Therapeutic significance of palliative operations for gastric cancer for survival and quality of life

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.

The prognostic role of palliative gastrectomy in advanced gastric cancer: a systematic review and meta-analysis

BACKGROUND

The effectiveness of palliative gastrectomy for advanced GC remains a topic of debate. This study sought to establish whether palliative gastrectomy has an impact on prolonging survival.

METHODS

We carried out systematic searches in PubMed, Cochrane Library, Web of Science, and the EMBASE databases from database inception to July 2023 to gather studies that examined the connection between palliative gastrectomy and the prognosis of advanced GC. The study employed overall survival as the primary outcome, with the hazard ratio serving as the selected parameter to gauge the association. Subgroup analyses were performed to delve into potential differences within the included studies, categorizing them by study region and sample size in order to examine possible sources of heterogeneity. The stability of individual studies was assessed through sensitivity analysis. The analysis included 20 articles, encompassing a total of 23,061 patients.

RESULTS

According to the meta-analysis results, patients who underwent palliative gastrectomy exhibited a noteworthy enhancement in overall survival (HR: 1.49; 95% CI: 1.12-1.99; P = 0.006) in comparison to those who did not receive this procedure. There was no association between the type of surgery and the length of hospital stay, as revealed by the analysis (HR = -0.02; 95% CI: -0.84-0.81; P = 0.970).

CONCLUSIONS

Based on this meta-analysis, patients with advanced gastric cancer who underwent palliative gastrectomy may experience an extended survival duration without a significant prolongation of their hospitalization.

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes

BACKGROUND

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population.

PATIENTS AND METHODS

Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated.

RESULTS

Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months.

CONCLUSIONS

Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

Survival benefits of palliative gastrectomy for gastric cancer patients with liver metastasis: a population-based propensity score-matched cohort analysis

Background and aims

Palliative primary tumor resection (pPTR) can benefit colorectal cancer patients with liver metastasis. Whether pPTR benefiting gastric cancer (GC) patients with liver metastasis is still controversial.

Methods

Data on patients with metastatic GC diagnosed between 2010 to 2019 was extracted from SEER database. Propensity score analysis with 1:1 matching was performed. The univariable and multivariable Cox proportional hazards regression models were used to explore prognostic factors. Kaplan-Meier method was used to analyze survival outcomes.

Results

Of 5691 GC patients with liver metastasis, 468 were included in the matched cohorts. The results showed that the median survival time was 6 months in the non-surgery groups and 14.5 months in the surgery groups (p < 0.001). Multivariable analysis showed that surgery was a protective prognostic factor for overall survival [hazard ratio (HR) = 0.416] as well as cancer-specific survival (HR = 0.417). Also, pPTR was only recommended for GC patients with isolated liver metastasis. Moreover, pPTR combined with chemotherapy brought the greatest therapeutic effect.

Conclusion

pPTR benefits GC patients with isolated liver metastasis, and GC patients with liver metastasis receiving pPTR combined with chemotherapy had the best survival outcomes than any other therapeutic model.

Does resection after neoadjuvant chemotherapy of docetaxel, oxaliplatin, and S-1 (DOS regimen) benefit for gastric cancer patients with single non-curable factor? a multicenter, prospective cohort study (Neo-REGATTA)

BACKGROUND

The Neo-REGATTA study evaluated the effectiveness and safety of Docetaxel, oxaliplatin, and S-1 (DOS regimen) followed by radical resection vs. chemotherapy in advanced gastric adenocarcinoma patients with single non-curable factor.

METHODS

This cohort study prospectively enrolled advanced gastric adenocarcinoma patients with single non-curable factor between November 2017 and June 2021. Patients without progression after four cycles of DOS were divided into resection group and chemotherapy group. The outcomes included overall survival (OS), progression-free survival (PFS) and safety. Effectiveness analysis was also performed by propensity score matching (PSM).

