Changes of Esophagogastric Junctional Adenocarcinoma and Gastroesophageal Reflux Disease Among Surgical Patients During 1988-2012: A Single-institution, High-volume Experience in China

Features of gastric cancer by anatomic subsite in northern China: A multi-center Health Science Report database study

BACKGROUND

The features of gastric cancer based on the anatomic site remain unknown in northern China patients.

AIM

To analyze gastric cancer features and associated trends based on the anatomical site in northern China patients.

METHODS

This cross-sectional study used incident gastric cancer case data from 10 Peking University-affiliated hospitals (2014 to 2018). The clinical and prevailing local features were analyzed.

RESULTS

A total of 10709 patients were enrolled, including antral (42.97%), cardia (34.30%), and stomach body (18.41%) gastric cancer cases. Cancer in the cardia had the highest male:female ratio, proportion of elderly patients, and patients with complications, including hypertension, diabetes, cerebrovascular, and coronary diseases (P < 0.001). gastric cancer involving the antrum showed the lowest proportion of patients from rural areas and accounted for the highest hospitalization rate and cost (each P < 0.001). The proportion of patients with cancer involving the cardia increased with an increase in the number of gastroesophageal reflux disease cases during the same period (P < 0.001). Multivariate analysis revealed that tumor location in the cardia increased the risk of in-hospital mortality (P = 0.046). Anatomical subsite was not linked to postoperative complications.

CONCLUSION

The features of gastric cancer based on the anatomical site differ between northern China and other regions, both globally and within the country. Social factors may account for these differences and should affect policy-making and clinical practice.

Model established based on blood markers predicts overall survival in patients after radical resection of types II and III adenocarcinoma of the esophagogastric junction

BACKGROUND

In recent years, the incidence of types II and III adenocarcinoma of the esophagogastric junction (AEG) has shown an obvious upward trend worldwide. The prognostic prediction after radical resection of AEG has not been well established.

AIM

To establish a prognostic model for AEG (types II and III) based on routine markers.

METHODS

A total of 355 patients who underwent curative AEG at The First Affiliated Hospital of Anhui Medical University from January 2014 to June 2015 were retrospectively included in this study. Univariate and multivariate analyses were performed to identify the independent risk factors. A nomogram was constructed based on Cox proportional hazards models. The new score models was analyzed by C index and calibration curves. The receiver operating characteristic (ROC) curve was used to compare the predictive accuracy of the scoring system and tumor-node-metastasis (TNM) stage. Overall survival was calculated using the Kaplan-Meier curve amongst different risk AEG patients.

RESULTS

Multivariate analysis showed that TNM stage (hazard ratio [HR] = 2.286, P = 0.008), neutrophil-to-lymphocyte ratio (HR = 2.979, P = 0.001), and body mass index (HR = 0.626, P = 0.026) were independent prognostic factors. The new scoring system had a higher concordance index (0.697), and the calibration curves of the nomogram were reliable. The area under the ROC curve of the new score model (3-year: 0.725, 95% confidence interval [CI]: 0.676-0.777; 5-year: 0.758, 95%CI: 0.708-0.807) was larger than that of TNM staging (3-year: 0.630, 95%CI: 0.585-0.684; 5-year: 0.665, 95%CI: 0.616-0.715).

CONCLUSION

Based on the serum markers and other clinical indicators, we have developed a precise model to predict the prognosis of patients with AEG (types II and III). The new prognostic nomogram could effectively enhance the predictive value of the TNM staging system. This scoring system can be advantageous and helpful for surgeons and patients.

Whether the infracardiac bursa protect right pleura during laparoscopic radical operation of Siewert type II adenocarcinoma of esophagogastric junction?

BACKGROUND

Transthoracic single-port assisted laparoscopic five-step maneuver inferior mediastinal lymphadenectomy for Siewert type II adenocarcinoma of esophagogastric junction (AEG) has superiority in lower mediastinal lymph nodes dissection and digestive tract reconstruction. However, the right pleura was probably ruptured in this surgical technique. The aim of this study was to explore whether the infracardiac bursa (ICB) exposed could protect right pleura.

METHODS

We retrospectively collected and evaluated the clinical and pathological data of patients who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymphadenectomy for Siewert II AEG at Guangdong Provincial Hospital of Chinese Medicine between May 2017 and February 2022.

RESULTS

A total of 49 patients were eligible, including 31 patients in ICB exposed group (group A) and 18 patients in ICB unexposed group (group B). There were no statistically significant differences in baseline characteristics between the two groups. 4 patients (12.9%) had right pleura rupture in group A, while 14 patients (77.8%) in group B, and the difference was statistically significant (p < 0.001). Compared with group B, the extubation time of endotracheal intubation (10.0 (6.0 ~ 12.0) vs. 13.0 (8.0 ~ 15.0) min, p = 0.003) and thoracic drainage tube stay (6.0 (5.0 ~ 7.0) vs. 8.0 (6.0 ~ 10.5) days, p = 0.041) were significantly shorted in the group A. The drainage volume of thorax (351.61 ± 125.00 vs. 418.61 ± 207.86 mL, p = 0.146) was non-significant less and the rate of complications (3.2% vs. 11.1%, p = 0.074) was non-significant lower in group A compared with group B. The postoperative hospital stay (9.0 (8.0,13.0) vs. 9.0 (8.0,12.0) days, p = 0.983) were similar in two groups. No serious adverse event occurred in any patient.

CONCLUSIONS

The ICB exposed could protect the right pleura and may promote postoperative recovery, which may be used as an anatomical marker in inferior mediastinal lymphadenectomy.

Adjuvant chemoradiotherapy vs adjuvant chemotherapy in locally advanced Siewert type II/III adenocarcinoma of gastroesophageal junction after D2/R0 resection

BACKGROUND

For Siewert type II/III adenocarcinoma of gastroesophageal junction (AGE), the efficacy of adjuvant chemoradiotherapy (CRT) after D2/R0 resection remains uncertain.

AIM

To determine whether CRT was superior to chemotherapy (CT) alone after D2/R0 resection for locally advanced Siewert type II/III AGE.

METHODS

We identified 316 locally advanced Siewert type II/III AGE patients who were treated with D2/R0 resection at National Cancer Center from 2011 to 2018. 57 patients received adjuvant CRT and 259 patients received adjuvant CT. We followed patients for overall survival (OS), relapse-free survival, and recurrence pattern.

RESULTS

Five-year OS rates of the CRT group and the CT group for all patients were 66.7% and 41.9% (P = 0.010). Five-year OS rates of the CRT group and the CT group for Siewert type III AGE patients were 65.7% and 43.9% (P = 0.006). Among the 195 patients whose recurrence information could be obtained, 18 cases (34.6%) and 61 cases (42.7%) were diagnosed as recurrence in the CRT group and CT group, respectively. The local and regional recurrence rates in the CRT group were lower than that in the CT group (22.2% vs 24.6%, 27.8% vs 39.3%). Multivariable cox regression analysis showed that vascular invasion, nerve invasion, and adjuvant CRT were important prognostic factors for Siewert type III AGE.

CONCLUSION

For locally advanced Siewert type III AGE, adjuvant CRT may prolong OS and reduce the regional recurrence rate.

Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy

Background

With the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis.

Methods

After stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired.

Results

The clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period.

Conclusion

Two purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

Adjuvant Chemoradiotherapy Versus Adjuvant Chemotherapy for Stage III Gastric or Gastroesophageal Junction Cancer After D2/R0 Resection

PURPOSE

To compare the survival benefit in the adjuvant chemoradiotherapy (CRT) group and chemotherapy (CT) group for stage III gastric or gastroesophageal junction (GEJ) cancer after D2/R0 resection.

METHODS AND MATERIALS

From January 2011 to May 2018, 819 patients (CRT group: 215 patients, CT group: 604 patients) diagnosed as pathological stage III after D2/R0 resection were retrospectively collected and the survival and recurrence patterns were analyzed. The baseline characteristics were balanced based on propensity score matching (PSM). The survival benefit was compared between two groups using Kaplan-Meier analysis and Cox regression model.

RESULTS

The 5-year overall survival (OS) rate in the CRT group was significantly higher than that in the CT group whether before or after the PSM. The multivariate Cox regression analysis identified the significant poor OS in patients with advanced TNM stage (P < 0.001) and patients who did not receive the adjuvant CRT (P = 0.008). For the recurrence patterns, 85 (39.5%) patients in the CRT group and 300 (49.7%) patients in the CT group were diagnosed as recurrence (P = 0.011). The regional recurrence in the CRT group was less than that in the CT group (20.5% vs. 35.1%, P = 0.028).

CONCLUSION

For patients diagnosed as stage III gastric cancer or gastroesophageal junction cancer, the addition of adjuvant chemoradiotherapy will significantly improve the overall survival and regional control.

Selection of Digestive Tract Reconstruction After Partial Gastric Sparing Surgery in Patients With Adenocarcinoma of the Esophagogastric Junction of cT2-T3 Stage

Objective

To investigate the appropriate reconstruction method of the digestive tract after partial gastric sparing surgery for adenocarcinoma of the esophagogastric junction of stage cT2-T3.

Methods

A retrospective analysis of the clinical data of patients with adenocarcinoma of the esophagogastric junction from January 2015 to January 2019 in the General Surgery Department of Zhengzhou University Affiliated Tumor Hospital was performed. Patients with intraoperative double tract anastomosis composed the double tract reconstruction (DTR) group, and patients with intraoperative oesophagogastrostomy with a narrow gastric conduit group composed the oesophagogastrostomy by a narrow gastric conduit (ENGC) group. We analysed and compared the short-term postoperative complications and long-term postoperative nutritional status of the two groups of patients.

