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Gemcitabine, 5-fluorouracil, and leucovorin in advanced biliary tract and gallbladder carcinoma†
A North Central Cancer Treatment Group Phase II Trial
Article first published online: 22 NOV 2004
Copyright © 2004 American Cancer Society
Volume 103, Issue 1, pages 111–118, 1 January 2005
How to Cite
Alberts, S. R., Al-Khatib, H., Mahoney, M. R., Burgart, L., Cera, P. J., Flynn, P. J., Finch, T. R., Levitt, R., Windschitl, H. E., Knost, J. A. and Tschetter, L. K. (2005), Gemcitabine, 5-fluorouracil, and leucovorin in advanced biliary tract and gallbladder carcinoma. Cancer, 103: 111–118. doi: 10.1002/cncr.20753
Additional participating institutions include the following: St. Cloud, Minnesota (Harold E. Windschitl, M.D.); Saskatchewan Cancer Centre, Saskatoon, and Allan Blair Cancer Centre, Regina, Saskatchewan, Canada (Muhammad Salim, M.D.); Ann Arbor Regional Community Clinical Oncology Program, Ann Arbor, Michigan (Philip J. Stella, M.D.); Medcenter One Health Systems, Bismarck, North Dakota (Ferdinand Addo, M.D.); Cedar Rapids Oncology Project Community Clinical Oncology Program, Cedar Rapids, Iowa (Martin Wiesenfeld, M.D.); Altru Health Systems, Grand Forks, North Dakota (Daniel J. Walsh, M.D.); Siouxland Hematology-Oncology Associates, Sioux City, Iowa (John C. Michalak, M.D.); and Missiouri Valley Cancer Consortium, Omaha, Nebraska (James A. Mailliard, M.D.).
- Issue published online: 17 DEC 2004
- Article first published online: 22 NOV 2004
- Manuscript Accepted: 14 SEP 2004
- Manuscript Revised: 23 AUG 2004
- Manuscript Received: 19 MAY 2004
- National Cancer Institute, Department of Health and Human Services. Grant Numbers: CA-25224, CA-37404, CA-15083, CA-63826, CA-35101, CA-35195, CA-35448, CA-35415, CA-60276, CA-63848, CA-52352, CA-37417, CA-35103, CA-63849
- gallbladder adenocarcinoma;
Gemcitabine has broad activity in a variety of solid tumors including biliary tract carcinomas. The authors evaluated 6-month survival, response, and toxicity associated with a combination of gemcitabine, 5-fluorouracil (5-FU), and leucovorin (LV) in patients with unresectable or metastatic biliary tract or gallbladder adenocarcinoma (ACA).
A 4-week course included 1000 mg/m2 gemcitabine by intravenous infusion over 30 minutes on Days 1, 8, and 15, 25 mg/m2 LV by intravenous push, and 600 mg/m2 5-FU by intravenous push after LV.
Forty-two patients were enrolled in 6 months, 35 of whom had metastatic disease. Patients with biliary tract ACA included 24 with hepatic disease (19 patients had intrahepatic disease and 5 patients had extrahepatic disease) and 4 with disease in the ampulla of Vater. All patients were evaluable and received a median of 4 courses of treatment (range, 1–21 courses). Commonly occurring severe toxicity (NCI CTC Grade 3 or worse) included: dyspnea (four patients), nausea (four patients), fatigue (seven patients), thrombocytopenia (six patients), emesis (four patients), and diarrhea (four patients). Five partial responses (9.5%) occurred, 3 of which were sustained for ≥ 8 weeks. No treatment-related deaths occurred. Thirty-two patients had disease progression and 38 died after a median follow-up of 20 months (range, 1.4–24 months). The median time to disease progression was 4.6 months (95% confidence interval [95% CI], 2.4–6.6%). The median survival period was 9.7 months (95% CI, 7–12%).
This combination regimen was manageable in patients with advanced biliary tract and gallbladder ACA. Of 42 patients, 24 (57%) survived ≥ 6 months, satisfying the primary end point of the trial. The length of survival suggested that gemcitabine, 5-FU, and LV had benefit equivalent to gemcitabine alone. Cancer 2005. © 2004 American Cancer Society.
