Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

Comparative efficacy and tolerability of targeted and immunotherapy combined with chemotherapy as first-line treatment for advanced gastric cancer: a Bayesian network meta-analysis

The use of target agents and immune checkpoint inhibitors have changed the treatment landscape for AGC in the first-line setting. However, the crosswise comparison between each regimen is rare. Therefore, we estimated the efficacy and safety of targeted therapy or immunotherapy with chemotherapy in AGC patients as the first-line treatment. Included studies were divided into "average" or "specific positivity" group according to whether the patients were selected by a certain pathological expression. We conducted a Bayesian network meta-analysis for all regimens in both groups. In average group, no regimen showed significant improvements in overall survival (OS) and progression free survival (PFS), while pembrolizumab and nivolumab combined with chemotherapy were ranked first and second respectively without an obvious safety difference. In specific positivity group, zolbetuximab plus chemotherapy significantly prolonged OS (HR 0.53, 95% CI 0.36-0.79) and PFS (HR 0.45, 95% CI 0.25-0.81). The top three regimens were zolbetuximab-chemotherapy, trastuzumab plus pertuzuma-chemotherapy and nivolumab-chemotherapy respectively, with no significant safety risk. For average patients, immune checkpoint inhibitor PD-1 plus chemotherapy will be the promising regimen. For patients with overexpression of CLDN18.2, zolbetuximab combined with chemotherapy comes with greater survival benefits, while for patients who have PD-L1 expression with no HER-2 or CLDN18.2 positivity, additional immune checkpoint inhibitor of PD-1 will be a good considered option.

Comparative efficacy and tolerability of targeted and immunotherapy combined with chemotherapy as first-line treatment for advanced gastric cancer: a Bayesian network meta-analysis

The use of target agents and immune checkpoint inhibitors have changed the treatment landscape for AGC in the first-line setting. However, the crosswise comparison between each regimen is rare. Therefore, we estimated the efficacy and safety of targeted therapy or immunotherapy with chemotherapy in AGC patients as the first-line treatment. Included studies were divided into "average" or "specific positivity" group according to whether the patients were selected by a certain pathological expression. We conducted a Bayesian network meta-analysis for all regimens in both groups. In average group, no regimen showed significant improvements in overall survival (OS) and progression free survival (PFS), while pembrolizumab and nivolumab combined with chemotherapy were ranked first and second respectively without an obvious safety difference. In specific positivity group, zolbetuximab plus chemotherapy significantly prolonged OS (HR 0.53, 95% CI 0.36-0.79) and PFS (HR 0.45, 95% CI 0.25-0.81). The top three regimens were zolbetuximab-chemotherapy, trastuzumab plus pertuzuma-chemotherapy and nivolumab-chemotherapy respectively, with no significant safety risk. For average patients, immune checkpoint inhibitor PD-1 plus chemotherapy will be the promising regimen. For patients with overexpression of CLDN18.2, zolbetuximab combined with chemotherapy comes with greater survival benefits, while for patients who have PD-L1 expression with no HER-2 or CLDN18.2 positivity, additional immune checkpoint inhibitor of PD-1 will be a good considered option.

Comparative efficacy and tolerability of targeted and immunotherapy combined with chemotherapy as first-line treatment for advanced gastric cancer: a Bayesian network meta-analysis

The use of target agents and immune checkpoint inhibitors have changed the treatment landscape for AGC in the first-line setting. However, the crosswise comparison between each regimen is rare. Therefore, we estimated the efficacy and safety of targeted therapy or immunotherapy with chemotherapy in AGC patients as the first-line treatment. Included studies were divided into "average" or "specific positivity" group according to whether the patients were selected by a certain pathological expression. We conducted a Bayesian network meta-analysis for all regimens in both groups. In average group, no regimen showed significant improvements in overall survival (OS) and progression free survival (PFS), while pembrolizumab and nivolumab combined with chemotherapy were ranked first and second respectively without an obvious safety difference. In specific positivity group, zolbetuximab plus chemotherapy significantly prolonged OS (HR 0.53, 95% CI 0.36-0.79) and PFS (HR 0.45, 95% CI 0.25-0.81). The top three regimens were zolbetuximab-chemotherapy, trastuzumab plus pertuzuma-chemotherapy and nivolumab-chemotherapy respectively, with no significant safety risk. For average patients, immune checkpoint inhibitor PD-1 plus chemotherapy will be the promising regimen. For patients with overexpression of CLDN18.2, zolbetuximab combined with chemotherapy comes with greater survival benefits, while for patients who have PD-L1 expression with no HER-2 or CLDN18.2 positivity, additional immune checkpoint inhibitor of PD-1 will be a good considered option.

Advances in Imaging of Inflammation, Fibrosis, and Cancer in the Gastrointestinal Tract

Gastrointestinal disease is prevalent and broad, manifesting itself in a variety of ways, including inflammation, fibrosis, infection, and cancer. However, historically, diagnostic technologies have exhibited limitations, especially with regard to diagnostic uncertainty. Despite development of newly emerging technologies such as optoacoustic imaging, many recent advancements have focused on improving upon pre-existing modalities such as ultrasound, computed tomography, magnetic resonance imaging, and endoscopy. These advancements include utilization of machine learning models, biomarkers, new technological applications such as diffusion weighted imaging, and new techniques such as transrectal ultrasound. This review discusses assessment of disease processes using imaging strategies for the detection and monitoring of inflammation, fibrosis, and cancer in the context of gastrointestinal disease. Specifically, we include ulcerative colitis, Crohn's disease, diverticulitis, celiac disease, graft vs. host disease, intestinal fibrosis, colorectal stricture, gastric cancer, and colorectal cancer. We address some of the most recent and promising advancements for improvement of gastrointestinal imaging, including unique discussions of such advancements with regard to imaging of fibrosis and differentiation between similar disease processes.

Development and validation of an artificial neural network model for non-invasive gastric cancer screening and diagnosis

Non-invasive and cost-effective diagnosis of gastric cancer is essential to improve outcomes. Aim of the study was to establish a neural network model based on patient demographic data and serum biomarker panels to aid gastric cancer diagnosis. A total of 295 patients hospitalized in Nanjing Drum Tower hospital diagnosed with gastric cancer based on tissue biopsy, and 423 healthy volunteers were included in the study. Demographical information and tumor biomarkers were obtained from Hospital Information System (HIS) as original data. Pearson's correlation analysis was applied on 574 individuals' data (training set, 229 patients and 345 healthy volunteers) to analyze the relationship between each variable and the final diagnostic result. And independent sample t test was used to detect the differences of the variables. Finally, a neural network model based on 14 relevant variables was constructed. The model was tested on the validation set (144 individuals including 66 patients and 78 healthy volunteers). The predictive ability of the proposed model was compared with other common machine learning models including logistic regression and random forest. Tumor markers contributing significantly to gastric cancer screening included CA199, CA125, AFP, and CA242 were identified, which might be considered as important inspection items for gastric cancer screening. The accuracy of the model on validation set was 86.8% and the F1-score was 85.0%, which were better than the performance of other models under the same condition. A non-invasive and low-cost artificial neural network model was developed and proved to be a valuable tool to assist gastric cancer diagnosis.

Perioperative outcomes of robotic versus laparoscopic distal gastrectomy for gastric cancer: a meta-analysis of propensity score-matched studies and randomized controlled trials

Background

Da Vinci robotic surgery system, a novel type of surgery, was widespread in surgical field. However, the perioperative outcomes of robotic distal gastrectomy (RDG) are still controversy, despite several observational studies and randomized controlled trials (RCT) had been reported. Therefore, we performed a meta-analysis of propensity score-matched (PSM) and RCT studies to evaluated the perioperative feasibility and safety of RDG.

