Effect of Neoadjuvant Chemotherapy Followed by Surgical Resection on Survival in Patients With Limited Metastatic Gastric or Gastroesophageal Junction Cancer: The AIO-FLOT3 Trial

Reassessment reveals underestimation of infiltration depth in surgical resection specimens with lymph-node positive T1b esophageal adenocarcinoma

Background and study aims

Endoscopic resection (ER) has proven effective and safe for T1 esophageal adenocarcinoma (EAC). However, uncertainty remains concerning risk-benefit return of esophagectomy for submucosal lesions (T1b). Surgical series in past decades have reported significant risk of lymph node metastasis (LNM) in T1b EAC, but these rates may be overestimated due to limitations in histological assessment of surgical specimens. We aimed to test this hypothesis by reassessing histological risk features in surgical specimens from T1b EAC cases with documented LNM.

Patients and methods

A retrospective cross-sectional study (1994-2005) was conducted. Patients who underwent direct esophagectomy without prior neoadjuvant therapy for suspected T1b EAC with LNM were included. Additional tissue sections were prepared from archival tumor blocks. A consensus diagnosis on tumor depth, differentiation grade, and lymphovascular invasion (LVI) was established by a panel of experienced pathologists.

Results

Specific depth of submucosal invasion (sm1 to sm3) was not specified in 10 of 11 archival case sign-out reports. LVI status was not reported in seven of 11 cases. Following reassessment, one patient was found to have deep tumor invasion into the muscularis propria (T2). The remaining 10 of 11 patients exhibited deep submucosal invasion (sm2-3), with five showing one or more additional risk features (poor differentiation and/or LVI).

Conclusions

Our findings highlight the potential for underestimating tumor depth of invasion and other high-risk features in surgical specimens. Despite the limited cohort size, our study confirmed a consistent high-risk histological profile across all cases. Caution is warranted when extrapolating LNM risk data from historic heterogeneous cross-sectional surgical cohorts to the modern ER era.

Effectiveness of conversion surgery in stage IV gastric cancer

BACKGROUND

For patients with stage IV gastric cancer (GC), systemic therapy is often the standard treatment, but the prognosis remains poor. Conversion surgery (CS) has emerged as a potential therapeutic option for selected patients who had certain response to chemotherapy. This study aims to compare the survival outcomes of CS versus continued chemotherapy (CT) in stage IV GC.

METHODS

We conducted a retrospective cohort study of 52 patients with stage IV gastric adenocarcinoma, from January-2018 to June-2023. Patients were divided into two groups: those who underwent CS (CS group) after a response to chemotherapy and those who continued with systemic chemotherapy (CT group). Baseline characteristics, chemotherapy toxicity, surgical outcomes, and survival data were analyzed and compared.

RESULTS

Among 52 patients, 26 patients underwent CS, while other 26 continued with CT. The CS group showed a significantly higher 3-year overall survival (OS) rate and median survival time (MST) compared to the CT group (36 % vs. 15 %, HR = 0.39, 95%CI: 0.19-0.79, p = 0.009; 23.4 months vs. 14.7 months, p < 0.001, respectively). Subgroup analysis by Yoshida classification revealed superior survival outcomes for CS in category 3 (MST: 26.1 months vs. 12.6 months, p < 0.001). Multivariate analysis indicated that CS were associated with a longer survival. No major postoperative complications were observed in the CS group.

CONCLUSIONS

Conversion surgery improved survival outcomes in selected stage IV GC patients compared to systemic chemotherapy alone. CS should be considered as a treatment option for patients who responds to initial chemotherapy, particularly those in Yoshida category 3.

Multimodality Treatment for Locally Advanced Gastric Adenocarcinoma

Gastric cancer is prevalent worldwide and is a leading cause of cancer-related death. Patients with GC often present at advanced stages at diagnosis. Patients with locally advanced diseases experience poor survival rates with surgery alone. Multimodality therapy, including peri-operative therapy and adjuvant therapy, has improved outcomes. However, there is no consensus on the optimal treatment approach. Molecular characteristics of GC may help guide treatment choices and studies are currently underway to evaluate other treatment modalities including immunotherapy and targeted therapy.

Is There a Role for Locoregional Therapies for Non-colorectal Gastrointestinal Malignancies?

The liver is the most common site of metastases from solid gastrointestinal tract tumors. Over the past few decades, the role of locoregional therapies, resection and thermal ablation, for neuroendocrine and colorectal liver metastases has been widely studied. However, for liver metastases originating from other gastrointestinal organs, the role of locoregional treatment remains unclear. This review summarizes and discusses the available evidence regarding benefits, risks, and indications for locoregional therapies for non-colorectal and non-neuroendocrine gastrointestinal liver metastases, highlighting the importance of multidisciplinary approach and patient selection.

The Value of Primary Tumor Resection in Patients with Liver Metastases: A 10-Year Outcome

OBJECTIVE

This study aimed to analyze the impact of primary tumor resection (PTR) on the prognosis of four common primary tumors with liver metastases, and to develop a prognostic model to visualize the PTR benefit rate of patients with liver metastases.

MATERIALS AND METHODS

Patients diagnosed with colorectal cancer liver metastases (CRLM), pancreatic cancer liver metastases (PLM), gastric cancer liver metastases (GLM), and breast cancer liver metastases (BLM) between 2004 and 2015 were retrospectively reviewed from the Surveillance, Epidemiology, and End Results (SEER) database and assigned to either the surgery or non-surgery groups. A 1:1 propensity score matching (PSM) was performed. Surgical patients who survived longer than the median cancer-specific survival (CSS) time for non-surgery patients constituted the benefit group. Logistic regression was conducted to explore the independent factors affecting surgical benefit, and a nomogram was established.

RESULTS

A total of 21,928 patients with liver metastases were included. After PSM for surgery and non-surgery patients, we found that PTR had a significant impact on the overall survival (OS) and CSS of CRLM, PLM, and BLM patients. In CRLM patients, age (p < 0.001), primary site (p = 0.006), grade (p = 0.009), N stage (p = 0.034), and histology (p = 0.006) affected the surgical benefit. In BLM patients, the independent factors were age (p = 0.002), race (p = 0.020), and radiotherapy (p = 0.043). And in PLM patients, chemotherapy was an independent factor associated with a survival benefit from PTR.

CONCLUSION

PTR improved OS and CSS in patients with CRLM, PLM, and BLM. A predictive model was established to identify suitable candidates for PTR in CRLM patients.

Gastric cancer liver metastases in China: a real-world, multicentre, prospective, observational cohort study protocol

INTRODUCTION

Gastric cancer liver metastases (GCLM) is a highly heterogeneous disease with a poor prognosis. The multidisciplinary diagnosis and treatment model is applied throughout the entire treatment process. In addition to the previous RECORD study, which was based on the C-GCLM classification system developed by our team, there is a lack of recent data on patient baseline characteristics, clinical treatment and efficacy evaluation. A large-scale prospective observational study is necessary to determine the current situation of GCLM treatment in China. The findings of this study may inform the development of relevant healthcare policies, clinical pathways and treatment guidelines.

METHODS AND ANALYSIS

This is a prospective, non-interventional, observational, multicentre, real-world study designed to monitor the general condition, treatment pattern and prognosis of patients with GCLM. Patients with GCLM were classified into three distinct categories: type I (resectable type), type II (potentially resectable type) and type III (unresectable type). The patients' general information, medical history, imaging results, laboratory tests, surgical and systemic therapy details will be recorded and subjected to analysis. The 2-year overall survival (OS) will be recorded as the primary endpoint. The different therapeutic modalities employed in the treatment of GCLM, including surgery, chemotherapy and immunotherapy, will be recorded as secondary endpoints. Additionally, the effects of these therapies on prognosis, including OS of type I, II and III; R0 resection and disease-free survival of type I; and successful conversion rate and R0 resection rate and event-free survival of type II will be documented.

ETHICS AND DISSEMINATION

This study involving human participants was reviewed and approved by the Ethics Committee of Chinese PLA General Hospital (no. S2023-724-02) and will be conducted in accordance with the guidelines of the Declaration of Helsinki. Study findings will be disseminated through international peer-reviewed journal articles as well as public, academic presentations at national and international conferences.

TRIAL REGISTRATION NUMBERS

NCT06493448; ChiCTR2400083955.