Biliary tract (intrahepatic, extrahepatic) and gallbladder carcinomas are uncommon malignancies. They tend to occur more frequently among women and American Indians/Alaska Natives.1–3 In general, ≥ 70% of patients with these types of disease will present with AJCC Stage III/IV disease.4, 5 Overall survival in patients with biliary tract carcinomas is reported to be poor.1, 4, 5 Only 15% of patients with untreated Stage II disease will survive 2 years after diagnosis and < 5% of those with Stage III/IV disease will survive 2 years. Approximately 60–80% of patients undergoing potentially curative resection of localized disease will develop locoregional disease recurrence.6
For patients with either locally advanced biliary tract carcinoma not amenable to combined chemotherapy/radiation therapy or metastatic disease, chemotherapy has served as the primary therapy. A variety of chemotherapy agents have been used, generally with poor responses. Several studies using 5-fluorouracil (5-FU) alone or in combination with other chemotherapy agents have shown mixed results. In general, 5-FU has produced few responses.7, 8 However, several recent small trials have suggested that high-dose 5-FU or 5-FU in combination with other agents may produce partial responses (PR) in up to one-third of patients.9–12
Several case reports have suggested that gemcitabine may have activity in biliary tract and gallbladder carcinomas.13, 14 Several Phase II studies have been reported subsequently. Using a weekly dose of 1000 mg/m2 of gemcitabine for 3 of every 4 weeks, a 36% PR rate was reported in a group of 26 patients with metastatic or unresectable gallbladder carcinoma.15 In a Phase II trial of 1200 mg/m2 of gemcitabine given weekly for 3 weeks followed by a 2-week rest period, 3 of 19 patients with biliary tract or gallbladder carcinoma (16%) achieved a PR.16 The median survival period was 6.5 months and the time to disease progression was 2.5 months. A Phase II trial of gemcitabine given every other week at a dose of 2200 mg/m2 reported a response rate of 22% and a median survival period of 11.5 months.17 In a separate Phase II trial of 13 patients with biliary tract or gallbladder carcinoma, no significant responses were observed with gemcitabine.18
The combination of gemcitabine, 5-FU, and leucovorin (LV) has been evaluated in several Phase I trials, building on preclincial studies demonstrating synergistic and additive effects in an ex vivo tumor model.19 Three Phase I studies evaluating the combination of gemcitabine, 5-FU, and LV have been completed to date.20–22 All these studies showed few significant side effects and evidence of meaningful antitumor activity. In the study by Berlin et al.,22 the combination of gemcitabine, 5-FU, and LV was given weekly for 3 weeks with a 1-week rest. The recommended Phase II doses from that study were 1000 mg/m2 of gemcitabine, 600 mg/m2 of 5-FU, and 25 mg/m2 of LV. At these doses, 1 NCI CTC (version 2) Grade 3 absolute neutrophil count (ANC) was observed but no other Grade 3/4 hematologic toxicity occurred. Nonhematologic toxicities were described as mild.
The combination of gemcitabine and 5-FU with or without LV has shown clinical activity in patients with biliary tract carcinomas. In the Phase I studies of Berlin et al.22 and Poplin et al.,20 one patient in each study with biliary tract carcinoma achieved a complete response (CR) and PR, respectively. The patient who developed the PR remained in the study for 40 months. Given the promising results of these studies, we performed a Phase II trial of gemcitabine, 5-FU, and LV in patients with biliary tract carcinomas. Based on the short median survival period in these studies, we used 6-month survival as the primary end point.
MATERIALS AND METHODS
Patients with histologically confirmed unresectable or metastatic biliary (i.e., intrahepatic, extrahepatic, or ampulla of Vater) or gallbladder adenocarcinoma (ACA) were required to be age ≥ 18 years and to have an Eastern Oncology Cooperative Group performance status (PS) score of 0–2. Disease not amendable to combined treatment with radiation therapy and chemotherapy. The following hematologic and chemistry parameters were recommended: ANC ≥ 1.5 × 109/L, platelet count ≥ 100 × 109/L, total bilirubin level ≤ 3.0 times the institutional upper normal limit (UNL), aspartate aminotransferase (AST) level ≤ 5 times the UNL, and creatinine level ≤ 1.5 times the UNL.
