Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial

Gastrectomy with Extended Lymphadenectomy: a North American Perspective

PURPOSE

Despite evidence of oncologic benefits from extended (D2) lymphadenectomy in gastric cancer from many East Asian studies, there is persistent debate over its use in the West, mainly due to perceived high rates of morbidity and mortality. This study evaluates the safety and efficacy of D2 dissection in a high-volume North American center.

METHODS

A prospectively entered database of all patients undergoing gastrectomy for cancer at a North American referral center from 2005 to 2016 was reviewed. Wedge resections, thoracoabdominal approach, emergency surgery, palliative operations, and non-adenocarcinoma cases were excluded.

RESULTS

Of 366 non-bariatric gastrectomies over this period, 175 met the inclusion criteria. Median age was 73 years and 69% were male. One hundred forty-one patients (80%) underwent D2 dissection, the rest having D1. There was no difference in postoperative complications (D1 = 44%: D2 = 42%), anastomotic leaks (D1 = 6%: D2 = 5%), and same-admission or 30-day mortality (D1 = 6%: D2 = 2%). D2 dissection was associated with higher pathological stage (72% > stage 1 vs 38% > stage 1; p < 0.05) and median lymph node yield (30 vs 14; p < 0.05), with no difference in complete resection (R0) rate (D1 = 98% vs D2 = 92%). Laparoscopic approach was employed in 34% (45/141) of D2 cases, resulting in shorter median length of stay (6 days vs 9; p < 0.05) and equivalent oncologic outcomes compared to open D2.

CONCLUSION

This study supports the use of D2 lymphadenectomy, by either open or laparoscopic approach, in high-volume North American centers as a safe and effective oncologic procedure for gastric cancer, with equivalent complication rates and superior lymph node yield to traditional D1 dissection.

Adjuvant chemoradiation for gastric carcinoma: State of the art and perspectives

An estimated 990,000 new cases of gastric cancer are diagnosed worldwide each year. Surgical excision, the only chance for prolonged survival, is feasible in about 20% of cases. Even after surgery, the median survival is limited to 12 to 20 months due to the frequency of locoregional and/or metastatic recurrences. This led to clinical trials associating surgery with neoadjuvant or adjuvant treatments to improve tumor control and patient survival. The most studied modalities are perioperative chemotherapy and adjuvant chemoradiotherapy. To date, evidence has shown a survival benefit for postoperative chemoradiotherapy and for perioperative chemotherapy. Phase III trials are ongoing to compare these two modalities. The aim of this review is to synthesize current knowledge about adjuvant chemoradiotherapy in the management of gastric adenocarcinoma, and to consider its prospects by integrating modern radiotherapy techniques.

Efficacy of Adjuvant S-1 Versus XELOX Chemotherapy for Patients with Gastric Cancer After D2 Lymph Node Dissection: A Retrospective, Multi-Center Observational Study

BACKGROUND

After curative resection of gastric cancer with D2 lymph node dissection, postoperative adjuvant chemotherapy with S-1 or capecitabine plus oxaliplatin (XELOX) is considered to be standard therapy in Eastern countries. This study aimed to compare the efficacies of adjuvant S-1 and XELOX chemotherapy for gastric cancer patients after D2 dissection based on disease-free survival (DFS).

METHODS

This retrospective observational study was conducted at 29 tertiary hospitals in Korea. Of 1898 patients who underwent curative resection and received adjuvant chemotherapy for gastric cancer between February 2012 and December 2013, 1088 patients who met the eligibility criteria were enrolled in the study. After propensity score-matching, the 3-year disease-free survival rate (DFS) was used to compare efficacies directly between adjuvant XELOX and S-1 chemotherapies for patients with stage 2 or 3 gastric cancer after D2 gastrectomy.

RESULTS

The 3-year DFS rates for the S-1 and XELOX groups did not differ significantly among disease stages 2A, 2B, and 3A (all p > 0.05). However, the survival rates for the S-1 group were significantly lower than for the XELOX group for stage 3B (65.8% vs. 68.6%; p = 0.019) and stage 3C (48.4% vs. 66.7%; p = 0.002) gastric cancer. The hazard ratios (HRs) of S-1 chemotherapy for recurrence compared with XELOX for stages 3B and 3C were respectively 2.030 [95% confidence interval (CI), 1.110-3.715; p = 0.022] and 2.732 (95% CI 1.427-5.234; p = 0.002).

CONCLUSIONS

Adjuvant XELOX chemotherapy was more effective than S-1 for patients with stage 3B or 3C gastric cancer after D2 lymph node dissection.

Surgical morbidity and mortality after neoadjuvant chemotherapy in the CRITICS gastric cancer trial

BACKGROUND

In order to determine the optimal combination of perioperative chemotherapy and chemoradiotherapy for Western patients with advanced resectable gastric cancer, the international multicentre CRITICS trial (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) was initiated. In this trial, patients with resectable gastric cancer were randomised before start of treatment between adjuvant chemotherapy or adjuvant chemoradiotherapy following neoadjuvant chemotherapy plus gastric cancer resection. The purpose of this study was to report on surgical morbidity and mortality in this trial, and to identify factors associated with surgical morbidity.

METHODS

Patients who underwent a gastrectomy with curative intent were selected. Logistic regression analyses were used to assess risk factors for developing postoperative complications.

RESULTS

Between 2007 and 2015, 788 patients were included in the CRITICS trial, of whom 636 patients were eligible for current analyses. Complications occurred in 296 patients (47%). Postoperative mortality was 2.2% (n = 14). Complications due to anastomotic leakage was cause of death in 5 patients. Failure to complete preoperative chemotherapy (OR = 2.09, P = 0.004), splenectomy (OR = 2.82, P = 0.012), and male sex (OR = 1.55, P = 0.020) were associated with a greater risk for postoperative complications. Total gastrectomy and oesophago-cardia resection were associated with greater risk for morbidity compared with subtotal gastrectomy (OR = 1.88, P = 0.001 and OR = 1.89, P = 0.038).

CONCLUSION

Compared to other Western studies, surgical morbidity in the CRITICS trial was slightly higher whereas mortality was low. Complications following anastomotic leakage was the most important factor for postoperative mortality. Important proxies for developing postoperative complications were failure to complete preoperative chemotherapy, splenectomy, male sex, total gastrectomy, and oesophago-cardia resection.

Effect of total number of harvested lymph nodes on survival outcomes after curative resection for gastric adenocarcinoma: findings from an eastern high-volume gastric cancer center

BACKGROUND

Greater lymph node retrieval in gastric cancer improves staging accuracy and may improve survival from increased clearance of nodal micrometastasis. This retrospective cohort study investigated if more lymph nodes removed in gastric cancer increases survival and if such effect is stage-specific due to differential risks of nodal micrometastasis and systemic disease.

METHODS

The prospectively collected database of curatively resected gastric cancer patients in National Cancer Center, South Korea between 2000 and 2009 was reviewed. Disease-free survival (DFS) and overall survival (OS) for all patients and for each stage according to number of lymph nodes examined (1-30, 31-45, > 45) were analyzed.