Emerging Trends in the Management of Gastric Malignancy with Peritoneal Dissemination: Same Disease, Heterogeneous Prognosis

Gastric cancer is a significant global contributor to cancer-related mortality. Stage IV gastric cancer represents a significant percentage of patients in Western countries, with peritoneal dissemination being the most prevalent site. Peritoneal disease comprises two distinct entities, macroscopic (P1) and microscopic (P0CY1), which are associated with poor long-term survival rates. Although the present standard of treatment is palliative chemotherapy, a global controversy has arisen concerning specific patients with limited disease burden or conversion to negative lavage cytology following chemotherapy. Available approaches include systemic or intraperitoneal chemotherapy, upfront gastrectomy, and conversion surgery. This review consolidated the current evidence regarding multimodal management, indicating prolonged survival for this distinct subgroup of patients. Considering the complexity of peritoneal metastases, the potential of the multimodal approach unveils promising prospects for identifying the optimal treatment for this particular subset of stage IV patients and thus enhancing their survival outcomes.

An Integrated Radiopathomics Machine Learning Model to Predict Pathological Response to Preoperative Chemotherapy in Gastric Cancer

RATIONALE AND OBJECTIVES

Accurately predicting the pathological response to chemotherapy before treatment is important for selecting the appropriate treatment groups, formulating individualized treatment plans, and improving the survival rates of patients with gastric cancer (GC).

METHODS

We retrospectively enrolled 151 patients diagnosed with GC who underwent preoperative chemotherapy and surgical resection at the Affiliated Hospital of Qingdao University between January 2015 and June 2023. Both pretreatment-enhanced computer technology images and whole slide images of pathological hematoxylin and eosin-stained sections were available for each patient. The image features were extracted and used to construct an ensemble radiopathomics machine learning model. In addition, a nomogram was developed by combining the imaging features and clinical characteristics.

RESULTS

In total, 962 radiomics and 999 pathomics signatures were extracted from 106 patients in the training cohort. A fusion radiopathomics model was constructed using 13 radiomics and 5 pathomics signatures. The fusion model showed favorable performance compared to single-omics models, with an area under the curve (AUC) of 0.789 in the validation cohort. Moreover, a combined radiopathomics nomogram (RPN) was developed based on radiopathomics features and the Borrmann type, which is a classification method for advanced GC according to tumor growth pattern and gross morphology. The RPN showed superior predictive performance in the training (AUC 0.880) and validation cohorts (AUC 0.797). The decision curve analysis showed that RPN could provide favorable clinical benefits to patients with GC.

CONCLUSIONS

RPN was able to predict the pathological response to preoperative chemotherapy with high accuracy, and therefore provides a novel tool for personalized treatment of GC.

The Role of Metastasectomy in Patients with Liver-Only Metastases from Gastric Adenocarcinoma

BACKGROUND

The role of metastasectomy in patients with liver-only metastases from gastric adenocarcinoma remains under investigation. Therefore, we performed a national registry analysis comparing surgical treatment options for patients with gastric adenocarcinoma and liver-only metastases.

PATIENTS AND METHODS

In this retrospective National Cancer Database (2010-2019) study, adults (≥ 18 years) with gastric adenocarcinoma and liver-only metastases (no brain, bone, or lung metastases) were included. Patients were stratified into four groups: no surgical treatment, primary tumor resection (PTR), liver metastasectomy, and PTR with liver metastasectomy. Survival was evaluated using the Kaplan-Meier method, log-rank test, and Cox regression.

RESULTS

Of 10,977 included patients, 93.6% underwent no surgical treatment, 4.6% PTR alone, 0.8% liver metastasectomy alone, and 1.0% both PTR and liver metastasectomy. The median OS after no surgical treatment was 6.5 months, after PTR alone 10.9 months, after liver metastasectomy alone 9.9 months, and after PTR and liver metastasectomy 18.6 months. In multivariable analysis, when adjusting for age, sex, race/ethnicity, insurance status, Charlson-Deyo score, chemotherapy, and radiation, PTR and liver metastasectomy was associated with superior OS compared with no surgical treatment (HR 2.17, 95% CI 1.76-2.69, p < 0.001), PTR alone (HR 1.42, 95% CI 1.12-1.79, p = 0.003), and liver metastasectomy alone (HR 1.96, 95% CI 1.45-2.64, p < 0.001).

CONCLUSIONS

These data suggest that, in highly selected patients with gastric adenocarcinoma and synchronous liver-only metastases and favorable biology, surgical resection might grant a survival advantage.

Multimodal Treatment of Resectable Esophageal Cancer

BACKGROUND

The current guidelines for the treatment of esophageal cancer recommend a multimodal approach that includes chemotherapy, targeted therapy and immunotherapy, radiation, and surgery. Despite advances in treatment, rates of treatment failure, pathologic incomplete response, tumor metastasis, and death remain unacceptably high.

METHODS

This study was a narrative literature review using the terms "resectable esophageal cancer" and "multimodal therapy" to identify prospective trials of neoadjuvant radiation and chemotherapy, individually or combined with surgery, for esophageal cancer. Trials performed between 1984 and 2022 were identified and analyzed.

CLINICALTRIALS

gov was queried to identify ongoing studies.

RESULTS

Twenty-one clinical studies were identified: 15 randomized controlled trials and 6 prospective nonrandomized trials. The results of the randomized trials suggest that multimodal therapy-in the form of neoadjuvant chemotherapy in combination with radiation or chemotherapy alone, followed by surgery-is associated with better rates of local disease control and partial clinical response and, potentially, longer survival than is surgery alone. Immunotherapy is an emerging option for the treatment of patients with esophageal cancer.

CONCLUSIONS

The treatment of patients with resectable esophageal cancer is rapidly evolving. Although previous treatment options have had only limited benefits for patients, significant progress has been made during last 3 decades. The results of the available studies suggest that advances in the treatment of esophageal cancer have the potential to improve survival in these patients; however, questions remain regarding mechanisms of action, patient selection, and the use of personalized approaches that are based on genetics.

IDO1 Expression and CD8+ T-Cell Levels Are Useful Prognostic Biomarkers in Preoperative Gastric Cancer Specimens Before Neoadjuvant Chemotherapy

The tumor immune microenvironment occupies an important position in gastric cancer. In this study, we investigated the relationship between indoleamine 2,3-dioxygenase 1 (IDO1), programmed cell death 1 ligand (PD-L1) expressioon, and CD8+ T-cell levels and their efficacy and prognostic value in preoperative gastric cancer specimens before neoadjuvant chemotherapy (NAC). A total of 162 patients with locally advanced gastric cancer were collected in this study. IDO1, PD-L1 expression, and CD8+ T-cell levels in the biopsy samples was detected by immunohistochemical staining, and the relationship between these indexes and the patients' clinicopathological parameters, chemotherapeutic efficacy, and prognosis were investigated. The IDO1 positivity rate was 43.2%. High expression of IDO1 was significantly associated with poor chemotherapeutic efficacy, lymph node metastasis (P<0.05). The PD-L1 positivity rate (using the combined positive score) was 38.2%, and was not related to any clinicopathological variable. Higher CD8+ T-cell levels were associated with a lower rate of lymph node metastasis and lower ypTNM stage (P<0.05). Higher CD8+ T-cell levels were negatively correlated with IDO1 expression (r=-0.224, P<0.05) and positively correlated with PD-L1 expression (r=0.254, P<0.05). Cox regression analysis demonstrated that higher CD8+ T-cell levels was an independent risk factor for overall survival (OS) and the expression of IDO1 had a significantly poorer disease-free survival (DFS). Overexpression of IDO1 and lower CD8+ T-cell levels were associated with poor survival in patients with gastric cancer who received neoadjuvant chemotherapy, and overexpression of IDO1 were associated with the poor tumor response. Our data suggest that IDO1 and CD8 testing of biopsy specimens might be a simple and effective prognostic biomarker for gastric cancer, and IDO1 could predict efficacy of neoadjuvant chemotherapy in gastric cancer.

