligometastases and oligo-recurrence of brain metastatic tumors are described. Classification of metastatic brain tumors such as oligo-recurrence in recursive partitioning analysis (RPA) class I is widely recognized and accepted (6). This class I contains patients with: KPS ≥70; age <65 years; controlled primary; and no extracranial metastases. All RPA class I patients thus show oligo-recurrence. However, RPA class I requires age <65 years, so if age is ≥65 years and even KPS 100, the patient is classified as RPA class II. Rapid progress has recently been made in reducing the invasiveness of surgery and radiotherapy. The age of 65 years is thus no longer the limit of aggressive therapy. The RPA classification was developed in 1997, and more than a decade has passed since the proposal of this classification. Given recent advances in modern medicine, oligo-recurrence is considered to be more appropriate.

of surgery and radiotherapy. The age of 65 years is thus no longer the limit of aggressive therapy. The RPA classification was developed in 1997, and more than a decade has passed since the proposal of this classification. Given recent advances in modern medicine, oligo-recurrence is considered to be more appropriate. Kocher et al. (7) compared 117 patients with one to three previously untreated cerebral metastases who underwent stereotactic radiosurgery (SRS) between 1991 and 1998 with 138 patients with one to three lesions treated using whole-brain radiotherapy (WBRT) between 1978 and 1991. The first modality represents a more powerful treatment of metastatic brain tumors. Of these patients, 32 were classified as RPA class I (SRS, n = 23; WBRT, n = 9). Median survival was 25.4 months with SRS, compared with 4.7 months with WBRT (P < 0.0001). Furthermore, Andrews et al. (8) reported a Phase III trial comparing WBRT to WBRT plus SRS, in which multivariate analysis indicated that patients with WBRT plus SRS survived longer than those with WBRT alone in RPA class I (P < 0.0001). These findings suggest that more powerful local treatment was efficacious for RPA class I. As for oligo-recurrence involving the brain, Niibe et al. (9) reported 17 metastatic brain tumors in 10 patients treated with SRS and surgery achieved 3-year local control in 90% and 3-year overall survival in 51.9%.

P < 0.0001). These findings suggest that more powerful local treatment was efficacious for RPA class I. As for oligo-recurrence involving the brain, Niibe et al. (9) reported 17 metastatic brain tumors in 10 patients treated with SRS and surgery achieved 3-year local control in 90% and 3-year overall survival in 51.9%. LUNG TUMOR Survival benefits were being reported for complete resection of metastatic lung tumors even in the 1990s. The International Registry of Lung Metastases (IRLM) reported that 5-year overall survival for patients with complete resection of metastatic lung tumors was 36%, compared with 13% for patients without (10). However, clinical outcomes with stereotactic body radiotherapy (SBRT) for Stage I primary lung tumors are reportedly almost the same as with surgery. Onihsi et al. (11) reported a 5-year overall survival of 70.8% for operable Stage I patients, equivalent to that with surgery. This indicates that oligo-recurrent patients, who have no extrathoracic lesions, could receive survival benefit from SBRT. In fact, Bloomgren et al. (12) first reported that 14 metastatic lung tumors in 10 patients treated with SBRT achieved 92% local control. Uematsu et al. (13) reported that 43 metastatic lung tumors in 22 patients treated with SBRT achieved 98% local control. Nagata et al. (14) using SBRT with 48 Gy in four fractions to the isocenter reported that nine metastatic lung tumors in nine patients achieved 67% local control. From the same institution as Nagata, Norihisa et al. (15) using SBRT at 48–60 Gy in four to five fractions to the isocenter reported that 43 metastatic lung tumors in 34 patients achieved a 2-year local control rate of 90% and a 2-year overall survival rate of 84.3%. These are excellent outcomes. However, all these analyses were retrospective. In 2009, Rusthoven et al. (16) reported a Phase I/II prospective study of SBRT for metastatic lung tumors. Thirty-eight metastatic lung tumors in 63 patients treated with SBRT achieved a 2-year local control rate of 96% and a 2-year overall survival of 39%. This result was inferior to that of surgery according to the IRLM. One of the important reasons of poor prognosis in SBRT is that the prospective study included patients with extrapulmonary lesions, meaning oligometastases and no oligo-recurrence. Limited to oligo-recurrence and the small numbers of lung metastases, overall survival may be better and might be almost equivalent to that of the IRLM (16).

nt reasons of poor prognosis in SBRT is that the prospective study included patients with extrapulmonary lesions, meaning oligometastases and no oligo-recurrence. Limited to oligo-recurrence and the small numbers of lung metastases, overall survival may be better and might be almost equivalent to that of the IRLM (16). LIVER TUMOR SBRT has also been applied to metastatic liver tumors. In 1998, Blomgren et al. reported that a pilot study using 20–40 Gy in one or two fractions to the periphery of the planning target volume (PTV) achieved 95% local control (17). Several prospective studies have recently been reported. Herfarth et al. (18) reported 56 metastatic liver tumors in 33 patients treated with SBRT using 14–26 Gy per fraction (prescribed to 80%), achieving 78% local control. Kavanagh et al. (19) reported 28 metastatic liver tumors in 21 patients treated with SBRT using 12–20 Gy in three fractions to the periphery of the PTV, achieving 93% local control. Mendez Romero et al. (20) reported 34 metastatic liver tumors in 14 patients treated with SBRT using 37.5 Gy in three fractions (prescribed to 65%), achieving 94% local control. In 2009, Rusthoven et al. (21) reported 63 metastatic liver tumors in 57 patients treated with SBRT using 36–60 Gy in three fractions, achieving a 3-year local control rate of 92% and a 2-year overall survival rate of 30%. BONE Oligo-recurrence and oligometastases of bone have been reported in breast cancer. The summary is that high-dose radiotherapy relieves pain for a long time and can even improve overall survival.

LIVER TUMOR SBRT has also been applied to metastatic liver tumors. In 1998, Blomgren et al. reported that a pilot study using 20–40 Gy in one or two fractions to the periphery of the planning target volume (PTV) achieved 95% local control (17). Several prospective studies have recently been reported. Herfarth et al. (18) reported 56 metastatic liver tumors in 33 patients treated with SBRT using 14–26 Gy per fraction (prescribed to 80%), achieving 78% local control. Kavanagh et al. (19) reported 28 metastatic liver tumors in 21 patients treated with SBRT using 12–20 Gy in three fractions to the periphery of the PTV, achieving 93% local control. Mendez Romero et al. (20) reported 34 metastatic liver tumors in 14 patients treated with SBRT using 37.5 Gy in three fractions (prescribed to 65%), achieving 94% local control. In 2009, Rusthoven et al. (21) reported 63 metastatic liver tumors in 57 patients treated with SBRT using 36–60 Gy in three fractions, achieving a 3-year local control rate of 92% and a 2-year overall survival rate of 30%. BONE Oligo-recurrence and oligometastases of bone have been reported in breast cancer. The summary is that high-dose radiotherapy relieves pain for a long time and can even improve overall survival. Niibe et al. (4) reported on solitary bone metastases in seven patients treated with conventional radiotherapy. Six of seven patients achieved complete remission of pain, which was prolonged at the last follow-up. Only one patient showed relapse of pain. This patient received 30 Gy in 10 fractions (BED10, 39 Gy), representing the smallest dose in that series (other patients received 40–50 Gy in 20–25 fractions; BED10 ≥ 48 Gy). In 2009, Milano et al. (22) reported 85 metastatic lesions in 40 breast cancer patients treated with SBRT, achieving a 2-year overall survival rate of 76% and a 4-year overall survival of 59%. Among these, the most favorable prognostic factor for breast oligometastatic patients was metastases only involving bone. This indicated high-dose radiotherapy using SBRT for bone metastases could contribute to patient survival.

SBRT, achieving a 2-year overall survival rate of 76% and a 4-year overall survival of 59%. Among these, the most favorable prognostic factor for breast oligometastatic patients was metastases only involving bone. This indicated high-dose radiotherapy using SBRT for bone metastases could contribute to patient survival. LYMPH NODES Oligometastases and oligo-recurrence of distant lymph node metastases have been reported for uterine cervical carcinoma. Uterine cervical carcinoma spreads through the lymphatic route rather than hematogenously (2,23). The first site of distant metastasis of uterine cervical carcinoma is the para-aortic lymph node. This has been confirmed in a large population-based study (2).

metastases have been reported for uterine cervical carcinoma. Uterine cervical carcinoma spreads through the lymphatic route rather than hematogenously (2,23). The first site of distant metastasis of uterine cervical carcinoma is the para-aortic lymph node. This has been confirmed in a large population-based study (2). Hong et al. (24) reported 35 patients with isolated para-aortic lymph node recurrence treated with concurrent chemoradiotherapy achieving a 5-year overall survival rate of 34%. Kim et al. (25) reported 12 patients treated with hyperfractionated radiotherapy totaling 60 Gy combined with concurrent chemoradiotherapy, achieving a 3-year overall survival rate of 19%. To date, the largest study has been reported by Niibe et al. (3) in Japan. They reported 84 patients treated with conventional radiotherapy with or without chemotherapy achieved a 5-year overall survival rate of 31.3%, similar to the 38% for 5-year overall survival rate in a previous, small, population-based study in Japan (26). Recently, Choi et al. (27) reported that 30 uterine cervical and corpus cancer patients with isolated para-aortic lymph node recurrence treated by SBRT using a cyberknife achieved a 4-year overall survival of 50.1%.

to the 38% for 5-year overall survival rate in a previous, small, population-based study in Japan (26). Recently, Choi et al. (27) reported that 30 uterine cervical and corpus cancer patients with isolated para-aortic lymph node recurrence treated by SBRT using a cyberknife achieved a 4-year overall survival of 50.1%. CONCLUSIONS Curative local therapy for oligometastases and oligo-recurrence represents a brilliant opening to the era of cancer therapy. Several decades ago, most metastatic and recurrent cancer patients died within a year. However, we cope with metastases or recurrences considering whether the state is oligometastases or oligo-recurrence. In the state of oligo-recurrence, all the gross tumors could be treated with local therapy, meaning curative treatment. However, in the state of oligometastases, clinicians should judge a primary site to be controlled or not before treatment. If the primary site is controlled, meaning oligo-recurrence, they should pursue to cure the patients. However, if the primary site is uncontrolled or extra-target metastases lesions exist, they intend to prolong survival not to pursue cure. More appropriate target cancers, treatment modalities and schedules should be established for oligometastases and oligo-recurrence. Moreover, adjuvant chemotherapy will improve dramatically because of molecular-targeted drugs. Further clinical studies are required in this field.

CONCLUSIONS Curative local therapy for oligometastases and oligo-recurrence represents a brilliant opening to the era of cancer therapy. Several decades ago, most metastatic and recurrent cancer patients died within a year. However, we cope with metastases or recurrences considering whether the state is oligometastases or oligo-recurrence. In the state of oligo-recurrence, all the gross tumors could be treated with local therapy, meaning curative treatment. However, in the state of oligometastases, clinicians should judge a primary site to be controlled or not before treatment. If the primary site is controlled, meaning oligo-recurrence, they should pursue to cure the patients. However, if the primary site is uncontrolled or extra-target metastases lesions exist, they intend to prolong survival not to pursue cure. More appropriate target cancers, treatment modalities and schedules should be established for oligometastases and oligo-recurrence. Moreover, adjuvant chemotherapy will improve dramatically because of molecular-targeted drugs. Further clinical studies are required in this field. Funding This study was supported in part by grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan, Ministry of Health, Labour and Welfare of Japan and Foundation for Promotion of Cancer Research of Japan. Conflict of interest statement None declared.

INTRODUCTION Mammalian target of rapamycin (mTOR) is an intracellular protein kinase that mediates cellular responses to growth factors, nutrients and changes in energy status and thereby plays an important role in the regulation of cell growth, cell division and angiogenesis. It controls ribosome biosynthesis and the transcription of genes for many proteins that participate in the cell cycle, metabolism, nutrient transport or utilization, or the response to hypoxia. Various signaling defects upstream of mTOR, some of which are relatively common, have been identified in cancer cells and result in loss of cell growth control, unrestrained proliferation, tumor angiogenesis, and other malignant characteristics. Defects in mTOR itself have not been identified in cancer, rendering this kinase both a well-situated and stable target for therapeutic intervention in cancers driven by defects in the mTOR signaling pathway (1–3).

cell growth control, unrestrained proliferation, tumor angiogenesis, and other malignant characteristics. Defects in mTOR itself have not been identified in cancer, rendering this kinase both a well-situated and stable target for therapeutic intervention in cancers driven by defects in the mTOR signaling pathway (1–3). RAD001 (everolimus) blocks the mTOR pathway by forming a complex with the immunophilin FK506-binding protein-12, which also binds mTOR with high affinity. This drug has exhibited antitumor activity with a variety of cancer cells both in vitro (4–9) and in vivo (10–12). In addition, the anticancer effects of RAD001 complement those of chemotherapy, radiation, hormonal agents and targeted therapeutics (13–15). RAD001 inhibits tumor growth dependent on angiogenesis by inhibiting the production of angiogenic growth factors and thereby reducing the proliferation of neovascular endothelial cells (3). Phase I studies of RAD001 have shown sustained inhibition of mTOR activity in tumor tissue at oral doses of ≥20 mg weekly or 5–10 mg daily (16). Continuous daily dosing with RAD001 has been found to result in a more profound and sustained inhibition of mTOR than that achieved with an intermittent weekly schedule (17,18). We have now performed a Phase I trial of RAD001 administered daily to Japanese patients with advanced solid tumors. The purpose of our study was to assess the pharmacokinetics, safety and tolerability of escalating oral doses of RAD001 in this patient population. An additional objective included evaluation of antitumor activity.

w performed a Phase I trial of RAD001 administered daily to Japanese patients with advanced solid tumors. The purpose of our study was to assess the pharmacokinetics, safety and tolerability of escalating oral doses of RAD001 in this patient population. An additional objective included evaluation of antitumor activity. We herein report that RAD001 can be safely administered at daily doses up to 10 mg to Japanese patients with advanced solid malignancies. A dosage of 10 mg/day is recommended for further development.

w performed a Phase I trial of RAD001 administered daily to Japanese patients with advanced solid tumors. The purpose of our study was to assess the pharmacokinetics, safety and tolerability of escalating oral doses of RAD001 in this patient population. An additional objective included evaluation of antitumor activity. We herein report that RAD001 can be safely administered at daily doses up to 10 mg to Japanese patients with advanced solid malignancies. A dosage of 10 mg/day is recommended for further development. PATIENTS AND METHODS Patient Population Japanese individuals ≥20 years of age with a histologically confirmed diagnosis of an advanced tumor refractory to or unsuitable for existing standard therapy were included in the study if they had >1 measurable lesion, a life expectancy of ≥3 months, and adequate or acceptable renal [serum creatinine concentration of ≤1.5× the upper limit of normal (ULN)], liver (serum bilirubin concentration of ≤1.25× ULN, serum transaminase activity of ≤3× ULN and serum albumin concentration of ≥3.5 g/dl) and bone marrow (absolute neutrophil count of ≥1500/mm3, platelet count of ≥1 × 105/mm3 and hemoglobin concentration of ≥9 g/dl) function. Patients with tumors or metastases in the central nervous system, uncontrolled infection, gastrointestinal impairment disease, active bleeding diathesis, other concurrent or uncontrolled medical disease, or a history of coagulation disorders as well as those under treatment with strong inhibitors or inducers of isoenzyme CYP3A4 were excluded from the study. All subjects provided written informed consent to participation in the study, which was approved by the Institutional Review Board of each participating center and was performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.

ducers of isoenzyme CYP3A4 were excluded from the study. All subjects provided written informed consent to participation in the study, which was approved by the Institutional Review Board of each participating center and was performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Study Design The study was an open-label, non-randomized, dose-escalation Phase I trial of RAD001 administered on a continuous once-daily schedule in a 28-day cycle to adult Japanese patients, with continuation of therapy after 28 days in the absence of progressive disease. The primary objective was to evaluate the tolerability/safety and dose-limiting toxicity (DLT) of RAD001, up to the dose level of 10 mg/day which is being used in the global study. The study had a ‘3 + 3’ design, with three patients recruited to each of three successive cohorts treated with RAD001 at 2.5, 5.0 or 10.0 mg/day. Patients were allowed to receive a higher RAD001 dose, at the investigator's discretion, if the higher dose had been confirmed as tolerable. Treatment was discontinued in the event of progressive disease, DLT, a dose delay of >14 days (or >42 days for hematologic DLTs), or withdrawal of consent. A DLT was defined as a hematologic (anemia, leukopenia, thrombocytopenia or neutropenia) or non-hematologic adverse event with a grade of ≥3 or a laboratory abnormality with a grade of ≥3 that occurred within the first 4 weeks of treatment and was suspected to be related to RAD001. Standard antiemetic prophylaxis and anti-hyperlipidemia therapy were allowed. Recruitment was permitted for Cohort 2 if DLTs were observed in 0/3 or ≤1/6 patients in Cohort 1, and for Cohort 3 if DLTs were observed in 0/3 or ≤1/6 patients in Cohort 2. DLTs in ≥2/6 patients in Cohort 1 would result in study discontinuation; DLTs in ≥2/6 patients in Cohort 2 or 3 would result in additional patient enrollment in Cohorts 1 and 2, respectively. The maximum-tolerated dose was defined as the dose at which two or more patients experienced a DLT in the first cycle.

Cohort 2. DLTs in ≥2/6 patients in Cohort 1 would result in study discontinuation; DLTs in ≥2/6 patients in Cohort 2 or 3 would result in additional patient enrollment in Cohorts 1 and 2, respectively. The maximum-tolerated dose was defined as the dose at which two or more patients experienced a DLT in the first cycle. Assessments Blood samples for pharmacokinetic analysis were collected on days 1 and 15 of cycle 1 at 0, 1, 2, 4, 6, 8 and 24 h after RAD001 administration. Blood samples for assessment of the trough concentration (Cmin) of RAD001 were obtained immediately before administration of the next dose on days 2, 8, 11, 15 and 16 of cycle 1 and on day 1 of cycle 2 as well as at the end of the study. Pharmacokinetic parameters of RAD001 determined for each cohort included the maximum blood concentration (Cmax), time of maximum concentration (tmax), area under the concentration-versus-time curve from time 0 to 24 h after drug administration (AUCτ, dosing interval) and apparent systemic clearance (CL/F). Drug safety and tolerability were assessed according to the NCI Common Terminology Criteria for Adverse Events (CTCAE) scale, version 3.0. Patients were monitored for adverse events throughout the study. Tumor volume was evaluated every 2 months and at the end of the study according to RECIST. Data were recorded for up to 28 days after discontinuation of treatment.

rding to the NCI Common Terminology Criteria for Adverse Events (CTCAE) scale, version 3.0. Patients were monitored for adverse events throughout the study. Tumor volume was evaluated every 2 months and at the end of the study according to RECIST. Data were recorded for up to 28 days after discontinuation of treatment. Statistics The number of patients in each proposed cohort was based on the standard ‘3 + 3’ design for dose-escalation studies. A total of 9–18 patients were planned to assess the safety and tolerability of RAD001, depending on observed toxicities. Descriptive statistics were used for evaluation of safety, efficacy and pharmacokinetic outcomes. RESULTS Patient Characteristics Between November 2005 and December 2006, nine patients with advanced, refractory solid tumors were enrolled in the study at the two participating centers (Kinki University School of Medicine and National Cancer Center Hospital East) (Table 1). The median age was 64 years (range, 49–74). All patients had received prior chemotherapy for their disease, and most of them had previously undergone cancer-related surgery. The median durations of RAD001 therapy were 57 days in the 2.5 mg/day cohort, 42 days in the 5 mg/day cohort and 98 days in the 10 mg/day cohort. Treatment was discontinued in all nine patients as a result of either progressive disease (n = 4), toxicities (n = 2), consent withdrawal (n = 2) or death (n = 1, hemorrhage). All patients were evaluable for drug safety and pharmacokinetics. Table 1. Patient characteristics

RESULTS Patient Characteristics Between November 2005 and December 2006, nine patients with advanced, refractory solid tumors were enrolled in the study at the two participating centers (Kinki University School of Medicine and National Cancer Center Hospital East) (Table 1). The median age was 64 years (range, 49–74). All patients had received prior chemotherapy for their disease, and most of them had previously undergone cancer-related surgery. The median durations of RAD001 therapy were 57 days in the 2.5 mg/day cohort, 42 days in the 5 mg/day cohort and 98 days in the 10 mg/day cohort. Treatment was discontinued in all nine patients as a result of either progressive disease (n = 4), toxicities (n = 2), consent withdrawal (n = 2) or death (n = 1, hemorrhage). All patients were evaluable for drug safety and pharmacokinetics. Table 1. Patient characteristics Characteristic No. of patients Sex Male 4 Female 5 Performance status (ECOG) 0 5 1 4 Previous therapy Surgery 8 Chemotherapy 9 Radiotherapy 3 Tumor type Colorectal cancer 3 Lung cancer 3 Esophageal cancer 1 Gastric cancer 1 Thyroid cancer 1 The median (range) age was 64 (49–74) years. ECOG, Eastern Cooperative Oncology Group.

eristic No. of patients Sex Male 4 Female 5 Performance status (ECOG) 0 5 1 4 Previous therapy Surgery 8 Chemotherapy 9 Radiotherapy 3 Tumor type Colorectal cancer 3 Lung cancer 3 Esophageal cancer 1 Gastric cancer 1 Thyroid cancer 1 The median (range) age was 64 (49–74) years. ECOG, Eastern Cooperative Oncology Group. Safety DLTs were not observed for any patient in the first cycle of treatment (28 days). Overall, the most common adverse events of all grades were thrombocytopenia (56% of patients), leukopenia (33%), anorexia (44%) and rash (44%) (Table 2). One patient with colon cancer and both lung and liver metastases was treated at the RAD001 dose of 5 mg/day experienced grade 2 pneumonitis after 142 days of therapy. The patient developed cough, and computed tomographic scan of the chest revealed new ground-glass opacities. The patient was hospitalized with PaO2 of 72.7 mmHg. Steroid treatment and discontinuation of RAD001 resulted in marked improvement of the patient within days. All toxicities of Grade 3 or 4 occurred at the dose of 10 mg/day, but none occurred in the first cycle and therefore did not qualify as DLTs. One patient with advanced esophageal carcinoma at a dose of 10 mg/day developed Grade 3 fatigue and stomatitis on day 58 and RAD001 was interrupted. The study drug was restarted on day 66 at a reduced dose of 5 mg/day. On day 71, the patient visited the hospital because of hemorrhage from the right supraclavicular tumor which was a metastatic focus. Although the patient was treated as an inpatient, the Grade 4 hemorrhage could not be controlled and the patient died on day 78. Since RAD001 markedly diminished the size of the patient's metastatic focus, the cause of death was hemorrhage from either the right supraclavicular metastatic focus or the enriched vessels. The study drug did not seem to be the direct cause of hemorrhage. The other two patients in the 10 mg/day cohort took RAD001 for >3 months. One patient with colorectal cancer was treated with 10 mg/day and experienced Grade 3 hyperglycemia on day 98. The patient was determined to have progressive disease on the same day. Another patient in the 10 mg/day cohort did not have any Grade 3 or 4 toxicities and discontinued RAD001 due to disease progression on day 154.

tient with colorectal cancer was treated with 10 mg/day and experienced Grade 3 hyperglycemia on day 98. The patient was determined to have progressive disease on the same day. Another patient in the 10 mg/day cohort did not have any Grade 3 or 4 toxicities and discontinued RAD001 due to disease progression on day 154. Table 2. Number of patients with adverse events in all courses thought to be attributable to RAD001 Adverse event RAD001 dose (mg/day) Total 2.5 (n = 3) 5 (n = 3) 10 (n = 3) G1/2 G3/4 G1/2 G3/4 G1/2 G3/4 Thrombocytopenia 0 0 2 0 3 0 5 Leukopenia 1 0 2 0 0 0 3 Neutropenia 1 0 0 0 0 0 1 Anemia 0 0 0 0 1 0 1 Anorexia 1 0 2 0 1 0 4 Rash 0 0 1 0 3 0 4 Stomatitis 1 0 0 0 0 1 2 Nausea 1 0 0 0 1 0 2 Mucosal inflammation 0 0 0 0 2 0 2 Diarrhea 0 0 2 0 0 0 2 Fatigue 0 0 1 0 0 1 2 Weight decreased 1 0 0 0 1 0 2 Elevated ALT or AST 2 0 0 0 0 0 2 Hyperglycemia 0 0 0 0 0 1 1 Hemorrhage 0 0 0 0 0 1 1 Pneumonitis 0 0 1 0 0 0 1 Hypertension 1 0 0 0 0 0 1 Glucose tolerance impaired 0 0 1 0 0 0 1 Includes all adverse events occurring in two or more patients or were ≥Grade 2. G, grade; ALT, alanine aminotransferase; AST, aspartate aminotransferase.

r AST 2 0 0 0 0 0 2 Hyperglycemia 0 0 0 0 0 1 1 Hemorrhage 0 0 0 0 0 1 1 Pneumonitis 0 0 1 0 0 0 1 Hypertension 1 0 0 0 0 0 1 Glucose tolerance impaired 0 0 1 0 0 0 1 Includes all adverse events occurring in two or more patients or were ≥Grade 2. G, grade; ALT, alanine aminotransferase; AST, aspartate aminotransferase. Pharmacokinetics Pharmacokinetic parameters of RAD001 are summarized in Table 3. The Cmax of RAD001 was apparent 2 h after administration of a single dose of the oral drug (Table 3 and Fig. 1A). The Cmin of RAD001 indicated that a steady state was attained after ∼8 days of repeated once-daily oral dosing (Fig. 1B). Determination of the AUCτ on days 1 and 15 revealed that the exposure to RAD001 achieved after multiple dosing was about twice that achieved after a single dose (Table 3). On day 1, Cmax and AUCτ increased almost dose-proportionally. At steady state (day 15), Cmax and AUCτ increased with increment of dose but dose-proportionality was not clear due to large inter-individual variability in the 5 mg/day cohort. Figure 1. Pharmacokinetics of RAD001. (A) Blood concentration of RAD001 after administration of a single oral dose (2.5, 5 or 10 mg) on day 1 of cycle 1. Data are means ± SD. (B) Blood trough concentration (Cmin) of RAD001 during continuous oral dosing for 29 days (cycle 1). Data are means ± SD. Table 3. Pharmacokinetic parameters of RAD001

Figure 1. Pharmacokinetics of RAD001. (A) Blood concentration of RAD001 after administration of a single oral dose (2.5, 5 or 10 mg) on day 1 of cycle 1. Data are means ± SD. (B) Blood trough concentration (Cmin) of RAD001 during continuous oral dosing for 29 days (cycle 1). Data are means ± SD. Table 3. Pharmacokinetic parameters of RAD001 RAD001 dose (mg/day) 2.5 (n = 3) 5 (n = 3) 10 (n = 3) Day 1 tmax (h) Median 1.98 1.00 2.00 Range 0.98–2.00 1.00–1.95 1.92–2.00 Cmax (ng/ml) 15.1 ± 2.48 31.5 ± 3.40 49.4 ± 14.8 AUCτ (ng h/ml) 85.2 ± 18.7 211 ± 50.0 401 ± 51.6 Day 15 tmax (h) Median 1.92 1.98 2.02 Range 1.00–1.98 1.93–1.98 2.00–2.20 Cmax (ng/ml) 16.8 ± 1.33 57.6 ± 17.6 65.9 ± 1.40 AUCτ (ng h/ml) 134 ± 24.1 543 ± 189 711 ± 113 CL/F (l/h) 19.1 ± 3.26 9.94 ± 3.21 14.3 ± 2.23 Data are means ± SD unless indicated otherwise. tmax, time of maximum concentration; Cmax, maximum blood concentration; AUCτ, area under the concentration-versus-time curve from time 0 to 24 h after drug administration; CL/F, apparent systemic clearance.

43 ± 189 711 ± 113 CL/F (l/h) 19.1 ± 3.26 9.94 ± 3.21 14.3 ± 2.23 Data are means ± SD unless indicated otherwise. tmax, time of maximum concentration; Cmax, maximum blood concentration; AUCτ, area under the concentration-versus-time curve from time 0 to 24 h after drug administration; CL/F, apparent systemic clearance. Tumor Response Among seven patients evaluable for tumor response, obvious tumor shrinkage was observed in two patients treated at the dose level of 10 mg/day. A 60-year-old male with advanced esophageal carcinoma who had been treated with seven prior chemotherapy regimens started treatment with RAD001 at 10 mg/day. After one cycle of RAD001 treatment, computed tomography revealed that lymph nodes with metastases in the right supraclavicular region had shrunk markedly (Fig. 2A). A 64-year-old male with gastric adenocarcinoma and liver metastases who had undergone four prior chemotherapy regimens showed a partial response to RAD001 that persisted for >4 months at the dose of 10 mg/day (Fig. 2B). Figure 2. Computed tomography images of tumor response to RAD001 treatment. (A) Shrinkage of metastases in supraclavicular lymph nodes in a patient with esophageal cancer. (B) Shrinkage of liver metastases in a patient with gastric cancer.

Tumor Response Among seven patients evaluable for tumor response, obvious tumor shrinkage was observed in two patients treated at the dose level of 10 mg/day. A 60-year-old male with advanced esophageal carcinoma who had been treated with seven prior chemotherapy regimens started treatment with RAD001 at 10 mg/day. After one cycle of RAD001 treatment, computed tomography revealed that lymph nodes with metastases in the right supraclavicular region had shrunk markedly (Fig. 2A). A 64-year-old male with gastric adenocarcinoma and liver metastases who had undergone four prior chemotherapy regimens showed a partial response to RAD001 that persisted for >4 months at the dose of 10 mg/day (Fig. 2B). Figure 2. Computed tomography images of tumor response to RAD001 treatment. (A) Shrinkage of metastases in supraclavicular lymph nodes in a patient with esophageal cancer. (B) Shrinkage of liver metastases in a patient with gastric cancer. DISCUSSION Evidence implicating the phosphatidylinositol 3-kinase–Akt–mTOR signaling pathway in the pathogenesis of a variety of malignancies has prompted the development of therapeutic strategies to modulate this pathway. RAD001 is an oral inhibitor of the mTOR pathway, and we have now performed a dose-escalation Phase I study of this drug in Japanese patients with advanced solid tumors in order to evaluate its safety and pharmacokinetics. Therapy with RAD001 at oral doses of up to 10 mg once daily was relatively well tolerated in the study subjects. Indeed, the safety and tolerability of RAD001 in the Japanese patients were similar to those observed in previous studies with larger populations of Caucasian patients, for whom the most common drug-related toxicities included rash, stomatitis and fatigue. Previous studies have reported that patients receiving RAD001 manifested hyperglycemia and hyperlipidemia, probably as a result of inhibition of mTOR-regulated glucose and lipid metabolism (16,18,19). Grade 3 hyperglycemia was observed in one patient treated with 10 mg/day, whereas hyperlipidemia was not observed in our study. One patient in our study developed pneumonitis of Grade 2, with this condition having previously been identified as a potential class-related toxicity for mTOR inhibitors that should be monitored in clinical trials with these agents (16–20). However, the condition of pneumonitis in our study was reversible after discontinuation of RAD001 treatment. The pharmacokinetic profile of RAD001 in Japanese patients was also similar to that in Caucasian patients. RAD001 was absorbed rapidly, with the Cmax being achieved as early as 1–2 h after oral administration. A recent Phase I study of RAD001 performed in Europe and the USA showed that the mean (±SD) Cmax in patients with advanced cancer was 32 ± 9 and 61 ± 17 ng/ml at daily doses of 5 and 10 mg, respectively, with a mean AUCτ of 238 ± 77 and 514 ± 231 ng h/ml, respectively (16). These results for Caucasian patients are similar to those obtained here with Japanese patients, especially for the dose level of 10 mg/day (Cmax of 65.9 ± 1.40 ng/ml and AUCτ of 711 ± 113 ng h/ml.

7 ng/ml at daily doses of 5 and 10 mg, respectively, with a mean AUCτ of 238 ± 77 and 514 ± 231 ng h/ml, respectively (16). These results for Caucasian patients are similar to those obtained here with Japanese patients, especially for the dose level of 10 mg/day (Cmax of 65.9 ± 1.40 ng/ml and AUCτ of 711 ± 113 ng h/ml. Given the limited number of patients in both studies, these results suggest that there are no substantial differences in the pharmacokinetics of RAD001 between the two populations. RAD001 has already undergone extensive clinical testing in the setting of renal and cardiac transplantation (21,22). Our present data are also supported by observations with 673 renal transplant patients who received RAD001 (23). This large cohort included 80% Caucasian patients and 2.5% patients of Asian origin with no significant differences in clearance of RAD001 being apparent between the Asian and Caucasian patients. The data from this study, combined with those from previous studies, suggest that the pharmacokinetic and safety data for RAD001 obtained in larger clinical trials with Caucasian patients are likely applicable to the Japanese population.

es in clearance of RAD001 being apparent between the Asian and Caucasian patients. The data from this study, combined with those from previous studies, suggest that the pharmacokinetic and safety data for RAD001 obtained in larger clinical trials with Caucasian patients are likely applicable to the Japanese population. Although response was not a primary outcome of our study, two of three patients treated with RAD001 at a daily dose of 10 mg manifested marked tumor shrinkage. This antitumor activity occurred in patients with esophageal and gastric cancer. One esophagogastric cancer patient also exhibited a partial response to RAD001 treatment at a daily dose of 5 mg in a previous Phase I study (16). The likelihood that these findings will extend to other patients is supported by recent studies suggesting that defects in the mTOR signaling pathway are important in the pathogenesis of these cancers. mTOR is an upstream regulator of hypoxia-inducible factor-1α, which is a key mediator of gastric cancer growth (24). Pre-clinical studies have shown that the mTOR inhibitor rapamycin inhibits the growth of human gastric adenocarcinoma cell lines, gastric cancer, gastrointestinal tumors, and the development of peritoneal carcinomatosis from gastric cancer in vitro or in vivo (24–27).

ch is a key mediator of gastric cancer growth (24). Pre-clinical studies have shown that the mTOR inhibitor rapamycin inhibits the growth of human gastric adenocarcinoma cell lines, gastric cancer, gastrointestinal tumors, and the development of peritoneal carcinomatosis from gastric cancer in vitro or in vivo (24–27). In conclusion, the results of our Phase I study suggest that RAD001 can be safely administered at a daily dose of 10 mg to Japanese patients with advanced solid malignancies. The pharmacokinetic characteristics of RAD001 in Japanese patients did not appear to differ from those previously observed in Caucasian patients. The safety profile and potential broad-spectrum efficacy of RAD001 thus warrant additional clinical evaluation of this new agent. Funding This study was sponsored by Novartis Pharma K.K. Conflict of interest statement The authors Katsutoshi Kurei and Ken Kobayashi are employed by Novartis Pharma. Acknowledgements We thank Richard McCabe and Nelson Erlick for comments on the manuscript.

INTRODUCTION 5-Fluorouracil (5-FU) is a mainstay of chemotherapy in advanced gastric cancer. Bolus injection of 5-FU resulted in a 13–20% of response rate and its protracted continuous infusion (PCI) resulted in 18–26% of response rate (1–3). Although few full-scale trials have been conducted to directly compare these two schedules of 5-FU treatment in gastric cancer based on its association with less myelosuppression and diarrhea, PCI is considered an acceptable reference treatment (4,5). However, 5-FU concentration in plasma significantly varies with PCI schedule. Also, ∼90% of administered 5-FU is metabolized mainly to α-fluoro-β-alanine, thus abolishing its antitumor effect. Finally, dihydropyrimidine dehydrogenase (DPD) is the main factor affecting the 5-FU chemosensitivity.

ference treatment (4,5). However, 5-FU concentration in plasma significantly varies with PCI schedule. Also, ∼90% of administered 5-FU is metabolized mainly to α-fluoro-β-alanine, thus abolishing its antitumor effect. Finally, dihydropyrimidine dehydrogenase (DPD) is the main factor affecting the 5-FU chemosensitivity. S-1 is an oral fluoropyrimidine that was developed to mimic PCI of 5-FU. High 5-FU levels were maintained both in plasma and in tumor tissues, with reduced gastrointestinal toxicity, by combining tegafur with two biomodulators, 5-chloro-2,4-dihydroxypyridine (CDHP) and potassium oxonate (Oxo). Tegafur is converted to 5-FU in the liver by cytochrome P4502A6. CDHP inhibits the catabolism of 5-FU by inhibiting DPD activity. The other component, Oxo, blocks phosphorylation of 5-FU in the intestine to reduce gastrointestinal toxicity (6,7). In the initial phase II trials conduced in Japan, S-1 monotherapy showed such a promising tumor response in gastric cancer that it was comparable to combination chemotherapies (8–10). However, subsequent studies did not reproduce this initial high tumor response but demonstrated differences in drug metabolism and toxicity among Japanese, USA and European populations. These data necessitated the evaluation of population-specific pharmacokinetic profiles to in-depth understand the ethnic differences and the pharmacologic property of S-1 (11–13). We conducted a multi-institutional phase II study of S-1 monotherapy in advanced gastric cancer, which is the first in a non-Japanese Asian population (14). The study proceeded with two dosage levels of S-1, 35 and 40 mg/m2, and pharmacokinetic evaluation was planned along with the study for the purpose of obtaining further information on S-1 in Korean population.

udy of S-1 monotherapy in advanced gastric cancer, which is the first in a non-Japanese Asian population (14). The study proceeded with two dosage levels of S-1, 35 and 40 mg/m2, and pharmacokinetic evaluation was planned along with the study for the purpose of obtaining further information on S-1 in Korean population. Our aims here are (i) to investigate the changes in the plasma level of S-1 in a treatment cycle; (ii) to obtain pharmacokinetic profiles after 28 days of consecutive administration to see the dosage effect and intercyclic differences with repetitive treatment of S-1 and finally (iii) to correlate with toxicity and antitumor activity. PATIENTS AND METHODS Patients Patients were enrolled when they have histologically confirmed gastric adenocarcinoma with inoperable or metastatic disease; age ≥18 years; performance status ≤2 according to the criteria of Eastern Cooperative Oncology Group; a life expectancy of ≥3 months, no prior chemotherapy for advanced disease (adjuvant chemotherapy should have been completed at least 6 months before enrollment); bidimensionally measurable lesions and adequate organ function (hemoglobin ≥10 g/dl, leukocyte ≥4000/μl, platelets ≥100 000/μl, serum creatinine ≤1.5× upper limit of normal (ULN), total bilirubin ≤1.25 × ULN and serum aminotransferase ≤2.5 × ULN). Patients were excluded if they had other active malignancies, brain metastasis or severe comorbid conditions. The protocol was approved by the institutional review board, and written informed consent was obtained from patients according to the institutional regulation.

1.25 × ULN and serum aminotransferase ≤2.5 × ULN). Patients were excluded if they had other active malignancies, brain metastasis or severe comorbid conditions. The protocol was approved by the institutional review board, and written informed consent was obtained from patients according to the institutional regulation. Treatment Plan Three patients were allocated to 35 mg/m2 group, and another three patients were allocated to 40 mg/m2 group. S-1 was administered twice a day within 1 h of breakfast and supper for 28 consecutive days. This was followed by a 14-day resting period. Dosage was calculated according to body surface area (BSA), which was different from Japanese dosing system (15). Planned dose intensity was 327 mg/m2/week for the 35 mg/m2 group, and 373 mg/m2/week for the 40 mg/m2 group. The schedule was repeated until disease progression, unacceptable toxicity or patient's withdrawal of consent. Imaging studies for tumor response were performed after each cycle, and tumor response was measured according to the World Health Organization (WHO) criteria. Adverse events were recorded every week and graded according to the NCI-common toxicity criteria (version 2.0).

able toxicity or patient's withdrawal of consent. Imaging studies for tumor response were performed after each cycle, and tumor response was measured according to the World Health Organization (WHO) criteria. Adverse events were recorded every week and graded according to the NCI-common toxicity criteria (version 2.0). Pharmacokinetic Study A pharmacokinetic study was performed in Cycles 1 and 3. In a treatment cycle, blood samples were collected in heparinized tube immediately before and 4 h after doses on days 1, 8 and 15. And on day 28, blood was collected before as well as 1, 2, 3, 6, 8, 10, 14, 24 and 48 h after the last administration of S-1. Plasma was isolated and stored at −80°C until analysis. Urine samples were collected 12 h before the last dose of S-1 and for the periods of 0–6, 6–12, 12–18 and 18–24 h after the last dosage of S-1. After estimation of the total urine volumes, 10 ml aliquots were stored at −80°C until analysis.

administration of S-1. Plasma was isolated and stored at −80°C until analysis. Urine samples were collected 12 h before the last dose of S-1 and for the periods of 0–6, 6–12, 12–18 and 18–24 h after the last dosage of S-1. After estimation of the total urine volumes, 10 ml aliquots were stored at −80°C until analysis. Analysis of tegafur, 5-FU, CDHP and Oxo was conducted according to the method described by Matsushita et al. (16,17). Briefly, tegafur was extracted with dichloromethane from each sample and analyzed using high-performance liquid chromatography equipped with an UV absorption spectrophotometer. 5-FU and CDHP were extracted with ethyl acetate. Oxo was separately extracted using a solid extraction column. They were analyzed using a negative-ion chemical ionization gas chromatography/mass spectrophotometer. The lower measurable limit of plasma levels for tegafur, 5-FU, CDHP and Oxo was 10, 1, 2 and 1 ng/ml, respectively. The pharmacokinetic parameters were derived using non-compartmental methods with ‘WinNonlin Professional’ version 5.0 (Pharsight Corp., Mountain View, CA, USA). The pharmacokinetic parameters included the determination of maximum plasma concentration (Cmax), time to maximum plasma concentration (Tmax), area under the plasma concentration-versus-time curve from time 0 to 48 h (AUC0–48 h) and plasma elimination half-life (T1/2). Pharmacokinetic analysis for the S-1 constituents in urine included the determination of the amount excreted at each collection interval and the cumulative amount excreted over a 24 h period.

, area under the plasma concentration-versus-time curve from time 0 to 48 h (AUC0–48 h) and plasma elimination half-life (T1/2). Pharmacokinetic analysis for the S-1 constituents in urine included the determination of the amount excreted at each collection interval and the cumulative amount excreted over a 24 h period. RESULTS Patient Characteristics Three patients were enrolled for each dosage group of 35 and 40 mg/m2. The six patients consisted of five men and one woman. Ages were between 28 and 66 years, and the median age was 61 years old. Three patients received prior gastrectomy. The median hemoglobin level was 11.3 (range: 10.0–13.5 g/dl). The median BSA was 1.66 m2 (range: 1.27–1.88 m2) and the median actual daily dose administered was 125 mg (range: 100–140 mg). The median daily dose divided by BSA was 71 mg/m2 (range: 69–73 mg/m2) for 35 mg/m2 group and 83 mg/m2 (range: 79–88 mg/m2) for 40 mg/m2 group. All the patients had normal baseline range of creatinine clearance, of which the median value was 80 ml/min (range: 68–112 ml/min).

administered was 125 mg (range: 100–140 mg). The median daily dose divided by BSA was 71 mg/m2 (range: 69–73 mg/m2) for 35 mg/m2 group and 83 mg/m2 (range: 79–88 mg/m2) for 40 mg/m2 group. All the patients had normal baseline range of creatinine clearance, of which the median value was 80 ml/min (range: 68–112 ml/min). Change of the Plasma Level of 5-FU in One Treatment Cycle Figure 1 shows the changes in the mean plasma level of 5-FU, the active metabolite of tegafur, measured on days 1, 8, 15 and 28 in Cycles 1 and 3. 5-FU readily appeared in plasma from day 1. With 35 mg/m2, the 4 h post-dose plasma level of 5-FU after single dose of S-1 was 56 ± 9 ng/ml. At 40 mg/m2, the 5-FU plasma level increased to 191 ± 94 ng/ml. The pre-dose (trough) and 4 h post-dose 5-FU levels were similar to one another on days 8, 15 and 28, indicating that 5-FU concentration in plasma reached the steady-state level on day 8. Also, the estimated steady-state level on day 8 was also dependent on dosage. At 35 mg/m2, the mean steady-state 5-FU level was 108 ± 21 ng/ml. At 40 mg/m2, it was 176 ± 114 ng/ml. There were no significant differences in pre-dose and 4 h post-dose plasma levels between Cycles 1 and 3, implying that there were no intercyclic cumulative effect of 5-FU. Figure 1. Changes in the average plasma level of 5-FU measured on days 1, 8, 15, and 28 after S-1 administration.

Change of the Plasma Level of 5-FU in One Treatment Cycle Figure 1 shows the changes in the mean plasma level of 5-FU, the active metabolite of tegafur, measured on days 1, 8, 15 and 28 in Cycles 1 and 3. 5-FU readily appeared in plasma from day 1. With 35 mg/m2, the 4 h post-dose plasma level of 5-FU after single dose of S-1 was 56 ± 9 ng/ml. At 40 mg/m2, the 5-FU plasma level increased to 191 ± 94 ng/ml. The pre-dose (trough) and 4 h post-dose 5-FU levels were similar to one another on days 8, 15 and 28, indicating that 5-FU concentration in plasma reached the steady-state level on day 8. Also, the estimated steady-state level on day 8 was also dependent on dosage. At 35 mg/m2, the mean steady-state 5-FU level was 108 ± 21 ng/ml. At 40 mg/m2, it was 176 ± 114 ng/ml. There were no significant differences in pre-dose and 4 h post-dose plasma levels between Cycles 1 and 3, implying that there were no intercyclic cumulative effect of 5-FU. Figure 1. Changes in the average plasma level of 5-FU measured on days 1, 8, 15, and 28 after S-1 administration. Change in Plasma Levels of Tegafur, CDHP and Oxo in One Treatment Cycle Figure 2 shows changes in the mean plasma levels of the three components of S-1 (tegafur, CDHP and Oxo) measured in Cycles 1 and 3. At a dose of 35 mg/m2, tegafur plasma concentration was ∼4000 ng/ml at each pre-dose and 4 h measurement on days 8, 15 and 28, indicating that its plasma concentration reached the steady-state which was around 4000 ng/ml. On the contrary, at 40 mg/m2, both pre- and post-dose levels kept increasing as S-1 administration continued through day 28, reaching as high as 6554 ± 2344 ng/ml. This suggests a dose-related accumulation of tegafur at 40 mg/m2.

cating that its plasma concentration reached the steady-state which was around 4000 ng/ml. On the contrary, at 40 mg/m2, both pre- and post-dose levels kept increasing as S-1 administration continued through day 28, reaching as high as 6554 ± 2344 ng/ml. This suggests a dose-related accumulation of tegafur at 40 mg/m2. Figure 2. Change in the average plasma level of S-1 components measured on days 1, 8, 15 and 28 after S-1 administration in Cycle 1: (A) tegafur, (B) CDHP and (C) Oxo. CDHP, 5-chloro-2,4-dihydroxypyridine; Oxo, potassium oxonate. CDHP and Oxo also reached steady-state on day 8. Although unclear for CDHP, Oxo plasma levels correlated with S-1 dosage. Moreover, like the case of 5-FU, there were no definite inter-cyclic differences in plasma levels between Cycles 1 and 3 for tegafur, CDHP and Oxo. Pharmacokinetics after 28 Days of Consecutive Administration Pharmacokinetic parameters of tegafur, 5-FU, CDHP and Oxo measured after the last dose on day 28 are summarized in Fig. 3 (also in Supplementary material, Table S1). At 35 mg/m2, mean Cmax for tegafur, 5-FU, CDHP and Oxo was 4484 ± 1231, 91 ± 23, 191 ± 14 and 33 ± 1.0 ng/ml, respectively. Mean AUC0–48 h was 99 907 ± 38 999, 750 ± 120, 1359 ± 373 and 337 ± 80 ng h/ml, respectively. Besides, the mean Cmax of 5-FU and three S-1 components increased with S-1 dosage. AUC was also dependent on dosage, but 5-FU AUC0–48 h increased only marginally to 767 ± 194 ng h/ml (3%). 5-FU was eliminated from plasma with mean T1/2 values that did not markedly vary with the dosage.

d 337 ± 80 ng h/ml, respectively. Besides, the mean Cmax of 5-FU and three S-1 components increased with S-1 dosage. AUC was also dependent on dosage, but 5-FU AUC0–48 h increased only marginally to 767 ± 194 ng h/ml (3%). 5-FU was eliminated from plasma with mean T1/2 values that did not markedly vary with the dosage. Figure 3. Pharmacokinetic profile of 5-FU and S-1 components measured on day 28 after the last dose of S-1: (A) tegafur, (B) 5-FU, (C) CDHP and (D) Oxo. Mean AUC0–48 h for 5-FU and CDHP increased in Cycle 3 compared with Cycle 1, whereas other parameters showed little inter-cyclic changes. This increase in 5-FU and CDHP might imply a correlation between DPD inhibition by CDHP and 5-FU levels after S-1 administration. The urinary excretion of tegafur, 5-FU, CDHP and Oxo within 24 h after administration of the last dose on day 28 was 37.3 ± 15.0, 17.1 ± 4.3, 154.5 ± 19.7 and 5.4 ± 1.1 µg, respectively. There was no correlation of S-1 urinary excretion with its dosage or cycle.

ibition by CDHP and 5-FU levels after S-1 administration. The urinary excretion of tegafur, 5-FU, CDHP and Oxo within 24 h after administration of the last dose on day 28 was 37.3 ± 15.0, 17.1 ± 4.3, 154.5 ± 19.7 and 5.4 ± 1.1 µg, respectively. There was no correlation of S-1 urinary excretion with its dosage or cycle. Correlation with Toxicity and Antitumor Effect Two patients underwent 3 cycles of treatment, three patients underwent 4 cycles of treatment and the remaining patient underwent 10 cycles. Two patients—from two in the 40 mg/m2 group—showed partial responses, whereas the disease was stable in the remaining patients. Also three patients—two in the 35 mg/m2 group and one in the 40 mg/m2 group—suffered Grade 3 anemia during treatment. We investigated the correlation between treatment outcome—toxicity and antitumor activity—and pharmacokinetic parameters. With Spearman's correlation coefficient, neither Cmax nor AUC correlated with toxicity or response. DISCUSSION Blood pharmacokinetics of 5-FU reflect those in tumors (18). In addition, there exists a clinical correlation between 5-FU AUC and treatment outcomes (19,20). However, reports on 5-FU plasma levels with PCI are inconsistent, which is due to its high dependency on the activity of DPD. S-1 was found to successfully allow an effect similar to that of long-term PCI of 5-FU, and the combination of a CDHP and tegafur makes the width of variation of the 5-FU plasma level narrow (15).

wever, reports on 5-FU plasma levels with PCI are inconsistent, which is due to its high dependency on the activity of DPD. S-1 was found to successfully allow an effect similar to that of long-term PCI of 5-FU, and the combination of a CDHP and tegafur makes the width of variation of the 5-FU plasma level narrow (15). We conducted a pharmacokinetic study of S-1, based on the doses used in our previous multinational Phase II study, which was the first performed in non-Japanese Asian population (14). We first evaluated the changes in the 5-FU plasma level during the treatment cycle. The non-toxic concentration of 5-FU is reported to be 195 ng/ml, and the steady-state concentration (Css) of 5-FU correlates with incidence of leucopenia (21). In the previous Japanese study of S-1 pharmacokinetics, peak plasma levels were reached 3.5 h after administration, which was the basis of our measuring 4 h post-dose level of 5-FU only once in this study (15). However, our post-dose level 5-FU after a single administration was only 56 ng/ml, which is half of that measured in the Japanese study (15). We thought that this difference seemed to be overcome by dose increment of S-1 to 40 mg/m2. At the dose of 40 mg/m2, we have attained the highest dose intensity of S-1 (367 mg/m2/week) ever reported in the Phase II trials. However, the 5-FU plasma level was 181 ng/ml, which is still in the non-toxic range for 5-FU. This explains, at least partially, the favorable compliance of our patients to S-1 and the low incidence of Grade 3 neutropenia in our trial (14).

st dose intensity of S-1 (367 mg/m2/week) ever reported in the Phase II trials. However, the 5-FU plasma level was 181 ng/ml, which is still in the non-toxic range for 5-FU. This explains, at least partially, the favorable compliance of our patients to S-1 and the low incidence of Grade 3 neutropenia in our trial (14). This low 5-FU level could be explained by two factors: (i) low conversion from tegafur and (ii) low activity of CDHP. CDHP attains its maximal concentration as early as 2 h in the Japanese trial, and its 4 h post-dose level was still ∼100 ng/ml. Although it would be hasty to infer a role for CDHP in our patients from a simple extrapolation of the Japanese data, we can at least think that general CDHP levels are not much different between the two populations (22). However, changes in the tegafur plasma level could provide a clue. The mean post-dose level of tegafur after a single S-1 administration was 1.68 µg/ml. In a Phase I/II study of a single administration of UFT, which is another combination formula with DPD inhibitor, and tegafur alone at 300 mg/body, the tegafur plasma level was 13.7 and 12.3 µg/ml, respectively. These levels are ∼8-fold higher than measured in our trial (22). Considering that the overall average dose of S-1 (as tegafur) was 63 mg/body, which was higher than Japanese study (50 mg/body), our levels were only 5-fold against that of UFT and tegafur. It indicates that the value of the plasma tegafur is lower than expected. Therefore, failing to achieve appropriate plasma level of tegafur could explain the low plasma 5-FU levels seen in our patients.

body, which was higher than Japanese study (50 mg/body), our levels were only 5-fold against that of UFT and tegafur. It indicates that the value of the plasma tegafur is lower than expected. Therefore, failing to achieve appropriate plasma level of tegafur could explain the low plasma 5-FU levels seen in our patients. In one treatment cycle, the plasma concentration of 5-FU, CDHP and Oxo readily attained the steady-state levels on day 8, which was consistent with a previous study (23). Tegafur increased in both trough and post-dose levels at the 40 mg/m2, but it did not necessarily accompany the increase in 5-FU level to the same extent. Taking the long half-life of tegafur into account, the result may reflect the accumulation of S-1—as the form of tegafur—and the saturation of the capacity to convert tegafur to 5-FU—such as cytochrome P4502A6 at 40 mg/m2 of S-1 (24). The conversion level of our patients would have been comparable to that of Japanese patients when considering the alleged similar inter-ethnic profile of cytochrome P4502A6 polymorphisms in the two populations (25).

aturation of the capacity to convert tegafur to 5-FU—such as cytochrome P4502A6 at 40 mg/m2 of S-1 (24). The conversion level of our patients would have been comparable to that of Japanese patients when considering the alleged similar inter-ethnic profile of cytochrome P4502A6 polymorphisms in the two populations (25). Many reports agree on the importance of evaluating potential ethnic differences in the metabolism of S-1, which lead to differential dose tolerance and toxicity. Myelosuppression was the toxicity that has precluded dose escalation in Japanese studies, whereas gastrointestinal and skin toxicity were the features of western trials. In addition, anemia was the unique toxicity encountered in a Korean Phase II study (14). Regardless, maximum tolerated doses were found to be higher in Asian studies than in western studies, and Korean study obtained the highest dose intensity ever reported with favorable compliance (14,26). Therefore, it seemed no wonder that our pharmacokinetic behaviors of S-1 and its components were more similar to those of Japanese findings rather than to those of Americans at an equivalent dose level of 35 mg/m2. Hoff et al. (12) noticed that AUC of 5-FU were similar among various trials, but those of tegafur were much higher in Japanese patients. This is partially explained by aforementioned ethnic variation in the cytochrome P450. Other authors speculated that this difference came from apparent difference in exposure to 5-FU resulting from different total doses due to different body sizes, as Japanese people have lower BSA than westerns (27). Mean value of daily S-1 dose per BSA is 71 mg/m2 in western patients and 76 mg/m2 in Japanese patients (27). For Korean patients, this value increases to 83 mg/m2 at 40 mg/m2. These findings, which are further supported by the present study, raised the question that pharmacogenomic approaches accounts for the difference in pharmacologic behavior among various ethnic groups. For tegafur, a dose-related increase in AUC was observed from 35 and 40 mg/m2 groups. However, AUC values of 5-FU and CDHP did not so much as those for tegafur. Although this observation may result from small absolute differences between these dose levels, it adds another potential example of saturated biotransformation of tegafur converting to 5-FU.

ease in AUC was observed from 35 and 40 mg/m2 groups. However, AUC values of 5-FU and CDHP did not so much as those for tegafur. Although this observation may result from small absolute differences between these dose levels, it adds another potential example of saturated biotransformation of tegafur converting to 5-FU. We demonstrated little changes in AUC or Cmax values of tegafur and Oxo between Cycles 1 and 3. This implies that a cumulative effect of S-1 is frivolous and that resting period of 2 weeks would be a reasonable wash-out period. However, we could notice the tendency that the mean AUC values and half-life of 5-FU and CDHP increased in Cycle 3 at 40 mg/m2. This increase might demonstrate a correlation between DPD inhibition by CDHP and 5-FU levels after S-1 administration. Allowing that all the patients maintained creatinine clearance within normal range throughout the entire treatment period, it may also suggest that the increasing risk of toxicity is plausible as treatment cycles progress in this dose level due to a cumulative effect of CDHP and 5-FU.

