Usefulness of Surgical Staging of Gastric Cancer in Neoadjuvant Chemotherapy Candidates: A Single-center Retrospective Study

BACKGROUND

The current expectancy of long-term survival of patients with pathological stage (pStage) III gastric cancer (GC) is not satisfactory. However, neoadjuvant chemotherapy (NAC) is expected to improve survival rates in these patients. An appropriate pretherapeutic diagnostic strategy is necessary for selecting patients who are eligible for NAC. Surgical findings can often identify serosal invasion or metastatic lymphadenopathy, thereby facilitating the selection of candidates for NAC. Therefore, we aimed to evaluate the accuracy and potential of surgical staging in improving the management and survival of patients with GC.

PATIENTS AND METHODS

We assessed the accuracy of surgical staging in comparison to preoperative staging using data from patients who underwent gastrectomy for GC. In addition, differences in survival after using the surgical staging criterion were assessed.

RESULTS

A total of 915 patients were evaluated in this study. The sensitivity of surgical staging in detecting pStage III in the surgical T4N0-3 plus surgical T3N1-3 group was satisfactory (79.3%). The proportion of patients with pStage I using the surgical staging criterion was 7.8%.

CONCLUSION

Surgical staging using laparoscopy or laparotomy may assist in selecting candidates for enrollment in clinical trials for NAC.

Clinical Impact of Preoperative Albumin-Bilirubin Status in Esophageal Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

The albumin-bilirubin (ALBI) score, which evaluates the perioperative liver function, was developed, and had a clinical impact on both the short- and long-term oncological outcomes in some malignancies. We evaluated the clinical impact of preoperative albumin-bilirubin status in patients with resectable esophageal cancer who received curative treatment.

PATIENTS AND METHODS

The study included 121 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2018. The risk factors for overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

Based on the 3- and 5-year OS rates, we set the cut-off value for the ALBI score at -2.7. Eighty patients were classified into the ALBI-low group (ALBI score <-2.7), 41 patients were categorized into the ALBI-high group (ALBI score >-2.7). The 3- and 5-year OS rates were 62.2% and 53.2%, respectively, in the ALBI-low group, and 42.2% and 35.2% in the ALBI-high group. There was a significant difference in OS (p=0.0113). The 3- and 5-year RFS rates were 43.1% and 40.3%, respectively, in the ALBI-low group and 37.7% and 26.1% in the ALBI-high group. There was a significant difference in RFS (p=0.048). When comparing the perioperative clinical course between the ALBI-high and ALBI-low groups, the incidence of postoperative anastomotic leakage was 46.3% (19/41) in the ALBI-high group, and 27.5% (22/80) in the ALBI-low group (p=0.038).

CONCLUSION

The ALBI status had a clinical impact on both OS and RFS in esophageal cancer patients. Therefore, ALBI may have potential application as a prognostic factor for esophageal cancer patients.

Machine-learning model derived gene signature predictive of paclitaxel survival benefit in gastric cancer: results from the randomised phase III SAMIT trial

OBJECTIVE

To date, there are no predictive biomarkers to guide selection of patients with gastric cancer (GC) who benefit from paclitaxel. Stomach cancer Adjuvant Multi-Institutional group Trial (SAMIT) was a 2×2 factorial randomised phase III study in which patients with GC were randomised to Pac-S-1 (paclitaxel +S-1), Pac-UFT (paclitaxel +UFT), S-1 alone or UFT alone after curative surgery.

DESIGN

The primary objective of this study was to identify a gene signature that predicts survival benefit from paclitaxel chemotherapy in GC patients. SAMIT GC samples were profiled using a customised 476 gene NanoString panel. A random forest machine-learning model was applied on the NanoString profiles to develop a gene signature. An independent cohort of metastatic patients with GC treated with paclitaxel and ramucirumab (Pac-Ram) served as an external validation cohort.

RESULTS

From the SAMIT trial 499 samples were analysed in this study. From the Pac-S-1 training cohort, the random forest model generated a 19-gene signature assigning patients to two groups: Pac-Sensitive and Pac-Resistant. In the Pac-UFT validation cohort, Pac-Sensitive patients exhibited a significant improvement in disease free survival (DFS): 3-year DFS 66% vs 40% (HR 0.44, p=0.0029). There was no survival difference between Pac-Sensitive and Pac-Resistant in the UFT or S-1 alone arms, test of interaction p<0.001. In the external Pac-Ram validation cohort, the signature predicted benefit for Pac-Sensitive (median PFS 147 days vs 112 days, HR 0.48, p=0.022).

CONCLUSION

Using machine-learning techniques on one of the largest GC trials (SAMIT), we identify a gene signature representing the first predictive biomarker for paclitaxel benefit.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry: C000000082 (SAMIT); ClinicalTrials.gov identifier, 02628951 (South Korean trial).

