Brief Article
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World J Gastroenterol. Jan 28, 2014; 20(4): 1067-1073
Published online Jan 28, 2014. doi: 10.3748/wjg.v20.i4.1067
Phase I study of postoperative radiotherapy combined with capecitabine for gastric cancer
Xin Wang, Jing Jin, Ye-Xiong Li, Hua Ren, Hui Fang, Shu-Lian Wang, Yue-Ping Liu, Wei-Hu Wang, Zi-Hao Yu, Yong-Wen Song, Xin-Fan Liu
Xin Wang, Jing Jin, Ye-Xiong Li, Hua Ren, Hui Fang, Shu-Lian Wang, Yue-Ping Liu, Wei-Hu Wang, Zi-Hao Yu, Yong-Wen Song, Xin-Fan Liu, Department of Radiation Oncology, Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Author contributions: Wang X, Jin J and Li YX designed the research; Wang X, Jin J, Li YX, Ren H, Fang H, Wang SL, Liu YP, Wang WH, Yu ZH, Song YW and Liu XF performed the research; Wang X collected and analyzed the data and wrote the paper; Jin J and Li YX modified the paper.
Supported by Beijing Hope Run Special Fund, No. LC2007A03
Correspondence to: Jing Jin, MD, Department of Radiation Oncology, Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Panjiayuan Nanli 17, Chaoyang District, Beijing 100021, China. jingjin1025@163.com
Telephone: +86-10-87787658 Fax: +86-10-67706153
Received: September 27, 2013
Revised: November 14, 2013
Accepted: December 12, 2013
Published online: January 28, 2014
Processing time: 121 Days and 18.9 Hours
Abstract

AIM: To determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of capecitabine combined with postoperative radiotherapy for gastric cancer.

METHODS: We enrolled patients with any T stage and node-positive gastroesophageal or gastric adenocarcinoma after complete resection with negative margins (R0) or microscopic (R1) or macroscopic (R2) resection. Intensity modulated radiotherapy (IMRT) using a five-to-seven-field, coplanar, sliding window technique was delivered to the tumor bed (T4b), anastomosis site, duodenal stump and regional lymph nodes (LNs) to a total dose of 45 Gy (1.8 Gy/fraction, 5 d/wk). Patients with R1 or R2 resection received 10.8 Gy as a boost. Capecitabine was administered twice daily on every radiotherapy treatment day in a dose-escalation schedule (mg/m2) of 625 (level I, n = 6), 700 (level II, n = 6), 800 (level III, n = 6), 900 (level IV, n = 0) and 1000 (level V, n = 0). DLT was defined as grade 4 leukopenia or neutropenia, grade 3-4 thrombocytopenia or anemia and grade 3-4 non-hematological toxicity.

RESULTS: Between October 2007 and August 2009, 18 patients (12 men, 6 women; median age, 54 years) were enrolled in the study. The median number of positive LNs was 6, and total number of resected LNs was 19. Twelve patients underwent R0 resection (66.7%). Fifteen patients received adjuvant chemotherapy under the leucovorin, fluorouracil and oxaliplatin (FOLFOX4) regimen. Six patients each were enrolled at dose levels I, II and III. Grade 1-3 leukopenia (16 patients, 88.9%), anorexia (15, 83.3%) and nausea (15, 83.3%) were the most common toxicities. Grade 3 anorexia/nausea and grade 4 vomiting occurred in one level-I patient. Grade 3 anorexia and nausea occurred in one level-II patient. One level-III patient developed grade 4 neutropenia, while another developed grade 3 radiation esophagitis. No abnormal liver or renal function examinations were observed. Three patients did not finish chemoradiotherapy because of DLTs and two without DLTs received sequential boosts (total dose, 55.8 Gy).

CONCLUSION: The MTD of capecitabine was 800 mg/m2 twice daily concurrent with IMRT for gastric cancer after surgery. The DLTs were anorexia/nausea, vomiting, neutropenia and radiation esophagitis.

Keywords: Radiotherapy; Capecitabine; Gastric cancer; Maximum tolerated dose; Dose-limiting toxicity

Core tip: Postoperative chemoradiotherapy is a good option for patients with locally advanced, gastric cancer who have undergone R0 and D0-1 lymphadenectomy. To avoid acute side effects and make the drug safer, a combination of the use of advanced techniques such as intensity modulated radiotherapy and mature chemotherapy regimens with capecitabine is highly recommended, especially in China which accounts for 40% of the world’s gastric cancer patients. The aim of this single-institution, phase I, clinical trial was to assess the feasibility and toxicity of a postoperative regimen involving dose escalation of capecitabine combined with IMRT for locally advanced gastric cancer.