U levels after S-1 administration. Allowing that all the patients maintained creatinine clearance within normal range throughout the entire treatment period, it may also suggest that the increasing risk of toxicity is plausible as treatment cycles progress in this dose level due to a cumulative effect of CDHP and 5-FU. Although sample size is small, our data demonstrate that pharmacokinetic behaviors of S-1 could not predict response and toxicity, also consistent with previous reports (20). We suggest that S-1 could be another target for pharmacogenetic/pharmacogenomic tools for future trials. To conclude, this is the first pharmacokinetic study performed in non-Japanese Asian population that tested the highest dose intensity ever obtained as S-1 monotherapy. Our data demonstrate (i) the similar pharmacokinetic behaviors to the Japanese population at equivalent dosage, (ii) possible saturation of tegafur conversion to 5-FU at 40 mg/m2, (iii) negligible cumulative effects at 35 mg/m2 between cycles and finally (iv) the poor relationship of pharmacokinetic behaviors with clinical outcomes. We believe that our data could provide a basis for schedule optimization of S-1 and for additional pharmacokinetic studies on the interaction with other antitumor agents for future clinical trial designs. Supplementary material Supplementary material is available at Japanese Journal of Clinical Oncology Online.

Although sample size is small, our data demonstrate that pharmacokinetic behaviors of S-1 could not predict response and toxicity, also consistent with previous reports (20). We suggest that S-1 could be another target for pharmacogenetic/pharmacogenomic tools for future trials. To conclude, this is the first pharmacokinetic study performed in non-Japanese Asian population that tested the highest dose intensity ever obtained as S-1 monotherapy. Our data demonstrate (i) the similar pharmacokinetic behaviors to the Japanese population at equivalent dosage, (ii) possible saturation of tegafur conversion to 5-FU at 40 mg/m2, (iii) negligible cumulative effects at 35 mg/m2 between cycles and finally (iv) the poor relationship of pharmacokinetic behaviors with clinical outcomes. We believe that our data could provide a basis for schedule optimization of S-1 and for additional pharmacokinetic studies on the interaction with other antitumor agents for future clinical trial designs. Supplementary material Supplementary material is available at Japanese Journal of Clinical Oncology Online. Funding This work was supported by the Korea Science and Engineering Foundation (KOSEF) grant funded by the Korean government (MOST) (R11-2000-082-03002-0). Funding to pay the Open Access publication charges for this article was provided by Hyun Cheol Chung. Conflict of interest statement None declared.

Supplementary material Supplementary material is available at Japanese Journal of Clinical Oncology Online. Funding This work was supported by the Korea Science and Engineering Foundation (KOSEF) grant funded by the Korean government (MOST) (R11-2000-082-03002-0). Funding to pay the Open Access publication charges for this article was provided by Hyun Cheol Chung. Conflict of interest statement None declared. Supplementary Material [Supplementary Data] Acknowledgements We thank clinical research coordinators (CRC) Seung Ah Kang, Eun Young Ju of Yonsei University College of Medicine and Hyun Jeong Ji of Jeil Pharmaceutical Co. for their sincere help with data documentation and technical assistance. We are also grateful to Hyung Sik Choie of Jeil Pharmaceutical Co. and J. Saruta of Taiho Pharmaceutical Co. of Japan for supplying S-1 for this study.

INTRODUCTION Localized prostate cancer has been treated with various methods, and the results were improved gradually. Of these technologies, surgical and radiological treatments play a leading part in the field (1). An important issue in radiotherapy is conjecture of the status of regional lymph nodes. There are many guidelines for the estimation of possible invasion in the lymph nodes, where they are estimated from the stage, prostate-specific antigen (PSA) and histological findings from biopsy (2,3). The predictive score obtained by assuming these guidelines, however, may be indefinite (4,5). On the basis of the uncertainty for predicting invasion, whole pelvic radiotherapy has been discussed to improve PSA-free survival (6). In order to exclude the influence of regional lymph nodes on whether invasion may be present, extirpation of them before radiotherapy seems to be advisable. The present study was undertaken first to perform the lymphadenectomy in patients with localized prostate cancer. Thereafter, the patients with N0 received radiotherapy alone.

exclude the influence of regional lymph nodes on whether invasion may be present, extirpation of them before radiotherapy seems to be advisable. The present study was undertaken first to perform the lymphadenectomy in patients with localized prostate cancer. Thereafter, the patients with N0 received radiotherapy alone. PATIENTS AND METHODS Patients Between January 1999 and January 2006, pelvic lymphadenectomy was performed in 168 patients with T1–T3 prostate cancer who selected rather non-aggressive treatment at Asahi General Hospital. For lymphadenectomy, the obturator, external and internal iliac lymph nodes were removed via an abdominal incision or laparoscopic surgery. Of these cases, 144 cases (86%) showed negative findings. Stage was defined with UICC TNM classification (6th edn, 2002). Risk was classified into low (T1bc and T2a, <10 ng/ml of PSA and ≤6 of Gleason score), intermediate (T2b,c or 10–20 ng/ml of PSA or 7 of Gleason score) or high (≥ T3 or ≥20 ng/ml of PSA or ≥8 of Gleason score) according to NCCN criteria (7). After radiotherapy, no adjuvant hormone therapy was administered until biochemical failure. PSA was determined every 3 or 6 months, and when elevation occurred, duration of determination was shortened. Biochemical failure was judged with Phoenix criteria (elevated 2 ng/ml of PSA or more from baseline, or clinical relapse) (8). Some patients with biochemical failure experienced second failure, which was judged with increase in PSA from baseline. Prostate biopsy was carried out with 8–12 cores via a perineal route. Gleason score was determined according to ISUP (9). Records of all patients were collected in June 2009 (follow-up, mean 57 months, median 52 months and range 9–119 months). After biochemical failure, most patients received hormone therapy with luteinizing hormone–releasing hormone agonist and 80 mg of bicalutamide daily until the hormone therapy failed. Evaluation for hormone therapy was determined from response to the therapy: decrease of ≥50% from baseline in the PSA (partial response, PR), increase of ≥25% from baseline in the PSA (progressive disease, PD) or change between PR and PD (no change, NC).

and 80 mg of bicalutamide daily until the hormone therapy failed. Evaluation for hormone therapy was determined from response to the therapy: decrease of ≥50% from baseline in the PSA (partial response, PR), increase of ≥25% from baseline in the PSA (progressive disease, PD) or change between PR and PD (no change, NC). PSA Kinetics PSA was determined as total PSA using AxSYM PSA Dainapack (Abbot, Tokyo, Japan). PSA-doubling time (PSA-DT) and velocity were calculated by linear regression. A slope was obtained by the least-square test with values of ln PSA (PSA-DT) or those of PSA (velocity) from three or more points. PSA-DT was obtained from ln 2/slope (10). Velocity was determined as a difference per year (11). Radiation Conformal radiation with a photon beam at 10 MV was used with a multileaf collimator (leaves 10 mm at isocenter). The clinical target volume was the whole prostate and the planning target volume was created by adding 10 mm anteroposterior and lateral margins. A conventional fractionation of 2 Gy/fraction was administered five times per week for 66 Gy of total radiation dose. Statistical Analysis Overall survival was calculated with the Kaplan–Meier method. Statistical difference was determined by the unpaired two-group t-test. Odds ratio was calculated by the logistic regression analysis. Values of P ≤ 0.05 were considered to be significant. All calculations were used with the StatView program.

stical Analysis Overall survival was calculated with the Kaplan–Meier method. Statistical difference was determined by the unpaired two-group t-test. Odds ratio was calculated by the logistic regression analysis. Values of P ≤ 0.05 were considered to be significant. All calculations were used with the StatView program. RESULTS Biochemical Failure Of 144 patients with negative node, 118 cases received radiation after confirming no distal metastatic disease using bone scan and abdominal echogram (Table 1). The other 26 cases were treated surgery or hormonal therapy as chosen by the patients. Of 118 patients who received radiation, 47 patients experienced biochemical failure (47 of 118, 40%). Until 36 months after radiation, 42 patients showed biochemical failure, in which high-risk patients were 34 (81%). Occurrence of biochemical failure gradually decreased in number and there was no failure in the remaining patients after 55 months of the latest failure. Duration of biochemical failure was mean of 21 months (median 17 months and range 4–55 months). Rate of failure was 24% in low-risk, 14% in intermediate-risk and 64% in high-risk patients. Table 1. Patients' characteristics Age (years) ≤60 4 61–70 7 71–80 102 ≥81 5 Initial PSA (ng/ml) <10 60 10.1–20 25 20.1–30 10 30.1–40 5 40.1–50 3 50.1–60 4 ≥60.1 11 Stage T1b 3 T1c 45 T2a 18 T2b 4 T2c 5 T3a 33 T3b 10 Gleason score ≤6 56 7 37 ≥8 25 PSA, prostate-specific antigen.

RESULTS Biochemical Failure Of 144 patients with negative node, 118 cases received radiation after confirming no distal metastatic disease using bone scan and abdominal echogram (Table 1). The other 26 cases were treated surgery or hormonal therapy as chosen by the patients. Of 118 patients who received radiation, 47 patients experienced biochemical failure (47 of 118, 40%). Until 36 months after radiation, 42 patients showed biochemical failure, in which high-risk patients were 34 (81%). Occurrence of biochemical failure gradually decreased in number and there was no failure in the remaining patients after 55 months of the latest failure. Duration of biochemical failure was mean of 21 months (median 17 months and range 4–55 months). Rate of failure was 24% in low-risk, 14% in intermediate-risk and 64% in high-risk patients. Table 1. Patients' characteristics Age (years) ≤60 4 61–70 7 71–80 102 ≥81 5 Initial PSA (ng/ml) <10 60 10.1–20 25 20.1–30 10 30.1–40 5 40.1–50 3 50.1–60 4 ≥60.1 11 Stage T1b 3 T1c 45 T2a 18 T2b 4 T2c 5 T3a 33 T3b 10 Gleason score ≤6 56 7 37 ≥8 25 PSA, prostate-specific antigen. The profiles of patients with biochemical failure and failure-free patients were compared (Table 2). Patients with biochemical failure showed the initial, 12 months later and nadir PSA values higher than those in failure-free patients and had a short duration between radiation and nadir. Influences on biochemical failure were the initial PSA values, stage and duration between radiation and nadir (Table 3). Since PSA-DT is a parameter for tumor growth, patients with failure were divided by PSA-DT. A positive relation between duration until nadir and PSA-DT was confirmed (Table 4). Table 2. Patient characteristics, PSA and duration to nadir in patients with or without biochemical failure

ween radiation and nadir (Table 3). Since PSA-DT is a parameter for tumor growth, patients with failure were divided by PSA-DT. A positive relation between duration until nadir and PSA-DT was confirmed (Table 4). Table 2. Patient characteristics, PSA and duration to nadir in patients with or without biochemical failure Failure (47) Failure-free (71) P value Age (years) 74, 75 (54–83) 75, 75 (61–82) ns No lymph node 9.3, 8, (–21) 9.1, 8, (2–28) ns Risk Low 8 26 Intermediate 4 25 High 35 20 Initial PSA (ng/ml) 43.0, 23.4 (4.1–290) 11.6, 7.5 (3.1–79.8) 0.0009 12 months PSA (ng/ml)a 3.1, 1.9 (0.1–14.5) 1.2, 0.8 (0.3–4.8) 0.019 Nadir PSA (ng/ml) 4.3, 1.9 (0.2–51.9) 0.8, 0.5 (0.01–5.5) 0.004 Radiation–nadir (months) 14.3, 12 (2–45) 27.5, 26 (1–69) <0.0001 Data are shown as mean and median (range), except ‘risk’ (number of cases). aPSA 12 months after radiation. Table 3. Logistic regression analysis for biochemical failure Odds ratio 95% CI Initial PSA (ng/ml) 1.054 1.019–1.090 Stage T2a 5.25 1.325–20.803 T3 6.927 1.837–26.121 Gleason 7b 0.462 0.128–1.666 ≥8 0.739 0.160–3.416 Nadir PSA (ng/ml) 1.477 0.977–2.233 Radiation–nadir (months) 0.95 0.908–0.993 aReference: stage T1. bReference: Gleason ≤6. Table 4. Factors influenced biochemical failure divided by PSA-DT PSA-DT≲8.3 (24) PSA-DT > 8.3 (23) P value Initial PSA (ng/ml) 51.3, 25 (4.1–290) 33.9, 18 (6–245) 0.322 Nadir PSA (ng/ml) 3.4, 2.0 (0.2–11.2) 5.2, 1.7 (0.4–51.9) 0.47 Radiation–nadir (months) 10.3, 9 (2–21) 18.5, 18 (5–45) 0.001 Radiation–failure (months) 18.5, 17 (4–36) 14.3, 13 (8–55) 0.06 Data are shown as mean and median (range).

PSA-DT > 8.3 (23) P value Initial PSA (ng/ml) 51.3, 25 (4.1–290) 33.9, 18 (6–245) 0.322 Nadir PSA (ng/ml) 3.4, 2.0 (0.2–11.2) 5.2, 1.7 (0.4–51.9) 0.47 Radiation–nadir (months) 10.3, 9 (2–21) 18.5, 18 (5–45) 0.001 Radiation–failure (months) 18.5, 17 (4–36) 14.3, 13 (8–55) 0.06 Data are shown as mean and median (range). Median of PSA-doubling time (DT) (8.3 months). Of 47 patients with biochemical failure, four cases did not receive an additional hormone therapy because of a slow rise in PSA. The other 43 patients received hormone therapy after failure, and responded well as PR, except for one patient who showed NC temporarily then showed a rapidly rising PSA and died of prostate cancer 46 months after the start of radiation.

cases did not receive an additional hormone therapy because of a slow rise in PSA. The other 43 patients received hormone therapy after failure, and responded well as PR, except for one patient who showed NC temporarily then showed a rapidly rising PSA and died of prostate cancer 46 months after the start of radiation. Second Biochemical Failure and Outcome Among 47 patients with first failure, 10 cases showed a second increase in PSA (21%). Risks of these 10 patients were 1 of low (1 of 8, 13%) and 9 of high (9 of 35, 26%). Duration between hormone treatment and the second failure was mean of 15 months (median 14 months and range 3–28 months). Factors estimated at first failure were compared between patients with second failure and those without second failure (Table 5). Patients with second failure showed shorter PSA-DT, shorter duration between radiation and first failure. These patients were treated with second-line hormone therapy and/or chemotherapy. Except for one dead patient, the other nine patients included seven showing favorable responses and two revealing slowly progressive disease. These nine patients were alive in June 2009. Table 5. Factors influencing second biochemical failure

e patients were treated with second-line hormone therapy and/or chemotherapy. Except for one dead patient, the other nine patients included seven showing favorable responses and two revealing slowly progressive disease. These nine patients were alive in June 2009. Table 5. Factors influencing second biochemical failure Second failure (10) No second failure (37) P value Initial PSA (ng/ml) 26.8, 15.8 (4.1–82.7) 47.4, 25.2 (5.7–290) 0.148 Nadir PSA (ng/ml) 4.6, 3.3 (0.2–11.2) 4.2, 1.4 (0.3–51.9) 0.83 Failure PSA (ng/ml) 10.6,.2.0 (2.6–31.9) 6.8, 4.0 (1–56.8) 0.29 Radiation–failure (months) 14.3, 14 (4–28) 31.7, 27 (5–55) <0.0001 PSA-DT (months) 4.8, 6 (0.9–11.2) 10.6, 9.6 (2.5–30.8) 0.0002 Velocity (ng/ml/year) 25.1, 11.5 (2.7–96.5) 6.0, 3.2 (0.4–31.9) 0.09 Data are shown as mean, median and range. All data are quoted from the first biochemical failure. Biochemical failure-free survival rate was 52% (61 of 118) at 3 years after radiation. Overall survival rate at 5 years was 87% (Fig. 1). There was only one patient due to prostate cancer-specific death. Eight patients died of other causes except for prostate cancer. There was no complication due to lymphadenectomy. Concerning the toxicity after radiation according to scoring of Radiation Therapy Oncology Group, 34% and 5% of early and late Grade 1–2 morbidity, respectively, showed in the genitourinary system, with 25% and 5% of early and late Grade 1–2 morbidity, respectively, in the rectum. No toxicity was developed for Grade 3 or higher.

the toxicity after radiation according to scoring of Radiation Therapy Oncology Group, 34% and 5% of early and late Grade 1–2 morbidity, respectively, showed in the genitourinary system, with 25% and 5% of early and late Grade 1–2 morbidity, respectively, in the rectum. No toxicity was developed for Grade 3 or higher. Figure 1. Overall survival of patients who received radiotherapy after confirming no lymph node invasion (118 cases). DISCUSSION Survival of patients with prostate cancer after radical treatment is influenced by the status of the regional lymph nodes. The number and findings of invasive nodes correlate with subsequent outcome (12,13). As a curative treatment with radiotherapy, aggressive radiation which includes the pelvic lymph nodes is controversial (14,15). In this discussion, the adverse effects caused by radiation to the outside of the prostate may be a serious consideration. Alternatively, lymphadenectomy before radiation may be proposed. The result from lymphadenectomy may help to determine the strategy of further treatment (16). Moreover, this procedure serves to make a contribution to the relationship between stage and status of lymph nodes. Surgical lymphadenectomy causes slight, if any, complications such as intraoperative injury and postoperative events (17). The most common complications are lymphocysts or lymphoceles after radical prostatectomy, but the present series performed lymphadenectomy alone, so such that adverse effect may be less likely to occur.

cal lymphadenectomy causes slight, if any, complications such as intraoperative injury and postoperative events (17). The most common complications are lymphocysts or lymphoceles after radical prostatectomy, but the present series performed lymphadenectomy alone, so such that adverse effect may be less likely to occur. Biochemical failure occurred in more than 50% of patients with high risk at 5 years after radiotherapy (18). For extended radiotherapy including pelvic area, biochemical failure in patients with high risk was 43% at 5 years (19). Patients receiving radical prostatectomy whose regional lymph nodes had been removed showed elevation of PSA a few years later. It was reported that the obturator, external and internal iliac nodes may be insufficient for the removal of all suspicious nodes (20,21). The limitation of lymph node management for curative treatment remains to be resolved. The similar biochemical-failure rate was noticed after radiation to patients with N0 in the present study. Together with the reports, it suggests that patients with high risk already have the small foci in the distant places. As most biochemical failure in high-risk patients occurred by 36 months, their tumors may be rapidly growing with an increase in 2 ng/ml or more of PSA in this term. Although late recurrence cannot be ruled out, incidence of biochemical failure slowly diminished thereafter.

dy have the small foci in the distant places. As most biochemical failure in high-risk patients occurred by 36 months, their tumors may be rapidly growing with an increase in 2 ng/ml or more of PSA in this term. Although late recurrence cannot be ruled out, incidence of biochemical failure slowly diminished thereafter. A plausible cause of biochemical failure may be an insufficient dose of radiation to the prostate. It has been claimed that a radiation dose of <70 Gy is insufficient for cure of prostate cancer (22,23). It is recommended that >72 Gy of radiation is administered to the prostate of patients with high risk. Although no cancerous mass in the prostate was found in the present study, an insufficient dose of radiation cannot be ruled out. The risk for recurrence after radiotherapy was pointed out with initial PSA, Gleason score and stage, which are well-known risk factors, and risk classification is used from these factors (24). Patients judged to be high risk might have progress in unfavorable courses. Duration of time between radiotherapy and biochemical failure influences the outcome (25). Among these factors, the level of PSA is crucial since patients with >30 ng/ml of PSA showed 20% of PSA-free rate at 5 years and this rate was independent of other factors (26). After radiotherapy, insufficient decrease in PSA to reach a low nadir and a rising pattern of PSA are also considered as factors for recurrence (27). Patients showed biochemical failure in short duration from radiation have rapidly growing tumors as estimated from short PSA-DT.

te was independent of other factors (26). After radiotherapy, insufficient decrease in PSA to reach a low nadir and a rising pattern of PSA are also considered as factors for recurrence (27). Patients showed biochemical failure in short duration from radiation have rapidly growing tumors as estimated from short PSA-DT. Additional hormone therapy is recommended along with radiotherapy for patients especially with high risk. Radiation combined with hormone therapy decreased the biochemical failure and improved clinical progression-free and cancer-specific survival (28). According to literatures, duration of hormone therapy varies between 4 months and 5 years, or up to appearance of progression (29). The adverse effects of hormone therapy have been indicated recently (30). In the present study, the response to hormone therapy was favorable in general, and this may be attributable to a hormone-naïve condition in patients. Duration of hormone therapy after biochemical failure seems to be long, and this might be due to the presence of residual cancer foci. The treatment period of hormone therapy with radiotherapy is an issue under debate, but it might be advisable to make treatment plans adaptable to the individual situations of patients.

Duration of hormone therapy after biochemical failure seems to be long, and this might be due to the presence of residual cancer foci. The treatment period of hormone therapy with radiotherapy is an issue under debate, but it might be advisable to make treatment plans adaptable to the individual situations of patients. CONCLUSION Patients with T1–T3 prostate cancer who were surgically confirmed to be N0 were treated with radiotherapy. Few biochemical failures were observed in patients with low and intermediate risks. Patients with high risk, however, showed biochemical failure in 64%, in whom 97% of failure occurred by 3 years after radiation. Initial and nadir PSA, and duration between radiation and nadir were the factors for biochemical failure. Some patients with first failure, mostly high risk, showed the second failure, and PSA-DT was the factor for second failure, suggesting that patients with second failure had rapidly growing hormone-independent tumors. Most patients after the biochemical failure responded well to hormone therapy, showing favorable results by delayed hormone therapy. It is emphasized that half of patients with high risk can be treated with radiation and lymphadenectomy alone. Conflict of interest statement None declared. Acknowledgements This work was approved by the Ethical Committee of the Asahi General Hospital.

INTRODUCTION In the head and neck region, we sometimes treat patients with cervical lymph node metastasis where a primary tumor cannot be identified by laryngoscopy, computed tomography (CT) and magnetic resonance imaging (MRI). Primary unknown cervical lymph node metastasis (PUCLNM) is reported in 2–9% of metastases in the head and neck region. Additional work-up including upper gastrointestinal endoscopy can detect possible primary lesions in about 10% of the patients, but the possible primary site is not identified in 90% of the patients with PUCLNM. The inability to find the primary tumor makes it difficult to decide on the most appropriate treatment for the patient, and the clinician must consider different options for the initial treatment. In some cases, the primary tumor is detected during treatment for the lymph node metastasis, but the primary site remains unidentified in some. In cases where the primary tumor is detected after the start of treatment, it is impossible to switch the treatment. Thus, to stage and evaluate the treatment strategy, the clinician should be able to detect the primary site before starting treatment.

node metastasis, but the primary site remains unidentified in some. In cases where the primary tumor is detected after the start of treatment, it is impossible to switch the treatment. Thus, to stage and evaluate the treatment strategy, the clinician should be able to detect the primary site before starting treatment. To find a primary lesion, blind biopsy (1–3) or tonsillectomy (4) is sometimes used in patients with PUCLNM. However, these surveillance methods do not always detect the primary lesion. In the case of PUCLNM, whole-neck irradiation will be indicated after cervical lymph node excision because we cannot pinpoint the primary cancer-based treatment strategy (5–7). Whole-neck irradiation causes adverse events such as salivary gland disorder, severe mucositis and taste disorder. In addition, if primary cancer could be detected after irradiation, re-irradiation would not be needed; this is important because surgery after irradiation increases the risk of leakage of the anastomosis. Muto et al. (8,9) reported that narrow-band imaging (NBI) can detect superficial cancer in the oropharynx and hypopharynx. Although NBI is expected to help identify the primary lesion in patients with PUCLNM, there are no reports on this issue. We surveyed primary lesions in such patients using NBI endoscopy of the gastrointestinal tract.

ported that narrow-band imaging (NBI) can detect superficial cancer in the oropharynx and hypopharynx. Although NBI is expected to help identify the primary lesion in patients with PUCLNM, there are no reports on this issue. We surveyed primary lesions in such patients using NBI endoscopy of the gastrointestinal tract. PATIENTS AND METHODS From January 2003 to December 2006, 46 consecutive patients with PUCLNM were surveyed about the primary site using a gastrointestinal NBI endoscope in National Cancer Center Hospital East, Chiba, Japan. Written informed consent for the examination was obtained from all patients. The definition of PUCLNM was in accordance with the report by Greenberg (10) as follows. It is proven to have malignant cells histologically. We cannot identify a primary tumor using ocular inspection or pharyngolarynx fiberoscopy. We cannot identify a primary tumor by CT or MRI. Other organs except the head and neck do not show a carcinoma. In all patients, the possible primary tumor could not be detected by examination using CT, MRI, pharyngolaryngoscopy and standard white-light gastrointestinal endoscopy. We used a magnifying videoendoscope (Q240Z, Olympus Medical Systems, Tokyo, Japan) and sequential RGB light source with NBI function (CLV-Q260SL, Olympus Medical Systems). The magnifying endoscope had a capability of ×80 optical magnification. The NBI system has been described in detail in previous studies (8,9). In this system, the central wavelengths of NBI were 415 and 540 nm, and each had a bandwidth of 30 nm.

RGB light source with NBI function (CLV-Q260SL, Olympus Medical Systems). The magnifying endoscope had a capability of ×80 optical magnification. The NBI system has been described in detail in previous studies (8,9). In this system, the central wavelengths of NBI were 415 and 540 nm, and each had a bandwidth of 30 nm. During the survey of the primary site in the head and neck region including the cervical esophagus, if the lesions showed both a well-demarcated brownish area and an irregular microvascular pattern (11), we diagnosed cancer. After this examination, we took a biopsy specimen to confirm the histological diagnosis. RESULTS The patients' characteristics are shown in Table 1. Thirty-eight patients were men and eight were women. Their median age was 66 years (range, 38–81 years). Twenty-eight cases were N2 and 18 cases were N3. Thirty-one patients had metastatic lymph nodes in the upper jugular area (Level II), 13 had middle jugular lymph node metastasis (Level III) and 2 had lower jugular lymph node metastasis (Level IV). Table 1. Patient characteristics

RESULTS The patients' characteristics are shown in Table 1. Thirty-eight patients were men and eight were women. Their median age was 66 years (range, 38–81 years). Twenty-eight cases were N2 and 18 cases were N3. Thirty-one patients had metastatic lymph nodes in the upper jugular area (Level II), 13 had middle jugular lymph node metastasis (Level III) and 2 had lower jugular lymph node metastasis (Level IV). Table 1. Patient characteristics Patients Age (years) 66 (38–81) Gender Male 38 Female 8 N stage N2a 4 N2b 20 N2c 4 N3 18 Levels of cervical metastasis Upper jugular (II) 31 Middle jugular (III) 13 Lower jugular (IV) 2 Thirty-eight patients were males and eight were females. Median age was 65 years (range, 38–81 years). Twenty-eight cases were N2 and 18 cases were N3. Thirty-one patients had metastatic lymph node in the upper jugular area (Level II), 15 had middle jugular lymph node metastasis (Level III) and 2 cases had lower jugular lymph node metastasis (Level IV).

d eight were females. Median age was 65 years (range, 38–81 years). Twenty-eight cases were N2 and 18 cases were N3. Thirty-one patients had metastatic lymph node in the upper jugular area (Level II), 15 had middle jugular lymph node metastasis (Level III) and 2 cases had lower jugular lymph node metastasis (Level IV). Twenty-six lesions were suspected to be the cancerous site in 25 patients. Sixteen lesions in 16 patients were confirmed histologically as squamous cell carcinoma. Histological assessment of all of the possible primary lesions showed the similar feature of squamous cell carcinoma. Thus, primary cancer in the head and neck region was detected in 16 patients (35%) by NBI endoscopy. The patients' characteristics are shown in Table 2. Ten patients had metastatic lymph nodes in the upper jugular area, five had middle jugular lymph node metastasis and one had lower jugular lymph node metastasis. Nine cases were N3 and seven cases were N2. All of the lesions detected were superficial neoplasia. Ten lesions were located in the hypopharynx and the remaining six lesions were located in the oropharynx (three were tonsil). All lesions were T1 stage or Tis, and all lesions were <2 cm in size. Biopsy specimens revealed that one lesion was intraepithelial cancer and the other had invaded to the subepithelial layer. Table 2. Characteristics of possible primary lesions detected by NBI

Twenty-six lesions were suspected to be the cancerous site in 25 patients. Sixteen lesions in 16 patients were confirmed histologically as squamous cell carcinoma. Histological assessment of all of the possible primary lesions showed the similar feature of squamous cell carcinoma. Thus, primary cancer in the head and neck region was detected in 16 patients (35%) by NBI endoscopy. The patients' characteristics are shown in Table 2. Ten patients had metastatic lymph nodes in the upper jugular area, five had middle jugular lymph node metastasis and one had lower jugular lymph node metastasis. Nine cases were N3 and seven cases were N2. All of the lesions detected were superficial neoplasia. Ten lesions were located in the hypopharynx and the remaining six lesions were located in the oropharynx (three were tonsil). All lesions were T1 stage or Tis, and all lesions were <2 cm in size. Biopsy specimens revealed that one lesion was intraepithelial cancer and the other had invaded to the subepithelial layer. Table 2. Characteristics of possible primary lesions detected by NBI Primary Endoscopic findings n (levels) Treatment 1 Oropharynx Superficial 3 (II) CRT 2 Oropharynx T1 3 (II) CRT 3 Hypopharynx Superficial 3 (II) RT 4 Oropharynx Superficial 3 (III) CRT 5 Hypopharynx Superficial 3 (II) CRT 6 Hypopharynx Superficial 3 (II) EMR + ND 7 Hypopharynx Superficial 3 (II) CRT 8 Hypopharynx Superficial 3 (II) Surgery + ND 9 Oropharynx Superficial 2b (III) Surgery + ND 10 Oropharynx T1 2a (II) Surgery + ND 11 Hypopharynx Superficial 2b (IV) Surgery + ND 12 Hypopharynx T1 2a (II) Surgery + ND 13 Hypopharynx Superficial 2b (II) EMR + ND 14 Hypopharynx Superficial 3 (III) RT 15 Oropharynx Superficial 2c (II) Surgery + ND 16 Hypopharynx Superficial 2b (III) EMR + ND Nine cases were N3 and seven cases were N2. Five cases were treated by concurrent chemoradiation therapy and in nine cases, primary site was removed by surgery or endoscopic resection and they underwent neck dissection for lymph node metastasis. NBI, narrow-band imaging; CRT, chemoradiation therapy; EMR, endoscopic mucosal resection; ND, neck dissection.

ere N2. Five cases were treated by concurrent chemoradiation therapy and in nine cases, primary site was removed by surgery or endoscopic resection and they underwent neck dissection for lymph node metastasis. NBI, narrow-band imaging; CRT, chemoradiation therapy; EMR, endoscopic mucosal resection; ND, neck dissection. Five patients were treated by concurrent chemoradiation therapy (CRT). Two patients were treated with a chemotherapy regimen comprising 5-fluorouracil (800 mg/m2, days 1–5) and cisplatin (80 mg/m2, day 1). Two patients were treated with tegafur-gimeracil-oteracil potassium (60 mg/m2, days 1–14) and cisplatin (20 mg/m2, day 1). One patient was treated with cisplatin (80 mg/m2, day 1). The irradiation field covered the whole neck, and the total radiation dose was 70 Gy (2 Gy/fr). Two patients were treated by radiation therapy (total 70 Gy) alone. For the other nine patients, the primary site was removed by surgery or endoscopic resection, followed by neck dissection of the lymph node metastasis. No patient received whole-neck irradiation after neck dissection. Treatment of the 20 patients who cannot detect cancer lesion were CRT (for N3 or N2b), and neck dissection and close follow-up with NBI endoscopy (for N2a or N2b).

Five patients were treated by concurrent chemoradiation therapy (CRT). Two patients were treated with a chemotherapy regimen comprising 5-fluorouracil (800 mg/m2, days 1–5) and cisplatin (80 mg/m2, day 1). Two patients were treated with tegafur-gimeracil-oteracil potassium (60 mg/m2, days 1–14) and cisplatin (20 mg/m2, day 1). One patient was treated with cisplatin (80 mg/m2, day 1). The irradiation field covered the whole neck, and the total radiation dose was 70 Gy (2 Gy/fr). Two patients were treated by radiation therapy (total 70 Gy) alone. For the other nine patients, the primary site was removed by surgery or endoscopic resection, followed by neck dissection of the lymph node metastasis. No patient received whole-neck irradiation after neck dissection. Treatment of the 20 patients who cannot detect cancer lesion were CRT (for N3 or N2b), and neck dissection and close follow-up with NBI endoscopy (for N2a or N2b). Figure 1 shows a representative case where the primary cancer was detected by NBI. This patient had a swollen lymph node (2.5 cm in size) on the left side of the upper jugular area (Level II) (Fig. 1). The specimen taken using a fine-needle aspiration method from the swollen lymph node revealed squamous cell carcinoma, which was confirmed later as metastatic. CT scan, MRI, laryngoscopy and standard gastrointestinal endoscopy could not detect any primary site. NBI detected easily a well-demarcated brownish area in the uvula to the right anterior palatine arch (Fig. 2B). In contrast, the conventional white-light image made it difficult to visualize the cancerous lesion (Fig. 2A). Magnifying the observation with NBI revealed easily an irregular microvascular pattern inside the lesion (Fig. 2D), but magnifying the observation with white light made it difficult to see this irregular microvascular pattern (Fig. 2C). We diagnosed cancer for this lesion. The biopsy specimen revealed squamous cell carcinoma, which was similar histologically to that of the metastatic lymph node. Treatment of this patient involved neck dissection and resection for primary disease, and we were able to avoid irradiation of the whole neck.

tern (Fig. 2C). We diagnosed cancer for this lesion. The biopsy specimen revealed squamous cell carcinoma, which was similar histologically to that of the metastatic lymph node. Treatment of this patient involved neck dissection and resection for primary disease, and we were able to avoid irradiation of the whole neck. Figure 1. Computed tomographic scan shows lymph node metastasis at left upper jugular area. Figure 2. (A–D) Endoscopic findings. Conventional white-light image (A), narrow-band imaging (NBI) image (B), magnifying conventional white-light image (C) and magnifying the NBI images (D). NBI detected a well-demarcated brownish area in the uvula to right anterior palatine arch (B). In contrast, conventional white-light image was difficult to visualize the cancerous lesion (A). Magnifying the observation with NBI revealed an irregular microvascular pattern inside the lesion (D). DISCUSSION We report for the first time that NBI endoscopy can detect possible primary cancer in patients with PUCLNM. Information about the primary site is very important for deciding on the appropriate treatment because the treatment strategy may differ for each primary site. Our data indicate that NBI can be helpful to the clinician when deciding on the treatment.

endoscopy can detect possible primary cancer in patients with PUCLNM. Information about the primary site is very important for deciding on the appropriate treatment because the treatment strategy may differ for each primary site. Our data indicate that NBI can be helpful to the clinician when deciding on the treatment. According to Greenberg (10), primary unknown carcinoma is defined when primary tumor cannot be detected by an autopsy. However, this definition cannot be applied in clinical decision-making. We defined a PUCLNM as one for which we could not detect any primary site by CT, MRI, laryngoscopy and gastrointestinal endoscopy (11). Although recent advance in technologies of CT, MRI and PET makes it possible to detect a small lesion precisely, the primary cancer is detected in only 2–9% of the patients with PUCLNM (1,2,12,13). Positron emission tomography (PET) or CT is also useful to detect occult cancer, but this primary site is too small to point out with PET. Random biopsy in the head and neck region may be useful for detecting possible primary cancer in patients with PUCLNM, but the detection rate is only around 10% (1,2). However, tonsillectomy is very useful to detect the primary cancer but tonsillectomy can detect only tonsil cancer. Because only 3 of 16 cases have a cancerous lesion on tonsil in this study, NBI endoscopy was better than tonsillectomy to detect occult tumor.

ith PUCLNM, but the detection rate is only around 10% (1,2). However, tonsillectomy is very useful to detect the primary cancer but tonsillectomy can detect only tonsil cancer. Because only 3 of 16 cases have a cancerous lesion on tonsil in this study, NBI endoscopy was better than tonsillectomy to detect occult tumor. In the esophagus, Lugol chromoendoscopy is useful for detecting superficial squamous cell carcinoma. However, Lugol's solution cannot be applied in the head and neck region because of the risk of aspiration into the airway. NBI is now recognized as a useful and safe method for detecting superficial squamous cell carcinoma in the head and neck region because it uses no solution and improves the visibility. Muto et al. (8,9,16) reported that both a well-demarcated brownish area and an irregular microvascular pattern are typical characteristics of the superficial squamous cell carcinoma in the head and neck region. In this study, we evaluated the lesion according to these two endoscopic characteristics, and we were able to confirm 64% (16/25) of the lesions in the suspicious cancerous area as squamous cell carcinoma. This positive rate is better than that from a random biopsy (∼10%). Finally, possible primary cancer could be detected in 35% (16/46) of the patients. These results indicate that NBI should be applied when surveying the primary site in patients with PUCLNM. Moreover, it is not impossible to detect cancerous lesion only using white-light endoscopy by trained endoscopist but NBI endoscopy is very easy for beginners to detect lesion.

cted in 35% (16/46) of the patients. These results indicate that NBI should be applied when surveying the primary site in patients with PUCLNM. Moreover, it is not impossible to detect cancerous lesion only using white-light endoscopy by trained endoscopist but NBI endoscopy is very easy for beginners to detect lesion. Nine of 16 patients underwent surgery or endoscopic resection of the primary site and subsequent lymph node dissection. In such cases, post-operative whole-neck radiation is one treatment option (13–15). However, the indications for post-operative radiation therapy for PUCLNM are still controversial because these patients are at high risk for developing metachronous multiple cancers in the head and neck region (16). If they received radiation therapy as a post-operative radiation therapy, there is no radiotherapy treatment option for the later appearance of a metachronously developed second primary cancer in the head and neck region (14–16). The clinician must thus plan the post-operative radiation therapy carefully. We cannot conclude with certainty whether the lesions detected by NBI were the true primary sites unless we identify their clonality. As a next step, we will compare the clonality of both primary sites and metastatic lymph nodes. In this study, at least, histological assessment showed the same histological features of the primary site and metastatic lymph node. Clinically, histological accordance would be enough to consider whether the lesion is primary.

next step, we will compare the clonality of both primary sites and metastatic lymph nodes. In this study, at least, histological assessment showed the same histological features of the primary site and metastatic lymph node. Clinically, histological accordance would be enough to consider whether the lesion is primary. Although we could not evaluate the depth of invasion in all patients, we know that micro-invasive cancer can metastasize to the lymph node. The risk of lymph node metastasis of superficial squamous cell carcinoma is unknown, but collection of data from a large number of cases should help clarify this. In conclusion, our data indicate that NBI has the potential to identify primary cancer in patients with PUCLNM. Identification of the primary site provides helpful information for deciding on the treatment strategy. Conflict of interest statement None declared.

INTRODUCTION ‘How much longer will my relative live, can he (she) pass this festival, doctor?’ is a question often raised by family caregivers in hospice. Knowing how long one will live allows the individual to bring closure to personal and family matters. An accurate prognostication can also help physicians in planning for appropriate care options those respect the wishes of the patients and their families. Duration of patients' survival after hospice enrollment is an important outcome indicator in end-of-life care because it is relevant to the cost of care and quality of patients received (1). It was also associated with families' perception of helpfulness and responsiveness from hospice services. Furthermore, late hospice referral could increase the risk of a major depressive disorder during the first year of bereavement (2). In the present study, late referral was defined as initiation of hospice care at ≤7 days before death (3). In Taiwan, late referral for inpatient hospice care was reported to be 32.5% in 2004 (4), which is similar to the 30.8% reported in the US national statistics in 2007 (5), 29–36% reported by Virnig et al. (6) and 35.1% reported by Farnon and Hofmann (7). When patients were enrolled in hospice with <7 days, hospice team often did not have enough time to become familiar with patients and their home situation. The goal for comprehensive care such as patients' wish to die at home might be difficult to be fulfilled (8). Part of the explanation for late referral can be attributed to difficulties in establishing an accurate prognosis (9).

m often did not have enough time to become familiar with patients and their home situation. The goal for comprehensive care such as patients' wish to die at home might be difficult to be fulfilled (8). Part of the explanation for late referral can be attributed to difficulties in establishing an accurate prognosis (9). Clinicians are usually optimistic in estimating survival prognosis (10–12). A number of prognostic scales are available to help improve the estimation of survival in terminal cancer patients. They can be grouped into two categories according to the parameters of scales. The first category focuses on clinical variables and performance status including the Morita's Palliative Prognostic Index (PPI) (13), Stone's PPI (14) and Chuang's Prognostic Score (CPS) (15). The second category focuses on clinical variables, performance status, clinical prediction of survival and laboratory data. They include the Pirovano's Palliative Prognostic Score (PaP) (12) and the Bozcuk's Intrahospital Cancer Mortality Risk Model (ICMRM) (16).

one's PPI (14) and Chuang's Prognostic Score (CPS) (15). The second category focuses on clinical variables, performance status, clinical prediction of survival and laboratory data. They include the Pirovano's Palliative Prognostic Score (PaP) (12) and the Bozcuk's Intrahospital Cancer Mortality Risk Model (ICMRM) (16). Clinical variables have been considered as better predictors of time to death than quality of end-of-life evaluation for terminal patients (17). However, few scales based solely on the laboratory data have been described in literature. Comparison of prediction accuracy between clinical factors and laboratory data was seldom discussed. The purpose of our study is to compare the accuracy in using laboratory data or clinical factors, or both, in predicting dying within 7 days of hospice admission for terminal cancer patients and to develop a computer-assisted model for prediction.

uracy between clinical factors and laboratory data was seldom discussed. The purpose of our study is to compare the accuracy in using laboratory data or clinical factors, or both, in predicting dying within 7 days of hospice admission for terminal cancer patients and to develop a computer-assisted model for prediction. PATIENTS AND METHODS We conducted a prospective, observational cohort study of 727 terminal cancer patients in a hospice ward at the Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, from November 2004 to May 2007. Patients with incurable cancer were referred from other wards of the same hospital, other hospitals or from patients' homes. The decision to admit a patient was based on an initial assessment according to the government regulations for hospice and palliative care. For the purpose of respecting the medical wishes of patients at the terminal stage of an incurable illness and safeguarding their rights, the ‘Hospice-Palliative Care Act’ was promulgated in Taiwan on 7 June 2000. Patient at terminal stage may establish will of consent in choice of hospice-palliative care. One of the main points of the Act is to allow a competent patient to refuse resuscitation attempts (18). The Bureau of the National Health Insurance also issued new reimbursement regulations effective from 1 July 2000 to provide inpatient hospice care to cancer patients who are recognized as incurable and are willing to receive hospice care. Recruitment of patients and design of the present study were approved by the Institutional Review Board of Buddhist Dalin Tzu Chi General Hospital (Nos B09303011 and B09502017). Written informed consents were obtained.

pice care to cancer patients who are recognized as incurable and are willing to receive hospice care. Recruitment of patients and design of the present study were approved by the Institutional Review Board of Buddhist Dalin Tzu Chi General Hospital (Nos B09303011 and B09502017). Written informed consents were obtained. Data on demographic characteristics, the presence and severity of clinical symptoms and signs, laboratory measurement and survival were collected by a team of experienced staff comprising physicians and senior nurses. All data were collected within 24 h of hospital admission and the accuracy of the data was rechecked in weekly team meeting. Eighteen symptoms and signs identified from previous studies (19–21) were assessed. Symptoms noted included pain, dyspnea, fatigue/tiredness (fatigue is perceived as unusual, abnormal or excessive whole-body tiredness, disproportionate to or unrelated to activity or exertion) (22), nausea, vomiting and constipation were graded according to the patients or caregiver descriptions, as follows: 0, never happened; 1, mild and seldom happened; 2, moderate or sometimes happened; 3, severe or continuously happened. Clinical signs for weight loss in the past 3 months, edema, ascites, jaundice and cognitive status, and the degree of severity were graded according to the clinical examination results: weight loss in the past 3 months (score as 0, no; 1, ≤5%; 2, 5–10%; 3, ≥10% as recalled by the patient or caregiver), edema (score as 0, no; 1, less than 1/2 finger breadth; 2, 1/2–1 finger breadth; 3, ≥1 finger breadth), ascites (score as 0, no; 1, only by ultrasound; 2, shifting dullness by physical examination; 3, umbilical protrusion), jaundice (score as 0, no; 1, slightly yellowish; 2, remarkably yellow; 3, deeply yellow or greenish) and cognitive status (score as 0, clear; 1, lethargy; 2, confusion or delirium; 3, comatose) (23–25). Other clinical signs including heart rhythm, poor appetite, medication for insomnia, fever, pressure sore, intervention tube placement and muscle power were evaluated according to their operating definitions: heart rhythm (irregular vs. regular), poor appetite (yes vs. no; yes defined as <500 cc of milk or <2 bowls of porridge by mouth or tube feeding within 24 h of admission), medication for insomnia (yes vs. no), fever (yes vs. no; yes defined as core temperature ≥37.5°C), intervention tube placement [yes vs. no; yes defined as had the intervention tube, e.g.

poor appetite (yes vs. no; yes defined as <500 cc of milk or <2 bowls of porridge by mouth or tube feeding within 24 h of admission), medication for insomnia (yes vs. no), fever (yes vs. no; yes defined as core temperature ≥37.5°C), intervention tube placement [yes vs. no; yes defined as had the intervention tube, e.g. percutaneous nephrostomy (PCN), percutaneous transhepatic cholangiodrainage (PTCD), pig tail for pleural effusion or ascites drainage, and feeding tube except nasogastric (NG) tube], and muscle power was calculated as the sum of muscle power of each extremity divided by four, muscle powers are graded using the Medical Research Council (MRC) scale of 0–5: 5, normal power; 4, moderate movement against resistance; 3, movement against gravity but not against resistance; 2, movement with gravity eliminated; 1, flicker of movement; 0, no movement. An additional 13 laboratory variables were examined, including white blood cell count, differential cell percentages, hemoglobin, blood urea nitrogen (BUN), creatinine, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), total bilirubin, albumin, serum sodium, serum potassium, corrected calcium and blood sugar. Time to death in days of subjects was recorded. When there was difficulty in verbal communication with patients, their status was obtained from their caregivers.

transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), total bilirubin, albumin, serum sodium, serum potassium, corrected calcium and blood sugar. Time to death in days of subjects was recorded. When there was difficulty in verbal communication with patients, their status was obtained from their caregivers. Statistical Analysis Statistical analyses were conducted using the SAS® software, Version 9.1.3 (SAS Institute Inc., Cary, NC, USA) and R 2.6.1 (R Foundation for Statistical Computing, Vienna, Austria) (http://www.r-project.org). Log-rank test was used for different group survival comparison. Univariate logistic regression was used for selecting significant variables associated with dying within 7 days of hospice admission. Model-fitting techniques for multiple logistic regression analysis, including (i) stepwise variable selection, (ii) the Hosmer–Lemeshow goodness-of-fit test and (iii) regression diagnostics including variance inflation factor were applied to assure the quality of analyses. Receiver operating characteristic (ROC) curves were employed for comparing the different models. Three prediction models for dying within 7 days were developed: (i) demographic data and laboratory data (Model 1); (ii) demographic data and clinical symptoms (Model 2); and (iii) combination of demographic data, laboratory data and clinical symptoms (Model 3). All statistical assessments were two-sided and evaluated at the 0.05 level of significant difference.

ays were developed: (i) demographic data and laboratory data (Model 1); (ii) demographic data and clinical symptoms (Model 2); and (iii) combination of demographic data, laboratory data and clinical symptoms (Model 3). All statistical assessments were two-sided and evaluated at the 0.05 level of significant difference. RESULTS The median time to death of the 727 terminal cancer patients enrolled in the study was 17 days. Male had poorer survival than female (P = 0.002). Time to death of ≤7 days occurred in 103 (24.0%) males and 49 (16.8%) females. The survival probability at 1 week after admission was 79% (Fig. 1). The demographic characteristics of the subjects are shown in Table 1. There was no difference in time to death between different age groups (P = 0.767). Bone (P = 0.009) and liver (P < 0.001) metastases significantly reduced time to death (Table 1). The different severities of clinical symptoms and signs are listed in Table 2 and the P values of log-rank tests were all <0.05. Sex, liver cancer, respiratory rate, heart rate, Grade 3 edema, muscle power score, jaundice, intervention tube, ECOG score, BUN, creatinine, albumin, SGOT and SGPT were significant factors for predicting dying within 7 days of hospice admission by univariate logistic analysis (Table 3). Figure 1. The Kaplan–Meier survival curve. Table 1. Characteristics of the study population (n = 727)

RESULTS The median time to death of the 727 terminal cancer patients enrolled in the study was 17 days. Male had poorer survival than female (P = 0.002). Time to death of ≤7 days occurred in 103 (24.0%) males and 49 (16.8%) females. The survival probability at 1 week after admission was 79% (Fig. 1). The demographic characteristics of the subjects are shown in Table 1. There was no difference in time to death between different age groups (P = 0.767). Bone (P = 0.009) and liver (P < 0.001) metastases significantly reduced time to death (Table 1). The different severities of clinical symptoms and signs are listed in Table 2 and the P values of log-rank tests were all <0.05. Sex, liver cancer, respiratory rate, heart rate, Grade 3 edema, muscle power score, jaundice, intervention tube, ECOG score, BUN, creatinine, albumin, SGOT and SGPT were significant factors for predicting dying within 7 days of hospice admission by univariate logistic analysis (Table 3). Figure 1. The Kaplan–Meier survival curve. Table 1. Characteristics of the study population (n = 727) Variable n (%) P Survival days, median (mean ± SD) 17 (30.3 ± 42) Admission days, median (mean ± SD) 10 (12.4 ± 9) Sex Female 294 (40.4) 0.002 Male 433 (59.6) Age (years) 40 32 ( 4.4) 0.767 40–64 285 (39.2) ≥65 410 (56.4) Diabetes 212 (29.2) 0.714 Hypertension 299 (41.1) 0.889 Admitted from Emergency Room 272 (37.4) 0.158 Outpatient department 216 (29.7) Oncology department 113 (15.5) Other outpatient department 126 (17.3) Cancer Lung 132 (18.2) <0.001 Liver 140 (19.3) Colon 83 (11.4) Stomach 41 ( 5.6) Head Neck cancer 97 (13.4) Pancreas 29 ( 4.0) Male genitourinary 24 ( 3.3) Female genitourinary 46 ( 6.3) Breast 25 ( 3.4) Esophagus 19 ( 2.6) Unknown and others 91 (12.5) Metastasis Bone 189 (26.0) 0.009 Lung 124 (17.1) 0.822 Liver 140 (19.3) <0.001 Brain 67 ( 9.2) 0.244 Operation 319 (43.9) 0.015 Chemotherapy 381 (52.4) 0.677 Radiotherapy 259 (35.6) <0.001 P, P value of log-rank test; SD, standard deviation.