Result

There were no statistically significant differences between the two groups of patients in terms of age, sex, preoperative haemoglobin level, albumin level, cT, cN, neoadjuvant therapy or not, pathological type and Siewert type. In terms of BMI and body weight, the ENGC group was higher than the DTR group, but the difference was not statistically significant (p = 0.099, p = 0.201). There was no significant difference between the two groups of patients in terms of upper resection margin, operation time, blood loss, tumor diameter, pT, pN and postoperative hospital stay. The gastric resection volume of the DTR group was much larger than that of the ENGC group, and there was a significant difference between the two (p = 0.000). The length of the lower resection margin of the DTR group was also significantly greater than that of the ENGC group (p = 0.000). In terms of surgical approach, the proportion of the DTR group with the abdominal approach was significantly higher than that of the ENGC group, and the difference between the two was statistically significant (p = 0.003). The postoperative exhaust time in the ENGC group was significantly shorter than that in the DTR group (p = 0.013). However, there was no statistically significant difference between the two groups in terms of anastomotic leakage, anastomotic bleeding, intestinal obstruction, abdominal infection, pneumonia, pancreatic leakage, lymphatic leakage,death within 30 days after surgery, or overall complications. In terms of anastomotic stenosis, the incidence in the ENGC group was higher than in the DTR group, and the difference was statistically significant (p = 0.001). There was no significant difference in oral PPI, haemoglobin or albumin levels in patients at 3 months, 6 months, or 12 months after surgery. Comparing reflux/heartburn symptoms at 3 months and 6 months after surgery, we found no statistically significant difference between the two, while in terms of reflux/heartburn symptoms at 12 months after surgery, the findings of the ENGC group were higher than those of the DTR group, and the difference was statistically significant (p = 0.045). In terms of poor swallowing, the ENGC group was always higher than the DTR group, and the difference between the two groups was statistically significant (p &lt; 0.05). There was no statistically significant difference in body weight between the two groups at 3 months or 6 months after surgery. At 12 months after surgery, the body weight of the patients in ENGC group was significantly higher than that in the DTR group, and the difference between the two groups was statistically significant (p = 0.039).

Conclusions

For patients with cT2-T3 stage oesophagogastric junction adenocarcinoma with tumours less than 4 cm in diameter, ENGC anastomosis is recommended for patients with a high tumour upper boundary, with obesity, short mesentery, or disordered vascular arch, and for routine patients, DTR anastomosis is recommended.

Clinical significance of lower perigastric lymph nodes dissection in Siewert type II/III adenocarcinoma of esophagogastric junction: a retrospective propensity score matched study

PURPOSE

The optimal surgical procedure, whether total gastrectomy (TG) or proximal gastrectomy (PG), for Siewert type II/III adenocarcinoma of esophagogastric junction (AEG) has not been standardised, primarily because the optimal extent of lymph node (LN) dissection for AEG based on the metastatic rate of perigastric LNs remains under debate. The aim of this study was to investigate the metastatic incidence and prognostic significance of lower perigastric lymph nodes (LPLN), including No.4d, 5, 6 and 12a LN stations, in Siewert type II/III AEG.

METHODS

A total of 701 patients with Siewert type II/III AEG who received transabdominal open gastrectomy (425 patients with TG and 276 patients with PG) from 2010 to 2015 in West China Hospital were retrospectively included. Based on the clinicopathological information of TG patients, the risk factors of LPLN-positive patients were evaluated, and the metastatic incidence as well as the therapeutic value (TV) index of each LN station was assessed. Moreover, the 5-year overall survival (OS) rates between LPLN-positive and LPLN-negative groups were compared in TG patients, and the postoperative survival difference between TG and PG patients was also compared, using propensity score matching (PSM) method.

RESULTS

Tumour size (≥ 5 cm, OR = 1.481, p = 0.002) and pT stage (pT4, OR = 2.755, p = 0.024) were significant risk factors for patients with LPLN metastasis. For patients with tumour size more than 5 cm or pT4 stage, the metastatic rates of LPLN for Siewert type II, III and II/III AEG were 31.67%, 34.69% and 33.03%, whereas the TV indexes of LPLN for them were 5.76, 5.62 and 5.38, respectively. LPLN was a significant independent prognostic factor (HR = 1.422, p = 0.028), and positive LPLN was related to worse prognosis (p < 0.05). For patients with tumour size more than 5 cm or pT4 stage, TG patients were illustrated to have a better prognosis than PG patients, with 5-year OS rates of 58.9% vs 38.2% for Siewert type II AEG (χ2 = 4.159, p = 0.041), 68.9% vs 50.2% for Siewert type III AEG (χ2 = 5.630, p = 0.018) and 65.1% vs 40.3% for Siewert type II/III AEG (χ2 = 12.604, p < 0.001), respectively.

CONCLUSIONS

LPLN metastasis is a poor prognostic factor for patients with Siewert II/III AEG. LPLN dissection may improve the long-term survival of patients with tumour size more than 5 cm or pT4 stage, and TG might be more suitable for this kind of cancer.

Comparison of Efficacy Between Transabdominal and Transthoracic Surgical Approaches for Siewert Type II Adenocarcinoma of the Esophagogastric Junction: A Systematic Review and Meta-Analysis

Background

The optimal surgical approach, whether transabdominal (TA) or transthoracic (TT), for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) remains controversial. This study compares the efficacy of TA and TT surgical approaches for Siewert type II AEG.

Methods

Studies comparing the surgical and oncological outcomes of TA and TT surgical approaches for Siewert type II AEG up to June 2021 were systematically searched on the Web of Science, PubMed, Embase, and Cochrane Library. A pooled analysis was performed for the available data regarding the baseline features, surgical, and oncological outcomes. The RevMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.

Results

Twelve studies with a total of 2,011 patients, including 985 patients in the TA group and 1,026 patients in the TT group, were included in this study. In the pooled analysis, the surgical outcomes, namely, operative time (MD = −54.61, 95% CI = −123.76 to 14.54, P = 0.12), intraoperative blood loss (MD = −28.85, 95% CI = −71.15 to 13.46, P = 0.18), the number of dissected lymph nodes (MD = 1.90, 95% CI = −1.32 to 5.12, P = 0.25), postoperative complications (OR = 0.84, 95% CI = 0.65 to 1.07, p = 0.16), anastomotic leakage rate (OR = 1.02, 95% CI = 0.63 to 1.65, p = 0.93), and postoperative death rate (OR = 0.89, 95% CI = 0.46 to 1.72, p = 0.73), and the oncological outcomes, namely, overall recurrence rate (OR = 0.75, 95% CI = 0.37 to 1.50, p = 0.41), 3-year overall survival (OS) rate (OR = 1.19, 95% CI = 0.54 to 2.65, p = 0.66), and 5-year OS rate (OR = 1.21, 95% CI = 0.84 to 1.74, p = 0.30) of the two groups were all comparable.

Conclusions

Both TA and TT surgical approaches are appropriate for Siewert type II AEG, and neither has a significant advantage in terms of short- and long-term outcomes. However, more high-quality randomized controlled trials are needed to confirm this conclusion.

A comparative study on perioperative outcomes between robotic versus laparoscopic D2 total gastrectomy

OBJECTIVE

Robotic surgery has been increasingly used worldwide owing to its advanced features. However, the significant benefits of robotic total gastrectomy (RTG) over laparoscopic total gastrectomy (LTG) have yet to be demonstrated. We conducted a prospective cohort study to compare the safety and efficacy of robotic and laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy for AGC.

METHODS

Between March 26, 2018 and July 30, 2021, 155 patients between 18 and 80 years of age with locally advanced gastric cancer (cT2-4a, N0/+, M0) were enrolled. The perioperative outcomes within 30 days after surgery were compared between the RTG (n = 69) and LTG (n = 73) groups on a per-protocol (PP) basis. Postoperative complications were evaluated according to the Clavien-Dindo classification.

RESULTS

The overall postoperative morbidity rate was 21.74% in the RTG group and 28.77% in the LTG group with no significant difference (P = 0.44), RTG was associated with a lower incidence of pneumonia (4.35% vs. 15.07%, P = 0.047). No mortality was observed in either group. There was no significant difference in the total operative time (284.48 vs. 271.73 min, P = 0.171), but RTG was associated with a lower estimated volume of blood loss (110 vs. 150 ml, P < 0.001) and more total retrieved lymph nodes (LNs) (41.36 vs 35.1, P = 0.019), more extraperigastric LNs (14.91 vs. 12.19, P = 0.024) and more LNs in the suprapancreatic areas (14.68 vs. 11.82, P = 0.017). The laboratory data (amylase, inflammatory, Albumin and T lymphocyte levels) of the RTG group were better than those of the LTG group.

CONCLUSION

According to the results of this prospective cohort study, for patients with locally advanced gastric cancer, Robotic surgery has advantages over laparoscopic surgery for radical total gastrectomy with D2 lymphadenectomy performed by well-trained doctors.

Serum metabolomic profiling for patients with adenocarcinoma of the esophagogastric junction

INTRODUCTION

The incidence of adenocarcinoma in the esophagogastric junction (AEG) has increased in the recent years. AEG is reported to have a worse prognosis compared with tumor confined to the stomach (non-AEG). Although the metabolic changes of non-AEG have been investigated in extensive studies, little effort focused on the metabolic profiling of AEG serum.

OBJECTIVES

Here we report an untargeted gas chromatography-mass spectrometry (GC-MS) method to explore the abnormal metabolism underlying AEG.

METHODS

GC-MS-based untargeted metabolomics approach combined with multivariate statistical analyses were used to study the metabolic profiling of serum samples from AEG patients (n = 70), non-AEG patients (n = 70) and health controls (n = 71).

RESULTS

A novel serum metabolic profiling of 18 metabolites from patients of AEG and non-AEG was indicated, in comparison with health controls. Moreover, AEG and non-AEG were also well-classified with 9 distinguishing metabolites including hypoxanthine, alanine, proline, pyroglutamate, glycine, lactate, succinic acid, glutamate and kynurenine, which produced a discriminatory model with an area under the Receiver Operating Characteristic (ROC) curve of 0.852, suggesting a distinct metabolic signature of AEG. Importantly, lactate and glutamate disclosed outcome-prediction values by multivariate cox-proportional hazard model and Kaplan-Meier method based on follow-up information for 2-5 years.

CONCLUSION

This is the first metabolomics study to identify serum metabolic signature of AEG. The distinguishing metabolites show a promising application on clinical diagnose and outcome prediction, and allow us to unveil several key metabolic variations coexisting in AEG, which may aid to understand the underlying metabolic mechanisms.

The abdominal-transhiatal surgical approach versus the thoracoabdominal surgical approach in Siewert type II adenocarcinoma of the esophagogastric junction: protocol for a multicenter prospective, open, parallel, and randomized controlled trial

Background

To date, Siewert type II adenocarcinoma of the esophagogastric junction (ST-II AEG) can be removed radically utilizing either the abdominal-transhiatal (TH) or the right thoracoabdominal (RTA) approaches. Because of a paucity of high-quality direct evidence, the appropriate surgical approach for ST-II AEG remains debatable. In the present, only several retrospective studies are available, representing ambiguous results. Thus, prospective randomized clinical trials are demanded to compare the survival, oncological outcomes, safety and efficiency and life quality between the TH and RTA approach in patients with resectable AEG of Siewert type II.

