Proximal Resection Line Determination Using Intraoperative Radiography in Laparoscopic Distal Gastrectomy for Gastric Cancer

BACKGROUND/AIM

Laparoscopic distal gastrectomy for gastric cancer has become a common procedure in many institutions. As manual palpation is impossible, various methods have been developed to identify the location of the tumor and determine the proximal resection line. Intraoperative endoscopy requires manpower and is time-consuming. The authors take an intraoperative X-ray. Here, we demonstrate our methods and outcomes.

PATIENTS AND METHODS

We preoperatively applied metal clips just proximal to the tumor through esophagogastroduodenoscopy. During surgery, we applied metal vessel clips to the greater and lesser curvatures of the planned resection line of the stomach and took an intraoperative X-ray to examine the distance between the planned resection line and the tumor. If the distance was appropriate, the stomach was resected on the planned line, and if the distance was judged to be insufficient, the stomach was resected on the more proximal line, as appropriate. An intraoperative frozen section of the proximal resection margin was examined, as appropriate.

RESULTS

We performed this method for 71 patients. Tumors were successfully resected together with preoperative endoscopic clips in all patients. In five patients, intraoperative frozen section of the proximal resection margins was positive; however, additional resection confirmed negative margins. One patient underwent total gastrectomy, and the remaining 70 patients underwent distal gastrectomy.

CONCLUSION

An intraoperative X-ray seems to be a simple and useful method for identifying the location of the tumor and determining the proximal resection line.

Neoadjuvant docetaxel, oxaliplatin and S-1 therapy for the patients with large type 3 or type 4 gastric cancer (OGSG1902): protocol of a multi-center, phase II study

Background

Large type 3 and type 4 gastric cancers have extremely poor prognoses. To address this, neoadjuvant chemotherapy may be a promising approach. The phase III JCOG0501 study, conducted to confirm the superiority of neoadjuvant S-1 plus cisplatin followed by D2 gastrectomy over upfront surgery, showed no survival benefit for neoadjuvant S-1 plus cisplatin. In Korea, the PRODIGY study, which was a phase III study of neoadjuvant docetaxel plus oxaliplatin plus S-1 (DOS) followed by surgery and adjuvant S-1 versus surgery and adjuvant S-1 for gastric cancer of T2-3N+ or T4Nany, showed that progression-free survival (PFS) was significantly superior in the neoadjuvant DOS arm. Therefore, DOS therapy may be a promising candidate for preoperative chemotherapy for large type 3 or type 4 gastric cancer.

Methods

Preoperative docetaxel 40 mg/m² and oxaliplatin 100 mg/m² will be intravenously administered on day1 every three weeks. S-1 will be orally administered 80 mg/m² on days 1–14 of a 21-day cycle. Patients will receive three courses of treatment and gastrectomy with ≥D2 lymph node dissection. Postoperative S-1 plus docetaxel therapy (DS) will be administered according to the JACCRO GC-07 (START-2) study. The primary endpoint is the 3-year PFS rate. Secondary endpoints include PFS time, overall survival time, pathological response rate, response rate according to RECIST version1.1, proportion of completion of neoadjuvant chemotherapy, R0 resection rate, proportion of completion of surgery, proportion of completion of protocol treatment, proportion of negative conversion of CY, adverse event occurrence rate, and nutritional evaluation. The null hypothesis for the 3-year PFS rate is 45% and the expected value is 60%. The total sample size is 46 considering that the registration period and follow-up period are two and three years, respectively.

Discussion

This is a prospective, multicenter, single-arm, open-label, phase II trial assessing the efficacy and safety of preoperative DOS and postoperative DS for large type 3 or type 4 gastric cancer. The results will inform future phase III trials and are expected to lead to new treatment strategies for large type 3 or type 4 gastric cancer.

Trial registration

Registered with Japan Registry of Clinical Trials on October 11, 2019 (jRCTs051190060).

Randomized phase II study of docetaxel versus paclitaxel in patients with esophageal squamous cell carcinoma refractory to fluoropyrimidine- and platinum-based chemotherapy: OGSG1201

BACKGROUND

There is no standard chemotherapy for esophageal squamous cell carcinoma (ESCC) refractory to first-line fluoropyrimidine- and platinum-based chemotherapy. We therefore performed a randomized, selection-design phase II trial to compare docetaxel (DTX) and paclitaxel (PTX) in this setting.