Conversion Therapy for Stage IV Gastric Cancer: Report From the Expert Consensus Meeting at KINGCA WEEK 2024

Conversion therapy is a treatment strategy that shifts from palliative systemic therapy to curative surgical treatment for primary and/or metastatic stage IV gastric cancer (GC). To address its clinical statements, the Korean Gastric Cancer Association aims to present a consensus on conversion therapy among experts attending KINGCA WEEK 2024. The KINGCA Scientific Committee and Development Working Group for Korean Practice Guidelines prepared preformulated topics and 9 clinical statements for conversion therapy. The Delphi method was applied to a panel of 17 experts for consensus and opinions. The final comments were announced after the statement presentation and discussed during the consensus meeting session of KINGCA WEEK 2024. Most experts agreed that conversion therapy provides a survival benefit for selected patients who respond to systemic therapy and undergo R0 resection (88.3%). Patients with limited metastases were considered good candidates (94.2%). The optimal timing was based on the response to systemic therapy (70.6%). The regimen was recommended to be individualized (100%) and the duration to be at least 6 months (88.3%). A minimally invasive approach (82.3%) and D2 lymph node dissection (82.4%) were considered for surgery. However, resection for metastases with a complete clinical response after systemic therapy was not advocated (41.2%). All experts agreed on the need for large-scale randomized-controlled trials for further evidence (100%). Recent advancements in treatment may facilitate radical surgery for patients with stage IV GC. Further evidence is warranted to establish the safety and efficacy of conversion therapy.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Current status and perspectives of esophageal cancer: a comprehensive review

Esophageal cancer (EC) continues to be a significant global health concern, with two main subtypes: esophageal squamous cell carcinoma and esophageal adenocarcinoma. Prevention and changes in etiology, improvements in early detection, and refinements in the treatment have led to remarkable progress in the outcomes of EC patients in the past two decades. This seminar provides an in-depth analysis of advances in the epidemiology, disease biology, screening, diagnosis, and treatment landscape of esophageal cancer, focusing on the ongoing debate surrounding multimodality therapy. Despite significant advancements, EC remains a deadly disease, underscoring the need for continued research into early detection methods, understanding the molecular mechanisms, and developing effective treatments.

Prognostic prediction and immune infiltration analysis based on lysosome and senescence state identifies MMP12 as a novel therapy target in gastric cancer

BACKGROUND AND AIMS

As humans undergo the aging process, they become more vulnerable to various types of cancers, including gastric cancer (GC), which is frequently associated with aging. The senescent phenotype is closely linked to lysosomes, but research on the combined impact of senescence and lysosomes on GC prognosis is scarce.

METHODS

To construct and validate a prognostic model for gastric cancer (GC), we obtained gene expression and clinical data of GC patients from Cancer Genome Atlas (TCGA) databases. We employed Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression for model construction and ConsensusClusterPlus R package for generating cluster heatmaps. The model's predictive ability was evaluated through Kaplan-Meier survival analysis and ROC curve analysis. Our analysis included an assessment of the senescence and lysosome state using expression profiles and immune infiltration analysis through CIBERSORT methods. Finally, we validated potential gene targets through cellular experiments.

RESULTS

"In this research, we discovered two subtypes of gastric cancer (GC), Cluster 1 and Cluster 2. These subtypes are characterized by the presence of lysosomes and senescence, and we have identified distinct molecular features unique to each subtype. We observed that Cluster 2 had a lower survival prognosis compared to Cluster 1. Additionally, we have developed a risk prediction model that takes into consideration the presence of lysosomes and senescence. Patients in the high-risk group, as predicted by our model, experienced shorter survival times. Further analysis included immune infiltration, immune checkpoint, and chemotherapy evaluation of GC patients. We have displayed the frequency of mutations and copy number variations (CNVs) in visual formats. Our cellular experiments demonstrated that the MMP12 gene serves as a protective factor in GC cells."

CONCLUSIONS

In conclusion, we have clarified the extensive relationship between lysosomes and senescence in GC and developed a risk signature to forecast the prognosis of GC patients. MMP12 could be a promising protective factor for GC patients and might present a novel concept for anticipating the efficacy of targeted therapies and immunotherapies in GC patients.

Identification of gastric cancer subtypes based on disulfidptosis-related genes: GPC3 as a novel biomarker for prognosis prediction

Gastric cancer (GC) is the fourth most common cancer type. "Disulfidptosis," a distinct form of cell death, is initiated through aberrant intracellular disulfide metabolism. Here, we identified various GC subtypes based on disulfidptosis-related genes (DRGs) and constructed a risk score model to identify relevant genes to help predict patient prognosis and guide treatment. We downloaded RNA sequencing (RNA-seq) data from the TCGA-STAD database, performed a difference analysis, and combined the data with GSE84437 to successfully perform an unsupervised clustering analysis based on DRGs and differentially expressed genes (DEGs). Risk-scoring models were established by screening prognosis-related DEGs. The GC samples were segregated into high-risk (HR) and low-risk (LR) groups according to their risk scores. We then evaluated the genes screened with the model in terms of prognosis, tumor, and immune cell infiltration. The response of patients with GC to immunological therapy was assessed using tumor mutational burden, microsatellite instability, and tumor immune dysfunction and exclusion scores. Using unsupervised cluster analysis, we identified two DRG clusters and two gene clusters that differed in prognosis and tumor microenvironment. A six-gene model was developed for risk score assessment. The LR group demonstrated superior performance compared to the HR group in terms of immunity, exhibiting greater sensitivity to immunotherapy. Thereafter, we selected the model gene GPC3 for single-gene analysis and verified it by experimental validation. The results demonstrated that GPC3 can serve as a standalone biomarker with promising clinical applicability in the prognostic prediction and clinical management of GC.

Curative treatment for oligometastatic gastroesophageal cancer- results of a prospective multicenter study

PURPOSE

Oligometastatic gastroesophageal cancer is a clinical entity with no standard treatment recommendation. Treatment with curative intent has recently emerged as an option for selected patients in contrast to the traditional palliative treatment strategy. This prospective study aimed to assess the safety and efficacy of combined systemic and local treatment with curative intent for patients with oligometastatic gastroesophageal cancer.

METHODS

In a multicenter study, consecutive patients with gastroesophageal cancer and metastases in the liver and/or extra-regional lymph nodes were screened for inclusion. Eligible patients were offered curatively intended perioperative chemotherapy followed by surgical resection or liver ablation. Primary endpoints were treatment safety and feasibility. Secondary outcomes included postoperative mortality, treatment response, progression-free survival, and overall survival. Subgroup analyses were stratified based on oligometastatic location.

RESULTS

A total of 29 (82.9%) patients completed treatment with surgical resection (93.1%), liver ablation (3.4%), or definitive chemoradiotherapy (3.4%). Postoperative complications were found in 19 (73.1%) patients, whereas postoperative mortality was 0%. The most common complications included infection (34.6%) and respiratory complications (34.6%). Median overall survival was 20.9 months (interquartile range 11.2-42.6) from diagnosis and 17.0 months (interquartile range 6.4-35.9) from surgery in patients who were treated with neoadjuvant chemotherapy followed by surgery. Median progression-free survival was 5.8 months (interquartile range 3.1-11.3).

CONCLUSION

This study found curative treatment to be a relatively safe option, with an overall survival of 20.8 months and no postoperative mortality.

Enhancing lymph node metastasis prediction in adenocarcinoma of the esophagogastric junction: A study combining radiomic with clinical features

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEJ) is increasing, and with poor prognosis. Lymph node status (LNs) is particularly important for planning treatment and evaluating the prognosis of patients with AEJ. However, the use of radiomic based on enhanced computed tomography (CT) to predict the preoperative lymph node metastasis (PLNM) status of the AEJ has yet to be reported.

PURPOSE

We sought to investigate the value of radiomic features based on enhanced CT in the accurate prediction of PLNM in patients with AEJ.

METHODS

Clinical features and enhanced CT data of 235 patients with AEJ from October 2017 to May 2023 were retrospectively analyzed. The data were randomly assigned to the training cohort (n = 164) or the external testing cohort (n = 71) at a ratio of 7:3. A CT-report model, clinical model, radiomic model, and radiomic-clinical combined model were developed to predict PLNM in patients with AEJ. Univariate and multivariate logistic regression were used to screen for independent clinical risk factors. Least absolute shrinkage and selection operator (LASSO) regression was used to select the radiomic features. Finally, a nomogram for the preoperative prediction of PLNM in AEJ was constructed by combining Radiomics-score and clinical risk factors. The models were evaluated by area under the receiver operating characteristic curve (AUC-ROC), calibration curve, and decision curve analyses.

RESULTS

A total of 181 patients (181/235, 77.02%) had LNM. In the testing cohort, the AUC of the radiomic-clinical model was 0.863 [95% confidence interval (CI) = 0.738-0.957], and the radiomic model (0.816; 95% CI = 0.681-0.929), clinical model (0.792; 95% CI = 0.677-0.888), and CT-report model (0.755; 95% CI = 0.647-0.840).

CONCLUSION

The radiomic-clinical model is a feasible method for predicting PLNM in patients with AEJ, helping to guide clinical decision-making and personalized treatment planning.

Conversion surgery for esophageal and esophagogastric junction cancer

As a result of the recent advances in first-line treatment including chemotherapy, radiation therapy, targeted therapy, and immune checkpoint inhibitor immunotherapy (ICI) for locally advanced/metastatic initially unresectable esophageal and esophagogastric junction cancer, surgery aiming at cure after initial treatment, so-called "conversion surgery" has become more common in this field. Several studies have indicated encouraging survival outcomes for patients after conversion surgery with R0 resection. However, various issues, such the utility and the safety of conversion surgery remain unclear. In this review, we will focus on the surgical treatment for initially unresectable esophageal and esophagogastric junction cancer after first- or later- line treatment and review recent evidence regarding the safety and the efficacy of conversion surgery. Multidisciplinary treatment including surgery may serve as a novel treatment strategy for esophageal and esophagogastric junction cancer, thus provide a curative treatment option and potentially contribute to better prognosis for initially untreatable diseases.