RESULTS

Of 4049 patients, 96.6% and 98.4% underwent D2 (perigastric and extragastric) lymphadenectomy and had ≥ 15 lymph nodes examined. Mean number of nodes examined was 43. Five-year OS & DFS rates were 83.3% and 80.7%. Patients with > 45 nodes examined had significantly lower DFS (p = 0.002) and OS (p = 0.007) compared to those with 1-30 and 31-45 nodes. However, proportion of patients with > 45 nodes examined increased with stage (p = 0.0005). Per stage, there was no significant difference in DFS and OS according to number of nodes examined except for stage IIIA favoring more nodes (p = 0.018 and p = 0.044, respectively). Similar trend was seen in stage IIB. Number of examined nodes positively correlated with number of pathologic nodes for all patients (r = 0.144, p < .001) but not for stage IIB and IIIA. Number of nodes examined was a significant survival predictor in stage IIIA.

CONCLUSION

Greater lymph node harvest showed improved survival in intermediate-stage gastric cancer.

Predictors of 30-day readmissions after gastrectomy for malignancy

BACKGROUND

The objective of this study is to identify risk factors associated with readmission after gastrectomy to potentially identify potential areas for targeted improvements. Hospital readmission after surgery is a topic of interest in health-care policy among hospitals, payers, and providers. Readmissions are associated with increased costs, morbidity, and mortality. Readmission rates have been proposed as a quality metric for hospitals and quality indicator of individual surgeon's performance. In addition, the Centers for Medicare and Medicaid Services has reduced payments to hospitals with excessive readmissions for certain diagnoses.

MATERIALS AND METHODS

All gastrectomy procedures for malignancy in patients aged ≥18 y from 2005 to 2011 were queried from the California State Inpatient Database. Patients who died during index admission were excluded. Descriptive statistics were examined between all baseline variables and readmission status. Logistic regression models were adjusted for age, race, sex, and insurance status.

RESULTS

A total of 6985 patients underwent gastrectomy for malignancy; 16.5% of the patients were readmitted after postoperative discharge. Readmission rate did not change significantly over time. Multivariable analysis demonstrated that the occurrence of any postoperative complications, postoperative length of stay greater than 10 d, discharge to skilled nursing facility or home health care, combined resection with distal pancreatectomy and/or splenectomy, and patient comorbidities like diabetes mellitus and renal failure were independently associated with readmissions.

CONCLUSIONS

The findings suggest that focusing on quality improvement efforts by targeting reduction of postoperative complications may reduce readmission rates.

Greater Lymph Node Retrieval Improves Survival in Node-Negative Resected Gastric Cancer in the United States

PURPOSE

Guidelines in western countries recommend retrieving ≥15 lymph nodes (LNs) during gastric cancer resection. This study sought to determine whether the number of examined lymph nodes (eLNs), a proxy for lymphadenectomy, effects survival in node-negative disease.

MATERIALS AND METHODS

The US National Cancer Database (2003-2011) was reviewed for node-negative gastric adenocarcinoma. Treatment was categorized by neoadjuvant therapy (NAT) vs. initial resection, and further stratified by eLN. Kaplan-Meier and Weibull models were used to analyze overall survival.

RESULTS

Of the 1,036 patients who received NAT, 40.5% had ≤10 eLN, and most underwent proximal gastrectomy (67.8%). In multivariate analysis, greater eLN was associated with improved survival (eLN 16-20: HR, 0.71; P=0.039, eLN 21-30: HR, 0.55; P=0.001). Of the 2,795 patients who underwent initial surgery, 42.5% had ≤10 eLN, and the majority underwent proximal gastrectomy (57.2%). In multivariate analysis, greater eLN was associated with improved survival (eLN 11-15: HR, 0.81; P=0.021, eLN 16-20: HR, 0.73; P=0.004, eLN 21-30: HR, 0.62; P<0.001, and eLN >30: HR, 0.58; P<0.001).

CONCLUSIONS

In the United States, the majority of node-negative gastrectomies include suboptimal eLN. In node-negative gastric cancer, greater LN retrieval appears to have therapeutic and prognostic value, irrespective of initial treatment, suggesting a survival benefit to meticulous lymphadenectomy.

Adjuvant Chemoradiotherapy With Epirubicin, Cisplatin, and Fluorouracil Compared With Adjuvant Chemoradiotherapy With Fluorouracil and Leucovorin After Curative Resection of Gastric Cancer: Results From CALGB 80101 (Alliance)

Purpose After curative resection of gastric or gastroesophageal junction adenocarcinoma, Intergroup Trial 0116 (Phase III trial of postoperative adjuvant radiochemotherapy for high risk gastric and gastroesophageal junction adenocarcinoma: Demonstrated superior survival for patients who received postoperative chemoradiotherapy with bolus fluorouracil (FU) and leucovorin (LV) compared with surgery alone. CALGB 80101 (Alliance; Phase III Intergroup Trial of Adjuvant Chemoradiation After Resection of Gastric or Gastroesophageal Adenocarcinoma) assessed whether a postoperative chemoradiotherapy regimen that replaced FU plus LV with a potentially more active systemic therapy could further improve overall survival. Patients and Methods Between April 2002 and May 2009, 546 patients who had undergone a curative resection of stage IB through IV (M0) gastric or gastroesophageal junction adenocarcinoma were randomly assigned to receive either postoperative FU plus LV before and after combined FU and radiotherapy (FU plus LV arm) or postoperative epirubicin, cisplatin, and infusional FU (ECF) before and after combined FU and radiotherapy (ECF arm). Results With a median follow-up duration of 6.5 years, 5-year overall survival rates were 44% in the FU plus LV arm and 44% in the ECF arm ( P_logrank = .69; multivariable hazard ratio, 0.98; 95% CI, 0.78 to 1.24 comparing ECF with FU plus LV). Five-year disease-free survival rates were 39% in the FU plus LV arm and 37% in the ECF arm ( P_logrank = .94; multivariable hazard ratio, 0.96; 95% CI, 0.77 to 1.20). In post hoc analyses, the effect of treatment seemed to be similar across all examined patient subgroups. Conclusion After a curative resection of gastric or gastroesophageal junction adenocarcinoma, postoperative chemoradiotherapy using a multiagent regimen of ECF before and after radiotherapy does not improve survival compared with standard FU and LV before and after radiotherapy.

Modified vs. standard D2 lymphadenectomy in distal subtotal gastrectomy for locally advanced gastric cancer patients under 70 years of age

The present study was conducted to investigate the prognosis and survival of patients with locally advanced gastric cancer who underwent distal subtotal gastrectomy with modified D2 (D1+) and D2 lymphadenectomy, under 70 years of age. The five-year overall survival rates of 390 patients were compared between those receiving D1+ and D2 lymphadenectomy. Univariate and multivariate analyses were used to identify factors that correlated with prognosis and lymph node metastasis. Tumor size (P=0.039), pT stage (P=0.011), pN stage (P<0.001), and lymphadenectomy (P=0.004) were identified as independent prognostic factors. Furthermore, tumor size (P=0.022), pT stage (P=0.012), and lymphadenectomy (P=0.028) were proven as independent factors predicting lymph node metastasis. In conclusion, cancers of larger size, higher pT stage, and with D1+ lymphadenectomy had a higher risk of lymph node metastasis. Standard D2 lymphadenectomy removes sufficient lymph nodes to improve staging accuracy and survival. Therefore, D2 lymphanectomy is recommended in distal subtotal gastrectomy for locally advanced gastric cancer, especially for cancers of larger size and higher pT stage.