Methods

A prospective, multicenter, open, randomized, and parallel controlled study named S2AEG will be conducted. Three hundred and twelve patients who match the inclusion criteria but not the exclusion criteria will be participating in the trial and randomly divided into the TH (156) and RTA (156) cohorts. The primary efficacy endpoint is the 3-year disease-free survival (DFS) following the operation. The rate of R0-resection, the number and site of lymph nodes infiltrated and dissected, postoperative complications, hospital days and life quality are the second endpoints.

Discussion

This study is the first prospectively randomized controlled trial aiming to compare the surgical outcomes between TH and RTA approaches in patients with resectable ST-II AEG. It is hypothesized that patients in the TH cohort would harvest equivalent oncological results and survival while maintaining acceptable life quality when compared to patients in the RTA cohort. Our findings will provide high-level clinical evidence for clinical decision-making on the appropriate surgical approach for patients with ST-II AEG. Embarked in November 2019, this research will be completed 3 years after the final participant’s enrolment date.

Trial registration

Clinical Trial.gov ID: NCT04910789 May 29, 2021. Name: S2AEG.

Clinicopathological characteristics, survival outcomes, and genetic alterations of younger patients with gastric cancer: Results from the China National Cancer Center and cBioPortal datasets

Background

The survival outcomes of younger patients with gastric cancer (GC) have remained controversial. This study explores the clinicopathological characteristics, survival outcomes, and genetic alterations of younger and older patients with GC.

Methods

Patients with GC were identified from the China National Cancer Center Gastric Cancer Database (NCCGCDB) during 1998–2018. Survival analysis was conducted using Kaplan–Meier estimates and Cox proportional hazards models. Sequencing datasets were enrolled from The Cancer Genome Atlas (TCGA) and Memorial Sloan–Kettering Cancer Center (MSKCC) databases.

Results

A total of 1146 younger (<40 years of age) and 16,988 older (≥40 years of age) cases were included in the study. Younger patients had more poorly differentiated lesions than older patients (53.7% vs. 33.8%, respectively; p < 0.0001), and were more often pTNM stage IV (19.5% vs. 11.8%, respectively; p < 0.001). The 5‐year overall survival (OS) of patients from the NCCGCDB increased from 1998 to 2018. Younger patients with pTNM stage III had a lower survival rate than older patients (p = 0.014), while no differences by age were observed at other stages. The mutation frequency of the LRP1B, GNAS, APC, and KMT2D genes was higher for older than younger patients (p < 0.05 for all genes). While not significantly different, younger patients from the TCGA and MSKCC databases were more likely to have CDH1, RHOA, and CTNNB1 gene mutations.

Conclusions

A stable proportion and improved survival of younger patients were reported using NCCGCDB data. Younger patients with pTNM stage III had lower rates of survival than older patients. Distinct molecular characteristics were identified in younger GC patients which may partly explain the histopathology and prognosis specific to this subpopulation.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy: A propensity score matching analysis

BACKGROUND

Laparoscopic total gastrectomy (LTG) has drawn increasing attention over the years. Although LTG has shown surgical benefits compared to open TG (OTG) in early stage gastric cancer (GC), little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy (NAT).

AIM

To compare the long- and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.

METHODS

Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups: LTG and OTG. Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.

RESULTS

In total, 185 patients were enrolled (LTG: 78; OTG: 109). Of these, 138 were paired after propensity score matching. After adjustment for propensity score matching, baseline parameters were similar between the two groups. Compared to OTG, LTG was associated with a significantly shorter length of hospital stay (P = 0.012). The rates of R0 resection, lymph node harvest, and postoperative morbidity did not significantly differ between the two groups. Overall survival (OS) outcomes were comparable between the two groups. Pathological T and N stages were found to be independent risk factors for OS.

CONCLUSION

LTG can be a feasible method for advanced GC patients following NAT, as it appears to be associated with better short- and comparable long-term outcomes compared to OTG.

Survival outcomes of neoadjuvant and adjuvant chemoradiotherapy for locally advanced adenocarcinoma of the oesophagogastric junction: a retrospective cohort study using the SEER database

BACKGROUND

Both neoadjuvant chemoradiotherapy (nCRT) and adjuvant chemoradiotherapy (aCRT) have survival advantages over surgery alone in patients with adenocarcinoma of the oesophagogastric junction (AEG). However, whether there is a difference in the survival benefit between these two treatments and who can benefit from them remains controversial, and there are currently no randomised controlled trials to address these issues. This study compared the survival outcomes of patients with locally advanced AEG receiving nCRT and aCRT.

METHODS

The data of patients with locally advanced AEG were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015). Patients in the nCRT and aCRT groups were propensity-score matched 1:1, and the Kaplan-Meier method and log-rank test were used for survival analysis between the two groups. Univariable and multivariable Cox regression models were performed to identify the prognostic factors.

RESULTS

Of the 1,436 cases diagnosed as locally advanced AEG, we included 442 in the final analysis. The median overall survival (OS) of the nCRT and aCRT cohorts were 30.0 and 25.0 months, respectively (P=0.042), and the median tumour specific survival times were 37.0 and 31.0 months, respectively (P=0.249). Multivariable Cox regression analysis showed that OS was independently related to age [<60 years vs. ≥70 years, hazard ratio (HR) =0.619, 95% CI: 0.510-0.751, P<0.001; 60-69 years vs. ≥70 years, HR =0.661, 95% CI: 0.536-0.814, P<0.001] and N stage (N2 vs. N1, HR =1.213, 95% CI: 1.002-1.468, P=0.048; N3 vs. N1, HR =1.606, 95% CI: 1.190-2.167, P=0.002). Through stratifying patients by TNM stage, stage IIIB, and N1 stage, we observed that patients receiving nCRT had a better prognosis.

CONCLUSIONS

Patients receiving nCRT had significantly better survival than those receiving aCRT. nCRT may offer some therapeutic benefits in patients with IIIB stage AEG.

Characterization of E-cadherin expression in normal mucosa, dysplasia and adenocarcinoma of gastric cardia and its influence on prognosis

BACKGROUND

Gastric cardia adenocarcinoma (GCA), which has been classified as type II adenocarcinoma of the esophagogastric junction in western countries, is of similar geographic distribution with esophageal squamous cell carcinoma in China, and even referred as "sister cancer" by Chinese oncologists. The molecular mechanism for GCA is largely unknown. Recent studies have shown that decreased expression of E-cadherin is associated with the invasion and metastasis of multiple cancers. However, the E-cadherin expression has not been well characterized in gastric cardia carcinogenesis and its effect on GCA prognosis.

AIM

To characterize E-cadherin expression in normal gastric cardia mucosa, dysplasia and GCA tissues, and its influence on prognosis for GCA.

METHODS

A total of 4561 patients with GCA were enrolled from our previously established GCA and esophageal cancer databases. The enrollment criteria included radical surgery for GCA, but without any radio- or chemo-therapy before operation. The GCA tissue from 4561 patients and matched adjacent normal epithelial tissue (n = 208) and dysplasia lesions (n = 156) were collected, and processed as tissue microarray for immunohistochemistry. The clinicopathological characteristics were retrieved from the medical records in hospital and follow-up was carried out through letter, telephone or home interview. E-cadherin protein expression was determined by two step immunohistochemistry. Kaplan–Meier and Cox regression analyses were used to correlate E-cadherin protein expression with survival of GCA patients.

RESULTS

Of the 4561 GCA patients, there were 3607 males with a mean age of 61.6 ± 8.8 and 954 females with a mean age of 61.9 ± 8.6 years, respectively. With the lesions progressed from normal gastric cardia mucosa to dysplasia and GCA, the positive immunostaining rates for E-cadherin decreased significantly from 100% to 93.0% and 84.1%, respectively (R² = 0.9948). Furthermore, E-cadherin positive immunostaining rate was significantly higher in patients at early stage (0 and I) than in those at late stage (II and III) (92.7% vs 83.7%, P = 0.001). E-cadherin positive expression rate was significantly associated with degree of differentiation (P = 0.001) and invasion depth (P < 0.001). Multivariate analysis showed that the GCA patients with positive E-cadherin immunostaining had better survival than those with negative (P = 0.026). It was noteworthy that E-cadherin positive expression rate was similar in patients with positive and negative lymph node metastasis. However, in patients with negative lymph node metastasis, those with positive expression of E-cadherin had better survival than those with negative expression (P = 0.036). Similarly, in patients with late stage GCA, those with positive expression of E-cadherin had better survival than those with negative expression (P = 0.011).

CONCLUSION

E-cadherin expression may be involved in gastric cardia carcinogenesis and low expression of E-cadherin may be a promising early biomarker and overall survival predictor for GCA.

Survival Benefit of Pyloric Lymph Node Dissection for Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction Based on Tumor Diameter: A Large Cohort Study

Background

It is unclear whether the dissection of pyloric lymph nodes (PLNs, No. 5 and No. 6 lymph nodes) is necessary for adenocarcinoma of the esophagogastric junction (AEG) with a tumor diameter >4 cm based on current guidelines. This study aimed at evaluating whether pyloric node lymphadenectomy is essential for patients with Siewert type II/III AEG according to different tumor diameters.

Methods

This study included 300 patients on whom transabdominal total gastrectomy was performed for Siewert type II/III AEG at a high-volume center in China from January 2006 to December 2015. The index of estimated benefit from lymph node dissection (IEBLD) was used to analyze the priority of pyloric lymphadenectomy.

Results

In Siewert type II AEG, the 5-year overall survival (OS) and the 5-year disease-free survival (DFS) were similar between patients with PLN-positive cancer and patients of stage III AEG without PLN metastasis (23.1% vs. 30.6%, p = 0.505; 23.1% vs. 27.1%, p = 0.678). However, in Siewert type III AEG, the OS and the DFS of patients with PLN-positive cancer were significantly lower than that of patients with stage III without PLN metastasis (7.9% vs. 27.8%, p = 0.021; 0 vs. 26.8%, p = 0.005). According to the IEBLD, the dissection of PLNs did not appear to be beneficial in either Siewert type II AEG or type III AEG, whereas a stratified analysis revealed that PLN dissection yielded a high therapeutic benefit for Siewert type II AEG with tumor diameters >4 cm.

Conclusion

We recommended that the PLNs be dissected in Siewert type II AEG when a tumor diameter is >4 cm. Total gastrectomy should be optional for Siewert type II AEG with a tumor diameter >4 cm and Siewert type III AEG.