Cross-sectional imaging of gastric cancer: pearls, pitfalls and lessons learned from multidisciplinary conference

Gastric cancer is rising in prevalence associated with high mortality, primarily due to late-stage detection, underscoring the imperative for early and precise diagnosis. Etiology involves an interplay of genetic susceptibilities and environmental factors with a prominent role of Helicobacter pylori infection. Due to its often-delayed symptom presentation, prompt and accurate diagnosis is necessary. A multimodal imaging approach, including endoscopic ultrasound (EUS), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) is critical for accurate staging. Each modality contributes unique advantages and limitations, highlighting the importance of integrating diagnostic strategy. Moreover, multidisciplinary conferences offer a vital collaborative platform, bringing together specialists from diverse fields for treatment planning. This synergistic approach not only enhances diagnostic precision but also improves patient outcome. This review highlights the critical role of imaging in diagnosis, staging, and management and advocates for interdisciplinary collaboration in early detection and comprehensive management of gastric cancer, aiming to reduce mortality.

Surgical Resection Enhances Survival in Patients With Liver Metastases From Gastric Cancer: A Population-Based, Case-Control Study

Background and Aims

Gastric cancer with liver metastases (GCLM) is a challenging condition that significantly reduces long-term survival rates, but recent advancements in surgical techniques have shown promise. This study aims to comprehensively evaluate the impact of surgical resection on survival rates in GCLM patients.

Methods

We conducted a population-based analysis utilizing the SEER database for patients diagnosed with GCLM between 2010 and 2015. Overall survival (OS) was compared between patients who underwent cancer-directed surgery (CDS) and those who did not. The overlap weighting method based on lasso regression with penalty factors was employed to minimize selection bias. Survival outcomes were compared using Kaplan-Meier curves and Cox proportional hazards models, with subgroup analyses to further explore the effects of surgery among patients.

Results

A total of 3694 patients with GCLM were identified. Of those, 354 (9.58%) patients underwent CDS. After propensity score adjustment, The median OS was significantly higher in the surgical resection group (12 months, 95% confidence interval (CI) 11-16) compared to the nonresection group (6 months, 95% CI: 5-6). Cox regression analysis revealed a substantial improvement in OS for the surgical resection group, with a hazard ratio (HR) of 0.562 (95% CI: 0.482-0.656), including patients with adverse conditions.

Conclusions

The analysis demonstrated a clear association between surgical resection and enhanced OS in GCLM patients. Nevertheless, further research endeavors should be undertaken to identify specific prognostic factors that aid in the selection of optimal candidates for surgical resection.

Prospective single-arm multicenter interventional study of surgical resection for liver metastasis from gastric cancer; 3-year overall and recurrence-free survival

OBJECTIVE

Potential benefit of surgical resection for liver metastasis from gastric cancer (LMGC) remains controversial because most previous studies were retrospective. We evaluated the outcomes of surgical resection following chemotherapy for LMGC in a prospective single-arm multicenter interventional study.

METHODS

Patients with synchronous or metachronous LMGC received 2-4 cycles of standard chemotherapy and proceeded to surgical resection if restaging showed a non-progressive disease with a chance of R0 resection. The primary endpoint was 3-year OS of R0 patients, with RFS as secondary. Prognostic factors for R0 patients were evaluated by multivariable Cox regression analysis.

RESULTS

Seventy patients were enrolled between 2011 and 2019. Two patients were ineligible, and 20 discontinued treatment before surgery. Of the 48 patients eventually undergoing surgery, 43 accomplished R0 resection of the primary and/or metastatic GC, while 1 ended in R2 resection and 4 were considered ineligible. Median and 3-year OS for R0 patients were 39.8 months (95 % confidence interval [CI], 26.9 to not reached) and 58.1 % (95 % CI, 43.1-71.8), respectively, while median and 3-year RFS were 14.9 months (95 % CI 7.9-34.0) and 34.9 % (95 % CI 22.2-50.1), respectively. On multivariable analysis, both multiple liver metastases and positive nodal status (pN1-3) were negatively associated with OS (multiple liver metastases: hazard ratio [HR] 2.71 (95 % CI, 1.16-6.35), P = 0.022; pN1-3: HR 9.11 (95 % CI, 1.22-68.2), P = 0.031).

CONCLUSION

R0 resection following chemotherapy for LMGC yielded promising survival, with multiple liver metastases and positive nodal status being significant indicators of poor prognosis.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN 000011445 (https://www.umin.ac.jp/ctr/).

Esophagectomy may have a role in stage IV esophageal adenocarcinoma

OBJECTIVE

We sought to determine whether aggressive local treatment provides a benefit in patients with stage IV esophageal adenocarcinoma and to determine factors associated with survival.

METHODS

Patients with clinical stage IV esophageal adenocarcinoma at diagnosis who underwent esophagectomy from 2010 to 2023 were identified from our prospectively maintained database. Clinicopathologic and demographic characteristics were compared among patients by stage. Overall survival was estimated using the Kaplan-Meier approach.

RESULTS

In total, 66 patients met the inclusion criteria. Of these, 30 (45%) had stage IVA disease, and 36 (55%) had stage IVB disease. Of the 36 patients with stage IVB disease, 26 had oligometastatic disease, and 10 had disseminated disease. All patients with stage IVA disease received standard neoadjuvant therapy followed by curative-intent surgery; 26 of these patients (87%) received chemoradiation. Patients with oligometastatic stage IVB disease underwent systemic therapy with the goal of surgical resection. Patients with disseminated stage IVB disease underwent palliative chemotherapy, which led to improvement in disease burden and performance of esophagectomy. Median time from the start of therapy to surgery was shorter for patients with stage IVA disease than patients with stage IVB disease (P < .001). Three-year progression-free survival was lower for patients with stage IVA disease (40% vs 56%), as was 3-year overall survival (57% vs 85%). Adjusted overall survival, from the start of therapy to most recent follow-up, was higher for patients with stage IVB disease.

CONCLUSIONS

Aggressive local treatment may provide a benefit for highly selected patients with advanced or metastatic esophageal adenocarcinoma.

Complete response of a metastatic microsatellite-stable gastric cancer after neoadjuvant chemoimmunotherapy: should we still operate? A case report and review of the literature

Gastric cancer often presents at an advanced stage in Western populations due to a lack of screening programs, leading to poor prognoses. Historically, palliative chemotherapy resulted in a median survival of 9.9 months. However, the introduction of the FLOT regimen and immunotherapy has significantly altered treatment outcomes. Oligometastatic gastric cancer, defined as metastasis limited to a single organ or a few sites, has emerged as a distinct subgroup with improved survival when treated with a combination of systemic and local therapies. We present the case of a 54-year-old male patient diagnosed with microsatellite-stable (MSS) oligometastatic gastric adenocarcinoma, including liver and peritoneal metastases, who achieved a complete pathological response following neoadjuvant chemoimmunotherapy with FOLFOX and nivolumab. Despite unfavorable prognostic factors, such as liver involvement and positive peritoneal cytology, the patient responded well to the treatment, allowing curative surgery. Postoperative histology confirmed complete regression of both the primary tumor and metastases, with no recurrence observed at the 1-year follow-up. This case shows the potential of combined chemoimmunotherapy to convert previously inoperable MSS gastric cancer to surgical candidates. Further research is needed to better define patient selection criteria and assess long-term outcomes for these patients.

A comprehensive overview of gastric cancer management from a surgical point of view

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Development and validation of a nomogram to predict the survival and estimate surgical benefits for gastric cancer with liver metastasis receiving primary tumor resection

Background

Surgical treatment has been widely controversial for gastric cancer accompanied by liver metastasis (GCLM). This paper aims to develop and validate a nomogram to predict the survival and estimate surgical benefits for GCLM patients.

Methods

A total of 616 GCLM patients from the Surveillance, Epidemiology, and End Results Program (SEER) database and 74 GCLM patients receiving primary tumor resection (PTR) from the Chinese center were included in this study. Patients from the SEER database were divided into training set (with PTR) (n=493) and non-operative set (without PTR) (n=123). Patients undergoing PTR from China were included as external validation set. Independent risk factors associated with the overall survival of GCLM patients undergoing PTR were identified in the training set via log-rank test and Cox regression analysis. Afterwards, a comprehensive model and corresponding nomogram were constructed and validated by validation set.