ry 46 ( 6.3) Breast 25 ( 3.4) Esophagus 19 ( 2.6) Unknown and others 91 (12.5) Metastasis Bone 189 (26.0) 0.009 Lung 124 (17.1) 0.822 Liver 140 (19.3) <0.001 Brain 67 ( 9.2) 0.244 Operation 319 (43.9) 0.015 Chemotherapy 381 (52.4) 0.677 Radiotherapy 259 (35.6) <0.001 P, P value of log-rank test; SD, standard deviation. Table 2. Prevalence of significant clinical signs by the symptoms/signs severity Clinical signs Prevalence by severity (0/1/2/3) P Cognitive function 501/120/59/47 <0.001 Edema 378/108/82/159 <0.001 Jaundice 517/108/42/60 <0.001 ECOG score 12/181/405/129a <0.001 Body weight loss 40/260/252/174 0.003 Ascites 483/123/66/55 <0.001 P, P value of log-rank test. aECOG score is 1–4. Table 3. Univariate logistic regression for the probability of dying within 7 days of hospice admission in terminal cancer patients

Clinical signs Prevalence by severity (0/1/2/3) P Cognitive function 501/120/59/47 <0.001 Edema 378/108/82/159 <0.001 Jaundice 517/108/42/60 <0.001 ECOG score 12/181/405/129a <0.001 Body weight loss 40/260/252/174 0.003 Ascites 483/123/66/55 <0.001 P, P value of log-rank test. aECOG score is 1–4. Table 3. Univariate logistic regression for the probability of dying within 7 days of hospice admission in terminal cancer patients Variable P OR 95% CI Age (per year) 0.084 1.01 1.00–1.03 Sex (male vs. female) 0.020 1.57 1.07–2.29 Liver cancer vs. other cancer <0.001 2.21 1.47–3.32 Lung cancer vs. other cancer 0.553 1.15 0.73–1.79 Diabetes history (yes vs. no) 0.674 0.91 0.58–1.42 Hypertension history (yes vs. no) 0.226 0.77 0.50–1.18 ECOG score (per score) <0.001 2.46 1.85–3.28 Respiratory rate (per 1/min) <0.001 1.08 1.04–1.12 Heart rate (per 1/min) <0.001 1.02 1.01–1.03 Edema (Grade 3 vs. others) <0.001 2.03 1.36–3.03 Mean muscle power (per score) <0.001 0.59 0.49–0.70 Fever (yes vs. no) 0.534 1.14 0.75–1.74 Jaundice (yes vs. no) <0.001 2.37 1.63–3.44 Intervention tube (yes vs. no) 0.029 0.43 0.20–0.92 WBC (per 103/μl) 0.609 1.001 0.996–1.006 Hemoglobin (per mg/dl) 0.305 1.05 0.96–1.14 Glucose (per mg/dl) 0.810 1.000 0.997–1.002 BUN (per mg/dl) <0.001 1.03 1.02–1.04 Creatinine (per mg/dl) <0.001 1.43 1.22–1.67 Albumin (per g/dl) 0.008 0.65 0.47–0.89 SGOT (per 10 IU/l) <0.001 1.04 1.02–1.05 SGPT (per 10 IU/l) <0.001 1.04 1.02–1.05 OR, odds ratio; WBC, white blood cell; BUN, blood urea nitrogen; SGOT, serum glutamic oxaloacetic transaminase; SGPT, serum glutamic pyruvate transaminase.

eatinine (per mg/dl) <0.001 1.43 1.22–1.67 Albumin (per g/dl) 0.008 0.65 0.47–0.89 SGOT (per 10 IU/l) <0.001 1.04 1.02–1.05 SGPT (per 10 IU/l) <0.001 1.04 1.02–1.05 OR, odds ratio; WBC, white blood cell; BUN, blood urea nitrogen; SGOT, serum glutamic oxaloacetic transaminase; SGPT, serum glutamic pyruvate transaminase. From laboratory variables and demographic data, four significant factors were identified to form Model 1 through stepwise logistic regression. The factors were hemoglobin, BUN, SGOT and albumin. From clinical symptoms and signs and demographic data, 10 significant prognostic clinical factors were identified to form Model 2. The factors were sex, hepatocellular carcinoma, fever, Grade 3 edema, jaundice, intervention tubes, ECOG scale, mean muscle power, heart rate and respiratory rate. The 10 significant factors identified to form Model 3 were sex, intervention tubes, Grade 3 edema, ECOG score, mean muscle power, hemoglobin, BUN, SGOT, respiratory rate and heart rate (Table 4). Table 4. Three computer-assisted estimated probability models for the prediction of dying within 7 days of hospice admission in terminal cancer patients

From laboratory variables and demographic data, four significant factors were identified to form Model 1 through stepwise logistic regression. The factors were hemoglobin, BUN, SGOT and albumin. From clinical symptoms and signs and demographic data, 10 significant prognostic clinical factors were identified to form Model 2. The factors were sex, hepatocellular carcinoma, fever, Grade 3 edema, jaundice, intervention tubes, ECOG scale, mean muscle power, heart rate and respiratory rate. The 10 significant factors identified to form Model 3 were sex, intervention tubes, Grade 3 edema, ECOG score, mean muscle power, hemoglobin, BUN, SGOT, respiratory rate and heart rate (Table 4). Table 4. Three computer-assisted estimated probability models for the prediction of dying within 7 days of hospice admission in terminal cancer patients Variable Model 1 Model 2 Model 3 β P OR β P OR β P OR Intercept −2.20 0.001 −6.52 <0.001 −7.76 <0.001 Hemoglobin (per mg/dl) 0.11 0.028 1.12 0.14 0.006 1.15 BUN (per mg/dl) 0.03 <0.001 1.03 0.03 <0.001 1.03 Albumin (per g/dl) −0.50 0.009 0.61 SGOT (per 10 IU/l) 0.03 0.001 1.03 0.03 <0.001 1.03 Sex (male vs. female) 0.77 0.001 2.17 0.68 0.004 1.98 Intervention tube (yes vs. no) −0.92 0.024 0.40 −0.93 0.027 0.40 Edema (Grade 3 vs. others) 0.54 0.019 1.72 0.61 0.013 1.83 ECOG (per score) 0.82 <0.001 2.27 0.76 <0.001 2.14 Muscle power (per score) −0.37 0.001 0.69 −0.30 0.009 0.74 Cancer (liver vs. others) 0.59 0.023 1.81 Fever (yes vs. no) 0.95 0.040 2.59 Jaundice (yes vs. no) 0.59 0.011 1.81 Respiratory rate (per 1/min) 0.07 0.005 1.07 0.06 0.019 1.06 Heart rate (per beat/min) 0.01 0.034 1.01 0.01 0.024 1.01 According to the logistic model: (Function 1) (Function 2)

0.001 0.69 −0.30 0.009 0.74 Cancer (liver vs. others) 0.59 0.023 1.81 Fever (yes vs. no) 0.95 0.040 2.59 Jaundice (yes vs. no) 0.59 0.011 1.81 Respiratory rate (per 1/min) 0.07 0.005 1.07 0.06 0.019 1.06 Heart rate (per beat/min) 0.01 0.034 1.01 0.01 0.024 1.01 According to the logistic model: (Function 1) (Function 2) where P is the probability of event, β0 the intercept, βn the parameter and χn the variable. We proposed a computer-assisted estimated probability (CEP) for predicting dying within 7 days of hospice admission in terminal cancer patients. The formula based on Model 2 is: When the cut-off score (P) was >0.6, the positive predictive value and the negative predictive value for patients dying within 7 days of hospice admission were 0.74 and 0.83. We compared the accuracy of these three models by ROC curves (Fig. 2). The area under the curve for Model 1 was 75.5%, Model 2 was 77.8% and Model 3 was 82.3%. Model 3 exhibited the best predictor value in comparison with the other two models (P = 0.005) and the trend was also significant (P = 0.002). The programming code for probability calculation based on the fitted model in the R environment (http://www.r-project.org/) is provided in Appendix 1. Figure 2. The receiver operating characteristic curve of three computer-assisted estimated probability models for prediction dying within 7 days of hospice admission in terminal cancer patients: Model 1, laboratory data and demographic data; Model 2, clinical factors and demographic data; Model 3, clinical factors, laboratory data and demographic data.

haracteristic curve of three computer-assisted estimated probability models for prediction dying within 7 days of hospice admission in terminal cancer patients: Model 1, laboratory data and demographic data; Model 2, clinical factors and demographic data; Model 3, clinical factors, laboratory data and demographic data. Validations were performed using split data sets, in which the model was trained on a randomly selected subset of half of the data and tested on the remaining data. Validation tests were repeated 10 times for different selections of training and test data. The models produced were similar to the original and performed nearly as well on test data as on training data. DISCUSSION The probability of dying within 7 days of hospice admission was 20.9%, which is better than the findings of 33.5% in Taiwan in 2004. Part of the reason is the new policy of integrating hospice service into acute care wards issued by the Bureau of Health Promotion, Department of Heath, Taiwan, in 2005. The new policy has a potential to expand the utilization of hospice care by cancer decedents. Barriers to accessing hospice care are complex and often overlapping, and some factors are related to physicians. For example, physicians often delay patients' referral to hospice because of their often over-optimistic view of their patients' prognosis shortly before death (26). By improving the accuracy of prediction of dying within 7 days of hospice admission, we hope to assist physicians in making a more realistic survival prediction in their patients.

ften delay patients' referral to hospice because of their often over-optimistic view of their patients' prognosis shortly before death (26). By improving the accuracy of prediction of dying within 7 days of hospice admission, we hope to assist physicians in making a more realistic survival prediction in their patients. The accuracy of predicting probability of dying within 7 days of hospice admission by the three models was significantly different. Model 2 (clinical factors and demographic data) was more accurate than Model 1 (laboratory tests and demographic data). The laboratory data were derived from the biochemical and blood tests of admission routine and it could supplement the prognostic power of clinical and demographic variables.

significantly different. Model 2 (clinical factors and demographic data) was more accurate than Model 1 (laboratory tests and demographic data). The laboratory data were derived from the biochemical and blood tests of admission routine and it could supplement the prognostic power of clinical and demographic variables. Previous studies have identified many putative prognostic factors in patients with advanced cancer, including clinical estimates of survival, demographic and clinical variables and laboratory parameters (27,28). Some groups have constructed prognostic scales using different combinations of these variables (12,16). Model 3 was the best predictive model and included performance status (ECOG score), five clinical variables (edema with degree 3 severity, mean score of muscle power, heart rate, respiratory rate and intervention tube), sex and three laboratory parameters (hemoglobin, BUN and SGOT). The factors of ECOG, edema with a degree 3 severity, heart rate and sex were significant predictors in previous studies (15–17,29–32). We identified five useful prognostic factors in this study: (i) the mean score of muscle power can express the weakness or energy level of a patient. A lower muscle power score correlated with a shorter predicted survival. (ii) For the basic vital signs of respiratory and heart rate, higher rates were significantly correlated with increased probability of mortality within 1 week, similar to an earlier study (33). (iii) Intervention tube, e.g. PCN, PTCD, pig tail drainage, feeding tube excluding NG tube, indicated that the patients were receiving aggressive interventions before being admitted to the palliative care unit and was associated with longer survival. Patients with placement of intervention tube had significantly lower risk for death in 7 days after admission in our study. The placement of intervention tube might prolong the survival days of the patients after the clinical issues had solved by the placement of the tube or that the placement of intervention tube was able to help the patients to live better. (iv) One unique finding in this study was that the higher hemoglobin indicated a higher probability of within 7-day survival, whereas the low hemoglobin group had a worse survival after 2 weeks. Anemia was a predictive factor for shorter survival in most studies, as measured in weeks to months survival (27). (v) BUN was also identified as a predictor in the previous study (34).

moglobin indicated a higher probability of within 7-day survival, whereas the low hemoglobin group had a worse survival after 2 weeks. Anemia was a predictive factor for shorter survival in most studies, as measured in weeks to months survival (27). (v) BUN was also identified as a predictor in the previous study (34). Terminal azotemia refers to the dehydration status and acute renal failure involved in the dying process. (vi) SGOT is the prognostic factor in patients with hepatocellular carcinoma (35), which is the leading cause of death in Taiwan for more than 20 years; and it is also identified in the other study (36). Previous studies have discussed prognostic tools for prediction of survival from weeks to months in advanced cancer patients with disparate results (37). However, prediction of dying within 7 days of hospice admission has rarely been discussed. The method of CEP can easily be calculated within 24 h of patient admission and can serve as a useful tool to assist estimation of survival prediction.

from weeks to months in advanced cancer patients with disparate results (37). However, prediction of dying within 7 days of hospice admission has rarely been discussed. The method of CEP can easily be calculated within 24 h of patient admission and can serve as a useful tool to assist estimation of survival prediction. Limitations of this study include recall bias and misclassification error. When the patients could not accurately recall their body weights 3 months before the study, calculation of weight loss had to be based on the information provided by patients' family members. Moreover, misclassification error may be present in the grading of the clinical signs such as severity of ascites, jaundice and cognitive status. In addition, data regarding symptoms on the regular chart such as extremity cyanosis, self-conscious dying and biologic parameters such as serum electrolytes, B12/C-reactive protein (38), serum lactate dehydrogenase and alkaline phosphatase were not included in data analysis. In conclusion, a CEP that utilized clinical factors, demographic factors and laboratory data were developed for patients with advanced cancer. We suggested using Model 2 as a readily accessible tool for making prediction and using Model 3 if laboratory data are available. It is hope that the CEP prognostic scale can assist clinicians in making accurate survival prediction and thus able to form treatment decisions that minimize harm and discomfort in patients. Funding This project was supported by grants from Buddhist Dalin Tzu Chi General Hospital (Project Nos DTCRD94-10 and DTCRD96-18).

In conclusion, a CEP that utilized clinical factors, demographic factors and laboratory data were developed for patients with advanced cancer. We suggested using Model 2 as a readily accessible tool for making prediction and using Model 3 if laboratory data are available. It is hope that the CEP prognostic scale can assist clinicians in making accurate survival prediction and thus able to form treatment decisions that minimize harm and discomfort in patients. Funding This project was supported by grants from Buddhist Dalin Tzu Chi General Hospital (Project Nos DTCRD94-10 and DTCRD96-18). Conflict of interest statement None declared. Appendix 1. Programming code in R for calculating probability of dying within 7 days after hospice admission in patients with terminal cancer Substitute the values for the variables X1 to X10 in the regression equation to calculate the probability of dying within 7 days after hospice admission.yhat <− (−6.52# constant +0.77*X1# X1 = sex (male = 1, female = 0) +0.59*X2# X2 = cancer (liver cancer = 1, others = 0) +0.82*X3# X3 = ECOG score +0.59*X4# X4 = jaundice (yes = 1, no = 0) +0.54*X5# X5 = edema (1 if edema = grade 3, 0 if otherwise) +0.95*X6# X6 = fever (yes = 1, no = 0) +0.07*X7# X7 = respiratory rate per minute +0.01*X8# X8 = heart rate, beat per minute −0.92*X9# X9 = intervention tube (yes = 1, no = 0) −0.37*X10# X10 = mean muscle power score phat <- 1/(exp(-(yhat)) + 1)phat# copy these syntax and paste on the R console

INTRODUCTION ABI-007 (Abraxane®; Abraxis Bioscience, Los Angels, CA, USA) is a novel Cremophor® EL (polyoxyethylated castor oil)-free albumin-bound nanoparticle formulation of paclitaxel. This formulation allows for a higher paclitaxel concentration in the suspension, serving to reduce the administration volume and time. No pre-medication to prevent the Cremophor® EL-induced hypersensitivity reaction is needed. In addition, non-polyvinyl chloride infusion system and in-line filtration are not necessarily applied given no leaching of plasticizers (1,2). In the Phase I study of every-3-week (Q3W) schedule conducted in the USA, the dose of ABI-007 was escalated from 135 to 375 mg/m2, and maximum tolerated dose (MTD) and recommended dose (RD) were established at 300 mg/m2. It was exceedingly higher than that of solvent-based paclitaxel (Taxol®; Bristol–Myers Squibb, Princeton, NJ, USA), 175 mg/m2 (1). Dose-limiting toxicities (DLTs) were keratitis, blurred vision, sensory neuropathy, stomatitis and neutropenia. Maximum concentration (Cmax) and the area under the curve from time zero to infinity (AUCinf) of paclitaxel increased linearly over the ABI-007 dose range of 135–300 mg/m2 administered over 30 min. Volume of distribution of ABI-007 is characterized by the larger distribution than solvent-based paclitaxel, indicating extensive extravascular distribution of the drug (3). Cmax and AUCinf values for individual patients correlated well with toxicities.

the ABI-007 dose range of 135–300 mg/m2 administered over 30 min. Volume of distribution of ABI-007 is characterized by the larger distribution than solvent-based paclitaxel, indicating extensive extravascular distribution of the drug (3). Cmax and AUCinf values for individual patients correlated well with toxicities. In the Phase III pivotal study of 454 patients with metastatic breast cancer, Q3W schedule of ABI-007 260 mg/m2 produced the superior outcome to the same schedule of solvent-based paclitaxel, 175 mg/m2: significantly higher response rate and prolonged time to progression [33% vs. 19% (P < 0.001) and 23.0 vs. 16.9 weeks (P= 0.006), respectively] and significantly lower incidence of Grade 4 neutropenia, despite a 49% higher paclitaxel dose [9% vs. 22% (P < 0.001)] (4). The dosage and schedule used in this Phase III study lead to the approved labeling worldwide. According to the clinical utility and study data reported overseas, ABI-007 seems to be an effective treatment. This Phase I study aimed to evaluate tolerability, DLT and RD in Japanese patients with solid tumors when administered in Q3W schedule. Efficacy, toxicity and pharmacokinetics (PK) were also evaluated as secondary objectives, followed by the evaluation on ethnic difference in PK.

007 seems to be an effective treatment. This Phase I study aimed to evaluate tolerability, DLT and RD in Japanese patients with solid tumors when administered in Q3W schedule. Efficacy, toxicity and pharmacokinetics (PK) were also evaluated as secondary objectives, followed by the evaluation on ethnic difference in PK. PATIENTS AND METHODS Patient Eligibility Patients aged 20–74 years with histologically or cytologically diagnosed malignant solid tumors refractory to standard therapies or for which there was no effective treatment were eligible. They had to have an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0–2, and a life expectancy of ≥60 days. Eligibility criteria also included adequate renal, liver and bone marrow function, defined as serum creatinine (Cr) ≤1.5 mg/dl, serum total bilirubin (TB) ≤1.5 mg/dl, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) <100 IU/l, respectively, serum albumin ≥3.0 g/dl, white blood cell count ≤12 000/mm3, absolute neutrophil count ≥2000/mm3, platelets ≥100 000/mm3 and hemoglobin ≥9.0 g/dl. Patients with prior exposure to taxanes were eligible for the study. Key exclusion criteria included the following: (i) surgery within 4 weeks; (ii) chemotherapy within 3 weeks; (iii) radiotherapy within 3 weeks; (iv) history of radiation to more than 30% of hematopoietic marrow; (v) pre-existing sensory neuropathy ≥Grade 2; (vi) pleural effusion and ascites that required drainage; (vii) brain metastasis showing symptoms or requiring treatment; (viii) hepatitis B or C virus or human immunodeficiency virus infection; (ix) chronic steroid treatment; (x) pregnancy, lactation, suspicion of being pregnant; (xi) serious pre-existing medical conditions such as uncontrolled infections, pulmonary fibrosis, diabetes, severe heart disease and psychogenic disorders.

ent; (viii) hepatitis B or C virus or human immunodeficiency virus infection; (ix) chronic steroid treatment; (x) pregnancy, lactation, suspicion of being pregnant; (xi) serious pre-existing medical conditions such as uncontrolled infections, pulmonary fibrosis, diabetes, severe heart disease and psychogenic disorders. This study was approved by the Institutional Review Board at the National Cancer Center and conducted according to Japanese Good Clinical Practice guidelines. All patients provided written informed consent prior to study entry. Study Design and Treatment This Phase I, open label, dose-finding study was conducted at National Cancer Center and National Cancer Center East. ABI-007 was supplied by TAIHO Pharmaceutical Co., Ltd, Tokyo Japan. Each vial contained 100 mg of paclitaxel and ∼900 mg of frozen-dried Albumin Human (United States Pharmacopeia). The prescribed dose of ABI-007 was prepared in 5 mg (paclitaxel)/ml of physiological saline as a suspension. The drug was administered via 30 min i.v. without pre-medication and in-line filtration.

yo Japan. Each vial contained 100 mg of paclitaxel and ∼900 mg of frozen-dried Albumin Human (United States Pharmacopeia). The prescribed dose of ABI-007 was prepared in 5 mg (paclitaxel)/ml of physiological saline as a suspension. The drug was administered via 30 min i.v. without pre-medication and in-line filtration. Evaluated dose levels were 200, 260 or 300 mg/m2, as shown in Table 1, repeated every 3 weeks. The rationale for selected dose range was the following: the upper level, 300 mg/m2—MTD determined in a US Phase I study; the middle level, 260 mg/m2—the approved dose in the US/EU, and the lower level, 200 mg/m2—one dose level below MTD examined in the foregoing Phase I study. The dose range also factored in PK: linear PK of ABI-007 over the dose range 80–300 mg/m2 and the same level and activity of CYP2C8 and CYP3A4 between Japanese and Caucasians (5). Dose escalation was capped at 300 mg/m2. In the event that MTD exceeded the cap, further steps in investigation would be discussed among study sponsor, principal investigator and medical experts. Table 1. Dose levels

Evaluated dose levels were 200, 260 or 300 mg/m2, as shown in Table 1, repeated every 3 weeks. The rationale for selected dose range was the following: the upper level, 300 mg/m2—MTD determined in a US Phase I study; the middle level, 260 mg/m2—the approved dose in the US/EU, and the lower level, 200 mg/m2—one dose level below MTD examined in the foregoing Phase I study. The dose range also factored in PK: linear PK of ABI-007 over the dose range 80–300 mg/m2 and the same level and activity of CYP2C8 and CYP3A4 between Japanese and Caucasians (5). Dose escalation was capped at 300 mg/m2. In the event that MTD exceeded the cap, further steps in investigation would be discussed among study sponsor, principal investigator and medical experts. Table 1. Dose levels Level Dose (mg/m2) No. of patients entered No. of courses 1 200 3 9 2 260 6 23 3 300 3 14 The dose escalation followed the standard ‘3 + 3’ rule. Three patients were evaluated at the first dose level, and in the absence of DLTs, three additional patients were entered at the next dose level. If one of the three patients encountered a DLT, another cohort was to be added at the same dose level. The MTD was defined as the dose level at which two out of three to six patients experienced DLT. The RD was defined as the dose level that is one level below MTD, and consequently, a total of six patients were to be treated at RD to further evaluate the safety profile.

her cohort was to be added at the same dose level. The MTD was defined as the dose level at which two out of three to six patients experienced DLT. The RD was defined as the dose level that is one level below MTD, and consequently, a total of six patients were to be treated at RD to further evaluate the safety profile. DLTs were pre-defined as any of the following drug-related toxicities that had occurred during the first course: (i) Grade 4 thrombocytopenia; (ii) Grade 3 thrombocytopenia requiring platelet transfusion; (iii) Grade 4 neutropenia over 4 days; (iv) Grade 3 or 4 febrile neutropenia; and (v) Grade 3 or 4 non-hematologic toxicity. Dose was reduced by one level when DLT occurred in the first course, and reduction was allowed when the toxicities corresponding to DLT or Grade 2 neuropathy occurred in the second course or later. Patient Evaluation Pre-treatment evaluation included a complete history and physical examination, a complete blood count with differential, serum chemistry profile, urinalysis including pregnancy test, chest X-ray and electrocardiogram. Serum chemistry profile included electrolytes, Cr, urea nitrogen, TB, AST, ALT, lactic dehydrogenase, alkaline phosphatase, total protein, albumin and C-reactive protein. Baseline imaging studies and serum tumor marker levels were obtained at the discretion of treating physician. Toxicity assessment, physical examination and all blood tests except serum tumor markers were repeated on a weekly basis.

ctic dehydrogenase, alkaline phosphatase, total protein, albumin and C-reactive protein. Baseline imaging studies and serum tumor marker levels were obtained at the discretion of treating physician. Toxicity assessment, physical examination and all blood tests except serum tumor markers were repeated on a weekly basis. Toxicities were graded according to Common Terminology Criteria for Adverse Events (CTCAE), version 3.0. Patients were considered evaluable for toxicity if they received at least one dose of the study drug. Objective response to therapy was assessed every 4–6 weeks according to Response Evaluation Criteria in Solid Tumors (RECIST), version 1.0 (6). Blood Sampling and PK Analysis Whole blood samples of 7 ml each were collected in 6 ml of heparinized tube and 1 ml of K3-EDTA tube to determine the PK of ABI-007 at time points: 0, 0.25, 0.5 (end of infusion), 0.75, 1, 1.5, 2, 4, 10, 24, 48 and 72 h. Heparinized samples were immediately centrifuged at 1000 g for 15 min in 4°C and resultant plasma was stored in aliquot, whereas K3-EDTA samples were softly mixed in normal temperature. These samples were stored at less than or equal to −20°C until analyzed. The sample was analyzed for paclitaxel using liquid chromatography/tandem mass spectrometry in Alta Analytical Laboratory (El Dorado Hills, CA, USA). The limit of quantification for paclitaxel in plasma and whole blood was 1.00 and 5.00 ng/ml, respectively, and the range of reliable response in these samples was 1.00–500 and 5.00–5000 ng/ml, respectively.

l using liquid chromatography/tandem mass spectrometry in Alta Analytical Laboratory (El Dorado Hills, CA, USA). The limit of quantification for paclitaxel in plasma and whole blood was 1.00 and 5.00 ng/ml, respectively, and the range of reliable response in these samples was 1.00–500 and 5.00–5000 ng/ml, respectively. PK parameters were determined from each patient's whole blood/plasma paclitaxel concentration profile. They were evaluated by non-compartmental analysis using the WinNonlin software package (Ver4.1, Pharsight Corp., CA, USA). The Cmax of paclitaxel was obtained directly from experimental data. The elimination constant (λz) was obtained by log-linear regression analysis of the terminal phase of the whole blood/plasma concentration vs. time profile. The elimination half-life (t1/2) was determined by taking the ratio of natural log of 2 and λz. The AUCinf was estimated by summing the areas from time zero to the last measured concentration–time point (AUC0–t), calculated using the linear-logarithmic trapezoidal method, and the extrapolated area. The dose–area relationship (i.e. total ABI-007 dose divided by AUCinf) was used to determine total body clearance (CL). The volume of distribution (Vz) was determined by taking the ratio between CL and λz. Descriptive statistics were used for baseline characteristics, safety assessment, and PK variables. Regression analysis of individual Cmax, and AUCinf vs. dose was performed to gain an appreciation of PK linearity. The SAS software package (ver8.2, SAS Institute, Inc., NC, USA) was used for statistical analysis.

PK parameters were determined from each patient's whole blood/plasma paclitaxel concentration profile. They were evaluated by non-compartmental analysis using the WinNonlin software package (Ver4.1, Pharsight Corp., CA, USA). The Cmax of paclitaxel was obtained directly from experimental data. The elimination constant (λz) was obtained by log-linear regression analysis of the terminal phase of the whole blood/plasma concentration vs. time profile. The elimination half-life (t1/2) was determined by taking the ratio of natural log of 2 and λz. The AUCinf was estimated by summing the areas from time zero to the last measured concentration–time point (AUC0–t), calculated using the linear-logarithmic trapezoidal method, and the extrapolated area. The dose–area relationship (i.e. total ABI-007 dose divided by AUCinf) was used to determine total body clearance (CL). The volume of distribution (Vz) was determined by taking the ratio between CL and λz. Descriptive statistics were used for baseline characteristics, safety assessment, and PK variables. Regression analysis of individual Cmax, and AUCinf vs. dose was performed to gain an appreciation of PK linearity. The SAS software package (ver8.2, SAS Institute, Inc., NC, USA) was used for statistical analysis. RESULTS Patients and Treatment Between August 2006 and June 2007, 12 patients were enrolled and treated in this study at two participating centers in Japan. Patient characteristics are summarized in Table 2. Most patients were male (83%) with a median age of 61 (range, 45–69) years and all patients were ECOG PS 0–1. The predominant type of tumor was non-small cell lung cancer (NSCLC). Nine patients had surgery for primary tumors, seven had received more than three prior chemotherapy regimens and eight had received prior taxane-containing chemotherapy.

with a median age of 61 (range, 45–69) years and all patients were ECOG PS 0–1. The predominant type of tumor was non-small cell lung cancer (NSCLC). Nine patients had surgery for primary tumors, seven had received more than three prior chemotherapy regimens and eight had received prior taxane-containing chemotherapy. Table 2. Patient characteristics Characteristics No. of patients Total no. of patients 12 Male/female 10/2 Age (years) Median 61 Range 45–69 ECOG performance status 0 3 1 9 Tumor type NSCLC 6 Parotid gland 1 Ovary 1 Bladder 1 Pharyngeal and esophageal 1 Colon 1 Thymoma 1 Prior treatment Surgery 9 Radiotherapy 3 Chemotherapy 12 No. of prior chemotherapy 1 1 2 4 ≥3 7 Prior taxane therapy Yes Solvent-based paclitaxel 1 Docetaxel 5 Solvent-based paclitaxel and docetaxel 2 No 4 ECOG, Eastern Cooperative Oncology Group; NSCLC, non-small cell lung cancer. The patients were treated at the following dose levels: 200 mg/m2 (Level 1, n = 3), 260 mg/m2 (Level 2, n = 6) and 300 mg/m2 (Level 3, n = 3). All were evaluable for safety and PK, and 11 for efficacy (one had no adequate measurable lesions for RECIST criteria).

Characteristics No. of patients Total no. of patients 12 Male/female 10/2 Age (years) Median 61 Range 45–69 ECOG performance status 0 3 1 9 Tumor type NSCLC 6 Parotid gland 1 Ovary 1 Bladder 1 Pharyngeal and esophageal 1 Colon 1 Thymoma 1 Prior treatment Surgery 9 Radiotherapy 3 Chemotherapy 12 No. of prior chemotherapy 1 1 2 4 ≥3 7 Prior taxane therapy Yes Solvent-based paclitaxel 1 Docetaxel 5 Solvent-based paclitaxel and docetaxel 2 No 4 ECOG, Eastern Cooperative Oncology Group; NSCLC, non-small cell lung cancer. The patients were treated at the following dose levels: 200 mg/m2 (Level 1, n = 3), 260 mg/m2 (Level 2, n = 6) and 300 mg/m2 (Level 3, n = 3). All were evaluable for safety and PK, and 11 for efficacy (one had no adequate measurable lesions for RECIST criteria). DLT, Tolerability and RD No DLTs were observed through the dose escalation to the highest Level 3; therefore, the MTD was not reached methodologically. To decide on the potential RD, study sponsor, medical advisor and principal investigators jointly reviewed the reference data in the foreign studies (1,4,7) and favored 260 mg/m2 from tolerability and safety perspectives, particularly the development of cumulative neurotoxicity. Additional three patients were then accrued to 260 mg/m2 cohort to repeat the assessment. None of DLTs being experienced by the additional patients, 260 mg mg/m2, was established as RD.

ies (1,4,7) and favored 260 mg/m2 from tolerability and safety perspectives, particularly the development of cumulative neurotoxicity. Additional three patients were then accrued to 260 mg/m2 cohort to repeat the assessment. None of DLTs being experienced by the additional patients, 260 mg mg/m2, was established as RD. Safety A total of 46 courses of ABI-007 was administered, and the median number of courses administered per patient was 3 (range, 1–11). No acute hypersensitivity reactions were observed during the infusion period. The most common toxicities were neutropenia, leucopenia, lymphopenia, alopecia and sensory neuropathy. The incidences of hematologic toxicities by dose level are shown in Table 3. Grade 3 or 4 neutropenia was often experienced in more than half of patients throughout the study; however, no febrile neutropenia was observed. The median time to onset of Grade 3 or 4 neutropenia was 15.0 (range, 8–34) days, and the median time to recovery to <Grade 2 was 6.5 (range, 3–14) days. There were no episodes of ≥Grade 2 or greater thrombocytopenia, and anemia was mostly mild. Frequent non-hematological toxicities were sensory neuropathy, alopecia, arthralgia/myalgia and rash (Table 4). The sensory neuropathy was manifested by paresthesia in a symmetric, stocking/glove distribution, and the median time to the first indication or exacerbation from the baseline was 7 days. The severity of non-hematologic toxicities was generally mild except for three cases of Grade 3 sensory neuropathy at Level 2 (n = 1) and Level 3 (n = 2), which cumulatively exacerbated from Grade 1 observed in the first week of the first course (range, 3–6 days from the administration) to Grade 3 during the third or later course (range, 3–11 courses from the administration). Among the three patients who experienced Grade 3 sensory neuropathy, one patient had received taxane-containing chemotherapy prior to the study. A variety of ocular toxicities including superficial keratopathy reported in the initial Phase I study of USA were not observed in this study. Treatment delay occurred in one patient at each Levels 2 and 3 due to the neurotoxicity, dose reduction occurred in two patients at each Levels 2 and 3 due to the neurotoxicity, and treatment was discontinued in three patients at each Levels 2 and 3, comprising five patients with treatment-related neurotoxicity and one patient with unrelated neutropenia.

ent at each Levels 2 and 3 due to the neurotoxicity, dose reduction occurred in two patients at each Levels 2 and 3 due to the neurotoxicity, and treatment was discontinued in three patients at each Levels 2 and 3, comprising five patients with treatment-related neurotoxicity and one patient with unrelated neutropenia. Table 3. Hematologic toxicities (all courses) Dose levels Level 1 (200 mg/m2) Level 2 (260 mg/m2) Level 3 (300 mg/m2) All No. of patients (no. of courses) n = 3 (9) n = 6 (23) n = 3 (14) n = 12 (46) CTCAE grade 1–2 3 4 1–2 3 4 1–2 3 4 1–2 3 4 Leucopenia 2 0 0 3 2 0 3 0 0 8 2 0 Neutropenia 1 1 0 1 3 1 1 2 0 2 6 2 Anemia 1 0 0 2 0 0 1 0 0 4 0 0 Thrombocytopenia 0 0 0 1 0 0 1 0 0 2 0 0 CTCAE, Common Terminology Criteria for Adverse Events. Table 4. Non-hematologic toxicities (all courses) Dose levels Level 1 (200 mg/m2) Level 2 (260 mg/m2) Level 3 (300 mg/m2) All No. of patients (no. of courses) n = 3 (9) n = 6 (23) n = 3 (14) n = 12 (46) CTCAE grade 1–2 3 1–2 3 1–2 3 1–2 3 Sensory neuropathy 1 0 5 1 1 2 7 3 Alopecia 3 0 4 0 3 0 10 0 Myalgia 0 0 6 0 3 0 9 0 Rash 2 0 4 0 1 0 7 0 Arthralgia 1 0 4 0 2 0 7 0 Asthenia 2 0 2 0 2 0 6 0 Motor neuropathy 0 0 3 0 2 0 5 0 Nausea 2 0 1 0 1 0 4 0 Anorexia 3 0 1 0 0 0 4 0 Vomiting 1 0 2 0 0 0 3 0 Diarrhea 2 0 0 0 0 0 2 0 Stomatitis 0 0 0 0 2 0 2 0 Grade 4 toxicities were not observed.

3 Alopecia 3 0 4 0 3 0 10 0 Myalgia 0 0 6 0 3 0 9 0 Rash 2 0 4 0 1 0 7 0 Arthralgia 1 0 4 0 2 0 7 0 Asthenia 2 0 2 0 2 0 6 0 Motor neuropathy 0 0 3 0 2 0 5 0 Nausea 2 0 1 0 1 0 4 0 Anorexia 3 0 1 0 0 0 4 0 Vomiting 1 0 2 0 0 0 3 0 Diarrhea 2 0 0 0 0 0 2 0 Stomatitis 0 0 0 0 2 0 2 0 Grade 4 toxicities were not observed. Response Eleven of 12 patients were evaluable for anti-tumor response (Table 5). Partial responses were observed in three NSCLC patients. Of them, two of whom had received docetaxel-containing chemotherapy prior to the study. The first patient, entered at Level 1, had received 6 courses of ABI-007, and the second and third patients, entered at Level 2, 11 and 6 courses, respectively. The both responders in Level 2 attained disease control until the treatment discontinuation due to the sensory neuropathy. Table 5. Anti-tumor response Tumor type Prior taxane therapy Response Level 1 (200 mg/m2) NSCLC + PD NSCLC + PR Parotid gland + PD Level 2 (260 mg/m2) NSCLC + PD NSCLC − PR Ovary + PD NSCLC + PR Colon − PD Thymoma − SD Level 3 (300 mg/m2) Bladder − SD NSCLC + NE Pharyngeal and esophageal + SD PD, progressive disease; PR, partial response; SD, stable disease; NE, not evaluable.

y Response Level 1 (200 mg/m2) NSCLC + PD NSCLC + PR Parotid gland + PD Level 2 (260 mg/m2) NSCLC + PD NSCLC − PR Ovary + PD NSCLC + PR Colon − PD Thymoma − SD Level 3 (300 mg/m2) Bladder − SD NSCLC + NE Pharyngeal and esophageal + SD PD, progressive disease; PR, partial response; SD, stable disease; NE, not evaluable. Pharmacokinetics Blood samples for PK analysis were available from all of 12 patients following the first course of treatment. A semi-log plot of the mean values of paclitaxel concentration for each dose level vs. time is shown in Fig. 1. After 30 min infusion of ABI-007, the concentration of paclitaxel began to decrease immediately upon cessation of the infusion with t1/2 of 17.3–27.3 h in the whole blood, which is nearly comparable with that of standard dose of solvent-based paclitaxel (6), and the decline of paclitaxel concentration from maximum was multiphasic. Figure 1. (a) Mean whole blood concentration–time profiles of paclitaxel. (b) Mean plasma concentration–time profiles of paclitaxel.

Pharmacokinetics Blood samples for PK analysis were available from all of 12 patients following the first course of treatment. A semi-log plot of the mean values of paclitaxel concentration for each dose level vs. time is shown in Fig. 1. After 30 min infusion of ABI-007, the concentration of paclitaxel began to decrease immediately upon cessation of the infusion with t1/2 of 17.3–27.3 h in the whole blood, which is nearly comparable with that of standard dose of solvent-based paclitaxel (6), and the decline of paclitaxel concentration from maximum was multiphasic. Figure 1. (a) Mean whole blood concentration–time profiles of paclitaxel. (b) Mean plasma concentration–time profiles of paclitaxel. The mean PK parameters of paclitaxel are summarized in Table 6. Cmax, AUC0–t and AUCinf of paclitaxel when administered as a 30 min infusion of ABI-007 increased with increasing dosage. CL and Vz of the blood sample showed the small inter-patient variability, and the mean ± SD values (CV%) for CL and Vz at the dose level of 260 mg/m2 were 18.1 ± 2.33 (12.9 CV%) (l/h/m2) and 510 ± 96.8 (19.0 CV%) (l/m2), respectively. These values slightly decreased with increased dosage. It was considered that there was no remarkable difference in calculated values of PK parameters between whole blood and plasma. Regression analysis suggested the dose-proportionality of ABI-007 within the dose range in this study (R2 of Cmax = 0.4470, R2 of AUCinf = 0.7177); however, it was difficult to establish the linearity due to those narrow dose range and small data size. Table 6. PK parameters of paclitaxel

The mean PK parameters of paclitaxel are summarized in Table 6. Cmax, AUC0–t and AUCinf of paclitaxel when administered as a 30 min infusion of ABI-007 increased with increasing dosage. CL and Vz of the blood sample showed the small inter-patient variability, and the mean ± SD values (CV%) for CL and Vz at the dose level of 260 mg/m2 were 18.1 ± 2.33 (12.9 CV%) (l/h/m2) and 510 ± 96.8 (19.0 CV%) (l/m2), respectively. These values slightly decreased with increased dosage. It was considered that there was no remarkable difference in calculated values of PK parameters between whole blood and plasma. Regression analysis suggested the dose-proportionality of ABI-007 within the dose range in this study (R2 of Cmax = 0.4470, R2 of AUCinf = 0.7177); however, it was difficult to establish the linearity due to those narrow dose range and small data size. Table 6. PK parameters of paclitaxel 200 mg/m2 (n = 3) 260 mg/m2 (n = 6) 300 mg/m2 (n = 3) Mean CV (%) Mean CV (%) Mean CV (%) Whole blood Cmax (ng/ml) 9430 28.3 11 635 13.0 13 833 15.3 AUCinf (ng h/ml) 10 360 22.0 14 593 13.7 19 138 12.2 t1/2 (h) 24.3 10.9 19.5 7.9 18.3 1.9 CL (l/h/m2) 19.9 21.6 18.1 12.9 15.8 11.2 Vz (l/m2) 689 15.3 510 19.0 417 9.7 Plasma Cmax (ng/ml) 9040 34.0 12 000 17.6 12 700 20.5 AUCinf (ng h/ml) 9146 29.6 13 330 20.7 16 271 11.2 t1/2 (h) 29.0 17.7 20.8 19.5 19.8 9.8 CL (l/h/m2) 23.1 26.4 20.2 21.5 18.6 10.6 Vz (l/m2) 935 11.7 620 36.9 527 7.0 PK, pharmacokinetic; CV, coefficient of variation; Cmax, maximum concentration; AUCinf, area under the concentration–time curve up to ∞ hours; t1/2, terminal elimination half-life; CL, clearance; Vz, volume of distribution based on terminal phase.

/h/m2) 23.1 26.4 20.2 21.5 18.6 10.6 Vz (l/m2) 935 11.7 620 36.9 527 7.0 PK, pharmacokinetic; CV, coefficient of variation; Cmax, maximum concentration; AUCinf, area under the concentration–time curve up to ∞ hours; t1/2, terminal elimination half-life; CL, clearance; Vz, volume of distribution based on terminal phase. DISCUSSION In the Phase I study where ABI-007 was administered in Q3W schedule in Japanese patients, no DLT occurred at any dose level of 200, 260 and 300 mg/m2. Because MTD was not reached by the 3 + 3 rule, selection of RD was attributed to the consideration of reasonable tolerability, toxicities and PK profile. Since paclitaxel treatment was characterized for the cumulative neurotoxicity, dose selection also took into account the development of sensory neuropathy throughout the study. Consequently, 260 mg/m2 was reassessed as potential RD and established as RD in the absence of applicable DLT. Outcome of sensory neuropathy in all treatment courses also provided the justification for the feasibility of 260 mg/m2 (Table 7). Among 260 and 300 mg/m2 cohorts, every patient experienced neuropathic events, in which Grade 3 or 4 event was more frequent in 300 mg/m2 (two out of three patients) than in 260 mg/m2 cohorts (one out of six patients). Moreover, all the three patients in 300 mg/m2 cohort discontinued the treatment due to neuropathic events as opposed to two out of six patients in 260 mg/m2 cohort. Table 7. Grade change in sensory neuropathy (all courses)

DISCUSSION In the Phase I study where ABI-007 was administered in Q3W schedule in Japanese patients, no DLT occurred at any dose level of 200, 260 and 300 mg/m2. Because MTD was not reached by the 3 + 3 rule, selection of RD was attributed to the consideration of reasonable tolerability, toxicities and PK profile. Since paclitaxel treatment was characterized for the cumulative neurotoxicity, dose selection also took into account the development of sensory neuropathy throughout the study. Consequently, 260 mg/m2 was reassessed as potential RD and established as RD in the absence of applicable DLT. Outcome of sensory neuropathy in all treatment courses also provided the justification for the feasibility of 260 mg/m2 (Table 7). Among 260 and 300 mg/m2 cohorts, every patient experienced neuropathic events, in which Grade 3 or 4 event was more frequent in 300 mg/m2 (two out of three patients) than in 260 mg/m2 cohorts (one out of six patients). Moreover, all the three patients in 300 mg/m2 cohort discontinued the treatment due to neuropathic events as opposed to two out of six patients in 260 mg/m2 cohort. Table 7. Grade change in sensory neuropathy (all courses) Level Case Before administration Course no. 1 2 3 4 5 6 7 8 9 10 11 Level 1 1-2 0 0 0 1 1 1 1a — — — — — Level 2 2-1 1 2 — — — — — — — — — — 2-2 0 1 1 1 1 1 1 1 1 2 2 3a 2-3 0 0 1 — — — — — — — — — Level 3 3-1 0 1 1 2 2 2 3a — — — — — 3-2 0 1 1 1 2 2a — — — — — — 3-3 0 2 2 3a — — — — — — — — Level 2 2-4 0 1 1 1 2 2 2a — — — — — 2-5 0 1 — — — — — — — — — — 2-6 0 1 1 — — — — — — — — — —, end of study.

0 0 1 1 1 1a — — — — — Level 2 2-1 1 2 — — — — — — — — — — 2-2 0 1 1 1 1 1 1 1 1 2 2 3a 2-3 0 0 1 — — — — — — — — — Level 3 3-1 0 1 1 2 2 2 3a — — — — — 3-2 0 1 1 1 2 2a — — — — — — 3-3 0 2 2 3a — — — — — — — — Level 2 2-4 0 1 1 1 2 2 2a — — — — — 2-5 0 1 — — — — — — — — — — 2-6 0 1 1 — — — — — — — — — —, end of study. aStudy-off due to sensory neuropathy. In terms of treatment-related toxicities, Grade 3 or 4 neutropenia was experienced in 15 of 46 treatment courses (32%). Nonetheless, no febrile neutropenia was observed. Median duration of recovery from Grade 3 or 4 to <Grade 2 was 6.5 days (range, 3–14). No treatment delay was caused by neutropenia. In addition, platelet decrease ≥Grade 2 was not observed throughout the study. On the whole, hematological toxicities were mild. In regard to sensory neuropathy, the median time to the first indication or exacerbation from the baseline was 7 days, which was relatively early to that of solvent-based paclitaxel. Especially for Grade 3 sensory neuropathy, the indication or exacerbation fell within the first week of the first course, ranging from 3 to 6 days; the time to improve from Grade 3 to Grade 2 or 1 was 21, 26 and 46 days in the respective cases. Although the improvement tended to delay when compared with median 22 days in a previous Phase III study (4), it still remains controversial because of the great difference in the sample sizes between the two studies. Meanwhile, other non-hematological toxicities including mucositis—the DLT of the US Phase I study—were generally mild to moderate up to 300 mg/m2.

n compared with median 22 days in a previous Phase III study (4), it still remains controversial because of the great difference in the sample sizes between the two studies. Meanwhile, other non-hematological toxicities including mucositis—the DLT of the US Phase I study—were generally mild to moderate up to 300 mg/m2. PK profiles of ABI-007 have revealed the small inter-patient variability, and the AUC and Cmax of paclitaxel increased with increasing the dosage. In whole blood samples, there was a significant correlation between the doses and PK parameters. The linearity was uncertain in the face of wide confidence interval (CI) with small sample size, however, presumable from the other reported data showing the linearity over a wide dose range: 80–300 mg/m2 (2) and PK equality between Japanese and western population (3). Anti-tumor response was demonstrated in the patients with NSCLC including the patients who had received prior taxane-containing therapy.

PK profiles of ABI-007 have revealed the small inter-patient variability, and the AUC and Cmax of paclitaxel increased with increasing the dosage. In whole blood samples, there was a significant correlation between the doses and PK parameters. The linearity was uncertain in the face of wide confidence interval (CI) with small sample size, however, presumable from the other reported data showing the linearity over a wide dose range: 80–300 mg/m2 (2) and PK equality between Japanese and western population (3). Anti-tumor response was demonstrated in the patients with NSCLC including the patients who had received prior taxane-containing therapy. Multiple previous studies of ABI-007 also reported the promising data in the patients with NSCLC. In a Phase II trial, 260 mg/m2 of ABI-007 was administered alone in the same Q3W schedule as our study in the first-line setting, overall response rate was 16.3% (95% CI, 5.24–27.31%) and the disease control rate was 48.8% (95% CI, 33.90–63.78%) (8). More recently, weekly (QW) schedule of ABI-007 was also reported: 125 mg/m2 of ABI-007 was administered in monotherapy on days 1, 8 and 15 every 4 weeks, the response rate was 30% ((95% CI, 16–44%) and the disease control rate was 50% (95% CI, 35–66%) (9). Despite the higher incidence of ≥Grade 3 neutropenia and sensory neuropathy relative to the Q3W schedule, QW schedule was well tolerated and active.

7 was administered in monotherapy on days 1, 8 and 15 every 4 weeks, the response rate was 30% ((95% CI, 16–44%) and the disease control rate was 50% (95% CI, 35–66%) (9). Despite the higher incidence of ≥Grade 3 neutropenia and sensory neuropathy relative to the Q3W schedule, QW schedule was well tolerated and active. In conclusion, no DLT observed at any dose levels, and ABI-007 was well tolerated up to 300 mg/m2 in Japanese patients. RD in this schedule was determined to be 260 mg/m2 in consideration of efficacy, toxicities and similarity of PK profile in the western studies. Additional studies of single-agent ABI-007 and platinum-based combinations are warranted. Funding This trial was funded by Taiho Pharmaceutical (Tokyo, Japan). Conflict of interest statement Hironobu Minami and Tomohide Tamura receive remuneration for the lectures from Taiho Pharmaceutical (Tokyo, Japan). Acknowledgements The preliminary results of this study were presented in part at the AACR-NCI-EORTC International Conference, San Francisco, CA, October 2007.

INTRODUCTION The incidence of breast cancer is increasing in Japan and many other Asian countries (1). Among Asian women with breast cancer, an estimated 20% (as determined by immunohistochemistry grading of 3+) to 28% (as determined by positive fluorescence in situ hybridization) of breast tumors are human epidermal growth factor receptor 2-positive (ErbB2+, HER2+) (Dr Y. Tan, personal communication, December 2009). ErbB2+ breast cancer is of clinical concern, given that these tumors are correlated with more aggressive disease and a poor prognosis (2–4). Clinical studies have clearly shown, however, that patients with ErbB2+ breast cancer can achieve meaningful clinical benefits from anti-erbB2 therapy (3).

cation, December 2009). ErbB2+ breast cancer is of clinical concern, given that these tumors are correlated with more aggressive disease and a poor prognosis (2–4). Clinical studies have clearly shown, however, that patients with ErbB2+ breast cancer can achieve meaningful clinical benefits from anti-erbB2 therapy (3). Lapatinib (GW572016) is a unique, orally bioavailable, small-molecule dual tyrosine kinase inhibitor developed by GlaxoSmithKline that targets tumor cells overexpressing both human epidermal growth factor receptor (EGFR; ErbB1) and ErbB2 tyrosine kinases (5). Lapatinib inhibition of ErbB1 and ErbB2 kinase activity prevents the activation of downstream cellular signals that promote tumor cell survival and proliferation (6–8) (Fig. 1). Using a rational drug design approach, more than 3200 quinazoline and quinazoline-like compounds with potential tyrosine kinase activity were screened and assayed. Lapatinib was eventually selected from these compounds as it was a selective and potent inhibitor of ErbB1 and ErbB2 that had predictable oral bioavailability and acceptable in vivo toxicity in the targeted patient population (9). First-in-human studies with lapatinib were initiated in 2001; in 2007 lapatinib was approved in the USA for use in combination with capecitabine for the treatment of ErbB2+ advanced or metastatic breast cancer in patients who had received previous treatment including an anthracycline, a taxane and trastuzumab (10) (Fig. 2). Additional approvals for this indication have been granted in 90 more countries, including Japan. The clinical development of lapatinib is continuing with attention focused on ErbB2+ breast cancer as well as other cancers that overexpress ErbB2. Figure 1. ErbB2 cellular signaling pathways and lapatinib mechanism of action. ErbB2 (HER2) is a transmembrane tyrosine kinase activated by dimerization with itself or other ErbB proteins (i.e. ErbB1, ErbB3). Binding of ErbB1 ligands to ErbB1 stimulates heterodimerization with ErbB2 and activation of downstream signaling pathways, including PI3K, Akt protein kinase and mTOR, resulting in an increase in cell proliferation. The PTEN protein has tumor suppressor activity in this signaling pathway and loss of PTEN, as well as upregulation of IGF-1R signaling, is associated with trastuzumab resistance.

and activation of downstream signaling pathways, including PI3K, Akt protein kinase and mTOR, resulting in an increase in cell proliferation. The PTEN protein has tumor suppressor activity in this signaling pathway and loss of PTEN, as well as upregulation of IGF-1R signaling, is associated with trastuzumab resistance. Lapatinib blocks the activation of the ErbB2 signaling pathway by inhibiting the intracellular tyrosine kinase of ErbB1 and ErbB2 and may circumvent trastuzumab resistance associated with upregulation of IGF-1R signaling. Lapatinib also binds to the p95 truncated variant of ErbB2 (p95 ErbB2) and inhibits cell proliferation in trastuzumab-resistant cells expressing p95 ErbB2. ErbB1, human epidermal growth factor receptor 1 (EGFR); ErbB2, human epidermal growth factor receptor 2 (ErbB2); IGF-1R, insulin-like growth factor-1 receptor; PI3K, phosphatidylinositol-3-kinase; PTEN, Phosphatase and tensin homolog deleted on chromosome 10; mTOR, mammalian target of rapamycin.

s expressing p95 ErbB2. ErbB1, human epidermal growth factor receptor 1 (EGFR); ErbB2, human epidermal growth factor receptor 2 (ErbB2); IGF-1R, insulin-like growth factor-1 receptor; PI3K, phosphatidylinositol-3-kinase; PTEN, Phosphatase and tensin homolog deleted on chromosome 10; mTOR, mammalian target of rapamycin. Figure 2. Timeline and history of the preclinical and clinical development of lapatinib. Preclinical development was initiated in 1991 and the first-in-human lapatinib clinical study was conducted in 2001. The proof of concept (POC) milestone to establish a registration indication for lapatinib was achieved in 2003. Lapatinib received registration approval from the US Food and Drug Administration (FDA) in 2007 for use in combination with capecitabine for the treatment of ErbB2+ advanced or metastatic breast cancer in patients who had received previous treatment including an anthracycline, a taxane and trastuzumab. Although lapatinib provides a new treatment option for the management of ErbB2+ breast cancer, clinicians and patients still face a number of clinical challenges, including: (i) managing trastuzumab failure; (ii) preventing and managing central nervous system (CNS) metastases; (iii) minimizing toxicity; and (iv) selecting the most appropriate partner for combination therapy with lapatinib.