The Clinical Influence of the CONUT Score on Survival of Patients With Gastric Cancer Receiving Curative Treatment

BACKGROUND

We investigated the influence of the preoperative Controlling Nutritional Status (CONUT) score on survival and recurrence of gastric cancer in patients after curative treatment.

PATIENTS AND METHODS

This study included 331 patients who underwent curative surgery followed by adjuvant treatment for gastric cancer between 2013 and 2017. The risk factors for overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

Based on the 1-, 3- and 5-year survival rates, a CONUT score of 2 was regarded as the optimal cut-off value for classification. The 3- and 5-year OS rates were 93.6% and 88.6%, respectively in the low-CONUT group, and 82.7% and 73.6% in high-CONUT group (p=0.022). The 3- and 5-year RFS rates were 78.8% and 68.7%, respectively, in the low-CONUT group, and 89.3% and 86.6%, respectively, in the high-CONUT group (p=0.05). A multivariate analysis showed that the CONUT score was a significant independent predictive factor for OS and RFS.

CONCLUSION

The CONUT score was a predictive factor for survival in patients who underwent curative treatment for gastric cancer. It is necessary to develop an effective plan for perioperative care and surgical strategy according to the CONUT score.

Clinical Influence of the Lymph Node Ratio on Lymph Node Metastasis-positive Gastric Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

The present study investigated the clinical impact of the lymph node ratio (LNR) on overall survival (OS) and recurrence-free survival (RFS) in cancer patients with lymph node metastasis who received curative treatment.

PATIENTS AND METHODS

Eighty-six patients who received curative surgery for gastric cancer between 2000 and 2015, and in whom lymph node metastasis was pathologically confirmed, were included in this study. The LNR was defined as the ratio of the number of metastatic lymph nodes to the total number of harvested lymph nodes.

RESULTS

A lymph node ratio of 0.23 was considered the optimal cutoff point for classification according to OS. Statistically significant differences were observed in the 3- and 5-year OS rates and 3- and 5-year RFS rates. The 3-year and 5-year OS rates in the LNR <0.23 group were 57.6% and 57.6%, respectively, whereas those in the LNR ≥0.23 group were 33.0% and 0% (p<0.001). The 3-year and 5-year RFS rates in the LNR <0.23 group were 45.9% and 43.6%, respectively, whereas those in the LNR >0.23 group were 25.2% and 0% (p=0.002). Regarding the site of first relapse, the incidence rates of peritoneal and lymph node metastasis in the LNR >0.23 group were significantly different in comparison to the LNR <0.23 group.

CONCLUSION

A high LNR was associated with significantly worse OS and RFS in patients who received curative treatment for gastric cancer. The lymph node metastasis status should be utilized in the development of treatment strategies for gastric cancer.

Increasing frequency of gene copy number aberrations is associated with immunosuppression and predicts poor prognosis in gastric adenocarcinoma

BACKGROUND

Patients with Epstein-Barr virus-positive gastric cancers or those with microsatellite instability appear to have a favourable prognosis. However, the prognostic value of the chromosomal status (chromosome-stable (CS) versus chromosomal instable (CIN)) remains unclear in gastric cancer.

METHODS

Gene copy number aberrations (CNAs) were determined in 16 CIN-associated genes in a retrospective study including test and validation cohorts of patients with gastric cancer. Patients were stratified into CS (no CNA), CINlow (1-2 CNAs) or CINhigh (3 or more CNAs). The relationship between chromosomal status, clinicopathological variables, and overall survival (OS) was analysed. The relationship between chromosomal status, p53 expression, and tumour infiltrating immune cells was also assessed and validated externally.

RESULTS

The test and validation cohorts included 206 and 748 patients, respectively. CINlow and CINhigh were seen in 35.0 and 15.0 per cent of patients, respectively, in the test cohort, and 48.5 and 20.7 per cent in the validation cohort. Patients with CINhigh gastric cancer had the poorest OS in the test and validation cohorts. In multivariable analysis, CINlow, CINhigh and pTNM stage III-IV (P < 0.001) were independently associated with poor OS. CIN was associated with high p53 expression and low immune cell infiltration.

CONCLUSION

CIN may be a potential new prognostic biomarker independent of pTNM stage in gastric cancer. Patients with gastric cancer demonstrating CIN appear to be immunosuppressed, which might represent one of the underlying mechanisms explaining the poor survival and may help guide future therapeutic decisions.

