ANTICANCER RESEARCH 28: 373-378 (2008)
Changes of Immunological Parameters Reflect Quality of Life-related Toxicity during Chemotherapy in Patients with Advanced Colorectal Cancer KAZUHIKO YOSHIMATSU, KOTARO KUHARA, HIROKO ITAGAKI, MASAKI AIZAWA, HAJIME YOKOMIZO, TAKASHI FUJIMOTO, TAISUKE OTANI, GAKUJI OSAWA, RIE KOBAYASHI and KENJI OGAWA
Department of Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawaku, Tokyo 116-8567, Japan
Abstract. Anticancer drugs may frequently induce host immunosuppression and symptomatic toxicities. Once symptomatic toxicity occurs, the patient's quality-of-life (QOL) is reduced. Since little is known of the relationship between host immunity and the toxicity of chemotherapy, the host immunity before and after chemotherapy was compared to assess whether it is related to symptomatic toxicity during chemotherapy. Patients and Methods: Fourteen patients with colorectal cancer underwent leucovorin /5-fluorouracil (LV/5-FU) treatment, or S-1/irinotecan (CPT-11). Host immunity (cytokine production of peripheral blood mononuclear cell (PBMC), serum soluble interleukin-2 receptor (sIL-2R) levels and phenotypic analyses of PBMC were measured before and after the first chemotherapy. Results: An increase of sIL-2R, CD4+CD25+ T-cells and the CD4/8 ratio in patients with symptomatic adverse reactions were found. These changes in the first chemotherapy were significantly different (p=0.0211, p= 0.0087, p=0.0234). Conclusion: The current study indicated that there are some parameters correlated with
Abbreviations: 5-FU, 5-fluorouracil; LV, leucovorin; CPT-11, irinotecan; PS, performance status; QOL, quality of life; PBMC, peripheral blood mono-nuclear cell; PHA, phytohemagglutinin; Con-A, Concanavalin-A; IL, interleukin; IFN, interferon; TNF, tumor necrosis factor; ELISA, enzyme-linked immunosorbent assay; mAb, monoclonal antibody; FOLFOX, infusional 5-FU/LV with oxaliplatin; FOLFIRI, infusional 5-FU/LV with irinotecan; DPD, dihydropyrimidine dehydrogenase; TS, thymidylate synthase; UGT, uridine diphosphate glucuronosyltransferase; ECOG, Eastern Coopera-tive Oncology Group. Correspondence to: Kenji Ogawa, MD, Department of Surgery, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan. Tel: +81 3 3810 1111, Fax: +81 3 3894 5493, e-mail:
[email protected] Key Words: Host immunity, CD4+CD25+ T-cell, soluble IL-2R, low-dose chemotherapy, colorectal cancer.
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toxicity during chemotherapy which effect QOL. In such patients, negative influences on host immunity, such as an increase of sIL2R and regulatory T-cells, and a decrease of cytotoxic T-cells could occurr. In recent years, chemotherapy for unresectable and metastatic colorectal cancer has been progressing. Recent additions to the chemotherapy armamentarium for this disease have begun to prolong median survival times (1-3). Current standard first-line regimens for metastatic colorectal cancer are FOLFOX (infusional 5-fluorouracil (5-FU)/leucovorin (LV) with oxaliplatin) and FOLFIRI (infusional 5-FU/LV with irinotecan (CPT-11)) (4). The addition of bevacizumab to a two-drug regimen (CPT-11 with 5-FU/LV) prolongs median survival to 20 months, with an increased amount of additional toxicity (5). Pharmacogenomics have received much attention from the increased expectations for so-called tailor-made medicine. Several studies have revealed that genetic factors are involved in different responses to therapy, such as the relationships between the adverse effects of some anticancer drugs and polymorphisms of drug metabolizing genes. Such relationships include 5-FU and the dihydropyrimidine dehydrogenase (DPD) or thymidylate synthase (TS) genes, CPT-11 and the uridine diphosphate glucuronosyl-transferase (UGT) 1A1 gene. The important cellular proteins for 5-FU metabolism are the major target enzymes, TS, and the ratelimiting enzyme in the degradation pathway, DPD. Adverse drug reactions to 5-FU-based chemotherapy have been reported to be, in part, the result of polymorphisms in the TS and DPD genes (6, 7). UGT1A1 promoter polymorphism was found to be predictive of the risk of diarrhea, emesis, and fatigue caused by chemotherapy with CPT-11 (8-10). Screening for UGT1A1 promoter polymorphism may be clinically useful for identifying patients at a higher risk of developing a severe or potentially life-threatening toxicity after CPT-11-based chemotherapy.
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ANTICANCER RESEARCH 28: 373-378 (2008) Table I. Patients' background.