The Effect of Neoadjuvant Chemoradiation on Anastomotic Leak and Additional 30-Day Morbidity and Mortality in Patients Undergoing Total Gastrectomy for Gastric Cancer

INTRODUCTION

In addition to increased perioperative morbidity, anastomotic leak following gastric resection for gastric cancer can have detrimental effects on overall and disease-free survival. The risk of anastomotic leak following neoadjuvant therapy remains unknown. The purpose of this study is to investigate the association of preoperative chemotherapy and radiation therapy with postoperative anastomotic leak and additional 30-day morbidity and mortality outcomes following total gastrectomy with reconstruction for gastric cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent total gastrectomy with reconstruction for gastric cancer from 2005 to 2012 were identified. Within the NSQIP database, anastomotic leak is captured as an organ space infection. The association of preoperative chemotherapy and radiation therapy with anastomotic leak and additional 30-day morbidity and mortality outcomes was investigated using chi-squared analysis, Fisher's exact test, and Student's t test.

RESULTS

A total of 1135 patients met inclusion criteria; 121 (10.7%) patients underwent preoperative chemotherapy within 30 days of surgery, and 53 (4.7%) patients underwent preoperative radiation therapy within 90 days of surgery. Neither preoperative chemotherapy nor radiation therapy was associated with an increased risk of anastomotic leak (p = 0.12 and p = 0.58, respectively). When compared to patients who did not undergo neoadjuvant therapy, patients who underwent either preoperative chemotherapy or radiation therapy did not experience a higher frequency of 30-day mortality (p = 0.41), cardiac (p = 0.49), wound (p = 0.76), renal (p = 0.13), septic (p = 0.55), or venous thromboembolism (p = 0.19) events and were significantly less likely to experience a pulmonary event (p = 0.02).

CONCLUSION

Neoadjuvant therapy prior to gastric resection for gastric cancer is not associated with an increased risk of anastomotic leak or other additional short-term morbidity or mortality.

The pattern of lymph node metastases in microsatellite unstable gastric cancer

BACKGROUND

Microsatellite instability (MSI) is one of the new groups of molecular divisions of gastric cancer (GC). The aim of this study was to investigate the pattern of lymph node metastasis according to MSI status.

METHODS

MSI analysis of 361 GC patients with information about lymph node stations was performed using 5 quasimonomorphic mononucleotide repeats. The metastasis rates for each lymphatic station was analyzed, combined with clinicopathologic characteristics. Stations were divided into compartments 1-3 on the basis of Japanese Classification. A median number (interquartile range, IQR) of 33 (18-50) lymph nodes were removed and analyzed.

RESULTS

N0 status was observed in 53.7% MSI patients, and in 29.7% microsatellite stable (MSS) (p < 0.001).The median value of involved nodes was 1 in MSI vs. 5 in MSS (p < 0.001). Furthermore, the number of involved node stations was significantly lower in the MSI group (p < 0.001). MSS tumors showed a higher propensity to spread to second and third compartment nodes. In absence of lymphovascular invasion only 3.2% cases demonstrated positive nodes beyond the first compartment. Skip metastases were seen in 6.1% MSS patients and 0% MSI (p = 0.011). No difference in the 10-year cancer related survival among MSI and MSS patients was found, for both those with 1st compartment (p = 0.223) and with 2nd compartment involvement (p = 0.814).

CONCLUSIONS

MSI GC shows a high rate of N0 stage, a lower number of lymph node metastases, and a less extensive spread to lymph node stations than MSS tumors. These data indicate that tailored lymphadenectomy may be investigated for these patients.

Treatment of localized gastric and gastroesophageal adenocarcinoma: the role of accurate staging and preoperative therapy

Gastric cancer is the third most common cause of cancer death worldwide, although it is not in the top 10 causes of cancer death in Northern America. Due to clear differences in incidence, screening, risk factors, tumor biology, and treatment between gastric cancers from Eastern and Western countries, our treatment is primarily guided by trials from Western countries. Patients undergo an extensive staging evaluation including high-quality CT imaging, endoscopic ultrasound, and diagnostic laparoscopy with peritoneal washings for cytology. Patients are presented in multidisciplinary conference with input from medical, radiation, and surgical oncology, in addition to further evaluation of existing studies and biopsy results by diagnostic radiology and pathology colleagues. Due to the well-documented difficulty in tolerating postoperative therapy, patients are frequently treated with preoperative chemotherapy and chemoradiotherapy. Extended lymph node (D2) dissection is routinely performed during subtotal or total gastrectomy. Ongoing trials in Western populations comparing preoperative chemotherapy to chemoradiotherapy will help inform the decision regarding the optimal treatment for patients with resectable gastric cancer. Additional studies are needed to identify predictors of treatment response to identify the optimal preoperative or perioperative approach. As peritoneal disease is the most common site of recurrence, studies are also urgently needed for more accurate methods of detecting peritoneal disease at diagnosis, and also investigating potential treatment modalities such as hyperthermic intraperitoneal chemotherapy.

Gastric Adenocarcinoma: A Multimodal Approach

Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies.

Huang's three-step maneuver shortens the learning curve of laparoscopic spleen-preserving splenic hilar lymphadenectomy

BACKGROUND

The goal of this study was to investigate the difference between the learning curves of different maneuvers in laparoscopic spleen-preserving splenic hilar lymphadenectomy for advanced upper gastric cancer.

METHODS

From January 2010 to April 2014, 53 consecutive patients who underwent laparoscopic spleen-preserving splenic hilar lymphadenectomy via the traditional-step maneuver (group A) and 53 consecutive patients via Huang's three-step maneuver (group B) were retrospectively analyzed.

RESULTS

No significant difference in patient characteristics were found between the two groups. The learning curves of groups A and B were divided into phase 1 (1-43 cases and 1-30 cases, respectively) and phase 2 (44-53 cases and 31-53 cases, respectively). Compared with group A, the dissection time, bleeding loss and vascular injury were significantly decreased in group B. No significant differences in short-term outcomes were found between the two maneuvers. The multivariate analysis indicated that the body mass index, short gastric vessels, splenic artery type and maneuver were significantly associated with the dissection time in group B. No significant difference in the survival curve was found between the maneuvers.

CONCLUSIONS

The learning curve of Huang's three-step maneuver was shorter than that of the traditional-step maneuver, and the former represents an ideal maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy.To shorten the learning curve at the beginning of laparoscopic spleen-preserving splenic hilar lymphadenectomy, beginners should beneficially use Huang's three-step maneuver and select patients with advanced upper gastric cancer with a body mass index of less than 25 kg/m² and the concentrated type of splenic artery.

Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA?

BACKGROUND

Gastric cancer remains a formidable treatment challenge. For decades, treatment consisted mostly of surgical intervention for this deadly disease. With improvements in the multi-disciplinary management of solid organ malignancies, the approach to this disease is being stepwise refined.

MAIN BODY

One of the prevalent controversies in the surgical management of gastric cancer rests on the need for adequate harvesting of lymph nodes. For decades, lymph node dissection is regarded as a staging technique useful in only upstaging the disease. The adoption of D2 lymphadenectomy has been particularly slow to mature. But with prevailing data from Asia consistently demonstrating a survival benefit from lymphadenectomy, it calls into question the notion of lymphadenectomy as being solely a staging procedure.

CONCLUSIONS

As gastric resection techniques are being better defined in western countries and surgical morbidities lowered on its execution, D2 lymphadenectomy is becoming more accepted as the new standard in the management of gastric cancer.

Current trends in multimodality treatment of esophageal and gastroesophageal junction cancer - Review article

PURPOSE

Multimodality treatment has now been widely introduced in the curatively intended treatment of esophageal and gastroesophageal junction cancer. We aim to give an overview of the scientific evidence for the available treatment strategies and to describe which trends that are currently developing.

