1Service de Cancérologie and 2Laboratoire dAnatomopathologie, Hôpital Paul Brousse, Villejuif, France
Received 9 January 2001; revised and accepted 11 June 2001.
Abstract
The chemotherapy of advanced gastric adenocarcinomas (GAs) is based on agents such as cisplatin, 5-fluorouracil and anthracyclins. Reproducible objective response rates are reported as ~40%. However, the median survival remains short, not exceeding 10 months. Amongst GA, a subset of tumours with increased plasma -fetoprotein (
FP) and/or ß human chorionic gonadotrophin (ßHCG) levels form a well-defined histopathological entity. This subgroup has been associated with poor prognosis, due to the presence of poorly differentiated and rapidly proliferating cells. No specific chemotherapy has been proposed for this particular form of GA. We report two cases of patients with GA and hypersecretion of
FP and/or ßHCG. Despite bulky liver metastases and resistance to two standard chemotherapy regimens, both patients exhibited sensitivity to chemotherapy combining bleomycin, oxaliplatin and etoposide. These results suggest that patients with this particular subset of GA may benefit from chemotherapy regimens similar to those given to germ-cell tumour patients.
Key words: adenocarcinoma, -fetoprotein, ß human chorionic gonadotrophin, chemotherapy, gastric
Introduction
A rare subset of tumours with hyperexcretion of tumour embryonic markers has been identified amongst gastric adenocarcinomas (GAs) [13]. ß human chorionic gonadotrophin (ßHCG) is an embryonic protein secreted in the syncitiotrophoblast of the placenta [4]. -fetoprotein (
FP) is an embryonic protein secreted by the yolksac, by the fetal liver and in the gut [5]. The determination of plasma ßHCG and
FP levels is routinely used for the diagnosis and follow-up of patients with germ-cell tumours, while
FP is also a marker for hepatoblastoma and hepatocellular carcinomas. Many adenocarcinomas have been described as being rarely associated with ßHCG hypersecretion including lung, colon, cervix and endometrial cancers [1]. Amongst these adenocarcinomas, the gastric origin was one of the most frequent. The incidence of this subset of GA ranges from 10.9 to 16.7% for ßHCG and from 1.3 to 19% for
FP [1, 2]. Tumours with
FP or ßHCG secretion are associated with a high proliferation rate and poor prognosis [3, 4]. Unfortunately, no information is available on their sensitivity to standard GA chemotherapy or to other therapeutic approaches. We report the outcome of two patients with a GA secreting ßHCG and/or
FP. Both patients were first treated with standard GA chemotherapy, including 5-fluorouracil (5-FU), cisplatin and either adriamycin or 4'epi-adriamycin. Their best response to chemotherapy, although heavily pretreated and with bulky disease, was observed using a third-line regimen combining bleomycin, oxaliplatin and etoposide (BOXE), and targeting the ßHCG- and/or
FP-secreting tumour subpopulation. These two case reports suggest that GAs with a rapidly growing undifferentiated contingent, secreting
FP and/or ßHCG may benefit from chemotherapy agents active in germ-cell tumours.