Table II. QOL-related toxicity (n=14). LV/5-FU S-1/CPT-11 Total (n=7) (n=7)
Age (years)
Gender Aim of therapy
Performance status QOL related toxicity
median (range)
1
2
3, 4
3 4 2 1 0
1 1 0 0 1
0 0 0 0 0
61 (50-73) 68 (62-74)
(M/F)
3/4
2/5
5/9
(adjuvant/ therapeutic)
3/4
0/7
3/11
0/1
2/5
1/6
3/11
(+/–)
2/5
4/4
6/8
However, little data have beeen reported regarding immunological changes in the host occurring on these adverse reactions after treatment with anticancer drugs. In this study, the host immunity before and after chemotherapy was compared to assess whether host immunity is related to symptomatic toxicity during chemotherapy.
Patients and Methods Patients. The study comprised 14 patients with colorectal cancer who underwent low-dose leucovorin/5-fluorouracil (LV/5-FU) treatment, or S-1 plus irinotecan (S-1/CPT-11) between April 2003 and June 2004. Three patients were indicated as requiring adjuvant therapy after surgery and the other eleven therapeutic treatment. The patients' background is summarized in Table I. The median age of LV/5-FU and S-1/CPT-1 treatment was 61 and 68 years, respectively. Three males and 4 females were treated with LV/5-FU, and 5 males and 2 females with S-1/CPT-11. Eastern Cooperative Oncology Group (ECOG) performance status of each group was one or less. Although all toxicities observed during the first cycle of chemotherapy were less than grade 2 (Table II), a symptomatic systemic adverse drug reaction (11) that reduces QOL, for example, fatigue, nausea, anorexia (QOL-related toxicity) was observed in 2 patients with LV/5-FU and 4 with S-1/CPT-11. The patients were divided into two groups with or without QOL-related toxicity. There were six patients with QOL-related toxicity (Table I). Chemotherapy regimens. Treatment with LV/5-FU was as follows: Patients were given LV at 20 mg/m2 immediately followed by 5-FU at 370 mg/m2 by intravenous infusion for two hours daily for 5 consecutive days (12, 13). Treatment with S-1/CPT-11 was as follows: S-1 was administered at a fixed dose of 40 mg/patient twice daily for 21 consecutive days, with a 7-day rest period. CPT-11 was infused intravenously at a fixed dose of 80 mg/patient over 90 min on day 1 and day 15 (14). Methods. Methods of host immunity measurement had been reported previously (15). Briefly, host immunity was measured before and after the first-time chemotherapy, respectively. The source of cytokines, except sIL-2R was from stimulated peripheral
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Grade
Nausea/vomiting Anorexia Fatigue Stomatitis Diarrhea
blood mononuclear cells (PBMC). To assess sIL-2R, each patient's serum was collected. CD4/8, Th1/2 ratio and CD4+CD25+ T-cells were determined using flow cytometric analysis. Isolation of PBMC and production of cytokines. PBMCs were obtained by centrifugation of heparinized venous blood over FicollConray gradients (IBL, Gumma, Japan) (400xg for 30 minutes at 18ÆC). The cell suspensions recovered at the interface were washed and resuspended in complete medium (RPMI 1640 supplemented with penicillin (200 IU/ml), streptomycin (100 µg/ml), L-glutamine (2 mM) and 10% heat-inactivated fetal calf serum). In order to assay the stimulation of cytokines, PBMCs were cultured at 1x106 cells in a total volume of 1 ml of complete medium. To assess cytokine production, PBMCs were stimulated in vitro with phytohemagglutin (PHA) (20 Ìg/ml) and concanavalin-A (Con-A) (7 Ìg/ml) for 24 h at 37ÆC in 5% carbon dioxide, supernatants were collected and immediately frozen for subsequent determination of cytokine concentration. The concentrations of human cytokines were determined using enzyme-linked immunosorbent assay (ELISA). The cytokines IL-10, IL-6, IL-12p70, IFN-Á, TNF-· and sIL-2R were assessed using commercial ELISA Kits (IL-10 and IFN-Á: BioSource Europe, Nivelles, Belgium; IL-6: Fuji Rebio, Tokyo, Japan; IL-12p70: R&D systems, Minneapolis, MN, USA; TNF-·: JIMRO, Takasaki, Japan; and sIL-2R: EURO/DPC, Gwynedd, UK) according to the manufacturer's instructions. Flow cytometric analysis. Flow cytometric analysis of PBMC was performed using a FACSorter (Becton Dickinson, Mountain View, CA, USA), using the Diva software (BD Biosciences, Mountain View, CA, USA). To determine the cell phenotype, two- and threecolor flow cytometry of PBMCs were performed using the following antibodies: anti-CD4, anti-CD8, anti-CD25, anti-IFN-Á and anti-IL-4. The area of positivity was determined using an isotype-matched control mAb. Ten thousand events for each sample were acquired. Statistical analysis. A comparison of the changes in both groups was statistically analyzed by repeated ANOVA using statistical software JMP 5.0.1 J (JMP Japan Tokyo, Japan). P