METHODS

We conducted a review of the scientific evidence for the different curatively intended treatment strategies that are available today. Relevant articles of randomized controlled trials, cohort studies, and meta analyses were included.

RESULTS

After a systematic search of relevant papers we have included 64 articles in the review. The results show that adenocarcinomas and squamous cell carcinomas of the esophagus and gastroesophageal junction are two separate entities and should be analysed and studied as two different diseases. Neoadjuvant treatment followed by surgical resection is the gold standard of the curatively intended treatment today. There is no scientific evidence to support the use of chemoradiotherapy over chemotherapy in the neoadjuvant setting for esophageal or junctional adenocarcinoma. There is reasonable evidence to support definitive chemoradiotherapy as a treatment option for squamous cell carcinoma of the esophagus.

CONCLUSION

The evidence base for curatively intended treatments of esophageal and gastroesophageal junction cancer is not very strong. Several on-going trials have the potential to change the gold standard treatments of today.

Status and Prospects of Robotic Gastrectomy for Gastric Cancer: Our Experience and a Review of the Literature

Since the first report of robotic gastrectomy, experienced laparoscopic surgeons have used surgical robots to treat gastric cancer and resolve problems associated with laparoscopic gastrectomy. However, compared with laparoscopic gastrectomy, the superiority of robotic procedures has not been clearly proven. There are several advantages to using robotic surgery for gastric cancer, such as reduced estimated blood loss during the operation, a shorter learning curve, and a larger number of examined lymph nodes than conventional laparoscopic gastrectomy. The increased operation time observed with a robotic system is decreasing because surgeons have accumulated experience using this procedure. While there is limited evidence, long-term oncologic outcomes appear to be similar between robotic and laparoscopic gastrectomy. Robotic procedures have a significantly greater financial cost than laparoscopic gastrectomy, which is a major drawback. Recent clinical studies tried to demonstrate that the benefits of robotic surgery outweighed the cost, but the overall results were disappointing. Ongoing studies are investigating the benefits of robotic gastrectomy in more complicated and challenging cases. Well-designed randomized control trials with large sample sizes are needed to investigate the benefits of robotic gastrectomy compared with laparoscopic surgery.

Introduction of laparoscopic gastrectomy for gastric cancer in a Western tertiary referral centre: A prospective cost analysis during the learning curve

AIM

To evaluate the costs of the introduction of a laparoscopic surgery program for gastric cancer in a Western community training hospital and tertiary referral centre for gastric cancer surgery.

METHODS

All patients who underwent surgery for gastric cancer with curative intent in 2013 and 2014 were prospectively included. Primary outcomes were costs regarding surgery and hospital stay.

RESULTS

Laparoscopic gastrectomy was used in 52 patients [mean age 68 years (± 9, range 50 to 87)] and open gastrectomy was used in 25 patients [mean age 70 years (± 10, range 46 to 85)]. Mean costs (in euro’s) of surgical instrumentation were significantly higher for laparoscopic surgery: 2270 ± 670 vs 1181 ± 680 in the open approach (P < 0.001). Costs of theatre use were higher in the laparoscopic group: mean 3819 ± 865 vs 2545 ± 1268 in the open surgery (P < 0.001). Total costs of hospitalization (i.e., costs of surgery and admission) were not different between laparoscopic and open surgery, 8187 ± 4864 and 7673 ± 8064 respectively (P = 0.729). Mean length of hospital stay was 9 ± 12 d in the laparoscopic group vs 14 ± 14 d in the open group (P = 0.044).

CONCLUSION

The introduction of laparoscopic gastrectomy for gastric cancer coincided with higher costs for theatre use and surgical instrumentation compared to the open technique. Total costs were not significantly different due to shorter length of stay and less intensive care unit (ICU) admissions and shorter ICU stay in the laparoscopic group.

Institutional variation in short- and long-term outcomes after surgery for gastric or esophagogastric junction adenocarcinoma: correlative study of two randomized phase III trials (JCOG9501 and JCOG9502)

BACKGROUND

A critical issue in multicenter randomized trials focusing on surgical techniques is quality control, as the quality of the surgery usually varies widely if the procedure employed is complicated. Few studies have evaluated interinstitutional variation in randomized trials in order to check not only the generalizability of the results but also the reliability of the study group itself.

METHODS

Two randomized phase III trials (JCOG9501 and JCOG9502) were conducted that compared standard and experimental surgery for gastric and esophagogastric junction adenocarcinomas. Mixed effects models were used to examine short- and long-term outcome data for 521 patients from 23 hospitals in JCOG9501 and 157 patients from 21 hospitals in JCOG9502.

RESULTS

In both trials, some variation was observed in the number of dissected lymph nodes, the operative time, and the volume of blood lost. Estimated 5-year overall survival after standard surgery differed among hospitals (JCOG9501, 58.0-75.1 %; JCOG9502, 49.1-58.7 %), while there was little variation in the hazard ratio for overall survival (OS) for experimental versus standard surgery (JCOG9501, 1.05-1.48; JCOG9502, 1.44-1.48). Higher hospital gastrectomy volume was significantly correlated with a lower proportion of postoperative complications in JCOG9501 (ρ = -0.524, P = 0.010) and reduced blood loss in JCOG9502 (ρ = -0.442, P = 0.045). OS was not correlated with hospital or surgeon volume.

CONCLUSIONS

There was some degree of interinstitutional variation in outcomes after standard surgery, but there was little variation in the hazard ratio for OS for experimental surgery, indicating that the final conclusions of the two randomized phase III trials can be generalized to their respective target populations.

Gastric cancer treatment: similarity and difference between China and Korea

Chinese populations have many demographic similarities to Korean populations. However, the long-term survival rates of gastric cancer patients in China are still not satisfactory when compared with Korea, especially for the advanced cases. In this article, we discuss about the similarity and difference of gastric cancer treatment in terms of screening, surgical approach, stomach resection, digestive tract reconstruction, lymphadenectomy, harvested lymph nodes, operative morbidity and mortality, postoperative chemotherapy as well as follow-up between China and Korea. Given that a variety of factors ranging from tumor characteristics to different treatment strategies are seen between the two countries, the reasons accounting for the differences in survival should be focused and the corresponding strategy should be considered and finally promote to improve the prognosis of gastric cancer.

Surgical Considerations in the Management of Gastric Adenocarcinoma

Since Theodor Billroth and César Roux perfected the methods of postgastrectomy reconstruction in as early as the late nineteenth century, surgical management of gastric cancer has made incremental progress. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer seems to have settled in favor of D2 dissection. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers. Frozen section analysis of margins seems partially helpful in this direction. Last, the role of palliative gastrectomy in patients with metastatic seems less important than initially thought.

East Versus West: Differences in Surgical Management in Asia Compared with Europe and North America

In recent decades, there has been considerable worldwide progress in the treatment of gastric cancer. Gastrectomy with a modified D2 lymphadenectomy (sparing the distal pancreas and spleen) has increasingly gained acceptance as a preferable standard surgical approach among surgeons in the East and the West. Despite growing consensus significant differences still exist in surgical techniques in clinical trials and clinical practices secondary to variations in epidemiology, clinicopathologic features, and surgical outcomes among geographic regions. In addition, Western physicians tend to prefer adjuvant chemotherapy and radiotherapy after surgery instead of using S-1 chemotherapy, as is the preference in the East.