Results

The survival of patients undergoing PTR (n=493) was longer than that without PTR (n=123) (log-rank test, p<0.0001) in SEER cohort. T stage (HR=1.40, 95% CI=1.14, 1.73), differentiation grade (HR=1.47, 95% CI=1.17, 1.85), non-hepatic metastases (HR=1.69, 95% CI=1.29, 2.21), and adjuvant therapy (HR=0.34, 95% CI= 0.28, 0.42) were closely related with the survival of GCLM with PTR, and thus, a four-factor nomogram was established. However, GCLM patients receiving PTR in the high-risk subgroup (n=255) screened out by the nomogram did not have better survival outcomes compared with patients without PTR (n=123) (log-rank test, p=0.25).

Conclusions

The nomogram could predict survival of GCLM patients receiving PTR with acceptable accuracy. In addition, although PTR did improve the survival of whole GCLM patients, patients in the high-risk subgroup were unable to benefit from PTR, which could assist clinicians to make decisions for the treatment of GCLM.

Analysis of the therapeutic effect and influencing factors on unresectable gastric cancer treated with conversion therapy

Background

Gastric cancer (GC) is one of the leading causes of cancer-related death in China, and with the extensive development of conversion therapy, the treatment of advanced unresectable gastric cancer (AUGC) patients has ushered in a new dawn. This study aimed to analyze the efficacy of conversion therapy in AUGC patients and explored the relevant factors affecting the efficacy.

Method

We collected information from GC patients who received conversion therapy from this center and designed a retrospective study.

Results

We collected relevant clinical data from 160 patients with AUGC. A total of 120 patients who underwent routine R0 resection were identified as conversion cases. A total of 25 patients (15.6%) achieved pCR, 92 patients (57.5%) achieved objective response rate (ORR), 140 patients (87.5%) achieved disease control rate (DCR), and 20 cases (12.5%) observed tumor progression. There were 86 patients who achieved pathological downgrading, with a total downgrading rate of 53.8%. Among the 160 patients, 37 patients (23.1%) had postoperative complications of varying degrees. A total of 72 patients (45.0%) had tumor recurrence/progression at the end of follow-up. The last chemotherapy and surgery (CST) (OR = 1.046, 95% CI 1.013-1.081, p = 0.006), tumor invasion (OR = 32.096, 95% CI 5.091-202.349, p < 0.001), and distant metastasis (OR = 7.050, 95% CI 1.888-26.323, p = 0.004) were independent factors influencing the efficacy of conversion therapy.

Conclusion

Conversion therapy may have a good therapeutic efficacy for AUGC, and some clinical factors affect the efficacy response.

Esophagectomy in patients with esophageal squamous cell carcinoma and distant nodal metastasis

The role of surgery in oligometastatic esophageal squamous cell carcinoma (ESCC) remains controversial. This study evaluated the oncological outcomes after esophagectomy in patients with ESCC with distant lymph node (LN) metastasis. Patients with ESCC and nodal metastasis treated with chemoradiotherapy or chemotherapy followed by esophagectomy between 2010 and 2020 were included. Overall survival (OS) and recurrence-free survival (RFS) were compared between patients with distant LN metastasis (dLN+) and exclusively regional LN metastasis (dLN-). The cohort comprised 69 dLN+ and 111 dLN- patients. Survival was significantly better in the dLN- group than in the dLN+ group (5-year OS, 51.9% vs. 25.5%, P < 0.001; RFS, 47.2% vs. 18.1%, P < 0.001). Stratified by the yp stage, 49 (44.1%) dLN- and 30 (43.5%) dLN+ patients achieved a pathological complete response (pCR). In the dLN- and dLN+ groups, the OS rates were significantly higher in the pCR group than in the non-pCR group (dLN-: 76.7% vs. 32.4%, P < 0.001; dLN+: 39.6% vs. 14.2%; P = 0.002). The dLN-/pCR group had the best OS, significantly outperforming the dLN-/non-pCR and dLN+/pCR groups. OS did not differ between the dLN-/non-pCR and dLN+/pCR groups. The dLN+/non-pCR group had the worst OS. The RFS analysis paralleled the OS findings. Patients with dLN+ disease had worse outcomes than their dLN- counterparts, irrespective of the pCR status. The survival rates were poor but comparable between the dLN+/pCR and dLN-/non-pCR groups. Adjuvant therapy may be required for dLN+ patients following systemic treatment and surgery, even after achieving pCR.

Efficacy and safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in ovarian cancer: a systematic review of current evidence

BACKGROUND

PIPAC is a recent approach for intraperitoneal chemotherapy with promising results for patients with peritoneal carcinomatosis. A systematic review was conducted to assess current evidence on the efficacy and outcomes of PIPAC in patients affected by ovarian cancer.

METHODS

The study adhered to the PRISMA guidelines. PubMed, Google Scholar and ClinicalTrials.gov were searched up to December 2023. Studies reporting data on patients with OC treated with PIPAC were included in the qualitative analysis.

RESULTS

Twenty-one studies and six clinical trials with 932 patients who underwent PIPAC treatment were identified. The reported first access failure was 4.9%. 89.8% of patients underwent one, 60.7% two and 40% received three or more PIPAC cycles. Pathological tumour response was objectivated in 13 studies. Intra-operative complications were reported in 11% of women and post-operative events in 11.5% with a 0.82% of procedure-related mortality. Quality of life scores have been consistently stable or improved during the treatment time. The percentage of OC patients who became amenable for cytoreductive surgery due to the good response after PIPAC treatment for palliative purposes is reported to be 2.3%.

CONCLUSION

The results showed that PIPAC is safe and effective for palliative purposes, with a good pathological tumour response and quality of life. Future prospective studies would be needed to explore the role of this treatment in different stages of the disease, investigating a paradigm shift towards the use of PIPAC with curative intent for women who are not eligible for primary cytoreductive surgery.

Surgical treatment for liver metastasis from gastric cancer: A systematic review and meta-analysis of long-term outcomes and prognostic factors

Chemotherapy is the mainstay treatment for liver metastasis from gastric cancer. However, some retrospective studies and meta-analyses have indicated the efficacy of hepatectomy, which is an aggressive treatment option. However, the optimal selection criteria for hepatectomy and the role of perioperative chemotherapy remain unclear. Therefore, a meta-analysis of studies on hepatectomy was performed to assess the impact of various factors on overall survival (OS). A systematic review was conducted in accordance with the PRISMA criteria using studies published until 2022. The primary outcome was the hazard ratio (HR) for OS. Comparisons were made between hepatectomy and nonhepatectomy, solitary and multiple metastases, synchronous and metachronous metastases, treatment with and without neoadjuvant chemotherapy, and treatment with and without adjuvant chemotherapy. A total of 50 studies involving 1966 patients who underwent hepatectomy were included in the analysis. The meta-analysis showed a 5-year OS rate of 25 %. A meta-analysis comparing hepatectomy with nonhepatectomy showed an HR of 0.2 for hepatectomy. A meta-analysis comparing solitary and multiple metastases showed a trend toward better OS in patients with solitary metastases (odds ratio [OR]: 0.35). A meta-analysis comparing synchronous and metachronous metastases showed favorable OS for patients with metachronous metastases (OR: 0.66). A meta-analysis comparing neoadjuvant chemotherapy with no neoadjuvant chemotherapy showed no difference in OS. In contrast, a meta-analysis comparing adjuvant chemotherapy with no adjuvant chemotherapy showed better OS for adjuvant chemotherapy (OR: 0.39). This retrospective study indicates that hepatectomy may benefit patients with liver metastases from gastric cancer, particularly those with solitary and metachronous metastases.

Are Palliative Interventions Worth the Risk in Advanced Gastric Cancer? A Systematic Review

Background: Less than 25% of gastric cancers (GC) are discovered early, leading to limited treatment options and poor outcomes (27.8% mortality, 3.7% 5-year survival). Screening programs have improved cure rates, yet post-diagnosis treatment guidelines remain unclear (systemic chemotherapy versus surgery). The optimal type of palliative surgery (palliative gastrectomy (PG), surgical bypass (SB), endoscopic stenting (ES)) for long-term outcomes is also debated. Methods: A literature review was conducted using PubMed, MEDLINE, and EMBASE databases along with Google Scholar with the search terms "gastric cancer" and "palliative surgery" for studies post-1985. From the initial 1018 articles, multiple screenings narrowed it to 92 articles meeting criteria such as "metastatic, stage IV GC", and intervention (surgery or chemotherapy). Data regarding survival and other long-term outcomes were recorded. Results: Overall, there was significant variation between studies but there were similarities of the conclusions reached. ES provided quick symptom relief, while PG showed improved overall survival (OS) only with adjuvant chemotherapy in a selective population. PG had higher mortality rates compared to SB, with ES having a reported 0% mortality, but OS improved with chemotherapy across both SB and PG. Conclusions: Less frail patients may experience an improvement in OS with palliative resection under limited circumstances. However, operative intervention without systemic chemotherapy is unlikely to demonstrate a survival benefit. Further research is needed to explore any correlations.