Methods

Studies were systematically searched in PubMed, Web of Science, Cochrane Library, and Embase database, and screened according to the defined limitations. The quality of PSM studies and RCT studies were respectively assessed by ROBINS-I and Cochrane risk-of-bias tool. Extracted data were analyzed by Review Manager 5.4.

Results

7 PSM studies and 1 RCT with a total of 2763 patients were included in this analysis. The longer operative time (MD = 31.42, 95% CI [22.88, 39.96], p < 0.00001), less blood loss (MD = − 25.89, 95% CI [− 36.18, − 15.6], p < 0.00001), more retrieved lymph nodes (MD = 3.46, 95% CI [2.94, 3.98], p < 0.00001), shorter time to first flatus (MD = − 0.08, 95% CI [− 0.13, − 0.02], p = 0.006) and liquid intake (MD = − 0.13, 95% CI [− 0.22, − 0.05], p = 0.002) were observed in RDG group compared with LDG group. There are no statistically significant in time to start soft diet, postoperative hospital stays, overall complications, complications Grade I–II, complications Grade ≥ III, anastomotic leakage, bleeding, intra-abdominal bleeding, intraluminal bleeding, ileus, abdominal infection, delayed gastric emptying and wound complications.

Conclusions

RDG showed less blood loss and more retrieved lymph nodes, revealed less time to first flatus and liquid intake after operation. But the operative time was longer in RDG group than in LDG. The incidence rate of postoperative complications was comparable between RDG and LDG.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients

INTRODUCTION

Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review.

CASE REPORT

A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved.

CONCLUSION

In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.

Prognostic value of tumor deposits in lymph node-negative gastric cancer: A propensity score matching study

BACKGROUND

The purpose of this study was to assess the prognostic value of TD in lymph node-negative GC.

METHODS

A retrospective study was conducted to collect the clinicopathological data from 1224 patients with lymph node-negative GC. According to their TD status, patients were categorized into TD-positive and TD-negative groups. Patients in both groups underwent a 1:1 propensity score matching analysis. Survival analysis was performed by the Kaplan-Meier method, and the differences between survival curves were measured by log-rank test. The cox proportional hazards model was used for univariate and multivariate analyses.

RESULTS

The TD-negative group had higher 5-year overall survival(OS) rate than TD-positive group(69.4%VS.36.4%,P < 0.05). Further subgroup analysis indicated that patients in the TD-negative group had higher 5-year OS rates than those in the TD-positive group in the T1-2, T3, and T4 subgroups(all with P < 0.05).The OS rates were decreased with the increase of the number of TD.The univariate Cox regression analysis demonstrated that tumor location in antrum, distal gastrectomy, perineural invasion, T4-stage,lymphovascular invasion and the number of TD were all associated with prognosis in patients undergoing curative gastric resection (P < 0.05).The multivariable analysis revealed that the number of TD, perineural invasion, lymphovascular invasion and T4 stage were independently associated with OS.

CONCLUSION

In lymph node-negative GC, TD is an independent risk factor for prognosis, regardless of T-stage, and patients with ≥3 TD have a worse prognosis.

Early-stage gastric and gastroesophageal junction cancer: Is there a survival benefit to neoadjuvant therapy?

BACKGROUND

Several randomized controlled trials have evaluated the efficacy of neoadjuvant chemotherapy in the management of resectable gastric cancer. Most patients in these studies had node-positive disease or more advanced T stage. The benefit of neoadjuvant therapy in patients with early-stage gastric cancer remains unclear.

METHODS

We queried the National Cancer Data Base to identify patients presenting with clinical stage IB gastric adenocarcinoma between 2006 and 2015. Multivariable logistic regression was used to identify factors associated with receipt of neoadjuvant therapy. Patients undergoing neoadjuvant therapy were 1:1 propensity matched for age, year of diagnosis, Charlson index, insurance, tumor location, tumor grade, surgical approach, lymph nodes examined, and receipt of adjuvant therapy. Log rank testing was used to evaluate differences in overall survival between matched cohorts.

RESULTS

A total of 1,258 patients met the inclusion criteria; 402 (32%) received neoadjuvant therapy. On multivariable logistic regression, increasing age (odds ratio 0.52, 95% confidence interval 0.34-0.80) was associated with reduced adjusted odds of undergoing neoadjuvant therapy, whereas proximal tumor location (odds ratio 3.67, 95% confidence interval 2.71-4.99) and poorly differentiated histology (odds ratio 1.78, 95% confidence interval 1.00-3.16) were associated with an increased adjusted odds of undergoing neoadjuvant therapy. A total of 271 patients undergoing neoadjuvant therapy were successfully matched to 271 patients undergoing upfront resection. There was no statistically significant difference in 5-year overall survival (58.8% vs 50.3%, P = .512) between matched cohorts.

CONCLUSION

Neoadjuvant therapy does not appear to be associated with an overall survival benefit in patients with stage IB stage gastric cancer.

Deep learning model for diagnosing early gastric cancer using preoperative computed tomography images

BACKGROUND

Early gastric cancer (EGC) is defined as a lesion restricted to the mucosa or submucosa, independent of size or evidence of regional lymph node metastases. Although computed tomography (CT) is the main technique for determining the stage of gastric cancer (GC), the accuracy of CT for determining tumor invasion of EGC was still unsatisfactory by radiologists. In this research, we attempted to construct an AI model to discriminate EGC in portal venous phase CT images.

METHODS

We retrospectively collected 658 GC patients from the first affiliated hospital of Nanchang university, and divided them into training and internal validation cohorts with a ratio of 8:2. As the external validation cohort, 93 GC patients were recruited from the second affiliated hospital of Soochow university. We developed several prediction models based on various convolutional neural networks, and compared their predictive performance.

RESULTS

The deep learning model based on the ResNet101 neural network represented sufficient discrimination of EGC. In two validation cohorts, the areas under the curves (AUCs) for the receiver operating characteristic (ROC) curves were 0.993 (95% CI: 0.984-1.000) and 0.968 (95% CI: 0.935-1.000), respectively, and the accuracy was 0.946 and 0.914. Additionally, the deep learning model can also differentiate between mucosa and submucosa tumors of EGC.

CONCLUSIONS

These results suggested that deep learning classifiers have the potential to be used as a screening tool for EGC, which is crucial in the individualized treatment of EGC patients.

Survival benefit of primary tumor resection for gastric cancer with liver metastasis: A propensity score-matched, population-based study

OBJECTIVES

Gastric cancer with liver metastasis (GCLM) is highly aggressive and has a poor prognosis. This study aims to evaluate the survival benefit of primary tumor resection (PTR) for gastric cancer with liver metastasis.

METHODS

Data on patients with GCLM was extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. A 1:1 propensity score matching (PSM) analysis was performed to minimize the heterogeneity between the PTR and no-PTR groups. The Kaplan-Meier method and Cox regression analysis were used to assess the impact of primary tumor resection (PTR) on overall survival (OS) and cause-specific survival (CSS).

RESULTS

A total of 3,001 patients with GCLM were included, with 328 patients treated with primary tumor resection (PTR), whereas the other 2,673 patients were not. Patients with PTR had a significantly higher OS and CSS rate than those without PTR in unmatched and PSM cohorts. In an unmatched cohort, the median OS was 12.0 months (95% CI, 10 months to 14 months) for those who underwent PTR and 4 months (95% CI, 4 months to 5 months) for those without PTR; the median CSS for those who underwent PTR was 12.0 months (95% CI, 10 months to14 months) and 4 months (95% CI, 4 months to 5 months) for those without PTR, respectively. After PMS, the median OS was 12.0 months (95% CI, 10 months to 17 months) for those who underwent PTR and 7 months (95% CI, 5 months to 10 months) for those without PTR, respectively; the median CSS for those who underwent PTR was 12.0 months (95% CI, 11 months to 17 months) and 7 months (95% CI, 5 months to 8 months) for those without PTR, respectively. In addition, multivariate Cox analysis in the PSM cohort showed that PTR, age, degree of tumor differentiation, and chemotherapy were independent prognostic factors for OS and CSS in GCLM. Specifically, PTR was a significant protective factor for OS (HR: 0.427; 95% CI, 0.325 to 0.561, P <0.001) and CSS (HR: 0.419; 95% CI, 0.313 to 0.561, P <0.001).