Previous use of gemcitabine and previous receipt of radiotion therapy to > 25% of the bone marrow were exclusion criteria. Pregnant or lactating patients were excluded from the study. Female participants were required to use adequate contraception methods to prevent pregnancy during treatment. Other contraindications included a history of brain or other central nervous system (CNS) metastases that were not amenable to local therapy. Patients with locally treatable disease were eligible if treatment was completed ≥ 4 weeks before the initiation of the study and there was no evidence of disease progression in the CNS. Previous biologic or immunologic therapy was not allowed within 4 weeks of study entry. Any history of a previous malignancy diagnosed within 5 years was not allowed, with the exception of basal or squamous cell carcinoma or skin and cervical carcinoma in situ.
The study was approved by the institutional review board (IRB) of the Mayo Clinic and Mayo Foundation (Rochester, MN) and by the IRBs of the individual memberships of the North Central Cancer Treatment Group (NCCTG) that elected to participate. Signed, written informed consent was obtained from all patients before therapy was initiated. The study was funded through the NCCTG grant from the National Cancer Institute (NCI). There was no direct industrial funding of the current study.
One 4-week course of treatment included a triple combination of agents that were administered on Days 1, 8, and 15. Gemcitabine (1000 mg/m2) diluted with 250 mL solution of normal saline was administered intravenously (i.v.) over 30 minutes. LV (25 mg/m2) was given i.v. as a rapid injection. Immediately thereafter, 600 mg/m2 of 5-FU was given i.v. via rapid injection. Cycles were repeated every 4 weeks if patients met criteria for further therapy. Dose adjustments were made as per a study-defined dose modification table depending on the type and severity of treatment-related toxicities.
Within 14 days before enrollment, patients were required to undergo a complete history, physical examination, serum pregnancy test, and tumor assessment via computed tomography (CT) or magnetic resonance imaging scan. A chest X-ray was required within 28 days before study enrollment. Levels of creatinine, AST, alkaline phosphatase, and total and direct bilirubin were monoitored. Hemoglobin level and platelet, differential, and leukocyte counts were also recorded.
During the course of treatment, hematologic parameters were collected weekly. Before the next course of treatment, a history of adverse events experienced was recorded and blood chemistry tests were repeated. Adverse events were collected using the NCI's Common Toxicity Criteria, Version 2.0 (NCI CTC V2.0; available from URL: http://ctep.cancer.gov/reporting/ctc.html [accessed 2004]). Unless noted otherwise, all adverse events are reported, regardless of attribution to study treatment. Tumor measurements were repeated at 8 weeks and 16 weeks, and then every 8–12 weeks unless more frequent assessments were needed to document response. A chest X-ray was to be performed as clinically indicated during treatment. After the discontinuation of study treatment, patients were observed for disease progression every 3 months for 1 year, then every 6 months for ≤ 4 years past their registration date. At the time of disease progression, patients were monitored for their status for a maximum of 4 years after registration.
If patients developed toxicity related to therapy, the doses of gemcitabine and 5-FU were adjusted based on protocol-defined dose modifications. For Grade 2 hematologic toxicity, the doses of these 2 drugs were decreased by 20% for the remaining weeks of the cycle and all future cycles. If Grade 3/4 hematologic toxicity occurred, treatment was held until recovery followed by a 30% dose reduction for the remaining weeks of the cycle and all future cycles. Similar adjustments were made for nonhematologic toxicities. Granulocyte–colony-stimulating factor was not allowed during the first cycle of therapy and was only to be used thereafter in a manner consistent with the guidelines of the American Society of Clinical Oncology.
Each patient's disease status was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) criteria.23 Measurable disease was defined as at least one lesion whose longest dimension (LD) could be measured accurately as ≥ 2.0 cm. Clinical lesions were measurable when they were superficial (e.g., skin nodules, palpable lymph nodes). Lesions observed on chest X-ray were acceptable as measurable lesions when they were defined clearly and surrounded by aerated lung. However, a CT scan was preferable. All other lesions (or sites of disease), including small lesions (longest dimension < 2.0 cm), were evidence of nonmeasurable disease.