Heterogeneity and prognosis of single organ metastases in gastric cancer

Background

While single organ metastases generally present a more optimistic prognosis compared to multiple metastases, the influence of the specific organ site for single organ metastases on prognosis remains undetermined. This retrospective study aimed to investigate the prognostic differences in late-stage gastric cancer with single organ metastasis.

Methods

Data for patients diagnosed with gastric cancer were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database for survival analysis, covering years spanning from 2010 to 2016. Furthermore, Kaplan-Meier survival curves and Cox regression were utilized to analyze overall survival (OS) and disease-specific survival (DSS). Additionally, given the impact of confounders and bias on the results, prognosis was further analyzed using propensity score matching (PSM) and floating absolute risk methods.

Results

A cohort comprising 4,297 patients diagnosed with gastric cancer and exhibiting single organ metastasis was hereby enrolled. Liver metastasis was the most common (71% of the total), while brain metastasis accounted for the least (1.7% of the total). Compared to other metastases, patients with bone metastasis presented the worst OS [hazard ratio (HR), 1.319; 95% confidence interval (CI): 1.207-1.442; P<0.001], and this remained consistent even upon the application of floating absolute risk (HR, 1.10; 95% CI: 1.01-1.20) and PSM methods (HR, 1.187; 95% CI: 1.053-1.339; P=0.005). In addition, subgroup analysis and interaction tests of OS revealed an interaction between age (P=0.02), histological type (P=0.002), and bone metastasis.

Conclusions

In patients with single organ metastasis of gastric cancer, the prognosis varies by the metastatic site, with bone metastasis presenting the poorest outcome. Overall, this study forges a foundation for further research on the mechanisms and patterns of different metastatic sites in gastric cancer and informs treatment strategies.

Efficacy of chemotherapy for patients with gastric cancer with early recurrence during or after adjuvant chemotherapy with S-1 alone: a multicenter retrospective study

This study aimed to survey the efficacy of chemotherapy regimens in the real world setting and explore the most promising regimen for patients experiencing early recurrence for gastric cancer. We retrospectively reviewed the clinical course of 207 patients with gastric cancer, who developed early recurrence during or within 6 months after completing S-1 adjuvant therapy at 19 Japanese institutions between 2012 and 2016. The treatment regimens after recurrence were fluoropyrimidines plus platinum-based regimens (FP) in 91 (44%) patients, paclitaxel-based regimens (PTX) in 102 (49%), and irinotecan-based regimens (IRI) in 14 (7%). The overall response and disease control rates were 28.7% and 54.1%. Median progression-free survival (PFS) and overall survival (OS) were 5.1 and 12.9 months, respectively. In the FP, PTX, and IRI regimens, the median PFS and OS were 5.9, 4.1, 4.1 months and 12.8, 12.9, and 11.8 months, respectively. The combination of PTX and ramucirumab showed survival comparable to capecitabine plus platinum. Multivariate analyses for OS showed that recurrence during adjuvant chemotherapy and undifferentiated histological type were independent poor prognostic factors. Although the prognosis of patients with early recurrence even with adjuvant S-1 was poor, PTX plus ramucirumab therapy could be a potential treatment option.

[Gender medicine in diseases of the upper gastrointestinal tract]

Benign and malignant diseases of the upper gastrointestinal tract show gender-specific differences. The frequent gastroesophageal reflux disease is a prime example: men have an erosive reflux disease more often than women and are also younger at the time of onset. The rate of progression to a metaplastic Barrett's esophagus is also higher in men. In the case of achalasia, there are indications that surgical treatment by laparoscopic Heller's myotomy and semifundoplication 180° according to Dor leads to a markedly better improvement in the symptoms in women compared to men, although they showed a more pronounced dilation of the tubular esophagus. The female hormone status influences the localization and histopathology of adenocarcinoma of the esophagogastric junction and gastric carcinoma. Premenopausal and postmenopausal carcinomas differ significantly in women. In addition, high microsatellite instability (MSI high) is more frequent in women and is associated with a generally significantly better prognosis. The MSI high gastric carcinomas of women show better survival than MSI high carcinomas of men. The future inclusion of gender-specific aspects in studies of the upper gastrointestinal tract is desirable in order to generate adequate data and to enable differentiated treatment stratification in the future.

Conversion surgery for gastric cancer with PM

It remains unclear whether the application of surgery to gastric cancer with peritoneal carcinomatosis prolongs survival. Twenty studies on conversion surgery were reviewed. Key points were the response to chemotherapy, complete resection, and a low tumor burden at the time of surgery. A bidirectional approach has been developed to increase the response rate. There are two different strategies in surgery. The outcomes of ongoing trials may clarify controversial issues.

Computed tomography-based radiomics nomogram for predicting therapeutic response to neoadjuvant chemotherapy in locally advanced gastric cancer : A scale for treatment predicting

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy results in various responses when used to treat locally advanced gastric cancer, we aimed to develop and validate a predictive model of the response to neoadjuvant chemotherapy in patients with gastric cancer.

METHODS

A total of 128 patients with locally advanced gastric cancer who underwent pre-treatment computed tomography (CT) scanning followed by neoadjuvant chemoradiotherapy were included (training cohort: n = 64; validation cohort: n = 64). We built a radiomics score combined with laboratory parameters to create a nomogram for predicting the efficacy of neoadjuvant chemotherapy and calculating scores for risk factors.

RESULTS

The radiomics score system demonstrated good stability and prediction performance for the response to neoadjuvant chemotherapy, with the area under the curve of the training and validation cohorts being 0.8 and 0.64, respectively. The radiomics score proved to be an independent risk factor affecting the efficacy of neoadjuvant chemotherapy. In addition to the radiomics score, four other risk factors were included in the nomogram, namely the platelet-to-lymphocyte ratio, total bilirubin, ALT/AST, and CA199. The model had a C-index of 0.8.

CONCLUSIONS

Our results indicated that radiomics features could be potential biomarkers for the early prediction of the response to neoadjuvant treatment.

The safety and efficacy of neoadjuvant immunochemotherapy following laparoscopic gastrectomy for gastric cancer: a multicentre real-world clinical study

BACKGROUND

The safety and efficacy of neoadjuvant immunochemotherapy (nICT) for locally advanced gastric cancer (LAGC) remain controversial.

METHODS

Patients with LAGC who received either nICT or neoadjuvant chemotherapy (nCT) at 3 tertiary referral teaching hospitals in China between January 2016 and October 2022 were analyzed. After propensity-score matching (PSM), comparing the radiological response, pathological response rate, perioperative outcomes, and early recurrence between the two groups.

RESULTS

After PSM, 585 patients were included, with 195 and 390 patients comprising the nICT and nCT groups, respectively. The nICT group exhibited a higher objective response rate (79.5% vs. 59.0%; P <0.001), pathological complete response rate (14.36% vs. 6.41%; P =0.002) and major pathological response rate (39.49% vs. 26.15%; P =0.001) compared with the nCT group. The incidence of surgical complications (17.44% vs. 16.15%, P =0.694) and the proportion of perioperative textbook outcomes (80.0% vs. 81.0%; P =0.767) were similar in both groups. The nICT group had a significantly lower proportion of early recurrence than the nCT group (29.7% vs. 40.8%; P =0.047). Furthermore, the multivariable logistic analysis revealed that immunotherapy was an independent protective factor against early recurrence [odds ratio 0.62 (95% CI 0.41-0.92); P =0.018]. No significant difference was found in neoadjuvant therapy drug toxicity between the two groups (51.79% vs. 45.38%; P =0.143).

CONCLUSIONS

Compared with nCT, nICT is safe and effective, which significantly enhanced objective and pathological response rates and reduced the risk for early recurrence among patients with LAGC.

TRIAL REGISTRATION

Clinical Trials.gov.