CONCLUSION

Primary tumor resection improves the survival of gastric cancer patients with liver metastasis.

CAR T-cells for colorectal cancer immunotherapy: Ready to go?

Chimeric antigen receptor (CAR) T-cells represent a new genetically engineered cell-based immunotherapy tool against cancer. The use of CAR T-cells has revolutionized the therapeutic approach for hematological malignancies. Unfortunately, there is a long way to go before this treatment can be developed for solid tumors, including colorectal cancer. CAR T-cell therapy for colorectal cancer is still in its early stages, and clinical data are scarce. Major limitations of this therapy include high toxicity, relapses, and an impermeable tumor microenvironment for CAR T-cell therapy in colorectal cancer. In this review, we summarize current knowledge, highlight challenges, and discuss perspectives regarding CAR T-cell therapy in colorectal cancer.

Machine learning-based identification of a novel prognosis-related long noncoding RNA signature for gastric cancer

Gastric cancer (GC) is one of the most common malignancies with a poor prognosis. Immunotherapy has attracted much attention as a treatment for a wide range of cancers, including GC. However, not all patients respond to immunotherapy. New models are urgently needed to accurately predict the prognosis and the efficacy of immunotherapy in patients with GC. Long noncoding RNAs (lncRNAs) play crucial roles in the occurrence and progression of cancers. Recent studies have identified a variety of prognosis-related lncRNA signatures in multiple cancers. However, these studies have some limitations. In the present study, we developed an integrative analysis to screen risk prediction models using various feature selection methods, such as univariate and multivariate Cox regression, least absolute shrinkage and selection operator (LASSO), stepwise selection techniques, subset selection, and a combination of the aforementioned methods. We constructed a 9-lncRNA signature for predicting the prognosis of GC patients in The Cancer Genome Atlas (TCGA) cohort using a machine learning algorithm. After obtaining a risk model from the training cohort, we further validated the model for predicting the prognosis in the test cohort, the entire dataset and two external GEO datasets. Then we explored the roles of the risk model in predicting immune cell infiltration, immunotherapeutic responses and genomic mutations. The results revealed that this risk model held promise for predicting the prognostic outcomes and immunotherapeutic responses of GC patients. Our findings provide ideas for integrating multiple screening methods for risk modeling through machine learning algorithms.

The Role of Surgery in the Management of Gastric Cancer: State of the Art

Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.

Prognostic nutritional index for predicting the clinical outcomes of patients with gastric cancer who received immune checkpoint inhibitors

OBJECTIVE

Although the application of immunotherapy in gastric cancer has achieved satisfactory clinical effects, many patients have no response. The aim of this retrospective study is to investigate the predictive ability of the prognostic nutrition index (PNI) to the prognosis of patients with gastric cancer who received immune checkpoint inhibitors (ICIs).

MATERIALS AND METHODS

Participants were 146 gastric cancer patients with ICIs (PD-1/PD-L1 inhibitors) or chemotherapy. All patients were divided into a low PNI group and a high PNI group based on the cut-off evaluated by the receiver operating characteristic (ROC) curve. We contrasted the difference in progression-free survival (PFS) and overall survival (OS) in two groups while calculating the prognosis factors for PFS and OS by univariate and multivariate analyses. Moreover, the nomogram based on the results of the multivariate analysis was constructed to estimate the 1- and 3-year survival probabilities.

RESULTS

There were 41 (28.1%) cases in the low PNI group and 105 (71.9%) cases in the high PNI group. The median survival time for PFS in the low PNI group and high PNI group was 12.30 months vs. 33.07 months, and 18.57 months vs. not reached in the two groups for OS. Patients in low PNI group were associated with shorter PFS and OS in all patients [Hazard ratio (HR) = 1.913, p = 0.013 and HR = 2.332, p = 0.001]. Additionally, in subgroup analysis, low PNI group cases also had poorer PFS and OS, especially in patients with ICIs. In addition, the multivariate analysis found that carbohydrate antigen 724 (CA724) and TNM stage were independent prognostic factors for PFS. At the same time, indirect bilirubin (IDBIL), CA724, PNI, and TNM stage were independent prognostic factors for OS.

CONCLUSION

Prognostic nutrition index was an accurate inflammatory and nutritional marker, which could predict the prognosis of patients with gastric cancer who received ICIs. PNI could be used as a biomarker for ICIs to identify patients with gastric cancer who might be sensitive to ICIs.

Pathological complete remission of a locally advanced gastric cancer by neoadjuvant therapy "sandwich" regimen as SOXAP+ fluorescence laparoscopic surgery +SOXAP: Case report

Gastric cancer is an extremely burdensome and challenging malignant tumor with a high incidence and a high mortality rate, which seriously results in a thorny prognosis for oncology patients. Surgical treatment combined with postoperative adjuvant therapy are currently the most regular methods for the treatment of locally advanced gastric cancer (LAGC), but long-term efficacy is not an ideal outcome. Therefore, herein we report a case of a pathologically confirmed complete remission of LAGC treated by the administration of neoadjuvant therapy combined with fluorescence laparoscopic surgery with more significant long-term survival. With that being mentioned, a 60-year-old man was diagnosed as moderately differentiated gastric antrum adenocarcinoma (T3N1M0). Moreover, after three cycles of SOXAP regimen (Oxaliplatin + S-1+Apatinib + Camrelizumab), and it was found out that the gastric lesion was smaller in size than before, total laparoscopic radical resection of the distal gastric cancer was performed at the time. Furthermore, no tumor cells were seen in gross specimen post operatively, achieving complete remission of the case. In addition, he also underwent three cycles of SOXAP regimen postoperatively. Interestingly and assuredly, he was in good health after an almost 2-year follow up period. These results suggest that this therapeutic regimen is a promising treatment modality for the management of locally advanced gastric cancers.

Nivolumab with or without chemotherapy for metastatic gastroesophageal cancers and future perspectives

INTRODUCTION

Gastroesophageal cancers (GEC) are frequently found at the advanced stage. GEC treatment advancements have been limited and prognosis, therefore, remains poor. Through numerous clinical trials, the addition of immune checkpoint inhibitors, including nivolumab, to conventional therapy has demonstrated a survival benefit.

AREAS COVERED

Here, we focus on the function of nivolumab in patients with advanced GECs. We discuss the most recent trials that led to nivolumab's incorporation into therapy and pathways forward.

EXPERT OPINION

Nivolumab in combination with chemotherapy appears well tolerated, with only a small number of patients reporting severe toxicity; therefore, it may be possible to add additional biological agents to improve outcomes. A number of 'nivolumab plus other agents' is currently being investigated, and we anticipate continued advancement in GEC management in the coming years.

Impact of examined lymph node number on accurate nodal staging and long-term survival of resected Siewert type II-III adenocarcinoma of the esophagogastric junction: A large population-based study

Background

We aimed to investigate the association between the number of examined lymph nodes (ELNs) and accurate nodal staging and long-term survival in Siewert type II-III Adenocarcinoma of the Esophagogastric Junction (AEG) by using large population-based databases and determined the optimal ELN number threshold.