Automated non-invasive identification of pelvic autonomic nerves with a handheld Raman spectrometer and potential application to nerve-sparing colorectal surgery: a preliminary study in surgical specimens

Background

Although minimally invasive surgery for colorectal cancer, whether performed as standard laparoscopic or robotic surgery, has been established as an oncologically safe procedure, postoperative urinary dysfunction and sexual dysfunction remain matters of concern, even when so-called nerve-sparing surgery is performed. We have hypothesized that Raman spectroscopy can be used intraoperatively as a non-invasive label-free means of objective identification of the pelvic nerves, and we conducted a preliminary study by applying a newly developed handheld Raman spectrometer to surgical specimens.

Methods

Samples of nervous tissue, colon cancer tissue, and tissues from surrounding pelvic organs were obtained from 25 patients undergoing colectomy. Raman spectra were obtained by irradiation with the Progeny™ Raman spectrometer. We looked for characteristic Raman shifts to distinguish nervous tissue from cancer tissue. To improve discrimination between nervous tissue and other tissues, the spectral data were subjected to principal component analysis.

Results

We detected characteristic differences in the spectra at 1,309 cm^-1, 1,442 cm^-1, and 1,658 cm^-1. A significant difference was detected at 1,442 cm^-1, and accuracy of the modality for identification of nervous tissue was 75%. The addition of principle component analysis (4 components) yielded 100% sensitivity, 85% specificity, and 90%, notably increasing accuracy from 75% to 90% in discriminating between nervous tissue and cancer tissue.

Conclusions

Raman spectroscopy holds promise for non-invasive intraoperative recognition of nervous tissue. We expect the modality to become a powerful clinical tool, compensating for the lack of tactile feedback intrinsic to minimally invasive colectomy and thus thwarting the risk of postoperative urinary and/or sexual dysfunction.

Impact of nuclear factor of activated T cells (NFAT) families as a poor prognostic factor in pancreatic cancer patients

584

Background: Pancreatic cancer microenvironment is crucial in cancer development, and cancer-stromal interactions have been recognized as important targets for cancer therapy. Nuclear factor of activated T-cells (NFAT) has been found in T cells as a transcriptional activator of IL-2, and known to be involved in various processes including the immune system. In cancer tissues, NFAT has been reported to be involved in metastasis. In breast and colorectal cancers, NFATc2 and NFAT5 have been reported to interact with integrins to promote cancer cell migration. On the other hand, in pancreatic cancer, NFAT5 has been reported to be a poor prognostic factor via regulation of PGK1 transcription. In the present study, we evaluated the expression of NFATc2 and NFAT5 in pancreatic cancer and examined their relationship with prognosis. Methods: One hundred and sixty five pancreatic cancer patients who underwent curative-intrent resection at our hospital between 2010 and 2020 were included in this study. We performed immunostaining for NFATc2 and NFAT5 using the tissue micro array. We evaluated the expression of NFATc2 and NFAT5 protein and examined their correlation with clinicopathological factors. Results: Of the 165 pancreatic cancer cases, we detected increased NFATc2 protein expression in cytoplasm of cancer cells in 53 cases (32.1%) and NFAT5 in 104 cases (63.0%), and NFATc2/NFAT5 co-expression in 43 cases (26.1%). NFATc2 expression was not correlated with any clinicopathological factors, NFAT5 expression was correlated with venous invasion (p = 0.047), and NFATc2/NFAT5 co-expression was slightly correlated with Stage (p = 0.054). Relapse free survival (RFS) was estimated in all 165 patients. There was no significant difference for RFS in either NFATc2-high group or NFAT5-high group (p = 0.314 or p = 0.574), however, NFATc2/NFAT5 co-expression group showed significantly poor RFS (p = 0.023). Overall survival (OS) was also estimated in all 165 patients. There was no significant difference for OS in either NFATc2-high group or NFAT5-high group (p = 0.146 or p = 0.529), however, NFATc2/NFAT5 co-expression group showed significantly poor survival (p = 0.006). In multivariate analysis, lymphatic invasion, curability and NFATc2/NFAT5 co-expression were independent prognostic factors for RFS, and lymphatic invasion, curability, presence of adjuvant therapy and NFATc2/NFAT5 co-expression were independent prognostic factors for OS. Conclusions: In pancreatic cancer, NFATc2/NFAT5 co-expression was suggested to be involved in the critical process of pancreatic cancer progression, and may be a novel therapeutic target.