ErbB2+ breast cancer, clinicians and patients still face a number of clinical challenges, including: (i) managing trastuzumab failure; (ii) preventing and managing central nervous system (CNS) metastases; (iii) minimizing toxicity; and (iv) selecting the most appropriate partner for combination therapy with lapatinib. The aim of our review is to provide clinicians in Asia with insight into how lapatinib may help address the clinical challenges associated with ErbB2+ breast cancer. For each challenge, we will summarize relevant preclinical and clinical evidence and provide our perspective on what this evidence means to the practicing clinician.

our review is to provide clinicians in Asia with insight into how lapatinib may help address the clinical challenges associated with ErbB2+ breast cancer. For each challenge, we will summarize relevant preclinical and clinical evidence and provide our perspective on what this evidence means to the practicing clinician. Managing Trastuzumab Failure: Role for Lapatinib? Trastuzumab has advanced the management of patients with ErbB2+ metastatic breast cancer; however, ∼66–88% of patients treated with trastuzumab as a single agent and 20–50% of those treated with trastuzumab in combination therapy do not respond to trastuzumab (i.e. de novo or primary resistance) (11,12). Further, many patients with metastatic breast cancer, who initially respond to trastuzumab, develop resistance (i.e. acquired or secondary resistance) and the majority of these patients develop progressive disease within 1 year of commencing treatment (13–16). Accumulating preclinical and clinical evidence suggests that de novo and acquired trastuzumab resistance in ErbB2+ breast cancer may occur via several different molecular mechanisms (3,11,17). Clinical data also indicate, however, that patients may benefit from continued ErbB2 suppression with trastuzumab therapy after tumor progression on trastuzumab (18–20). Alternatively, evidence also exists that suggests that other anti-erbB2 therapies, such as lapatinib, may provide benefit in patients with ErbB2+ breast cancers that do not respond to trastuzumab therapy (19,21).

t from continued ErbB2 suppression with trastuzumab therapy after tumor progression on trastuzumab (18–20). Alternatively, evidence also exists that suggests that other anti-erbB2 therapies, such as lapatinib, may provide benefit in patients with ErbB2+ breast cancers that do not respond to trastuzumab therapy (19,21). Preclinical Evidence: Trastuzumab Failure and Lapatinib The potential for lapatinib to inhibit ErbB2-driven tumor cell growth in trastuzumab-resistant breast cancers has been investigated in various preclinical studies, including studies on trastuzumab failure associated with (i) transactivation of ErbB2 by other tyrosine kinases such as insulin-like growth factor-1 receptor (IGF-1R); (ii) expression of p95 ErbB2, a truncated form of ErbB2 lacking the extracellular trastuzumab-binding domain; and (iii) increase in phosphatidylinositol-3-kinase (PI3K)/Akt signaling due to loss of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expression or PI3K catalytic subunit alpha (PI3KCA) mutation (Fig. 1).

sion of p95 ErbB2, a truncated form of ErbB2 lacking the extracellular trastuzumab-binding domain; and (iii) increase in phosphatidylinositol-3-kinase (PI3K)/Akt signaling due to loss of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expression or PI3K catalytic subunit alpha (PI3KCA) mutation (Fig. 1). A number of in vitro studies have clearly shown that ErbB2+ breast cancer cells, rendered trastuzumab-resistant by long-term exposure to trastuzumab, remain responsive to lapatinib (22,23). Trastuzumab failure may be mediated, at least in part, by upregulation of IGF-1R. For example, preclinical studies have shown that IGF-1R interaction with ErbB2 is increased in trastuzumab-resistant breast cancer cells (24,25). Encouragingly, lapatinib was shown to block ErbB2 and IGF-1R crosstalk and inhibit cell growth in a trastuzumab-resistant breast cancer cell line (23). Results from preclinical studies also suggest that lapatinib may be effective in treating p95 ErbB2+ trastuzumab-resistant breast cancers. Owing to the absence of a trastuzumab-binding domain on p95 ErbB2, breast tumor cell lines and tumor xenografts expressing this truncated variant of ErbB2 appear to be resistant to trastuzumab. In vitro and in vivo studies have demonstrated that lapatinib can effectively inhibit the growth of trastuzumab-resistant breast cancer cell lines and tumor xenografts that express p95 ErbB2, presumably because lapatinib targets the intracellular tyrosine kinase component of ErbB2 (26).

to be resistant to trastuzumab. In vitro and in vivo studies have demonstrated that lapatinib can effectively inhibit the growth of trastuzumab-resistant breast cancer cell lines and tumor xenografts that express p95 ErbB2, presumably because lapatinib targets the intracellular tyrosine kinase component of ErbB2 (26). Trastuzumab resistance may also be mediated in some ErbB2+ breast tumors by an increase in PI3K/Akt signaling associated with either the loss or inactivation of PTEN expression or PI3KCA mutation (17,27). Presence of PTEN is associated with tumor suppressor activity (17). Loss of PTEN appears to counteract the anti-tumor effects of trastuzumab by promoting PI3K/Akt activation, which, in turn, stimulates tumor cell growth (17). In vitro studies in PTEN-deficient ErbB2+ breast tumor cell lines showed that tumor cells remained responsive to lapatinib and that lapatinib sensitivity appeared to be PTEN-independent (28). Transfection of ErbB2-overexpressing cell lines with mutant PI3KCA or wild-type PI3KCA resulted in trastuzumab resistance, suggesting that activation of the PI3K signaling pathway by PI3KCA mutation appeared to mediate resistance (27). Further, oncogenic mutations of PI3KCA, identified in several different ErbB2+ human breast cancer cell lines, are associated with trastuzumab resistance in vitro (29). Contrary to earlier preclinical findings that showed that lapatinib sensitivity was PTEN-independent, a recent in vitro study has shown that hyperactivation of the PI3K pathway by either loss-of-function mutations in PTEN or PI3KCA mutation may also confer resistance to lapatinib in breast cancer cell lines (30). Another recent in vitro study found that isolated clones of ErbB2+ breast cancer cell lines with acquired resistance to lapatinib were also cross-resistant to trastuzumab and exhibited increased expression of AXL, a receptor tyrosine kinase (31). This finding suggests that upregulation of AXL may be a novel mechanism involved in the development of lapatinib and trastuzumab resistance. Additional preclinical studies are required to determine the role of PI3K activation and AXL upregulation in modulating lapatinib and trastuzumab resistance.

tyrosine kinase (31). This finding suggests that upregulation of AXL may be a novel mechanism involved in the development of lapatinib and trastuzumab resistance. Additional preclinical studies are required to determine the role of PI3K activation and AXL upregulation in modulating lapatinib and trastuzumab resistance. Lapatinib has yet to be investigated in other molecular mechanisms of trastuzumab resistance, such as MUC4-mediated resistance. Preclinical studies have shown that the overexpression of the membrane-bound mucin glycoprotein, MUC4, in a trastuzumab-resistant human cell line, interferes with the binding of trastuzumab to ErbB2 (32). Tumors that overexpress MUC4 may potentially promote tumorigenesis by activating ErbB2, suppressing apoptosis and inhibiting immune recognition of tumor cells (11,33). Collectively, the results from these and other preclinical studies provided a strong scientific rationale for the conduct of clinical studies with lapatinib in patients with trastuzumab-resistant ErbB2+ breast cancer.

Lapatinib has yet to be investigated in other molecular mechanisms of trastuzumab resistance, such as MUC4-mediated resistance. Preclinical studies have shown that the overexpression of the membrane-bound mucin glycoprotein, MUC4, in a trastuzumab-resistant human cell line, interferes with the binding of trastuzumab to ErbB2 (32). Tumors that overexpress MUC4 may potentially promote tumorigenesis by activating ErbB2, suppressing apoptosis and inhibiting immune recognition of tumor cells (11,33). Collectively, the results from these and other preclinical studies provided a strong scientific rationale for the conduct of clinical studies with lapatinib in patients with trastuzumab-resistant ErbB2+ breast cancer. Clinical Evidence: Trastuzumab Failure and Lapatinib Clinical evidence from a recent systematic review of observational studies (18) and a randomized clinical trial (20) suggest that patients with breast tumors that progress on trastuzumab treatment may still benefit from continued ErbB2 suppression with trastuzumab (19). However, accumulating clinical data also indicates that treatment with other anti-erbB2 therapies, such as lapatinib, may also improve clinical outcomes in this patient population (19,34). Several clinical trials have been undertaken to examine the effect of lapatinib in patients with trastuzumab-resistant ErbB2+ breast cancer (19,35,36). The pivotal EGF100151 study (Table 1) (36), was a Phase III, randomized, controlled trial of 399 patients with ErbB2+ locally advanced or metastatic progressive disease. Patients were randomized to lapatinib plus capecitabine or to capecitabine alone. Treatment with lapatinib plus capecitabine significantly increased time to progression (TTP), compared with capecitabine alone (6.2 versus 4.3 months, respectively; hazard ratio [HR; 95% CI] = 0.57; 0.43–0.77; P < 0.001; Fig. 3). Significant differences in the overall response rate (ORR: 24 versus 14%; odds ratio [OR, 95% CI] = 1.9, 1.1–3.4; P = 0.017) and clinical benefit rate (CBR: 29 versus 17%; [OR, 95% CI] = 2.0, 1.2–3.3; P = 0.008) were observed (36). An exploratory subgroup analysis was also completed to assess the effect of the extent of pretreatment on TTP and overall survival (OS) (34,37). Among patients pretreated with fewer than three regimens, both TTP and OS were significantly greater for those treated with lapatinib plus capecitabine compared with capecitabine alone (TTP: 49.4 versus 19.7 weeks, respectively, [HR, 95% CI] = 0.37, 0.18–0.77; P = 0.006; OS: 87.3 versus 55.1 weeks, respectively, [HR, 95% CI] = 0.51, 0.30–0.86; P = 0.009).

than three regimens, both TTP and OS were significantly greater for those treated with lapatinib plus capecitabine compared with capecitabine alone (TTP: 49.4 versus 19.7 weeks, respectively, [HR, 95% CI] = 0.37, 0.18–0.77; P = 0.006; OS: 87.3 versus 55.1 weeks, respectively, [HR, 95% CI] = 0.51, 0.30–0.86; P = 0.009). Among patients pretreated with more than three regimens, TTP, but not OS, was significantly greater for those treated with lapatinib plus capecitabine compared with capecitabine alone (TTP: 25.4 versus 18.6 weeks, respectively, [HR, 95% CI] = 0.59, 0.43–0.82; P = 0.001; OS: 71.4 versus 66.6 weeks, respectively, [HR, 95% CI] = 0.95, 0.76–1.21; P = 0.7) (34,37). These findings indicate that lapatinib plus capecitabine was superior to capecitabine alone in patients whose disease had progressed on trastuzumab and that less heavily pretreated patients had the greatest benefit in terms of improved TTP and OS compared with more heavily pretreated patients. The results from the EGF100151 trial facilitated registration approval for the use of lapatinib in combination with capecitabine to treat patients with ErbB2+ breast cancer whose disease has progressed after treatment with trastuzumab-based regimens. Table 1. Phase III trials of lapatinib plus chemotherapy or non-chemotherapy agents for locally advanced or metastatic breast cancer

pproval for the use of lapatinib in combination with capecitabine to treat patients with ErbB2+ breast cancer whose disease has progressed after treatment with trastuzumab-based regimens. Table 1. Phase III trials of lapatinib plus chemotherapy or non-chemotherapy agents for locally advanced or metastatic breast cancer Reference Patient population Therapy N Outcomes Lapatinib plus chemotherapy agents Cameron et al. (36) (EGF100151) ErbB2+, LABC or MBC Lapatinib + capecitabine versus capecitabine 399 TTP: 6.2 versus 4.3 months; HR (95% CI): 0.57 (0.43–0.77); P < 0.001 CBR: 29 versus 17%; OR (95% CI): 2.0 (1.2–3.3); P = 0.008 ORR: 24 versus 14%; OR (95% CI): 1.9 (1.1–3.4); P = 0.017 OS: 15.6 versus 15.3 months; HR (95% CI): 0.78 (0.55–1.12); P = 0.177 Di Leo et al. (74). (EGF30001) First-line MBC Lapatinib + paclitaxel versus placebo + paclitaxel 579 ErbB2+ subgroup (n = 86) TTP: 36.4 versus 25.1 weeks; HR (95% CI): 0.53 (0.31–0.89); P = 0.005 CBR: 69.4 versus 40.5%; OR (95% CI): 3.5 (1.3–9.7); P = 0.011 ORR: 63.3 versus 37.8%; OR (95% CI): 3.0 (1.1–8.5); P = 0.023 OS: 104.6 versus 82.4 weeks; HR (95% CI): 0.74 (0.4–1.4); P = 0.365 Lapatinib plus non-chemotherapy agents Johnston et al. (66) (EGF30008) First-line MBC Lapatinib + letrozole versus placebo + letrozole 1286 Primary population: ErbB2+ (n = 219) PFS: 8.2 versus 3.0 months; HR (95% CI): 0.71 (0.53–0.96); P = 0.019 CBR: 48 versus 29%, OR (95% CI): 0.4 (0.2–0.8); P = 0.003 ORR: 28 versus 15%, OR (95% CI): 0.4 (0.2–0.9); P = 0.021 OS: 33.3 versus 32.3 months; HR (95% CI): 0.74 (0.5–1.1); P = 0.113 O'Shaughnessy et al. (42); Blackwell et al. (35) (EGF104900) ErbB2+, MBC Lapatinib + trastuzumab versus lapatinib 296 PFS: 12.0 versus 8.1 weeks; HR (95% CI): 0.73 (0.57–0.93); P = 0.008 CBR: 24.7 versus 12.4%, OR (95% CI): 2.2 (1.2–4.5); P = 0.020 ORR: 10.3 versus 6.9%, OR (95% CI): 1.5 (0.6–3.9); P = 0.46 OS: 60.7 versus 41.4 weeks; HR (95% CI): 0.74 (0.57–0.97); P = 0.026 CBR, clinical benefit rate; CI, confidence interval; ErbB2+, human epidermal growth factor receptor 2-positive; HR, hazard ratio; LABC, locally advanced breast cancer; MBC, metastatic breast cancer; OR, odds ratio; ORR, overall response rate; OS, overall survival PFS, progression-free survival; TTP, time to progression.

BR, clinical benefit rate; CI, confidence interval; ErbB2+, human epidermal growth factor receptor 2-positive; HR, hazard ratio; LABC, locally advanced breast cancer; MBC, metastatic breast cancer; OR, odds ratio; ORR, overall response rate; OS, overall survival PFS, progression-free survival; TTP, time to progression. Figure 3. Time to progression (TTP) in patients with ErbB2+ breast cancer treated with lapatinib plus capecitabine compared with capecitabine alone (EGF100151 study). Data include the intent-to-treat population of patients with ErbB2+, trastuzumab-resistant, locally advanced or metastatic breast cancer. Five patients with competing risk were censored. Figure adapted and reprinted from the publication by Cameron et al. (36) with kind permission from Springer Science + Business media.

Data include the intent-to-treat population of patients with ErbB2+, trastuzumab-resistant, locally advanced or metastatic breast cancer. Five patients with competing risk were censored. Figure adapted and reprinted from the publication by Cameron et al. (36) with kind permission from Springer Science + Business media. Lapatinib, as monotherapy, has been investigated in several clinical studies in patients with trastuzumab-naïve or trastuzumab-refractory ErbB2+ locally advanced or metastatic breast cancer (38–41). Clinical findings in these studies suggest that lapatinib monotherapy had anti-tumor activity in both trastuzumab-naive and trastuzumab-refractory patient populations and that the treatment was well-tolerated (38–41). Lapatinib, in combination with trastuzumab, was also assessed in a randomized clinical study of 296 patients with trastuzumab-refractory ErbB2+ metastatic breast cancer (35,42). In this study (EGF104900 study; Table 1), lapatinib plus trastuzumab significantly improved median OS, compared with lapatinib alone (60.7 versus 41.4 weeks; [HR, 95% CI = 0.74, 0.57–0.97; P = 0.026) in patients heavily pretreated with trastuzumab (35). These clinical benefits reinforce the merit of continued ErbB2 suppression and dual blockade of ErbB2 after disease progression.

uzumab significantly improved median OS, compared with lapatinib alone (60.7 versus 41.4 weeks; [HR, 95% CI = 0.74, 0.57–0.97; P = 0.026) in patients heavily pretreated with trastuzumab (35). These clinical benefits reinforce the merit of continued ErbB2 suppression and dual blockade of ErbB2 after disease progression. Consistent with preclinical findings, clinical studies have shown that truncation of the extracellular domain of ErbB2 (p95 ErbB2), loss of PTEN expression, or PI3KCA mutations in ErbB2+ breast cancer is associated with a poor response to trastuzumab and may be markers for trastuzumab failure (17,26,43). Further support for a role for lapatinib in the management of patients with trastuzumab failure comes from a clinical study of patients with ErbB2+ breast tumors expressing low PTEN or PI3KCA mutations (43). This study showed that low PTEN expression or PI3KCA mutation was correlated with trastuzumab, but not lapatinib, resistance (43). This clinical finding is discordant with recent preclinical evidence that suggests that loss-of-function mutations in PTEN or PI3KCA mutations could confer lapatinib resistance in ErbB2+ human breast cancer cell lines (30). The lack of a validated clinical test to identify patients with low PTEN tumors and relatively low patient numbers may potentially have limited the findings in the clinical study. Further clinical studies using a validated measure of PTEN expression in ErbB2+ breast tumors are required to better establish a potential correlation between low PTEN and resistance to lapatinib (30).

th low PTEN tumors and relatively low patient numbers may potentially have limited the findings in the clinical study. Further clinical studies using a validated measure of PTEN expression in ErbB2+ breast tumors are required to better establish a potential correlation between low PTEN and resistance to lapatinib (30). Given the promising findings from preclinical studies, the role of concomitant inhibition of the IGF-1R and ErbB2 signaling pathways is currently being investigated in a Phase II study in patients with trastuzumab-resistant locally advanced or metastatic ErbB2+ breast cancer (44). Patients will be treated with lapatinib plus capecitabine with or without the anti-IGF-1R monoclonal antibody, cixutumumab (IMC-A12). The primary endpoint will be progression-free survival (PFS) (45). This study should provide timely and critical insight into whether lapatinib plus capecitabine can overcome IGF-1R-mediated trastuzumab failure. On the basis of the results from preclinical and clinical studies, lapatinib, may have an important role in improving the management of ErbB2+ trastuzumab-resistant progressive disease.

Given the promising findings from preclinical studies, the role of concomitant inhibition of the IGF-1R and ErbB2 signaling pathways is currently being investigated in a Phase II study in patients with trastuzumab-resistant locally advanced or metastatic ErbB2+ breast cancer (44). Patients will be treated with lapatinib plus capecitabine with or without the anti-IGF-1R monoclonal antibody, cixutumumab (IMC-A12). The primary endpoint will be progression-free survival (PFS) (45). This study should provide timely and critical insight into whether lapatinib plus capecitabine can overcome IGF-1R-mediated trastuzumab failure. On the basis of the results from preclinical and clinical studies, lapatinib, may have an important role in improving the management of ErbB2+ trastuzumab-resistant progressive disease. Preventing and Managing CNS Metastases in ErbB2+ Breast Cancer Preventing and managing CNS metastases has emerged as an increasingly important clinical challenge for clinicians treating patients with ErbB2+ breast cancer. Approximately 25–50% of trastuzumab-treated patients will develop CNS metastases (46,47). Currently, those who develop CNS metastases have few effective treatment options available. Systemic chemotherapy, surgery (including stereotactic radiosurgery), whole brain radiotherapy and continued trastuzumab therapy provide some improvement in OS; however, the median time from the diagnosis of CNS metastases to death is only 4–15 months (46–48). On the basis of comparisons with historical controls (i.e. patients treated in the pretrastuzumab era), there has been an apparent increase in the incidence of CNS metastases in trastuzumab-treated patients with ErbB2+ breast cancer (46,47,49). Several hypotheses have been suggested for the observed increase in CNS metastases in this patient population, including: ErbB2+ tumors appear to have a more aggressive phenotype and are more likely to metastasize to the CNS (49–51);

f CNS metastases in trastuzumab-treated patients with ErbB2+ breast cancer (46,47,49). Several hypotheses have been suggested for the observed increase in CNS metastases in this patient population, including: ErbB2+ tumors appear to have a more aggressive phenotype and are more likely to metastasize to the CNS (49–51); The availability of trastuzumab therapy has resulted in better control of systemic disease, which has increased survival, but paradoxically, has also increased the opportunity for CNS metastases to develop (46); and The blood-brain barrier (BBB) may create a ‘sanctuary’ site in the CNS by preventing systemic anti-cancer agents from entering the CNS, thus, allowing ErbB2+ tumors to colonize and grow (46,52) Trastuzumab's large molecular size prevents the antibody from crossing the BBB and inhibiting the growth of ErbB2+ CNS tumors. In patients treated with trastuzumab, the ratio of trastuzumab levels in serum to trastuzumab levels in cerebrospinal fluid was 420:1. After whole brain radiotherapy, this ratio was reduced to 76:1, suggesting that the BBB was still an effective barrier to trastuzumab, even though the barrier was somewhat impaired by radiotherapy (53). Although systemic disease appears to be responsible for the lower survival rates in patients with ErbB2+ breast cancer in the pretrastuzumab era, the use of trastuzumab has altered the clinical course of the disease (46,47). Thus, with improved systemic control, the treatment of CNS disease is now a clinically relevant issue that requires effective proactive management.

for the lower survival rates in patients with ErbB2+ breast cancer in the pretrastuzumab era, the use of trastuzumab has altered the clinical course of the disease (46,47). Thus, with improved systemic control, the treatment of CNS disease is now a clinically relevant issue that requires effective proactive management. Lapatinib is a logical candidate to assess in clinical studies for the treatment and prevention of CNS metastases in patients with ErbB2+ breast cancer because of its potent anti-erbB2 activity and its small molecular size. Preclinical and clinical studies indicate that lapatinib can penetrate the BBB and exert an anti-tumor effect in the CNS.

ndidate to assess in clinical studies for the treatment and prevention of CNS metastases in patients with ErbB2+ breast cancer because of its potent anti-erbB2 activity and its small molecular size. Preclinical and clinical studies indicate that lapatinib can penetrate the BBB and exert an anti-tumor effect in the CNS. Preclinical Evidence: CNS Metastases in ErbB2+ Breast Cancer and Lapatinib The recent development of an in vivo mouse model of ErbB2+ brain metastases has helped researchers gain new insights into the cellular and molecular mechanisms involved in CNS metastases (51). Further, this model has proven to be a valuable tool to assess novel therapies that may inhibit the colonization and growth of ErbB2+ tumor cells within the brain. To develop this model, a brain-seeking derivate of a human breast cancer cell line overexpressing ErbB1 (MDA-MB-231) was transfected with an ErbB2-expressing vector (231-BR-HER2) or with an empty control vector (231-BR-vector) (51). After intracardiac injection of 231-R-ER2 or 231-BR-vector cells into BALB/c nude mice, metastatic brain lesions were shown to form 20 to 25 days later. Compared with 231-BR-vector control cells overexpressing only ErbB1, 231-BR-HER2 cells overexpressing ErbB1/ErbB2 showed a 2.5- to 3.0-fold increase in colonization (i.e. large metastases: >300 microns in any single dimension) in the brain. These findings suggest that ErbB2 expression plays an important role in promoting the growth of these cells and the development of brain metastases (51).

R-HER2 cells overexpressing ErbB1/ErbB2 showed a 2.5- to 3.0-fold increase in colonization (i.e. large metastases: >300 microns in any single dimension) in the brain. These findings suggest that ErbB2 expression plays an important role in promoting the growth of these cells and the development of brain metastases (51). Administration of 30 or 100 mg/kg lapatinib 5 days after injection of cells in this mouse model significantly decreased the total number of large metastases detected in the brains of mice injected with 231-BR-HER2 cells by 50–53% (P < 0.001) (Fig. 4) (54). Further, lapatinib also decreased the number of large metastases in the ErbB1-overexpressing control cells, but only at the highest dose tested. In vitro, lapatinib was shown to inhibit cell proliferation and migration, as well as block the phosphorylation of ErbB1 and ErbB1/ErbB2 in 231-BR-vector control and 231-BR-HER2 brain-seeking breast cancer cell lines, respectively (54). Taken together, these results indicate that lapatinib may prevent the proliferation of ErbB2+ breast cancer cells in the brain. Figure 4. Lapatinib inhibition of metastatic colonization of mouse brain by ErbB2-positive human breast cancer cells in a mouse model of brain metastases. Human breast cancer cells expressing ErbB1/ErbB2 (231-BR-HER2) or ErbB1 (231-BR-vector) and enhanced green fluorescent protein (EGFP) were administered by intracardiac injection into the left ventricle of BALB/c nude mice. Five days after injection mice were administered lapatinib (30 or 100 mg/kg body weight) or vehicle twice-daily for 24 days by oral gavage. Brains were dissected at necropsy and imaged to detect EGFP expression in metastases derived from the injected 231-BR cells. Representative dorsal whole brain images from two mice in each treatment group are shown. Image reprinted from the publication entitled “Effect of lapatinib on the outgrowth of metastatic breast cancer cells to the brain” by Gril et al. (54) with permission from Oxford University Press. ErbB1, human epidermal growth factor receptor 1; ErbB2, human epidermal growth factor receptor 2.

eatment group are shown. Image reprinted from the publication entitled “Effect of lapatinib on the outgrowth of metastatic breast cancer cells to the brain” by Gril et al. (54) with permission from Oxford University Press. ErbB1, human epidermal growth factor receptor 1; ErbB2, human epidermal growth factor receptor 2. Clinical Evidence: CNS Metastases in ErbB2+ Breast Cancer and Lapatinib A potential role for lapatinib in reducing CNS metastases was first apparent from an exploratory analysis of data from a Phase III study of lapatinib plus capecitabine versus capecitabine alone in patients with advanced ErbB2+ breast cancer (EGF100151) (36,55). This analysis showed that lapatinib plus capecitabine treatment was associated with a lower rate of CNS tumor progression, compared with capecitabine alone (2% [n = 4] versus 6% [n = 13], respectively; P = 0.045 (36).

citabine versus capecitabine alone in patients with advanced ErbB2+ breast cancer (EGF100151) (36,55). This analysis showed that lapatinib plus capecitabine treatment was associated with a lower rate of CNS tumor progression, compared with capecitabine alone (2% [n = 4] versus 6% [n = 13], respectively; P = 0.045 (36). This finding raised interest in the results from an exploratory analysis of data from a Phase II pilot study of lapatinib monotherapy in 39 patients with ErbB2+ breast cancer who had CNS metastases (56). This analysis showed that lapatinib treatment was associated with a decrease in tumor volume in some patients. Of the 34 patients analyzed, 3 (9%) patients achieved at least a 50% reduction in CNS tumor volume and 7 (21%) patients achieved at least a 10–30% reduction in CNS tumor volume (56). A larger Phase II study (EGF105084) was conducted to investigate the effects of lapatinib monotherapy on CNS tumor volume in 242 patients with ErbB2+ breast cancer whose CNS tumors had progressed after trastuzumab therapy and cranial radiotherapy (57). Of the 200 patients in this study with available data, 19 (8%) patients had at least a 50% reduction in tumor volume and 50 (21%) patients had at least a 20% reduction in tumor volume (57).

in 242 patients with ErbB2+ breast cancer whose CNS tumors had progressed after trastuzumab therapy and cranial radiotherapy (57). Of the 200 patients in this study with available data, 19 (8%) patients had at least a 50% reduction in tumor volume and 50 (21%) patients had at least a 20% reduction in tumor volume (57). Given the findings from the two Phase II studies and the results from the large Phase III lapatinib plus capecitabine registration trial (EGF100151), an extension to the EGF105084 study was deemed appropriate. In the extension phase, patients with ErbB2+ breast cancer whose CNS disease had progressed on lapatinib monotherapy were treated with lapatinib plus capecitabine (57). Findings from this study indicate that lapatinib plus capecitabine treatment was associated with a reduction in the volume of brain metastases. Of the 50 patients who entered the extension phase, 10 (20%, 95% exact CI: 3.0–33.7) patients had an objective CNS response. Further, 11 (22%) patients had at least a 50% reduction in tumor volume and 20 (40%) patients had at least a 20% reduction in tumor volume (57).

ith a reduction in the volume of brain metastases. Of the 50 patients who entered the extension phase, 10 (20%, 95% exact CI: 3.0–33.7) patients had an objective CNS response. Further, 11 (22%) patients had at least a 50% reduction in tumor volume and 20 (40%) patients had at least a 20% reduction in tumor volume (57). More recently, lapatinib plus capecitabine was evaluated in a lapatinib expanded access program (LEAP) and a French Authorisation Temporaire d'Utilisation (ATU) program for ErbB2+ breast cancer patients with CNS metastases (58). These programs provided patients with an opportunity to receive lapatinib after regulatory approval, but before the agent was commercially available. Preliminary analyses of the LEAP/ATU data also suggest that lapatinib plus capecitabine had anti-tumor activity in patients with CNS metastases. Of the 138 patients with progressive disease, 3 (2%) had a complete CNS response and 22 (16%) had a partial CNS response (58). Several other clinical trials are now underway to assess the role of lapatinib in preventing or treating CNS metastases in patients with ErbB2+ breast cancer (Table 2); the results of these studies are eagerly awaited. Table 2. Ongoing clinical trials to assess the role of lapatinib in preventing or treating central nervous system metastases in patients with early or advanced/metastatic ErbB2+ breast cancer

ng or treating CNS metastases in patients with ErbB2+ breast cancer (Table 2); the results of these studies are eagerly awaited. Table 2. Ongoing clinical trials to assess the role of lapatinib in preventing or treating central nervous system metastases in patients with early or advanced/metastatic ErbB2+ breast cancer Studya Patient population Study design and treatment regimen Phase N Efficacy endpoints NCT00374322 (EGF105485, TEACH) Early BC adjuvant Double-blind, RCT, lapatinib versus placebo III 3000 1°: DFS No trastuzumab 2°: OS, CNS RFI NCT00490139 (EGF106708, BIG 2-06, ALTTO) BC, adjuvant Open label, RCT, lapatinib versus trastuzumab versus trastuzumab followed by lapatinib versus lapatinib + trastuzumab III 8000 1°: DFS 2°: OS, TTR, TTDR, Incidence of CNS metastases NCT00553358 (EGF106903, BIG 1-06, NeoALTTO) BC, neoadjuvant Open label, RCT, lapatinib versus trastuzumab versus lapatinib + trastuzumab III 450 1°: DFS 2°: OS, TTR, TTDR, Incidence of CNS metastases NCT00667251 (EGF108919, COMPLETE) Stage IV MBC Open label, RCT, lapatinib + paclitaxel or docetaxel versus trastuzumab + paclitaxel or docetaxel III 600 1°: PFS 2°: ORR, OS, CBR, Incidence of CNS metastases NCT00820222 (EGF111438, CEREBREL) Stage IV MBC Open label, RCT, lapatinib + capecitabine versus trastuzumab + capecitabine III 650 1°: Incidence of CNS metastases as first site of progression aStudy identification codes for trials registered in the National Institutes of Health Clinical Trials Registry (http://clinicaltrials.gov, accessed 5 November 2009). BC, breast cancer; 1°, primary endpoint; 2°, secondary endpoint(s); CBR, clinical benefit rate; CNS, central nervous system; CNS RFI, central nervous system recurrence-free intervals; DFS; disease-free survival; MBC, metastatic breast cancer; OS, overall survival; PFS, progression-free survival; RCT, randomized controlled trial; TTDR, time to distant recurrence; TTR, time to recurrence.

BR, clinical benefit rate; CNS, central nervous system; CNS RFI, central nervous system recurrence-free intervals; DFS; disease-free survival; MBC, metastatic breast cancer; OS, overall survival; PFS, progression-free survival; RCT, randomized controlled trial; TTDR, time to distant recurrence; TTR, time to recurrence. In summary, preclinical and clinical studies have yielded promising results regarding the role that lapatinib may have in preventing and managing CNS metastases in patients with ErbB2+ breast cancer. Minimizing Toxicity: The Promise of Chemotherapy-free Regimens Minimizing the adverse outcomes and toxicity associated with the use of chemotherapeutic treatments is a challenge for both clinicians and patients. These adverse outcomes increase the cost and complexity of care and reduce the patient's quality of life (59). With advances in our understanding of the pathophysiology of ErbB2+ breast cancer, we are now able to consider whether ErbB2+ breast cancer could be managed with chemotherapy-free regimens such as lapatinib plus trastuzumab (as previously described) or lapatinib plus letrozole. This is an exciting possibility for clinician and patient alike. Preclinical and clinical evidence indicate that this possibility may be achieved for selected patients through the use of therapies that target more than one growth signaling receptor. The combined use of other targeted therapies, such as lapatinib and anti-estrogens, could not only yield clinical benefits, but could also help overcome the problem of endocrine therapy resistance.

ty may be achieved for selected patients through the use of therapies that target more than one growth signaling receptor. The combined use of other targeted therapies, such as lapatinib and anti-estrogens, could not only yield clinical benefits, but could also help overcome the problem of endocrine therapy resistance. Preclinical Evidence: Chemotherapy-free Regimens and Lapatinib Preclinical studies support the rationale for pursuing chemotherapy-free treatments for breast cancer; these studies have shown that lapatinib can have additive or synergistic inhibitory effects when combined with anti-estrogen therapies. Results from in vitro studies on breast cancer cell lines demonstrate that lapatinib and tamoxifen can cause a faster and more profound inhibition of cell cycle progression than tamoxifen alone (60). The synergistic effects of lapatinib and tamoxifen treatment were reflected in a greater increase in p27 and a greater decrease in cyclin D1 and cyclin E-cdk2 activity, relative to the effect of either drug alone (60). Results from in vitro studies with lapatinib plus fulvestrant have shown that these agents can additively or synergistically inhibit the growth of breast cancer cell lines (31). Lapatinib plus fulvestrant have been shown to promote G1-S blockade and increase apoptosis in an additive manner (61). Together, lapatinib and fulvestrant decreased the expression levels of Bcl-2 and survivin and increased the expression levels of p21 and p27 (61). Lapatinib plus fulvestrant have also been shown to synergistically inhibit the growth of a number of breast cancer cell lines through the downregulation of cell signaling proteins, such as p-PDK1, ERK1/2 and p-ERK (62).

the expression levels of Bcl-2 and survivin and increased the expression levels of p21 and p27 (61). Lapatinib plus fulvestrant have also been shown to synergistically inhibit the growth of a number of breast cancer cell lines through the downregulation of cell signaling proteins, such as p-PDK1, ERK1/2 and p-ERK (62). As ErbB2+ tumors have an increased resistance to endocrine therapy, compared with ErbB2-negative (ErbB2–) tumors (31,63), much attention has focused on whether anti-ErbB2 therapies might restore or enhance sensitivity to endocrine therapies. The molecular crosstalk between the estrogen receptor (ER) and the ErbB1/ErbB2 signaling pathways may contribute to endocrine resistance (64) (Fig. 5). Therefore, treatments that interfere with the ErbB1/ErbB2 signaling pathway, such as lapatinib, have the potential to modify ER and ErbB crosstalk and subsequently restore sensitivity to endocrine therapy. Results from preclinical studies support this hypothesis. Lapatinib and tamoxifen effectively inhibited the growth of tamoxifen-resistant breast cancer xenograft tumors in vivo; both the rate and volume of tumor growth were reduced with combined treatment (60). Lapatinib in combination with estrogen deprivation also effectively blocked the growth of lapatinib-resistant ErbB2+ breast cancer cell colonies (31). Figure 5. Molecular crosstalk between the ER and ErbB1/ErbB2 cellular signaling pathways in endocrine-resistant ErbB2-positive breast cancer cells. Estrogen bound to the ER activates estrogen-regulated genes via a classical signaling pathway. ErbB1/ErbB2 stimulation by growth factors results in activation of the PI3K/Akt and MAPK signaling pathways, leading to tumor cell growth. Long-term tamoxifen therapy may promote endocrine resistance via bidirectional crosstalk between the ER and growth factor receptor (i.e. IGF-1R or ErbB1/ErbB2) signaling pathway components. Bidirectional activation of these pathways promotes ER phosphorylation and ER target gene transcription as well as ErbB1/ErbB2/MAPK-mediated signaling and IGF-1R-mediated PI3K/Akt growth signaling pathways. Modulation of these pathways by combined use of lapatinib and anti-estrogen therapy (e.g. letrozole) may overcome endocrine resistance.

on of these pathways promotes ER phosphorylation and ER target gene transcription as well as ErbB1/ErbB2/MAPK-mediated signaling and IGF-1R-mediated PI3K/Akt growth signaling pathways. Modulation of these pathways by combined use of lapatinib and anti-estrogen therapy (e.g. letrozole) may overcome endocrine resistance. CBP, cAMP response element binding protein (CREB)-binding protein; ER, estrogen receptor; ErbB1, human epidermal growth factor receptor 1; ErbB2, human epidermal growth factor receptor 2; mitogen-activated protein kinase; MEK, mitogen-activated protein kinase kinase; P, phosphate; p90RSK, p90 ribosomal S6 kinase; p160, p160 steroid receptor co-activator protein(s); PI3K, phosphatidylinositol-3-kinase; PTEN, phosphatase and tensin homologue deleted on chromosome 10; RAF, murine leukemia viral oncogene homologue 1; SOS, son-of-seven less guanine nucleotide exchange factor. Figure adapted from the publication by Johnston (64) (Fig. 1) with permission from the American Association for Cancer Research. Collectively, the results from in vitro and in vivo preclinical studies have provided strong justification for clinical trials on the efficacy and safety of chemotherapy-free regimens, such as anti-estrogens plus lapatinib, for treating ErbB2+ breast cancer.

CBP, cAMP response element binding protein (CREB)-binding protein; ER, estrogen receptor; ErbB1, human epidermal growth factor receptor 1; ErbB2, human epidermal growth factor receptor 2; mitogen-activated protein kinase; MEK, mitogen-activated protein kinase kinase; P, phosphate; p90RSK, p90 ribosomal S6 kinase; p160, p160 steroid receptor co-activator protein(s); PI3K, phosphatidylinositol-3-kinase; PTEN, phosphatase and tensin homologue deleted on chromosome 10; RAF, murine leukemia viral oncogene homologue 1; SOS, son-of-seven less guanine nucleotide exchange factor. Figure adapted from the publication by Johnston (64) (Fig. 1) with permission from the American Association for Cancer Research. Collectively, the results from in vitro and in vivo preclinical studies have provided strong justification for clinical trials on the efficacy and safety of chemotherapy-free regimens, such as anti-estrogens plus lapatinib, for treating ErbB2+ breast cancer. Clinical Evidence: Chemotherapy-free Regimens and Lapatinib Currently, treatment guidelines do not recommend the use of targeted treatment regimens for the management of ER-positive (ER+)/ErbB2+ breast cancer, except for patients with visceral crisis (65). The results from a number of completed (Table 1) and ongoing (Table 3) clinical trials may justify changes to treatment guidelines and clinical practice. For example, recent results from the EGF30008 clinical trial (66) (Table 1) support the use of a first-line chemotherapy-free treatment regimen for postmenopausal women with ER+/ErbB2+ metastatic breast cancer. In this Phase III, randomized, double-blind, placebo-controlled trial, trastuzumab-naïve patients with either ErbB2+ or ErbB2− metastatic breast cancer (N = 1286) received either lapatinib plus letrozole or letrozole plus placebo. The primary endpoint was PFS (as assessed by the investigator) in the ER+/ErbB2+ population (n = 219). In this primary outcome population, treatment with lapatinib plus letrozole significantly increased PFS, compared with letrozole plus placebo (8.2 versus 3.0 months, respectively; [HR, 95% CI] = 0.71, 0.53–0.96; P = 0.019). Significant differences were also apparent in this population for the ORR (28 versus 15%, P = 0.021) and CBR (48 versus 29%, P = 0.003). There was no significant difference in OS between the two regimens (33.3 versus 32.3 months, P = 0.113); however, at the time of publication of these data, <50% of the OS events had been recorded. In the intent-to-treat (ITT) population, there was a modest, but significant, increase in PFS (11.9 versus 10.8 months [HR, 95% CI] = 0.86, 0.76–0.98; P = 0.026) (66). Exploratory analyses examining the effect of early (more than 6 months before study entry) versus recent (<6 months before study entry) tamoxifen discontinuation on clinical outcomes were also completed for the ER+/ErbB2− population of patients.

(11.9 versus 10.8 months [HR, 95% CI] = 0.86, 0.76–0.98; P = 0.026) (66). Exploratory analyses examining the effect of early (more than 6 months before study entry) versus recent (<6 months before study entry) tamoxifen discontinuation on clinical outcomes were also completed for the ER+/ErbB2− population of patients. These analyses showed a trend toward improved PFS and CBR in the lapatinib plus letrozole arm, compared with the letrozole plus placebo arm, for those patients who had ceased tamoxifen <6 months before study entry (PFS: 8.3 versus 3.1 months, respectively, P = 0.117; CBR: 44 versus 32%, respectively). This trend was not observed in the subpopulation of patients who had ceased tamoxifen more than 6 months before study entry (PFS: 14.7 versus 15.0 months, P = 0.522; CBR: 62 versus 64%). Although the difference did not reach statistical significance, these findings suggest a potential benefit for combination treatment with lapatinib plus letrozole for patients with ER+/ErbB2− breast cancer who develop tamoxifen resistance early during adjuvant treatment with tamoxifen (66). Results from the safety analyses of the ITT population in the EGF30008 trial showed that adverse events were similar and manageable between the two treatment regimens. The most common adverse events were diarrhea, rash, nausea, arthralgia and fatigue (66). Treatment guidelines for the management of lapatinib-associated toxicities (primarily diarrhea and rash) are now available (67–71). As clinical experience with lapatinib has increased, clinicians are now able to manage these toxicities more effectively in their routine clinical practice. Table 3. Ongoing clinical trials of lapatinib combination therapy for early or advanced/metastatic breast cancer

rily diarrhea and rash) are now available (67–71). As clinical experience with lapatinib has increased, clinicians are now able to manage these toxicities more effectively in their routine clinical practice. Table 3. Ongoing clinical trials of lapatinib combination therapy for early or advanced/metastatic breast cancer Studya Patient population Study design and treatment regimen Phase N Lapatinib plus chemotherapy agents NCT00753207 Relapsed stage III/IV BCb Open label, dose escalation to MTD, lapatinib + epirubicin I 24 NCT00513058 ErbB2+ relapsed stage III/IV BC Open label, dose escalation to MTD, lapatinib + vinorelbine I 60 NCT00614978 (LAPTEM) ErbB2+ relapsed brain metastases in BC Open label, dose escalation to MTD, lapatinib + temozolamide I 18 NCT00477464 (109749) Japanese ErbB2+ trastuzumab-failed MBC Open label, single-arm, lapatinib + capecitabine II 50 NCT00313599 ErbB2+ relapsed stage III/IV solid tumor Open label, dose escalation to MTD, lapatinib + Nab-paclitaxel I 22 NCT00709761 ErbB2+ second-line MBC Open label, single-arm, lapatinib + Nab-paclitaxel II 60 NCT00331630 ErbB2+ BC, neoadjuvant Open label, pilot study, lapatinib + Nab-paclitaxel II 30 NCT00756470 ErbB2+ inflammatory BC, neoadjuvant Open label, single-arm, lapatinib + paclitaxel then lapatinib + fluorouracil + epirubicin + cyclophosphamide II 60 NCT00404066 ErbB2+ BC, neoadjuvant Open label, single-arm, doxorubicin + cyclophosphamide then lapatinib + docetaxel II 72 Lapatinib plus chemotherapy and non-chemotherapy agents NCT00632489 Relapsed stage III/IV solid tumorb Open label, dose escalation to MTD in three arms, lapatinib + LBH589 versus LBH589 + capecitabine versus lapatinib + LBH589 + capecitabine I 55 NCT00820872 ErbB2+ BC, adjuvant Open label, single-arm, lapatinib + docetaxel + carboplatin + trastuzumab II 33 NCT00841828 ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + epirubicin + cyclophosphamide + docetaxel versus trastuzumab + epirubicin + cyclophosphamide + docetaxel II 102 NCT00769470 ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + carboplatin + docetaxel versus trastuzumab + carboplatin + docetaxel versus lapatinib + trastuzumab + carboplatin + docetaxel II 140 NCT00684983 (45) ErbB2+ first-line or relapsed MBC Open label, RCT, lapatinib + capecitabine + IMC-A12 versus lapatinib + capecitabine II 154 NCT00770809 (CALGB 40 601) ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + paclitaxel versus trastuzumab + paclitaxel versus lapatinib + trastuzumab + paclitaxel III 400 NCT0

NCT00684983 (45) ErbB2+ first-line or relapsed MBC Open label, RCT, lapatinib + capecitabine + IMC-A12 versus lapatinib + capecitabine II 154 NCT00770809 (CALGB 40 601) ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + paclitaxel versus trastuzumab + paclitaxel versus lapatinib + trastuzumab + paclitaxel III 400 NCT0 0667251 (EGF108919, COMPLETE) ErbB2+ stage IV MBC Open label, RCT, lapatinib + paclitaxel or docetaxel versus trastuzumab + paclitaxel or docetaxel III 600 NCT00820222 (EGF111438, CEREBREL) ErbB2+ stage IV MBC Open label, RCT, lapatinib + capecitabine versus trastuzumab + capecitabine III 650 NCT00567554 (GepaQuinto) ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + epirubicin + cyclophosphamide + docetaxel versus trastuzumab + epirubicin + cyclophosphamide + docetaxel versus bevacizumab + epirubicin + cyclophosphamide + docetaxel versus epirubicin + cyclophosphamide + docetaxel versus paclitaxel III 2547 Lapatinib plus non-chemotherapy agents NCT00352443 Relapsed stage III/IV solid tumorb Open label, dose escalation to MTD, lapatinib + everolimus I 48 NCT00499681 ErbB2+ BC, neoadjuvant Double-blind, RCT, lapatinib + letrozole versus placebo + letrozole II 36 NCT00118157 Tamoxifen-resistant MBCb Open label, single-arm, lapatinib + tamoxifen II 41 NCT00548184 ErbB2+ BC, neoadjuvant Double-blind RCT, lapatinib + trastuzumab + endocrine therapy versus lapatinib + trastuzumab II 64 NCT00390455 (CALGB 40 302) First-line or relapsed advanced BCb Open label, RCT, lapatinib + fulvestrant versus placebo + fulvestrant III 324 NCT00688194 Aromatase inhibitor-relapsed MBCb Double-blind, RCT, lapatinib + fulvestrant versus placebo + fulvestrant versus lapatinib + aromatase inhibitor + fulvestrant versus aromatase inhibitor + fulvestrant III 396 NCT00553358 (EGF106903, BIG 1-06, NeoALTTO) ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib versus trastuzumab versus lapatinib + trastuzumab; addition of paclitaxel for all treatment arms after 6 weeks III 450 NCT00486668 (NSABP B-41) ErbB2+ BC, neoadjuvant Open label, RCT, lapatinib + AC + paclitaxel versus trastuzumab + AC + paclitaxel versus lapatinib + trastuzumab + AC + paclitaxel III 522 NCT00490139 (EGF106708, BIG 2-06, ALTTO) ErbB2+ BC, adjuvant Open label, RCT, lapatinib versus trastuzumab versus trastuzumab then lapatinib versus lapatinib + trastuzumab III 8000 AC, doxorubicin + cyclophosphamide; BC, breast cancer; ErbB2+, human epidermal growth factor receptor 2-positive; MBC, metastatic breast cancer; MTD, maximum tol

, BIG 2-06, ALTTO) ErbB2+ BC, adjuvant Open label, RCT, lapatinib versus trastuzumab versus trastuzumab then lapatinib versus lapatinib + trastuzumab III 8000 AC, doxorubicin + cyclophosphamide; BC, breast cancer; ErbB2+, human epidermal growth factor receptor 2-positive; MBC, metastatic breast cancer; MTD, maximum tol erated dose; RCT, randomized controlled trial. aStudy identification codes for trials registered in the National Institutes of Health Clinical Trials Registry (http://clinicaltrials.gov, accessed 5 November 2009). bPatient population ErbB2 status unknown. The efficacy and safety results from this major clinical trial indicate that concurrent inhibition of ER and ErbB2 could indeed provide a new, oral, chemotherapy-free treatment regimen for patients with ER+/ErbB2+ metastatic breast cancer. Clinical acumen would still be required, however, to determine the most appropriate treatment strategy for each patient. Clinicians would need to take patient-related factors into account, such as the relative resistance to endocrine therapy, age, symptom status, rate of disease progression, tumor burden and extent of visceral disease.

ould still be required, however, to determine the most appropriate treatment strategy for each patient. Clinicians would need to take patient-related factors into account, such as the relative resistance to endocrine therapy, age, symptom status, rate of disease progression, tumor burden and extent of visceral disease. Selecting the Most Appropriate Partners for Combination Therapy with Lapatinib In an ideal world, clinicians would be able to review evidence from head-to-head comparator trials in different patient populations to help them select the most appropriate combination treatment regimen for each particular patient. In the real world, clinicians have to take several factors into account when deciding on which combinations of chemotherapeutic and non-chemotherapeutic agents are most appropriate for a particular patient. These factors might include synergy between agents, non-overlapping toxicity profiles, non-cross-resistant mechanisms of action, previous treatment exposure, generalizability of clinical data and affordability. These factors will likely also influence a clinician's choice of lapatinib-containing combination therapies that have been shown to be of clinical benefit in specific patient populations.

rofiles, non-cross-resistant mechanisms of action, previous treatment exposure, generalizability of clinical data and affordability. These factors will likely also influence a clinician's choice of lapatinib-containing combination therapies that have been shown to be of clinical benefit in specific patient populations. Preclinical Evidence: Combination Therapy with Lapatinib Given lapatinib's targeted mechanism of action on ErbB1/ErbB2, preclinical studies have also been conducted to investigate the efficacy of lapatinib when partnered with either chemotherapy or other targeted non-chemotherapy agents. In the ErbB2+ BT474 mouse xenograft model, combinations of lapatinib and various chemotherapy agents (e.g. paclitaxel, docetaxel and vinorelbine) have resulted in significantly greater tumor growth inhibition than that achieved with chemotherapy agents alone (72). In addition, synergy between the lapatinib derivative, GW282974X and the capecitabine metabolite, 5′-deoxy-5-flurouridine, has been demonstrated in vitro (73). Preclinical studies have also shown the benefits of partnering lapatinib with non-chemotherapy agents that target pathways different to the ErbB2 pathway. As described in previous sections, lapatinib has been shown to act synergistically with endocrine treatments, such as tamoxifen and fulvestrant (60–62). Targeting the same pathway, but in different ways has also proven beneficial. Lapatinib, which targets both the ErbB1 and ErbB2 intracellular tyrosine kinase domain, has shown synergy in vitro with trastuzumab, which targets the ErbB2 extracellular domain, in the ErbB2-overexpressing MDA-MB-361 breast cancer cell line (22). The positive results from these preclinical studies provided the scientific justification for investigating lapatinib combination therapy in clinical trials.

n, has shown synergy in vitro with trastuzumab, which targets the ErbB2 extracellular domain, in the ErbB2-overexpressing MDA-MB-361 breast cancer cell line (22). The positive results from these preclinical studies provided the scientific justification for investigating lapatinib combination therapy in clinical trials. Clinical Evidence: Combination Therapy with Lapatinib The encouraging results from preclinical studies with lapatinib combination therapy are being complemented by positive efficacy and safety results from completed (Table 1) and ongoing (Table 3) clinical trials. In addition to trials using lapatinib plus capecitabine combination therapy, clinical trials of lapatinib and other chemotherapy agents have also had positive results. For example, lapatinib plus paclitaxel combination therapy in patients with ErbB2+ breast cancer resulted in a significant increase in TTP, compared with paclitaxel alone (EGF30001 study; Table 1). The most common adverse events (e.g. alopecia, rash and diarrhea) were expected and manageable (74). The availability of a large number of other effective chemotherapeutic agents for metastatic breast cancer and the lack of overlapping toxicities has allowed the development of ongoing clinical trials that combine lapatinib with other chemotherapy agents, such as docetaxel, doxorubicin, epirubicin, vinorelbine and temozolamide (Table 3). Promising efficacy and safety results have also been achieved in clinical trials of lapatinib and non-chemotherapy agents. Significant increases in PFS have been achieved when lapatinib has been partnered with letrozole (EGF30008) (66) or with trastuzumab (EGF104900) (Table 1) (35,42); there were no unexpected adverse events with either regimen and each regimen was well-tolerated. Interest in the potential role of vascular endothelial growth factor (VEGF) in ErbB2+ breast cancer has also led to clinical trials of lapatinib and non-chemotherapy agents that target VEGF or the VEGF receptor. A combination of lapatinib plus the VEGF receptor inhibitor, pazopanib, was associated with a significant increase in the proportion of patients who were progression-free at 12 weeks, compared with the proportion of patients treated with lapatinib alone (VEG20007) (75). Encouraging results were also obtained for PFS at 12 weeks in a single-arm clinical trial of lapatinib plus the anti-VEGF antibody, bevacizumab (EGF103890) (76).

se in the proportion of patients who were progression-free at 12 weeks, compared with the proportion of patients treated with lapatinib alone (VEG20007) (75). Encouraging results were also obtained for PFS at 12 weeks in a single-arm clinical trial of lapatinib plus the anti-VEGF antibody, bevacizumab (EGF103890) (76). These combination regimens were well-tolerated and adverse events were consistent with expectations.

se in the proportion of patients who were progression-free at 12 weeks, compared with the proportion of patients treated with lapatinib alone (VEG20007) (75). Encouraging results were also obtained for PFS at 12 weeks in a single-arm clinical trial of lapatinib plus the anti-VEGF antibody, bevacizumab (EGF103890) (76). These combination regimens were well-tolerated and adverse events were consistent with expectations. CONCLUSION The management of patients with ErbB2+ breast cancer presents a number of challenges for clinicians in Asia, especially given the increasing incidence of breast cancer in Asia and the adverse clinical consequences of ErbB2+ breast cancer. Of particular clinical concern are challenges such as trastuzumab therapy failure, the development of CNS metastases, chemotherapy-related toxicity and selecting the most appropriate partners for combination therapy. Preclinical and clinical evidence suggests that lapatinib may help address these clinical challenges. Preclinical and clinical studies have shown that lapatinib is effective in inhibiting the growth of ErbB2+ tumors, including trastuzumab-resistant tumors. Notably, lapatinib plus capecitabine is approved for the treatment of patients with ErbB2+ locally advanced or metastatic breast cancer who develop progressive disease after treatment with trastuzumab-based regimens. Clinical studies have also shown that lapatinib, in combination with hormonal agents (e.g. letrozole), may provide a chemotherapy-free treatment option for postmenopausal patients with ER+/ErbB2+ metastatic breast cancer. More recently, promising results have emerged on the use of lapatinib to prevent and treat CNS metastases and on the synergy that may be achieved when lapatinib is combined with chemotherapeutic and non-chemotherapeutic agents for the treatment of ErbB2+ breast cancer. The number and nature of ongoing studies with lapatinib highlight the strong international interest in gaining further insight into how lapatinib may enhance the future management of ErbB2+ breast cancer. Nevertheless, considering the existing evidence base and our own clinical experience, we believe that lapatinib is a clinically effective and well-tolerated targeted oral therapy that clinicians in Asia, and around the world, can use judiciously to enhance their current management of patients with ErbB2+ breast cancer.