Long-Term Efficacy of Neoadjuvant Concurrent Chemoradiotherapy for Potentially Resectable Advanced Siewert Type II and III Adenocarcinomas of the Esophagogastric Junction

Background

Reports have shown that neoadjuvant concurrent chemoradiotherapy (nCRT) increases the R0 resection rate for patients with Siewert type II or III adenocarcinoma of the gastroesophageal junction (AEG). However, the long-term efficacy of nCRT for AEG patients remains unclear. In this multicenter study, we investigated the long-term results of AEG patients treated with nCRT.

Methods

A total of 149 patients with potentially resectable advanced AEG (T3/4, Nany, M0) were randomly divided into two groups: the nCRT-treated group (treated group) (n = 76) and the surgery group (control group) (n = 73). The primary endpoint was disease-free survival (DFS), and the secondary outcome indexes included the R0 resection rate, HER-2 expression, tumor regression grade (TRG), objective response rate (ORR), disease control rate (DCR), overall survival (OS), and adverse events.

Results

In the treated group, the overall therapeutic efficacy rate was 40.8%, and the pathological complete response (pCR) rate was 16.9%. The rates of patients who underwent R0 resection in the treated and control groups were 97.0% and 87.7%, respectively (p < 0.05). The toxic effects were mainly graded 1–2 in the treated group. The median DFS times in the treated and control groups were 33 and 27 months, respectively (p = 0.08), whereas the median OS times were 39 and 30 months, respectively (p = 0.01). The median DFS times of patients with positive and negative HER-2 expression in the treated group were 13 and 43 months, respectively (p = 0.01), and the median OS times were 27 and 41 months, respectively (p = 0.01).

Conclusion

Surgery after nCRT improved the efficacy of treatment for AEG patients and thus provided a better prognosis.

Clinical Trial Registration

The trial is registered with ClinicalTrials.gov (number NCT01962246).

Outcomes of Laparoscopic Total Gastrectomy Combined With Spleen-Preserving Hilar Lymphadenectomy for Locally Advanced Proximal Gastric Cancer: A Nonrandomized Clinical Trial

IMPORTANCE

The long-term survival of patients with laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) for advanced upper-third gastric cancer (AUTGC) and the association of splenic hilar lymph node (LN-10) metastasis with survival remain controversial.

OBJECTIVE

To evaluate the long-term outcomes of LSTG and the value index of LN-10 metastasis for patients with AUTGC.

DESIGN, SETTING, AND PARTICIPANTS

The Chinese Laparoscopic Gastrointestinal Surgery Study 4 (CLASS-04) was a prospective, multicenter, single-arm trial that involved 19 centers in China. A total of 251 eligible patients with clinical stage T2, T3, or T4a upper-third gastric cancer without distant metastases were enrolled from September 1, 2016, to October 31, 2017. The final follow-up was on December 31, 2020.

INTERVENTIONS

All patients were enrolled to undergo LSTG.

MAIN OUTCOMES AND MEASURES

The main outcomes were the 3-year overall survival (OS) and disease-free survival (DFS). Multivariate analyses were used to explore the association of LN-10 metastasis with survival.

RESULTS

Among the 251 patients, 246 (98.0%; mean [SD] age, 60.1 [9.4] years; 197 [80.1%] male) underwent LSTG and completed the study. The 3-year OS was 79.1% (95% CI, 74.0%-84.2%), and the 3-year DFS was 73.1% (95% CI, 67.4%-78.8%). In addition, the 3-year therapeutic value index of LN-10 dissection was 4.5, exceeding the indexes for the partial D2 LN group (including LNs 5, 6, 11d, and 12a). Nineteen patients (7.7%) with LN-10 metastasis had significantly worse survival than the nonmetastasis group, and multivariate analysis revealed that splenic LN-10 metastasis was an independent risk factor (OS: hazard ratio [HR], 2.38; 95% CI, 1.08-5.26; P = .03; DFS: HR, 2.28; 95% CI, 1.12-4.63; P = .02). Moreover, patients with LN-10 metastasis were more likely to have recurrence (42.1% vs 20.7%, P = .03), especially when multiple site metastasis was present (21.1% vs 4.4%, P = .01). However, patients with LN-10 metastasis who received adjuvant chemotherapy had significantly better OS and DFS than those without adjuvant chemotherapy and achieved the same oncologic effect as those without LN-10 metastasis.

CONCLUSIONS AND RELEVANCE

This results of this study suggest that LSTG for AUTGC has feasible long-term outcomes. In addition, patients with LN-10 metastasis may have worse survival and may be more prone to recurrence.

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

BACKGROUND

The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).

METHODS

A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.

RESULTS

Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.

CONCLUSION

This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.

Lymph Node Ratio Is an Independent Prognostic Factor for Patients with Siewert Type II Adenocarcinoma of Esophagogastric Junction: Results from a 10-Year Follow-up Study

PURPOSE

Emerging evidences suggest that lymph node ratio (LNR), the number of metastatic lymph node (LN) to the total number of dissected lymph nodes (NDLN), may predict survival in multiple types of solid tumor. However, the prognostic role of LNR in adenocarcinoma of the esophagogastric junction (AEG) remains uninvestigated. The present study is intended to determine the prognostic value of LNR in the patients with Siewert type II AEG.

METHODS

A total of 342 patients with Siewert type II AEG who underwent R0 resection were enrolled in this study. The optimal cutoff of LNR was stratified into tertiles using X-tile software. The log-rank test was used to evaluate the survival differences, and multivariate Cox regression analyses were performed to determine the independent prognostic variables.

RESULTS

The optimal cutoff of LNR were classified as LNR = 0, LNR between 0.01 and 0.40, and LNR > 0.41. Patients with high LNR had a shorter 5- and 10-year disease-specific survival (DSS) rate (8.5%, 1.4%) compared with those with moderate LNR (20.4%, 4.9%) and low LNR (58.0%, 27.5%) (P < 0.001). Multivariate Cox regression analysis indicated that LNR was an independent factor for DSS after adjusting for confounding variables (P < 0.05). Furthermore, after stratification by NDLN between NDLN < 15 group and NDLN ≥ 15 group, the LNR remained a significant predictor for DSS (P < 0.05).

CONCLUSIONS

LNR is an independent predictor for DSS in patients with Siewert type II AEG regardless of NDLN. Patients with higher LNR have significantly shorter DSS.

Efficacy and safety of neoadjuvant chemoradiotherapy plus apatinib for patients with locally advanced, HER2-negative, Siewert's type II-III adenocarcinoma of esophagogastric junction: a single-arm, open-label, phase II trial

This study aimed to investigate the efficacy and safety of concurrent neoadjuvant chemoradiotherapy (CRT) plus apatinib in treating locally advanced, HER2-negative, Siewert's type II-III adenocarcinoma of esophagogastric junction (AEG) patients. Thirty eligible patients were analyzed in this single-arm, open-label, phase II trial. Patients received neoadjuvant regimen as follows: two cycles of apatinib (orally, 250 mg/day on day 1-28), two cycles of capecitabine (orally, 1,000 mg/m² twice daily on day 1-14), oxaliplatin (intravenously, 130 mg/m² on day 1), and concurrent radiotherapy (a total dose of 45 Gy in 25 fractions) started on day 1 of chemotherapy. Then, surgery was performed within 8-12 weeks after the completion of neoadjuvant therapy. This trial was registered on the ClinicalTrials.gov website (access number: NCT03349866). After neoadjuvant CRT plus apatinib treatment, 18 (60.0%) patients achieved objective response, 29 (96.7%) patients achieved disease control, and 20 (66.7%) patients achieved down-staging. Encouragingly, tumor regression grade (TRG) 0, TRG 1, TRG 2 and TRG 3 were observed in 33.3%, 20.0%, 30.0% and 10.0% patients, respectively; the pathological complete response rate was 33.3%, and the R0 resection rate was 93.3%. Regarding survivals, the 1-year and 2-year progression-free survival rates were 96.7% and 88.1%, respectively. Meanwhile, the 1-year and 2-year overall survival rates were 100.0% and 96.6%, respectively. As to safety, the majority of the adverse events were of mild grade, and the post-operative complications were manageable. In conclusion, neoadjuvant CRT plus apatinib exhibits high efficacy and acceptable tolerance in patients with locally advanced, HER2-negative, Siewert's type II-III AEG.

Application value of hand-sewn anastomosis in totally laparoscopic total gastrectomy for gastric cancer

Background

Digestive tract reconstruction in totally laparoscopic total gastrectomy can be divided into two types: instrument anastomosis and hand-sewn anastomosis. This study explored the feasibility and safety of hand-sewn sutures in esophagojejunostomy of totally laparoscopic total gastrectomy, compared with instrument anastomosis using an overlap linear cutter.

Methods

This retrospective cohort study was conducted from January 2017 to January 2020 at one institution. The clinical data of 50 patients who underwent totally laparoscopic total gastrectomy, with an average follow-up time of 12 months, were collected. The clinicopathologic data, short-term survival prognosis, and results of patients in the hand-sewn anastomosis (n=20) and the overlap anastomosis (n=30) groups were analyzed.

Results

There were no significant differences between the groups in sex, age, body mass index, American Society of Anesthesiologists score, tumor location, preoperative complications, abdominal operation history, tumor size, pTNM stage, blood loss, first postoperative liquid diet, exhaust time, or postoperative length of hospital stay. The hand-sewn anastomosis group had a significantly prolonged operation time (204±26.72min versus 190±20.90min, p=0.04) and anastomosis time (58±22.0min versus 46±15.97min, p=0.029), and a decreased operation cost (CNY 77,100±1700 versus CNY 71,900±1300, p<0.0001). Postoperative complications (dynamic ileus, abdominal infection, and pancreatic leakage) occurred in three patients (15%) in the hand-sewn anastomosis group and in four patients (13.3%) in the overlap anastomosis group (anastomotic leakage, anastomotic bleeding, dynamic ileus, and duodenal stump leakage).

Conclusion

The hand-sewn anastomosis method of esophagojejunostomy under totally laparoscopic total gastrectomy is safe and feasible and is an important supplement to linear and circular stapler anastomosis. It may be more convenient regarding obesity, a relatively high position of the anastomosis, edema of the esophageal wall, and short jejunal mesentery.

A novel risk score system for prognostic evaluation in adenocarcinoma of the oesophagogastric junction: a large population study from the SEER database and our center

Background

The incidence rate of adenocarcinoma of the oesophagogastric junction (AEG) has significantly increased over the past decades, with a steady increase in morbidity. The aim of this study was to explore a variety of clinical factors to judge the survival outcomes of AEG patients.