Phosphorylation of hTERT at threonine 249 is a novel tumor biomarker of aggressive cancer with poor prognosis in multiple organs

Recent evidence indicates that RNA‐dependent RNA polymerase (RdRP) activity of human telomerase reverse transcriptase (hTERT) regulates expression of target genes and is directly involved in tumor formation in a telomere‐independent manner. Non‐canonical function of hTERT has been considered as a therapeutic target for cancer therapy. We have previously shown that hTERT phosphorylation at threonine 249 (p‐hTERT), which promotes RdRP activity, is an indicator of an aggressive phenotype and poor prognosis in liver and pancreatic cancers, using two cohorts with small sample sizes with polyclonal p‐hTERT antibody. To clarify the clinical relevance of p‐hTERT, we developed a specific monoclonal antibody and determined the diagnostic and prognostic value of p‐hTERT in cancer specimens using a large cohort. A monoclonal antibody for phosphorylated hTERT (p‐hTERT) at threonine 249 was developed and validated. The antibody was used for the immunohistochemical staining of formalin‐fixed, paraffin‐embedded specimens from 1523 cases of lung, colon, stomach, pancreatic, liver, breast, and kidney cancers. We detected elevated p‐hTERT expression levels in cases with a high mitotic activity, high pathological grade, and high nuclear pleomorphism. Elevated p‐hTERT expression was an independent prognostic factor for lung, pancreatic, and liver cancers. Furthermore, p‐hTERT expression was associated with immature and aggressive features, such as adenosquamous carcinoma (lung and pancreas), invasive type of cancer (lung), high serum alpha‐fetoprotein level (liver), and triple‐negative status (breast). In conclusion, RdRP activity indicated by p‐hTERT expression predicts aggressive cancer phenotypes in various types of cancer. Thus, p‐hTERT is a novel biomarker for the diagnosis of aggressive cancers with a poor prognosis. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Assessment of the use of computed tomography colonography in early detection of peritoneal metastasis in patients with gastric cancer: A prospective cohort study

Peritoneal metastasis (PM) is one of the most frequent forms of gastric cancer recurrence. In this study, we aimed to use computed tomography (CT) colonography (CTC) to detect signs of PM earlier in patients in whom PM was suspected but not yet diagnosed. CTC was used to evaluate patients with clinical symptoms or general CT findings that were suspicious but not sufficient to confirm PM. In total, 18 patients with suspected PM were enrolled. Ten patients (55.6%) had PM on CTC. Abnormal colonic deformities were identified at locations other than those of the lesions detected by general CT in seven patients. The sensitivity and specificity of CTC for the detection of PM were 83.3% and 100%, respectively. The median overall survival after CTC was 201 days in the CTC-positive group, which was significantly shorter than that in the CTC-negative group (945 days, p = 0.01). In the multivariate analysis, a positive CTC finding was the only factor independently associated with survival (p = 0.005). According to our experience with 18 patients, CTC can be an alternative to conventional imaging for early detection of PM. Further prospective studies with larger sample sizes are warranted to confirm and validate these findings. University hospital Medical Information Network Clinical Trials Registry (UMIN-CTR): Registration number: UMIN000044167.

Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years

BACKGROUND

Endoscopic resection, especially endoscopic submucosal dissection (ESD), is increasingly performed in elderly patients with early gastric cancer, and lesions beyond the expanded indications are also resected endoscopically in some patients. It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.

AIM

To assess the efficacy and feasibility of gastric ESD for elderly patients, and define high-risk lesions and prognostic indicators.

METHODS

Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014, 179 sessions (15.3%) were performed in patients aged ≥ 80 years, and 172 of these sessions were done in patients with a final diagnosis of gastric cancer. These patients were studied retrospectively to evaluate short-term outcomes and survival. The short-term outcomes included the rates of en bloc resection and curative resection, complications, and procedure-related mortality. Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010. Fisher’s exact test was used to statistically analyze risk factors. Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test. Survival rates at each time point were based on Kaplan-Meier estimation. Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test. To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting, we used the least absolute shrinkage and selection operator (LASSO) Cox regression model including factors curative/ noncurative, age, gender, body mass index, prognostic nutritional index, Charlson comorbidity index (CCI), Glasgow prognostic score, neutrophil-to-lymphocyte ratio, and antithrombotic agent use. We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation. P < 0.05 was considered statistically significant.

RESULTS

The en bloc dissection rate was 97.1%, indicating that a high quality of treatment was achieved even in elderly patients. As for complications, the rates of bleeding, perforation and aspiration pneumonitis were 3.4%, 1.1% and 0.6%, respectively. These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients. A dissection incision > 40 mm, lesions associated with depressions, and lesions with ulcers were risk factors for post-ESD bleeding, and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients (P < 0.05). Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding. The overall survival (OS) did not differ significantly between curative and noncurative ESD (P = 0.69). In patients without additional surgery, OS rate was significantly lower in patients with a high CCI (≥ 2) than in those with a low CCI (≤ 1) (P < 0.001).

CONCLUSION

Gastric ESD is feasible even in patients aged ≥ 80 years. Observation without additional surgery after noncurative ESD is reasonable, especially in elderly patients with CCI ≥ 2.