Nevertheless, considering the existing evidence base and our own clinical experience, we believe that lapatinib is a clinically effective and well-tolerated targeted oral therapy that clinicians in Asia, and around the world, can use judiciously to enhance their current management of patients with ErbB2+ breast cancer. Funding To enhance reader access to this peer-reviewed article, the authors opted for an open access publication. The open access and color printing publication charges for this article were funded by GlaxoSmithKline Asia Pacific. Conflict of interest statement Arlene Chan has received payments as an advisory board member from Roche and for speaking from Roche and GlaxoSmithKline; Junichi Kurebayashi has received payments for speaking from GlaxoSmithKline; Brunilde Gril has received grant support from the US Department of Defense Breast Cancer Research Program; Li Liu is an employee of and has shares in GlaxoSmithKline; Yen-Shen Lu has received grant support and payments for speaking from GlaxoSmithKline; Hanlim Moon is an employee of and has shares in GlaxoSmithKline; Charles Vogel has received grant support and payments for consulting and speaking from Genentech and grant support and payments for consulting, speaking and participation as a clinical trial investigator and advisory board member from GlaxoSmithKline.

ne; Hanlim Moon is an employee of and has shares in GlaxoSmithKline; Charles Vogel has received grant support and payments for consulting and speaking from Genentech and grant support and payments for consulting, speaking and participation as a clinical trial investigator and advisory board member from GlaxoSmithKline. Acknowledgements The authors take full responsibility for the content of the manuscript, but wish to acknowledge Dr Patricia S. Steeg (National Cancer Institute, National Institutes of Health) as well as scientific and medical personnel at GlaxoSmithKline for reviewing this manuscript. The authors also acknowledge the independent medical writing assistance provided by Julie Ely, PhD and Karen Woolley, PhD of ProScribe Medical Communications (www.proscribe.com.au), funded from an unrestricted financial grant from GlaxoSmithKline Asia Pacific. ProScribe's services complied with international guidelines for Good Publication Practice 2.

INTRODUCTION Colorectal cancer is the third leading cause of cancer deaths worldwide. The number of patients affected by this disease continues to increase steadily (1–3) and ∼42 000 deaths occur annually in Japan (3).

INTRODUCTION Colorectal cancer is the third leading cause of cancer deaths worldwide. The number of patients affected by this disease continues to increase steadily (1–3) and ∼42 000 deaths occur annually in Japan (3). FOLFOX4, a bi-weekly schedule of intravenous bolus and infusional 5-fluorouracil/folinic acid plus oxaliplatin (Elplat®) is a widely used regimen for the first-line treatment of metastatic colorectal cancer (MCRC) (4,5). However, oral fluoropyrimidines can replace the intravenous fluoropyrimidine component of combination regimens. Capecitabine (Xeloda®) is an oral fluoropyrimidine with similar efficacy to bolus 5-fluorouracil/folinic acid when given as first-line treatment for MCRC (6–8) or as adjuvant therapy for stage III colon cancer (9). It has also been successfully combined with oxaliplatin as the capecitabine plus oxaliplatin (XELOX) regimen, which consists of a 21-day intermittent schedule of capecitabine combined with a 3-weekly dose of oxaliplatin (10,11). A pivotal phase III study (NO16966) recently demonstrated that XELOX was non-inferior in terms of efficacy to FOLFOX4 as the first-line treatment for patients with MCRC (12). The same study further showed that adding bevacizumab (Avastin®) to oxaliplatin-based chemotherapy significantly improved progression-free survival (PFS) by 20% in the first-line treatment of MCRC (13). However, most of the clinical development of these regimens has been performed in Europe and the USA, although the NO16966 study included a small number of centers in Central and Eastern Asia (12,13). It has not been clarified if XELOX with the dose and schedule applied mainly to Caucasian patients shows a similar efficacy and toxicity profile in Japanese patients. To address this issue, we conducted a Phase I/II study to evaluate the safety and efficacy of XELOX plus bevacizumab in Japanese patients with MCRC.

13). It has not been clarified if XELOX with the dose and schedule applied mainly to Caucasian patients shows a similar efficacy and toxicity profile in Japanese patients. To address this issue, we conducted a Phase I/II study to evaluate the safety and efficacy of XELOX plus bevacizumab in Japanese patients with MCRC. PATIENTS AND METHODS Study Design A prospective, multicenter, open-label study with a three-step design was conducted to evaluate the efficacy and safety of the commonly used dose of XELOX plus bevacizumab in Japanese patients with MCRC. The purpose of step 1 was to evaluate the initial safety of XELOX in six patients; step 2 was to evaluate the initial safety of XELOX plus bevacizumab in six patients; and step 3 was to evaluate the efficacy and safety of XELOX plus bevacizumab in 48 patients plus the six patients from step 2. The criterion for proceeding to the next phase was the occurrence of dose-limiting toxicity (DLT) in less than or equal to two of six patients. An independent review committee (IRC) was scheduled to evaluate safety immediately after the first cycle in steps 1 and 2. The previous phase I trial determined the recommended dose of the XELOX regimen (14) and DLT was defined as grade 4 neutropenia for 5 days or more, or febrile neutropenia, or grade ≥3 neutropenia associated with grade 3/4 complications (e.g. stomatitis, diarrhea); or grade ≥3 gastrointestinal toxicities, grade 3 hand-foot syndrome (HFS), grade ≥3 peripheral neuropathy, or any grade 4 hematological toxicity or any other clinically significant grade ≥3 non-hematological toxicity which did not recover within 2 days with appropriate therapy.

omplications (e.g. stomatitis, diarrhea); or grade ≥3 gastrointestinal toxicities, grade 3 hand-foot syndrome (HFS), grade ≥3 peripheral neuropathy, or any grade 4 hematological toxicity or any other clinically significant grade ≥3 non-hematological toxicity which did not recover within 2 days with appropriate therapy. The study was performed in accordance with the Declaration of Helsinki and Good Clinical Practice. Written informed consent was obtained from all patients participating in this study. The protocol was approved by the independent ethics committee or institutional review board at each site.

omplications (e.g. stomatitis, diarrhea); or grade ≥3 gastrointestinal toxicities, grade 3 hand-foot syndrome (HFS), grade ≥3 peripheral neuropathy, or any grade 4 hematological toxicity or any other clinically significant grade ≥3 non-hematological toxicity which did not recover within 2 days with appropriate therapy. The study was performed in accordance with the Declaration of Helsinki and Good Clinical Practice. Written informed consent was obtained from all patients participating in this study. The protocol was approved by the independent ethics committee or institutional review board at each site. Patients At study enrollment, patients were required to fulfill all of the following criteria: age ≥20 and ≤74 years, Eastern Cooperative Oncology Group (EGOG) performance status of 0 or 1, life expectancy ≥3 months, histologically proven adenocarcinoma of the colon or rectum that was considered to be unrespectable with at least one measurable metastasis (RECIST guidelines) (15), no prior systemic chermotherapy for MCRC, no progression within 6 months of adjuvant therapy completion (if received), neutrophil count ≥1500/mm3, platelet count ≥100 000/mm3, hemoglobin level ≥9.0 g/dl, total bilirubin ≤1.5 times the institutional upper limit of normal (ULN), aspartate aminotransferase (AST), alanine aminotransferase and alkaline phosphatase ≤2.5 times ULN, creatinine ≤1.5 times ULN and creatinine clearance ≥50 ml/min. Some of the exclusion criteria were as follows: brain tumors or brain metastases, clinically detectable ascites; major surgery, open biopsy or significant traumatic injury within 4 weeks before enrollment, fine needle aspiration biopsy or central venous line placement within 1 week before enrollment, bleeding diathesis or coagulopathy, international normalized ratio ≥1.5 within 1 week before enrollment, non-healing bone fracture, urinary protein ≥1+ within 1 week before enrollment, uncontrolled hypertension or peptic ulcer, clinically significant cardiovascular disease, chronic, daily treatment with high-dose aspirin (≥325 mg/day) or non-steroidal anti-inflammatory medications, or peripheral neuropathy of at least grade 1. The inclusion and exclusion criteria were almost identical to those used in the NO16966 study (12,13).

peptic ulcer, clinically significant cardiovascular disease, chronic, daily treatment with high-dose aspirin (≥325 mg/day) or non-steroidal anti-inflammatory medications, or peripheral neuropathy of at least grade 1. The inclusion and exclusion criteria were almost identical to those used in the NO16966 study (12,13). Treatment Oxaliplatin was supplied by Yakult Honsha Co., Ltd (Tokyo, Japan) and capecitabine and bevacizumab were supplied by Chugai Pharmaceutical Co., Ltd (Tokyo, Japan). XELOX consisted of a 2-h intravenous infusion of oxaliplatin 130 mg/m2 on day 1 plus oral capecitabine 1000 mg/m2 twice daily for 2 weeks of a 3-week cycle. The first dose of capecitabine was given in the evening of day 1 and the last dose in the morning of day 15. Bevacizumab at a dose of 7.5 mg/kg was administered as a 30- to 90-min intravenous infusion before oxaliplatin on day 1 of the 3-week cycle. Treatment was continued until disease progression, intolerable adverse events or withdrawal of consent.

s given in the evening of day 1 and the last dose in the morning of day 15. Bevacizumab at a dose of 7.5 mg/kg was administered as a 30- to 90-min intravenous infusion before oxaliplatin on day 1 of the 3-week cycle. Treatment was continued until disease progression, intolerable adverse events or withdrawal of consent. Treatment was to be interrupted if grade 2–4 toxicities occurred. No dose modification of bevacizumab was performed. The dose of capecitabine was to be adjusted for grade 3 or 4 thrombocytopenia or neutropenia, febrile neutropenia or non-hematological toxicities of grade 2 or higher, according to a standard scheme described in detail by Blum et al. (16). The dose of oxaliplatin was to be reduced to 100 or 85 mg/m2 if patients experienced grade 3 or 4 thrombocytopenia or neutropenia, febrile neutropenia, or grade 3 non-hematological toxicity, and for grade 3 neurosensory toxicity lasting more than 7 days, or grade 2 neurosensory toxicity persisting between cycles. For grade 3 neurosensory toxicity persisting between cycles, oxaliplatin was to be discontinued. This treatment plan was almost identical to that of the NO16966 study (12,13). If oxaliplatin and/or bevacizumab were discontinued, treatment with the remaining components could be continued, such as capecitabine with or without bevacizumab after discontinuation of oxaliplatin, and XELOX or capecitabine after discontinuation of bevacizumab. Continuation of oxaliplatin or bevacizumab without capecitabine was not permitted.

cizumab were discontinued, treatment with the remaining components could be continued, such as capecitabine with or without bevacizumab after discontinuation of oxaliplatin, and XELOX or capecitabine after discontinuation of bevacizumab. Continuation of oxaliplatin or bevacizumab without capecitabine was not permitted. Efficacy and Safety Evaluation Tumor assessments with computed tomography scan were performed within 2 weeks before registration to this study and repeated every 6 weeks. Response rate was evaluated by the investigators according to RECIST version 1.0 (15). Tumor responses were confirmed by the IRC. PFS was defined as the duration from the date of the first dose of the study drug to the date of first confirmation of disease progression as determined by the IRC, or death from any cause, and censored at the last tumor assessment if a patient withdrew before progression. Overall survival (OS) was defined as the duration from the first dose of study drug to death. Time to response was defined as the time interval from the first dose of study drug to the first detection of ≥30% decrease of tumor size assessed by the IRC for patients with a confirmed overall response of PR or CR. Response duration was defined as the time interval from the first detection of ≥30% decrease of tumor size to disease progression assessed by the IRC and censored at the last tumor assessment if a patient withdrew before progression.

r size assessed by the IRC for patients with a confirmed overall response of PR or CR. Response duration was defined as the time interval from the first detection of ≥30% decrease of tumor size to disease progression assessed by the IRC and censored at the last tumor assessment if a patient withdrew before progression. Safety was assessed weekly for the first eight cycles of the treatment. Adverse events were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0 (17). All adverse events were evaluated until 28 days after the last dose of study drug. Statistical Analysis The primary study endpoints were safety and overall response rate (ORR) as assessed by the IRC. Secondary endpoints were PFS, OS, time to response and response duration. Forty-eight patients were required to test the null hypothesis (P = p0 or lower) versus the alternative hypothesis (P = pA or higher) with a one-sided α-level of 2.5% and a power of 80% when the critical ORR (p0) was 35% and the expected ORR (pA) was 55%. The total number of patients recruited to receive XELOX plus bevacizumab was estimated to be 54 (6 for Step 2 and 48 for Step 3) to allow for patients who might be ineligible for efficacy evaluation. ORRs were presented with 95% confidence interval (CI). The probabilities of time-to-event parameters were estimated using the Kaplan–Meier method with 95% CI.

Forty-eight patients were required to test the null hypothesis (P = p0 or lower) versus the alternative hypothesis (P = pA or higher) with a one-sided α-level of 2.5% and a power of 80% when the critical ORR (p0) was 35% and the expected ORR (pA) was 55%. The total number of patients recruited to receive XELOX plus bevacizumab was estimated to be 54 (6 for Step 2 and 48 for Step 3) to allow for patients who might be ineligible for efficacy evaluation. ORRs were presented with 95% confidence interval (CI). The probabilities of time-to-event parameters were estimated using the Kaplan–Meier method with 95% CI. RESULTS Patient Characteristics A total of 64 patients were enrolled between February 2006 and November 2006 from 11 centers in Japan. Six patients were enrolled in step 1 and received XELOX and 58 patients were enrolled in steps 2 and 3 and received XELOX plus bevacizumab. All patients (n = 64) were included in the safety analysis. One patient was excluded from the efficacy analysis because he received bevacizumab as part of a different clinical trial. Therefore, six patients were included in the efficacy evaluation of XELOX and 57 patients were included in the efficacy evaluation of XELOX plus bevacizumab.

) were included in the safety analysis. One patient was excluded from the efficacy analysis because he received bevacizumab as part of a different clinical trial. Therefore, six patients were included in the efficacy evaluation of XELOX and 57 patients were included in the efficacy evaluation of XELOX plus bevacizumab. The baseline demographic characteristics of the enrolled study patient population are shown in Table 1. The median age of the patients treated with XELOX was 58.5 years (range, 40–68 years) and with XELOX plus bevacizumab was 57.0 years (range, 33–74 years). ECOG performance status with XELOX was 0 in all 6 patients, and with XELOX plus bevacizumab was 0 in 50 patients and 1 in 8 patients. Table 1. Baseline demographic characteristics Characteristic XELOX (n = 6) XELOX plus bevacizumab (n = 58) No. of patients % No. of patients % Sex Male 5 83 40 69 Female 1 17 18 31 Age Median 58.5 57.0 Range 40–68 33–74 ECOG performance status 0 6 100 50 86 1 0 0 8 14 Primary tumor site Colon 4 67 31 53 Rectum 2 33 27 47 Metastatic site Liver 5 83 45 78 Lung 2 33 28 48 Lymph node 0 0 27 47 Other 3 50 5 9 No. of organs involved 1 2 33 25 43 2 4 67 21 36 3 0 0 10 17 >3 0 0 2 3 Adjuvant therapy Yes 1 17 8 14 No 5 83 50 86 ECOG, Eastern Cooperative Oncology Group.

6 100 50 86 1 0 0 8 14 Primary tumor site Colon 4 67 31 53 Rectum 2 33 27 47 Metastatic site Liver 5 83 45 78 Lung 2 33 28 48 Lymph node 0 0 27 47 Other 3 50 5 9 No. of organs involved 1 2 33 25 43 2 4 67 21 36 3 0 0 10 17 >3 0 0 2 3 Adjuvant therapy Yes 1 17 8 14 No 5 83 50 86 ECOG, Eastern Cooperative Oncology Group. Treatment Duration In the six patients participating in step 1, the median duration of treatment was 6.5 months (range, 0.5–14 months) with a median of 8.5 treatment cycles (range, 1–17 cycles). XELOX combination therapy was administered for a median of 7.0 cycles (range, 1–17 cycles). One patient subsequently went on to receive a further 6 cycles of capecitabine monotherapy for a total of 13 cycles. In steps 2 and 3, the median duration of treatment was 7.6 months (range, 0.1–34.8 months) with a median of 10.5 treatment cycles (range, 1–47 cycles). XELOX plus bevacizumab combination therapy was administered for a median of 9.0 cycles (range, 1–27 cycles). After discontinuation of oxaliplatin, 17 patients (29%) continued with capecitabine and bevacizumab combination therapy and received a median of 5.0 cycles (range, 1–34 cycles). Four patients (7%) received XELOX therapy for a median of 2.0 cycles (range, 1–5 cycles) during permanent or temporary discontinuation of bevacizumab. The median relative dose intensity (ratio of dose received to dose planned) was 0.74 (range: 0.41–1.00) for capecitabine, 0.86 (range: 0.55–1.00) for oxaliplatin and 0.91 (range: 0.58–1.01) for bevacizumab.

In steps 2 and 3, the median duration of treatment was 7.6 months (range, 0.1–34.8 months) with a median of 10.5 treatment cycles (range, 1–47 cycles). XELOX plus bevacizumab combination therapy was administered for a median of 9.0 cycles (range, 1–27 cycles). After discontinuation of oxaliplatin, 17 patients (29%) continued with capecitabine and bevacizumab combination therapy and received a median of 5.0 cycles (range, 1–34 cycles). Four patients (7%) received XELOX therapy for a median of 2.0 cycles (range, 1–5 cycles) during permanent or temporary discontinuation of bevacizumab. The median relative dose intensity (ratio of dose received to dose planned) was 0.74 (range: 0.41–1.00) for capecitabine, 0.86 (range: 0.55–1.00) for oxaliplatin and 0.91 (range: 0.58–1.01) for bevacizumab. Efficacy At the final data cut-off date (30 June 2009), the median duration of follow-up was 32.0 months. Thirty-three patients had died of disease progression and two patients were still receiving study medication. Tumor responses (ORR, time to response, response duration and PFS) are based on the median duration of follow-up of 15.2 months. The analysis of efficacy is shown in Table 2. The ORR (complete plus partial response) with XELOX was 67% (4/6) (95% CI: 22.3–95.7%), and with XELOX plus bevacizumab was 72% (41/57) (95% CI: 58.5–83.0%). The median PFS with XELOX plus bevacizumab was 11.0 months (95% CI: 9.6–12.5 months) (Fig. 1) and the median OS was 27.4 months (95% CI: 22.0 months–not calculated) (Fig. 2). Table 2. Analysis of efficacy

ith XELOX was 67% (4/6) (95% CI: 22.3–95.7%), and with XELOX plus bevacizumab was 72% (41/57) (95% CI: 58.5–83.0%). The median PFS with XELOX plus bevacizumab was 11.0 months (95% CI: 9.6–12.5 months) (Fig. 1) and the median OS was 27.4 months (95% CI: 22.0 months–not calculated) (Fig. 2). Table 2. Analysis of efficacy Endpoint XELOX (n = 6) XELOX plus bevacizumab (n = 57) Median progression-free survival, months 8.3 11.0 95% confidence interval 5.8–13.8 9.6–12.5 Median overall survival, months – 27.4 95% confidence interval – 22.0-NC Response rate, % 67 72 95% confidence interval 22.3–95.7 58.5–83.0 Complete response 0 2 Partial response 4 39 Stable disease 1 9 Progressive disease 0 1 Not evaluable 1 6 Median time to response, months 2.6 2.7 95% confidence interval 1.2–NC 1.5–2.8 Median response duration, months 6.4 9.7 95% confidence interval 2.8–11.3 6.7–9.9 NC, not calculated. Figure 1. Progression-free survival (XELOX plus bevacizumab). Figure 2. Overall survival (XELOX plus bevacizumab). NC, not calculated. Eight patients (14%) treated with XELOX plus bevacizumab underwent surgery with curative intent: none experienced a serious adverse event as a result of surgery and four patients (7%) had no residual disease. The sites of resection being curative by surgery were liver (n = 7), lymph node (n = 1), cholesyst (n = 2) and colon primary tumor (n = 2).

with XELOX plus bevacizumab underwent surgery with curative intent: none experienced a serious adverse event as a result of surgery and four patients (7%) had no residual disease. The sites of resection being curative by surgery were liver (n = 7), lymph node (n = 1), cholesyst (n = 2) and colon primary tumor (n = 2). Safety No DLT occurred during either step 1 or step 2. All six patients treated with XELOX and 31 (53%) patients treated with XELOX plus bevacizumab discontinued study treatment because of disease progression. Ten (17%) patients withdrew from XELOX plus bevacizumab because of adverse events, which comprised dehydration and anorexia; gastric varices haemorrhage; enteritis infectious; anorexia, herpes zoster and nausea; neutropenia; AST increased and alanine aminotransferase increased; infected epidermal cyst; peripheral sensory neuropathy; epididymitis; HFS (one patient, respectively). No patient died within 28 days after study medication. All patients (n = 64) experienced at least one adverse event during the study, most of which were mild to moderate in severity (Table 3). The most common adverse events with XELOX plus bevacizumab were neurosensory toxicity (93%), anorexia (90%), fatigue (83%) and HFS (78%). The most common grade 3/4 adverse events were neurosensory toxicity (17%) and neutropenia (16%). Table 3. Incidence of common adverse events

e mild to moderate in severity (Table 3). The most common adverse events with XELOX plus bevacizumab were neurosensory toxicity (93%), anorexia (90%), fatigue (83%) and HFS (78%). The most common grade 3/4 adverse events were neurosensory toxicity (17%) and neutropenia (16%). Table 3. Incidence of common adverse events Adverse event XELOX (n = 6) XELOX plus bevacizumab (n = 58) Grade 1–4 Grade 3–4 Grade 1–4 Grade 3–4 No. % No. % No. % No. % Neurosensory toxicity 6 100 1 17 54 93 10 17 Anorexia 5 83 0 0 52 90 2 3 Fatigue 4 67 0 0 48 83 3 5 Hand-foot syndrome 4 67 1 17 45 78 1 2 Nausea 6 100 0 0 43 74 0 0 Pigmentary disturbance 2 33 0 0 36 62 0 0 Stomatitis 2 33 0 0 33 57 1 2 Diarrhea 4 67 0 0 32 55 2 3 Neutropenia 3 50 0 0 30 52 9 16 Vomiting 1 17 0 0 27 47 1 2 Nose bleed 1 17 0 0 23 40 0 0 Proteinuria 0 0 0 0 19 33 3 5 Hypertension 0 0 0 0 19 33 3 5 Thrombocytopenia 2 33 1 17 13 22 4 7 Pulmonary thrombosis 0 0 0 0 1 2 1 2 Jugular vein thrombosis 0 0 0 0 1 2 0 0 For patients receiving XELOX plus bevacizumab, dose reductions were required for capecitabine in 32 patients (55.2%); the major reasons were HFS (n = 7), neutropenia (n = 6) and diarrhea (n = 6). Capecitabine doses were reduced to 75% of starting dose in 18 patients and to 50% in 14 patients. Dose reductions were required for oxaliplatin in 30 patients (51.7%) due to neurosensory toxicity (n = 15), neutropenia (n = 7) and other toxicities, and in most of these patients (n = 27) the oxaliplatin dose was reduced to 100 mg/m2.

doses were reduced to 75% of starting dose in 18 patients and to 50% in 14 patients. Dose reductions were required for oxaliplatin in 30 patients (51.7%) due to neurosensory toxicity (n = 15), neutropenia (n = 7) and other toxicities, and in most of these patients (n = 27) the oxaliplatin dose was reduced to 100 mg/m2. DISCUSSION In this prospective trial for Japanese patients with MCRC, XELOX plus bevacizumab achieved a high response rate of 72%, and eight patients (14%) proceeded to surgery with curative intent. The median PFS and the median OS for XELOX plus bevacizumab were 11.0 and 27.4 months, respectively.

doses were reduced to 75% of starting dose in 18 patients and to 50% in 14 patients. Dose reductions were required for oxaliplatin in 30 patients (51.7%) due to neurosensory toxicity (n = 15), neutropenia (n = 7) and other toxicities, and in most of these patients (n = 27) the oxaliplatin dose was reduced to 100 mg/m2. DISCUSSION In this prospective trial for Japanese patients with MCRC, XELOX plus bevacizumab achieved a high response rate of 72%, and eight patients (14%) proceeded to surgery with curative intent. The median PFS and the median OS for XELOX plus bevacizumab were 11.0 and 27.4 months, respectively. Previous randomized or observational trials which included the XELOX plus bevacizumab regimen as first-line therapy have been conducted mainly in North America and Europe (13,18–22). The NO16966 study showed a longer PFS and OS in the XELOX plus bevacizumab arm compared with the XELOX plus placebo arm in a subgroup analysis, which reported a median PFS of 9.3 versus 7.4 months, HR = 0.77 (95% CI: 0.63–0.94, P = 0.0026) and a median OS of 21.6 versus 19.0 months (HR was not shown) (23,24). Furthermore, another phase III trial (CAIRO2) reported a response rate of 50.0%, a median PFS of 10.7 months and a median OS of 20.3 months in the XELOX plus bevacizumab arm (18). The patient baseline demographic characteristics of the enrolled study patient population were similar to those of previous clinical trials in Western patients, except that the proportion of rectal cancer whose prognosis is worse than that of colon cancer was higher in this study (47% versus 23–35%) (4,6–8,11,12). Thus, the efficacy data from our study compares favorably with that reported in other recently conducted studies in predominantly Western patients, although in comparing the efficacy data from 57 patients of this single arm study to those of randomized phase III trials caution should be exercised.

3–35%) (4,6–8,11,12). Thus, the efficacy data from our study compares favorably with that reported in other recently conducted studies in predominantly Western patients, although in comparing the efficacy data from 57 patients of this single arm study to those of randomized phase III trials caution should be exercised. The administration schedule and doses selected for our study were identical to those used in the NO16966 study (12,13). The median relative dose intensity was similar with that in the XELOX plus bevacizumab arm of the NO16966 study (0.74 versus 0.73 for capecitabine, 0.86 versus 0.81 for oxaliplatin and both 0.91 for bevacizumab). The relative dose intensity was reported in another phase II trial (TREE-2) as well, a median of 0.76 for capecitabine, 0.91 for oxaliplatin and 0.96 for bevacizumab in the XELOX plus bevacizumab arm, whereas the starting dose of capecitabine was reduced to 850 mg/m2 twice daily and the median duration of the therapy was 19 weeks in that study (14). The safety profile observed in our study was similar to that observed in previous clinical trials with Western patients, including the NO16966 study (12,13,18–22). It is notable that the incidence of grade 3/4 diarrhea was only 3%, which is considerably lower than that reported with XELOX plus bevacizumab in the previous phase II and III studies (19–21%) (12,18,19,22). A lower incidence of diarrhea has been reported in other studies of Japanese or Asian patients treated with fluoropyrimidine-based chemotherapy (25–27). In addition, clinical trials including other oral fluoropyrimidines, such as UFT, have reported lower incidence of grade 3/4 diarrhea in Japanese patients than in Western patients (9.1 versus 22.2%) (28). A reason for this regional variation remains unclear, but it is speculated that differences in dietary folate intake may be a potential explanation (29). Regarding to HFS, although the overall incidence of HFS in our study (78%) was higher than that in the XELOX plus bevacizumab arm of the NO16966 study (39%), the incidence of grade 3 HFS appeared significantly lower (2 versus 12%). The incidence of dose modification (including treatment interruption and delay) due to HFS was similar among the studies (data not shown), as well as the dose intensity of capecitabine as described above. Therefore, the difference in incidences of grade 3 HFS, unfortunately, is not well explained at this time. However, a number of factors may explain this difference.

atment interruption and delay) due to HFS was similar among the studies (data not shown), as well as the dose intensity of capecitabine as described above. Therefore, the difference in incidences of grade 3 HFS, unfortunately, is not well explained at this time. However, a number of factors may explain this difference. The dose modification of capecitabine due to adverse events other than HFS (e.g. neutropenia, increase of AST, fatigue, anorexia), which occurred at higher incidences in our study compared with the NO16966 study, might be one such factor (data not shown). Difference in frequency of visits could also be factor. Patients received medical examination once every week during first eight cycles in this study, resulting in the treatment interruption in the middle of first 2 weeks of a cycle in four patients among eleven patients who developed grade 2 or grade 3 HFS. Another potential reason might be differences in prophylactic administration (e.g. a moisturizer, steroid ointment, urea ointment etc.). In terms of hematologic toxicities, grade 3/4 neutropenia occurred at 16% in patients receiving XELOX plus bevacizumab in our study which was higher than in the XELOX/XELOX + placebo arm of the NO16966 study (6%) (12), whereas no febrile neutropenia was observed in any patient in our study. The difference in the incidence of grade 3/4 neutropenia may in part be derived from an increased frequency of hematological examination, which was performed once every week in this study in contrast to once every 3 weeks at day 1 in the pivotal phase III study. Known bevacizumab-specific events (i.e. coagulopathy, hypertension, bleeding) were generally mild to moderate in severity in our study, and grade 3/4 events occurred at similar or lower incidence to that reported in Western patients (13). It is concluded that XELOX plus bevacizumab is well tolerated in Japanese patients with MCRC.

zumab-specific events (i.e. coagulopathy, hypertension, bleeding) were generally mild to moderate in severity in our study, and grade 3/4 events occurred at similar or lower incidence to that reported in Western patients (13). It is concluded that XELOX plus bevacizumab is well tolerated in Japanese patients with MCRC. Only one patient (2%) treated with XELOX plus bevacizumab experienced grade 3 HFS, compared with an incidence of 13% in a previous phase II study of capecitabine monotherapy (1250 mg/m2 twice daily) in Japanese patients with MCRC (25). In addition, dose reduction of capecitabine due to HFS was required for less patients in our study (12.1 versus 31.7%). This may be attributable to the 20% reduced dose of capecitabine used in the XELOX regimen compared with capecitabine monotherapy. In the present trial, six patients received only XELOX. The ORR was 67%, grade 3 adverse events developed in three patients (one event each, respectively) and no significant safety finding was observed. XELOX without bevacizumab is a widely used regimen in a first-line setting for MCRC patients (NCCN guideline) (30). The NO16966 study demonstrated an encouraging efficacy as described above, and another phase III trial showed an ORR of 42%; PFS of 9.3 months; and median OS of 19.9 months in the XELOX arm, with a good safety profile (31). Thus, XELOX seems to be acceptable as an option for a standard regimen for MCRC in Japan, although the data provided in our study is limited to a small population.

above, and another phase III trial showed an ORR of 42%; PFS of 9.3 months; and median OS of 19.9 months in the XELOX arm, with a good safety profile (31). Thus, XELOX seems to be acceptable as an option for a standard regimen for MCRC in Japan, although the data provided in our study is limited to a small population. In conclusion, in this study, XELOX plus bevacizumab was effective with manageable tolerability profile for Japanese patients with MCRC. The efficacy and safety profile of XELOX plus bevacizumab in this study was consistent with that observed in Western patients, whereas showing a notably lower incidence of diarrhea. Moreover, the XELOX regimen requires only one visit per 3-week cycle for a 2- or 3-h infusion, which may provide a marked advantage over the FOLFOX regimen in terms of the convenience for both patients and clinical staff. Therefore, XELOX plus bevacizumab may be considered as a possible standard treatment for Japanese patients with MCRC. Funding This work was supported by Chugai Pharmaceutical Co. Ltd and Yakult Honsha Co. Ltd. Conflict of interest statement None declared. Acknowledgements We are indebted to Dr Yuh Sakata, Dr Ichinosuke Hyodo and Dr Kunihisa Miyakawa for their help in the assessment of efficacy and evaluation of safety. We are also grateful to Dr Tetsuo Taguchi, Dr Nagahiro Saijo and Dr Atsushi Ohtsu for supporting the study.

Funding This work was supported by Chugai Pharmaceutical Co. Ltd and Yakult Honsha Co. Ltd. Conflict of interest statement None declared. Acknowledgements We are indebted to Dr Yuh Sakata, Dr Ichinosuke Hyodo and Dr Kunihisa Miyakawa for their help in the assessment of efficacy and evaluation of safety. We are also grateful to Dr Tetsuo Taguchi, Dr Nagahiro Saijo and Dr Atsushi Ohtsu for supporting the study. Appendix The following investigators cared for the patients in this study: Kuniaki Shirao (Oita University, Faculty of Medicine, Yufu, Oita) and Takashi Sekikawa (Toyosu Hospital, Showa University School of Medicine, Tokyo).

INTRODUCTION Breaking bad news is a stressful experience for the oncologist (1–6); moreover, it contributes to diminished confidence in communication skills and higher expectations of a negative outcome. The experience of dealing with distressed, angry and reproachful patients is also associated with burnout (7). Previous studies have suggested that oncologist-perceived burden is caused by several factors associated with the patient, the patient's family, the oncologists themselves and the medical environment (8,9). An oncologist's communication style affects the extent of emotional distress felt by the patient and the patient's family (10). The most difficult conversations involved discussing the discontinuation of curative treatment and admission to a hospice (4); therefore, it is important to clarify the extent of the burden experienced by the oncologist when communicating the discontinuation of anticancer treatment. Many studies have been conducted to clarify patients' preferences and experiences in receiving bad news in oncology settings (11–14), and several clinical guidelines and expert recommendations have been published (1,15,16). Moreover, recent intervention trials have demonstrated that structured communication skills training can improve physicians' skills in breaking bad news (17–19).

and experiences in receiving bad news in oncology settings (11–14), and several clinical guidelines and expert recommendations have been published (1,15,16). Moreover, recent intervention trials have demonstrated that structured communication skills training can improve physicians' skills in breaking bad news (17–19). Despite the existence of many experience-based recommendations and studies into the psychological effects on patients and their families, to our knowledge, only a few studies have explored the extent of the burden on oncologists when communicating the discontinuation of anticancer treatment. Therefore, the aims of the present study were to: (i) clarify the level of oncologist-perceived burden when communicating the discontinuation of anticancer treatment to patients; (ii) identify factors contributing to this burden; and (iii) explore potentially useful strategies to alleviate oncologist-perceived burden. PATIENTS AND METHODS Subjects The present study was a cross-sectional anonymous multicenter nationwide survey of oncologists in cancer centers across Japan. Questionnaires were mailed to 620 eligible oncologists in February 2007 and again 2 months later to those oncologists who had not yet responded. If the oncologists did not want to participate in the survey, we requested that they return the questionnaire without replying to any of the questions. The participating institutions were 12 cancer centers selected from the 15 cancer centers that make up the Japanese Association of Clinical Cancer Centers.

t responded. If the oncologists did not want to participate in the survey, we requested that they return the questionnaire without replying to any of the questions. The participating institutions were 12 cancer centers selected from the 15 cancer centers that make up the Japanese Association of Clinical Cancer Centers. We recognized potential sampling bias with this method, but decided to use convenient institutions because we felt that the risk of sampling bias would be minimized by a large number of participants. Eligibility criteria for the participants were as follows: (i) oncologists specializing in gastroenterology, respiratory medicine, breast oncology, hematology, medical oncology, urology, gynecology, otolaryngology, orthopedics, pediatrics, neurosurgery or dermatology; and (ii) the oncologist's name had to appear on his/her medical facility's website. The website of all Japanese cancer centers shows the complete list of all physicians in that center. We regarded the completion and return of the questionnaire as consent to participate in the study. The institutional review board of the principal investigator confirmed the study's ethical and scientific validity. Questionnaire A questionnaire was developed based on a review of the literature (2,3,8,9) and discussions among the authors. Content validity was assessed by full agreement of the authors, and face validity was confirmed by a pilot test of 20 potential participants.

Eligibility criteria for the participants were as follows: (i) oncologists specializing in gastroenterology, respiratory medicine, breast oncology, hematology, medical oncology, urology, gynecology, otolaryngology, orthopedics, pediatrics, neurosurgery or dermatology; and (ii) the oncologist's name had to appear on his/her medical facility's website. The website of all Japanese cancer centers shows the complete list of all physicians in that center. We regarded the completion and return of the questionnaire as consent to participate in the study. The institutional review board of the principal investigator confirmed the study's ethical and scientific validity. Questionnaire A questionnaire was developed based on a review of the literature (2,3,8,9) and discussions among the authors. Content validity was assessed by full agreement of the authors, and face validity was confirmed by a pilot test of 20 potential participants. As background data, oncologists reported their age, gender, clinical experience in oncology, specialty, previous experience with formal communication skills training, attitudes toward disease and prognosis disclosure for terminally ill patients, and the number of patients to whom they would usually communicate the discontinuation of anticancer treatment annually.

r age, gender, clinical experience in oncology, specialty, previous experience with formal communication skills training, attitudes toward disease and prognosis disclosure for terminally ill patients, and the number of patients to whom they would usually communicate the discontinuation of anticancer treatment annually. The primary endpoint was oncologist-perceived burden imposed by communicating the discontinuation of anticancer treatment to patients. Given the lack of existing validated instruments, the following outcome parameters were developed by the authors. First, the level of oncologist-perceived burden was evaluated by the question, ‘What level of burden do you feel when you communicate with patients about discontinuation of anticancer treatment?’ Answers to this question were rated on a five-point scale ranging from 1 (I do not feel any burden at all) to 5 (I feel a heavy burden). In addition, we investigated the impact of the burden on motivation to continue working in oncology by asking oncologists, ‘How often do you feel some level of desire to stop oncology work due to this burden’. Again, answers were rated on a five-point scale ranging from 1 (not at all) to 5 (always). We extracted 20 potential sources of burden from the literature (8,9) and questioned oncologists on their level of perceived burden relating to each of these sources. Oncologists were requested to rate their degree of burden on a five-point Likert-type scale ranging from 1 (I do not feel any burden) to 5 (I feel a heavy burden).

breaking bad news to the patient; the fact that evidence from a certain group is not applicable to every patient; and, finally, an inability to answer philosophical questions regarding death and the value of life. Table 3. Sources of oncologist-reported burden when communicating discontinuation of anticancer treatment ‘Not burdened at all’, no. (%) ‘Not particularly burdened’, no. (%) ‘Slightly burdened’, no. (%) ‘Burdened’,  no. (%) ‘Heavily burdened’, no.

ed 20 potential sources of burden from the literature (8,9) and questioned oncologists on their level of perceived burden relating to each of these sources. Oncologists were requested to rate their degree of burden on a five-point Likert-type scale ranging from 1 (I do not feel any burden) to 5 (I feel a heavy burden). In addition, we developed a list of 14 potentially useful strategies to alleviate oncologists' perceived burden derived from a previous report (20) and from a qualitative study using in-depth interviews with three oncologists. The oncologists were requested to rate their level of agreement with each of these strategies on a six-point Likert-type scale ranging from 1 (not necessary) to 6 (absolutely necessary). Statistical Analyses For comparisons, respondents were classified into two groups: oncologists who rated themselves as ‘heavily burdened’ or ‘burdened’ (high-level burden) and then all other oncologists (low-level burden). This cut-off point was selected on the basis of the actual distribution of the data and enabled the entire sample to be divided into two equal-sized groups for comparison.

groups: oncologists who rated themselves as ‘heavily burdened’ or ‘burdened’ (high-level burden) and then all other oncologists (low-level burden). This cut-off point was selected on the basis of the actual distribution of the data and enabled the entire sample to be divided into two equal-sized groups for comparison. To explore the determinants of levels of oncologist-reported burden, we screened 7 background variables and 20 sources of burden. Univariate analyses were performed using Student's t-test or the χ2 test, as appropriate. To assess the results in 20 comparisons, the P value necessary for statistical significance was defined as 0.0025 (0.05/20) using the Bonferroni correction. Multiple logistic regression analyses were then performed using a forward elimination procedure. All potential predictors with statistical significance as ascertained by the univariate analyses were included as independent variables in multiple logistic regression analyses. All analyses were performed using SPSS version 11.0. RESULTS Of the 620 questionnaires mailed to oncologists, 10 were undeliverable because of incorrect addresses and 416 oncologists returned questionnaires, resulting in a response rate of 67%. Of the questionnaires returned, 3 were excluded due to missing data in primary endpoints and 19 were returned without any of the questions being answered. Thus, a total of 394 responses were analyzed, giving an effective response rate of 67% (394/591). The oncologists' characteristics are summarized in Table 1. Table 1. Background of respondent oncologists

excluded due to missing data in primary endpoints and 19 were returned without any of the questions being answered. Thus, a total of 394 responses were analyzed, giving an effective response rate of 67% (394/591). The oncologists' characteristics are summarized in Table 1. Table 1. Background of respondent oncologists Age (years) Median 43 Inter-quartile range 37–50 Male gender [no. (%)] 371 (91) Oncology experience (years) Median 15 Inter-quartile range 8–20 Number of communications concerning discontinuation of anticancer treatment annually Median 8 Inter-quartile range 3–15 Attitudes toward disease and prognosis disclosure for terminally ill patientsa [no. (%)] Routinely, without patient's request 55 (14) If necessary, without patient's request 234 (59) If necessary, and if the patient explicitly asks 78 (19) Routinely, and if the patient explicitly asks 21 (5.3) Specialtya [no. (%)] Gastroenterology 116 (30) Respiratory medicine 50 (13) Breast oncology 42 (10) Hematology, medical oncology 42 (10) Urology 32 (8.3) Gynecology 30 (7.8) Otolaryngology 24 (6.2) Orthopedics 19 (4.9) Neurosurgery 12 (3.1) Pediatrics 13 (3.3) Dermatology 5 (1.3) Received formal training in breaking bad news [no. (%)] 59 (16.5) aPercentages do not add up to 100% because of missing data.

ology 42 (10) Hematology, medical oncology 42 (10) Urology 32 (8.3) Gynecology 30 (7.8) Otolaryngology 24 (6.2) Orthopedics 19 (4.9) Neurosurgery 12 (3.1) Pediatrics 13 (3.3) Dermatology 5 (1.3) Received formal training in breaking bad news [no. (%)] 59 (16.5) aPercentages do not add up to 100% because of missing data. Overall levels of oncologist-reported burden relating to communication of the discontinuation of anticancer treatment were: heavily burdened, 13%; burdened, 34%; slightly burdened, 37%; not particularly burdened, 13%; or not burdened at all, 1.3% (Table 2). Clinical oncologists rated their level of desire to stop oncology work because of this burden as: not at all, 55% (n = 218); rarely, 26% (n = 106); sometimes, 11% (n = 45); often, 5.3% (n = 21); or always, 1.0% (n = 4). Table 2. Levels of oncologist-reported burden when communicating discontinuation of anticancer treatment No. (%) Heavily burdened 53 (13) Burdened 136 (34) Slightly burdened 147 (37) Not particularly burdened 53 (13) Not burdened at all 5 (1.3)

Overall levels of oncologist-reported burden relating to communication of the discontinuation of anticancer treatment were: heavily burdened, 13%; burdened, 34%; slightly burdened, 37%; not particularly burdened, 13%; or not burdened at all, 1.3% (Table 2). Clinical oncologists rated their level of desire to stop oncology work because of this burden as: not at all, 55% (n = 218); rarely, 26% (n = 106); sometimes, 11% (n = 45); often, 5.3% (n = 21); or always, 1.0% (n = 4). Table 2. Levels of oncologist-reported burden when communicating discontinuation of anticancer treatment No. (%) Heavily burdened 53 (13) Burdened 136 (34) Slightly burdened 147 (37) Not particularly burdened 53 (13) Not burdened at all 5 (1.3) The oncologists' ratings of the 20 potential sources of burden relating to the communication of discontinuation of anticancer treatment are given in Table 3. More than 20% of respondents reported feeling ‘heavily burdened’ or ‘burdened’ by the following factors: insufficient time to break bad news; feeling that breaking bad news will deprive the patient of hope; the possibility that the breaking of bad news is interrupted by other tasks; concern that the patient may lose self-control; opposition from the patient's family to breaking bad news to the patient; the fact that evidence from a certain group is not applicable to every patient; and, finally, an inability to answer philosophical questions regarding death and the value of life. Table 3. Sources of oncologist-reported burden when communicating discontinuation of anticancer treatment

breaking bad news to the patient; the fact that evidence from a certain group is not applicable to every patient; and, finally, an inability to answer philosophical questions regarding death and the value of life. Table 3. Sources of oncologist-reported burden when communicating discontinuation of anticancer treatment ‘Not burdened at all’, no. (%) ‘Not particularly burdened’, no. (%) ‘Slightly burdened’, no. (%) ‘Burdened’,  no. (%) ‘Heavily burdened’, no. (%) Insufficient time to break bad news 12 (3.1) 61 (15) 90 (22) 151 (36) 82 (20) Feeling that breaking bad news will deprive the patient of hope 12 (3.1) 34 (8.7) 152 (37) 135 (33) 63 (15) Possibility that the time for breaking bad news is interrupted by other tasks 18 (4.6) 86 (21) 102 (25) 120 (29) 71 (17) Concern that the patient may lose self-control 16 (4.1) 83 (21) 163 (39) 108 (26) 25 (6.0) Opposition from family members to breaking bad news to the patient 39 (9.9) 96 (24) 134 (32) 91 (22) 36 (8.7) Evidence from a certain group does not always apply to the patient 43 (10) 122 (31) 133 (32) 70 (17) 28 (6.7) The oncologist is unable to answer philosophical questions regarding death and the value of life 37 (9.5) 122 (31) 140 (34) 74 (18) 21 (5.0) Concern that the oncologist may be blamed by the patient's family 73 (18) 141 (35) 104 (25) 63 (15) 15 (3.6) Feeling a sense of guilt because oncologists cannot provide effective anticancer treatment 83 (21) 140 (35) 102 (25) 56 (14) 14 (3.4) Opposition from patients to breaking bad news to their families 70 (17) 171 (43) 87 (21) 47 (11) 19 (4.6) Concern that the oncologist may be criticized by the patient 75 (19) 149 (37) 107 (26) 56 (14) 9 (2.2) Fear of talking to patients whom oncologist does not know very well 84 (21) 138 (35) 108 (26) 54 (13) 10 (2.4) Scientific evidence is not always predictable or reproducible 43 (10) 122 (31) 133 (32) 70 (17) 28 (6.7) Lack of confidence in oncological medical skills 63 (16) 172 (43) 106 (26) 49 (12) 5 (1.2) Concern that the oncologist does not have the latest knowledge 80 (20) 179 (45) 97 (23) 36 (8.7) 2 (0.5) Uneasiness in changing roles from curing patients to caring for patients 111 (28) 176 (44) 68 (16) 34 (8.2) 4 (1.0) Concern that oncologists cannot answer all knowledge-based questions posed by the patient 94 (24) 186 (47) 81 (20) 29 (7.0) 3 (0.7) Oncologists fear their own illness and death 122 (31) 178 (45) 62 (15) 26 (6.3) 4 (1.0) Concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient 89 (22) 195 (49) 85 (20) 24 (5.8) 3 (0.7) Fear that oncologists themselves may become very emotionally involved, such as expres

ogists fear their own illness and death 122 (31) 178 (45) 62 (15) 26 (6.3) 4 (1.0) Concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient 89 (22) 195 (49) 85 (20) 24 (5.8) 3 (0.7) Fear that oncologists themselves may become very emotionally involved, such as expres sing anger or sadness 107 (27) 209 (53) 59 (14) 18 (4.3) 0 (0) Percentages do not add up to 100% due to missing data.

ogists fear their own illness and death 122 (31) 178 (45) 62 (15) 26 (6.3) 4 (1.0) Concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient 89 (22) 195 (49) 85 (20) 24 (5.8) 3 (0.7) Fear that oncologists themselves may become very emotionally involved, such as expres sing anger or sadness 107 (27) 209 (53) 59 (14) 18 (4.3) 0 (0) Percentages do not add up to 100% due to missing data. Univariate analysis (Table 4) showed that oncologists with high-level burden were significantly more likely to report the following concerns: feeling that breaking bad news will deprive the patient of hope; concern that the oncologist may be blamed by the patient's family; concern that the patient may lose self-control; insufficient time to break bad news; possibility that the time for breaking bad news is interrupted by other tasks; opposition from the patient's family to breaking bad news to the patient; evidence from a certain group is not applicable to every patient; an inability to answer philosophical questions regarding death and the value of life; feeling a sense of guilt because oncologists cannot provide adequate treatment; concern that the oncologist may be criticized by the patient; scientific evidence is not always predictable or reproducible; opposition from patients to breaking bad news to their families; fear of talking to patients whom the oncologist do not know very well; lack of confidence in oncological medical skills; uneasiness in changing roles from curing patients to caring for patients; and a concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient. Table 4. Determinants of oncologist-reported burden when communicating discontinuation of anticancer treatment

al medical skills; uneasiness in changing roles from curing patients to caring for patients; and a concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient. Table 4. Determinants of oncologist-reported burden when communicating discontinuation of anticancer treatment Univariate analyses Multivariate analyses Low level (n = 206) High level (n = 190) P value Odds ratio (95% CI) P value Feeling that breaking bad news will deprive the patient of hope 3.1 ± 0.9 3.8 ± 0.8 <0.01 1.8 (1.4–2.5) <0.01 Concern that the oncologist may be blamed by the patient's family 2.1 ± 0.8 2.8 ± 1.1 <0.01 1.5 (1.2–1.9) <0.01 Concern that the patient may lose self-control 2.8 ± 0.8 3.4 ± 0.9 <0.01 1.4 (1.1–1.9) <0.01 Insufficient time to break bad news 3.3 ± 1.0 3.8 ± 0.9 <0.01 1.2 (0.99–1.6) 0.049 Possibility that the time for breaking bad news is interrupted by other tasks 3.1 ± 1.0 3.5 ± 1.1 <0.01 Opposition from family members to breaking bad news to the patient 2.7 ± 1.0 3.2 ± 1.1 <0.01 Evidence from a certain group does not always apply to every patient 2.6 ± 0.9 3.0 ± 1.1 <0.01 The oncologist is unable to answer philosophical questions regarding death and the value of life 2.5 ± 0.8 3.0 ± 1.0 <0.01 Feeling a sense of guilt because oncologists cannot provide effective anticancer treatment 2.1 ± 0.9 2.7 ± 1.1 <0.01 Concern that the oncologist may be criticized by the patient 2.1 ± 0.8 2.7 ± 1.0 <0.01 Scientific evidence is not always predictable or reproducible 2.3 ± 0.8 2.7 ± 1.0 <0.01 Opposition from patients to breaking bad news to their families 2.2 ± 0.8 2.6 ± 1.2 <0.01 Fear of talking to patients whom the oncologist does not know very well 2.2 ± 0.9 2.5 ± 1.1 <0.01 Lack of confidence in oncological skills 2.2 ± 0.8 2.5 ± 0.9 <0.01 Uneasiness in changing roles from curing patients to caring for patients 1.9 ± 0.8 2.3 ± 0.9 <0.01 Concern that an objective stance cannot be maintained if the oncologist becomes too intimate with the patient 1.9 ± 0.7 2.2 ± 0.8 <0.01 Concern that the oncologist does not have the latest knowledge 2.1 ± 0.8 2.2 ± 0.9 0.24 Fear that the oncologist may become very emotionally involved, such as expressing anger or sadness 1.9 ± 0.6 2.0 ± 0.8 0.24 Concern that the oncologist cannot answer all knowledge-based questions posed by the patient 2.0 ± 0.8 2.2 ± 0.9 0.34 Fear of the oncologists' own illness and death 1.9 ± 0.7 2.0 ± 1.0 0.78 Oncologists who rated their burden level as heavily burdened or burdened (high-level

ing anger or sadness 1.9 ± 0.6 2.0 ± 0.8 0.24 Concern that the oncologist cannot answer all knowledge-based questions posed by the patient 2.0 ± 0.8 2.2 ± 0.9 0.34 Fear of the oncologists' own illness and death 1.9 ± 0.7 2.0 ± 1.0 0.78 Oncologists who rated their burden level as heavily burdened or burdened (high-level group) are compared as a single group against all others (low-level group). Multiple logistic regression analyses used the high-level burden group as the dependent variable. Each condition was rated on a scale of 1 (do not feel any burdened) to 5 (feel heavily burdened). Multiple logistic regression analysis (Table 4) revealed that independent determinants of high-level burden were: feeling that breaking bad news will deprive the patient of hope; concern that the oncologist may be blamed by the patient's family; concern that the patient may lose self-control; and insufficient time to break bad news. Seven backgrounds of the oncologist, including age, specialty, attitudes toward disease and prognosis disclosure for terminally ill patients, oncology experience, previous experience with formal communication skills training, or number of communications concerning discontinuation of anticancer treatment annually, are not the determinants of levels of oncologist-reported burden.