Methods

Data on Stage I-III Siewert type II-III AEG patients from 2010 to 2014 respectively from the United States (US) SEER database and a Chinese large medical center institutional registry were analyzed for correlation between the ELN number and stage migration (node negative-to-positive) and overall survival (OS) by using multivariable-adjusted logistic and Cox regression models, respectively. The series of odds ratios (ORs), and hazard ratios (HRs) were fitted with a LOWESS smoother, and the structural breakpoints were determined by Chow test. The selected optimal cut point was then validated with the 2015 to 2016 SEER database.

Results

Both the US cohort(n=1387) and China cohort(n=981) showed significantly increases from node-negative to node-positive disease (OR_theUS1.032,95%CI 1.017–1.046;OR_China1.034,95%CI 1.002–1.065) and enhancements in overall survival (HR_theUS0.970,95%CI 0.961-0.979;HR_China0.960,95%CI 0.940-0.980) with the increasing ELN number after controlling for confounders. Associations for both stage migration and overall survival were still significant in most subgroups’ stratification. Cut point analysis showed a threshold ELN number of 18, which was validated both in the cohorts where it originated and in an independent SEER data cohort(n=379).

Conclusions

More ELNs are associated with accurate nodal staging(negative-to-positive) as well as higher overall survival in resected Siewert types II-III AEG, We recommend 18 ELNs as the optimal cut point for the quality assessment of postoperative lymph node examination or prognostic stratification in clinical practice.

A meta-analysis with systematic review: Efficacy and safety of immune checkpoint inhibitors in patients with advanced gastric cancer

Background

While the efficacy of immune checkpoint inhibitors (ICIs) is increasingly recognized in advanced gastric cancer (aGC), overall survival (OS) has not been consistently improved across the different randomized controlled trials (RCTs). This meta-analysis aimed to quantify the efficacy and safety of ICI and explore potential predictive tumor tissue biomarkers in aGC.

Methods

A random-effect pairwise meta-analysis was used to evaluate the primary outcome of OS. Sensitivity analysis was performed to investigate the effects of ICIs on PD-L1 status, TMB, MSI-H, and the Asian patient population. We extracted the OS Kaplan-Meier curves from the included trials to compare the effect of PD-L1 status on response to ICIs using DigitizeIt 2.5 and Guyot's algorithm.

Results

A pairwise meta-analysis of seven RCTs included in this study showed that ICIs were more effective than the comparator in improving OS (pooled HR: 0.84). We demonstrated that PD-1 ICIs were additive when combined with the comparator arm (pooled HR: 0.79). A sensitivity analysis showed that PD-1 ICIs were associated with better OS outcomes in the Asian patient population as monotherapy (pooled HR: 0.66) or in combination with chemotherapy (pooled HR: 0.83). We demonstrated that tumors with PD-L1 ≥1 (P = 0.02) and PD-L1 ≥10 (P = 0.006) derived OS benefit from ICI monotherapy. Equally, MSI-H (P <0.00001) and TMB-high (P <0.0001) tumors derived favorable survival benefits from ICIs.

Conclusions and relevance

The results of this meta-analysis suggest that ICIs result in improved OS outcomes in aGC. The benefits varied with different ethnicities, class of ICI, PD-L1 expression, MSI status, and TMB.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero, identifier (CRD42019137829).

Stratified analysis of multiple management of gastric cancer: A population-based study of incidence, mortality and DALY

The aim was to illuminate the difference in incidence, mortality, and disability-adjusted life-years (DALYs) of gastric cancer (GC) between the United States of America (US) and China. The multiple management was analyzed with stratification to explore an effective survival improvement strategy. The Global Burden of Disease Study data was analyzed to assess GC morbidity, mortality and DALYs from 1990 to 2019 in the US and China. The age-period-cohort model was established to generate estimation of metrics. Verification was completed and stratified analysis of the multiple management was performed by accessing data of Surveillance, Epidemiology, and End Results database in 1992 to 2019. Continuous downtrends in GC incidence, mortality and DALYs from 1990 to 2019 and persistent uptrends in 1-, 3-year survival from 1992 to 2019 were observed in the US population. In the Chinese population, the overall trends of incidence, mortality and DALYs decreased with a fluctuating manner. The lower overall survival rates were observed in elderly, unmarried patients, distant disease and poor grade, as well as patients lacking of medical treatment (P < .05). In stratified analyses, single local therapy decreased and the other modalities increased over time across different stages. Moreover, combined treatment and single systemic therapy decreased, but single local and conservative therapy increased with age. The study quantified the incidence, GC-specific mortality and DALYs in the US and China and estimated stage profiles, 1- and 3-year survival in the US. The heavy burden on later-onset GC (>70) and potential increase on early-onset GC (<40) needed to be addressed. Combined modalities and single chemotherapy were becoming more widely used over time, however, their uses decreased with age because of poor physical fitness. Our findings provide new insights into management tailoring appropriately to specific subgroups contributes to the increasing survival rate.

Risk factors associated with peritoneal carcinomatosis of gastric cancer in staging laparoscopy: A systematic review and meta-analysis

Background

The optimal indications of staging laparoscopy in gastric cancer to detect peritoneal carcinomatosis are still controversial. We performed this systematic review and meta-analysis to quantify the relevance of the preoperative factors with peritoneal carcinomatosis to explore the indications of staging laparoscopy.

Materials and methods

Systematic searches were conducted using Medline, Embase, and the Cochrane Library in December 2021. On the basis of calculating the odds ratio (OR) of each factor, we quantified the association between the risk factors and peritoneal carcinomatosis such as clinical T/N stage, Borrmann type, and tumor markers, using meta-analysis with a random-effects model.

Results

A total of 21 case-control studies and one cohort study were obtained. T stage, N stage, and differentiation degree were most widely studied, with OR values of 2.96 (95% CI: 1.87–4.69), 1.22 (95% CI: 0.86–1.73), and 1.91 (95% CI: 1.42–2.56), respectively. Among all the factors, elevated CA125 (OR = 19.45, 95% CI: 4.71–80.30), Borrmann type IV (OR = 7.68, 95% CI: 3.62–16.27), and large tumor diameter (OR = 5.12, 95% CI: 2.55–10.31) had the highest OR. In particular, CA125 had the best predictability for peritoneal carcinomatosis but was only mentioned by three articles.

Conclusions

There was a cognitive gap between the awareness and importance of risk factors for peritoneal carcinomatosis. In addition to T4 stage, patients with factors with high OR, such as Borrmann type IV, large tumor diameter, and elevated CA125, should undergo staging laparoscopy.

Detection of asymptomatic recurrence following curative surgery improves survival in patients with gastric cancer: A systematic review and meta-analysis

Background

To date, there is no evidence that intensive follow-up provides survival benefit in gastric cancer patients undergoing curative gastrectomy. The aim of this study is to investigate the efficacy of detection of asymptomatic recurrence using intensive surveillance strategy in long-term survival after curative gastric cancer surgery.

Methods

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Infrastructure, Clinical Trials Registry and Google Scholar was performed up to April 2022. The primary outcomes were survival outcomes: overall survival, recurrence-free survival and post-recurrence survival. The secondary endpoints were clinicopathological features, recurrence patterns and treatment after recurrence. The registration number of this protocol is PROSPERO CRD42022327370.

Results

A total of 11 studies including 1898 participants were included. In the pooled analysis, the detection of asymptomatic recurrence was significantly associated with an improved overall survival compared to patients showing symptoms of recurrence (HR=0.67; 95%CI: 0.57-0.79; P<0.001), which was primarily driven by the prolongation of post-recurrence survival (HR=0.51; 95%CI: 0.42-0.61; P<0.001), since there was no significant difference observed in recurrence-free survival (HR=1.12; 95%CI: 0.81-1.55; P=0.48) between the two groups. Meanwhile, male sex and advanced T stage were more frequently observed in the symptomatic recurrence group. Furthermore, patients in the symptomatic recurrence group had a higher proportion of peritoneal relapse but lower proportion of distant lymph node metastasis. Additionally, patients in the symptomatic recurrence group were less likely to receive surgery treatment and post-recurrence chemotherapy.