The Association of the Lymphocyte-to-C-Reactive-Protein Ratio With Gastric Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

We investigated the association of the preoperative lymphocyte-to-C-reactive-protein ratio (LCR) with gastric cancer survival and recurrence after curative treatment.

PATIENTS AND METHODS

This study included 480 patients who underwent curative surgery followed by adjuvant treatment for gastric cancer between 2013 and 2017. The prognostic factors for overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

A LCR of 7,000 was regarded as the optimal critical point of classification, considering the 1-, 3- and 5-year survival rates. The OS rates at 3 and 5 years after surgery were 84.4% and 73.9% in the low-LCR group, respectively, and 92.4% and 87.0% in the high-LCR group, respectively, and were statistically significantly different. The RFS rates at 3 and 5 years after surgery were 78.8% and 68.7% in the low-LCR group, respectively, and 89.3% and 86.6% in the high-LCR group, respectively, with a statistically significant difference. A multivariate analysis showed that the LCR was a significant independent prognostic factor for both OS and RFS.

CONCLUSION

The LCR was a significant prognostic factor for survival in patients who underwent curative treatment for gastric cancer.

Clinical Significance of the Prealbumin Level in Gastric Cancer Patients Who Receive Curative Treatment

BACKGROUND

We investigated the clinical influence of the prealbumin level on the gastric cancer survival and recurrence after curative treatment.

METHODS

This study included 447 patients who underwent curative treatment for gastric cancer between 2013 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

A prealbumin level of 20 mg/dl was regarded as the optimal point of classification, considering the 3- and 5-year survival rates. The OS rates at 3 and 5 years after surgery were 80.7% and 65.0% in the low-prealbumin group, respectively, and 93.1% and 87.9% in the high-prealbumin group, respectively, a statistically significant difference (p < 0.001). The RFS rates at 3 and 5 years after surgery were 71.7% and 68.0% in the low-prealbumin group, respectively, and 90.1% and 84.7% in the high-prealbumin group, respectively, a statistically significant difference (p = 0.031). A multivariate analysis demonstrated that the prealbumin level was a significant independent risk factor for the OS and RFS. In addition, the rate of introduction of adjuvant chemotherapy was significantly lower and the frequency of peritoneal recurrence and lymph node recurrence significantly higher in the low-prealbumin group than in the high-prealbumin group.

CONCLUSION

Prealbumin is a risk factor for the survival in patients who undergo curative treatment for gastric cancer. It is necessary to develop an effective plan of perioperative care and surgical strategy according to the prealbumin level.

Safety and Feasibility of Gastrectomy for Gastric Cancer in Patients Receiving Antiplatelet and/or Anticoagulation Treatment

BACKGROUND/AIM

The number of patients who have cardiovascular-morbidities and use antiplatelet and/or anticoagulation therapy is rapidly growing worldwide. The present study evaluated the safety and feasibility of gastrectomy for gastric cancer in patients who received antiplatelet and/or anticoagulation therapy in the perioperative period.

PATIENTS AND METHODS

Cases were selected from the medical records of consecutive patients who were diagnosed with gastric cancer and underwent complete resection at the Kanagawa Cancer Center from 2013 to 2017. The patients were divided into the antiplatelet and/or anticoagulation treatment group and the non-antiplatelet and/or anticoagulation treatment group.

RESULTS

Five hundred and six patients underwent gastrectomy for gastric cancer and were analyzed in the present study. Among them, 62 patients (12.3%) received anticoagulation therapy (anticoagulation group). When the anticoagulation and non-anticoagulation groups were compared, although there were some differences in patient background factors, the surgical findings, perioperative clinical course, and details of postoperative complications were similar. The incidence of postoperative bleeding was 0.8% (4/506) in all patients. The incidence of postoperative bleeding was 1.6% (1/62) in the anticoagulation group and 0.7% (3/446) in the non-anticoagulation group. Preoperative anticoagulation therapy was not identified as a significant independent risk factor for postoperative bleeding.

CONCLUSION

These results suggest that curative gastrectomy for gastric cancer is safe and feasible, regardless of the perioperative use of antiplatelet and/or anticoagulation treatment. In addition, the perioperative use of antiplatelet and/or anticoagulation treatment was not a significant risk factor for postoperative bleeding after gastrectomy for gastric cancer.

Low Preoperative Albumin-to-Globulin Ratio Is a Marker of Poor Prognosis in Patients With Esophageal Cancer

AIM

Recent studies have reported that the albumin-to-globulin ratio (AGR) may be a useful inflammatory-nutritional biomarker to predict postoperative complications and poor prognosis in various types of patients with cancer. However, its prognostic value in patients with esophageal cancer is still unclear. We aimed to examine the utility of the AGR for predicting the short- and long-term outcomes in patients with esophageal cancer who underwent curative resection.