Methods

We first obtained the clinical data of AEG patients from the Surveillance, Epidemiology, and End Results Program (SEER) database. Univariate and least absolute shrinkage and selection operator (LASSO) regression models were used to build a risk score system. Patient survival was analysed using the Kaplan-Meier method and the log-rank test. The specificity and sensitivity of the risk score were determined by receiver operating characteristic (ROC) curves. Finally, the internal validation set from the SEER database and external validation sets from our center were used to validate the prognostic power of this model.

Results

We identified a risk score system consisting of six clinical features that can be a good predictor of AEG patient survival. Patients with high risk scores had a significantly worse prognosis than those with low risk scores (log-rank test, P-value < 0.0001). Furthermore, the areas under ROC for 3-year and 5-year survival were 0.74 and 0.75, respectively. We also found that the benefits of chemotherapy and radiotherapy were limited to stage III/IV AEG patients in the high-risk group. Using the validation sets, our novel risk score system was proven to have strong prognostic value for AEG patients.

Conclusions

Our results may provide new insights into the prognostic evaluation of AEG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08558-1.

Serum CYR61 as a potential biomarker for the diagnosis of esophagogastric junction tumor

BACKGROUND

Esophagogastric junction tumor (EGJ) is a rare but fatal disease with a rapid rising incidence worldwide in the late 20 years, and it lacks a convenient and safe method for diagnosis. The present study aimed to evaluate the potential of serum CYR61 as a biomarker for the diagnosis of EGJ tumor.

METHODS

Enzyme-linked immunosorbent assay (ELISA) was used to estimate CYR61 levels in sera of 152 EGJ tumor patients and 137 normal controls. Receiver operating characteristics (ROC) was carried out to evaluate the diagnostic accuracy. The Mann-Whitney's U test was used to compare the difference of serum levels of CYR61 between groups. And chi-square tests were employed to estimate the correlation of the positive rate of serum CYR61 between/among subgroups.

RESULTS

Serum CYR61 levels were statistically lower in EGJ tumor and early-stage EGJ tumor patients than those in normal controls (P<0.0001). The sensitivity, specificity and the area under the curve (AUC) of this biomarker in EGJ tumor were 88.2%, 43.8% and 0.691, respectively, and those for early stage of EGJ tumor were 80.0%, 66.4% and 0.722, respectively. Analyses showed that there was no correlation between the clinical data and the levels of CYR61 (P>0.05).

CONCLUSION

The present study showed that CYR61 might be a potential biomarker to assist the diagnosis of EGJ tumor.

Screening and clinical significance of lymph node metastasis-related genes within esophagogastric junction adenocarcinoma

Background

Despite recent improvements in treatment technologies, such as surgical resection and chemoradiotherapy, the prognosis of patients with esophagogastric junction adenocarcinoma (EJA) remains poor due to early lymph node metastasis. Since few studies have investigated genes associated with lymph node metastasis in EJA, we aimed to screen lymph node metastasis‐associated genes and clarify their expression status and prognostic significance in EJA.

Methods

The differential frequency of mutations between carcinoma and para‐carcinoma tissues from 199 cases with EJA was detected using targeted next‐generation sequencing (tNGS). Following a stratified analysis to determine that gender has no effect on the frequency of gene mutations, lymph node metastasis‐related genes, including CDK6, MET, NOTCH1, and LRP1B, were screened, and CDK6 and LRP1B were selected for further study as they displayed significant differences in mutation rates. Differences in their expression status were verified using immunohistochemical (IHC) staining in 18 CDK6‐ and 17 LRP1B‐mutated samples and a randomly matched control group.

Results

tNGS revealed that CDK6 and LRP1B mutation frequencies were significantly different between EJA cases with (N ≥ 1) or without (N = 0) lymph node metastasis. In particular, CDK6 mutation frequency was expected less, whereas that of LRP1B was remarkably higher in cases with stage N0 than in those with stage N ≥ 1. IHC staining confirmed significant differences in CDK6 and LRP1B expression status between the study and control cohorts. Chi‐square tests revealed that a high CDK6 expression status correlated significantly with smoking history (p = 0.044), T stage (p = 0.035), N stage (p = 0.000), and advanced TNM stage (p = 0.001) in EJA, whereas a high LRP1B expression status only correlated with BMI (p = 0.013) and N stage (p = 0.000). Furthermore, as confirmed by survival status investigation, a high LRP1B expression status predicted good prognosis, and a high CDK6 expression status was an independent predictor of poor prognosis in patients with EJA.

Conclusions

Taken together, the findings of this study demonstrate that a high CDK6 and LRP1B expression status promotes and inhibits lymph node metastasis in patients with EJA, respectively, suggesting that both CDK6 and LRP1B are significantly potential predictors of lymph node metastasis and prognosis in EJA.

Could neoadjuvant chemotherapy increase postoperative complication risk of laparoscopic total gastrectomy? A mono-institutional propensity score-matched study in China

BACKGROUND

The potential survival benefit of neoadjuvant chemotherapy (NC) in patients with advanced gastric cancer has been widely recognized. With the development of minimally invasive surgery, which is represented by laparoscopy, the effect of NC on the safety of laparoscopic gastrectomy remains to be further explored.

AIM

To compare the short-term outcomes of laparoscopic total gastrectomy (LTG) after NC (NC-LTG) with LTG alone.

METHODS

A total of 92 patients who underwent NC-LTG and 381 patients who received LTG alone at the Chinese PLA General Hospital between September 2015 and September 2020 were retrospectively included in our study. We used propensity-score matching (PSM) to balance baseline bias. After 1:1 PSM, 73 patients were included in each group with no statistically significant difference in baseline characteristics.

RESULTS

The NC-LTG group exhibited a longer operation time (244.10 ± 48.13 min vs 225.74 ± 45.33 min, P = 0.019) and increased intraoperative blood loss [150 (100-300) mL vs 100 (100-200) mL, P = 0.011] compared to the LTG group. The 30-d postoperative morbidity of the NC-LTG group was 20.5% (15/73), and that of the LTG group was 13.7% (10/73). There were no significant differences in 30-d severe complication rates or anastomotic leakage rates. Subgroup analysis showed that the patients with pTNM (pathological tumor-node-metastasis classification) T0N0-II in the NC-LTG group underwent a longer operation than the LTG group, while no significant difference was found in any perioperative index for the pTNM III patients. A multivariate analysis showed that an operation time longer than 240 min was an independent risk factor (odds ratio = 3.021, 95% confidence interval: 1.160-7.868, P = 0.024), while NC was not an independent risk factor for postoperative complications in LTG.

CONCLUSION

Despite a longer operation time and more blood loss after NC-LTG, which indicate surgical difficulty, NC-LTG exhibits acceptable short-term outcomes compared to LTG, suggesting the safety and feasibility of NC-LTG.

Clinical and prognostic features of MMP-2 and VEGF in AEG patients

Adenocarcinoma of the esophagogastric junction (AEG) has been increased in recent years and has become a worldwide problem that seriously affects human health. The purpose of the study is to investigate the clinical and prognostic characteristics of the matrix metalloproteinase-2 (MMP-2) and vascular endothelial growth factor (VEGF) expression in AEG patients. A total of 69 patients were enrolled in this study. The result showed that the high expression of MMP-2 was significantly associated with tumor differentiation (P < 0.05) and depth of invasion (pT, P < 0.05). The high expression of VEGF was significantly associated with pT (P < 0.05) and lymph node metastasis (pN, P < 0.05). There was a positive correlation between MMP-2 and VEGF expression (P < 0.01). The 5-year survival rate for the 69 AEG patients was 40.6% and it was significantly associated with tumor differentiation (P < 0.05), pN (P < 0.01), pTNM stage (P < 0.01), MMP-2 expression (P < 0.05), and VEGF expression (P < 0.05). Cox multivariate regression demonstrated that tumor differentiation and pN were independent factors for the 5-year survival rate. Our study showed that MMP-2 and VEGF could work synergistically in AEG development.

Laparoscopic infrapyloric lymph nodes dissection through the right bursa omentalis approach for gastric cancer

BACKGROUND

A complete dissection of infrapyloric lymph nodes is the key to a curative gastrectomy, which can be sometimes technically challenging in laparoscopic surgery.

METHODS

One hundred and eighteen patients with gastric cancer undergoing laparoscopic gastrectomy with D2 lymphadenectomy in which the infrapyloric lymph nodes were dissected through the right bursa omentalis approach were included. The clinicopathologic characteristics and surgical outcomes were analyzed retrospectively.

RESULTS

The laparoscopic gastrectomy with D2 lymphadenectomy was successful in all 118 patients with no open conversion. The mean operation time was 246.6 ± 45.7 min. The mean estimated blood loss was 87.0 ± 35.9 mL. Postoperative complications occurred in 17.8% of the patients, which were treated successfully with conservative therapy or aspiration in all. There were no No.6 lymphadenectomy-associated complications, such as injury of transverse colon, vessels of mesocolon, pancreas or duodenum, no pancreatitis, pancreatic leakage or postoperative hemorrhage. The mean postoperative hospital stay was 9.6 ± 3.7 days. On average, the total lymph nodes harvested were 36.8 ± 12.9, in which the ones from the infrapyloric area were 5.1 ± 3.1.

CONCLUSION

Laparoscopic dissection of infrapyloric lymph nodes through the right bursa omentalis approach seems to be feasible and safe, facilitating a more complete No.6 lymphadenectomy for gastric cancer.

Laparoscopic proximal gastrectomy with double-tract reconstruction for upper third gastric cancer

Background

Proximal gastrectomy with double-tract reconstruction (DTR) has been used for upper third gastric cancer as a function-preserving procedure. However, the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with DTR remain uncertain. This study compared open proximal gastrectomy (OPG) with DTR and LPG with DTR for proximal gastric cancer.

Methods

Sixty-four patients who had undergone OPG with DTR and forty-six patients who had undergone LPG with DTR were enrolled in this case–control study. The clinical characteristics, surgical outcomes and postoperative nutrition index were analysed retrospectively.

Results

The operation time was significantly longer in the LGP group than in the OPG group (258.3 min vs 205.8 min; p = 0.00). However, the time to first flatus and postoperative hospital stay were shorter in the LPG group [4.0 days vs 3.5 days (p = 0.00) and 10.6 days vs 9.2 days (p = 0.001), respectively]. No significant difference was found between the two groups in the number of retrieved lymph nodes, complications or reflux oesophagitis. The nutrition status was assessed using the haemoglobin, albumin, prealbumin and weight levels from pre-operation to six months after surgery. No significant difference was found between the groups.