y, attitudes toward disease and prognosis disclosure for terminally ill patients, oncology experience, previous experience with formal communication skills training, or number of communications concerning discontinuation of anticancer treatment annually, are not the determinants of levels of oncologist-reported burden. Strategies to relieve oncologist-reported burden when communicating the discontinuation of anticancer treatment were also investigated. Table 5 lists the percentage of oncologists who agreed with each of the 14 strategies suggested to alleviate oncologists' perceived burden. More than 20% of respondents considered the following strategies to alleviate oncologist-reported burden as ‘absolutely necessary’: that an inpatient hospice is readily available and that patient information is exchanged smoothly among facilities; quiet and private rooms are available for breaking bad news; after breaking bad news, a nurse, psychologist or medical social worker is available to provide emotional support; and a reduction in oncologists' total workload to give them sufficient time to break bad news. Table 5. Oncologists' opinion on strategies suggested to alleviate the burden associated with communicating discontinuation of anticancer treatment

chologist or medical social worker is available to provide emotional support; and a reduction in oncologists' total workload to give them sufficient time to break bad news. Table 5. Oncologists' opinion on strategies suggested to alleviate the burden associated with communicating discontinuation of anticancer treatment Necessary (%) Absolutely necessary (%) Inpatient hospice is readily available and patient information is exchanged smoothly among facilities 49 36 Quiet and private rooms are available for breaking bad news 56 25 After breaking bad news, a nurse, psychologist or medical social worker is available for emotional support 63 24 A reduction in the oncologist's total workload to give sufficient time for the breaking of bad news 54 23 While breaking bad news, a nurse, psychologist or medical social worker is available for emotional support 56 13 Having an opportunity to attend educational workshops about how to break bad news 51 6.8 A psychiatrist or psychologist is available for consultation if the oncologist feels overburdened 42 6.6 Before breaking bad news, having the opportunity to discuss the situation with colleagues and receive advice 54 6.1 After breaking bad news, specialists in physician–patient communication are available to give advice to the oncologist about how they should break bad news 60 5.5 Having opportunities to share experiences and feelings with the colleagues within the hospital 51 5.5 Before breaking bad news, information about what the patient and family want to know is available from nurses 65 5.0 Before breaking bad news, the oncologist receives a memo from the patient and family about what they want to know 61 3.8 After breaking bad news, the oncologist receives a questionnaire to identify what the patient and the family are feeling and thinking 65 3.3 Have an opportunity to share experiences and feelings with colleagues from other hospitals 47 3.0

t receives a memo from the patient and family about what they want to know 61 3.8 After breaking bad news, the oncologist receives a questionnaire to identify what the patient and the family are feeling and thinking 65 3.3 Have an opportunity to share experiences and feelings with colleagues from other hospitals 47 3.0 DISCUSSION To the best of our knowledge, this is the first large multicenter nationwide survey to investigate oncologist-reported burden when communicating the discontinuation of anticancer treatment. The first important finding of the present study was the demonstration of the oncologist-reported burden when communicating the discontinuation of anticancer treatment to patients. Of the oncologists surveyed, 47% reported high levels of burden when communicating the discontinuation of anticancer treatment. Moreover, 17% of the oncologists surveyed reported that they sometimes, often or always want to stop oncology work because of this burden. Multiple studies have revealed that a major contributor to physicians' burnout is communication with patients and families (21–26). The present study confirms that communication with patients and families is a major source of oncologists' work-related stress. In particular, the present study highlights that communicating the discontinuation of anticancer treatment can be a heavy burden for oncologists and that it is urgent that strategies are developed to alleviate this burden.

t communication with patients and families is a major source of oncologists' work-related stress. In particular, the present study highlights that communicating the discontinuation of anticancer treatment can be a heavy burden for oncologists and that it is urgent that strategies are developed to alleviate this burden. The present study also evaluated oncologists' opinions regarding the strategies likely to be effective in reducing this burden. The strategies perceived to be potentially effective included: ready availability of an inpatient hospice and smooth exchange of patient information among facilities; availability of quiet and private rooms for the breaking of bad news; the provision of emotional support from a nurse, psychologist or medical social worker after the patient has received the bad news; and a reduction in oncologists' total workload to give them sufficient time to break the bad news. Moreover, multiple logistic regression analyses revealed that independent determinants of high-level burden were: a feeling that breaking bad news will deprive the patient of hope; concern that the oncologist may be blamed by the patient's family; concern that the patient may lose self-control; and insufficient time to break bad news. These results reveal that there are three main areas that, if addressed, could significantly alleviate oncologist-reported burden: (i) improving oncologists' communication skills; (ii) allowing sufficient time for communication with patients and their families; and (iii) developing a multidisciplinary care model with other professionals and facilities.

e three main areas that, if addressed, could significantly alleviate oncologist-reported burden: (i) improving oncologists' communication skills; (ii) allowing sufficient time for communication with patients and their families; and (iii) developing a multidisciplinary care model with other professionals and facilities. This study emphasizes the importance of communication skills. Previous studies suggested that communication skills training increases both patient satisfaction (27,28) and oncologists' confidence (29). However, to the best of our knowledge, existing communication skills training does not specifically address issues surrounding the discontinuation of anticancer treatments. The present study highlights the importance, under these difficult circumstances, of helping the patient maintain hope, dealing with the oncologists' fear of being blamed by the patients and their families, and strengthening patient self-control. The results indicate that a communication skills training program specifically targeting skills for communicating the discontinuation of anticancer treatment needs to be developed. This program should include strategies to deal with oncologists' concerns, such as that by breaking bad news to a patient, the oncologist will deprive the patient of hope, that the oncologist may be blamed by the patient's family and that the patient may lose self-control.

of anticancer treatment needs to be developed. This program should include strategies to deal with oncologists' concerns, such as that by breaking bad news to a patient, the oncologist will deprive the patient of hope, that the oncologist may be blamed by the patient's family and that the patient may lose self-control. The oncologists surveyed stressed the importance of a reduction in their total workload to give them sufficient time to facilitate effective communication with patients. A previous study suggested that physicians face excessive workloads that are associated with a lower quality of patient care (30). Several studies have suggested that the perception of having insufficient time to communicate with patients is the factor most strongly associated with oncologist burnout (22,31). In Japan, according to a 2008 revision by the Ministry of Health, Labor and Welfare in Japan of the payment of fees for medical treatment, an additional fee for outpatient care can be applied when a physician is directly involved in clinical practice for 5 min or longer. This indicates that the Ministry of Health, Labor and Welfare in Japan defines the time for consultation and implies that most physicians in Japan are too busy to spend 5 min or more on each outpatient. These results stress that a reduction in physicians' workload is vital.

ved in clinical practice for 5 min or longer. This indicates that the Ministry of Health, Labor and Welfare in Japan defines the time for consultation and implies that most physicians in Japan are too busy to spend 5 min or more on each outpatient. These results stress that a reduction in physicians' workload is vital. Many oncologists surveyed in the present study agreed with the importance of multidisciplinary cooperation with other professionals and facilities. Two types of cooperation were considered to be particularly valuable: (i) that after breaking bad news, a nurse, psychologist or medical social worker was available to follow up with patients and their families; and (ii) the availability of other facilities, especially inpatient palliative care units. Previous studies have shown that cancer patients' participation in nurse-led interventions resulted in an improvement in depressive moods (32,33). Multiple intervention studies have indicated that practice-based interprofessional collaboration can improve patients' health-care processes and outcomes (34). Furthermore, existing literature indicates that regional palliative care programs succeed in increasing family satisfaction (35,36). These findings suggest that developing a multidisciplinary team to support oncologists, not only within a hospital, but also beyond the hospital (as a region), is of considerable importance in achieving patient and family satisfaction. As the number of palliative care units in Japan is not enough, increasing the reimbursement for inpatient hospice would be important as policy. Moreover, because oncologist burden was not measured in these previous studies, prospective observational or interventional studies are needed to determine whether a team approach, such as in-hospital and regional palliative care programs, could alleviate oncologist burden.

patient hospice would be important as policy. Moreover, because oncologist burden was not measured in these previous studies, prospective observational or interventional studies are needed to determine whether a team approach, such as in-hospital and regional palliative care programs, could alleviate oncologist burden. The limitations of the present study include the moderate (67%) effective response rate, which may mean that the entire oncological population is not represented by the oncologists who participated in the present study. Furthermore, because this study was performed in Japan, the results are likely to be influenced by factors relating to Japanese culture and the Japanese health-care system and, as such, may not be applicable to other countries. In conclusion, a considerable number of oncologists experienced high levels of burden in communicating the decision to discontinue anticancer treatment. To alleviate oncologist burden, potentially useful strategies include: (i) communication skills training specifically targeting discontinuation of anticancer treatment; (ii) a reduction in total workload to allow oncologists sufficient time to break bad news; and (iii) the development of a multidisciplinary model to facilitate cooperation with other professionals and facilities.

include: (i) communication skills training specifically targeting discontinuation of anticancer treatment; (ii) a reduction in total workload to allow oncologists sufficient time to break bad news; and (iii) the development of a multidisciplinary model to facilitate cooperation with other professionals and facilities. Authors' Contribution H.O.: conception and design, provision of the study material, collection of data, data analysis and interpretation, manuscript writing and administrative support. T.M.: conception and design, provision of the study material, data analysis and interpretation, final approval of the manuscript, administrative support, and financial support. T.E., H.A., K.T., A.O. and K.S.: provision of the study material and final approval of the manuscript. Funding This study was supported by grants from the Ministry of Health, Labour and Welfare of Japan. Funding to pay the Open Access publication charges was provided by Hiroyuki Otani. Conflict of interest statement None declared.

INTRODUCTION Breast cancer is one of the most common cancers worldwide (1). The age-standardized incidence rate is the first among all female cancers, and it is continuously increasing in Japan (2,3), although Japan has a lower risk of breast cancer in comparison with Western countries. The incidence peaks at ages 45–49, and the mortality peaks at ages 55–59 in Japan (2). In breast cancer screening, it is essential to undertake effective screening with appropriate methodology. Effective screening should be supported by evidence of a reduced mortality rate. At present, mammography (MG) is the only method for breast cancer screening that has such evidence. However, MG does not achieve sufficient screening accuracy in breasts with high mammary gland density. Dense breasts are common at ages below 50 and are more common in Japanese populations than in Western populations (4). As the US Preventive Services Task Force (USPSTF) recommends against routine screen MG in women aged 40–49 years, the issue of breast imaging to screen women aged 40–49 still remains unclear (5).

sity. Dense breasts are common at ages below 50 and are more common in Japanese populations than in Western populations (4). As the US Preventive Services Task Force (USPSTF) recommends against routine screen MG in women aged 40–49 years, the issue of breast imaging to screen women aged 40–49 still remains unclear (5). Since ultrasonography (US) achieves better accuracy in breast cancer detection even in dense breasts (6) and supplemental screening US has the potential to depict early breast cancers not seen on MG (6–8), several single-institution observational studies in screening setting began. As mentioned in the WHO guidelines, ‘population-based cancer screening’ conducted as a public health program should be undertaken only when there is evidence of a reduced mortality rate (9). Before introducing any new technology in population-based breast cancer screening, it is essential to evaluate the effectiveness. However, randomized controlled trials (RCTs), cohort studies or case–control studies have not been completed to assess the efficacy of screening US to reduce breast cancer mortality, and the effectiveness has not been verified.

in population-based breast cancer screening, it is essential to evaluate the effectiveness. However, randomized controlled trials (RCTs), cohort studies or case–control studies have not been completed to assess the efficacy of screening US to reduce breast cancer mortality, and the effectiveness has not been verified. Therefore, we have planned an RCT to assess effectiveness of screening US for breast cancer, the Japan Strategic Anti-cancer Randomized Trial (J-START) in 2006. The defined study population is women aged 40–49 years, because this is the age range at which breast cancer peaks in Japan (2) and because a high percentage of Japanese women aged 40s have dense breast. This is a large-scale controlled trial, designed to study 50 000 women with MG and US (intervention group) and 50 000 controls with MG only (control group).

ed 40–49 years, because this is the age range at which breast cancer peaks in Japan (2) and because a high percentage of Japanese women aged 40s have dense breast. This is a large-scale controlled trial, designed to study 50 000 women with MG and US (intervention group) and 50 000 controls with MG only (control group). The primary endpoints of this trial are the inter-group comparisons of the sensitivity and specificity, and the secondary endpoint is the inter-group comparison of the accumulated incidence rate of advanced breast cancer during the follow-up period. The most important index in the evaluation of the effectiveness of cancer screening is the mortality rate from the cancer in question in the target population. However, in view of the natural history of breast cancer, the 4-year period scheduled in the strategic study grant is too short to observe a significant inter-group difference. Although the rate of advanced breast cancer could be a surrogate for mortality reduction, it is necessary to have a system that has the long-term follow-up of the survival status of individuals even after the completion of the strategic study, J-START.

grant is too short to observe a significant inter-group difference. Although the rate of advanced breast cancer could be a surrogate for mortality reduction, it is necessary to have a system that has the long-term follow-up of the survival status of individuals even after the completion of the strategic study, J-START. This study may have several limitations. First, the screening interval is 2 years, despite evidence that screening MG at age 40–49 years is more effective with annual screening. The recent USPSTF, however, recommends biannual MG screening in view of reducing ‘harm’, i.e. higher recall rate at age 40–49 years (5). Secondly, the study population, which is so different from that in Western countries, may limit the generalization of study outcomes. Most countries in Asia, however, demonstrate the similar trend of breast cancer incidence as observed in Japan; therefore, this trial may influence their health strategy against breast cancer. Nevertheless, for women aged 40–49 years even in Western countries, there is a limitation of MG screening as the USPSTF recommends against the routine use of screening MG for this age group. Thirdly, the study may be underpowered to provide follow-up data on breast cancer deaths because of the low breast cancer risk of native Japanese women. In this context, as much as 100 000 women are targeted in this trial to ensure the statistical power be sufficient enough in comparison between the two groups.

group. Thirdly, the study may be underpowered to provide follow-up data on breast cancer deaths because of the low breast cancer risk of native Japanese women. In this context, as much as 100 000 women are targeted in this trial to ensure the statistical power be sufficient enough in comparison between the two groups. PROTOCOL DIGEST OF THE STUDY Purpose The aim of this study is to assess the effectiveness of screening US for breast cancer in women aged 40–49 (Fig. 1). Figure 1. J-START study design. MG, mammography; US, ultrasonography. Study Setting This study is a multi-institutional prospective RCT, with 42 participating centers in 23 prefectures in Japan as of 31 March 2011. Endpoints The primary endpoints of this trial are sensitivity and specificity, based on the data of each incremental cancer detection rate, false-positives and false-negatives should be forthcoming in 2 years. The secondary endpoint is the rate of advanced breast cancers, as this has been demonstrated in the screening MG RCTs to be a surrogate for mortality reduction (10). Eligibility Criteria Inclusion criteria are as follows: women aged 40–49 years when registered; women signed the informed consent to participate in the study. Exclusion criteria are as follows: women with a history of breast cancer; women with a history of malignant disease other than breast cancer within 5 years; women in severe condition, who are not expected to live for 5 years.

Eligibility Criteria Inclusion criteria are as follows: women aged 40–49 years when registered; women signed the informed consent to participate in the study. Exclusion criteria are as follows: women with a history of breast cancer; women with a history of malignant disease other than breast cancer within 5 years; women in severe condition, who are not expected to live for 5 years. Treatment Methods Patient Assignments Each participating center confirms the participants’ eligibility and screening methods are assigned according to the random number provided by the Japan Clinical Research Supporting Unit (J-CRSU) Data Center. Cluster randomization is also used in some institutions.

women in severe condition, who are not expected to live for 5 years. Treatment Methods Patient Assignments Each participating center confirms the participants’ eligibility and screening methods are assigned according to the random number provided by the Japan Clinical Research Supporting Unit (J-CRSU) Data Center. Cluster randomization is also used in some institutions. Screening Method and Assessment For the intervention arm, US and MG are performed at the same time. For the control arm, MG is performed. The technologists and the physicians involved in this trial are asked to finish 2-day, 16-h education program for the standardization of US screening for breast cancer. Regarding the procedure in screening with US, the handheld US is performed by a technologist or by a physician, and later, the US image is interpreted by a physician. An interpretation of MG is performed by a physician who is not regulated to be the same doctor interpreting US image or not, although the categorization of the two modalities are defined separately in the protocol. The findings of MG and/or US are subsequently evaluated by authorized screeners and are classified into five categories as follows: Category 1, negative; Category 2, benign finding(s); Category 3, probably benign finding(s); Category 4, suspicious abnormality; and Category 5, malignancy. The women who are rated in Category 3 or higher by the MG and/or US are referred for further diagnostic examinations.

e classified into five categories as follows: Category 1, negative; Category 2, benign finding(s); Category 3, probably benign finding(s); Category 4, suspicious abnormality; and Category 5, malignancy. The women who are rated in Category 3 or higher by the MG and/or US are referred for further diagnostic examinations. Statistical Analysis The sample size was calculated on the hypothesis that adjunct US is expected to improve sensitivity of the intervention group compared with the control group. Our previous data demonstrated the lower sensitivity of MG screening, 71% in women aged 40–49, when compared with those in women aged 50–59 and 60–69, 85 and 86%, respectively (11). Assuming that the sensitivity increases from 71 to 86% by adding US to MG, 42 500 subjects for each arm is needed to make it 5% statistical significance (two-sided) with 80% power. Thus, the number of 100 000 subjects (two arms combined) is set to be a targeted sample size to verify the primary endpoint, a sensitivity improvement in the intervention group when compared with the control group.

42 500 subjects for each arm is needed to make it 5% statistical significance (two-sided) with 80% power. Thus, the number of 100 000 subjects (two arms combined) is set to be a targeted sample size to verify the primary endpoint, a sensitivity improvement in the intervention group when compared with the control group. Follow-up Period The participants are invited to be screened 2 years after the first recruitment or asked to answer questionnaires of health status, history of receiving other screening program, incidence of breast cancer, and history of hospital consultation with any breast symptoms within 2 years. For evaluating the actual evidence of a reduced mortality rate of the intervention group compared with the control group, there must be needed to establish follow-up strategies for a long time period and systematic, nationwide population-based cancer registries. Registration of the Protocol The J-START was registered on the University Hospital Medical Information Network Clinical Trial Registration (UMIN-CTR), Japan (registration number: UMIN000000757), on 2007. Details are available at the following address: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000000910&language=E. Funding This work was supported by the 3rd term comprehensive control research for cancer (grant number: H-18-Senryaku-001), the Ministry of Health, Labour and Welfare of Japan. Conflict of interest statement None declared.

INTRODUCTION The incidence of renal cell carcinoma (RCC) in Japan is increasing. Results of a survey conducted from January 2002 through December 2002 in all 47 prefectures revealed the crude incidence rates of RCC to be ∼8.2 males and 3.6 females per 100 000 persons, an increase of ∼1000 individuals compared with results obtained in a similarly conducted 1997 survey (1). In general, approximately one-third of patients with RCC present with metastatic disease (mRCC), which has a 5 year survival rate of 10% (2). The vascular endothelial growth factor receptor-tyrosine kinase inhibitors (VEGFr-TKI) sorafenib and sunitinib are now approved in Japan, Europe and the USA for the treatment of unresectable or metastatic RCC based on their demonstrated benefit in clinical trials (3,4). These targeted agents have become the standard therapy for mRCC. Until recently, however, no standard therapy existed for patients with mRCC that progressed after treatment with VEGFr-TKI-targeted agents.

A for the treatment of unresectable or metastatic RCC based on their demonstrated benefit in clinical trials (3,4). These targeted agents have become the standard therapy for mRCC. Until recently, however, no standard therapy existed for patients with mRCC that progressed after treatment with VEGFr-TKI-targeted agents. Everolimus is an orally administered inhibitor of the mammalian target of rapamycin (mTOR) and was approved by the United States Food & Drug Administration (US FDA) in March 2009, the European Medicines Agency (EMEA) in August 2009 and in Japan in January 2010 for the treatment of unresectable or metastatic RCC. mTOR is a cytoplasmic serine/threonine kinase that acts as an integration point for three key inputs: (i) extracellular stimulation by growth factors including VEGF; (ii) nutrient availability; and (iii) intracellular energy status. The convergence of these upstream signals, combined with positive and negative feedback mechanisms, determines whether mTOR is activated. Once activated, mTOR initiates a downstream cascade that triggers the cell's translational machinery to produce proteins required for a variety of cellular functions, including metabolism, growth, proliferation and angiogenesis. Dysregulation of signaling elements both upstream and downstream of mTOR has been implicated in many cancers (5–8).

tiates a downstream cascade that triggers the cell's translational machinery to produce proteins required for a variety of cellular functions, including metabolism, growth, proliferation and angiogenesis. Dysregulation of signaling elements both upstream and downstream of mTOR has been implicated in many cancers (5–8). In a Phase II trial, everolimus demonstrated antitumor activity in patients with mRCC who experienced disease progression after treatment with cytokines, chemotherapy or erlotinib and bevacizumab (9). Everolimus was subsequently evaluated in RECORD-1 (Renal Cell cancer treatment with Oral RAD001 given Daily), the pivotal, Phase III, randomized, placebo-controlled trial of patients with mRCC who had progressed on VEGFr-TKI. Results of this trial, which enrolled patients from 10 countries, including Japan, led to the US FDA and EMEA approval of everolimus. RECORD-1 demonstrated that treatment with everolimus plus best supportive care (BSC) prolonged progression-free survival (PFS) compared with placebo plus BSC (4.9 vs. 1.9 months, respectively; P < 0.001; hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.25–0.43) (10). Consequently, everolimus represents a viable treatment option for patients with VEGFr-TKI-refractory disease.

pportive care (BSC) prolonged progression-free survival (PFS) compared with placebo plus BSC (4.9 vs. 1.9 months, respectively; P < 0.001; hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.25–0.43) (10). Consequently, everolimus represents a viable treatment option for patients with VEGFr-TKI-refractory disease. Results of a Phase I clinical and pharmacokinetic study of everolimus in previously treated Japanese patients with advanced solid tumors demonstrated that its pharmacokinetics and tolerability were similar to those observed in previous studies with large populations of Caucasian patients, for whom the most common drug-related toxicities included rash, stomatitis and fatigue. No dose-limiting toxicities were noted (11). The current analysis was initiated to assess the efficacy and safety of everolimus in the Japanese subgroup of patients who participated in RECORD-1. PATIENTS AND METHODS Patients The RECORD-1 inclusion and exclusion criteria have been described in detail previously (12). Briefly, patients ≥18 years of age were eligible for enrollment if they had been diagnosed with metastatic carcinoma and had histologic or cytologic confirmation of clear cell RCC, had measurable disease, showed disease progression on or within 6 months of treatment with sunitinib, sorafenib or both, and exhibited adequate Karnofsky performance status (≥70%), blood counts and serum chemistry. Prior therapy with bevacizumab and cytokines was permitted. Written informed consent was obtained from each patient before screening procedures were initiated.

or within 6 months of treatment with sunitinib, sorafenib or both, and exhibited adequate Karnofsky performance status (≥70%), blood counts and serum chemistry. Prior therapy with bevacizumab and cytokines was permitted. Written informed consent was obtained from each patient before screening procedures were initiated. Study Design RECORD-1 was a prospective, randomized, double-blind, placebo-controlled, international, multicenter, parallel-group Phase III trial (NCT00410124). It contained five phases: (i) screening/baseline; (ii) blinded treatment; (iii) open-label treatment; (iv) follow-up; and (v) extension treatment. The study design incorporated two planned interim analyses and a final analysis. The protocol specified that the interim analyses were to be carried out when ∼30 and 60% of the 290 PFS events (per central radiology) required for the final analysis had been reached. The protocol and all amendments issued prior to or during the study were reviewed by the local independent ethics committee or institutional review board for each center, and the study was conducted according to the ethical principles of the Declaration of Helsinki. Patients were randomized in a 2:1 ratio to receive everolimus 10 mg/day (n = 277) or matching placebo (n = 139) in conjunction with BSC. Randomization was stratified by the number of prior VEGFr-TKI therapies (1 or 2) and Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic criteria for patients with previously treated mRCC (favorable, intermediate or poor) (10,13). Treatment cycles were 28 days in length.

placebo (n = 139) in conjunction with BSC. Randomization was stratified by the number of prior VEGFr-TKI therapies (1 or 2) and Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic criteria for patients with previously treated mRCC (favorable, intermediate or poor) (10,13). Treatment cycles were 28 days in length. Patients continued on blinded treatment until tumor progression or unacceptable toxicity, death or discontinuation for any other reason. Dose modifications were permitted for clinically significant hematologic or other adverse events, as described previously (12). Patients randomized to receive placebo who demonstrated evidence of progression by investigator assessment were unblinded and permitted to cross over to receive open-label everolimus (12). Efficacy Analyses The primary efficacy endpoint was PFS by central review. Tumor response was assessed at scheduled intervals with the Response Evaluation Criteria in Solid Tumors (RECIST) (14), based on imaging studies by the investigators and independent central radiology review (12). Secondary efficacy endpoints included overall survival (OS) and tumor response.

was PFS by central review. Tumor response was assessed at scheduled intervals with the Response Evaluation Criteria in Solid Tumors (RECIST) (14), based on imaging studies by the investigators and independent central radiology review (12). Secondary efficacy endpoints included overall survival (OS) and tumor response. Safety Analyses Safety analyses were carried out as described previously (12). Briefly, all adverse events were monitored and recorded, and laboratory parameters, vital signs, physical examinations and concomitant therapies were assessed regularly and recorded. The National Cancer Institute's Common Terminology Criteria (NCI-CTC) version 3.0 were used to grade adverse events and laboratory abnormalities (12). To detect radiologic lung changes suggestive of pneumonitis, a central radiology review of chest computed tomography scans and chest X-rays was performed. Statistical Analyses The full analysis set included all randomized patients; the safety population consisted of all patients who received at least one dose of study drug and who had at least one post-baseline safety assessment.

Safety Analyses Safety analyses were carried out as described previously (12). Briefly, all adverse events were monitored and recorded, and laboratory parameters, vital signs, physical examinations and concomitant therapies were assessed regularly and recorded. The National Cancer Institute's Common Terminology Criteria (NCI-CTC) version 3.0 were used to grade adverse events and laboratory abnormalities (12). To detect radiologic lung changes suggestive of pneumonitis, a central radiology review of chest computed tomography scans and chest X-rays was performed. Statistical Analyses The full analysis set included all randomized patients; the safety population consisted of all patients who received at least one dose of study drug and who had at least one post-baseline safety assessment. PFS and OS curves in each treatment group were estimated with Kaplan–Meier analysis. HR for the Japanese subpopulation was obtained from an unstratified Cox proportional hazard model. As previously reported for the overall population (12), PFS and OS were statistically compared among the groups with a stratified, one-sided log-rank test, adjusting for strata defined by the MSKCC risk criteria. HRs were obtained from a stratified Cox proportional hazards model, using the strata defined by the MSKCC risk criteria.

reported for the overall population (12), PFS and OS were statistically compared among the groups with a stratified, one-sided log-rank test, adjusting for strata defined by the MSKCC risk criteria. HRs were obtained from a stratified Cox proportional hazards model, using the strata defined by the MSKCC risk criteria. The blinded phase of RECORD-1 was stopped on 28 February 2008, based on the efficacy of everolimus shown in the second interim analysis (10). Compared with data for the second interim analysis (collected up to 15 October 2007; 191 PFS events), data for the final analysis were based on 75 additional PFS events, 6 additional patients accrued and 4.5 months of additional blinded follow-up. The cutoff date of follow-up for OS was 15 November 2008. RESULTS Patient Demographics and Disposition Of the 416 patients randomized to treatment in the overall trial, the subpopulation of Japanese patients in the final analysis included 15 patients who received everolimus and 9 patients who received placebo. The baseline characteristics and prior therapies of these 24 Japanese patients and the 416-patient overall population are shown in Table 1 (10). The Japanese subpopulation was 79% male and the median age was 63.5 years. The Japanese subpopulation was similar to the overall trial population, with the exceptions that the predominant VEGFr-TKI therapy of the Japanese patients was sorafenib instead of sunitinib and that almost all Japanese patients had received prior treatment with interferon. Table 1. Baseline characteristics and prior therapies in RECORD-1 (10)

n was similar to the overall trial population, with the exceptions that the predominant VEGFr-TKI therapy of the Japanese patients was sorafenib instead of sunitinib and that almost all Japanese patients had received prior treatment with interferon. Table 1. Baseline characteristics and prior therapies in RECORD-1 (10) Characteristic Overall population Japanese patients Everolimus (n = 277) Placebo (n = 139) Everolimus (n = 15) Placebo (n = 9) Sex, n (%) Female 61 (22) 33 (24) 1 (7) 4 (44) Male 216 (78) 106 (76) 14 (93) 5 (56) Median age (range), year 61 (27–85) 60 (29–79) 65 (48–77) 62 (46–73) KPS, ≥90/≤80, % 64/36 68/32 80/20 100/0 % MSKCC risk Favorable/intermediate/poor 29/56/14 28/57/15 33/60/7 44/44/11 Sites of metastases, % Lung 73 81 87 89 Bone 37 30 33 11 Liver 33 38 20 33 Prior therapies, % Nephrectomy 97 96 100 100 Radiotherapy 31 27 20 11 VEGFr-TKI therapy Sunitinib 45 43 13 22 Sorafenib 29 31 80 78 Both 26 26 7 0 Other systemic therapy Immunotherapy 65 67 100 89 Chemotherapy 13 16 13 11 Hormone therapy 2 4 0 0 Other 5 3 0 0 KPS, Karnofsky performance status; MSKCC, Memorial Sloan-Kettering Cancer Center; VEGFr-TKI, vascular endothelial growth factor receptor-tyrosine kinase inhibitor.

13 22 Sorafenib 29 31 80 78 Both 26 26 7 0 Other systemic therapy Immunotherapy 65 67 100 89 Chemotherapy 13 16 13 11 Hormone therapy 2 4 0 0 Other 5 3 0 0 KPS, Karnofsky performance status; MSKCC, Memorial Sloan-Kettering Cancer Center; VEGFr-TKI, vascular endothelial growth factor receptor-tyrosine kinase inhibitor. By the end of the double-blind phase, five Japanese patients in the everolimus group had discontinued (disease progression, n = 4; withdrew consent, n = 1) and eight patients in the placebo group had discontinued (all due to disease progression). These eight patients from the placebo group then crossed over to receive open-label everolimus. All 24 Japanese patients were included in the full analysis set and in the safety population. In the overall population, 202 patients in the everolimus group and 133 patients in the placebo group had discontinued therapy, with the primary reasons being disease progression and adverse events in the everolimus group (n = 137 and n = 36, respectively) and disease progression and death for the placebo group (n = 124 and n = 4, respectively).

202 patients in the everolimus group and 133 patients in the placebo group had discontinued therapy, with the primary reasons being disease progression and adverse events in the everolimus group (n = 137 and n = 36, respectively) and disease progression and death for the placebo group (n = 124 and n = 4, respectively). Treatment Administration The median duration of treatment in the Japanese subpopulation was 135 days in the everolimus group and 96 days in the placebo group (overall population: 141 and 60 days, respectively). The median cumulative dose of everolimus was 1160 mg, the median dose intensity was 9.9 mg/day and the median relative dose intensity was 0.99 (overall population: 1252.5 mg, 10.0 mg/day and 1.0, respectively). In the Japanese subpopulation, dose reduction and/or interruption was necessary in eight patients in the everolimus group (53.3%; for five of eight patients, this was due to an adverse event) and in no patients in the placebo group; corresponding rates for the overall population were 46 and 15%, respectively, most commonly for an adverse event in both groups (39 and 9%, respectively).

as necessary in eight patients in the everolimus group (53.3%; for five of eight patients, this was due to an adverse event) and in no patients in the placebo group; corresponding rates for the overall population were 46 and 15%, respectively, most commonly for an adverse event in both groups (39 and 9%, respectively). Efficacy Assessment Everolimus appeared to prolong PFS compared with placebo in the Japanese subpopulation. By independent central radiology review, median PFS was 5.75 months (95% CI, 4.90 months to not reached) with everolimus and 3.61 months (95% CI, 1.91–9.03 months) with placebo (Fig. 1A). The HR was 0.19, with a 95% CI of 0.05–0.83. In the overall population, median PFS was 4.90 months (95% CI, 3.98–5.52 months) with everolimus and 1.87 months (95% CI, 1.84–1.94 months) with placebo, translating into a highly significant HR of 0.33 (95% CI, 0.25–0.43; P < 0.001; Fig. 1B). Figure 1. Median progression-free survival in the (A) Japanese subpopulation and (B) overall population (10) of RECORD-1 by central radiology review. Figure 1B reprinted with permission from Wiley & Sons. Copyright 2010. All rights reserved (10).

a highly significant HR of 0.33 (95% CI, 0.25–0.43; P < 0.001; Fig. 1B). Figure 1. Median progression-free survival in the (A) Japanese subpopulation and (B) overall population (10) of RECORD-1 by central radiology review. Figure 1B reprinted with permission from Wiley & Sons. Copyright 2010. All rights reserved (10). Median OS in the Japanese subpopulation was not reached in the everolimus group and was 14.9 months (95% CI, 11.0–16.8 months) in the placebo group at the cutoff date of 15 November 2008 (Fig. 2A). The HR was 0.30, with a 95% CI of 0.07–1.27. There were no on-treatment deaths among Japanese patients in either treatment group. One Japanese patient who had been treated with everolimus died during the follow-up period, over 6 months after the last dose. In the overall population, median OS was 14.8 months with everolimus and 14.4 months with placebo, translating into a non-significant HR of 0.87 (95% CI, 0.65–1.17; P = 0.16; Fig. 2B) that was influenced by the 80% rate of crossover from placebo to open-label everolimus (10). Figure 2. Median overall survival in the (A) Japanese subpopulation and (B) overall population (10) of RECORD-1. Figure 2B reprinted with permission from Wiley & Sons. Copyright 2010. All rights reserved (10).

= 0.16; Fig. 2B) that was influenced by the 80% rate of crossover from placebo to open-label everolimus (10). Figure 2. Median overall survival in the (A) Japanese subpopulation and (B) overall population (10) of RECORD-1. Figure 2B reprinted with permission from Wiley & Sons. Copyright 2010. All rights reserved (10). The best overall response based on central radiologic assessment was stable disease (SD) in 14 of 15 patients who received everolimus (the response of 1 patient was unknown) and SD in 6 of 9 patients who received placebo (the other 3 patients had progressive disease). No patient achieved a partial response (PR) at the final analysis, but in a subsequent efficacy assessment made in an open-label extension phase only for Japanese subjects, one patient achieved a PR as an investigator-assessed best overall response. In the overall population, the SD rates were 185 of 277 (67%) with everolimus and 45 of 139 (32%) with placebo, with an additional 5 patients in the everolimus group (1.8%) achieving a PR.

open-label extension phase only for Japanese subjects, one patient achieved a PR as an investigator-assessed best overall response. In the overall population, the SD rates were 185 of 277 (67%) with everolimus and 45 of 139 (32%) with placebo, with an additional 5 patients in the everolimus group (1.8%) achieving a PR. Safety As summarized in Table 2, stomatitis, infections and rash were the predominant adverse events among Japanese patients in the everolimus group during the blinded-study phase, with incidences that were notably higher than the incidences in the overall population. Most adverse events were mild (Grade 1) to moderate (Grade 2) in severity and were resolved with dose interruption and/or reduction. In the Japanese subpopulation, there were two reports of Grade 2 interstitial lung disease and two reports of Grade 1 pneumonitis during everolimus therapy, for a total on-treatment occurrence of pneumonitis (based on grouped terms) of 27%. The corresponding pneumonitis incidence among the everolimus group in the overall population was 14%, including Grade 1/2 (n = 27) as well as Grade 3 (n = 10) events. None of the Japanese patients stopped therapy permanently because of pneumonitis. With respect to the two Japanese cases of Grade 2 pneumonitis (reported as interstitial lung disease), study treatment was interrupted, corticosteroid therapy was instituted and everolimus was resumed at a reduced dose, with eventual resolution of the interstitial lung disease. Despite increased reporting of non-infectious pneumonitis for Japanese patients compared with the overall study population, central review of chest computed tomography scans for radiologic lung changes suggestive of pneumonitis found a similar incidence of radiologic changes in the Japanese and the overall population. Table 2. Incidence of adverse events, irrespective of relationship to treatment and laboratory abnormalities in the Japanese subpopulation of RECORD-1

mputed tomography scans for radiologic lung changes suggestive of pneumonitis found a similar incidence of radiologic changes in the Japanese and the overall population. Table 2. Incidence of adverse events, irrespective of relationship to treatment and laboratory abnormalities in the Japanese subpopulation of RECORD-1 Overall population Japanese patients Everolimus (n = 274), n (%) Placebo (n = 137), n (%) Everolimus (n = 15), n (%) Placebo (n = 9), n (%) All Grades Grade 3/4 All Grades Grade 3/4 All Grades Grade 3/4 All Grades Grade 3/4 Adverse eventa (total) 265 (97) 142 (52)/36 (13) 128 (93) 32 (23)/7 (5) 15 (100) 6 (40)/0 5 (56) 0/0 Stomatitisb 120 (44) 11 (4)/1 (<1) 11 (8) 0/0 11 (73) 0/0 1 (11) 0/0 Infectionsc 101 (37) 19 (7)/7 (3) 25 (18) 2 (1)/0 10 (67) 1 (7)/0 2 (22) 0/0 Rash 80 (29) 3 (1)/0 9 (7) 0/0 10 (67) 0/0 0 0/0 Dysgeusia 28 (10) 0/0 3 (2) 0/0 7 (47) 0/0 0 0/0 Epistaxis 49 (18) 0/0 0 0/0 6 (40) 0/0 0 0/0 Diarrhea 81 (30) 4 (1)/0 9 (7) 0/0 6 (40) 0/0 0 0/0 Cough 82 (30) 2 (<1)/0 22 (16) 0/0 5 (33) 0/0 2 (22) 0/0 Edema peripheral 68 (25) 2 (<1)/0 11 (8) 1 (<1)/0 5 (33) 0/0 0 0/0 Pneumonitisd 37 (14) 10 (4)/0 0 0/0 4 (27) 0/0 0 0/0 Nail disorder 14 (5) 0/0 0 0/0 4 (27) 0/0 0 0/0 Constipation 53 (19) 1 (<1)/0 24 (18) 1 (<1)/0 4 (27) 0/0 1 (11) 0/0 Anorexia 69 (25) 4 (1)/0 19 (14) 1 (<1)/0 3 (20) 0/0 0 0/0 Cheilitis 4 (1) 0/0 0 0/0 3 (20) 0/0 0 0/0 Eyelid edema 11 (4) 0/0 0 0/0 3 (20) 0/0 0 0/0 Arthralgia 28 (10) 3 (1)/0 14 (10) 2 (1)/0 3 (20) 0/0 1 (11) 0/0 Hemorrhoid 15 (6) 0/0 1 (<1) 0/0 3 (20) 0/0 0 0/0 Nausea 72 (26) 4 (1)/0 26 (19) 0/0 3 (20) 0/0 0 0/0 Vomiting 56 (20) 6 (2)/0 16 (12) 0/0 3 (20) 0/0 1 (11) 0/0 Fatigue 84 (31) 15 (6)/0 37 (27) 4 (3)/1 (<1) 3 (20) 0/0 1 (11) 0/0 Pyrexia 54 (20) 2 (<1)/0 12 (9) 0/0 3 (20) 0/0 0 0/0 Laboratory abnormality Hematology Hemoglobin decreased 253 (92) 33 (12)/3 (1) 108 (79) 7 (5)/1 (<1) 14 (93) 0/0 6 (67) 0/0 Lymphocytes decreased 139 (51) 43 (16)/6 (2) 39 (28) 7 (5)/0 6 (40) 2 (13)/0 3 (33) 0/0 Platelets decreased 64 (23) 3 (1)/0 3 (2) 0/1 (<1) 4 (27) 1 (7)/0 0 0/0 Neutrophils decreased 37 (14) 0/1 (<1) 5 (4) 0/0 4 (27) 0/0 1 (11) 0/0 Biochemistry Cholesterol increased 212 (77) 12 (4)/0 48 (35) 0/0 13 (87) 0/0 7 (78) 0/0 Triglycerides increased 200 (73) 2 (<1)/0 46 (34) 0/0 9 (60) 1 (7)/0 4 (44) 0/0 Glucose increased 157 (57) 42 (15)/1 (<1) 34 (25) 2 (1)/0 8 (53) 1 (7)/0 0 0/0 Creatinine increased 137 (50) 4 (1)/0 46 (34) 0/0 6 (40) 0/0 3 (33) 0/0 Phosphate decreased 102 (37) 17 (6)/0 11 (8) 0/0 6 (40) 0/0 2 (22) 0/0

7) 0/0 7 (78) 0/0 Triglycerides increased 200 (73) 2 (<1)/0 46 (34) 0/0 9 (60) 1 (7)/0 4 (44) 0/0 Glucose increased 157 (57) 42 (15)/1 (<1) 34 (25) 2 (1)/0 8 (53) 1 (7)/0 0 0/0 Creatinine increased 137 (50) 4 (1)/0 46 (34) 0/0 6 (40) 0/0 3 (33) 0/0 Phosphate decreased 102 (37) 17 (6)/0 11 (8) 0/0 6 (40) 0/0 2 (22) 0/0 Aspartate transaminase increased 68 (25) 1 (<1)/1 (<1) 9 (7) 0/0 4 (27) 0/0 0 0/0 Alanine transaminase increased 58 (21) 3 (1)/0 5 (4) 0/0 5 (33) 0/0 0 0/0 Bilirubin increased 8 (3) 2 (<1)/1 (<1) 3 (2) 0/0 0 0/0 0 0/0 aIncludes events that occurred in ≥3 patients in the Japanese subpopulation and corresponding data for the overall population. Data for the overall population are not all inclusive, only capturing the most common events in the Japanese subpopulation. bIncludes aphthous stomatitis, mouth ulceration and tongue ulceration. cIncludes all infections. dIncludes interstitial lung disease, lung infiltration, pneumonitis, pulmonary alveolar hemorrhage, alveolitis, pneumopathy and pulmonary toxicity.

Data for the overall population are not all inclusive, only capturing the most common events in the Japanese subpopulation. bIncludes aphthous stomatitis, mouth ulceration and tongue ulceration. cIncludes all infections. dIncludes interstitial lung disease, lung infiltration, pneumonitis, pulmonary alveolar hemorrhage, alveolitis, pneumopathy and pulmonary toxicity. Treatment-related Grade 3/4 adverse events were infrequently reported, with no specific type reported in >1 patient in the Japanese subpopulation (all of which were Grade 3) and incidences of individual events typically <5% in the overall population (with a few exceptions with respect to laboratory abnormalities). No Grade 4 adverse events were reported. In the Japanese subpopulation, no adverse event led to study discontinuation in the double-blind phase, whereas the adverse event-related discontinuation rates in the overall population were 13.9 and 2.9% for the everolimus and placebo groups, respectively. The most common adverse events resulting in everolimus discontinuation were dyspnea and pneumonitis (n = 7 [3.6%] for each). DISCUSSION The results of RECORD-1 established that daily treatment with oral everolimus prolongs PFS in patients with mRCC that has progressed on VEGFr-TKI therapies and generally is well tolerated, fulfilling an unmet medical need in this patient population. The results of this subgroup analysis of patients in RECORD-1 suggest that a similar benefit is expected for Japanese patients.

with oral everolimus prolongs PFS in patients with mRCC that has progressed on VEGFr-TKI therapies and generally is well tolerated, fulfilling an unmet medical need in this patient population. The results of this subgroup analysis of patients in RECORD-1 suggest that a similar benefit is expected for Japanese patients. The Japanese subpopulation analysis was limited by the small number of patients in the trial (n = 24); however, the PFS results in the Japanese subgroup aligned with the PFS results obtained in the overall trial population. It was speculated that the longer PFS of both everolimus and placebo groups in the Japanese subpopulation compared with the overall population may have been caused by the better overall condition of patients enrolled in the study. Although OS was likely confounded by the crossover design of the trial, results trended toward a benefit for everolimus compared with placebo, similar to findings in the overall trial population.

compared with the overall population may have been caused by the better overall condition of patients enrolled in the study. Although OS was likely confounded by the crossover design of the trial, results trended toward a benefit for everolimus compared with placebo, similar to findings in the overall trial population. In addition, the types of adverse events occurring in the Japanese patients were similar to those occurring in the overall trial population. The most common event in the everolimus group was rash, followed in decreasing order by stomatitis, dysgeusia, diarrhea, epistaxis, cough and peripheral edema. These events also occurred with a relatively high frequency (≥10% incidence) in the overall population of RECORD-1. The pharmacokinetic profile of everolimus in a Phase I study in previously treated Japanese patients with advanced solid tumors was similar to that observed in previous studies with large populations of Caucasian patients (11), suggesting no difference in treatment exposure between these two ethnic populations. The increased incidence of adverse events may be due to differences in ethnicity, stricter investigation of the Japanese physicians in identifying adverse events, or the small number of Japanese patients in this study. Most adverse events were mild/moderate in severity and there was no evidence of worsening adverse events. The majority of adverse events requiring treatment resolved after dose interruption and/or reduction, and patients were able to continue receiving everolimus.

or the small number of Japanese patients in this study. Most adverse events were mild/moderate in severity and there was no evidence of worsening adverse events. The majority of adverse events requiring treatment resolved after dose interruption and/or reduction, and patients were able to continue receiving everolimus. Non-infectious pneumonitis is a known class effect of rapamycin and its derivatives, possibly representing a hypersensitivity reaction; however, its etiology has not been fully characterized (15,16). A diagnosis of non-infectious pneumonitis should be considered in patients presenting with non-specific respiratory signs and symptoms (to include pyrexia, cough or dyspnea) and in whom infectious, neoplastic and other non-medicinal causes have been excluded by appropriate investigation. According to the data reported here for everolimus in mRCC, the incidence of non-infectious pneumonitis was increased among Japanese patients, at 27 vs. 11% for the overall population; the impact of the small sample size on this disparate finding is unknown. However, it was noted during the central review of results that the radiological changes observed did not support the higher incidence of non-infectious pneumonitis reported in Japanese when compared with the overall population. Nonetheless, it is encouraging that the four Japanese cases were limited to Grade 1/2 severity and all were successfully managed, resulting in the resolution of the toxicity and the ability to continue treatment (with treatment interruption and dose reduction for the 2 patients with Grade 2 events).

overall population. Nonetheless, it is encouraging that the four Japanese cases were limited to Grade 1/2 severity and all were successfully managed, resulting in the resolution of the toxicity and the ability to continue treatment (with treatment interruption and dose reduction for the 2 patients with Grade 2 events). In conclusion, the results of this subgroup analysis suggest that the benefits of everolimus in Japanese patients with mRCC are similar to those observed in the overall pivotal Phase III trial population. These findings, along with those of previous studies of everolimus in Japanese patients, suggest that everolimus is a valuable treatment option for Japanese patients with mRCC that has progressed on VEGFr-TKI therapy. Funding Financial support for medical editorial assistance was provided by Novartis Pharmaceuticals. Conflict of interest statement Drs Takeshi Tajima, Akio Kasuga, Yoshie Fujita are employed by Novartis Pharma K.K. Dr Andrea Kay is employed by and owns stock in Novartis Pharma K.K. Drs Hideyuki Akaza, Hiro-omi Kanayama, Hirotsugu Uemura and Nobuo Shinohara declare the following potential conflict of interest: Medical advisor of everolimus on Novartis Pharma K. K. (compensated); Seminar presentation in the seminar hosted by Novartis Pharma K.K. (compensated). Acknowledgements We thank Amy Zannikos for editorial assistance with this manuscript. Appendix In addition to the authors listed in the author field, following are the authors who contributed equally to this study. Takeshi Tajima, Akio Kasuga, Yoshie Fujita: Novartis Pharma K.K, Tokyo, Japan.

Conflict of interest statement Drs Takeshi Tajima, Akio Kasuga, Yoshie Fujita are employed by Novartis Pharma K.K. Dr Andrea Kay is employed by and owns stock in Novartis Pharma K.K. Drs Hideyuki Akaza, Hiro-omi Kanayama, Hirotsugu Uemura and Nobuo Shinohara declare the following potential conflict of interest: Medical advisor of everolimus on Novartis Pharma K. K. (compensated); Seminar presentation in the seminar hosted by Novartis Pharma K.K. (compensated). Acknowledgements We thank Amy Zannikos for editorial assistance with this manuscript. Appendix In addition to the authors listed in the author field, following are the authors who contributed equally to this study. Takeshi Tajima, Akio Kasuga, Yoshie Fujita: Novartis Pharma K.K, Tokyo, Japan. Andrea Kay: Novartis Pharma Corporation, Florham Park, NJ, USA.

INTRODUCTION Breast cancer is currently curable if detected and treated early, with a better prognosis than other cancers. However, recurrent breast cancer is hard to cure, but can be treated to improve symptoms and quality of life and prolong survival time. S-1 is a formulation comprising tegafur (FT), a prodrug of 5-fluorouracil (5-FU), gimeracil (CDHP), which inhibits dihydropyrimidine dehydrogenase (a catabolic enzyme of 5-FU) and oteracil potassium (Oxo), which inhibits orotate phosphoribosyltransferase (a kinase for 5-FU) at a molar ratio of 1:0.4:1 (FT:CDHP:Oxo). It is currently used for the treatment of breast cancer, gastric cancer, colorectal cancer, head and neck cancer, non-small cell lung cancer, pancreatic cancer and biliary cancer. S-1 is expected to be a therapeutic option that reduces the burden on patients because it can be administered orally on an outpatient basis, thereby reducing the number of hospital visits (1,2). S-1 was approved for the treatment of inoperable or recurrent breast cancer in 2005 and had a response rate of 41.7% in a Phase II study involving patients previously treated with a single regimen and 21.8% in another Phase II study involving patients who were unresponsive to taxanes (3,4).

S-1 is a formulation comprising tegafur (FT), a prodrug of 5-fluorouracil (5-FU), gimeracil (CDHP), which inhibits dihydropyrimidine dehydrogenase (a catabolic enzyme of 5-FU) and oteracil potassium (Oxo), which inhibits orotate phosphoribosyltransferase (a kinase for 5-FU) at a molar ratio of 1:0.4:1 (FT:CDHP:Oxo). It is currently used for the treatment of breast cancer, gastric cancer, colorectal cancer, head and neck cancer, non-small cell lung cancer, pancreatic cancer and biliary cancer. S-1 is expected to be a therapeutic option that reduces the burden on patients because it can be administered orally on an outpatient basis, thereby reducing the number of hospital visits (1,2). S-1 was approved for the treatment of inoperable or recurrent breast cancer in 2005 and had a response rate of 41.7% in a Phase II study involving patients previously treated with a single regimen and 21.8% in another Phase II study involving patients who were unresponsive to taxanes (3,4). Trastuzumab is a humanized monoclonal antibody (4D5) designed to bind to the extracellular domain of human epidermal growth factor receptor 2 (HER2). The NCCN guidelines recommend trastuzumab, either with or without chemotherapy, as the first-line treatment for patients with HER2-overexpressing breast cancer (5). Trastuzumab can be combined with fluoropyrimidines, and the efficacy in combination with capecitabine has been reported (6). However, the safety of trastuzumab when used in combination with S-1 has not been studied in detail.

otherapy, as the first-line treatment for patients with HER2-overexpressing breast cancer (5). Trastuzumab can be combined with fluoropyrimidines, and the efficacy in combination with capecitabine has been reported (6). However, the safety of trastuzumab when used in combination with S-1 has not been studied in detail. Data from the current post-marketing surveillance of S-1 involving Japanese patients with inoperable or recurrent breast cancer are presented. The safety of combined treatment with S-1 and trastuzumab was also evaluated in this article. PATIENTS AND METHODS Patients Patients with inoperable or recurrent breast cancer to be treated with S-1 for 2 years from January 2006 to December 2007 were included in the surveillance. Drug Administration S-1 was administered according to the ‘Dosage and Administration’ section of the package insert: ‘A cycle consisting of repeated oral administration at an initial dose calculated from the body surface area twice daily (after breakfast and dinner) for 28 consecutive days followed by a 14-day washout period should be repeated’. After three cycles, a survey form was collected and each item on the form was assessed.