Case report 1
In March 1996, epigastric pains revealed a gastric linitis in a 40-year-old man. There was cryptorchism in his history. A partial oesogastrectomy associated with a splenectomy and a gastroplasty was performed. Histology of the gastric tumour revealed a weakly mucosecretant adenocarcinoma with contingent of independent cells. Because of nodal involvement, the patient received post-surgical chemotherapy with 5-FU, methotrexate and adriamycin (FAMTX protocol). He developed a liver metastasis while on therapy. Another chemotherapy regimen combining 5-FU, epirubicin and cisplatin (ECF protocol) was initiated. Stable disease was the best tumour response after eight cycles and a surgical resection of the unique liver metastasis was performed. The histology of the liver metastasis confirmed the presence of a weakly mucosecretant adenocarcinoma with trabecular architecture, different from the primitive tumour with some contingents compatible with the diagnosis of embryonic carcinoma. Immunohistochemical staining was negative for ßHCG and FP in the liver metastasis. Post-surgical treatment with cimetidin was given. In July 1997, 3 months after the last ECF cycle, liver disease progression was diagnosed and ECF protocol was reintroduced. In October 1997, after three more cycles of ECF, an abdominal computer tomography (CT) scan re-vealed a major hepatic tumour progression. The clinical status became altered (with a performance status of 2), the patient was subicteric, had major hepatomegaly with severe liver pain and biological evidence of metastatic liver failure [bilirubin 35 mmol/l, 2 x upper normal value (N)]. His life expectancy was evaluated as less than 1 month. The plasma ßHCG and
FP levels were high at 111 IU/l (22 N) and 1400 ng/ml (140 N), respectively. The carcinoembryonic antigen (CEA) level was 50 ng/ml (10 N) and the CA 19-9 level was 3609 IU/ml (100 N). Ultrasonography of the testicles revealed a left hydrocele. There was no retroperitoneal lymphadenopathy on the abdominal CT scan. Chemotherapy targeting the ßHCG- and
FP-secreting population was initiated using a BOXE regimen. The general condition improved after the first cycle, abdominal pains disappeared, plasma ßHCG level returned to normal and the plasma
FP level decreased by 80% within 3 weeks, with an apparent half-life of less than 1 week. In December 1997, after three cycles, the performance status was normal. The
FP level had fallen by 96%, the CEA level decreased by 50% and the CA 19-9 level by 90%. Haematological toxicity was evaluated weekly using the NCI-CTC common criteria. The patient presented a febrile grade 3 neutropenia with grade 4 thrombocytopenia after the first cycle. While his general condition improved, the subsequent cycles were better tolerated with grade 3 afebrile neutropenia and grade 3 thrombocytopenia. In February 1998, an abdominal CT scan, performed after six cycles, showed a partial response of more than 75% of the liver metastases (Figure 1). However, hepatic pain reappeared in March 1998 with a concomitant rise in tumour markers. Despite two other chemotherapy regimens based on ifosfamide or irinotecan hydrochloride (CPT-11), the liver metastases progressed, the patient developed liver failure and died in August 1998, 29 months after diagnosis and 10 months after having started the BOXE regimen for rapidly progressing liver metastases. At necropsy, a massive liver involvement with large necrosis was found. No embryonic carcinoma contingent was found. The testicles, the retroperitoneum and the mediastinum were macroscopically normal.
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A 75-year-old man presented in September 1997 with epigastric pain, hiccups, dysphagia and alteration of his general health. He had no particular history of gastric disorders. The gastric fibroscopy revealed a tumour of the cardia. A thoracic and abdominal CT scan showed liver and lung metastases. Histology of the gastric tumour revealed a poorly differentiated adenocarcinoma, weakly mucosecreting and without an embryonic contingent. Immunohistochemical investigations were negative for both ßHCG and FP. At diagnosis, the plasma
FP level was elevated to 40 ng/ml (7 N), the plasma CA 19-9 level was 85 IU/ml (2 N), plasma ßHCG and CEA levels were normal. The ultrasound examination of the testicles was normal. No retroperitoneal lymphadenopathies were detectable on the abdominal CT scan. Chemotherapy combining theprubicin (pirarubicin or THP-adriamycin), mitomycin C, folinic acid, 5-FU and cisplatin was initiated. After one cycle, a functional improvement was noted, dysphagia was less severe and the hiccups had disappeared. But after the second cycle, the clinical symptoms worsened and a CT scan and gastroscopy documented a disease progression. The plasma
FP level rose to 350 ng/ml and the plasma CA 19-9 level reached 95 IU/ml. In November 1997, a second-line investigational therapy combining CPT-11 and oxaliplatin resulted in a partial response of the lung metastases but this was associated with hepatic progression. The patient rapidly developed hepatomegaly with deformation of the abdomen. The plasma
FP level was still rising at 4700 ng/ml (700 N) and the plasma CA 19-9 level rose to 170 IU/ml (5 N). A third-line chemotherapy targeting the
FP-secreting tumour cells was initiated using a BOXE regimen, in March 1998. The plasma
FP levels fell by >50% within the first 8 days. The patient had a fatal septic shock during aplasia (grade 4 febrile neutropenia, grade 4 thrombocytopenia) after this first cycle. The necropsy revealed important tumour necrosis both in the cardia and in the liver. An anatomopathological complete remission of the lung metastases was noted. The immunohistochemical staining was positive for
FP in the gastric tumour. The testicles, the retroperitoneum and the mediastinum were macroscopically normal.