PATIENTS AND METHODS

Eligible patients were randomly assigned to receive either DTX (70 mg/m² on day 1 of each 21-day cycle) or PTX (100 mg/m² on days 1, 8, 15, 22, 29 and 36 of each 49-day cycle). The primary end-point was overall survival (OS), and secondary end-points included progression-free survival (PFS), time to treatment failure (TTF), response rate (RR) and safety.

RESULTS

Seventy-eight eligible patients (N = 39 in each group) were included for efficacy analysis. OS was significantly longer in the PTX group than in the DTX group (median, 8.8 versus 7.3 months; hazard ratio [HR], 0.62; P = 0.047). A significant benefit of PTX over DTX was also apparent in PFS (median, 4.4 versus 2.1 months; HR, 0.49; P = 0.002) and TTF (median, 3.8 versus 2.1 months; HR, 0.45; P < 0.001). RR (25.6% versus 7.7%, P = 0.065) were higher in the PTX group than in the DTX group. Compared to the PTX group, neutropenia (28% versus 80%) and leukopenia (28% versus 76%) of grade ≥3 as well as febrile neutropenia (0% vs. 46%, P < 0.0001) occurred more frequently in the DTX group.

CONCLUSION

PTX showed a significantly better efficacy as well as a more manageable toxicity compared with DTX.

CLINICAL TRIAL REGISTRATION

UMIN000007940.

Risk factors for superficial incisional surgical site infection after gastrectomy: analysis of patients enrolled in a prospective randomized trial comparing skin closure methods

BACKGROUND

Surgical site infection is one of the commonest complications of gastrointestinal surgery. The nature of surgical procedures and wound closure methods may influence the incidence of superficial incisional surgical site infection. Patients enrolled in a prospective randomized controlled trial comparing skin closure methods are the best subjects for analyzing surgical site infection risk.

METHOD

From a cohort of 1080 patients who had been enrolled in our previous randomized controlled trial, data for 685 patients who had undergone elective open total gastrectomy or distal gastrectomy for gastric cancer were extracted. The incidences of superficial incisional surgical site infection after total gastrectomy and distal gastrectomy were compared and risk factors for superficial incisional surgical site infection were investigated by univariate analyses using logistic regression models.

RESULTS

In all, 42 patients (6.1 %) developed superficial incisional surgical site infections after gastrectomy; 15 of 288 patients (5.2 %) developed these infections after total gastrectomy, and 27 of 397 patients (6.8 %) developed these infections after distal gastrectomy-these differences are not significant. According to univariate analysis, age (75 years or older or younger than 75 years) was the only risk factor for superficial incisional surgical site infections (P = 0.049). There was a tendency for the incidence of superficial incisional surgical site infection to increase in parallel with age.

CONCLUSION

The incidence of superficial incisional surgical site infection did not differ between total gastrectomy and distal gastrectomy. Advanced age was the only identified risk factor for superficial incisional surgical site infections after gastrectomy.

Our experience of treating undifferentiated gastric carcinoma: report of four cases

Undifferentiated gastric carcinoma is a rare histopathological type of cancer that does not show any differentiation toward adenocarcinoma or squamous cell carcinoma. It is thought to be highly malignant, and is associated with a poor prognosis. However, its clinical behavior has not yet been fully analyzed because of its rarity. We herein review the clinical characteristics and prognoses of patients with undifferentiated gastric carcinoma treated at our institutions. Among 2,651 gastric cancer patients, four (0.2 %) were histopathologically diagnosed to have undifferentiated carcinoma. These four patients included three males and one female. The median age of the patients was 60-year old (range 47-75). Three cases had distant metastases at diagnosis. One of these three cases was treated with chemotherapy alone, and the other two were treated with palliative gastrectomy and chemotherapy. The patient with no distant metastasis underwent curative gastrectomy and adjuvant chemotherapy. All patients died of cancer at a median of 5.4 (range 3.5-7.1) months after their diagnoses.