Association Between Waiting Time from Diagnosis to Treatment and Survival in Patients with Curable Gastric Cancer: A Population-Based Study in the Netherlands

Background

In the Netherlands, a maximum waiting time from diagnosis to treatment (WT) of 5 weeks is recommended for curative cancer treatment. This study aimed to evaluate the association between WT and overall survival (OS) in patients undergoing gastrectomy for cancer.

Methods

This nationwide study included data from patients diagnosed with curable gastric adenocarcinoma between 2005 and 2014 from the Netherlands Cancer Registry. Patients were divided into two groups: patients who received neoadjuvant therapy followed by gastrectomy, or patients who underwent gastrectomy as primary surgery. WT was analyzed as a categorical (≤5 weeks [Reference], 5–8 weeks, >8 weeks) and as a discrete variable. Multivariable Cox regression analysis was used to assess the influence of WT on OS.

Results

Among 3778 patients, 1701 received neoadjuvant chemotherapy followed by gastrectomy, and 2077 underwent primary gastrectomy. In the neoadjuvant group, median WT to neoadjuvant treatment was 4.6 weeks (interquartile range [IQR] 3.4–6.0), and median OS was 32 months. In the surgery group, median WT to surgery was 6.0 weeks (IQR 4.3–8.4), and median OS was 25 months. For both groups, WT did not influence OS (neoadjuvant: 5–8 weeks, hazard ratio [HR] 0.82, p = 0.068; >8 weeks, HR 0.85, p = 0.354; each additional week WT, HR 0.96, p = 0.078; surgery: 5–8 weeks, HR 0.91, p = 0.175; >8 weeks, HR 0.92, p = 0.314; each additional week WT, HR 0.99, p = 0.264).

Conclusions

Longer WT until the start of curative treatment for gastric cancer is not associated with worse OS. These results could help to put WT into perspective as indicator of quality of care and reassure patients with gastric cancer.

Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy

BACKGROUND

We sought to determine the sites of recurrence and identify predicting factors for recurrence and survival in patients who underwent gastrectomy for adenocarcinoma at an institution where preoperative therapy is commonly used for advanced gastric cancer.

METHODS

We collected clinicopathologic data and sites of recurrence from a prospectively maintained database of patients who underwent potentially curative resection of gastric or gastroesophageal adenocarcinoma at our institution in 1995-2014, and we assessed associations between these characteristics and recurrence patterns and survival.

RESULTS

We identified 488 patients who underwent R0 resection of localized gastric cancer. The median age was 63 years (interquartile range 53-71 years), and 60% were male. The most common T and N categories, per endoscopic ultrasonography, were T3 (58%) and N0 (61%). Preoperative treatment was used in 61% of patients. A total of 125 (26%) patients experienced recurrence during follow-up. Recurrences were locoregional in 19 patients (15%), peritoneal in 61 (49%), and nonperitoneal distant in 67 (54%). The peritoneum also was the most common organ of recurrence (49%), followed by the liver (21%). The median time from primary resection to recurrence was 2.7 years for locoregional, 1.3 years for peritoneal, and 0.6 years for nonperitoneal distant recurrence (p = 0.01). Median overall survival was markedly shorter after peritoneal and nonperitoneal distant recurrences than after locoregional recurrences.

CONCLUSIONS

The peritoneum was a common site of recurrence after curative resection of gastric cancer and was associated with poor survival. Prophylactic treatment targeting the peritoneal cavity might improve survival of advanced gastric cancer.

Patterns of Care for Radiotherapy in the Neoadjuvant and Adjuvant Treatment of Gastric Cancer: A Twelve-Year Nationwide Cohort Study in Korea

Purpose

Although Korea has the highest incidence of gastric cancer worldwide and D2-lymphadenectomies are routinely performed, radiotherapy (RT) practice patterns have not been well studied. Therefore, we examined RT usage trends for neoadjuvant/adjuvant patients and identified factors associated with RT. We also examined survival benefits and net medical cost advantages of adding RT.

Materials and Methods

Patients diagnosed with gastric cancer who underwent gastrectomy from 2002-2013 were identified using National Health Insurance Service-National Sample Cohort.

Results

Annually, 30.9 cases per 100,000 population in crude rate underwent gastrectomy in 230 hospitals and 49.8% received neoadjuvant/adjuvant therapy in 182 hospitals. For neoadjuvant/adjuvant patients, postoperative chemo-RT was administered in 4% of cases in 26 hospitals. No significant trends regarding treatment type were observed over time. Having undergone RT was inversely associated with being ≥ 60 years old and having a low income. Having undergone RT was positively related to having a Charlson comorbidity index ≥ 4, hospital location and hospital volume (≥ 2,000 beds). Significant portions of patients treated with RT in this nation (52%) were concentrated in one large-volume hospital. Use of RT linked to increased cost of primary treatment, yet not to reduced overall medical expense. RT did not influence both on overall and disease-specific survivals after adjusting for potential confounders (p > 0.05).

Conclusion

RT was uncommonly utilized as adjuvant or neoadjuvant treatment by physicians in Korea. Despite intrinsic drawback in this data, we did not find either survival benefit or net medical cost advantage by adding RT in adjuvant treatment.

A High Lymph Node Yield is Associated with Prolonged Survival in Elderly Patients Undergoing Curative Gastrectomy for Cancer: A Dutch Population-Based Cohort Study

Purpose

The aim of this study was to evaluate the influence of lymph node yield (LNY) on postoperative mortality and overall survival in elderly patients with gastric cancer.

Methods

This population-based study included data from The Netherlands Cancer Registry of patients who underwent curative gastrectomy for adenocarcinoma between 2006 and 2014. Patients were divided into two groups based on age (<75 years, young; ≥75 years, elderly). LNY was analyzed as both a categorical variable (low, <15 nodes; intermediate, 15–25 nodes; high, >25 nodes), and a discrete variable. Multivariable analysis was used to evaluate the influence of LNY on 30- and 90-day mortality, as well as overall survival.

Results

A total of 3764 patients were included in the study; 2387 (63%) were classified as ‘young’, and 1377 (37%) were classified as ‘elderly’. The median LNY was 14 in the young group, compared with 11 in the elderly group (p < 0.001). In the elderly group, 851 (62%) patients had a low LNY, 333 (24%) had an intermediate LNY, and 174 (13%) had a high LNY. Multivariable analysis demonstrated that in the elderly patients, a higher LNY was associated with a prolonged overall survival (low: reference; intermediate: hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.62–0.88, p < 0.001; high: HR 0.59, 95% CI 0.45–0.78, p < 0.001), but not with 30-day (p = 0.940) and 90-day mortality (p = 0.573). For young patients, these results were comparable.

Conclusion

In both young and elderly patients, a high LNY is associated with prolonged survival but not with an increase in postoperative mortality. Therefore, an extensive lymphadenectomy is the preferred strategy for all patients during gastrectomy in order to provide an optimal oncological result.

Differences in the multimodal treatment of gastric cancer: East versus west

There has been a great deal of interest about varying treatment paradigms of gastric cancer in Eastern and Western countries. Differences in tumor biology, screening initiatives, surgical approach, extent of lymphadenectomy, and neoadjuvant versus adjuvant chemotherapy regimens have been studied and documented in the literature. The purpose of this review is to give an updated report on the current status and management differences in the treatment of gastric cancer between Eastern and Western countries.