Conclusion

The detection of asymptomatic recurrence using intensive follow-up was associated with an appreciable improvement in overall survival. However, more robust data from high-quality studies are still required to verify this issue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327370, identifier CRD42022327370.

A literature review on the potential clinical implications of streptococci in gastric cancer

Streptococcus is widely found in nature and the human body, and most species are not pathogenic. In recent years, studies have found that Streptococcus is associated with gastric cancer. Streptococcus was found to be enriched in the oral cavity, stomach and intestine of gastric cancer patients and found to be increased in gastric cancer tissues, suggesting that Streptococcus may be the pathogenic bacteria underlying gastric cancer. This review discusses the discovery of Streptococcus, the relationship between Streptococcus and gastric cancer, and the possible carcinogenic mechanism of Streptococcus and summarizes the progress of the research on the role of Streptococcus in gastric cancer to provide new ideas for the early detection, diagnosis and treatment of gastric cancer.

Intraoperative Tumor Detection Using Pafolacianine

Cancer is a leading cause of death worldwide, with increasing numbers of new cases each year. For the vast majority of cancer patients, surgery is the most effective procedure for the complete removal of the malignant tissue. However, relapse due to the incomplete resection of the tumor occurs very often, as the surgeon must rely primarily on visual and tactile feedback. Intraoperative near-infrared imaging with pafolacianine is a newly developed technology designed for cancer detection during surgery, which has been proven to show excellent results in terms of safety and efficacy. Therefore, pafolacianine was approved by the U.S. Food and Drug Administration (FDA) on 29 November 2021, as an additional approach that can be used to identify malignant lesions and to ensure the total resection of the tumors in ovarian cancer patients. Currently, various studies have demonstrated the positive effects of pafolacianine’s use in a wide variety of other malignancies, with promising results expected in further research. This review focuses on the applications of the FDA-approved pafolacianine for the accurate intraoperative detection of malignant tissues. The cancer-targeting fluorescent ligands can shift the paradigm of surgical oncology by enabling the visualization of cancer lesions that are difficult to detect by inspection or palpation. The enhanced detection and removal of hard-to-detect cancer tissues during surgery will lead to remarkable outcomes for cancer patients and society, specifically by decreasing the cancer relapse rate, increasing the life expectancy and quality of life, and decreasing future rates of hospitalization, interventions, and costs.

Case report: Long response to PD-1 blockade after failure of trastuzumab plus chemotherapy in advanced Epstein-Barr virus-associated gastric cancer

Background

Trastuzumab-containing chemotherapy is the first-line treatment for advanced gastric cancer (GC) with HER2 positive. Although PD-1 inhibitors significantly improved the outcome of GC patient’s refractory to previous chemotherapy regimens, few studies explore the role of anti-PD-1 therapy overcomes resistance to trastuzumab plus chemotherapy in advanced Epstein-Barr Virus-associated gastric cancer (EBVaGC) with PD-L1 and HER2 positive.

Case Presentation

We report a case of advanced EBVaGC in a 45-year-old man presenting with fatigue, dysphagia, and weight loss for several months. Initial endoscopy revealed a large tumor at the gastroesophageal junction. Computed tomography revealed GC accompanied by multiple lymph nodes and hepatic and pulmonary metastases. The immunohistochemistry indicated that HER-2 and PD-L1 were overexpressed, and tumor cells were positive for EBV-encoded small RNA (EBER) by in situ hybridization. Trastuzumab plus DCS was started as first-line chemotherapy with a PFS of 4 months and shifted to trastuzumab plus FOLFIRI or gemcitabine as second-/third-line therapy. After five-cycle nivolumab monotherapy, the patient received partial response and was treated with total radical gastrectomy plus sequential radiotherapy. He continued the postoperative immunotherapy over 30 cycles with a PFS of 28 months. Due to a new abdominal lymph node metastasis confirmed by PET-CT, he received toripalimab as the next-line treatment and achieved complete remission as the best objective response.

Summary

We presented an advanced HER2-positive EBVaGC patient with PD-L1 high expression, refractory to trastuzumab plus chemotherapy, and had a durable clinical benefit sequence with a single dose of the PD-1 inhibitor.

Perspectives on the Management of Oligometastatic Disease in Esophago-Gastric Cancer

Gastric adenocarcinoma and esophageal cancer are the fifth and seventh most common cancer types worldwide. At the time of initial diagnosis, up to 50% of esophagogastric cancers present with distant metastatic lesions and are candidates for chemotherapy. Curative surgery in this stage is still an experimental approach. Only a small number of these metastatic patients show an oligometastatic disease with no uniform definition of what oligometastatic means in gastric cancer. Nevertheless, the question remains unanswered as to whether these patients are still candidates for curative concepts. Some studies have attempted to answer this question but have not been adequately designed to address the role of a curative-intended multimodal therapy in this setting. The current FLOT-5 is designed to potentially provide a definitive answer to the question of whether curatively intended surgery plays a role or is a disadvantage in this setting.

Role of Nivolumab in the Management of First-Line Unresectable Advanced or Recurrent Gastric Cancer in Combination with Chemotherapy: Lessons from the Japanese Experience

Recently, immune checkpoint inhibitor (ICI), such as anti-programmed cell death-1 (PD-1) or programmed cell death ligand-1 (PD-L1) monoclonal antibodies, has provided clinical benefits in various cancer types including advanced gastric cancer (AGC). Nivolumab, a monoclonal anti-PD-1 antibody, firstly showed an improvement in the overall survival (OS) in patients with AGC in the ATTRACTION-2 trial. Recently, chemotherapy plus nivolumab, as a first-line treatment for AGC, showed both OS and progression-free survival (PFS) benefits in patients with PD-L1 combined positive score (CPS) ≥5 in the global CheckMate-649 trial, and demonstrated PFS benefit irrespective of CPS status in the Asian ATTRACTION-4 trial. Based on these results, chemotherapy plus nivolumab in a first-line treatment was approved worldwide. However, the approval requirements and recommendations are different according to the approval agent or country. Thus, this review summarized the clinical trials of chemotherapy plus anti-PD1 antibody as a first-line treatment and focused on the role of nivolumab combined with chemotherapy mainly from the viewpoint of the Japanese experience.

The Role of ctDNA in Gastric Cancer

Simple Summary

DNA release from tumour cells (call circulating tumour DNA) into the blood stream can be found in patients with gastric cancer through a blood test call a liquid biopsy. This less invasive test can assess the genetic make-up of tumours to provide important information on the mechanisms of cancer development, identify mutations which can be targeted with drugs and could be used to screen for patients with gastric cancer. This article will review the current and future uses of liquid biopsies in gastric cancer.

Abstract

Circulating tumour DNA (ctDNA) has potential applications in gastric cancer (GC) with respect to screening, the detection of minimal residual disease (MRD) following curative surgery, and in the advanced disease setting for treatment decision making and therapeutic monitoring. It can provide a less invasive and convenient method to capture the tumoural genomic landscape compared to tissue-based next-generation DNA sequencing (NGS). In addition, ctDNA can potentially overcome the challenges of tumour heterogeneity seen with tissue-based NGS. Although the evidence for ctDNA in GC is evolving, its potential utility is far reaching and may shape the management of this disease in the future. This article will review the current and future applications of ctDNA in GC.