All measurable lesions (≥ 2.0 cm) up to a maximum of 10 lesions representative of all involved organs were identified as target lesions and recorded and measured at baseline. A sum of the LD for all target lesions was calculated and reported as the baseline sum LD. The baseline sum LD was used as a reference to characterize further the objective tumor response of the measurable dimension of the disease. All nonmeasurable lesions were identified as nontarget lesions and were also recorded at baseline. Measurements were not required for these lesions, and they were followed as “present” or “absent.”
All identified sites of disease were followed on reevaluation. Total disappearance of target lesions constituted a CR, whereas a minimum of a 30% decrease in the sum of the LDs of the lesions was classified as a PR. New lesions or a 20% increase in the sum of the LDs of the target lesions was evidence of progressive disease (PD). Otherwise, patients were classified as having stable disease (SD). To confirm the assessment, patients were reevaluated for disease status within 4–6 weeks of achieving a CR or PR. Similarly, SD was reassessed within 6–8 weeks. Nontarget lesions were also classified as CR, PD, or SD. The definition of response based on nontarget lesions is described elsewhere.23 Patients had PD if they experienced significant clinical deterioration that could not be attributed to study treatment or other medical conditions. These conditions included worsening of tumor-related symptoms, a ≥ 10% weight loss, or a decline in PS of > 1 level. Subsequent treatment was at the treating physician's discretion and included treatments provided in clinical practice.
Duration of response was calculated from the first date of a patient's objective status of either a CR or a PR to the date of disease progression (or last tumor assessment). Time to disease progression was calculated from the date of registration to the date of disease progression (or last tumor assessment). Time to death was calculated from the date of registration to the date of death (or last contact). Patients lost to follow-up were counted as having no disease progression (alive) on their date of last tumor assessment (contact).
The primary end point of the current trial is 6-month survival. All eligible patients having initiated study treatment were evaluable for the primary end point. The 6-month survival rate was calculated as the number of evaluable patients alive within 6 months of registration, divided by the total number of evaluable patients. A 2-stage, Phase II study design was used to test whether there was sufficient evidence to determine that the 6-month survival rate was ≥ 30% (i.e., clinically promising) versus ≤ 10% (i.e., clinically inactive). Four of the initial 22 evaluable patients surviving ≥ 6 months after registration warranted the enrollment of an additional 18 patients. Eight of all 40 evaluable patients surviving ≥ 6 months after registration were sufficient evidence of promising activity with respect to a larger proportion of patients alive at 6 months. The study design had 90% power at the 0.03 level of significance to detect a 6-month survival rate of ≥ 30%. The 95% confidence intervals (95% CI) were calculated using the method of Duffy and Santner24 and any patient enrolled past the 40th would be included in the second stage of accrual for this calculation.
Summary statistics and frequency tables were used to summarize baseline patient characteristics and adverse event rates. Adverse events are reported as a maximum severity per patient and adverse event classification (e.g., diarrhea). Hematologic adverse events have been converted to a common grading scale versus reporting as a nadir. All attributions collected for adverse events are reported unless otherwise indicated. Kaplan–Meier methodology was used to estimate the distributions of duration of response, time to disease progression, and time to death.25 All analyses were conducted using SAS Version 8.0 (SAS Institute, Inc., Cary, NC). Two-sided P values were reported and P < 0.05 were considered to be statistically significant.
Forty-two patients were enrolled between June 2001 and March 2002 from 16 NCCTG membership institutions. All patients were eligible and the distribution of various baseline characteristics is summarized in Table 1. At study entry, patients had a median age of 65 years (range, 31–77 years). A majority of patients presented with either intrahepatic (45%) or extrahepatic (12%) biliary tract carcinomas. Evidence of metastatic disease was present in 35 patients at the time of study enrollment.
|ECOG performance status|
|Biliary - intrahepatic||19 (45)|
|Biliary - extrahepatic||5 (12)|
|Ampulla of Vater||4 (10)|
|Incomplete resection||35 (83)|
|Metastatic at study entry||35 (83)|
With all patients no longer receiving active treatment at the time of last follow-up, a median of 4 courses of treatment (range, 1–21 courses of treatment) was given. Reasons for discontinuing study treatment included disease progression (79%), toxicity/refusal (10%), or other reasons (11%). On Day 15 of treatment with gemcitabine, 19 patients received an average of 2 courses of treatment (range, 1–10 courses of treatment), whereas on Day 8, 12 patients received an average of 2 courses of treatment (range, 1–7 courses of treatment). This was similar for treatment with 5-FU.