Distal gastrectomy versus total gastrectomy for distal gastric cancer

Even though more than a century later, after the first case of gastrectomy has been successfully performed, the best surgical treatment for distal gastric cancer still remains controversial. Thus, the present study was designed to compare the survival impact of distal (DG) or total gastrectomy (TG) for distal gastric cancer. A total of 1262 distal gastric cancer patients were enrolled in current study including 1157 patients who underwent DG and 157 patients who underwent TG. The postoperative complications and 5-year overall survival were compared between the 2 groups. TG group presented a longer surgical time, a higher volume of intraoperative bleeding, and a larger number of excised lymph nodes (all P < 0.05) compared with the DG group. The postoperative complications were comparable (all P >0.05). The 5-year overall survival rate of DG group was significantly higher than that of TG group (67.6% vs 44.3%, P < 0.001). However, multivariate analysis showed that type of resection was not an independent prognostic factor for distal gastric cancer (P > 0.05). The factor-stratified multivariate analysis showed that only in the subgroup of Tumor-node-metastasis staging system (TNM) stage III (P = 0.049), TG was the independent prognostic factor for poor survival. In conclusion, DG was as feasible as TG; however, TG did not increase the survival rate. DG brought better long-term survival than TG in patients with TNM stage III tumor. We recommended that DG should be the optimal surgical procedure for distal gastric cancer under the premise of negative resection margin.

Lymphadenectomy: state of the art

The extent of lymphadenectomy in gastric cancer (GC) surgery has been for long time a matter of debate. Randomized trials performed in the West reported worse results of D2 dissection, in terms of postoperative complications and long-term survival benefit, than Eastern series and observational studies from specialized Western centers. However, long-term re-evaluation of such trials and in depth-analysis of other experiences demonstrated the potential benefit of D2 in reducing the probability of cancer-related death and the safety of this procedure when avoiding unnecessary spleno-pancreatectomy and in centers with ad adequate surgical volume. Nowadays, the D2 is considered the standard treatment in most guidelines all over the world. More limited procedures (D1, D1 plus) may be adequate in selected cases, and more extended dissections (D2 plus) could be indicated in advanced forms with high risk of metastases to distant nodes, but in specialized centers or in the setting of clinical studies. The integration with neoadjuvant therapies and multimodality approach could offer a chance of cure in groups of patients with poor results when approached with standard treatment.

Equipping the 8th Edition American Joint Committee on Cancer Staging for Gastric Cancer with the 15-Node Minimum: a Population-Based Study Using Recursive Partitioning Analysis

BAKCGROUND

The recently proposed 8th American Joint Committee on Cancer (AJCC) staging for gastric cancer (GC) did not include the evaluated lymph node (ELN) count as a prognostic indicator. In this study, we performed recursive partitioning analysis (RPA) to objectively combine the 15-ELN threshold and 8th AJCC stage to refine the staging for GC.

METHODS

We analyzed 19,018 patients with non-metastatic GC from the Surveillance, Epidemiology, and End Results database. The dataset was randomly divided into training and validation sets.

RESULTS

For each 8th AJCC stage, survival was significantly better for patients with ≥15 ELNs versus those with <15 ELNs (P < 0.001 for all). RPA divided non-metastatic GC into seven stages: RPA-IA (8th AJCC IA with ≥15 ELNs), RPA-IB (IA with <15 ELNs and IB/IIA with ≥15 ELNs), RPA-IIA (IB with <15 ELNs and IIB with ≥15 ELNs), RPA-IIB (IIA with <15 ELNs and IIIA with ≥15 ELNs), RPA-IIIA (IIB with <15 ELNs), RPA-IIIB (IIIA with <15 ELNs and IIIB ≥15 ELNs), and RPA-IIIC (IIIB with <15 ELNs and IIIC). The corresponding 5-year survival rates were 84.1, 70.3, 52.8, 41.4, 32.9, 21.7, and 10.2%, respectively (P < 0.001 for all pairwise comparisons). The RPA staging outperformed the 8th AJCC staging in terms of discrimination and homogeneity among the SEER training and validation sets, as well as an independent Chinese cohort.

CONCLUSION

By equipping the 8th AJCC stage with the 15-ELN threshold, the proposed RPA staging is superior to the 8th AJCC staging without overcomplicating.

Adjuvant capecitabine plus oxaliplatin after D2 gastrectomy in Japanese patients with gastric cancer: a phase II study

BACKGROUND

Adjuvant chemotherapy with XELOX (capecitabine plus oxaliplatin) has been shown to be beneficial following resection of gastric cancer in South Korean, Chinese, and Taiwanese patients. This phase II study (J-CLASSIC-PII) was undertaken to evaluate the feasibility of XELOX in Japanese patients with resected gastric cancer.

METHODS

Patients with stage II or III gastric cancer who underwent curative D2 gastrectomy received adjuvant XELOX (eight 3-week cycles of oral capecitabine, 1000 mg/m² twice daily on days 1-14, plus intravenous oxaliplatin 130 mg/m² on day 1). The primary endpoint was dose intensity. Secondary endpoints were safety, proportion of patients completing treatment, and 1-year disease-free survival (DFS) rate.

RESULTS

One hundred patients were enrolled, 76 of whom completed the study as planned. The mean dose intensity was 67.2 % (95 % CI, 61.9-72.5 %) for capecitabine and 73.4 % (95 % CI, 68.4-78.4 %) for oxaliplatin, which were higher than the predefined age-adjusted threshold values of 63.4 % and 69.4 %, respectively, and the study therefore met its primary endpoint. The 1-year DFS rate was 86 % (95 % CI, 77-91 %). No new safety signals were identified.

CONCLUSIONS

The feasibility of adjuvant XELOX in Japanese patients with resected gastric cancer is similar to that observed in South Korean, Chinese, and Taiwanese patients in the Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer (CLASSIC) study. Based on findings from this study and the CLASSIC study, the XELOX regimen can be considered an adjuvant treatment option for Japanese gastric cancer patients who have undergone curative resection.

The Ratio-Based N Staging System Can More Accurately Reflect the Prognosis of T4 Gastric Cancer Patients with D2 Lymphadenectomy Compared with the 7th American Joint Committee on Cancer/Union for International Cancer Control Staging System

PURPOSE

The utility of N classification has been questioned after the 7th edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) was published. We evaluated the correlation between ratio-based N (rN) classification with the overall survival of pathological T4 gastric cancer patients who underwent D2 lymphadenectomy.

MATERIALS AND METHODS

We reviewed 222 cases of advanced gastric cancer patients who underwent curative gastrectomy between January 2006 and December 2015. The T4 gastric cancer patents were classified into four groups according to the lymph node ratio (the number of metastatic lymph nodes divided by the retrieved lymph nodes): rN0, 0%; rN1, ≤13.3%; rN2, ≤40.0%; and rN3, >40.0%.

RESULTS

The rN stage showed a large down stage migration compared with pathological T4N3 (AJCC/UICC). There was a significant difference in overall survival between rN2 and rN3 groups in patients with pT4N3 (P=0.013). In contrast, the difference in metastatic lymph nodes was not significant in these patients (≥16 vs. <15; P=0.177). In addition, the rN staging system showed a more distinct difference in overall survival than the pN staging system for pathological T4 gastric cancer patients.

CONCLUSIONS

Our results confirm that rN staging could be a good alternative for pathological T4 gastric cancer patients who undergo D2 lymphadenectomy. However, before applying this system to gastric cancer patients who undergo D2 lymphadenectomy, a larger sample size is required to further evaluate the usefulness of the rN staging system for all stages, including less advanced stages.