Licoricidin combats gastric cancer by targeting the ICMT/Ras pathway in vitro and in vivo

Licoricidin, a type of isoflavonoid, is extracted from the root of Glycyrrhiza glabra. It has been widely proven that licoricidin possesses multiple biological activities, including anti-cancer effects and a powerful antimicrobial effect against Helicobacter pylori (H. pylori). However, the exact mechanism of licoricidin against gastric cancer remains unclear. In this study, we comprehensively explored the effects of licoricidin on MGC-803 gastric cancer cells in vitro and in vivo and further elucidated its mechanism of action. Our results revealed that licoricidin exhibited multiple anti-gastric cancer activities, including suppressing proliferation, inducing apoptosis, arresting the cell cycle in G₀/G₁ phase, and inhibiting the migration and invasion abilities of MGC-803 gastric cancer cells. In addition to this, a total of 5861 proteins were identified by quantitative proteomics research strategy of TMT labeling, of which 19 differential proteins (two upregulated and 17 downregulated) were screened out. Combining bioinformatics analyses and the reported roles in cancer progression of the 19 proteins, we speculated that isoprenyl carboxyl methyltransferase (ICMT) was the most likely target of licoricidin. Western blot assays and IHC assays subsequently proved that licoricidin significantly downregulated the expression of ICMT, both in MGC-803 cells and in xenograft tumors. Moreover, licoricidin effectively reduced the level of active Ras-GTP and blocked the phosphorylation of Raf and Erk, which may be involved in its anti-gastric cancer effects. In summary, we first demonstrated that licoricidin exerted favorable anti-gastric cancer activities via the ICMT/Ras pathway, which suggests that licoricidin, as a natural product, could be a novel candidate for the management of gastric cancer.

Signaling pathways and therapeutic interventions in gastric cancer

Gastric cancer (GC) ranks fifth in global cancer diagnosis and fourth in cancer-related death. Despite tremendous progress in diagnosis and therapeutic strategies and significant improvements in patient survival, the low malignancy stage is relatively asymptomatic and many GC cases are diagnosed at advanced stages, which leads to unsatisfactory prognosis and high recurrence rates. With the recent advances in genome analysis, biomarkers have been identified that have clinical importance for GC diagnosis, treatment, and prognosis. Modern molecular classifications have uncovered the vital roles that signaling pathways, including EGFR/HER2, p53, PI3K, immune checkpoint pathways, and cell adhesion signaling molecules, play in GC tumorigenesis, progression, metastasis, and therapeutic responsiveness. These biomarkers and molecular classifications open the way for more precise diagnoses and treatments for GC patients. Nevertheless, the relative significance, temporal activation, interaction with GC risk factors, and crosstalk between these signaling pathways in GC are not well understood. Here, we review the regulatory roles of signaling pathways in GC potential biomarkers, and therapeutic targets with an emphasis on recent discoveries. Current therapies, including signaling-based and immunotherapies exploited in the past decade, and the development of treatment for GC, particularly the challenges in developing precision medications, are discussed. These advances provide a direction for the integration of clinical, molecular, and genomic profiles to improve GC diagnosis and treatments.

A multiphase contrast-enhanced CT radiomics model for prediction of human epidermal growth factor receptor 2 status in advanced gastric cancer

Background: Accurate evaluation of human epidermal growth factor receptor 2 (HER2) status is of great importance for appropriate management of advanced gastric cancer (AGC) patients. This study aims to develop and validate a CT-based radiomics model for prediction of HER2 overexpression in AGC.

Materials and Methods: Seven hundred and forty-five consecutive AGC patients (median age, 59 years; interquartile range, 52–66 years; 515 male and 230 female) were enrolled and separated into training set (n = 521) and testing set (n = 224) in this retrospective study. Radiomics features were extracted from three phases images of contrast-enhanced CT scans. A radiomics signature was built based on highly reproducible features using the least absolute shrinkage and selection operator method. Univariable and multivariable logistical regression analysis were used to establish predictive model with independent risk factors of HER2 overexpression. The predictive performance of radiomics model was assessed in the training and testing sets.

Results: The positive rate of HER2 was 15.9% and 13.8% in the training set and testing set, respectively. The positive rate of HER2 in intestinal-type GC was significantly higher than that in diffuse-type GC. The radiomics signature comprised eight robust features demonstrated good discrimination ability for HER2 overexpression in the training set (AUC = 0.84) and the testing set (AUC = 0.78). A radiomics-based model that incorporated radiomics signature and pathological type showed good discrimination and calibration in the training (AUC = 0.85) and testing (AUC = 0.84) sets.

Conclusion: The proposed radiomics model showed favorable accuracy for prediction of HER2 overexpression in AGC.

Tumor Microenvironment, Clinical Features, and Advances in Therapy for Bone Metastasis in Gastric Cancer

Gastric cancer (GC) is one of the most malignant neoplasms worldwide, accounting for about 770,000 deaths in 2020. The incidence of gastric cancer bone metastasis (GC-BM) is low, about 0.9–13.4%, and GC patients develop GC-BM because of a suitable bone microenvironment. Osteoblasts, osteoclasts, and tumor cells interact with each other, secreting cytokines such as PTHrP, RANK-L, IL-6, and other growth factors that disrupt the normal bone balance and promote tumor growth. The functions and numbers of immune cells in the bone microenvironment are continuously inhibited, resulting in bone balance disorder due to the cytokines released from destroyed bone and growing tumor cells. Patients with GC-BM are generally younger than 65 years old and they often present with a later stage of the disease, as well as more aggressive tumors. They usually have shorter overall survival (OS) because of the occurrence of skeletal-related events (SREs) and undetected bone destruction due to the untimely bone inspection. Current treatments of GC-BM focus mainly on gastric cancer and SRE-related treatment. This article reviews the clinical features, possible molecular pathogeneses, and the most commonly used diagnostic methods and treatments of bone metastasis in gastric cancer.

Molecular Pathology of Gastric Cancer

Gastric cancer (GC) is one of the most common lethal malignant neoplasms worldwide, with limited treatment options for both locally advanced and/or metastatic conditions, resulting in a dismal prognosis. Although the widely used morphological classifications may be helpful for endoscopic or surgical treatment choices, they are still insufficient to guide precise and/or personalized therapy for individual patients. Recent advances in genomic technology and high-throughput analysis may improve the understanding of molecular pathways associated with GC pathogenesis and aid in the classification of GC at the molecular level. Advances in next-generation sequencing have enabled the identification of several genetic alterations through single experiments. Thus, understanding the driver alterations involved in gastric carcinogenesis has become increasingly important because it can aid in the discovery of potential biomarkers and therapeutic targets. In this article, we review the molecular classifications of GC, focusing on The Cancer Genome Atlas (TCGA) classification. We further describe the currently available biomarker-targeted therapies and potential biomarker-guided therapies. This review will help clinicians by providing an inclusive understanding of the molecular pathology of GC and may assist in selecting the best treatment approaches for patients with GC.

Treatment Outcome and Safety of the TCX Regimen for Advanced Gastric Cancer: A Prospective Cohort Study

Objective

To evaluate the outcome and safety of the paclitaxel, carboplatin, and capecitabine (TCX) regimen in patients with advanced gastric cancer.

Methods

Advanced gastric cancer patients received the TCX regimen for up to six cycles, which were 3 weeks apart. Paclitaxel (175 mg/m2) was given over a 3-hour infusion, followed by carboplatin in a 1-hour infusion on day 1. Capecitabine (850 mg/m2) was given orally twice daily from day 1 to day 14. Primary endpoints were progression-free survival (PFS) and overall survival (OS).