PATIENTS AND METHODS

This was a retrospective cohort analysis reviewing the medical records of consecutive patients who underwent esophagectomy for clinical stage I to III esophageal cancer at Yokohama City University. A total of 105 patients were identified between 2005 and 2018. The overall survival (OS), recurrence-free survival (RFS), and postoperative complication rates were compared between patients with high AGR (>1.48) and those with low AGR (≤1.48) group.

RESULTS

A total of 57 and 48 patients were classified into the high and low AGR groups, respectively. There was no significant difference between the two groups in the rate of overall postoperative complications of more than Clavien-Dindo grade 3 (50.9% vs. 54.2%, p=0.85). The long-term findings showed that 5-year OS and RFS rates were significantly better for the group with a high AGR (67.2% vs. 33.8%, p<0.001 and 51.6% vs. 28.5%, p=0.003, respectively).

CONCLUSION

This study suggests that a low preoperative AGR is a risk factor for poor RFS and OS in patients who are planning to undergo curative surgery for esophageal cancer. AGR may be a useful biomarker for establishing treatment strategies to improve patients' survival.

The Clinical Influence of the C-Reactive Protein-to-Albumin Ratio in Patients Who Received Curative Treatment for Gastric Cancer

BACKGROUND

We investigated the impact of the pre-surgical C-reactive protein-to-albumin ratio (CAR) on survival and recurrence after curative treatment for gastric cancer.

PATIENTS AND METHODS

This study included 481 patients who underwent curative treatment for gastric cancer between 2013 and 2017. The risk factors for overall (OS) and recurrence-free (RFS) survival were identified.

RESULTS

A CAR of 0.05 was regarded as the optimal critical point of classification considering the 3- and 5-year survival rates and patients were divided according to their CAR. The OS rates at 3 and 5 years after surgery were significantly higher at 92.5% and 87.9%, respectively, in the low-CAR group compared with 84.9% and 71.9%, respectively, in the high-CAR group. The corresponding RFS rates were 89.1% and 85.5%, and 81.0% and 72.2%, respectively, also a significant difference. A multivariate analysis demonstrated that the CAR was a significant independent risk factor for the OS and marginally significant independent risk factor for the RFS. In addition, the incidences of pancreatic fistula and abdominal abscess were significantly higher and the rate of introduction of adjuvant chemotherapy significantly lower in the high-CAR group.

CONCLUSION

The CAR was a risk factor influencing survival in patients who underwent curative treatment for gastric cancer. An effective perioperative care plan and surgical strategy need to be developed according to the CAR.

Can D3 Lymph Node Dissection for Patients With Colon Cancer With a Poor C-Reactive Protein/Albumin Ratio Improve Survival Outcomes?

AIM

D3 lymph node dissection (LND) for stage II and III colon cancer has been shown to improve prognosis, however, it generally increases surgical stress. Studies have reported that the C-reactive protein/albumin ratio (CAR) may be a useful inflammatory-nutritional biomarker to predict postoperative complications and poor prognosis for with various types of cancer. Our purposes were to assess the short- and long-term outcomes of D3 LND in patients with a high preoperative CAR (≥ 0.04).

PATIENTS AND METHODS

This was a retrospective cohort analysis reviewing a prospectively collected database of Yokohama City University and three affiliated hospitals. A total of 449 patients with stage II or III colon cancer with high CAR who underwent primary resection with D2 or D3 LND were identified between 2008 and 2020. The primary and secondary outcomes of interests were the 3-year recurrence-free survival and postoperative complication rates.

RESULTS

After propensity matching, 230 patients were evaluated. There was no significant difference between the D3 and D2 groups in the rate of postoperative complications overall (14.8% versus 11.3%, p=0.558), however, the incidence of anastomotic leakage tended to be greater in the D3 group (9.6% versus 2.6%, p=0.050). The long-term findings showed that there was no significant difference between the two groups (3-year recurrence-free survival rate: 77.2% versus 77.2%, p=0.880).

CONCLUSION

D3 LND did not improve survival outcomes for patients with colon cancer with a poor CAR in this study. D2 LND may be a treatment option for patients with stage II-III colon cancer with a high preoperative CAR.

Preoperative Pre-albumin Concentration as a Predictor of Short-term Outcomes in Elderly Patients With Colorectal Cancer

BACKGROUND/AIM

Population aging results in increasing numbers of elderly persons undergoing surgery for colorectal cancer. We sought to identify objective preoperative indicators of outcomes, with a view toward development of safe, effective treatments for such patients.

PATIENTS AND METHODS

The study included 99 patients aged 80 years or more, who were treated surgically for stage I- III colorectal cancer. Preoperative nutritional status was compared retrospectively between those who suffered postoperative complications (n=40) and those who did not (n=59).