RESULTS

A total of 73 patients were enrolled and 13 patients were withdrawn due to disease progression after 4 cycles of DOS. Afterwards, 35 and 25 participants were in the resection and chemotherapy groups, respectively. After a median follow-up time of 30.0 months, the median PFS and OS were 9.0 months, and 18.0 months for the chemotherapy group, but not reached in the resection group. After PSM, 19 matched participants were in each group, and the median PFS and OS were longer in resection group than that in chemotherapy group. The most common grade 3 or 4 adverse events both in the resection group and chemotherapy groups were neutropenia (5.7%, 8.0%) and leukopenia (5.7%, 8.0%).

CONCLUSIONS

Radical resection might provide survival benefit compared with continuous chemotherapy alone in advanced gastric adenocarcinoma patients who had a disease control after DOS, with a good safety profile.

TRIAL REGISTRATION

The study protocol was registered on ClinicalTrial.gov (NCT03001726, 23/12/2016).

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Outcomes After Surgical Palliation of Patients With Gastric Cancer

INTRODUCTION

Surgery is an option for symptom palliation in patients with metastatic gastric cancer. Operative outcomes after palliative interventions are largely unknown. Herein, we assess the trends of surgical palliation use for patients with gastric cancer and describe outcomes of patients undergoing surgical palliation compared to nonsurgical palliation.

METHODS

Patients with clinical Stage IV gastric cancer in the National Cancer Database (2004-2015) who received surgical or nonsurgical palliation were selected. We identified factors associated with palliative surgery. Survival differences were assessed by Kaplan-Meier estimate, Cox proportional hazard regression, and log rank test.

RESULTS

Six thousand eight hundred twenty nine patients received palliative care for gastric cancer. Most patients (87%, n = 5944) received nonsurgical palliation: 29% radiation therapy, 57% systemic treatment, and 14% pain management. The number of patients receiving palliative care increased between 2004 and 2015; however, use of surgical palliation declined significantly (22% in 2004, 8% in 2015; P < 0.001). Median overall survival (OS) for the cohort was 5.65 mo (95% confidence interval 5.45-5.85); 1-year and 2-year OS were 24% and 9%, respectively. Older age at diagnosis and diagnosis between 2004 and 2006 were significantly associated with undergoing surgical palliation. Patients who underwent surgical palliation had significantly shorter median OS and a 20% higher hazard of mortality than those who received nonsurgical palliation.

CONCLUSIONS

Patients with metastatic gastric cancer experience very short survival. While palliative surgery is used infrequently, the observed association with shorter median OS underscores the importance of careful patient selection. Palliative surgery should be offered judiciously and expectations about outcomes clearly established.

Palliative Gastrectomy vs. Gastrojejunostomy for Advanced Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Advanced gastric cancer is the fifth leading cause of cancer-related deaths. Patients with metastatic advanced gastric cancer commonly develop a gastric outlet obstruction that considerably worsens their quality of life. Surgical interventions such as gastrojejunostomy and palliative gastrectomy are commonly administered to alleviate this obstruction. However, whether one intervention is better than another at improving morbidity- and mortality-related outcomes is unclear. Thus, in this meta-analysis, we compare outcomes of palliative gastrectomy and gastrojejunostomy (overall hospital stay length, time to oral intake, survival, and complication rates) in patients with metastatic advanced gastric cancer to identify the best procedure.

Objective: To compare morbidity and mortality outcomes of palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer.

Methods: We followed the PRISMA guidelines to systematically search Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE for relevant studies. We conducted a random-effects meta-analysis to find differential outcomes between palliative gastrectomy and gastrojejunostomy among variables such as time to oral intake, overall hospital stay length, complication rates, and survival in patients with metastatic advanced gastric cancer.