Results

Among 83 patients at stage IVa and IVb, the median PFS was 9.3 months; 6-month, 1-year, and 2-year PFS were 74.6%, 32.5%, and 14.4%, respectively. The median OS was 17.0 months; 6-month, 1-year, and 2-year OS were 97.5%, 68.7%, and 21.7%, respectively. In the multivariable Cox regression model, higher CEA was associated with poor OS. Common adverse events included hand-food syndrome (77.9%), peripheral neuropathy (63.2%), fatigue (68.7%), and nausea (54.2%).

Conclusion

The TCX regimen provided good survival and a better safety profile. More clinical trials are needed to confirm its treatment efficacy and safety, especially in comparison with other triplet regimens.

Relationship between lymph nodes examined and survival benefits with postoperative radiotherapy in oral cavity squamous cell carcinoma patients with stage T1-2N1M0

Background

This study aims to explore the relationship between the lymph nodes examined and survival benefits of postoperative radiotherapy in oral cavity squamous cell carcinoma patients with stage T1-2N1M0.

Methods

This study retrieved patients who underwent dissection of the primary site and neck lymph nodes for pT1-2N1M0 oral cavity squamous cell carcinoma without adverse nodal features from the Surveillance, Epidemiology, and End Results database from 2004 to 2015. Propensity score matching analysis was conducted, and the best cutoff value of the lymph nodes examined was determined by X-tile. Cancer-specific survival was the primary outcome. Univariable and multivariable analyses were performed to assess the relation between postoperative radiotherapy and cancer-specific survival, adjusting for other prognostic factors.

Results

A total of 469 patients were finally enrolled according to our exclusion criteria, and then 119 pairs of patients were matched by propensity score matching analysis. The best cutoff value of the lymph nodes examined was determined by X-tile, stratifying patients into lymph nodes examined ≤16 group and lymph nodes examined >16 group. For the whole matched cohort, the choice of postoperative radiotherapy had no correlation with other factors (all p’s > 0.05), and postoperative radiotherapy made no contribution to a better survival outcome for patients (p = 0.289). After stratified by the lymph nodes examined, in the lymph nodes examined ≤16 group, significantly improved CSS was found for those who undertook postoperative radiotherapy compared to those who just received surgery (unadjusted hazard ratio, 0.541; 95% confidence interval, 0.333–0.878; p = 0.013).

Conclusions

Our study revealed that pT1-2N1M0 oral cavity squamous cell carcinoma patients were more likely to benefit from postoperative radiotherapy when unsatisfactory neck dissection was conducted, indicating that the number of lymph nodes examined might be a factor when clinicians do therapeutic planning for early-stage oral cavity squamous cell carcinoma patients.

Targeting myeloid villains in the treatment with immune checkpoint inhibitors in gastrointestinal cancer

Despite the clinical outcomes being extremely limited, blocking immune inhibitory checkpoint pathways has been in the spotlight as a promising strategy for treating gastrointestinal cancer. However, a distinct strategy for the successful treatment is obviously needed in the clinical settings. Myeloid cells, such as neutrophils, macrophages, dendritic cells, and mast cells, are the majority of cellular components in the human immune system, but have received relatively less attention for the practical implementation than T cells and NK cells in cancer therapy because of concentration of the interest in development of the immune checkpoint blocking antibody inhibitors (ICIs). Abnormality of myeloid cells must impact on the entire host, including immune responses, stromagenesis, and cancer cells, leading to refractory cancer. This implies that elimination and reprogramming of the tumor-supportive myeloid villains may be a breakthrough to efficiently induce potent anti-tumor immunity in cancer patients. In this review, we provide an overview of current situation of the IC-blocking therapy of gastrointestinal cancer, including gastric, colorectal, and esophageal cancers. Also, we highlight the possible oncoimmunological components involved in the mechanisms underlying the resistance to the ICI therapy, particularly focusing on myeloid cells, including unique subsets expressing IC molecules. A deeper understanding of the molecular and cellular determinants may facilitate its practical implementation of targeting myeloid villains, and improve the clinical outcomes in the ICI therapy of gastrointestinal cancer.

Prognostic characteristics and clinical response to immunotherapy targeting programmed cell death 1 for patients with advanced gastric cancer with liver metastases

Background

The specific efficacy of immunotherapy for patients with liver metastases of gastric cancer is unclear. This study set out to explore the treatment response and related prognostic factors for patients with liver metastases of gastric cancer treated with immunotherapy.

Patients and methods

This retrospective cohort study included 135 patients with unresectable advanced gastric cancer. According to the presence of liver metastases and/or first-line treatment with immunotherapy, patients were divided into the following three groups: I-LM(-) group(patients without liver metastases treated with immunotherapy, n=66), I-LM(+) group(patients with liver metastases treated with immunotherapy, n=36), C-LM(+) group(patients with liver metastases treated with chemotherapy and/or target therapy, n=33). Cox regression analyses were used to identify factors associated with survival in all patients and the three groups, respectively.

Results

For the patients with liver metastases treated with immunotherapy, multivariate analysis showed that only the presence of peritoneal metastases was significantly associated with shorter PFS [hazard ratios (HR), 3.23; 95% CI, 1.12-9.32; P=0.030] and the patients with peritoneal metastases had shorter median PFS than patients without peritoneal metastases(3.1 vs 18.4 months; P=0.004), while the objective response rate was 100% in patients with HER2-positive (2 complete radiographic responses and 2 partial responses; 3 of 4 patients were still ongoing benefits [median follow-up time, 15.3 months ; interquartile range(IQR), 6.3-17.9 months]).

Conclusions

The findings suggest that patients with various types of gastric cancer liver metastases respond differently to immune checkpoint inhibitors, HER2-positive patients may derive clinical benefits from immune checkpoint inhibitors, while the presence of peritoneal metastases is associated with resistance.

Versican enrichment predicts poor prognosis and response to adjuvant therapy and immunotherapy in gastric cancer

Background

Increasing evidence has revealed an important role of versican (VCAN) on various aspects of cancer progression. Here, we assessed the impact of VCAN expression on prognosis and the response to adjuvant therapy and immunotherapy in patients with gastric cancer (GC).

Methods

Four independent cohorts containing 1353 patients with GC, were utilized to investigate the effect of VCAN expression on prognosis and response to adjuvant therapy in GC. Two cohorts treated with immune checkpoint blockades were included to assess the predict value of VCAN expression on response to immunotherapy. Moreover, the bulk RNA-seq and single-cell RNA-seq data were analyzed to illustrate the role of VCAN in tumor microenvironment. Clinical outcomes of patient subgroups were compared by Kaplan-Meier curves with the log-rank test.

Result

High VCAN expression was associated with poor prognosis for patients with GC. Compared with patients with high VCAN expression, patients with low VCAN expression benefited more from adjuvant chemotherapy and adjuvant chemoradiotherapy. Moreover, patients with high VCAN expression tended to be resistant to immunotherapy, and VCAN could serve as a promising indicator for predicting the response to immunotherapy. VCANhigh tumors showed a specific microenvironment with more cancer associated fibroblasts infiltration and significant enrichment of stromal relevant signaling pathways.

Conclusion

VCAN could predict the response to adjuvant chemotherapy, adjuvant chemoradiotherapy and immunotherapy in GC, and designing new medicine target to VCAN might be an effective way to improve the efficacy of several treatment options for GC.