Conclusion

LPG with DTR can be safely performed for proximal gastric cancer patients by experienced surgeons.

Potential Value of Radiomics in the Identification of Stage T3 and T4a Esophagogastric Junction Adenocarcinoma Based on Contrast-Enhanced CT Images

Purpose

This study was designed to evaluate the predictive performance of contrast-enhanced CT-based radiomic features for the personalized, differential diagnosis of esophagogastric junction (EGJ) adenocarcinoma at stages T3 and T4a.

Methods

Two hundred patients with T3 (n = 44) and T4a (n = 156) EGJ adenocarcinoma lesions were enrolled in this study. Traditional computed tomography (CT) features were obtained from contrast-enhanced CT images, and the traditional model was constructed using a multivariate logistic regression analysis. A radiomic model was established based on radiomic features from venous CT images, and the radiomic score (Radscore) of each patient was calculated. A combined nomogram diagnostic model was constructed based on Radscores and traditional features. The diagnostic performances of these three models (traditional model, radiomic model, and nomogram) were assessed with receiver operating characteristics curves. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and areas under the curve (AUC) of models were calculated, and the performances of the models were evaluated and compared. Finally, the clinical effectiveness of the three models was evaluated by conducting a decision curve analysis (DCA).

Results

An eleven-feature combined radiomic signature and two traditional CT features were constructed as the radiomic and traditional feature models, respectively. The Radscore was significantly different between patients with stage T3 and T4a EGJ adenocarcinoma. The combined nomogram performed the best and has potential clinical usefulness.

Conclusions

The developed combined nomogram might be useful in differentiating T3 and T4a stages of EGJ adenocarcinoma and may facilitate the decision-making process for the treatment of T3 and T4a EGJ adenocarcinoma.

Total laparoscopic transabdominal-transdiaphragmatic approach for treating Siewert II tumors: a prospective analysis of a case series

Background

Although the morbidity of gastric cancer has decreased, the incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing. Furthermore, no consensus exists on which surgical approach should be applied for Siewert type II AEG. The purpose of our study was to evaluate the technical safety and feasibility of a new surgical approach.

Methods

Sixty patients with Siewert type II AEG underwent laparoscopic total gastrectomy with the total laparoscopic transabdominal-transdiaphragmatic (TLTT) approach, which needs an incision in the diaphragm.

Results

The median operative time, reconstruction time, and estimated blood loss were 214.8 ± 41.6 min, 29.40 ± 7.1 min, and 209.0 ± 110.3 ml, respectively. All of the patients had negative surgical margins.

Conclusion

There were no intraoperative complications or conversions to open surgery. Our surgical procedure provides a unique option for the safe application of laparoscopic lower mediastinal lymph node dissection and gastrointestinal reconstruction.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800014336. Registered on 31 December 2017 - Prospectively registered, http://www.chictr.org.cn/edit.aspx?pid=23111&htm=4.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02136-2.

The Survival Benefit and Safety of Splenectomy for Gastric Cancer With Total Gastrectomy: Updated Results

Background

Splenectomy was traditionally performed to dissect the splenic hilar lymph nodes. Considering the important functions of spleen, whether splenectomy would bring beneficial to gastric cancer patients is debatable. This meta-analysis aimed to make an updated evaluation on the effectiveness and safety of splenectomy.

Methods

Literature searches were performed to identify eligible RCTs concerning effectiveness or safety of splenectomy with gastrectomy from PubMed, MEDLINE, CBMdisc, EMBASE, and Cochrane Central Register of Controlled Trials. Two reviewers completed the study selection, data extraction, and quality assessment independently. The meta-analyses were performed by RevMan 5.3.

Results

A total of 971 patients from four studies were included (485 in splenectomy group and 486 in spleen preservation group). Splenectomy did not increase 5-year overall survival rate (RR=1.05, 95% CI: 0.96, 1.16) or increase postoperative mortality (RR=1.21, 95% CI: 0.41, 3.54). However, the analysis demonstrated that gastrectomy with splenectomy had significantly higher incidence of postoperative complications (RR=1.80, 95% CI: 1.33, 2.45). No significant differences were found in terms of the number of resected lymph nodes and reoperation rate; however, splenectomy had a tendency to prolong the duration of surgery and hospital stays. Subgroup analyses indicated that splenectomy could not increase overall survival rate for either whole or proximal gastric cancer. Sensitivity analyses also found similar results compared to the primary analyses.

Conclusions

Splenectomy cannot benefit the survival of patients with tumor located at lesser curvature, and it could instead increase postoperative morbidity.

Esophagogastric junction adenocarcinoma shares characteristics with gastric adenocarcinoma: Literature review and retrospective multicenter cohort study

The incidence of esophagogastric junction (EGJ) adenocarcinoma has been gradually increasing in Asia, just like in Western countries a few decades ago. Despite recent advances in next-generation sequencing and multimodal treatments, EGJ adenocarcinoma is still an aggressive malignancy with poor outcomes. Clinically, EGJ adenocarcinoma can be separated into Barrett's adenocarcinoma and cardiac adenocarcinoma, with frequent similarities observed. Barrett's adenocarcinoma is likely to be of gastric origin in terms of its premalignant background, risk factors, and stem cell regulators. Recent comprehensive genomic analyses suggest that immunotherapy may be essential for high-level microsatellite instability (MSI-H)- and Epstein-Barr virus (EBV)-associated subtypes, and against the immunosuppressive phenotype in genomically stable (GS) subtypes, in the treatment of EGJ and gastric adenocarcinoma. Although the chromosomal instability (CIN) subtype dominates EGJ adenocarcinoma, there is still a need to investigate the other molecular subtypes and their targets. Because of the distinctive characteristics of tumor location of EGJ adenocarcinoma, we also described the results of a multicenter cohort study of EGJ adenocarcinoma, comparing Siewert type I (distal esophagus), II (cardia of the stomach), and III (subcardia) tumors. We show that type I tumors were frequently accompanied by Barrett's esophagus (78%, P < .0001), with a significantly unfavorable outcome (multivariate EGJ-cancer-specific mortality hazard ratio = 1.81, 95% CI, 1.06-2.97; P = .031). In addition, over half (56%) of these cases experienced disease recurrence in the lymph nodes. Our findings suggest that Barrett's adenocarcinoma may be an aggressive phenotype of EGJ adenocarcinoma due to the potential risk of tumor spread through the complex lympho-vascular network of the esophagus.

Reappraise role of No. 10 lymphadenectomy for proximal gastric cancer in the era of minimal invasive surgery during total gastrectomy: a pooled analysis of 4 prospective trial

BACKGROUND

For patients with locally advanced proximal gastric cancer (LAPGC), the individualized selection of patients with highly suspected splenic hilar (No. 10) lymph node (LN) metastasis to undergo splenic hilar lymphadenectomy, is a clinical dilemma. This study aimed to re-evaluate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) and to identify the population who would benefit from it.

METHODS

A total of 1068 patients (D2 group = 409; D2 + No. 10 group = 659) who underwent laparoscopic total gastrectomy from four prospective trials between January 2015 and July 2019 were analyzed.

RESULTS

No significant difference in the incidence (16.9% vs. 16.4%; P = 0.837) of postoperative complications were found between the two groups. The metastasis rate of No. 10 LN among patients in the D2 + No. 10 group was 10.3% (68/659). Based on the decision tree, patients with LAPGC with tumor invading the greater curvature (Gre), patients with non-Gre-invading LAPGC with a tumor size > 5 cm and clinical positive locoregional LNs were defined as the high-priority No. 10 dissection group. The metastasis rate of No. 10 LNs in the high-priority group was 19.4% (41/211). In high-priority group, the 3-year overall survival of the D2 + No. 10 group was better than that of the D2 group (74.4% vs. 42.1%; P = 0.005), and the therapeutic index of No. 10 was higher than the indices of most suprapancreatic stations.

CONCLUSIONS

LSPSHL for LAPGC is safe and feasible when performed by experienced surgeons. LSPSHL could be recommended for the high-priority group patients even without invasion of the Gre.

Lymphovascular Invasion as a Prognostic Factor in Non-Metastatic Adenocarcinoma of Esophagogastric Junction After Radical Surgery

Purpose

Tumors with lymphovascular invasion (LVI) are thought to be associated with lymph node metastasis and to lead to a worse prognosis. However, the effect of LVI on the prognosis of adenocarcinoma of esophagogastric junction (AEG) is still unclear.

Patients and Methods

We retrospectively analyzed 224 consecutive patients with non-metastatic AEG who underwent radical surgery in our hospital from 2004 to 2018. Inverse probability weighting (IPW) analysis was used to eliminate the selection bias. IPW-adjusted Kaplan–Meier curves and Cox proportional hazards models were used to compare disease-specific survival (DSS) and overall survival (OS) between patients with and without LVI.

Results

A total of 224 patients with non-metastatic AEG who underwent radical resection were included in the study and 96 (42.9%) patients developed LVI. Survival analysis showed that LVI were associated with worse DSS (hazard ratio (HR) = 3.12; 95% CI: 1.93–5.03) and worse OS (HR = 2.33; 95% CI: 1.61–3.38). The results were consistent across subgroups stratified by pathologic N stage. Subgroup analysis demonstrated that Siewert type III (HR= 3.20, 95% CI: 1.45–7.06) was associated with worse DSS, but not Siewert type I/II (HR= 1.46, 95% CI: 0.94–2.31, P-interaction=0.047).

Conclusion

LVI are associated with worse prognosis in AEG. LVI had a worse effect on DSS in Siewert type III AEG than Siewert type I/II AEG.

Long-term outcomes and prognostic factor analysis of resected Siewert type II adenocarcinoma of esophagogastric junction in China: a seven-year study

Background

The incidence rate of adenocarcinoma of the esophagogastric junction (AEG) has significantly increased over the past two decades. Surgery remains the only curative treatment. However, there are currently few studies on Chinese AEG patients. The purpose of this study was to retrospectively analyze the survival and prognostic factors of AEG patients in our center.

Methods

Between January 2008 and September 2014, 249 AEG patients who underwent radical resection were enrolled in this retrospective study, including 196 males and 53 females, with a median age of 64 (range 31–82). Prognostic factors were assessed with the log-rank test and Cox univariate and multivariate analyses.

Results

The 5-year survival rate of all patients was 49%. The median survival time of all enrolled patients was 70.1 months. Pathological type, intraoperative blood transfusion, tumor size, adjuvant chemotherapy, duration of hospital stay, serum CA199, CA125, CA242 and CEA, pTNM stage, lymphovascular or perineural invasion, and the ratio of positive to negative lymph nodes (PNLNR) were significantly associated with overall survival when analyzed in univariate analysis.