Discussion
These two clinical cases show that GA patients with hypersecretion of FP or ßHCG may be resistant to standard GA chemotherapy but sensitive to a third-line treatment, similar to the bleomycin, etoposide, cisplatin (BEP) regimen used in germ-cell tumours. Hence, in patients who exhibit a similar history of rapid, and even acute, clinical tumour progression (the patients could indicate the precise day of disease acceleration due to onset of a sudden liver pain), massive liver involvement with large zones of necrosis and low differentiation of the tumour, it may be appropriate to measure plasma ßHCG and
FP levels either from diagnosis (patient 2) or following a period of indolent disease (patient 1).
The gastric origin of the hypersecretion of ßHCG and FP in this type of disease has been demonstrated by immunohistochemical investigations [7, 8]. However, these methods may not be sensitive enough to detect secreting cells in the presence of large zones of tumour necrosis, as observed in the liver metastases of our two patients. We could only detect
FP in the primary gastric tumour of one of them.
A study compared 27 samples of GA tumours with hypersecretion of FP, with 505
FP-negative samples [9]. Despite no anatomopathological difference between the two groups regarding the gastric tumour type,
FP-secreting tumours were more frequently associated with liver metastases (72% compared with 9.7%, P <0.01), lymph node and venous invasion. It was unclear whether
FP secretion reflected the aggressiveness or advanced stage of the tumour. The 5-year survival of
FP-secreting GA was 11.6% compared with 52.8% in non-
FP-secreting GA (P <0.001). In another series of 54 patients with early GA,
FP correlated with low differentiation (P <0.034) and poor prognosis (P <0.0001) [3].
FP-producing GA had high proliferation activity, low apoptosis and rich neovascularisation. Hence, these groups of GA appeared more aggressive and more rapidly progressive than common GA [10].
Bone metastases are five times more frequent in ßHCG-secreting GA than in other GA (P <0.005) [11]. ßHCG also correlated with a worse prognosis in a multivariate analysis of 290 GA patients (hazard ratio =1.7, 95% confidence interval 1.12.8) [6].
The most active anticancer agents in GA patients in phase II studies achieving objective tumour response rates of at least 15% are 5-FU, anthracyclins, mitomycin-C, cisplatin [12], etoposide [13] and, more recently, CPT-11 [14] and docetaxel [15]. The response rate to combination chemotherapy may exceed 50% [12]. However, the median survival of metastatic GA patients remains short, not exceeding 10 months [12]. After failure of first-line chemotherapy, no treatment has achieved a significant tumour response rate. Both patients had received two previous chemotherapy regimens and were resistant or refractory to 5-FU, anthracyclins and cisplatin (Table 1). In the first clinical case, a >75% partial response could be obtained on bulky liver metastases with BOXE (Figure 1). This dramatic effect was associated with major clinical benefit and survival gain. In both cases, we noted a fall in plasma FP level with an apparent plasma half-life <7 days. Evidence of histological tumour response was also obtained at necropsy for both patients.
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Footnotes
+ Correspondence to: Dr F. Goldwasser, Service de cancérologie, Hôpital Paul Brousse, 14 Ave Paul Vaillant Couturier, 94800 Villejuif, France. Tel: +33-145-59-36-49; Fax: +33-140-96-99-47; E-mail: f.goldwasser@wanadoo.fr
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