Extragastric recurrence in patients who underwent surgical resection of stage I gastric cancer: Incidence, risk factors, and value of abdominal computed tomography as a postoperative surveillance method

Extragastric recurrence after radical resection of stage I gastric cancer is very rare. We investigated the incidence of extragastric recurrence and risk factors in patients who underwent surgical resection of stage I gastric cancer and evaluated the value of abdominal CT as a surveillance tool. This retrospective study enrolled 914 patients with stage I gastric cancer who underwent surgical resection at a single tertiary hospital. We investigated extragastric recurrence during the follow-up period, and disease-free survival (DFS) was assessed. Over a median follow-up period of 39 months, the overall incidence of extragastric recurrence was 2.2% (20/914). Risk factors for extragastric recurrence included deep submucosal invasion (SM2-3), muscularis propria invasion, and lymph node metastasis (hazard ratio [HR]=10.37, 28.101, and 6.843; P = .028, .002, and .001, respectively). Based on the number of risk factors, patients were stratified into 3 subgroups: low-risk (pT1aN0, pT1b(SM1)N0, 496/914), moderate-risk (pT1aN1, pT1b(SM1)N1, pT1b(SM2-3)N0, pT2N0, 369/914), and high-risk (pT1b(SM2-3)N1, 49/914). DFS was significantly longer in the low-risk group, followed by the moderate-risk and high-risk groups. We propose that postoperative CT surveillance should be omitted for stage 1A cases involving the mucosa and SM1 because of the extreme rarity of extragastric recurrence.

Risk Factors and Prognostic Impact of Postoperative Complications in Patients with Advanced Gastric Cancer Receiving Neoadjuvant Chemotherapy

Background: Neoadjuvant chemotherapy is important to improve the prognosis of patients with advanced gastric cancer. However, it may result in postoperative complications (POCs). The aim of this study is to evaluate risk factors and prognostic impact of POCs in patients receiving neoadjuvant chemotherapy. Methods: We retrospectively collected clinical information of patients who underwent curative gastrectomy after receiving neoadjuvant chemotherapy between 2011 and 2018. Overall survival (OS) was analyzed using the Kaplan–Meier method. Logistic regression and Fisher’s exact test were used to evaluate risk factors for complications. Results: A total of 176 patients were included in our study. The 3-year OS rates for the complication group (n = 30) and non-complication group (n = 146) were 36.7% and 52.7%, respectively (p = 0.0294). Age, BMI, multivisceral resection and operation time were independent risk factors for POCs in patients. Patients with multivisceral resection were more likely to suffer from grade III-IV complications (p = 0.026). Inflammation complications might occur in patients with high BMI (p = 0.017). Low preoperative albumin seemed to be a risk factor for leakage complications (p = 0.033). Conclusions: Our study revealed that patients with POCs had a poor prognosis and we identified the risk factors for complications so that POCs can be avoided in time.

Gastrectomy with or without Complete Omentectomy for Advanced Gastric Cancer: A Meta-Analysis

Background and Objectives: Surgery remains the only possible curative treatment for advanced gastric cancer (AGC). Peritoneal metastases are estimated to occur in approximately 55–60% AGC patients. Greater omentum is the most common metastatic area in AGC. At present, omentectomy alone or bursectomy are usually carried out during gastric cancer surgery. We performed a meta-analysis in order to evaluate long-term and short-term outcomes among AGC patients, who have undergone radical gastrectomy with or without complete omentectomy (CO). Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Meta-analysis was performed by use of RevMan (Computer program) Version 5.4. Results: The eight included studies covered an approximately 20 years long study period (2000–2018). Almost all included studies were retrospective ones and originated from Asian countries. Meta-analysis indicated gastrectomy without CO as significantly associated with longer 3-year (RR: 0.94, 95% CI: 0.90–0.98, p = 0.005) and 5-year overall survivals (OS) (RR: 0.93, 95% CI: 0.88–0.98, p = 0.007). Moreover, we found longer operative time (MD: 24.00, 95% CI: −0.45–48.45, p = 0.05) and higher estimated blood loss (MD: 194.76, 95% CI: 96.40–293.13, p = 0.0001) in CO group. Conclusions: Non-complete omentectomy (NCO) group had a statistically greater rate in 3-year and 5-year OSs than the CO group, while the CO group had significantly longer operative time and higher estimated blood loss than the NCO group. Further randomized, possibly multi-center trials may turn out of paramount importance in confirming our results.

Number of Examined Lymph Nodes as a Risk Factor for Recurrence in pT1N+ or pT2-3N0 Gastric Cancer

BACKGROUND/AIM

Japanese Gastric Cancer Treatment Guidelines do not recommend adjuvant chemotherapy after radical gastrectomy for pathological stage (p) T1N+ or pT2~3N0 gastric cancer. However, some patients experience disease recurrence. This study aimed to identify the risk factors for recurrence in pT1N+ or pT2-3N0 gastric cancer.

PATIENTS AND METHODS

The study included 157 patients with diagnosed pT1N+ or pT2-3N0 gastric cancer who underwent radical gastrectomy at our institution between January 2001 and December 2020. Clinicopathological data and surgical data were obtained. Independent prognostic factors were analyzed using a Cox proportional hazards regression model.

RESULTS

Thirteen patients (8.3%) experienced disease recurrence. Multivariate analysis revealed that the number of examined lymph nodes was an independent prognostic factor for recurrence-free survival (hazard ratio=10.90; 95% confidence interval=1.39-85.86; p=0.023). The group with ≤35 examined lymph nodes had significantly worse recurrence-free survival compared with the group with ≥36 examined lymph nodes (80.7% versus 98.7%; p=0.0005).

CONCLUSION

The number of examined lymph nodes (≤35) was an independent risk factor for recurrence after radical gastrectomy with pT1N+ or pT2-3N0 gastric cancer.

Translation and validation of the Patient-Generated Subjective Global Assessment against the Mini-Nutritional Assessment for patients with gastric cancer

Objective

This study aimed to (1) translate the PG-SGA into Korean according to a translation guideline, (2) validate the translated version against the Mini-Nutritional Assessment, and (3) determine the prevalence of malnutrition in patients with gastric cancer.

Methods

The translation of the PG-SGA was based on the Guidelines for Translation by the International Society for Pharmacoeconomics and Outcomes Research Task Force for Translation and Cultural Adaptation Group. The translated version was validated in 226 patients with gastric cancer, using the area under the receiver operating characteristic curve analysis (AUC-ROC), measures of sensitivity, specificity, and the Youden index. The prevalence of malnutrition was analyzed using descriptive statistics.

Results

The AUC-ROC Korean version of the PG-SGA was 0.85, and a score of 12 was the most optimal cut-off score, with a sensitivity of 78.6% and a Youden index of 0.54. One-third of participants were malnourished, and 70% of them had more than one physical symptom affecting their food intake.

Conclusions

The Korean version of the PG-SGA is an effective and valid assessment tool for evaluating malnutrition in patients with gastric cancer. A new cut-off score could be used in patients with gastric cancer to assess malnutrition.

•

The Korean version of PG-SGA has undergone a systematic translation process.

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It is a valid instrument for assessing malnutrition in patients with gastric cancer.

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Nurses could assess patients’ symptoms related to food intake using PG-SGA.

Gastric Cancer: Emerging Trends in Prevention, Diagnosis, and Treatment

Gastric adenocarcinoma (GC) is the fourth leading cause of global cancer mortality, and the leading infection-associated cancer. Helicobacter pylori is the dominant risk factor for GC and classified as an IARC class I carcinogen. Surveillance of gastric premalignant conditions is now indicated in high-risk patients. Upper endoscopy is the gold standard for GC diagnosis, and image-enhanced endoscopy increases the detection of gastric premalignant conditions and early gastric cancer (EGC). Clinical staging is crucial for treatment approach, defining early gastric cancer, operable locoregional disease, and advanced GC. Endoscopic submucosal dissection is the treatment of choice for most EGC. Targeted therapies are rapidly evolving, based on biomarkers including MSI/dMMR, HER2, and PD-L1. These advancements in surveillance, diagnostic and therapeutic strategies are expected to improve GC survival rates in the near term.