Oligometastatic esophageal cancer cured by systemic therapy combined with radiotherapy to primary tumor and metastasis (metastasis-directed therapy)-small case series

The prognosis of metastatic esophageal cancer (EC) remains poor with an average life expectancy of around 9-12 months with standard systemic chemotherapy. The concept of oligometastatic disease (OMD) in EC cancer is controversial with no universally accepted definition. From the original cohort of metastatic oesophago-gastric (OG) cancer patients, 4 cases were identified that developed unusually favourable outcome with long-term survival and probable cure. In retrospect, all patients had OMD at presentation with striking similarities in terms of their clinical presentation, staging, treatment response and outcomes. All patients presented with locally advanced EC and 1-2 areas of metastatic disease (bone, lung, non-regional lymph node (LN) involvement). All were treated with combined therapeutic strategy using initial systemic chemotherapy followed by local radiotherapy to primary tumor and adjacent areas of visible/residual metastatic disease (metastasis-directed therapy). All patients experienced long-term survival (range = 7-13 years) with no evidence of recurrence and probable cure. The present case series adds to the growing pool of evidence indicating OM EC cancer represents a distinct and prognostically favorable subgroup.

Current trends in the management of Gastro-oEsophageal cancers: Updates to the ESSO core curriculum (ESSO-ETC-UGI-WG initiative)

Gastro-oEsophageal Cancers (GECs) are severe diseases whose management is rapidly evolving. The European Society of Surgical Oncology (ESSO) is committed to the generation and spread of knowledge, and promotes the multidisciplinary management of cancer patients through its core curriculum. The present work discusses the approach to GECs, including the management of oligometastatic oesophagogastric cancers (OMEC), the diagnosis and management of peritoneal metastases from gastric cancer (GC), the management of Siewert Type II tumors, the importance of mesogastric excision, the role of robotic surgery, textbook outcomes, organ preserving options, the use of molecular markers and immune check-point inhibitors in the management of patients with GECs, as well as the improvement of current clinical practice guidelines for the management of patients with GECs. The aim of the present review is to provide a concise overview of the state-of-the-art on the management of patients with GECs and, at the same time, to share the latest advancements in the field and to foster the debate between surgical oncologists treating GECs worldwide. We are sure that our work will, at the same time, give an update to the advanced surgical oncologists and help the training surgical oncologists to settle down the foundations for their future practice.

Minimally Invasive Ivor Lewis Esophagectomy

Minimally invasive Ivor Lewis esophagectomy is a technically demanding operation that requires an experienced surgeon, assistant, and anesthesiologist. The preoperative workup should focus on the extent of disease and extent of resection required, as well as the cardiopulmonary fitness of the patient. Surgical outcomes show decreased postoperative pain, decreased morbidity largely due to a reduction in respiratory complications, and decreased length of stay. Quality metrics and 5-year overall survival are equivalent to traditional open esophagectomy.

International consensus on the management of metastatic gastric cancer: step by step in the foggy landscape : Bertinoro Workshop, November 2022

BACKGROUND

Many gastric cancer patients in Western countries are diagnosed as metastatic with a median overall survival of less than twelve months using standard chemotherapy. Innovative treatments, like targeted therapy or immunotherapy, have recently proved to ameliorate prognosis, but a general agreement on managing oligometastatic disease has yet to be achieved. An international multi-disciplinary workshop was held in Bertinoro, Italy, in November 2022 to verify whether achieving a consensus on at least some topics was possible.

METHODS

A two-round Delphi process was carried out, where participants were asked to answer 32 multiple-choice questions about CT, laparoscopic staging and biomarkers, systemic treatment for different localization, role and indication of palliative care. Consensus was established with at least a 67% agreement.

RESULTS

The assembly agreed to define oligometastases as a "dynamic" disease which either regresses or remains stable in response to systemic treatment. In addition, the definition of oligometastases was restricted to the following sites: para-aortic nodal stations, liver, lung, and peritoneum, excluding bones. In detail, the following conditions should be considered as oligometastases: involvement of para-aortic stations, in particular 16a2 or 16b1; up to three technically resectable liver metastases; three unilateral or two bilateral lung metastases; peritoneal carcinomatosis with PCI ≤ 6. No consensus was achieved on how to classify positive cytology, which was considered as oligometastatic by 55% of participants only if converted to negative after chemotherapy.

CONCLUSION

As assessed at the time of diagnosis, surgical treatment of oligometastases should aim at R0 curativity on the entire disease volume, including both the primary tumor and its metastases. Conversion surgery was defined as surgery on the residual volume of disease, which was initially not resectable for technical and/or oncological reasons but nevertheless responded to first-line treatment.

Prognostic Role of Preoperative Chemotherapy in Liver-Limited Metastasis from Gastric Cancer

BACKGROUND

We investigated the prognostic role of preoperative chemotherapy in patients who underwent hepatectomy for liver-limited metastasis (LLM) from gastric cancer (GC).

METHODS

A retrospective analysis was conducted for 52 consecutive patients who underwent macroscopically complete (R0 or R1) resection for synchronous or metachronous LLM from GC.

RESULTS

Of the 52 patients, 18 (35%) received preoperative chemotherapy (PC group), while 34 (65%) underwent upfront surgery (US group). The PC group had a significantly longer overall survival than the US group (cumulative 5-year OS rate: 47.6% vs. 24.8%, p = 0.041). Multivariate analysis of OS revealed that preoperative chemotherapy was an independent favorable prognostic factor (hazard ratio: 0.445, p = 0.036). Patients showing a partial response to preoperative chemotherapy on RECIST had an improved OS compared with those exhibiting stable or progressive disease after preoperative chemotherapy and with US (p = 0.025), even among those with solitary LLM (p = 0.062) and multiple LLM (p = 0.026). At recurrence after hepatectomy for LLM, the PC group had a significantly higher incidence of solitary tumors than the US group (p = 0.043) and had a higher chance to undergo surgical resection for recurrent sites (p = 0.006).

CONCLUSIONS

Preoperative chemotherapy can be recommended for patients with LLM from GC. The evaluation of the efficacy of preoperative chemotherapy offers additional information to determine the surgical indication for LLM.

Leptomeningeal Carcinomatosis in Early Gastric Cancer: A Case Report and Literature Review

Leptomeningeal carcinomatosis (LC) is a rare site of metastasis in solid tumors, and it is associated with poor prognosis due to disabling symptoms and a scarcity of treatment options. This condition is an uncommon entity in gastric cancer (GC). We present a case of primary LC manifestation in a patient with an incidental diagnosis of localized node-negative GC. We additionally perform a literature review and discuss the diagnostic and therapeutic challenges. In conclusion, LC from GC represents a rare condition with a dramatic prognosis. Its diagnosis might be very challenging. A multidisciplinary approach appears to be the best strategy for the management of LC from GC.

Benefit of a multimodal approach combining chemotherapy and surgery in oligometastatic gastric cancer: experience from a tertiary referral center

Introduction

Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide with limited therapeutic options. The aim of this study was to analyze the value of adding surgery to the first-line treatment in patients with oligometastatic GC (OGC).

Methods

This retrospective study included patients with OGC who underwent induction chemotherapy followed by surgery of both primary tumor and synchronous metastasis between April 2012 and April 2022. Endpoints were overall survival (OS) and relapse-free survival (RFS) analyzed by the Kaplan-Meier method. Prognostic factors were assessed with the Cox model.

Results

Data from 39 patients were collected. All cases were referred to our multidisciplinary tumor board (MTB) to evaluate the feasibility of radical surgery. After a median follow-up of 33.6 months (mo.), median OS was 26.6 mo. (95% CI 23.8-29.4) and median RFS was 10.6 mo. (95% CI 6.3-14.8). Pathologic response according to the Mandard criteria (TRG 1-3, not reached versus 20.5 mo. for TRG 4-5; HR 0.23, p=0.019), PS ECOG ≤ 1 (26.7 mo. for PS ≤ 1 versus 11.2 mo. for PS >1; HR 0.3, p=0.022) and a low metastatic burden (26.7 mo. for single site versus 12.9 mo. for ≥2 sites; HR 0.34, p=0.039) were related to good prognosis. No major intraoperative complications nor surgery-related deaths occurred in our series.

Discussion

A sequential strategy of preoperative chemotherapy and radical surgical excision of both primary tumor and metastases was demonstrated to significantly improve OS and RFS. Multidisciplinary evaluation is mandatory to identify patients who could benefit from this strategy.

Survival in esophageal cancer with nonregional lymphadenopathy: a propensity score-matched analysis

BACKGROUND

Survival among patients with esophageal cancer with stage IV nonregional lymphadenopathy treated with neoadjuvant therapy and surgical resection is not well described. This study aimed to compare the survival outcomes of patients with nonregional lymphadenopathy with a propensity-matched cohort of patients with locoregional disease.

METHODS

This was a retrospective cohort analysis of a prospectively maintained database from a regional upper gastrointestinal cancer network in Quebec, Canada. From January 2010 to December 2022, patients with radiologically suspicious nonregional retroperitoneal or supraclavicular lymphadenopathy were identified. Using 1:1 propensity score matching, a control group without nonregional disease was created.