Conclusions

Our study found that adjuvant chemotherapy, PNLNR, intraoperative blood transfusion, tumor size, perineural invasion, serum CEA, and duration of hospital stay after surgery had significance in multivariate analysis and were independent risk factors for survival.

The Prognostic Value of the Prognostic Nutritional Index (PNI) in Radically Resected Esophagogastric Junction Adenocarcinoma

To determine the influence of preoperative prognostic nutritional index in adenocarcinoma of the esophagogastric junction, this study was conducted to analyze 420 patients with adenocarcinoma of the esophagogastric junction who underwent surgery. A total of 120 healthy volunteers were included as the healthy control group. The cutoff values of prognostic nutritional index for predicting survival were obtained according to the receiver operating characteristic curve. The clinic-pathological feature and survival were compared between low and high prognostic nutritional index group. Results showed that the prognostic nutritional index in the patient group was lower than that in the healthy control group (P < 0.05). The level of prognostic nutritional index was significantly associated with tumor differentiation, Siewert type, tumor size, body mass index, and hemoglobin levels (P < 0.05). The level of prognostic nutritional index was negatively correlated with age of onset, tumor differentiation, Siewert type, tumor size, depth of tumor, but positively associated with the levels of body mass index and hemoglobin. Multivariate analysis revealed that prognostic nutritional index was an independent factor associated with disease-free survival (P = 0.027) and overall survival (P = 0.003). In conclusion, low prognostic nutritional index may be considered as an independent adverse prognostic marker in patients with adenocarcinoma of the esophagogastric junction.

Immunogenic characteristics of microsatellite instability-low esophagogastric junction adenocarcinoma based on clinicopathological, molecular, immunological and survival analyses

Microsatellite instability (MSI) is categorized by mutation frequency: high MSI (MSI-H), low MSI (MSI-L) and microsatellite stable (MSS). MSI-H tumors have a distinct immunogenic phenotype, with immunotherapies using checkpoint inhibitors already approved for the treatment of MSI-H gastroesophageal adenocarcinoma (GEA); this is not observed for MSI-L or MSS. Here, we tested the hypothesis that MSI-L tumors are also a distinct phenotype and potentially immunogenic. MSI-PCR assays (BAT25, BAT26, BAT40, D2S123, D5S346 and D17S250) were performed on 363 Epstein-Barr virus-negative, surgically resected esophagogastric junction (EGJ) adenocarcinoma samples. Tumors were characterized as MSI-H (≥2 markers), MSI-L (1 marker) or MSS (0 markers). CD8+ cell counts, PD-L1 and HER2 expression levels, TP53 mutations, epigenetic alterations and prognostic significance were also examined. All pathological and molecular experiments were conducted using serial, whole-tumor sections of chemo-naïve surgical specimens. MSI-H and MSI-L were assigned to 28 (7.7%) and 24 (6.6%) cases, respectively. Compared to MSS cases, MSI-L cases had significantly higher intratumoral CD8+ cell infiltration (P = .048) and favorable EGJ cancer-specific survival (multivariate hazard ratio = 0.35, 95% CI, 0.12-0.82; P = .012). MSI-L tumors were also significantly associated with TP53-truncating mutations as compared to MSI-H (P = .009) and MSS (P = .012) cases, and this trend was also observed in GEA data from The Cancer Genome Atlas (TCGA). Indel mutational burden among TCGA MSI-L tumors was significantly higher than that of MSS tumors (P = .016). These results suggest that MSI-L tumors may have a distinct tumor phenotype and be potentially immunogenic in EGJ adenocarcinoma.

Enhanced Recovery after Surgery in Elderly Gastric Cancer Patients Undergoing Laparoscopic Total Gastrectomy

BACKGROUND

The aim of this study was to evaluate the effects of the enhanced recovery after surgery (ERAS) program versus conventional perioperative care on the short-term postoperative outcomes among elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy.

METHODS

Elderly patients with gastric cancer (age ≥ 65 y) who are undergoing laparoscopic total gastrectomy were randomized to ERAS or conventional perioperative care groups. Short-term postoperative outcomes, including postoperative hospital stay, mortality, complications, readmission rate, and reoperation rate were compared between the two groups. In addition, blood samples were taken preoperatively (baseline) and on postoperative days 1, 3, and 5. Systemic human leukocyte antigen (HLA)-DR expression on monocytes and C-reactive protein (CRP) were analyzed.

RESULTS

Of the 171 eligible patients, 85 patients were assigned to receive ERAS program treatment (ERAS group) and 86 patients to receive conventional care (conventional group). The patients' characteristics were comparable. Postoperative hospital stay was shorter in the ERAS group than in the conventional group (11 [7-11] versus 13 [8-20] d, P < 0.001). Hospital mortality, overall morbidity, morbidity ≥ Clavien-Dindo (C-D) grade II, readmission rate, and reoperation rate did not show significant differences between the two groups. However, morbidity ≥ C-D grade IIIa was lower in the ERAS group than that in the conventional group (8.2% versus 18.6%, P = 0.047). The ERAS program shortened the number of days to postoperative first flatus, first defecation, semifluid diet, and soft bland diet. Moreover, the ERAS program increased the HLA-DR expression on monocytes and decreased the CRP levels on postoperative days 1, 3, and 5.

CONCLUSIONS

The ERAS program was feasible and effective for elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. The benefits of ERAS were associated with improvement of impaired immune function and suppression of inflammatory reaction.

Short-term outcomes of robotic- versus laparoscopic-assisted Total Gastrectomy for advanced gastric Cancer: a propensity score matching study

BACKGROUND

Few studies have been designed to evaluate the short-term outcomes between robotic-assisted total gastrectomy (RATG) and laparoscopy-assisted total gastrectomy (LATG) for advanced gastric cancer (AGC). The purpose of this study was to assess the short-term outcomes of RATG compared with LATG for AGC.

METHODS

We retrospectively evaluated 126 and 257 patients who underwent RATG or LATG, respectively. In addition, we performed propensity score matching (PSM) analysis between RATG and LATG for clinicopathological characteristics to reduce bias and compared short-term surgical outcomes.

RESULTS

After PSM, the RATG group had a longer mean operation time (291.14 ± 59.18 vs. 270.34 ± 52.22 min, p = 0.003), less intraoperative bleeding (154.37 ± 89.68 vs. 183.77 ± 95.39 ml, p = 0.004) and more N2 tier RLNs (9.07 ± 5.34 vs. 7.56 ± 4.50, p = 0.016) than the LATG group. Additionally, the total RLNs of the RATG group were almost significantly different compared to that of the LATG group (34.90 ± 13.05 vs. 31.91 ± 12.46, p = 0.065). Moreover, no significant differences were found between the two groups in terms of the length of incision, proximal resection margin, distal resection margin, residual disease and postoperative hospital stay. There was no significant difference in the overall complication rate between the RATG and LATG groups after PSM (23.8% vs. 28.6%, p = 0.390). Grade II complications accounted for most of the complications in the two cohorts after PSM. The conversion rates were 4.55 and 8.54% in the RATG and LATG groups, respectively, with no significant difference (p = 0.145), and the ratio of splenectomy were 1.59 and 0.39% (p = 0.253). The mortality rates were 0.8 and 0.4% for the RATG and LATG groups, respectively (p = 1.000).

CONCLUSION

This study demonstrates that RATG is comparable to LATG in terms of short-term surgical outcomes.

Circulating Levels of L1-cell Adhesion Molecule as a Serum Biomarker for Early Detection of Gastric Cancer and Esophagogastric Junction Adenocarcinoma

Background: Low serum L1 cell adhesion molecule (L1CAM) has been found in several malignant tumors. Here, we aimed to evaluate the diagnostic potential for serum L1CAM in patients with gastric cancers (GC) and esophagogastric junction adenocarcinoma (EJA). Methods: Enzyme-linked immunosorbent assay (ELISA) was carried out to detect L1CAM level in sera of 148 GC patients, 59 EJA patients and 148 healthy controls. Receiver operating characteristics (ROC) was employed to evaluate diagnostic accuracy. Results: The concentrations of serum L1CAM were significantly lower in GC and EJA than those in healthy controls (P<0.001). Detection of L1CAM provided a sensitivity of 83.1%, a specificity of 62.2%, and an area under the curve (AUC) of 0.769 (95% CI: 0.715-0.823) in diagnosing GC, and a sensitivity of 66.1%, a specificity of 62.2%, and an AUC of 0.672 (95% CI: 0.590-0.755) in diagnosing EJA. Similar results were observed in the diagnosis of early-stage GC (0.681 (95%CI: 0.596-0.766)) and early-stage EJA (0.674 (95%CI: 0.528-0.820)). Analysis of clinical data showed that the levels of L1CAM were significantly associated with lymph node metastasis in GC (P<0.05). Conclusions: Our study showed that serum L1CAM might be a diagnostic biomarker for GC and EJA.

Patterns of recurrence in adenocarcinoma of the esophagogastric junction: a retrospective study

Background

The prognosis of adenocarcinoma of the esophagogastric junction (AEG) is poor. Understanding the postoperative recurrence pattern of AEG is helpful to verify the effectiveness of treatment and optimize subsequent treatment, so as to improve prognosis.

Methods

This single-center retrospective study included patients with stage III AEG who underwent surgical treatment between January 2009 and December 2016. According to the different postoperative treatment arm, patients were divided into surgery and surgery plus chemotherapy groups. Recurrence-free survival was used as the outcome to compare the recurrence site and pattern between the groups.

Results

In total, were 306 patients enrolled, 123 in the surgery group and 183 in the surgery plus chemotherapy group. During follow-up (median 17.1 months) of 24 months after surgery, 62.0% of patients had tumor recurrence. The overall recurrence rates in the surgery and surgery plus chemotherapy groups were 86.9% and 77.0%, respectively. The recurrence patterns of both groups were mainly distant metastasis. Postoperative chemotherapy reduced the incidence of hematogenous dissemination from 51.2 to 42.0%. Multivariate Cox analysis showed that the pN stage increased the risk of recurrence, while surgery plus chemotherapy reduced the risk.

Conclusions

Patients with AEG have a risk of hematogenous dissemination after surgery. Postoperative treatment arm and pN stage were independent risk factors in patients with AEG. Surgery plus chemotherapy can improve recurrence-free survival and reduce distant metastasis, but they do not have a beneficial role in controlling local recurrence.