RESULTS

Univariate analysis revealed low prealbumin (PreAlb) concentration (p=0.032) and low platelet-to-lymphocyte ratio (p=0.116) as risk factors for postoperative complications. Multivariate analysis showed preoperative PreAlb concentration to be an independent risk factor (OR=0.884; 95% confidence interval=0.791-0.989; p=0.024) associated with postoperative length of hospital stay (coef.=-0.336, p=0.002).

CONCLUSION

PreAlb, a rapid turnover protein, shows promise as a simple predictor of postoperative complications in elderly patients treated for colorectal surgery.

Development and validation of deep learning classifiers to detect Epstein-Barr virus and microsatellite instability status in gastric cancer: a retrospective multicentre cohort study

BACKGROUND

Response to immunotherapy in gastric cancer is associated with microsatellite instability (or mismatch repair deficiency) and Epstein-Barr virus (EBV) positivity. We therefore aimed to develop and validate deep learning-based classifiers to detect microsatellite instability and EBV status from routine histology slides.

METHODS

In this retrospective, multicentre study, we collected tissue samples from ten cohorts of patients with gastric cancer from seven countries (South Korea, Switzerland, Japan, Italy, Germany, the UK and the USA). We trained a deep learning-based classifier to detect microsatellite instability and EBV positivity from digitised, haematoxylin and eosin stained resection slides without annotating tumour containing regions. The performance of the classifier was assessed by within-cohort cross-validation in all ten cohorts and by external validation, for which we split the cohorts into a five-cohort training dataset and a five-cohort test dataset. We measured the area under the receiver operating curve (AUROC) for detection of microsatellite instability and EBV status. Microsatellite instability and EBV status were determined to be detectable if the lower bound of the 95% CI for the AUROC was above 0·5.

FINDINGS

Across the ten cohorts, our analysis included 2823 patients with known microsatellite instability status and 2685 patients with known EBV status. In the within-cohort cross-validation, the deep learning-based classifier could detect microsatellite instability status in nine of ten cohorts, with AUROCs ranging from 0·597 (95% CI 0·522-0·737) to 0·836 (0·795-0·880) and EBV status in five of eight cohorts, with AUROCs ranging from 0·819 (0·752-0·841) to 0·897 (0·513-0·966). Training a classifier on the pooled training dataset and testing it on the five remaining cohorts resulted in high classification performance with AUROCs ranging from 0·723 (95% CI 0·676-0·794) to 0·863 (0·747-0·969) for detection of microsatellite instability and from 0·672 (0·403-0·989) to 0·859 (0·823-0·919) for detection of EBV status.

INTERPRETATION

Classifiers became increasingly robust when trained on pooled cohorts. After prospective validation, this deep learning-based tissue classification system could be used as an inexpensive predictive biomarker for immunotherapy in gastric cancer.

FUNDING

German Cancer Aid and German Federal Ministry of Health.

Prognostic significance of the preoperative C-reactive protein-to-albumin ratio in patients with colorectal cancer

Background

The aim of the present study was to determine the utility of the C-reactive protein-to-albumin ratio (CAR) for predicting the overall survival (OS) in locally advanced colorectal cancer (CRC) patients.

Patients and Methods

This retrospective multicenter study was performed using data from a prospectively maintained database of pathological Stage II or III patients undergoing CRC surgery at the Yokohama City University, Department of Surgery, and its affiliated institutions between April 2000 and March 2016. The risk factors for the OS were identified.

Results

A CAR of 0.03 was considered to be the optimal cutoff point for classification based on the 1-, 3-, and 5-year survival rates and receiver operating characteristic curve. The OS rates at 3 and 5 years after surgery were 92.4% and 85.7% in the CAR-low group, respectively, and 86.7% and 81.1% in the CAR-high group. A multivariate analysis showed that the CAR was a significant independent risk factor for the OS. When comparing the patients' demographic and clinical characteristics between the CAR ≤0.03 and >0.03 groups, the incidence of patients who received adjuvant chemotherapy and the incidence of postoperative complications were significantly different between the two groups.

Conclusion

The present study showed that the preoperative CAR was a risk factor for the OS in patients who underwent surgery for CRC. To improve the patients' survival, CAR might be a useful tool for devising treatment strategies.

Clinical Significance of Chemokine Receptor CXCR4 and CCR7 mRNA Expression in Patients With Colorectal Cancer

BACKGROUND/AIM

The chemokine receptors C-X-C chemokine receptor type 4 (CXCR4) and C-C chemokine receptor type 7 (CCR7) play an important role in the invasion and metastasis of cancer. This study investigated the relationship between relative expression of CXCR4 and CCR7 mRNA, clinicopathological factors, and outcomes in patients with colorectal cancer (CRC).