Does a Higher Cutoff Value of Lymph Node Retrieval Substantially Improve Survival in Patients With Advanced Gastric Cancer?-Time to Embrace a New Digit

BACKGROUND

The present study assessed the impact of the retrieval of >25 lymph nodes (LNs) on the survival outcome of patients with advanced gastric cancer after curative-intent gastrectomy.

PATIENTS AND METHODS

A total of 5,386 patients who had undergone curative gastrectomy for gastric cancer from 1994 to 2011 were enrolled. The clinicopathological parameters and overall survival (OS) were analyzed according to the number of LNs examined (≤15, n = 916; 16-25, n = 1,458; and >25, n = 3,012).

RESULTS

The percentage of patients with >25 LNs retrieved increased from 1994 to 2011. Patients in the LN >25 group were more likely to have undergone total gastrectomy and to have a larger tumor size, poorer tumor differentiation, and advanced T and N stages. Hospital mortality among the LN ≤15, LN 16-25, and LN >25 groups was 6.1%, 2.7%, and 1.7%, respectively (p < .0001). The LN >25 group consistently exhibited the most favorable OS, in particular, with stage II disease (p = .011) when OS was stratified according to tumor stage. Similarly, the LN >25 group had significantly better OS in all nodal stages (from N1 to N3b). The discrimination power of the lymph node ratio (LNR) for the LN ≤15, LN 16-25, and LN >25 groups was 483, 766, and 1,560, respectively. Multivariate analysis demonstrated that the LNR was the most important prognostic factor in the LN >25 group.

CONCLUSION

Retrieving more than 25 lymph nodes during curative-intent gastrectomy substantially improved survival and survival stratification of advanced gastric cancer without compromising patient safety. The Oncologist 2017;22:97-106Implications for Practice: D2 lymph node (LN) dissection is currently the standard of surgical management of gastric cancer, which is rarely audited by a third party. The present study, one of the largest surgical series worldwide, has shown that the traditionally recognized retrieval of ≥16 LNs during curative-intent gastrectomy might not be adequate in regions in which locally advanced gastric cancers predominate. The presented data show that retrieval of >25 LNs, which more greatly mimics D2 dissection, improves long-term outcomes and survival stratification without compromising patient safety.

A novel scoring system associating with preoperative platelet/lymphocyte and clinicopathologic features to predict lymph node metastasis in early gastric cancer

BACKGROUND

Precise determination of the lymph node status is critical for determining appropriate treatment for early gastric cancer (EGC). This study attempted to establish a simple, effective risk scoring system to predict lymph node metastasis (LNM) in EGC by investigating the relationship between platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) and EGC LNM.

MATERIALS AND METHODS

We retrospectively reviewed 312 operable patients with EGC. The clinical utility of PLR and NLR was tested by receiver operating characteristic curves. The scoring system was developed using independent risk factors. Finally, 89 EGC patients were collected from prospective database to validate the scoring system's accuracy.

RESULTS

The optimal PLR and NLR cut-off values were 106 and 2.97, respectively. High NLR (P = 0.009) and PLR (P = 0.007) values were associated with LNM of EGC in univariate analyses, although only high PLR (P = 0.025) was an independent risk factor in multivariate analyses, together with age (P = 0.009), differentiation (P = 0.017), invasive depth (P < 0.001), and tumor size (P = 0.003). The scoring system's accuracy for retrospective and prospective data was 0.781 (95% confidence interval: 0.721-0.841) and 0.817 (95% confidence interval 0.714-0.920), respectively.

CONCLUSIONS

Preoperative PLR and NLR correlate with EGC LNM. Our scoring system is reliable, accurate, and effective in predicting LNM in EGC patients.

Long-Term Survival in Patients with Postoperative Intra-Abdominal Infectious Complications After Curative Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

BACKGROUND

It has been reported that postoperative complications after curative surgery for gastric cancer adversely affect long-term survival; however, postoperative complications may confound other patient characteristics or tumor factors associated with survival outcome. In the present study, covariates were adjusted by propensity score matching to clarify whether postoperative complications truly affect survival outcome.

METHODS

The present study was performed on 1541 patients who underwent curative gastrectomy for gastric cancer between 2002 and 2009. Patients were divided into two groups based on the occurrence (174 patients) or absence (1367 patients) of postoperative intra-abdominal infectious complications. Survival outcomes were compared between groups using propensity score matching analysis.

RESULTS

Most clinicopathological characteristics differed significantly between the two groups, but these differences disappeared after propensity score matching. After matching, overall survival was significantly poorer in patients with postoperative intra-abdominal infectious complications [hazard ratio (HR) 1.43, 95 % confidence interval (CI) 1.02-2.00; p = 0.036], as was relapse-free survival (HR 1.42, 95 % CI 1.03-1.96; p = 0.034).

CONCLUSIONS

Intra-abdominal infectious complications adversely affected survival outcome when patients were matched by propensity scores, which included demographic data as covariates. Thus, it is important to avoid the development of intra-abdominal infectious complications to improve long-term survival.

Potentially Curable Cancers of the Esophagus and Stomach

Gastric and gastroesophageal adenocarcinomas continue to be a major health burden globally and collectively represent the third leading cause of cancer death. Among patients with metastatic disease, most die of their cancer because of the limited number of modestly effective treatment regimens available today. The progress against these cancers has been slow compared with many other solid tumors despite many attempts. In-depth molecular profiling has also not been completed. Even when these cancers are localized, they impose considerable challenges for the patient, relatives, and treatment team alike. Localized gastric or gastroesophageal cancer is best managed with a multidisciplinary approach. This review focuses on the management of localized cancers by reviewing the current literature and explaining certain principles that help guide therapy for these patients. The future, however, will afford numerous opportunities, including exploitation of initial data from The Cancer Genome Atlas, to identify novel targets and drugs, harness the prowess of the immune system, and customize therapy for each patient.

Lymph nodes metastasis of gastric cancer: Measurement with multidetector CT oblique multiplanar reformation-correlation with histopathologic results

The aim of this study was to retrospectively evaluate the ability of multidetector computed tomography (MDCT) oblique multiplanar reformation (MPR) for differentiating metastatic lymph nodes (LNs) in patients with gastric cancer.Seventy-nine patients with gastric cancer underwent preoperative computed tomography (CT). One-to-one correlation of LN was made between CT oblique multiplanar reformation and histopathologic slides. Long diameters, short diameters, and short-to-long axis ratios of LNs were evaluated to differentiate metastasis.Short diameters of nodes performed better for diagnosing metastasis than long diameters and short-to-long ratios. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve of short diameter were 57.8%, 74.7%, 68.2%, and 0.713, respectively. With different thresholds of short diameters of nodes (No. 8 group >6 mm and other groups >4 mm), total sensitivity, specificity, and accuracy can reach 57.2%, 79.0%, and 70.3%, respectively.MDCT oblique MPR images have certain reference value to distinguish metastasis of LNs in gastric cancer. The diagnostic power for LN metastasis of gastric cancer can be improved by using different threshold for No. 8 group LNs and other groups.