Gemcitabine and 5-FU were both reduced in 17% (107 of 642) of cycles due to hematologic adverse events. 5-FU was reduced in < 1% (3 of 642) of cycles due to mucositis, stomatitis, or pharyngitis. During Cycle 1, 98.7% (range, 56–100%) and 98.7% (range, 57–100%) of the planned dose of 5-FU and gemcitabine, respectively, were given. During Cycle 2, 70.1% (range, 33–100%) and 80% (range, 33–100%) of the planned doses of 5-FU and gemcitabine, respectively, were given. Despite the need for dose modifications, ≥ 79% of patients received all 3 weeks of treatment with both drugs during the first 2 cycles of therapy.
Table 2 contains a summary of the adverse events observed. All 42 patients had ≥ 1 postbaseline adverse event assessment. Overall, 40% (17 of 42) and 17% (7 of 42) had Grade 3 and Grade 4 hematologic adverse events, respectively. Forty-three percent (18 of 42) and 12% (5 of 42) of patients experienced Grade 3 and Grade 4 nonhematologic events, respectively.
|NCI CTC V2.0 adverse event type||Frequency (%)|
|Grade 3||Grade 4|
|Neutropenia||13 (40.6)||6 (18.8)|
|Leukopenia||2 (6.3)||1 (3.1)|
|Thrombosis||3 (9.4)||2 (6.3)|
|Infection, no neutropenia||3 (9.4)||0|
|Infection, with neutropenia||1 (3.1)||0|
Two patients died of causes unrelated to study treatment. A patient with gallbladder carcinoma was admitted to the hospital after Day 15 of Course 13 for epigastric pain, which was determined later to be associated with an ulcer of the distal esophagus. This patient became rapidly hypotensive and developed massive gastrointestinal bleeding. The patient's family had requested that no extraordinary measures be performed in the case of cardiopulmonary arrest and the patient died within 4 days of initial hospitalization. A second patient with metastatic biliary carcinoma was admitted to the hospital during the second course of treatment, with anemia and rectal bleeding. Despite blood transfusions, this patient became bedridden and developed progressive hypoxemia and died within 6 days of being hospitalized. The source of bleeding was not determined.
Response, Disease Progression, and Survival
All patients have ≥ 1 postbaseline tumor assessment and are evaluable for response (Figs. 1 and 2). Three patients with gallbladder carcinoma achieved a PR, which was sustained for approximately 3 months and and was achieved subsequently to developing metastatic lesions in the liver, lung, and pericolonic fat. Two patients with biliary carcinoma achieved a PR. The overall estimated confirmed (i.e., sustained) response rate was 12% (95% CI, 1–16%). Forty-one patients experienced disease progression, and had an overall median time to disease progression of 4.6 months (95% CI, 2.4–6.6%). Disease progression most often included hepatic involvement, which occurred in 24 of 44 patients (60%). Other sites of disease progression included the lymph nodes, abdomen, bone, lung, colon, peritoneum, and pelvis. At the time of last follow-up, 38 patients had died, with a median survival of 9.7 months (95% CI, 7–12%). The observed 6-month survival rate was 76% (95% CI, 64–90%), with 32 patients surviving and 10 patients having died within 6 months of registration. At the time of last follow-up, 4 patients (9.5%) were alive with a median follow-up of 20 months (range, 14–24 months). Table 3 contains a more detailed summary of patient outcome for each of the disease categories (i.e., biliary vs. gallbladder carcinoma).