: ‘A cycle consisting of repeated oral administration at an initial dose calculated from the body surface area twice daily (after breakfast and dinner) for 28 consecutive days followed by a 14-day washout period should be repeated’. After three cycles, a survey form was collected and each item on the form was assessed. Survey Method A prospective post-marketing surveillance was performed at 313 sites in Japan from which approval of the director of the site was obtained and a contract was concluded. The prior registration form was faxed to the registration center through the central registration system no later than the first day of treatment. The survey items consisted of patient background, treatment state, concomitant medication/concurrent therapy, clinical laboratory test and adverse events. As the key survey items, the presence or absence of hand and foot syndrome at the start of TS-1 treatment and its onset in each course were surveyed. All adverse events that developed during three cycles of treatment with TS-1 were recorded on the case report form, and adverse events were recorded by the treating physician through interview and by laboratory tests. Adverse events were graded according to the Common Terminology Criteria for Adverse Events (CTCAE, version 3.0) and tabulated using MedDRA/J (ver.11.1) Preferred Term (PT). Red blood cell counts decreased were recorded as anemia for the assessment. Any medication or therapy used concomitantly was recorded on the survey form.

e events were graded according to the Common Terminology Criteria for Adverse Events (CTCAE, version 3.0) and tabulated using MedDRA/J (ver.11.1) Preferred Term (PT). Red blood cell counts decreased were recorded as anemia for the assessment. Any medication or therapy used concomitantly was recorded on the survey form. Statistics Analyses were performed using the statistical package SAS 9.1 (SAS Institute, Cary, NC, USA). A logistic regression model was used to explore factors that may influence the development of adverse drug reactions. The significance level was set at 5%. RESULTS Patients A total of 1468 patients from 313 institutions were enrolled between January 2006 and December 2007. Of these, 1444 patients were treated with S-1. A completed survey form was collected from 1420 patients. Patients who received their first dose before the contract of the surveillance study was concluded were excluded. Therefore, 1361 patients were included in the safety evaluation. The reasons for S-1 treatment were inoperable/recurrent disease in 1308 patients, adjuvant therapy in 51 patients and neoadjuvant therapy in 2 patients. Of the patients with inoperable/recurrent breast cancer, 679 patients were treated with S-1 alone and 629 patients were treated with S-1 in combination with other anticancer drug(s) (Fig. 1). Figure 1. Patients' background.

bserved in this survey. Hand and foot syndrome was reported by 113 patients during any one of the three cycles, with an incidence of 8.3% (113/1361 patients). Eighty patients with no pre-treatment findings experienced hand and foot syndrome after the initiation of S-1 treatment; an incidence of 6.2% (80/1300 patients). SAFETY EVALUATION OF PATIENTS TREATED WITH S-1 + TRASTUZUMAB Patient Characteristics S-1 alone was used to treat 679 patients with inoperable/recurrent breast cancer and in combination with other anticancer drug(s) in 629 patients. The most common combination was S-1 + trastuzumab (118 patients), followed by anastrozole (84 patients), letrozole (80 patients) and exemestane (71 patients). The characteristics of the patients treated with S-1 alone and of those treated with S-1 + trastuzumab are shown in Table 3. There were significant differences in expression of hormone receptor and/or HER2, complications and previous therapy (chemotherapy or hormone therapy). The median duration of treatment with S-1 was not significantly different between patients treated with S-1 alone (59 days) and those treated with S-1 + trastuzumab (66 days). Table 3. Patient characteristics (S-1 alone vs. S-1 in combination with trastuzumab)

disease in 1308 patients, adjuvant therapy in 51 patients and neoadjuvant therapy in 2 patients. Of the patients with inoperable/recurrent breast cancer, 679 patients were treated with S-1 alone and 629 patients were treated with S-1 in combination with other anticancer drug(s) (Fig. 1). Figure 1. Patients' background. Adverse Drug Reactions The number and incidence of common adverse drug reactions included in the safety evaluation are shown in Table 1. At least one adverse drug reaction was reported by 858 patients, with an overall incidence of 63.0% (858/1361). The incidence of Grade 3 or higher adverse drug reactions in a descending order was 14.7% (200/1361), including neutrophil count decreased (4.2%; 57/1361), white blood cell count decreased (3.4%; 46/1361), anemia (including red blood cell count decreased, 2.5%; 34/1361), diarrhea (1.5%; 21/1361) and platelet count decreased (1.4%; 19/1361). The incidences of other Grade 3 or higher adverse drug reactions were lower than 1%. The number and incidence of adverse drug reactions according to the patient characteristics are shown in Table 2. Multivariate analysis using a logistic regression model revealed that the factors such as allergic predisposition, medical history, pre-treatment abnormal renal function, previous therapy (radiation therapy) and initial daily dose of S-1 per body surface area were associated with the development of adverse drug reactions. The most influential factor was allergic predisposition, which was associated with ∼3.3-fold higher risk of adverse drug reactions (Fig. 2). Table 1. Number of patients with adverse drug reactions and incidence of adverse drug reactions (ADRs)

surface area were associated with the development of adverse drug reactions. The most influential factor was allergic predisposition, which was associated with ∼3.3-fold higher risk of adverse drug reactions (Fig. 2). Table 1. Number of patients with adverse drug reactions and incidence of adverse drug reactions (ADRs) ADRs Number of patients with ADRs (%) Number of patients with Grade 3 or more severe ADRs (%) Overall 858 (63.0) 200 (14.7) Hematologic toxicity Anemia (including red blood cell count decreased) 174 (12.8) 34 (2.5) Neutrophil count decreased 159 (11.7) 57 (4.2) Platelet count decreased 138 (10.1) 19 (1.4) White blood cell count decreased 227 (16.7) 46 (3.4) Non-hematologic toxicity Anorexia 85 (6.2) 10 (0.7) Diarrhea 139 (10.2) 21 (1.5) Nausea 90 (6.6) 7 (0.5) Stomatitis 64 (4.7) 5 (0.4) Vomiting 48 (3.5) 9 (0.7) Hepatic function abnormal 54 (4.0) 7 (0.5) Palmar–plantar erythrodysesthesia syndrome 68 (5.0) 2 (0.1) Rash 23 (1.7) 1 (0.1) Malaise 31 (2.3) 3 (0.2) Alanine aminotransferase increased 52 (3.8) 4 (0.3) Aspartate aminotransferase increased 68 (5.0) 6 (0.4) Blood bilirubin increased 123 (9.0) 6 (0.4) Blood alkaline phosphatase increased 74 (5.4) 8 (0.6) Table 2. Number of patients with ADRs and incidence of ADRs in relation to patient characteristics

ADRs Number of patients with ADRs (%) Number of patients with Grade 3 or more severe ADRs (%) Overall 858 (63.0) 200 (14.7) Hematologic toxicity Anemia (including red blood cell count decreased) 174 (12.8) 34 (2.5) Neutrophil count decreased 159 (11.7) 57 (4.2) Platelet count decreased 138 (10.1) 19 (1.4) White blood cell count decreased 227 (16.7) 46 (3.4) Non-hematologic toxicity Anorexia 85 (6.2) 10 (0.7) Diarrhea 139 (10.2) 21 (1.5) Nausea 90 (6.6) 7 (0.5) Stomatitis 64 (4.7) 5 (0.4) Vomiting 48 (3.5) 9 (0.7) Hepatic function abnormal 54 (4.0) 7 (0.5) Palmar–plantar erythrodysesthesia syndrome 68 (5.0) 2 (0.1) Rash 23 (1.7) 1 (0.1) Malaise 31 (2.3) 3 (0.2) Alanine aminotransferase increased 52 (3.8) 4 (0.3) Aspartate aminotransferase increased 68 (5.0) 6 (0.4) Blood bilirubin increased 123 (9.0) 6 (0.4) Blood alkaline phosphatase increased 74 (5.4) 8 (0.6) Table 2. Number of patients with ADRs and incidence of ADRs in relation to patient characteristics Number of patients Number of patients with ADRs (%) Age ≥20 to <30 1 1 (100.0) ≥30 to <40 44 23 (52.3) ≥40 to <50 207 135 (65.2) ≥50 to <60 459 285 (62.1) ≥60 to <70 389 263 (67.6) ≥70 to <80 216 126 (58.3) ≥80 45 25(55.6) PS 0 835 517 (61.9) 1 397 261 (65.7) 2 100 61 (61.0) 3 21 14 (66.7) 4 8 5 (62.5) Purpose of use Inoperable 137 81 (59.1) Recurrent 1171 746 (63.7) Post-operative adjuvant therapy 51 30 (58.8) Pre-operative therapy 2 1 (50.0) Allergic predisposition No 1307 815 (62.4) Yes 39 34 (87.2) Unknown 15 9 (60.0) Medical history No 1185 733 (61.9) Yes 149 107 (71.8) Unknown 27 18 (66.7) Complications No 1052 646 (61.4) Yes 309 212 (68.6) Pre-treatment abnormal hepatic function No 1145 723 (63.1) Yes 79 58 (73.4) Unknown 137 77 (56.2) Pre-treatment abnormal renal function No 1189 754 (63.4) Yes 78 60 (76.9) Unknown 94 44 (46.8) Previous therapy (surgery) No 167 96 (57.5) Yes 1187 758 (63.9) Unknown 7 4 (57.1) Previous therapy (radiation therapy) No 919 551 (60.0) Yes 426 296 (69.5) Unknown 16 11 (68.8) Previous therapy (chemotherapy or hormone therapy) No 118 70 (59.3) Yes 1235 784 (63.5) Unknown 8 4 (50.0) Initial daily dose of S-1 per body surface area (mg/m2) ≤60 208 115 (55.3) >60 to ≤70 516 311 (60.3) >70 to ≤80 599 404 (67.4) >80 38 28 (73.7) Concomitant drug (chemotherapy or hormone therapy) No 707 445 (62.9) Yes 654 413 (63.1) Concomitant therapy (radiation therapy) No 1304 822 (63.0) Yes 57 36 (63.2) PS, performance status.

ly dose of S-1 per body surface area (mg/m2) ≤60 208 115 (55.3) >60 to ≤70 516 311 (60.3) >70 to ≤80 599 404 (67.4) >80 38 28 (73.7) Concomitant drug (chemotherapy or hormone therapy) No 707 445 (62.9) Yes 654 413 (63.1) Concomitant therapy (radiation therapy) No 1304 822 (63.0) Yes 57 36 (63.2) PS, performance status. Figure 2. Logistic regression analysis of all adverse drug reactions. PS, performance status. Hand and Foot Syndrome A clinical trial suggested that the incidence of hand and foot syndrome was 21.8% (12/55 patients) in previously treated breast cancer patients (2); higher than that seen in other cancers. In addition to adverse drug reactions as study items, the presence or absence of hand and foot syndrome prior to S-1 treatment, as well as the occurrence of hand and foot syndrome during each treatment cycle, was investigated to determine whether a similar trend was observed in this survey. Hand and foot syndrome was reported by 113 patients during any one of the three cycles, with an incidence of 8.3% (113/1361 patients). Eighty patients with no pre-treatment findings experienced hand and foot syndrome after the initiation of S-1 treatment; an incidence of 6.2% (80/1300 patients).

ons and previous therapy (chemotherapy or hormone therapy). The median duration of treatment with S-1 was not significantly different between patients treated with S-1 alone (59 days) and those treated with S-1 + trastuzumab (66 days). Table 3. Patient characteristics (S-1 alone vs. S-1 in combination with trastuzumab) Patient characteristics Number of patients (%) Fisher's exact test S-1 alone (n= 679) S-1 + trastuzumab (n= 118) Age <65 459 (67.6) 89 (75.4) P= 0.106 ≥65 220 (32.4) 29 (24.6) Median 60 56 — Minimum–maximum 29–92 34–80 PS 0 416 (61.3) 64 (54.2) P= 0.089 1 200 (29.5) 44 (37.3) 2 52 (7.7) 5 (4.2) 3 8 (1.2) 4 (3.4) 4 3 (0.4) 1 (0.8) Histology Papillotubular carcinoma 187 (27.5) 29 (24.6) P= 0.731 Solid-tubular carcinoma 149 (21.9) 29 (24.6) Scirrhous carcinoma 236 (34.8) 40 (33.9) Other 72 (10.6) 11 (9.3) Unknown 35 (5.2) 9 (7.6) Menopause Before 84 (12.4) 14 (11.9) P= 0.554 After 578 (85.1) 99 (83.9) Unknown 17 (2.5) 5 (4.2) Hormone receptor ER(−) and PgR(−) 303 (44.6) 75 (63.6) P< 0.001 Other 376 (55.4) 43 (36.4) HER2 0–2 506 (74.5) 22 (18.6) P< 0.001 3 73 (10.8) 95 (80.5) Unknown 100 (14.7) 1 (0.8) Complication No 543 (80.0) 84 (71.2) P= 0.038 Yes 136 (20.0) 34 (28.8) Previous therapy (chemotherapy or hormone therapy) No 69 (10.2) 2 (1.7) P= 0.003 Yes 603 (88.8) 115 (97.5) Unknown 7 (1.0) 1 (0.8) Initial daily dose of S-1 per body surface area (mg/m2) ≤60 87 (12.8) 14 (11.9) P= 0.745 >60 to ≤70 264 (38.9) 52 (44.1) >70 to ≤80 305 (44.9) 49 (41.5) >80 23 (3.4) 3 (2.5) Number of days of actual treatment with S-1 (days) Median 59 66 P= 0.084 Mean 58 62 25th–75th percentile 29–84 42–84 Minimum–maximum 1–132 5–142 Number of days of actual treatment with trastuzumab (days) Median — 8 — Mean 8 25th–75th percentile 3–11 Minimum–maximum 1–23 The P-value from Wilcoxon's rank-sum test is shown for PS, initial daily dose of S-1 per body surface area and duration of treatment with S-1. ER, estrogen; PgR, progesterone; HER2, human epidermal growth factor receptor 2.

tment with trastuzumab (days) Median — 8 — Mean 8 25th–75th percentile 3–11 Minimum–maximum 1–23 The P-value from Wilcoxon's rank-sum test is shown for PS, initial daily dose of S-1 per body surface area and duration of treatment with S-1. ER, estrogen; PgR, progesterone; HER2, human epidermal growth factor receptor 2. Comparison of Adverse Drug Reactions Between S-1 Alone and S-1 + Trastuzumab The most common adverse drug reactions recorded in patients treated with S-1 alone or with S-1 + trastuzumab are shown in Table 4. The overall incidence of adverse drug reactions was 63.5% (431/679 patients) in patients treated with S-1 alone and 55.9% (66/118 patients) in patients treated with S-1 + trastuzumab. There were no marked differences in the incidence of other adverse drug reactions between the two groups. Table 4. List of ADRs

Table 4. The overall incidence of adverse drug reactions was 63.5% (431/679 patients) in patients treated with S-1 alone and 55.9% (66/118 patients) in patients treated with S-1 + trastuzumab. There were no marked differences in the incidence of other adverse drug reactions between the two groups. Table 4. List of ADRs ADRs S-1 alone (n= 679) S-1 + trastuzumab (n= 118) Fisher's exact test Number of patients with ADRs (%) Number of patients with Grade 3 or more severe ADRs (%) Number of patients with ADRs (%) Number of patients with Grade 3 or more severe ADRs (%) Incidence of ADRs Incidence of Grade 3 or more severe ADRs Overall 431 (63.5) 99 (14.6) 66 (55.9) 19 (16.1) P= 0.124 P= 0.674 Hematologic toxicity Anemia (including red blood cell count decreased) 77 (11.3) 19 (2.8) 17 (14.4) 3 (2.5) P= 0.354 P= 1.000 Neutrophil count decreased 74 (10.9) 28 (4.1) 17 (14.4) 6 (5.1) P= 0.273 P= 0.622 Platelet count decreased 67 (9.9) 11 (1.6) 11 (9.3) 0 (0.0) P= 1.000 P= 0.384 White blood cell count decreased 105 (15.5) 22 (3.2) 23 (19.5) 6 (5.1) P= 0.278 P= 0.286 Non-hematologic toxicity Anorexia 44 (6.5) 4 (0.6) 9 (7.6) 1 (0.8) P= 0.688 P= 0.552 Diarrhea 66 (9.7) 11 (1.6) 18 (15.3) 3 (2.5) P= 0.075 P= 0.448 Nausea 47 (6.9) 3 (0.4) 5 (4.2) 0 (0.0) P= 0.417 P= 1.000 Stomatitis 36 (5.3) 3 (0.4) 5 (4.2) 1 (0.8) P= 0.822 P= 0.474 Vomiting 25 (3.7) 6 (0.9) 6 (5.1) 2 (1.7) P= 0.441 P= 0.337 Hepatic function abnormal 28 (4.1) 5 (0.7) 3 (2.5) 0 (0.0) P= 0.606 P= 1.000 Palmar–plantar erythrodysesthesia syndrome 42 (6.2) 1 (0.1) 3 (2.5) 1 (0.8) P= 0.133 P= 0.274 Rash 10 (1.5) 0 (0.0) 3 (2.5) 0 (0.0) P= 0.423 — Malaise 13 (1.9) 1 (0.1) 2 (1.7) 0 (0.0) P= 1.000 P= 1.000 Alanine aminotransferase increased 31 (4.6) 2 (0.3) 7 (5.9) 1 (0.8) P= 0.486 P= 0.382 Aspartate aminotransferase increased 43 (6.3) 5 (0.7) 3 (2.5) 0 (0.0) P= 0.133 P= 1.000 Blood bilirubin increased 56 (8.2) 4 (0.6) 13 (11.0) 1 (0.8) P= 0.374 P= 0.552 Blood alkaline phosphatase increased 31 (4.6) 3 (0.4) 7 (5.9) 0 (0.0) P= 0.486 P= 1.000

rase increased 31 (4.6) 2 (0.3) 7 (5.9) 1 (0.8) P= 0.486 P= 0.382 Aspartate aminotransferase increased 43 (6.3) 5 (0.7) 3 (2.5) 0 (0.0) P= 0.133 P= 1.000 Blood bilirubin increased 56 (8.2) 4 (0.6) 13 (11.0) 1 (0.8) P= 0.374 P= 0.552 Blood alkaline phosphatase increased 31 (4.6) 3 (0.4) 7 (5.9) 0 (0.0) P= 0.486 P= 1.000 DISCUSSION We set out to determine whether monotherapy with S-1 or combination therapy of S-1 and trastuzumab would be effective in the treatment of breast cancer. With the remarkable progress in cancer therapy over recent years, a variety of therapeutic options are now available. For example, molecular-targeted therapy is increasingly used, emphasizing tailored medicine, and various combination therapies are being administered to further enhance the antitumor effects. However, it is impossible to evaluate the efficacy and safety of all possible drug combinations before marketing. Post-marketing surveillance can be used to collect data from patients who have received a variety of combination therapies because there are not as many restrictions on the administration methods used as there are in clinical studies. Therefore, stratified analysis of patients given combined drug treatments using post-marketing surveillance may provide significant information that can complement the pre-marketing data. In addition, post-marketing surveillance may help to obtain information from patient subgroups that have been excluded from clinical studies and highlight previously unknown adverse drug reactions.

eatments using post-marketing surveillance may provide significant information that can complement the pre-marketing data. In addition, post-marketing surveillance may help to obtain information from patient subgroups that have been excluded from clinical studies and highlight previously unknown adverse drug reactions. Therefore, we reported the results of the current post-marketing surveillance of S-1 for the treatment of inoperable or recurrent breast cancer (covering 2 years from 2006), and also explored the safety of S-1 when used in combination with trastuzumab (the most commonly used combination drug). The most common Grade 3, or higher, severe adverse drug reactions were: neutrophil count decreased (4.2%), white blood cell count decreased (3.4%), anemia (including red blood cell count decreased; 2.5%), diarrhea (1.5%) and platelet count decreased (1.4%). In a Phase II clinical study of S-1 in patients with taxane-resistant inoperable or recurrent breast cancer, the incidence of common Grade 3, or higher, adverse drug reactions were: neutrophil count decreased (10.9%), white blood cell count decreased (9.1%), anorexia (5.5%) and diarrhea (5.5%) (4), illustrating that the incidence of adverse reactions was lower in the current study.

stant inoperable or recurrent breast cancer, the incidence of common Grade 3, or higher, adverse drug reactions were: neutrophil count decreased (10.9%), white blood cell count decreased (9.1%), anorexia (5.5%) and diarrhea (5.5%) (4), illustrating that the incidence of adverse reactions was lower in the current study. The presence or absence of allergic disposition was shown in Fig. 2 as the factor having the strongest impact on the onset of adverse drug reactions. This was possibly because many of the subjects with allergic disposition had a history of hypersensitivity to drugs. The factor with the second highest odds ratio was baseline renal dysfunction. Correlationship between lowered renal function and onset of adverse events was also shown in the risk analysis of adverse events in the drug use investigation (3758 subjects with gastric cancer) performed in 1999 (7). It is presumed that gimeracil is not excreted in patients with renal dysfunction, because the route of excretion of gimeracil, the active ingredient of this drug, was via the kidney, and thereby the blood concentration of 5-FU is maintained at a higher level compared with patients with normal renal function.

1999 (7). It is presumed that gimeracil is not excreted in patients with renal dysfunction, because the route of excretion of gimeracil, the active ingredient of this drug, was via the kidney, and thereby the blood concentration of 5-FU is maintained at a higher level compared with patients with normal renal function. The package insert states that a Phase II clinical study of S-1 showed the incidence of hand and foot syndrome to be 21.8% (12/55 patients); higher than that for other cancers (4). Therefore, we examined whether a similar trend was observed in the current surveillance. The incidence of palmar–plantar erythrodysesthesia syndrome was 5.0% higher than that in previous post-marketing surveillances for other cancers [0.2% (8/3808 patients) for gastric cancer, 0% (0/375 patients) for head and neck cancer and 0.06% (1/1669 patients) for non-small cell lung cancer]. In agreement with the clinical study, the current surveillance study suggests that the incidence of hand and foot syndrome may be higher in inoperable or recurrent breast cancer than in other cancers. In addition, hand and foot syndrome occurred in 37, 30 and 13 out of 80 patients after the start Cycles 1, 2 and 3, respectively. The incidence was the highest after Cycle 1, but almost as high after Cycle 2, indicating that patients should be carefully monitored up to after Cycle 2.

reast cancer than in other cancers. In addition, hand and foot syndrome occurred in 37, 30 and 13 out of 80 patients after the start Cycles 1, 2 and 3, respectively. The incidence was the highest after Cycle 1, but almost as high after Cycle 2, indicating that patients should be carefully monitored up to after Cycle 2. For inoperable or recurrent breast cancer, anthracyclines and taxanes are the standard chemotherapeutic agents for HER2-negative breast cancer (5). Chemotherapy combined with trastuzumab improves survival times in HER2-positive breast cancer. Response rate with trastuzumab was 55.9% when used in combination with AC therapy and 41.3% when used in combination with paclitaxel, in an overseas Phase III study (8). However, due to the high incidence of peripheral nerve disorders associated with taxanes (9,10), and bone marrow depression and phlebitis associated with vinorelbine (11), there is a need for new regimens that cause fewer adverse drug reactions.

n used in combination with paclitaxel, in an overseas Phase III study (8). However, due to the high incidence of peripheral nerve disorders associated with taxanes (9,10), and bone marrow depression and phlebitis associated with vinorelbine (11), there is a need for new regimens that cause fewer adverse drug reactions. In the current surveillance study, the most common combination drug was trastuzumab. The overall incidence of adverse drug reactions was 63.5% (431/679 patients) in patients treated with S-1 alone and 55.9% (66/118 patients) in patients treated with S-1 + trastuzumab. This suggested that combination therapy did not increase the incidence of adverse drug reactions. In addition, the incidence of adverse drug reactions analyzed according to the patient characteristics, revealing no particular characteristic resulting in a significant difference. In our hospital, a combination of S-1 and trastuzumab was administered to patients with HER2-positive metastatic breast cancer, and trastuzumab was found to have little effect on the pharmacokinetics of S-1 and caused no serious adverse drug reactions (12). In conclusion, the current surveillance showed that monotherapy with S-1 or combination therapy with S-1 + trastuzumab was well tolerated for inoperable or recurrent breast cancer patients. However, since this was a post-marketing surveillance study, efficacy could not be evaluated according to the RECIST criteria as is common for clinical studies. Further studies are needed to evaluate the safety and efficacy of S-1 with or without trastuzumab.

olerated for inoperable or recurrent breast cancer patients. However, since this was a post-marketing surveillance study, efficacy could not be evaluated according to the RECIST criteria as is common for clinical studies. Further studies are needed to evaluate the safety and efficacy of S-1 with or without trastuzumab. Funding This surveillance study was sponsored by Taiho Pharmaceutical Co., Ltd. Conflict of interest statement None declared. Acknowledgements We express our sincere gratitude to the physicians in each medical institution and to all those involved in this post-marketing surveillance. We also thank Professor J. Patrick Barron of the Department of International Medical Communications Centre of Tokyo Medical University (Tokyo, Japan), a remunerated consultant of Taiho Pharmaceutical for his review of this report.

INTRODUCTION Cetuximab (Erbitux®) is a human/mouse chimeric monoclonal immunoglobulin G1 antibody that targets the epidermal growth factor receptor (EGFR) to inhibit its signalling and shows anti-tumour effects by binding to EGFR competitively with ligands (1,2). Cetuximab, administered alone or in combination with irinotecan, showed efficacy in the treatment of patients with EGFR-positive metastatic colorectal cancer (CRC) who are refractory to irinotecan (3). Subsequent studies confirmed the efficacy and safety of cetuximab alone or in combination with chemotherapy (4,5). Moreover, it was reported that KRAS status is a predictive marker of response to cetuximab (6–8). Based on these studies and a Japanese phase II study (9) in which cetuximab was administered in combination with irinotecan in 39 patients with EGFR-positive metastatic CRC refractory to irinotecan, cetuximab was approved in Japan as second-line and later treatment for EGFR-positive metastatic CRC in July 2008. In Japan, post-marketing surveillance (PMS) has been introduced to verify the safety and the clinical efficacy of medicines in practical use, and practice standards of PMS have been established under a ministerial order. As a condition of its approval, PMS of all patients receiving cetuximab during a certain period was requested by the Ministry of Health, Labour and Welfare. In this report, treatment status and safety in the clinical use of cetuximab are examined based on prospectively aggregated PMS data.

In Japan, post-marketing surveillance (PMS) has been introduced to verify the safety and the clinical efficacy of medicines in practical use, and practice standards of PMS have been established under a ministerial order. As a condition of its approval, PMS of all patients receiving cetuximab during a certain period was requested by the Ministry of Health, Labour and Welfare. In this report, treatment status and safety in the clinical use of cetuximab are examined based on prospectively aggregated PMS data. PATIENTS AND METHODS Enrolment Following the launch of cetuximab on 19 September 2008, all patients to be treated with cetuximab were enrolled in advance using the central enrolment method. Patient information, including gender, age and treatment line, was collected from a company (Merck Serono Co., Ltd. and Bristol-Myers K.K.) prepared enrolment sheet. The company checked whether the patients met the following conditions for proper use upon approval: positive EGFR, no history of hypersensitivity to the components of the product, performance status (PS) 0–1, no interstitial lung diseases (ILDs) and refractoriness or intolerance to previous chemotherapy. To detect adverse drug reactions (ADRs) with an incidence of 0.2% and a probability of at least 95%, and to complete the enrolment within 1 year after launch, the target number of patients was determined to be 1800.

PATIENTS AND METHODS Enrolment Following the launch of cetuximab on 19 September 2008, all patients to be treated with cetuximab were enrolled in advance using the central enrolment method. Patient information, including gender, age and treatment line, was collected from a company (Merck Serono Co., Ltd. and Bristol-Myers K.K.) prepared enrolment sheet. The company checked whether the patients met the following conditions for proper use upon approval: positive EGFR, no history of hypersensitivity to the components of the product, performance status (PS) 0–1, no interstitial lung diseases (ILDs) and refractoriness or intolerance to previous chemotherapy. To detect adverse drug reactions (ADRs) with an incidence of 0.2% and a probability of at least 95%, and to complete the enrolment within 1 year after launch, the target number of patients was determined to be 1800. Treatment In accordance with the statement on the package insert, the initial dose of cetuximab was administered at 400 mg/m2 over 2 h followed by weekly infusions of 250 mg/m2 over 1 h. As there were no data available on the efficacy and safety of cetuximab in combination with oxaliplatin-based regimens at the beginning of the surveillance in Japan, it was recommended to use irinotecan or FOLFIRI (folinic acid, fluorouracil and irinotecan) as a combination chemotherapy.

nfusions of 250 mg/m2 over 1 h. As there were no data available on the efficacy and safety of cetuximab in combination with oxaliplatin-based regimens at the beginning of the surveillance in Japan, it was recommended to use irinotecan or FOLFIRI (folinic acid, fluorouracil and irinotecan) as a combination chemotherapy. To reduce the risk of infusion reactions (IRs), pre-medication with antihistamines is recommended in the ‘precautions for use’ section on the package insert for cetuximab. Likewise, concomitant use of corticosteroid is also suggested to reduce the risk of IRs. Monitoring The observation period was defined as the time between the first administration and the last administration of cetuximab. The case report forms including information of treatment status and ADRs filled out by physicians were collected three times (at Week 4, Week 8 and final administration). Safety Evaluation Severities of adverse events (AEs) were assessed mainly according to the Common Terminology Criteria for Adverse Events version 3.0 (CTCAE v3.0). As priority survey items, the incidence and severity of IRs, skin disorders, ILDs, electrolyte abnormalities including hypomagnesaemia, cardiotoxicity, gastrointestinal disorders, thrombosis/embolism, delayed wound healing and eye disorders (e.g. keratitis) were surveyed. AEs that the physicians and the company defined as being related to cetuximab treatment were analysed as ADRs.

in disorders, ILDs, electrolyte abnormalities including hypomagnesaemia, cardiotoxicity, gastrointestinal disorders, thrombosis/embolism, delayed wound healing and eye disorders (e.g. keratitis) were surveyed. AEs that the physicians and the company defined as being related to cetuximab treatment were analysed as ADRs. Statistical Analysis All analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, NC, USA). The incidences of ADRs, the number of treatment and duration of treatment were compared among patients characteristics and therapeutic factors using the χ2 test, Fisher's exact test, the Wilcoxon rank sum test or the non-paired t-test. P< 0.05 was considered to represent a statistically significant difference. The Kaplan–Meier method was used to calculate the cumulative incidence of ADRs. RESULTS Patient Characteristics Between 19 September 2008 and 5 January  2009, 2126 patients were enrolled from 637 institutions. Excluding 154 patients who did not receive cetuximab treatment, but including 34 who were treated with cetuximab outside of the enrolment condition, 2006 patients were included in the analysis. The cut-off date was set at 5 January 2010 (including patients continuing treatment). The patient characteristics are shown in Table 1. The median age was 64 years (range, 18–87), the male/female ratio was 1:0.6 and 93.2% of patients received cetuximab as third-line or later treatment (Table 1). In this surveillance, KRAS testing was performed in 15%. Table 1. Patient characteristics and clinical use

RESULTS Patient Characteristics Between 19 September 2008 and 5 January  2009, 2126 patients were enrolled from 637 institutions. Excluding 154 patients who did not receive cetuximab treatment, but including 34 who were treated with cetuximab outside of the enrolment condition, 2006 patients were included in the analysis. The cut-off date was set at 5 January 2010 (including patients continuing treatment). The patient characteristics are shown in Table 1. The median age was 64 years (range, 18–87), the male/female ratio was 1:0.6 and 93.2% of patients received cetuximab as third-line or later treatment (Table 1). In this surveillance, KRAS testing was performed in 15%. Table 1. Patient characteristics and clinical use n % (A) Patient characteristics Sex Male 1234 61.5 Female 772 38.5 Age <65 years 1032 51.4 ≥65 years 971 48.4 Unknown 3 0.2 Tumour site (including overlapping sites) Colon 1235 61.6 Rectum 775 38.6 PS 0 1370 68.3 1 630 31.4 2 2 0.1 Unknown 4 0.2 Treatment line Second line 133 6.6 Third line and later treatment 1869 93.2 Others 4 0.2 Previous chemotherapy (−) 3 0.2 (+) 2003 99.9 FOLFIRI 1510 75.3 FOLFOX 1854 92.4 5-FU/LV 370 18.4 Irinotecan 261 13.0 UFT/LV 337 16.8 Bevacizumab 923 46.0 Previous surgery (−) 81 4.0 (+) 1925 96.0 Previous radiation therapy (−) 1650 82.3 (+) 355 17.7 Unknown 1 0.0 EGFR-IHC Positive 1974 98.4 Negative 29 1.4 Not tested 3 0.2 KRAS status Wild 249 12.4 Mutant 53 2.6 Not tested 1691 84.3 Unknown 13 0.7 Comorbidity (−) 1019 50.8 (+) 974 48.6 Unknown 13 0.6 (B) Clinical use No. of treatments <4 253 12.6 4 to <16 900 44.9 16 to <32 524 26.1 32 to <48 255 12.7 ≥48 74 3.7 Duration of treatment <4 weeks 276 13.8 4 to < 16 weeks 739 36.8 16 to <32 weeks 489 24.4 32 to <48 weeks 280 14.0 ≥48 weeks 222 11.1 Cumulative dose <1500 mg/m2 435 21.7 1500 to <3000 mg/m2 493 24.6 3000 to < 9000 mg/m2 832 41.5 ≥9000 mg/m2 236 11.8 Unknown 10 0.5 Combination chemotherapy (−) 460 22.9 (+) 1546 77.1 Irinotecan 1255 62.6 FOLFIRI 256 12.8 Others 35 1.7 Combination radiation therapy (−) 1943 96.9 (+) 59 2.9 Unknown 4 0.2 Pre-medicationa No 14 0.7 Antihistamine alone 185 9.2 Corticosteroid alone 23 1.2 Antihistamine + corticosteroid 1783 88.9 PS, performance status; 5-FU, 5-fluorouracil; LV, leucovorin; UFT, tegafur-uracil; EGFR, epidermal growth factor receptor; IHC, immunohistochemistry.

therapy (−) 1943 96.9 (+) 59 2.9 Unknown 4 0.2 Pre-medicationa No 14 0.7 Antihistamine alone 185 9.2 Corticosteroid alone 23 1.2 Antihistamine + corticosteroid 1783 88.9 PS, performance status; 5-FU, 5-fluorouracil; LV, leucovorin; UFT, tegafur-uracil; EGFR, epidermal growth factor receptor; IHC, immunohistochemistry. aExcluded unknown (one patient). State of Clinical Use In total, 77.1% of patients received cetuximab in combination with chemotherapy, and the rest received cetuximab alone. Almost all patients (99.3%) received pre-medication, and most of these (88.9%) were treated with both antihistamines and corticosteroids (Table 1). The median duration of treatment was 15.3 weeks (range, 1–73.9), the median numbers of treatment was 13 (range, 1–61) and the median cumulative dose was 3255 mg/m2 (range, 50.0–17 680.9). A total of 11.1% of patients continued cetuximab treatment for >48 weeks (Table 1). The number of treatment and the duration of treatment by patient characteristics are shown in Fig. 1. Treatment duration did not differ among treatment line. The number of treatment was significantly higher, and the duration of treatment was significantly longer in the patients with combination chemotherapy, wild KRAS tumours and skin disorders (P< 0.0001). Figure 1. Number and duration of treatment by patient characteristics. The bars show the median duration of the cetuximab treatment for each subgroup of patients. *P< 0.0001 (the non-paired t-test).

was significantly longer in the patients with combination chemotherapy, wild KRAS tumours and skin disorders (P< 0.0001). Figure 1. Number and duration of treatment by patient characteristics. The bars show the median duration of the cetuximab treatment for each subgroup of patients. *P< 0.0001 (the non-paired t-test). Safety The overall incidence of ADRs (any grade) was 89.6% (n = 1797), and that of ADRs of ≥grade 3 was 21.5% (n= 432) (Table 2). Among patient characteristics affecting the incidence of ≥grade 3 ADRs, significant differences were observed in the comorbidity (presence, 25.5% vs. none, 18.1%; P< 0.0001) and combination chemotherapy (presence, 23.2% vs. none, 15.9%; P= 0.0006). There were no significant differences by age (<65 years, 21.4% vs. ≥ 65 years, 21.6%; P= 0.91). Table 2. Incidence of adverse drug reactions (ADRs) Any grade ≥Grade 3 n % n % Overall incidence of ADRs 1797 89.6 432 21.5 Incidence of priority survey items Infusion reactions 114 5.7 22 1.1 Skin disorders 1679 83.7 212 10.6 Interstitial lung diseases 24 1.2 15 0.7 Electrolyte abnormalities including hypomagnesaemia 231 11.5 24 1.2 Cardiotoxicity 17 0.9 5 0.2 Gastrointestinal disorders 464 23.1 77 3.8 Thrombosis/embolism 11 0.6 8 0.4 Delayed wound healing 5 0.3 1 0.05 Eye disorders 53 2.6 1 0.05

5.7 22 1.1 Skin disorders 1679 83.7 212 10.6 Interstitial lung diseases 24 1.2 15 0.7 Electrolyte abnormalities including hypomagnesaemia 231 11.5 24 1.2 Cardiotoxicity 17 0.9 5 0.2 Gastrointestinal disorders 464 23.1 77 3.8 Thrombosis/embolism 11 0.6 8 0.4 Delayed wound healing 5 0.3 1 0.05 Eye disorders 53 2.6 1 0.05 Incidences of the priority survey items are shown in Table 2. IRs were observed in 5.7% of patients (n= 114), whereas IRs ≥grade 3 were observed in 1.1% (n= 22). Most IRs (83.3%; n= 95), especially those of ≥grade 3 (20 out of 22) occurred at the first administration of cetuximab (Fig. 2). The median time to the onset of ≥grade 3 IRs was 10 min (range, 2 min to 8 h). Among the 22 patients with IRs of ≥grade 3, 21 developed IRs within 60 min after the start of administration. There were no differences in the incidence of IRs among pre-medication groups (data not shown). Figure 2. Timing of infusion reactions (IRs). The bars show the incidence of IRs for each number of cetuximab treatments received. One patient with a grade 3 IR was excluded because the time to the onset of IR was unknown.

. There were no differences in the incidence of IRs among pre-medication groups (data not shown). Figure 2. Timing of infusion reactions (IRs). The bars show the incidence of IRs for each number of cetuximab treatments received. One patient with a grade 3 IR was excluded because the time to the onset of IR was unknown. Skin disorders were the most frequently observed ADRs, accounting for 83.7% of patients (n= 1679, any grade). In the seven categories grouped by symptom, dermatitis acneiform/rash (n= 1579, 78.7%) was observed most frequently, followed by dry skin (n= 442, 22.0%) and paronychia (n= 353, 17.6%). The cumulative incidence of each disorder over time after the start of administration of cetuximab is shown in Fig. 3. The median time to the onset of each skin disorder was 15 days for dermatitis acneiform/rash, 30 days for dry skin and 52 days for paronychia. Figure 3. Cumulative incidence of skin disorders. The lines show the cumulative incidence of each skin disorder over time from the start of administration of cetuximab using the Kaplan–Meier methods. Skin disorders were divided into seven categories as grouped by symptoms, which is different from the counting based on the system organ class (SOC) classification of Medical Dictionary for Regulatory Activities Terminology (MedDRA).

ver time from the start of administration of cetuximab using the Kaplan–Meier methods. Skin disorders were divided into seven categories as grouped by symptoms, which is different from the counting based on the system organ class (SOC) classification of Medical Dictionary for Regulatory Activities Terminology (MedDRA). ILDs were observed in 1.2% of patients (n= 24), and ILDs ≥grade 3 were reported in 0.7% (n= 15). The outcomes included recovery in 2 patients, lower severity in 6 patients, non-recovery in 5 patients, death in 10 patients and unknown in 1 patient. The median time to onset of ILDs was 101 days (range, 17–431), indicating no certain tendency in time to onset of ILDs. Electrolyte abnormalities (any grade, 11.5%; ≥grade 3, 1.2%) included hypomagnesaemia (10.8%), hypocalcaemia (0.5%), hyperkalaemia (0.4%), hypokalaemia (0.3%), hyponatraemia (0.2%), hypochloraemia (0.1%) and hypophosphataemia (0.1%). The median time to onset of hypomagnesaemia was 57 days (range, 3–418 days), and a higher rate of hypomagnesaemia was observed in patients undergoing long-term administration. Cardiotoxicity was observed in 17 patients (0.9%) and cardiotoxicity ≥grade 3 was reported in 0.2% (n= 5). Cardiotoxicity included myocardial infarction, cardiac failure, right cardiac failure and coronary spastic angina. All five patients with cardiotoxicity ≥grade 3 were treated with cetuximab plus irinotecan or FOLFIRI, and four patients died.

in 17 patients (0.9%) and cardiotoxicity ≥grade 3 was reported in 0.2% (n= 5). Cardiotoxicity included myocardial infarction, cardiac failure, right cardiac failure and coronary spastic angina. All five patients with cardiotoxicity ≥grade 3 were treated with cetuximab plus irinotecan or FOLFIRI, and four patients died. Other ADRs developed including diarrhoea (any grade, 15.1%; ≥grade 3 2.5%), leukopenia (4.3%; 2.0%) and neutropenia (2.8%; 2.2%). Leukopenia and neutropenia did not occur in the cetuximab alone group, and the incidence of diarrhoea in this group was lower than that in the combination chemotherapy group (5.2 vs. 18.0%, P< 0.001) (Fig. 4). Figure 4. The incidence of adverse drug reactions (ADRs) with/without combination chemotherapy. The bars show the incidence of ADRs in patients with/without combination chemotherapy. Combi Cx (−): patients receiving cetuximab alone. Combi Cx (+): patients receiving cetuximab in combination with chemotherapy. A total of 780 patients died during the surveillance period. Of these, a causal relationship with cetuximab could not be ruled out in 22 patients (1.1%). Of the 66 patients (3.3%) who died within 30 days, a causal relationship with cetuximab could not be ruled out in seven patients (0.4%). DISCUSSION This report shows the results of a large-scale surveillance in which all patients treated with cetuximab were collected prospectively within a certain period after launch.

A total of 780 patients died during the surveillance period. Of these, a causal relationship with cetuximab could not be ruled out in 22 patients (1.1%). Of the 66 patients (3.3%) who died within 30 days, a causal relationship with cetuximab could not be ruled out in seven patients (0.4%). DISCUSSION This report shows the results of a large-scale surveillance in which all patients treated with cetuximab were collected prospectively within a certain period after launch. The incidence of ADRs in this surveillance (89.6%) was similar to that (93.0%) reported in the MABEL study, in which the efficacy and safety of the combination with irinotecan were studied in 1147 patients with EGFR-positive metastatic CRC refractory or intolerant to irinotecan (10), and that (100%) reported in a Japanese phase II study (9). Because IRs occurred frequently at the first administration of cetuximab and most of the severe reactions occurred within 1 h after administration, careful observation during the first 1 h is therefore important in cetuximab treatment. It was reported that the incidence of IRs was decreased by administering antihistamine and corticosteroid as pre-medication (11). Accordingly, the Japanese package insert for cetuximab recommends pre-medication with an antihistamine (and corticosteroid), and 88.9% of patients received both pre-medications in this surveillance. So, the incidence of IRs in this report (5.7%) might be lower than that in the MABEL study (15.4%).

pre-medication (11). Accordingly, the Japanese package insert for cetuximab recommends pre-medication with an antihistamine (and corticosteroid), and 88.9% of patients received both pre-medications in this surveillance. So, the incidence of IRs in this report (5.7%) might be lower than that in the MABEL study (15.4%). Skin disorders were the most frequent ADRs, and the time to event was different for each disorder similar to previous reports (12). The occurrence of skin disorders is considered a predictive factor for the efficacy of EGFR inhibitors (4,13), and it is important to manage skin disorders by considering the occurrence time of each symptom to continue the cetuximab treatment. The incidence of ILDs in this surveillance (1.2%) was higher than that in the MABEL study (0.3%) (14). With other drugs, it has been suggested that the incidence of ILDs in Japanese patients is higher than that in Caucasian patients (15,16). ILDs are often followed by serious outcomes including death, while no certain tendency in time of onset of ILDs was observed in this surveillance. Urgent consultation with a respiratory specialist and the introduction of corticosteroid pulse therapy should be considered when observing suspicious symptoms and/or images of ILDs.

often followed by serious outcomes including death, while no certain tendency in time of onset of ILDs was observed in this surveillance. Urgent consultation with a respiratory specialist and the introduction of corticosteroid pulse therapy should be considered when observing suspicious symptoms and/or images of ILDs. The incidence of cardiotoxicity was low in this surveillance (0.9%), and all patients with cardiotoxicity ≥grade 3 were treated with irinotecan as combination chemotherapy. Cardiotoxicity has also been reported following fluorouracil treatment (17) and it is important to pay close attention when administering cetuximab in combination with these drugs. Diarrhoea, leukopenia and neutropenia are frequently observed ADRs caused by cytotoxic anti-cancer drugs, but in this surveillance, they were rarely observed with administration of cetuximab alone. Based on this finding, cetuximab can be used safely in elderly patients and those receiving the drug as later-line treatment. Although 93.2% of 2006 patients in this surveillance were treated in third-line or later treatment, the median duration of treatment was 15.3 weeks (range, 1–73.9), and 11.1% received long-term treatment >48 weeks, while that in the CO.17 study, in which cetuximab alone was administered to patients refractory or intolerant to fluorouracil, oxaliplatin and irinotecan, was 8.1 weeks (range, 1–60) (4). Based on these observations, cetuximab treatment is considered controllable and clinically effective in practical use in a later-line setting in Japan.

O.17 study, in which cetuximab alone was administered to patients refractory or intolerant to fluorouracil, oxaliplatin and irinotecan, was 8.1 weeks (range, 1–60) (4). Based on these observations, cetuximab treatment is considered controllable and clinically effective in practical use in a later-line setting in Japan. In addition, higher number of treatments and longer duration of treatment were observed in the patients with wild KRAS tumours and those who developed skin disorders. Treatment duration might be considered as a surrogate of the efficacy of treatment including cetuximab. Thus, it might indicate that these patients had obtained the clinical benefit from cetuximab treatment. KRAS status has been reported to be a predictive factor of response to cetuximab since 2006 (6), and the indication for the use of cetuximab was changed to KRAS wild-type metastatic CRC in July 2008 by the European Medicines Agency, and in September 2009 by the US Food and Drug Administration. At the beginning of this surveillance, there was no description regarding KRAS status on the Japanese package insert for cetuximab, and KRAS testing was not covered by insurance. Therefore, only 15% (n= 263) of the patients included in this surveillance had undergone KRAS testing. It is now recommended that KRAS testing, which has been covered by insurance since April 2010 in Japan, should be conducted before the administration of cetuximab.

ximab, and KRAS testing was not covered by insurance. Therefore, only 15% (n= 263) of the patients included in this surveillance had undergone KRAS testing. It is now recommended that KRAS testing, which has been covered by insurance since April 2010 in Japan, should be conducted before the administration of cetuximab. CONCLUSIONS We conducted a prospective PMS in Japanese patients receiving cetuximab for the treatment of metastatic CRC. There was no notable difference in the profiles and incidence of ADRs compared with previous reports from other countries. Although >90% of the patients received cetuximab as third-line or later treatment, the treatment was maintained with a median duration of 15 weeks. Thus, cetuximab is considered well tolerated and clinically useful for Japanese patients. Funding This PMS was funded and undertaken by Merck Serono Co., Ltd. and Bristol-Myers Squibb Corp. in accordance with the conditions for approval. Merck Serono Co., Ltd. was responsible for development of the protocol and for the analysis of the data.

CONCLUSIONS We conducted a prospective PMS in Japanese patients receiving cetuximab for the treatment of metastatic CRC. There was no notable difference in the profiles and incidence of ADRs compared with previous reports from other countries. Although >90% of the patients received cetuximab as third-line or later treatment, the treatment was maintained with a median duration of 15 weeks. Thus, cetuximab is considered well tolerated and clinically useful for Japanese patients. Funding This PMS was funded and undertaken by Merck Serono Co., Ltd. and Bristol-Myers Squibb Corp. in accordance with the conditions for approval. Merck Serono Co., Ltd. was responsible for development of the protocol and for the analysis of the data. Conflict of interest statement Megumi Ishiguro received a consulting fee from Taiho Pharmaceutical Co., Ltd, and lecture honoraria from Chugai Pharmaceutical Co., Ltd, Taiho Pharmaceutical Co., Ltd and Yakult Honsha Co., Ltd; Toshiaki Watanabe received lecture honoraria from Chugai Pharmaceutical Co., Ltd, Taiho Pharmaceutical Co., Ltd, Yakult Honsha Co., Ltd, Takeda Pharmaceutical Company, Merck Serono Co., Ltd and Bristol-Myers K.K.; Taroh Satoh received lecture honoraria from Chugai Pharmaceutical Co., Ltd, Taiho Pharmaceutical Co., Ltd, Yakult Honsha Co., Ltd, Takeda Pharmaceutical Company, Daiichi Sankyo Company, Merck Serono Co., Ltd and Bristol-Myers K.K.; Yuh Sakata received lecture honoraria from Taiho Pharmaceutical Co., Ltd and Yakult Honsha Co., Ltd and a royalty from International Inc. Synergy; Kenichi Sugihara received lecture honoraria from Chugai Pharmaceutical Co., Ltd, Taiho Pharmaceutical Co., Ltd, Merck Serono Co., Ltd, Takeda Pharmaceutical Company, Bristol-Myers K.K. and Yakult Honsha Co., Ltd; Hideyuki Ito is an employee of Merck Serono Co., Ltd; Taku Seriu is an employee of Bristol-Myers K.K.

ergy; Kenichi Sugihara received lecture honoraria from Chugai Pharmaceutical Co., Ltd, Taiho Pharmaceutical Co., Ltd, Merck Serono Co., Ltd, Takeda Pharmaceutical Company, Bristol-Myers K.K. and Yakult Honsha Co., Ltd; Hideyuki Ito is an employee of Merck Serono Co., Ltd; Taku Seriu is an employee of Bristol-Myers K.K. Acknowledgements We are grateful to the physicians and patients for their cooperation in this surveillance, Merck Serono Co., Ltd., Japan and Bristol-Myers K.K., Japan. All authors are members of the cetuximab advisory board.

INTRODUCTION Astellas Pharma Inc. was formed in April 2005 by the merger of two research and development (R&D)-driven companies, namely Yamanouchi Pharmaceutical Co., Ltd, and Fujisawa Pharmaceutical Co., Ltd. ‘Astellas’ expresses the idea of ‘aspired stars’ and ‘advanced stars’ based on the Latin ‘stella’, Greek ‘aster’ and English ‘stellar’, which all refer to ‘stars’. ‘Astellas’ also sounds like the Japanese phrase ‘a-su wo te-ra-su’ which means ‘to shine on tomorrow’ (1). In this paper, we describe our drug discovery strategy in view of our guiding principles, current research activities and future perspectives, with a particular focus on oncology. OUR GUIDING PRINCIPLES: PHILOSOPHY, MESSAGE AND VISION At our very start, we clarified our guiding principles as our philosophy, corporate message and vision. Our philosophy is to contribute toward improving the health of people around the world through the provision of innovative and reliable pharmaceutical products. Our corporate message is that we will be the ‘Leading Light for Life’ to deliver world-class state-of-the-art pharmaceuticals that promise people from around the world a healthier life (2). For patients and their families and for ourselves, we have further condensed our message into the phrase ‘Changing tomorrow’ (3).