Learning curve for gastric cancer patients with laparoscopy-assisted distal gastrectomy: 6-year experience from a single institution in western China

Laparoscopy-assisted distal gastrectomy (LADG) is widely used for gastric cancer (GC) patients nowadays. This study aimed to investigate the time trend of outcomes so as to describe the learning curve for GC patients with LADG at a single medical institution in western China over a 6-year period.A total of 246 consecutive GC patients with LADG were divided into 5 groups (group A: 46 patients from 2006 to 2007; group B: 47 patients in 2008; group C: 49 patients in 2009; group D: 73 patients in 2010; and group E: 31 patients in 2011). All surgeries were conducted by the same surgeon. Comparative analyses were successively performed by Mann-Whitney U test or Student t test among the 5 different groups for the clinical data, including clinicopathologic characteristics, surgical parameters, postoperative course, and survival outcomes, through which the learning curve was described.There were no differences in the baseline information among the 5 groups (P > 0.05), and the proportion of advanced GC patients with LADG slightly increased from 58.7% to 77.4% during the 6 years. Besides, the proportion of D2/D2+ lymphadenectomy and the number of retrieved lymph nodes gradually grew from 60.9% to 80.6% and from 20.0 to 28.8, respectively. In addition, the operation time decreased from 299.2 to 267.8 minutes, while the estimated blood loss dropped from 175.2 to 146.8 mL. Furthermore, some surgical parameters (surgical duration and blood loss) and postoperative course (such as postoperative complications, the time to ambulation, to first flatus, and to first liquid intake as well as the length of hospital stay) were all observed to be significantly different between group A and other groups (P < 0.05), illustrating a similar downward trend and remaining stable to form a plateau after 46 cases in group A. However, no difference on overall survival was found among these 5 groups, and multivariate analysis indicated that factors, such as age, tumor differentiation, tumor size, and T stage as well as N stage, were independent prognostic factors for patients with LADG.Improvement on surgical parameters and postoperative course can be seen over the past years, and the cutoff value of the learning curve of LADG for surgeons with rich experience in open operation might be 46 cases.

Outcomes of octogenarians undergoing gastrectomy performed for malignancy

BACKGROUND

Studies on perioperative outcomes of octogenarians with gastric cancer are limited by small sample size. Our aim was to determine the outcomes of gastrectomy and the variation of treatments associated with advanced age (≥80 y).

METHODS

The National Surgical Quality Improvement Program database was queried from 2005 to 2011. Patients who underwent gastrectomy for malignancy were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes.

RESULTS

Of 2591 cases, 487 patients were octogenarians (≥80) and 2104 were nonoctogenarians (<80). Overall, 4.9% of patients had disseminated cancer. Octogenarians had higher 30-d mortality (7.2% versus 2.5%, P < 0.01) and more major complications (31.4% versus 25.5%, P < 0.01), though fewer octogenarians underwent total gastrectomy (24.0% versus 43.2%, P < 0.01) and extended lymphadenectomy (10.1% versus 17.4%, P < 0.01) than the nonoctogenarian cohort. On multivariate analysis, age ≥80 y was associated with major complications (OR, 1.3; 95% CI, 1.03-1.6; P = 0.03) and increased mortality (OR, 3.0; 95% CI, 1.9-4.9; P < 0.01).

CONCLUSIONS

Advanced age (≥80 y) was associated with worse outcomes in patients undergoing gastrectomy for malignancy. Therefore, careful staging is necessary to reduce unnecessary operations in this population. Furthermore, surgeons must place greater attention on optimizing the octogenarian population before surgery.

Postoperative chemoradiotherapy versus chemotherapy for R0 resected gastric cancer with D2 lymph node dissection: an up-to-date meta-analysis

BACKGROUND

This meta-analysis aims to provide more evidence on the role of postoperative chemoradiotherapy (CRT) for gastric cancer (GC) patients in Asian countries where D2 lymphadenectomy is prevalent.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs), extracted data of survival and toxicities, and pooled data to evaluate the efficacy and toxicities of CRT compared with chemotherapy (CT) after D2 lymphadenectomy.

RESULTS

A total of 960 patients from four RCTs were selected. The results showed that postoperative CRT significantly reduced loco-regional recurrence rate (LRRR: RR = 0.50, 95 % CI = 0.34-0.74, P = 0.0005) and improved disease-free survival (DFS: HR = 0.73, 95 % CI = 0.60-0.89, P = 0.002). However, CRT did not affect distant metastasis rate (DMR: RR = 0.81, 95 % CI = 0.60-1.08, P = 0.15) and overall survival (OS: HR = 0.91, 95 % CI = 0.74-1.11, P = 0.34). The main grade 3-4 toxicities manifested no significant differences between the two groups.

CONCLUSIONS

Overall, CRT after D2 lymphadenectomy may reduce LRRR and prolong DFS. The role of postoperative CRT should be further investigated in the population with high risk of loco-regional recurrence.

Evolution of gastric surgery techniques and outcomes

Surgical management of gastric cancer improves survival. However, for some time, surgeons have had diverse opinions about the extent of gastrectomy. Researchers have conducted many clinical studies, making slow but steady progress in determining the optimal surgical approach. The extent of lymph node dissection has been one of the major issues in surgery for gastric cancer. Many trials demonstrated that D2 dissection resulted in greater morbidity and mortality than D1 dissection. However, long-term outcomes demonstrated that D2 dissection resulted in longer survival than D1 dissection. In 2004, the Japan Clinical Oncology Group reported a pivotal trial which was performed to determine whether para-aortic lymph node dissection combined with D2 dissection was superior to D2 dissection alone and found no benefit of the additional surgery. Gastrectomy with pancreatectomy, splenectomy, and bursectomy was initially recommended as part of the D2 dissection. Now, pancreas-preserving total gastrectomy with D2 dissection is standard, and ongoing trials are addressing the role of splenectomy. Furthermore, the feasibility and safety of laparoscopic gastrectomy are well established. Survival and quality of life are increasingly recognized as the most important endpoints. In this review, we present perspectives on surgical techniques and important trials of these techniques in gastric cancer patients.

Strategies to improve treatment outcome in gastric cancer: a retrospective analysis of patients from two high-volume hospitals in Korea and China

China has high incidence of gastric cancer (GC). However, the treatment outcomes of China were unsatisfactory compared to those of Korea. We performed this study to compare tumour characteristics, treatment parameters, and survival outcomes of GC patients between Korea and China based on the databases of two high-volume hospitals, with the aim of identifying indicators of GC prognosis. Data of patients undergoing gastrectomy for GC from 2006 to 2010 were analysed retrospectively. Subgroup survival analyses, stratified by clinicopathologic factors and multivariable analyses, were performed. The interactive roles of chemotherapy and D2 lymphadenectomy for overall survival were also investigated. Among 1365 Chinese and 4981 Korean patients, the proportion of early cancer detection in Chinese patients was much lower relative to that of Korean patients. There were no significant differences between countries in terms of surgical morbidity and mortality. The overall 5-year survival rates were 54.3% and 81.4%; when stratified by clinicopathologic factors, the survival were generally statistically higher in Korean patients. Gender, age, T stage, N stage, extent of lymphadenectomy, radicality of surgery, resection type, and chemotherapy were independently associated with survival in patients without metastasis. Survival rates for stage II and III GC differed significantly between the two countries, but this difference was eliminated among patients who underwent D2 lymphadenectomy or received chemotherapy. These treatments were given to patients with advanced-stage diagnoses (approximately 20% and 80% of patients, respectively). Treatment type was selected as independent prognostic factors in stage I-III and D2/D2+, with chemotherapy resulting in the best prognosis. Many differences in GC tumour characteristics exist between two countries. Early cancer detection and standardized treatment in Korea contribute to superior survival rates. Promotion of an early screening program, training and dissemination of standard D2 lymphadenectomy, and appropriate applications of chemotherapy would improve survival outcomes.