|Event||Biliary (n = 28)||Gallbladder (n = 14)||Overall (n = 42)|
|Time to disease progression|
|Median||4.6 mos (3.1–5.8)a||5.2 mos (1.7–9.1)||4.6 mos (2.4–5.7)|
|6 mos||32% (19–55)||50% (30–84)||38% (26–56)|
|12 mos||11% (4–31)||21% (8–58)||14% (7–30)|
|18 mos||7% (2–27)||11% (2–59)||9% (3–24)|
|Median||9.9 mos (7.8–12.2)||7.2 mos (3.6–11.7)||9.7 mos (7.2–11.7)|
|6 mos||82% (69–97)||64% (44–95)||76% (64–90)|
|12 mos||43% (28–66)||21% (8–58)||36% (24–54)|
|18 mos||25% (13–47)||14% (4–52)||21% (12–38)|
A modest response was observed in the current Phase II study of gemcitabine, 5-FU, and LV for patients with locally advanced or metastatic biliary tract and gallbladder carcinomas. The combination was generally well tolerated. Overall, 5 confirmed PRs were observed, with an estimated rate of 12% (95% CI, 1–16%). This compares with published PR rates of 16–30% reported for the use of gemcitabine alone.16, 17, 26, 27 Three of the five responses occurred in patients with gallbladder carcinoma. The median survival in our trial was 9.7 months, which compares well with the 6.5–11.5 months in the single-agent gemcitabine trials. The combination of gemcitabine, 5-FU, and LV, based on the dose and schedule as used in our trial, has activity equivalent to gemcitabine alone.
It is possible that a more prolonged infusion of 5-FU may enhance the activity of the combination. When used alone, a 5-day infusion of 5-FU reportedly produced no responses in 18 previously untreated patients with biliary tract or gallbladder carcinoma.7 However, in a trial of gemcitabine combined with a 3-hour infusion of 5-FU for biliary tract and pancreatic carcinoma, a higher response rate was observed.28 In that trial, 9 patients with biliary tract carcinoma received the combination of gemcitabine and prolonged infusion of 5-FU weekly for 3 weeks. Three of the nine patients had a PR. In an interim report of a trial using gemcitabine and capecitabine, 5 of 15 patients with biliary tract ACA achieved a PR.29 These results suggest that additional studies of gemcitabine and infusion of 5-FU or capecitabine may be reasonable.
Gemcitabine combined with other agents may provide other potential options of building on the activity of gemcitabine alone. The combination of gemcitabine and cisplatin has been explored in several studies. In a group of 11 patients with locally advanced or metastatic gallbladder ACA, a response rate of 64% was reported, including 1 CR.30 Toxicity was described as mild and manageable. Two other studies using similar schedules of gemcitabine and cisplatin have reported responses rates of 28–33%.31, 32
Based on the current study and others, gemcitabine remains an important component of chemotherapy regimens for biliary tract and gallbladder ACA. Additional studies of gemcitabine combined with other agents are underway or in development. Based on the results of the current study and other reported studies, the potential benefit of 5-FU, when added to gemcitabine, remains uncertain.
- 12Treatment of advanced adenocarcinomas of the exocrine pancreas and the gallbladder with 5-fluorouracil, high dose levofolinic acid and oral hydroxyurea on a weekly schedule. Results of a multicenter study of the Southern Italy Oncology Group (G.O.I.M.). Cancer. 1996; 78: 1300–1307., , , et al.
- 19Ex vivo ATP tumor testing of gemcitabine for combination chemotherapy and biochemical modulation [abstract]. Proc Am Assoc Cancer Res. 1998; 39: 310., , , et al.
- 23New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst. 2000; 92: 205–216., , , et al.
- 29Phase II trial of gemcitabine plus capecitabine (GemCap) in patients with advanced or metastatic adenocarcinoma of the biliary tract [abstract]. Proc Am Assoc Cancer Res. 2003; 22: 317a., , , et al.
- 31A well tolerated and highly effective regimen for locally advanced and metastatic biliary tract cancers with gemcitabine and cisplatin [abstract]. Proc Am Assoc Cancer Res. 2003; 22: 367., , , et al.
- 32Phase II study of gemcitabine plus cisplatin in biliary tract cancer [abstract]. Proc Am Assoc Cancer Res. 2003; 22: 304., , , et al.