PATIENTS AND METHODS

We studied 202 patients who underwent surgery for CRC. The expression levels of CXCR4 and CCR7 mRNA in cancerous tissue were measured using quantitative real-time reverse-transcriptase polymerase chain reaction.

RESULTS

High CCR7 mRNA expression levels in CRC tissues were positively associated with tumour size and were more frequently associated with cancer of the rectum than of the colon. Moreover, outcomes were significantly poorer in patients with high CCR7 mRNA expression than in those with low expression. On multivariate Cox regression analysis, a higher CCR7 mRNA expression level was a significant independent predictor of poorer overall survival in patients with CRC.

CONCLUSION

Overexpression of CCR7 mRNA may be a useful independent prognostic factor in patients with CRC.

The age-adjusted Charlson comorbidity index is an independent prognostic factor in pancreatic cancer patients who receive curative resection followed by adjuvant chemotherapy

Background

We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on the pancreatic cancer survival and recurrence after curative surgery followed by adjuvant chemotherapy.

Patients and Methods

This study included 155 patients who underwent curative surgery followed by adjuvant chemotherapy for pancreatic cancer between 2005 and 2014. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified.

Results

An ACCI of 8 was regarded as the optimum critical point of classification considering the 1-, 3- and 5-year survival rates. The OS rates at 3 and 5 years after surgery were 25.7% and 19.0% in the ACCI-low group, respectively, and 7.6% and 0% in the ACCI-high group, which amounted to a statistically significant difference (P = 0.019). The RFS rates at 3 and 5 years after surgery were 17.3% and 13.8% in the ACCI-low group, respectively, and 7.1% and 0% in the ACCI-high group, which amounted to a marginally statistically significant difference (P = 0.104). A multivariate analysis showed that the ACCI was a significant independent risk factor for both the OS and RFS.

Conclusions

The ACCI was a risk factor for the OS in patients who underwent curative surgery followed by adjuvant chemotherapy for pancreatic cancer. An effective plan is needed for determining the optimum surgical strategy according to the ACCI.

Therapeutic results of Denver percutaneous peritoneovenous shunt in cancer patients with malignant ascites

Background

Intractable ascites secondary to malignant disease deteriorates patients' quality of life. The purpose of this study was to evaluate the safety and efficacy of percutaneous peritoneovenous (Denver) shunt in treating intractable malignant ascites in cancer patients.

Materials and Methods

Thirty-five patients who had undergone Denver peritoneovenous shunt for the treatment of ascites associated with malignant tumor from October 2014 to 2017 were retrospectively analyzed. The demographic characteristics, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analyses were performed.

Results

The sites of primary tumor were pancreatic cancer in 19 patients, bile duct cancer in 8, gallbladder cancer in 5, breast cancer in 2, and peritoneal malignant mesothelioma in 1. Palliation of abdominal distention was achieved in 29 patients (82.9%). Postoperative complications of Grade 2 or higher were seen in 11 patients (31.4%), and Grade 5 complications were observed in three patients (8.6%). Patients with a high American Society of Anesthesiologists (ASA) grade and high ascites drainage volume had a significantly higher incidence of postoperative complications than a low ASA grade and low ascites drainage volume, and a multivariate logistic analysis showed that the intraoperative ascites drainage volume was an independent risk factor for all complications.

Conclusions

The Denver shunt for malignant ascites is useful for improving patients' quality of life if the indications are selected properly. Drainage of intraoperative ascites was a risk factor for postoperative complications after the Denver shunt technique in cancer patients with malignant ascites. Further experience and discussion are necessary to establish the patient selection criteria.

Clinical Significance of TAP1 and DLL4 Expression in Patients With Locally Advanced Gastric Cancer

BACKGROUND/AIM

Cancer stem cells (CSCs) are reported to associated with cancer metastasis, relapse, and chemoresistance. This study examined the clinical significance of the expression of two CSC markers, the transporter associated with antigen processing 1 (TAP1) and the Delta-like 4 (DLL4) protein, in patients with locally advanced GC.

PATIENTS AND METHODS

This study was performed using samples obtained from 413 pathological stage II/III GC patients after curative gastrectomy. We examined TAP1 and DLL4 expression using immunohistochemical analysis with tissue microarray and examined the association between TAP1 or DLL4 expression, clinicopathological factors and survival.

RESULTS

High TAP1 expression was associated with better overall survival compared to low TAP1 expression (p=0.004). Furthermore, in multivariate analysis, high TAP1 expression was defined as a predictive factor for good survival. There was no significant difference between DLL4 expression and clinicopathological features and overall survival.

CONCLUSION

TAP1 expression may be a useful prognostic marker in patients with locally advanced GC.