RESULTS

Of the 1235 patients identified, 39 met the inclusion criteria and were allocated to the study group of whom 35 of 39 (89%) had adenocarcinoma. Retroperitoneal and supraclavicular lymphadenopathy occurred in 26 of 39 patients (67%) and 13 of 39 patients (33%). Of the 39 patients, 34 (87%) received neoadjuvant chemotherapy, and 5 (13%) received chemoradiotherapy. After resection, ypN0 of nonregional lymph node stations occurred in 21 of 39 patients (54%). When comparing the study group with a matched non-stage IV control group, the median overall survival was similar in patients with retroperitoneal lymphadenopathy (21.0 months [95% CI, 8.0-21.0] vs 27.0 months [95% CI, 13.0-41.0]; P = .262) but not with supraclavicular disease (13.0 months; 95% CI, 8.0-18.0; P = .039). The median follow-up intervals were 40.1 months (95% CI, 1.0-83.0) for the study group and 70.0 (95% CI, 33.0-106.0) for the control groups.

CONCLUSION

Compared with a matched cohort of patients with similar disease burden but not stage IV disease, retroperitoneal lymphadenopathy did not negatively affect survival outcomes. Multimodal curative intent therapy may be appropriate in select cases.

Conversion surgery for stage IV gastric cancer with multiple liver metastases with a complete pathological response to S-1 plus oxaliplatin therapy

Although patients with stage IV gastric cancer who respond well to systemic chemotherapy can be treated with gastrectomy, the prognosis of patients with multiple liver metastases is poor. We herein describe a patient with stage IV gastric cancer with multiple liver metastases who underwent conversion surgery after systemic treatment with S-1 plus oxaliplatin. The patient was a 62-year-old man. Upper gastrointestinal endoscopy revealed a 30-mm type 2 tumor in the greater curvature of the stomach at the anterior wall, and biopsy revealed a poorly differentiated adenocarcinoma. Imaging showed three suspected liver metastases in liver segment S8. The patient was judged to have gastric cancer, cStage IV (cT3N1M1(H)), and systemic chemotherapy was administered. He was treated with a total of six courses of chemotherapy. After re-evaluation, the primary tumor had shrunk significantly, and liver metastases could not be detected. Confirming no signs of seeding by laparoscopy, robot-assisted pylorus-preserving gastrectomy with D2 dissection and laparoscopic partial hepatic (S8) resection were performed. The patient was diagnosed with a complete pathological response. Conversion surgery is an option for stage IV gastric cancer when distant metastases are controlled with chemotherapy and when R0 resection is possible.

Effects of tumor marker regression load score on long-term prognosis of gastric cancer patients undergoing radical surgery after neoadjuvant chemotherapy

BACKGROUND

The effects of the dynamics of serum tumor markers (CA72-4, CEA, CA19-9, CA125 and AFP) before and after neoadjuvant chemotherapy (NACT) on the prognosis of gastric cancer(GC) patients remain unclear.

METHODS

The training set contained 334 GC patients from Fujian Medical University Union Hospital (FJMUUH) and 113 GC patients in Qinghai University Affiliated Hospital (QhUAH) were used as an external validation set. Tumor marker regression load (ΔTMRL) indicator, including ΔCA72-4, ΔCEA, ΔCA19-9, ΔCA125, and ΔAFP, is defined as [(postNACT marker- preNACT marker)/preNACT marker]. Tumor marker regression load score (TMRLS) consists of ΔCA72-4, ΔCEA and ΔCA125. The predictive performance of the nomogram-TMRLS was evaluated using the area under the receiver operating characteristic(ROC) curve(AUC), decision curve analysis(DCA), and C-index.

RESULTS

Patients from FJMUUH were divided into two groups, TMRLS-low and TMRLS-high, determined by R package maxstat. Survival analysis revealed a higher 3-year overall survival(OS) in the TMRLS-low than in the TMRLS-high group. The TMRLS-high group who received postoperative adjuvant chemotherapy(AC) showed a significantly higher 3-year OS rate than those who did not. Multivariate COX regression analysis indicated that TMRLS was an independent prognostic factor for OS. A nomogram for predicting OS based on TMRLS showed a significantly higher C-index and AUC than the ypTNM stage. The above results were also found in the QhUAH external validation cohort.

CONCLUSION

TMRLS is a novel independent prognostic factor for GC who underwent NACT and a radical gastrectomy. Furthermore, the TMRLS-high group, who received postoperative AC, may achieve better survival outcomes. Notably, the predictive performance of the nomogram-TMRLS significantly outperformed that of the ypTNM stage.

Regional Therapy Approaches for Gastric Cancer with Limited Peritoneal Disease

PURPOSE

Despite advances in systemic therapy, outcomes of patients with gastric cancer (GC) peritoneal carcinomatosis (PC) remain poor, in part because of poor penetrance of systemic therapy into peritoneal metastasis due to the plasma-peritoneal barrier and anarchic intra-tumoral circulation. Hence, regional treatment approach with administration of chemotherapy directly into the peritoneal cavity (intraperitoneal, IP) under various conditions, combined with or without cytoreductive surgery (CRS) has remained an area of significant research interest. The purpose of this review is to provide high-level evidence for regional treatment approaches in the management of GCPC with limited peritoneal disease.

METHODS

A review of the current literature and ongoing clinical trials for regional IP therapies for GCPC was performed. Studies included in this review comprise of phase III randomized controlled trials, non-randomized phase II studies, high-impact retrospective studies, and active ongoing clinical trials for each available IP modality.

RESULTS

The three common IP approaches are heated intraperitoneal chemotherapy (HIPEC), normothermic intraperitoneal chemotherapy (NIPEC) and more recently introduced, pressurized intraperitoneal aerosolized chemotherapy (PIPAC). These IP approaches have been combined with systemic therapy and/or CRS with varying degrees of promising results, demonstrating evidence of improvements in survival rates and peritoneal disease control. Patient selection, optimization of systemic therapy, and completeness of cytoreduction have emerged as major factors influencing the design of contemporary and ongoing trials.

CONCLUSION

IP chemotherapy has a clear role in the management of patients with GCPC, and when combined with CRS in appropriately selected patients has the potential to significantly improve survival. Ongoing and upcoming IP therapy clinical trials hold great promise to shape the treatment paradigm for GCPC.

Advances in the Surgical Management of Esophageal Cancer

Radical esophagectomy with two or three-field lymphadenectomy remains the mainstay of curative treatment for localized esophageal cancer, often in combination with systemic chemotherapy and/or radiotherapy. In this article, we describe notable advances in the surgical management of esophageal cancer over the past decade that have led to an improvement in both surgical and oncologic outcomes. In addition, we discuss new approaches to surgical management currently under investigation that have the potential to offer further benefits to appropriately selected patients. These incremental breakthroughs primarily include advances in endoscopic and minimally invasive techniques, perioperative management protocols, as well as the application of local therapies, including surgery, to oligometastatic disease.

European clinical practice guidelines for the definition, diagnosis, and treatment of oligometastatic esophagogastric cancer (OMEC-4)

INTRODUCTION

The OligoMetastatic Esophagogastric Cancer (OMEC) project aims to provide clinical practice guidelines for the definition, diagnosis, and treatment of esophagogastric oligometastatic disease (OMD).

METHODS

Guidelines were developed according to AGREE II and GRADE principles. Guidelines were based on a systematic review (OMEC-1), clinical case discussions (OMEC-2), and a Delphi consensus study (OMEC-3) by 49 European expert centers for esophagogastric cancer. OMEC identified patients for whom the term OMD is considered or could be considered. Disease-free interval (DFI) was defined as the time between primary tumor treatment and detection of OMD.

RESULTS

Moderate to high quality of evidence was found (i.e. 1 randomized and 4 non-randomized phase II trials) resulting in moderate recommendations. OMD is considered in esophagogastric cancer patients with 1 organ with ≤ 3 metastases or 1 involved extra-regional lymph node station. In addition, OMD continues to be considered in patients with OMD without progression in number of metastases after systemic therapy. 18F-FDG PET/CT imaging is recommended for baseline staging and for restaging after systemic therapy when local treatment is considered. For patients with synchronous OMD or metachronous OMD and a DFI ≤ 2 years, recommended treatment consists of systemic therapy followed by restaging to assess suitability for local treatment. For patients with metachronous OMD and DFI > 2 years, upfront local treatment is additionally recommended.

DISCUSSION

These multidisciplinary European clinical practice guidelines for the uniform definition, diagnosis and treatment of esophagogastric OMD can be used to standardize inclusion criteria in future clinical trials and to reduce variation in treatment.