Esophageal Suspension Method for Hand-Sewn Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy: A Simple, Safe, and Feasible Suturing Technique

Background: Totally laparoscopic total gastrectomy (TLTG) not only is difficult to operate but also has high technical requirements and a long learning curve. Therefore, it has not been widely carried out yet, and esophagojejunostomy is one of its difficulties. Relevant studies have shown that intracorporeal hand-sewn esophagojejunostomy is safe, feasible and low-cost, but it is complicated and time-consuming and requires a high-suture technique. This study introduces a simple, safe and feasible hand-sewn technique. Methods: The clinical data of 32 patients with the esophageal suspension method for hand-sewn esophagojejunostomy (suspension group) after TLTG were collected from February 2018 to June 2019. During the same period, 32 patients with traditional hand-sewn esophagojejunostomy (traditional group) after TLTG were used as the control group. Results: The operative time, anastomosis time, exhaust time and hospitalization time of the suspension group were shorter than those of the traditional group. The intraoperative blood loss in the suspension group was less than that in the traditional group. There were no postoperative complications associated with the suspension group. Conclusion: For those who have some experience in laparoscopic suture technique, the esophageal suspension method for hand-sewn esophagojejunostomy after TLTG is a simple, safe, and feasible suture technique.

Laparoscopic versus open gastrectomy for Siewert type II/III adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

The potential advantages of laparoscopic gastrectomy (LG) compared with open gastrectomy (OG) for Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) have not been fully clarified. The aim of this meta-analysis was to evaluate the safety and efficacy of LG for Siewert type II/III AEG, compared with OG.

METHODS

A comprehensive search was performed in various medical databases up to December 30, 2018. Seven non-randomized controlled trials comparing LG and OG for Siewert type II/III AEG were included. Outcomes evaluated including operation time, estimated blood loss, number of retrieved lymph nodes (LNs), post-operation complications, postoperative hospital stay, time to first flatus, time to ambulation, and overall survival (OS).

RESULTS

Seven studies of 1915 patients were included for meta-analysis. The estimated blood loss [weighted mean difference (WMD) = - 77.49, 95%CI - 111.84 to - 43.15; P < 0.00001] was significantly less and the postoperative hospital stay (WMD = - 1.98, 95%CI - 2.14 to - 1.83; P < 0.00001) was significantly shorter in the LG group than in the OG group, while the operation time, number of retrieved LNs, time to first flatus, and time to ambulation showed no significant difference between LG and OG groups. The overall postoperative complications [odds ratio (OR) 0.78, 95%CI 0.60-1.02; P = 0.07] in LG group were less than those in OG group, although the difference was not significant between the two groups.

CONCLUSION

LG can achieve short-term surgical outcomes comparable to OG, with respect to safety and efficiency in treatment of Siewert type II/III AEG.

Preoperative Neutrophil Lymphocyte Ratio Can Be Used as a Predictor of Prognosis in Patients With Adenocarcinoma of the Esophagogastric Junction: A Systematic Review and Meta Analysis

Objective: Neutrophil lymphocyte ratio (NLR), Lymphocyte mononuclear cell ratio (LMR), and Platelet lymphocyte ratio (PLR) can be used as various prognostic factors for malignant tumors, but the value of prognosis for patients with adenocarcinoma of the esophagogastric junction (AEG) has not been determined. This study used meta-analysis to assess the value of these indicators in the evaluation of AEG prognosis. Methods: Relevant literatures on the prognostic relationship between NLR, LMR, PLR, and AEG was retrieved from PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials, Wanfang data, and Chinese National Knowledge Infrastructure. The search time from database establishment to June 30, 2019. The language is limited to English and Chinese. Data was analyzed using Stata 15.0 software. Result: Six retrospective studies were included, five of them involved NLR and six of them involved PLR. No LMR literature that adequately satisfied the conditions was retrieved. Increased NLR was significantly associated with a significant reduction in overall survival (OS), cancer-specific survival (CSS), or disease specific survival (DSS) in patients with AEG [hazard ratio (HR) = 1.545, 95% CI: 1.096-2.179, P < 0.05]. Subgroup analysis showed that NLR had significant value in the prognosis of both Chinese and Non-Chinese patients (P = 0.009 vs. P = 0.000). NLR had significant prognostic value for ≥3 and <3 groups (P = 0.022 vs. P = 0.000). NLR has a significant prognostic value for samples ≥500 and <500 (P = 0.000 vs. P = 0.022). NLR and OS/CSS/DSS single factor meta-regression showed that regional NLR cut-off values and sample size may be the source of heterogeneity in AEG patients (all P < 0.05). There was no significant association between elevated PLR and OS in patients with AEG (HR = 1.117, 95% CI: 0.960-1.300, P > 0.05). PLR had no significant prognostic value for both Chinese and UK patients (P = 0.282 vs. P = 0.429). PLR had no significant prognostic value for ≥150 group and <150 group (P = 0.141 and P = 0.724). No significant prognostic value was found in either the 300 group and <300 group (P = 0.282 vs. P = 0.429). Conclusion: Preoperative NLR rise was an adverse prognostic indicator of AEG. High-risk patients should be treated promptly. The results showed that PLR was not recommended as a prognostic indicator of AEG.

How to decide surgical procedure for esophagogastric junction cancer?

Standard surgical procedure for esophagogastric junction cancer, especially adenocarcinoma, has still remained controversial. Various procedures has been allowed and applied for Siewert type II tumors. Negative long resection margin had been regarded as essential in decision on the procedure. Recent papers have, however, shown the priority of invasion length to each side (esophagus and stomach), because it relates the frequency and sites of lymph node metastasis to be dissected. And, the size of remnant stomach is, also, important when a proximal gastrectomy is considered.

The Postoperative outcomes of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy for patients with adenocarcinoma of the esophagogastric junction

OBJECTIVES

Adenocarcinoma of the esophagogastric junction (AEG) is one of the most aggressive and poor prognosis cancers. To date, no standard procedures have been established for the surgical treatment of Siewert type II. In this study, we proposed the approach of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy (TLILD2) and aimed to investigate the patterns of lymph node metastasis and long-term survival.

METHODS

From June 2015 to June 2018, 72 patients accepted TLILD2 and enrolled in this study. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method and compared by log-rank tests.

RESULTS

There was no case of postoperative death in this study, and the most common complication was anastomotic mediastinal fistula (5/72, 6.9%). A total of 2811 lymph nodes were retrieved, and the positivity rate was 11.9% (334/2811). The positivity rate of celiac and mediastinal lymph nodes was 14.4% (314/2186) and 3.2% (20/625), respectively. The percentage of patients who had positive celiac and mediastinal lymph nodes reached up to 58.3% (42/72) and 8.3% (6/72), respectively. The DFS and DSS of these 72 patients were 94% and 93.4% at 1 year after surgery and 59.8% and 62% at 3 years after surgery, respectively. The pTNM stage showed a significant difference between DFS and DSS.

CONCLUSIONS

TLILD2 could be a potential way to promote long-term survival of AEG patients. On the basis of the patterns of lymph nodes metastasis, we suggest that lower mediastinal and D2 celiac lymphadenectomy is necessary to improve the oncological outcome.

The Application of Spleen-Preserving Splenic Regional Laparoscopic Lymphadenectomy with Spleen Kept In Situ and Laparotomy with Spleen Lifted Out of the Abdomen for Locally Advanced Proximal Gastric Cancer: A Retrospective Study

Background and Purpose

Findings whether laparoscopic lymphadenectomy with spleen kept in situ or laparotomy with spleen lifted out of the abdomen is more effective remain inconclusive. This study is aimed at comparing outcomes of spleen-preserving splenic regional laparoscopic lymphadenectomy with spleen kept in situ versus laparotomy with spleen lifted out of the abdomen for locally advanced proximal gastric cancer.

Methods

Data from patients with locally advanced proximal gastric cancer were collected from January 2011 to January 2014. A total of 246 patients were identified who received D2 radical total gastrectomy together with spleen-preserving splenic regional lymphadenectomy. Of those patients, 87 patients underwent laparoscopic splenic regional lymphadenectomy with spleen kept in situ (LSKS-SRLA) and 159 patients underwent laparotomy with spleen lifted out of the abdomen (LSLA-SRLA). Surgical outcomes and long-term outcomes were compared between the two groups.

Results

The total number of lymph node dissection, intraoperative blood loss volume, intraoperative injury cases, and postoperative complications had no statistically significant difference between the two groups. The number of splenic regional lymph node dissections was 3.90 ± 1.05 per case in the LSLA-SRLA group and 2.89 ± 1.04 in the LSKS-SRLA group. The operation time, length of the incision, and hospital days were shorter in the LSKS-SRLA group. The total recurrence and metastatic rates and 3-year cumulative survival rate had no statistically significant difference between the two groups.

Conclusions

Similar long-term outcomes were achieved in the LSKS-SRLA and LSLA-SRLA groups for locally advanced proximal gastric cancer. However, in the aspects of surgical time, length of incision, and postoperative recovery, the LSKS-SRLA group had obvious advantages.

Short-Term Surgical Outcomes of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction Versus Laparoscopic Total Gastrectomy for Adenocarcinoma of Esophagogastric Junction: A Matched-Cohort Study

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) is performed as a function-preserving surgery for patients with adenocarcinoma of esophagogastric junction. However, whether LPG with DTR has postoperative advantages over laparoscopic total gastrectomy (LTG) is debatable. To evaluate benefits of LPG with DTR, we compared short-term surgical outcomes between LPG with DTR and LTG for adenocarcinoma of esophagogastric junction (AEG).

METHODS

Twelve patients who underwent LPG with DTR for AEG between February 2016 and August 2017 were included. Twenty-four patients who underwent LTG in the same period were matched to LPG with DTR cases for demographics, comorbidities, tumor characteristics, and tumor node metastasis stage. Short-term surgical outcomes were compared between the two groups.

RESULTS

Demographics of the LPG with DTR group and LTG group were comparable. The number of harvested lymph nodes in the LPG with DTR group was less than that in the LTG group, and the amount of estimated blood loss, the operative time, the days of gas-passing, start of diet, postoperative hospital stay were not significantly different between the groups. Furthermore, the postoperative reflux symptom in the LPG with DTR group was not significantly different with that in the LTG group. However, the increasing percentages of the serum albumin, total protein, and hemoglobin levels in the LPG with DTR group were significantly higher than those in the LTG group.

CONCLUSIONS

This study reveals that LPG with DTR may be a valuable procedure for the treatment of AEG because it has the advantages over LTG in terms of postoperative serum albumin, total protein, and hemoglobin.