Our corporate message is that we will be the ‘Leading Light for Life’ to deliver world-class state-of-the-art pharmaceuticals that promise people from around the world a healthier life (2). For patients and their families and for ourselves, we have further condensed our message into the phrase ‘Changing tomorrow’ (3). We went on to decide ‘VISION 2015’ as our management vision in order to show how Astellas must look in the year 2015. In this vision, we constructed our business model, a ‘Global Category Leader’ (GCL). A GCL shows high competitiveness by providing value-added products globally in several categories where high unmet medical needs exist and a high degree of expertise is required, and thereby takes a leading position in such ‘categories’. At the same time, we established our important R&D categories including urology, immunology including transplantation and infectious diseases, neuroscience, diabetes mellitus complications and metabolic diseases, and oncology (4).

gree of expertise is required, and thereby takes a leading position in such ‘categories’. At the same time, we established our important R&D categories including urology, immunology including transplantation and infectious diseases, neuroscience, diabetes mellitus complications and metabolic diseases, and oncology (4). OUR RESEARCH PLATFORM We strongly believe that we need to reinforce our research capabilities by approaching new technologies and new research areas in a timely manner in order to create innovative drugs (5). In 2009, we started operation of an X-ray beam line at the Photon Factory of the High Energy Accelerator Research Organization, Tsukuba, purposely built for efficient elucidation of protein structures for use by Astellas and academic institutions (6) (Fig. 1). We also created the Bioimaging Research Laboratories at our Tsukuba Research Center in order to enhance our capability in drug discovery and translational sciences (7) (Fig. 2). In addition, we are keen to strengthen our capability in other important technology platforms including proteomics (8) and bioinformatics (9,10). Figure 1. Astellas beamline at the High Energy Accelerator Research Organization (KEK). Left: Aerial view of the KEK campus located 9 km north of the Astellas Tsukuba Research Center. Top right: The plan of the PF-AR experimental hall. Astellas beam line (red color) is placed in the NE3 section. Bottom right: The NE-3A deck for X-ray diffraction experiments colored in Red and Gray (Astellas Corporate Brand Color). AR-NE3A, an X-ray beamline with a beam energy of 6.5 GeV ring, is designed for high-throughput macromolecular crystallography which is applied in a structure-based drug design (SBDD). KEK and Astellas jointly developed a fully automated data collection and processing system inside the NE-3A deck. This system can collect X-ray diffraction data sets from more than 200 samples per day by optimizing the schedules of sample exchange, centering, data collection and data processing.

sed drug design (SBDD). KEK and Astellas jointly developed a fully automated data collection and processing system inside the NE-3A deck. This system can collect X-ray diffraction data sets from more than 200 samples per day by optimizing the schedules of sample exchange, centering, data collection and data processing. Figure 2. Astellas' Bioimaging Research Laboratories (BIRL). Upper left: Building of BIRL at Astellas Tsukuba Research Center. Upper right: Automated system for PET tracers developed in-house. Lower left: Positron emission tomography (PET)/computed tomography scanner for small animal studies (Inveon, Siemens). Lower right: PET scanner for large animal studies (SHR-17000, co-developed with Hamamatsu Photonics K.K.). In view of treatment modality, Astellas had specialized primarily in small molecules, including natural products. Therefore, we in-licensed VelocImmune technology from Regeneron Pharmaceuticals, Inc., in order to efficiently generate fully human monoclonal antibodies (11) and acquired Agensys, Inc., in order to strengthen our drug discovery of antibodies in cancer (12). OUR RESEARCH APPROACH Based on our in-house research and introduction from other companies in the past few years, our current oncology R&D programs consist of the following three approaches (13): Precision medicine Mechanisms of action with application across multiple tumor types Leveraging Astellas' current capabilities in urology and other therapeutic area

OUR RESEARCH APPROACH Based on our in-house research and introduction from other companies in the past few years, our current oncology R&D programs consist of the following three approaches (13): Precision medicine Mechanisms of action with application across multiple tumor types Leveraging Astellas' current capabilities in urology and other therapeutic area In the past, we took the second and third approaches in our drug discovery. From the second approach, we created YM155, a selective survivin suppressant for multiple tumors (14,15). From the third approach, we created potential treatments for hormone-dependent cancers including YM511, an aromatase inhibitor (16), and YM580, a non-steroidal androgen receptor antagonist (17). Through our experience in these drug discovery programs and subsequent clinical trials, we had fostered the notion that we must deliver novel therapies for improving the health of well-defined populations of patients suffering from a number of cancers. The establishment of our principles on top of the above-mentioned mindset naturally shifted our research approach in a direction in which we can offer highly effective therapeutic options for precisely defined patient populations based on molecular targeting and precise diagnosis. We call it the precision medicine approach (5,13,18) (Fig. 3). Figure 3. Astellas' precision medicine approach. Astellas would like to realize ‘right drug for right patients’ by offering medicines targeting pathogenic molecules (we call it Precision Medicine) combined with companion diagnostic tests fitting to such medicines.

it the precision medicine approach (5,13,18) (Fig. 3). Figure 3. Astellas' precision medicine approach. Astellas would like to realize ‘right drug for right patients’ by offering medicines targeting pathogenic molecules (we call it Precision Medicine) combined with companion diagnostic tests fitting to such medicines. Precision medicine is becoming a treatment option for certain cancers. In July 2011, the US Food and Drug Administration (FDA) published the draft guidance for in vitro companion diagnostic devices (19). In August 2011, the FDA approved Zelboraf™ (vemurafenib), a kinase inhibitor, for the treatment of patients with unresectable or metastatic melanoma whose tumors express a gene mutation called BRAF V600E together with a diagnostic test to detect such mutation in patients' melanoma cells (20). The FDA also approved Xalkori® (crizotinib), a kinase inhibitor, for the treatment of patients with locally advanced or metastatic non-small cell lung cancer who express the abnormal anaplastic lymphoma kinase (ALK) gene together with a diagnostic test to detect such abnormal gene (21) ACTIVITIES IN OUR RESEARCH SITES Astellas has three sites for oncology drug discovery, namely Astellas Pharma Inc. Tsukuba Research Center at Tsukuba, Ibaraki, Japan, OSI Pharmaceuticals, LLC at Farmingdale, NY, USA, and Agensys, Inc. at Santa Monica, CA, USA. The three research sites pursue precision medicine in a diverse manner based on the research platform and research strategy of each site.

scovery, namely Astellas Pharma Inc. Tsukuba Research Center at Tsukuba, Ibaraki, Japan, OSI Pharmaceuticals, LLC at Farmingdale, NY, USA, and Agensys, Inc. at Santa Monica, CA, USA. The three research sites pursue precision medicine in a diverse manner based on the research platform and research strategy of each site. Tsukuba Research Center focuses on the creation of small molecules that inhibit the function of molecules which are essential for the survival or growth of tumor cells as a result of either genetic or epigenetic alterations to the drug target molecules themselves or in the presence of certain genetic or epigenetic contexts. In order to create drugs to well-defined patient populations, Tsukuba Research Center is placing significant emphasis on efforts to identify and validate novel molecular targets based on in-house research and external collaborations. It should be noted that these ‘target discovery’ efforts also form the basis of translational research for determination of the right patients. Based on this research style, we created ASP3026, an inhibitor of ALK tyrosine kinase (22,23).

e novel molecular targets based on in-house research and external collaborations. It should be noted that these ‘target discovery’ efforts also form the basis of translational research for determination of the right patients. Based on this research style, we created ASP3026, an inhibitor of ALK tyrosine kinase (22,23). OSI joined Astellas in 2010 (24), and it is pursuing small molecule drug discovery with a different style using different precision medicine strategies. During the development of erlotinib, an inhibitor of epidermal growth factor receptor tyrosine kinase, OSI completed much research to better understand which patients optimally benefit from this therapy and which patients would become refractory or resistant (25–27). This research led OSI to focus on drug discovery and translational research related to epithelial–mesenchymal transition (26,28,29) and compensatory activation mechanisms in oncogenic signal transduction (27,30,31) for both publicly known as well as novel oncology targets. In addition, OSI is doing extensive translational research to identity novel biomarkers for patient selection based on the characterization of gene and protein signatures in responsive tumor cells (32).

able 5, the 2- or 3-year LC and overall survival rates obtained with proton therapy are 75–96 and 55–66%, respectively (70–73). The degree of liver dysfunction attributable to coexisting liver cirrhosis and the number of tumors in the liver significantly affected patient survival (72). Table 5. Hepatocellular carcinoma Author Ions No. of patients Tumor diameter (range) (mm) Dose/fractions Local control Overall survival 3 years 5 years 3 years 5 years Bush et al. (70), LLUMC Proton 34 57 (T1–T4) 63 GyE/15 fr 75.0% (2 years) — 55.0% (2 years) — Kawashima et al. (71), NCCHE Proton 40 45 (25–82) 76 GyE/20 fr 96.0% (2 years) — 66.0% — Chiba et al. (72), Tsukuba Proton 162 38 (15–145) 5–72 GyE/10–24fr 90.0% 86.9% 45.0% 23.5% Fukumitsu et al. (73), Tsukuba Proton 51 28 (8–93) 66 GyE/10 fr 94.5% 87.8% 49.2% 38.7% Kato et al. (74,75), NIRS C-ion 69 40 (12–120) 52.8 GyE/4 fr 94.0% 81.0% 50.0% 33.0% Imada et al. (76), NIRS C-ion 64 — Porta hepatis group 52.8 GyE/4 fr — 87.8% — 22.2% — Non-porta hepatis group 52.8 GyE/4 fr 95.7% 34.8% Imada et al. (77), NIRS C-ion 40 38 (14–95) High-dose group: 42.8–45.0 GyE/2 fr 95.0% — 72.0% — 77 45 (15–140) Low-dose group: 32.0–40.8 GyE/2 fr 74.0% — 54.0% —

ion mechanisms in oncogenic signal transduction (27,30,31) for both publicly known as well as novel oncology targets. In addition, OSI is doing extensive translational research to identity novel biomarkers for patient selection based on the characterization of gene and protein signatures in responsive tumor cells (32). Agensys joined Astellas in 2007 (12). Agensys specializes in drug discovery of antibodies for cancer therapy, focusing on the creation of novel monoclonal antibodies from two aspects. First, Agensys invested in identifying novel antigen molecules or epitopes which are selectively expressed on the surface of certain sets of tumor cells. These antigen molecules or epitopes are molecular targets for Agensys' antibodies as well as biomarkers for the selection of the right patients. Agensys is focusing to create antibody–drug conjugates (ADCs, also known as ‘immunoconjugates’) to these antigens. ADC is an antibody covalently attached to a cytotoxic molecule (such as tubulin inhibitor or DNA minor groove binder) via a linker. Once an ADC binds to the antigen on a tumor cell, it is internalized into the tumor cell and the cytotoxic molecule is released to cause cell death (33). This unique combination of novel molecular targets and ADC technology is expected to provide innovative therapeutic options for precision medicine to the patients for whom no effective drug currently exists. Agensys has put three ADCs into clinical trials so far, with AGS-22M6E (also known as ASG-22ME), an ADC targeting nectin-4, as the latest example (34). Secondly, Agensys is using its panel of patient-derived xenografts (PDX) to validate antibody targets in cancers and develop functional antibodies. The panel of over 60 PDX, representing 14 different indications, provides unique preclinical models and allows preclinical evaluation of targets that are required for tumor growth and survival in a particular microenvironment that may not be found or required for growth of xenografts of conventional cell lines. The anti-prostate stem cell antigen antibody AGS-1C4D4 completing a Phase II study in pancreatic cancer is the most advanced example of this approach (35,36).

re required for tumor growth and survival in a particular microenvironment that may not be found or required for growth of xenografts of conventional cell lines. The anti-prostate stem cell antigen antibody AGS-1C4D4 completing a Phase II study in pancreatic cancer is the most advanced example of this approach (35,36). The chemical compounds and antibodies created by our three research sites, together with in-licensed compounds, form our oncology development pipeline as shown in Table 1. Table 1. Astellas' oncology development pipeline

re required for tumor growth and survival in a particular microenvironment that may not be found or required for growth of xenografts of conventional cell lines. The anti-prostate stem cell antigen antibody AGS-1C4D4 completing a Phase II study in pancreatic cancer is the most advanced example of this approach (35,36). The chemical compounds and antibodies created by our three research sites, together with in-licensed compounds, form our oncology development pipeline as shown in Table 1. Table 1. Astellas' oncology development pipeline Code no., generic name Classification Therapeutic target Phase Origin Remarks ASP3550, degarelix GnRH receptor antagonist Prostate cancer Filed Ferring Pharmaceuticals MDV3100 Androgen antagonist Prostate cancer III Medivation Erlotinib (Tarceva) HER1/EGFR tyrosine kinase inhibitor Non-small cell lung cancer (first line for patients with EGFR mutation, adjuvant), hepatocellular carcinoma III In-house (OSI) New indication OSI-906 IGF-1R/IR tyrosine kinase inhibitor Adrenocortical carcinoma (ACC), ovarian cancer, non-small cell lung cancer, hepatocellular carcinoma III (ACC), II (others) In-house (OSI) Ref. (30) ASP4130, tivozanib Triple VEGF receptors inhibitor Renal cell carcinoma (RCC), breast cancer, colorectal cancer III (RCC), II (others) AVEO Pharmaceuticals, Inc. YM155 Survivin suppressant Breast cancer, non-Hodgkin's lymphoma II In-house (Tsukuba) Refs (14,15) AC220 FLT3 kinase inhibitor Acute myeloid leukemia II Ambit Biosciences Corporation AGS-1C4D4 Antibody (prostate stem cell antigen) Pancreatic cancer II In-house (Agensys) Refs (34,35) OSI-027 mTOR kinase inhibitor Renal cell carcinoma II In-house (OSI) AGS-16M8F Antibody-drug conjugate (ADC) Cancer I In-house (Agensys) ASG-5ME ADC Cancer I In-house (Agensys) Co-development with Seattle Genetics ASP1707 Small molecule Prostate cancer, endometriosis I In-house (Tsukuba) ASP3026 ALK kinase inhibitor Cancer I In-house (Tsukuba) Refs (21,22) ASP9521 Small molecule Prostate cancer I In-house (Tsukuba) AGS-22M6E ADC Cancer I In-house (Agensys) Ref. (33), Co-development with Seattle Genetics GnRH, gonadotropin-releasing hormone; HER1, human epidermal growth factor receptor 1; EGFR, epidermal growth factor receptor; IGF-1R, insulin-like growth factor receptor 1; IR, insulin receptor; VEGF, vascular endothelial growth factor; FLT3, fetal liver tyrosine kinase 3.

ef. (33), Co-development with Seattle Genetics GnRH, gonadotropin-releasing hormone; HER1, human epidermal growth factor receptor 1; EGFR, epidermal growth factor receptor; IGF-1R, insulin-like growth factor receptor 1; IR, insulin receptor; VEGF, vascular endothelial growth factor; FLT3, fetal liver tyrosine kinase 3. This table is based on the status of November 2011. Astellas is not developing YM511 or YM580. Astellas has out-licensed FK228 to Gloucester Pharmaceuticals Inc. (currently Celgene Corporation) and YM753 to Oncolys BioPharma Inc. The three research sites have multiple collaborations that span sites on the basis of research programs as well as platform technologies. The research activities at the sites are coordinated through a team consisting of research leaders, clinical leaders, including medical oncologists, and strategy leaders. This team reviews the research activities of each site and offers ideas for improvement of research programs at each site and to facilitate further collaboration.

activities at the sites are coordinated through a team consisting of research leaders, clinical leaders, including medical oncologists, and strategy leaders. This team reviews the research activities of each site and offers ideas for improvement of research programs at each site and to facilitate further collaboration. In concluding this chapter, we would like to describe how we tackle rapidly progressing fields, taking epigenetics as an example. When molecules involved in epigenetic modification of histone emerged as therapeutic targets, both of our parent companies utilized their natural product technology platform to the discover histone deacetylase inhibitors, namely FK228 and YM753 (37). Since then, a number of epigenetic modification mechanisms have been identified as potential therapeutic targets and biomarkers (38), and we now see this progress as an opportunity for novel drug discovery based on our current mindset and technology platforms.

istone deacetylase inhibitors, namely FK228 and YM753 (37). Since then, a number of epigenetic modification mechanisms have been identified as potential therapeutic targets and biomarkers (38), and we now see this progress as an opportunity for novel drug discovery based on our current mindset and technology platforms. FUTURE PERSPECTIVES We have described our research activities with emphasis on what we are doing in our research sites. However, our research activities are already based on a number of external collaborations (39), and we seek further opportunity of such collaborations in order to create and deliver novel treatments to cancer patients. We understand that such opportunity is not only in the accomplishments of basic science, but also in the findings and insights derived from clinical practice. While we understand that the feedback of clinical findings to drug discovery in a timely and appropriate manner is a big challenge, it is our hope that we can take this challenge with the readers of this paper. Conflict of interest statement Yutaka Yanagita, PhD, is an employee of Astellas Pharma Inc. Toichi Takenaka, DVM, PhD, is a Senior Scientific Advisor and a former Chairman of the Board of Astellas Pharma Inc.

FUTURE PERSPECTIVES We have described our research activities with emphasis on what we are doing in our research sites. However, our research activities are already based on a number of external collaborations (39), and we seek further opportunity of such collaborations in order to create and deliver novel treatments to cancer patients. We understand that such opportunity is not only in the accomplishments of basic science, but also in the findings and insights derived from clinical practice. While we understand that the feedback of clinical findings to drug discovery in a timely and appropriate manner is a big challenge, it is our hope that we can take this challenge with the readers of this paper. Conflict of interest statement Yutaka Yanagita, PhD, is an employee of Astellas Pharma Inc. Toichi Takenaka, DVM, PhD, is a Senior Scientific Advisor and a former Chairman of the Board of Astellas Pharma Inc. Acknowledgement Figure 1 was kindly provided by the High Energy Accelerator Research Organization (KEK). We thank many colleagues in Astellas for their support in preparing the manuscript. This paper is dedicated to the late Dr Teruhisa Noguchi, the pioneer of biotechnology and genomics-based drug discovery in Japan who led drug discovery at the former Yamanouchi Pharmaceutical Inc., one of the parent companies of Astellas, as an Executive Vice President.

INTRODUCTION The primary principle of radiotherapy (RT) lies on precise localization of sufficient dose in the target lesion while minimizing the damage to the surrounding normal tissues. The success of the treatment therefore largely depends on the performance and capacity of the accelerator, treatment planning system and other related devices, as well as the quality of the radiation beams employed. This was proved by the fact that when the energy of photons (X-rays and gamma rays) reached the order of megavoltage in the 1950s, which marked the beginning of a modern RT, a significant improvement in local control (LC) had been obtained. The question is then raised whether improved LC could be associated with improved survival, despite the fact that many patients eventually succumb to distant metastases. There has been ample evidence that in a large number of malignancies, the local recurrence or relapse is correlated with distant metastasis and the impact of improved LC on survival is mediated via a reduction in deaths caused by local progression and a reduction in distant metastasis (1). In this context, ion beams such as protons and carbon ions, when compared with photons, provide beneficial dose distribution and, in the case of carbon ions being heavier than protons, a larger relative biological effectiveness (RBE), leading to a higher probability of tumor control with the lesser volume of the surrounding normal tissues irradiated and reduction in the frequency and severity of radiation morbidity.

eficial dose distribution and, in the case of carbon ions being heavier than protons, a larger relative biological effectiveness (RBE), leading to a higher probability of tumor control with the lesser volume of the surrounding normal tissues irradiated and reduction in the frequency and severity of radiation morbidity. CHARACTERISTICS OF CARBON IONS Physical Aspects When compared with photons and fast neutrons, which are characterized by an exponential absorption of dose with depth, ion beams demonstrate an increase in energy deposition with penetration depth up to the sharp maximum at the end of their range, known as a Bragg peak. The peak is typically narrow, a few millimeters at the 80% level, and the dose at the peak is several times greater than the dose in the plateau. The particle range is determined by the energy of the incoming particles.

ion with penetration depth up to the sharp maximum at the end of their range, known as a Bragg peak. The peak is typically narrow, a few millimeters at the 80% level, and the dose at the peak is several times greater than the dose in the plateau. The particle range is determined by the energy of the incoming particles. The quality of dose distribution is affected by the energy spread and range straggling, whose magnitude is smaller for carbon ions than protons, as well as by the degree of lateral sharpness (penumbra) that is dependent upon the Coulomb scattering and becomes smaller with increasing the mass of particles (2). Therefore, when comparing dose distributions between carbon ion beams and proton beams, the lateral fall-off around the target volume is more rapid in carbon ion beams than proton beams. In the region beyond the distal end of the peak, however, almost no dose is deposited in protons but a small dose in carbon ions because the primary carbon ions undergo nuclear interactions and fragment into particles with lower atomic number, producing a fragmentation tail beyond the peak. The biological effect of this fragmentation tail is small because the tail contains only fragments with low atomic number.

ns but a small dose in carbon ions because the primary carbon ions undergo nuclear interactions and fragment into particles with lower atomic number, producing a fragmentation tail beyond the peak. The biological effect of this fragmentation tail is small because the tail contains only fragments with low atomic number. Since the original peak is too narrow and sharp to be used directly for the treatment of lesions with different shapes and sizes, broadening of the narrow peak is necessary to conform to the size and shape of the lesions. This has been achieved in two ways: a beam-scattering method with a passive beam delivery system (2,3) and a beam-scanning method with an active beam delivery system (4,5). In a beam-scattering method, the narrow peaks are swept over an extended region by a ridge filter to create the spread-out Bragg peak (SOBP) corresponding to the size of the target volume (Fig. 1). The shape of the ridge filter is designed to apply a gradient to the physical dose in order to achieve a uniform cell killing or isoeffect over the SOBP. For placing the SOBP precisely to the target, a combination of a range modulator, collimator and compensator is used in this method. In a beam-scanning method, on the other hand, the peak position is dynamically moved within the target by changing the beam energy in the accelerator or changing the beam penetration using absorbers, by which the sufficient dose can be precisely conformed to the target volume. Figure 1. Dose distributions of ion beams. The ionization density increases with depth and the relative biological effectiveness (RBE) increases as they travel deeper in the body. The ratio of the RBE for the peak to plateau of carbon ions becomes larger than that of proton beams.

cisely conformed to the target volume. Figure 1. Dose distributions of ion beams. The ionization density increases with depth and the relative biological effectiveness (RBE) increases as they travel deeper in the body. The ratio of the RBE for the peak to plateau of carbon ions becomes larger than that of proton beams. Radiobiological Aspects The rate at which particle beams lose energy when penetrating into the tissue increases with the mass of the particles and is known as linear energy transfer (LET). Photons, electrons and protons are sparsely ionizing radiations and referred to as low-LET radiations, while fast neutrons and carbon ions are densely ionizing high-LET radiations. The LET has been used to evaluate the biological effects of radiations based on the fact that as the LET increases, the RBE also increases (6,7). Here, the RBE is defined as the ratio of two doses of different radiations given under identical conditions including dose fractionation and the tissue irradiated. In contrast to neutron beams whose LET remains uniformly high at any depth, the LET of carbon ion beams increases steadily with increasing the depth to reach the maximum in the peak region. This property is extremely advantageous from the therapeutic point of view, as the RBE of carbon ion beams also increases as they advance deeper to the tumor-lying region (Fig. 1).

formly high at any depth, the LET of carbon ion beams increases steadily with increasing the depth to reach the maximum in the peak region. This property is extremely advantageous from the therapeutic point of view, as the RBE of carbon ion beams also increases as they advance deeper to the tumor-lying region (Fig. 1). Tepper et al. (8) and Goldstein et al. (9) investigated RBE values for single and fractionated doses for jejunal crypt cell survival after irradiation with various ions at different positions of the SOBP. They observed an increasing effectiveness of ions with increasing ion charge (and mass). As the ion mass increased, the increase in the RBE was first observed in the peak region and then extended to the plateau region. When different ion species were compared, carbon ions were characterized by the highest peak-to-plateau RBE ratio, which was also confirmed in early skin reactions of the mouse after carbon ion irradiation (10,11). Carbon ion beams are therefore considered to have the ‘best balance’ in terms of both the physical dose distribution and biological effect. This opens up a promising potential for the highly effective use of carbon ions in such tumors that are deeply located and resistant to photon beams.

arbon ion irradiation (10,11). Carbon ion beams are therefore considered to have the ‘best balance’ in terms of both the physical dose distribution and biological effect. This opens up a promising potential for the highly effective use of carbon ions in such tumors that are deeply located and resistant to photon beams. The tumors with low radioresponsiveness against low-LET radiations are assumed to have a high proportion of hypoxic cells, poor reoxygenation pattern and high intrinsic repair capacity. It is also assumed that such tumors could benefit from high-LET radiations because the reduction in the oxygen enhancement ratio (OER) is achieved with increasing LET, together with the reduction in differences in radiosensitivity related to the position of the cells in the cell cycle, providing the rationale of introducing high-LET carbon ions in cancer therapy. Local values for the RBE can be as high as 2.0–3.5 for carbon ions and depend on many factors, which have to be addressed during the treatment planning.

differences in radiosensitivity related to the position of the cells in the cell cycle, providing the rationale of introducing high-LET carbon ions in cancer therapy. Local values for the RBE can be as high as 2.0–3.5 for carbon ions and depend on many factors, which have to be addressed during the treatment planning. CLINICAL ADVANTAGES OF CARBON IONS Improved Therapeutic Gain Although the RBE of high-LET carbon ions is greater than that of low-LET protons or photons, the clinical interest lies in the existence of differential effects between the tumor and normal tissue that favor the normal tissue. In this regard, radiobiological advantages expected from the use of carbon ions are: the repair of radiation damage is less, repopulation of the tissue is suppressed, OER is reduced and cell cycle dependency of radiosensitivity is reduced. These characteristics become the maximum at the peak region and, combined with improved physical dose localization, may play a major role in improving the therapeutic ratio of carbon ion beams when compared with proton and photon beams.

uppressed, OER is reduced and cell cycle dependency of radiosensitivity is reduced. These characteristics become the maximum at the peak region and, combined with improved physical dose localization, may play a major role in improving the therapeutic ratio of carbon ion beams when compared with proton and photon beams. Batterman et al. (12) investigated the relationship between the RBE values and the volume-doubling time in lung metastases after fast neutron irradiation. They found that the RBE of fast neutron beams was larger with greater volume-doubling time and that neutron beams had a higher RBE value than photon beams for slow-growing tumors such as salivary gland tumor, prostate cancer and bone/soft tissue sarcomas. In the case of salivary gland tumors, the RBE for fractionated RT was found to be ∼8.0 compared with the values in the range of 3.0–3.5 expected for late damage in most normal tissues. Laramore et al. (13) summarized those tumor types and clinical situations in which fast neutron therapy offered an advantage. These findings could also be applied to carbon ion beams whose RBE is similarly high as that of fast neutron beams, and thereby, carbon ion RT could be effective against locally advanced, photon-resistant tumors as well as those located near critical structures.

tions in which fast neutron therapy offered an advantage. These findings could also be applied to carbon ion beams whose RBE is similarly high as that of fast neutron beams, and thereby, carbon ion RT could be effective against locally advanced, photon-resistant tumors as well as those located near critical structures. Hypofractionated Radiotherapy Because of its unique physical and biological properties, it is theoretically possible in carbon ion RT to perform hypofractionated RT with significantly smaller number of fractions than has been used in standard photon RT. Experiments with fast neutron beams have demonstrated that increasing the dose per fraction tended to lower the RBE for both tumor and normal tissues, but the RBE for the tumor did not decrease as rapidly as the RBE for normal tissues (14). These experiments led to the assumption that the therapeutic ratio would increase rather than decrease, even though the fraction dose was increased. Similar results have been obtained in experiments conducted with carbon ions (11,15), providing the biological rationale for the validity of the short-course, hypofractionated regimen in carbon ion RT.

ssumption that the therapeutic ratio would increase rather than decrease, even though the fraction dose was increased. Similar results have been obtained in experiments conducted with carbon ions (11,15), providing the biological rationale for the validity of the short-course, hypofractionated regimen in carbon ion RT. Progress in dose escalation has been made at the National Institute of Radiological Sciences (NIRS) in Japan on a scale that permits the RT for Stage I lung cancer and liver cancer to be completed in one and two fractions, respectively. Even for other tumors such as head and neck cancer, prostate cancer and bone/soft tissue sarcomas that generally require a relatively prolonged irradiation time, it has been possible to accomplish the definitive treatment in16 fractions over 4 weeks in carbon ion RT. Currently, the average number of fractions and the treatment time per patient is 13 fractions in ∼3 weeks without enhancing toxicity (16–18).

sarcomas that generally require a relatively prolonged irradiation time, it has been possible to accomplish the definitive treatment in16 fractions over 4 weeks in carbon ion RT. Currently, the average number of fractions and the treatment time per patient is 13 fractions in ∼3 weeks without enhancing toxicity (16–18). Potential Suppression of Metastases Ogata et al. (19) reported that carbon ion irradiation induced DNA damage, which possibly suppressed the metastatic capabilities of tumor cells, leading to suppression of pulmonary metastases in vivo. They postulated that the suppression of metastases might have been caused by carbon ion irradiation producing a higher proportion of double-strand DNA breaks than does X-ray irradiation. Their findings have been also confirmed by Tamaki et al. (20) and Akino et al. (21). This may be an advantage of carbon ion RT, although further studies are warranted to confirm these findings. Secondary cancer induction after neutron and carbon ion RT, however, is of particular concern since valid clinical data are not yet available.

ave been also confirmed by Tamaki et al. (20) and Akino et al. (21). This may be an advantage of carbon ion RT, although further studies are warranted to confirm these findings. Secondary cancer induction after neutron and carbon ion RT, however, is of particular concern since valid clinical data are not yet available. TREATMENT PLANNING The first preparatory procedure to ensure the proper administration of carbon ion RT is the fabrication of immobilization devices for each particular patient. Computed tomography (CT) scans for treatment planning are then taken with the patient wearing these devices. For the determination of target volume, fusion images using CT, magnetic resonance imaging and positron emission tomography images have been frequently employed (Fig. 2). For the treatment of moving organs, the respiratory-gated irradiation devices have also been applied at the time of CT scans (22). At present, the respiration-synchronized irradiation is only feasible in a passive method but is under development in an active scanning method. The CT image data obtained in this manner are then transferred to the treatment planning system. At this stage, the irradiation parameters in terms of the number of irradiation portals and their directions are determined in conjunction with delineation of the target volume. Figure 2. In treatment planning, fusion images using the computed tomography, magnetic resonance imaging and positron emission tomography are commonly used (left). Dose distributions of the different planes and facial surface (middle). The patient with adenoid cystic cancer before and after carbon ion radiotherapy (right).

re 2. In treatment planning, fusion images using the computed tomography, magnetic resonance imaging and positron emission tomography are commonly used (left). Dose distributions of the different planes and facial surface (middle). The patient with adenoid cystic cancer before and after carbon ion radiotherapy (right). Treatment planning for carbon ion RT has been performed by the beam-scattering method (broad beam) developed at NIRS and the beam-scanning method developed at the Gesellschaft für Schwerionenforschung (GSI). The NIRS approach is based on clinical experience with high-LET neutron beams, in which the estimation of the clinically relevant RBE values is implemented as a two-step procedure; biological RBE is distinguished from the ‘clinical RBE’. For shaping the SOBP, the human salivary gland (HSG) tumor cell line was selected as an in vitro model system because the initial patients to receive carbon ion RT were those with adenocarcinomas (3). The GSI approach for selection of the RBE is based on the Local Effect Model, which allows the calculation of the biological effectiveness essentially based on two sets of input data, including physical characterization for radiation fields and biological characterization for the response of the cells or tissues, parameterized by a modified linear-quadratic approach (23). The treatment planning for the NIRS approach is performed by HIPLAN (24).

ectiveness essentially based on two sets of input data, including physical characterization for radiation fields and biological characterization for the response of the cells or tissues, parameterized by a modified linear-quadratic approach (23). The treatment planning for the NIRS approach is performed by HIPLAN (24). CARBON ION THERAPY FACILITIES Historically, ion beam RT was begun using proton beams at the Lawrence Berkeley National Laboratory (LBNL) in 1954. Since then, the efficacy of heavier charged nuclei such as helium, carbon, nitrogen, neon, silicon and argon had been assessed for clinical use at LBNL. The major pioneering work for heavy ions was done at LBNL between 1977 and 1992, in which most patients were treated with helium and neon ions (25,26). In 1994, the clinical study on Carbon ion RT was started in NIRS using carbon ions generated by HIMAC, which was the world's first accelerator complex dedicated to cancer therapy. At present, there are more than 30 proton therapy facilities in operation, while carbon ion RT is performed in 5 facilities worldwide. Following the HIMAC/NIRS, the GSI in Darmstadt, Germany, started carbon ion RT in 1997, which terminated clinical application and was succeeded by Heidelberg Ion-Beam Therapy Center (HIT) in 2009. The HIT is the facility having both protons and carbon ions for clinical use (27). The Hyogo Ion Beam Medical Center (HIBMC) in Japan, established in 2001, is the first facility dedicated to proton/carbon treatment. At the Institute of Modern Physics (IMP) in Lanzhou, China, clinical trials have been performed since 2006, where carbon ion beams with energy up to 100 MeV/u have been supplied only for the treatment of superficial tumors. Based on technological research and development at NIRS, a downsized carbon-ion facility was realized as the Gunma University Heavy Ion Medical Center (GHMC), Gunma University in Japan, where a clinical study took place in 2010 (28).

nergy up to 100 MeV/u have been supplied only for the treatment of superficial tumors. Based on technological research and development at NIRS, a downsized carbon-ion facility was realized as the Gunma University Heavy Ion Medical Center (GHMC), Gunma University in Japan, where a clinical study took place in 2010 (28). In the Foundation CNAO, Italy, the accelerator complex was completed for proton/carbon treatment, in which the clinical study on proton therapy started in October 2011, and carbon ion RT is due to start in about 1 year. Under the license agreement between the GSI and the vendor company, proton/carbon facilities modeled on HIT are under construction in Marburg and Kiel, Germany, as well as in Shanghai, China. At present, however, there is uncertainty whether these institutions will be really built as has been planned. There are four more institutions with a carbon ion facility under construction: two in Japan, one in Austria and one in Lanzhow, China. Among them, the SAGA-HIMAT in Tosu, Japan, is unique in terms of its construction being based on a public–private partnership. The other facility is Kanagawa Cancer Center, Japan, in which both a passive and an active beam delivery system will be installed.

ction: two in Japan, one in Austria and one in Lanzhow, China. Among them, the SAGA-HIMAT in Tosu, Japan, is unique in terms of its construction being based on a public–private partnership. The other facility is Kanagawa Cancer Center, Japan, in which both a passive and an active beam delivery system will be installed. CLINICAL RESULTS OF CARBON ION RT By the end of 1988, a total of 239 patients received a minimum neon physical dose of 10 Gy (median follow-up for survivors 32 months) at LBNL. Compared with historical results, the improved outcome was obtained for several types of tumors including advanced or recurrent macroscopic salivary gland carcinomas, paranasal sinus tumors, advanced soft tissue sarcomas, macroscopic sarcomas of the bone, locally advanced prostate carcinomas and biliary tract carcinomas (25,26). However, the treatment results of malignant gliomas, pancreatic, gastric, esophageal, lung and advanced or recurrent head and neck cancer appeared no better than those achieved with conventional X-ray therapy. Unfortunately, clinical research at LBNL was terminated in 1992 as the result of budget constraints in addition to the aging of the machine.

as needed on the radiation-induced reactions of the main bronchus. This type of cancer is characterized by relatively superficial lesions and has been successfully controlled with 57.6 GyE in 9 fractions over 3 weeks. On the other hand, for a central-type tumor forming a bulky lesion, the higher dose has been employed. Hepatocellular Cancer Hepatocellular carcinoma (HCC) is one of the most common tumors in the world, causing 662 000 deaths per year with about half of them in China (68). HCC is one of the cancers with poor prognosis in China, where chronic hepatitis B is found in 90% of cases. In Japan, chronic hepatitis C is more common and is associated with 90% of HCC cases. The outcome of HCC is generally poor because only 10–20% of HCC can be removed completely with surgery, and the 5-year survival rate is ∼15% (69). HCC is associated with liver cirrhosis in 85% of all cases, which is itself a serious disorder of the liver. Although the tolerance of the liver to irradiation is generally small, proton therapy has been extensively applied for this disease. As shown in Table 5, the 2- or 3-year LC and overall survival rates obtained with proton therapy are 75–96 and 55–66%, respectively (70–73). The degree of liver dysfunction attributable to coexisting liver cirrhosis and the number of tumors in the liver significantly affected patient survival (72). Table 5. Hepatocellular carcinoma

of malignant gliomas, pancreatic, gastric, esophageal, lung and advanced or recurrent head and neck cancer appeared no better than those achieved with conventional X-ray therapy. Unfortunately, clinical research at LBNL was terminated in 1992 as the result of budget constraints in addition to the aging of the machine. Stimulated by the promising results of ion beam therapy at LBNL, carbon ion RT was started at NIRS in 1994, where all patients have been treated within prospective Phase I/II or Phase II studies. In dose-escalation Phase I/II studies, the same rule of fixing both the total number of fractions and overall treatment time has been employed, and the total dose has been escalated in incremental steps of 5 or 10%. When the recommended dose was thus established in the Phase I/II study, it was then used in the following Phase II study. Since 1994, more than 6500 patients have been treated with carbon ions, demonstrating the benefit of carbon ion RT over other modalities in various types of tumors in terms of high LC and survival rates. A significant reduction in the overall treatment time with acceptable toxicities has been achieved in most cases (16–18). At GSI, the first patient was treated in 1997 using the beam line of GSI's heavy-ion synchrotron that had been primarily used for physics research. The clinical study at GSI was terminated in 2008; until then, over 450 patients were treated with carbon ions. The main indications were patients with chordomas and chondrosarcomas of the skull base, locally advanced adenoid cystic carcinomas (ACCs) as well as the chordoma and chondrosarcoma of the sacrum and prostate cancer (27).

study at GSI was terminated in 2008; until then, over 450 patients were treated with carbon ions. The main indications were patients with chordomas and chondrosarcomas of the skull base, locally advanced adenoid cystic carcinomas (ACCs) as well as the chordoma and chondrosarcoma of the sacrum and prostate cancer (27). Head and Neck Tumors Results of proton therapy for head and neck tumors are difficult to evaluate because it has been frequently used as a boost therapy or combined with surgery with a variety of pathological types reported as a whole (29,30). Carbon ion RT has been found to offer radiobiological advantages in histologically non-squamous cell tumors such as ACC, adenocarcinoma, malignant melanoma and various sarcomas in prospective dose-escalation trials (31–33).

erapy or combined with surgery with a variety of pathological types reported as a whole (29,30). Carbon ion RT has been found to offer radiobiological advantages in histologically non-squamous cell tumors such as ACC, adenocarcinoma, malignant melanoma and various sarcomas in prospective dose-escalation trials (31–33). Adenoid cystic carcinoma ACC is a rare form of adenocarcinoma, which is a broad term describing any cancer arising from glandular tissues. ACC is found mainly in the head and neck region and most commonly occurs in the salivary glands. Regardless of where it starts, ACC tends to spread along nerves (perineural invasion) or through the bloodstream. The most common site of metastasis is the lung. It spreads to the lymph nodes in only ∼5–10% of cases. The results of treatment for photon RT or surgery ranged from 27 to 72% for the 5-year LC rate and from 25 to 85% for the 5-year survival rate (34,35). In Table 1, an experience of proton therapy on 23 patients is reported, in which about half of the patients were treated with surgical resection followed by proton irradiation (36). There were three Grade III and one Grade IV late toxicities (17% ≥ Grade III late reactions). In contrast, there were no patients with ≥Grade III toxicities for a total of 151 patients with locally advanced ACC involving the oropharynx and the paranasal sinus treated with carbon ion RT alone at NIRS (32). The 5-year LC rate was 74% in spite of including 78 cases (52%) of T4 and 40 cases (26%) with recurrent tumors after surgery and/or chemotherapy. For 32 patients who seemed to be locally operable, the 5-year LC rate was improved to 96%. At GSI, patients with paranasal sinus cancers were treated with combined stereotactic photon RT to the clinical target volume, followed by a carbon ion boost to the gross target volume (33). Locoregional control rates for the combined photon and carbon ions were better than those observed in historical series of patients treated with photon intensity-modulated RT (IMRT) alone, although the difference was not statistically significant. Table 1. Adenoid cystic carcinomas of the head and neck

get volume (33). Locoregional control rates for the combined photon and carbon ions were better than those observed in historical series of patients treated with photon intensity-modulated RT (IMRT) alone, although the difference was not statistically significant. Table 1. Adenoid cystic carcinomas of the head and neck Institutions No. of patients Treatment 5-year local control (%) 5-year overall survival (%) Late ≥GIII injury Iowa, 2009 (34) 54 Surgery alone 72 85 — 10 Photon alone 27 25 — Florida, 2004 (35) 101 Photon alone 56 57 12.9% MGH, 2006 (36) 23 Proton ± surgery 93 77 17% Heidelberg, 2001 (37) 29 Neutron ± surgery 75 59 19% GSI, 2005 (33) 34 Photon alone 25 (4 years) 78 (4 years) <5% 29 Photon + carbon boost 78 (4 years) 76 (4 years) NIRS, 2011 (32) 151 Carbon alone (all pats) 74 72 None 32 Carbon alone (T1–T3) 96 92 119 Carbon alone (T4 or recurrences) 71 69

Proton ± surgery 93 77 17% Heidelberg, 2001 (37) 29 Neutron ± surgery 75 59 19% GSI, 2005 (33) 34 Photon alone 25 (4 years) 78 (4 years) <5% 29 Photon + carbon boost 78 (4 years) 76 (4 years) NIRS, 2011 (32) 151 Carbon alone (all pats) 74 72 None 32 Carbon alone (T1–T3) 96 92 119 Carbon alone (T4 or recurrences) 71 69 Mucosal malignant melanoma Mucosal malignant melanoma of the head and neck (MMHN) is a rare type of tumor. Radical local excision used to be the treatment that provided a chance of cure, although the prognosis was generally grave. Adding RT to surgery in tumors that could be radically excised did not confer any statistically significant advantage in reducing local recurrence or improving survival (38–40). There has been no reported data for proton therapy, possibly because MMHN is considered to be resistant to proton beams. From 1997 to 2010, a total of 198 patients with MMHN were treated with carbon ions with or without chemotherapy at NIRS (32). In the initial study, 102 patients were treated with carbon ion RT alone with 57.6 GyE in 16 fractions over 4 weeks (41). The 5-year survival rate was 35%, which was similar to the most favorable results of surgery combined with or without RT or chemotherapy. This study strongly suggested the need of adding systemic therapy for the prevention of distant metastasis. Therefore, in the subsequent study for 96 patients, concomitant chemotherapy (DAV: Day 1: dacarbazine (DTIC) 120 mg/m2 + nimustine 70 mg/m2 + vincristine 0.7 mg/m2; Days 2–5: DTIC 120 mg/m2) with a 4-week interval, a total of five courses, was administered for the first course at the start of carbon ion RT, second course at the completion of RT and three courses thereafter (32). Although the LC rate remained almost the same, the 5-year survival rate improved by 23% and became 58% (Table 2). These results would be the best so far reported in the literature. Table 2. Mucosal malignant melanomas of the head and neck

ion RT, second course at the completion of RT and three courses thereafter (32). Although the LC rate remained almost the same, the 5-year survival rate improved by 23% and became 58% (Table 2). These results would be the best so far reported in the literature. Table 2. Mucosal malignant melanomas of the head and neck Treatment Author Year No. of patients 5-year overall survival (%) Surgery (±RT, ±chemo) Chang et al. (38) 1998 163 32 Patel et al. (39) 2002 59 35 Lund et al. (40) 1999 58 28 Carbon alone Yanagi et al. (41) 2009 102 35 Carbon + chemo (DAV) Hasegawa et al. (32) 2011 96 58

ion RT, second course at the completion of RT and three courses thereafter (32). Although the LC rate remained almost the same, the 5-year survival rate improved by 23% and became 58% (Table 2). These results would be the best so far reported in the literature. Table 2. Mucosal malignant melanomas of the head and neck Treatment Author Year No. of patients 5-year overall survival (%) Surgery (±RT, ±chemo) Chang et al. (38) 1998 163 32 Patel et al. (39) 2002 59 35 Lund et al. (40) 1999 58 28 Carbon alone Yanagi et al. (41) 2009 102 35 Carbon + chemo (DAV) Hasegawa et al. (32) 2011 96 58 Bone and soft tissue sarcomas of the head and neck Bone and soft tissue sarcomas of the head and neck are rare mesenchymal malignant neoplasms accounting for <10% of all bone and soft tissue sarcomas and ∼1% of all head-and-neck neoplasms. Wide resection with enough safety margins is usually difficult, and delivery of high radiation dose is limited by the vicinity of critical normal tissue structures including the spinal cord, brain stem and eyes. Accordingly, the LC rates for these tumors are lower compared with the extremities (42). In resectable cases, the 5-year LC rate of combined surgery and RT, surgery alone and RT alone are 60–70, around 54 and 43–50%, respectively (43); however, in unresectable sarcomas, the prognosis is miserable (44). There are no reported data for proton therapy as a sole treatment, possibly because these types of tumors are considered difficult to treat with low-LET protons. In a dose-escalation study on carbon ion RT conducted at NIRS, the 5-year LC rate using 64.0 or 57.6 GyE (n = 16) was only 24%, whereas for the patients receiving 70.4 GyE in 16 fractions (n = 39), the 5-year LC rate was improved significantly to 73% and the 5-year survival rate was 48% with acceptable toxicities (32,45). These results would be the best so far reported in the literature for unresectable sarcomas.

57.6 GyE (n = 16) was only 24%, whereas for the patients receiving 70.4 GyE in 16 fractions (n = 39), the 5-year LC rate was improved significantly to 73% and the 5-year survival rate was 48% with acceptable toxicities (32,45). These results would be the best so far reported in the literature for unresectable sarcomas. Skull Base and Upper Cervical Spine Tumors Major types of tumors of the skull base and the upper cervical spine include chordoma, chondrosarcoma, olfactory neurogenic tumor and meningioma, for which complete resection is rarely achieved because of the vicinity to the critical normal structures (46). They are generally resistant to photon beams. While improvements have been achieved with proton and helium ion therapy, the variance of LC rates among different centers is significant, possibly due to patient selection and differences in treatment techniques employed (47–52). It is of note that in the case of chordoma, there are still many cases who develop recurrences even after 5 years. Munzenrider and Liebsch (48) reported that the LC rate was 73% at 5 years after proton therapy, whereas it was only 54% at 10 years. In this regard, carbon ion RT holds a promising potential of improving long-term results, most likely due to increased biological effects of carbon ions as well as the sharp lateral fall-off permitting better sparing of critical organs (53–55).

s 73% at 5 years after proton therapy, whereas it was only 54% at 10 years. In this regard, carbon ion RT holds a promising potential of improving long-term results, most likely due to increased biological effects of carbon ions as well as the sharp lateral fall-off permitting better sparing of critical organs (53–55). A total of 76 patients with skull base and paracervical tumors including 44 chordoma, 14 chondrosarcoma, 9 olfactory neuroblastoma, 7 malignant meningioma, 1 giant cell tumor and 1 neuroendocrine carcinoma were treated with carbon ions at NIRS. There were no patients who developed serious acute (Grade ≥4) or late (Grade ≥3) reactions. The 5-year LC and survival rates for all 76 patients were 88 and 82%, respectively (55).

9 olfactory neuroblastoma, 7 malignant meningioma, 1 giant cell tumor and 1 neuroendocrine carcinoma were treated with carbon ions at NIRS. There were no patients who developed serious acute (Grade ≥4) or late (Grade ≥3) reactions. The 5-year LC and survival rates for all 76 patients were 88 and 82%, respectively (55). In the current study, at NIRS for 47 chordoma patients who received 60.8 GyE in 16 fractions, the 5-year survival rate was 87%. As shown in Table 3, the 5- and 10-year LC rates for these patients were 88 and 80%, respectively, without serious toxic reactions. When comparing the treatment results of different modalities reported in the literature for chordoma, the observation period of 5 years may not be long enough and an even longer period may be needed. In this context, when compared with proton therapy, the better LC rates at 5 and 10 years after carbon ion RT should have confirmed the radiobiological advantage of carbon ions. The GSI reported that cumulative LC and survival rates at 5 years were 70 and 86% for chordomas and 87 and 100% at 4 years for chondrosarcomas, respectively. Severe late toxicity was observed in <5% of all patients, while the overall treatment time was significantly reduced to 3 weeks (46,53). Table 3. Chordomas of the skull base and upper cervical spine

and survival rates at 5 years were 70 and 86% for chordomas and 87 and 100% at 4 years for chondrosarcomas, respectively. Severe late toxicity was observed in <5% of all patients, while the overall treatment time was significantly reduced to 3 weeks (46,53). Table 3. Chordomas of the skull base and upper cervical spine Ions Author Year No. of patients Median dose Median follow-up (years) Local control Late ≥GIII injury 5 years 10 years Proton ± photon Hug et al.  (47) (Loma Linda) 1999 33 72 59% 7% Munzenrider and Liebsch (48) (MGH) 1999 169 66–83 3.4 73% 54% Noël et al. (49) (CPO) 2003 100 67.0 2.6 54% (4 years) 6% Igaki et al. (50) (Tsukuba) 2004 13 72.0 5.8 46% Ares et al. (51) (PSI) 2009 42 73.5 3.2 (mean) 62% — 6% Helium Castro et al. (52) (LB) 1994 53 65.0 4.3 63% Carbon Schulz-Ertner et al. (53) (GSI) 2007 96 60.0 2.6 (Ave.) 70% — 5% Mizoe et al. (54) (NIRS) 2009 39 48–60.8 4.7 82% 82% None Current study (NIRS) 2012 47 60.8 3.7 88% 80% None

(Tsukuba) 2004 13 72.0 5.8 46% Ares et al. (51) (PSI) 2009 42 73.5 3.2 (mean) 62% — 6% Helium Castro et al. (52) (LB) 1994 53 65.0 4.3 63% Carbon Schulz-Ertner et al. (53) (GSI) 2007 96 60.0 2.6 (Ave.) 70% — 5% Mizoe et al. (54) (NIRS) 2009 39 48–60.8 4.7 82% 82% None Current study (NIRS) 2012 47 60.8 3.7 88% 80% None Non-small Cell Lung Cancer For localized non-small cell lung cancer (NSCLC), the standard treatment used to be surgical resection. In recent years, however, an increasing number of patients have been treated with hypofractionated stereotactic body RT (SBRT) and ion beam therapy (56–59). Timmerman et al. (59) reported 3-year results from RTOG 0236, where 55 patients with biopsy-proven peripheral T1-T2N0M0 NSCLC measuring <5 cm in diameter (T1; 44, T2; 11) were treated using the prescribed dose of 18 Gy × 3 fractions (54 Gy total) in 1.5–2 weeks. The estimated 3-year primary tumor control rate and 3-year overall survival rate were 97.6 and 55.8%, respectively (Table 4). These are highly favorable results; however, protocol-specified treatment-related adverse events were quite high; Grades 3 and 4 were reported in seven (12.7%) and two (3.6%) patients, respectively. For SBRT as reported, toxicity appears to be a more significant problem, although 2-year LC rates are similar to proton therapy. Table 4. Stage I NSCLC

ults; however, protocol-specified treatment-related adverse events were quite high; Grades 3 and 4 were reported in seven (12.7%) and two (3.6%) patients, respectively. For SBRT as reported, toxicity appears to be a more significant problem, although 2-year LC rates are similar to proton therapy. Table 4. Stage I NSCLC Author Dose fractionation No. of patients (IA:IB) Overall survival Local control Late ≥GIII Stereotactic radiotherapy Baumann et al. (56) (Sweden, 2009) 45–66 Gy/3 fr 57 (40:17) 60% (3 years) 92% (3 years) 28% Fakiris et al. (57) (Indiana, 2009) T1: 60 Gy/3 fr, T2: 66 Gy/3 fr 70 (34:36) 42.7% (3 years) 88.1% (3 years), T1: 100%, T2: 77% 10% Ricardi et al. (58) (Torino, 2009) 45 Gy/3 fr 62 (43:19) 57.1% (3 years) 87.8% (3 years) <10% Timmerman et al. (59) (RTOG, 2010) 54 Gy/3 fr/1.5–2 weeks 55 (44:11, <5 cm) 55.8% (3 years) 97.6% (3 years) 10∼27% Proton beam therapy Bush et al. (60) (LLUMC, 2004) 51 CGE/10 fr/2 weeks (n = 22), 60 CGE/10 fr/2 weeks (n = 46) 68 (29:39) 44% (3 years) 74% (3 years), T1: 87%, T2: 49% None Iwata et al. (61) (Hyogo, 2010) 80.0 GyE/20 fr (n = 20) 60.0 GyE/10 fr (n = 37) 57 (27:30) 73% (3 years) 81% (3 years) 1.8% Nihei et al. (62) (NCCE, 2006) 70–94 GyE/20 fr 37 (17:20) 84% (2 years) 80% (2 years) 8.1% Nakayama et al. (63) (Tsukuba, 2010) Peripheral: 66.0 GyE/10 fr, central: 72.6 GyE/22 fr 55 (Lesions 30:28) 97.8% (2 years) 97.0% (2 years) 3.6% Carbon ion therapy Miyamoto et al. (64) (NIRS, 2003) 59.4–95.4 GyE/18 fr/6 weeks (n = 47), 68.4–79.2 GyE/9 fr/3 weeks (n = 34) 81 (40:41) 42% (5 years), T1: 64%, T2: 22% 79% (5 years) 3.7% Miyamoto et al. (65) (NIRS, 2007) 72 GyE/9 fr/3 weeks 50 (29:21) 50% (5 years), T1: 55%, T2: 43% 95% (5 years) 2.0% Miyamoto et al. (66) (NIRS, 2007) T1: 52.8 GyE/4fr/1 week, T2: 60.0 GyE/4 fr/1 week 79 (42:37) 45% (5 years), T1: 62%, T2: 25% 90% (5 years), T1: 98%, T2: 80% None Yamamoto et al. (67) (NIRS, 2011) Single fractionation (36–48 GyE/1 day) 139 (83:56) 76.9% (3 years) 85% (3 years), T1: 87.6%, T2: 79.7% None NSCLC, non-small cell lung cancer; fr, fractions.

1: 52.8 GyE/4fr/1 week, T2: 60.0 GyE/4 fr/1 week 79 (42:37) 45% (5 years), T1: 62%, T2: 25% 90% (5 years), T1: 98%, T2: 80% None Yamamoto et al. (67) (NIRS, 2011) Single fractionation (36–48 GyE/1 day) 139 (83:56) 76.9% (3 years) 85% (3 years), T1: 87.6%, T2: 79.7% None NSCLC, non-small cell lung cancer; fr, fractions. In proton therapy, 3-year in-field control rates of 74 and 81% were observed in 68 and 57 patients, respectively, and overall survival rates for these two groups were 44 and 73%, respectively (60,61). Similar to experiences of SBRT, there are no data yet reported for proton therapy based on observation for 5-year or longer (60–63).

rapy, 3-year in-field control rates of 74 and 81% were observed in 68 and 57 patients, respectively, and overall survival rates for these two groups were 44 and 73%, respectively (60,61). Similar to experiences of SBRT, there are no data yet reported for proton therapy based on observation for 5-year or longer (60–63). In carbon ion RT at NIRS, respiratory gating and image-guided RT have been integrated in order to allow for further sparing of normal lung tissues (22). Because of assumed difference in normal tissue tolerance, Stage I NSCLC was divided into two groups, peripheral type and central type. For peripheral tumors, the fraction number and treatment time have been reduced in gradual steps from 18 fractions/6 weeks through 9 fractions/3 weeks and 4 fractions/1 week and eventually to single-fraction treatment (64–67). In 129 patients treated at NIRS with 9- and 4-fraction regimens, there were no serious toxic reactions, and the 5-year LC rate was 95% for 9 fractions and 90% for 4 fractions (65,66). The 5-year overall survival rate for 9 and 4 fractions was 50.0 and 45.0%, respectively (corresponding cause-specific survival rates were 76 and 62%, respectively). Currently, a dose-escalation study for evaluating a single-fraction treatment with carbon ions is ongoing, in which high rates of LC and survival have been obtained with only minor toxicity (67).

nd 4 fractions was 50.0 and 45.0%, respectively (corresponding cause-specific survival rates were 76 and 62%, respectively). Currently, a dose-escalation study for evaluating a single-fraction treatment with carbon ions is ongoing, in which high rates of LC and survival have been obtained with only minor toxicity (67). For the treatment of the central type of NSCLC at NIRS, a larger fraction number has been used than for peripheral tumors, because it was felt that more careful observation was needed on the radiation-induced reactions of the main bronchus. This type of cancer is characterized by relatively superficial lesions and has been successfully controlled with 57.6 GyE in 9 fractions over 3 weeks. On the other hand, for a central-type tumor forming a bulky lesion, the higher dose has been employed.

.0% 81.0% 50.0% 33.0% Imada et al. (76), NIRS C-ion 64 — Porta hepatis group 52.8 GyE/4 fr — 87.8% — 22.2% — Non-porta hepatis group 52.8 GyE/4 fr 95.7% 34.8% Imada et al. (77), NIRS C-ion 40 38 (14–95) High-dose group: 42.8–45.0 GyE/2 fr 95.0% — 72.0% — 77 45 (15–140) Low-dose group: 32.0–40.8 GyE/2 fr 74.0% — 54.0% — The eligibility criteria for enrollment for carbon ion RT at NIRS was that other therapies appeared to offer no potential of sufficient efficacy or other treatments had proved ineffective in local tumor control (74–77). In an attempt to develop a hypofractionated regimen, dose-escalation studies have been successively implemented from 15 fractions/5 weeks through 12 fractions/3 weeks, 8 fractions/2 weeks, 4 fractions/1 week and eventually 2 fractions in 2 days. It was possible to conduct all these fractionation regimens only with minor toxicities. In 69 patients treated with 52.8 GyE in 4 fractions, post-treatment impairment in hepatic function was minimal and the 5-year LC and survival rates were 81 and 33%, respectively (75). There were no significant differences in LC and survival rates and toxicities between the patients whose tumors were located within 2 cm from the main portal vein (porta hepatis group) and those who had tumors more than 2 cm from the main portal vein (non-porta hepatis group) (76). Since 2003, even a shorter irradiation schedule of 2 fractions in 2 days has been employed in a dose-escalation study, in which a total of 117 patients were treated with a total dose ranging from 32.0 to 45.0 GyE. There have been no therapy-related deaths and no severe adverse events (77). The patients who received a higher dose appeared to have better LC and survival rates than those who received a lower dose.

a dose-escalation study, in which a total of 117 patients were treated with a total dose ranging from 32.0 to 45.0 GyE. There have been no therapy-related deaths and no severe adverse events (77). The patients who received a higher dose appeared to have better LC and survival rates than those who received a lower dose. In conclusion, proton therapy has been documented as yielding similar tumor control probabilities when compared with carbon ion RT in HCC. However, there is a major difference in dose fractionation between the two regimens: the conventional regimen in proton therapy and the more hypofractionated regimen in carbon ion RT.