Results: From 963 studies, we found 7 eligible studies with 642 patients (70.3 ± 4.7 years) who had undergone palliative gastrectomy or gastrojejunostomy. Our meta-analysis revealed an insignificant (p > 0.05) differences in terms of overall survival duration (Hedge's g, 1.22), complication risks (odds ratio, 1.35), and time to oral intake (g, 0.62) and hospital stay length (g, 0.12) between patients undergoing gastrojejunostomy and palliative gastrectomy.

Conclusion: In this present study we observed no statistically significant differences in terms of morbidity and mortality outcomes after palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer. Therefore, no conclusions can be drawn for the variables evaluated. This study provides a preliminary overview of the risks associated with gastrojejunostomy and palliative gastrectomy to help gastroenterologists manage patients with metastatic advanced-stage gastric cancer.

Is D2 Lymphadenectomy Alone Suitable for Gastric Cancer With Bulky N2 and/or Para-Aortic Lymph Node Metastases After Preoperative Chemotherapy?

Background

For gastric cancer (GC) with extensive lymph node metastasis (bulky N2 and/or para-aortic lymph node metastases), there is no standard therapy worldwide. In Japan, preoperative chemotherapy (PCT) followed by D2 gastrectomy plus para-aortic lymph node dissection (PAND) is considered the standard treatment for these patients. However, in China, the standard operation for GC patients with only bulky N2 metastases was D2 gastrectomy. Besides, after PCT, whether doing PAND improves survival or not is debatable for GC patients with para-aortic lymph node (PAN) metastases. Therefore, we conducted this study to investigate whether D2 lymphadenectomy alone is suitable for these patients after PCT.

Methods

We retrospectively collected data on patients from our electronic medical record system. GC patients with bulky N2 and/or PAN metastases who underwent D2 lymphadenectomy alone after PCT were enrolled. The survival outcomes and chemotherapy responses were analyzed and compared with the results of the JCOG0405 study.

Results

From May 2009 to December 2017, a total of 83 patients met all eligibility criteria and were enrolled. The median survival duration for all patients was 40.0 months. The 3-year and 5-year OS rates for all patients were 50.3% and 45.6%, respectively. For patients with only bulky N2 metastasis, the 3-year and 5-year OS rates were 77.1% and 71.6%, respectively, which were similar to the results of the JCOG0405 study (82.7% and 73.4%). For patients with only PAN metastases, the 3-year and 5-year OS rates were 50.0% and 50.0%, respectively, which seemed to be lower than those of the JCOG0405 study (64.3% and 57.1%). For patients with bulky N2 and PAN metastases, the 3-year and 5-year OS rates were 7.4% and 0.0%, respectively, which were lower than those of the JCOG0405 study (20.0% and 20.0%).

Conclusion

The results of our study suggest that D2 lymphadenectomy alone is suitable for GC patients with only bulky N2 metastasis after PCT. However, D2 lymphadenectomy alone perhaps is not suitable for patients with bulky N2 and PAN metastases after PCT.

Palliative gastrectomy for metastatic gastric adenocarcinoma: A national population-based cohort study

BACKGROUND

The impact of palliative gastrectomy for metastatic gastric adenocarcinoma, especially by site of metastasis remains unclear.

METHODS

The National Cancer Database, 2010-2015, was used to identify patients with clinical metastatic (cM1) gastric adenocarcinoma (n = 19,411) at diagnosis. The main variable was index management for cM1 gastric adenocarcinoma (ie, no treatment, palliative chemotherapy, or palliative gastrectomy). Cox multivariable analyses were used to account for treatment selection bias and reported as hazard ratio (HR) and 95% confidence interval.

RESULTS

Of 19,411 patients, 10,893 (56%) received palliative chemotherapy, and only 1,101 (6%) received palliative gastrectomy only. The median survival was 6.1 months, and 5-year survival was 4% in the entire cohort. Patients receiving palliative gastrectomy had a significantly longer survival than patients without any treatment or palliative chemotherapy (median: 12.8 vs 1.8 vs 9.5 months, P < .001), which remained after multivariable adjustment (HR: 0.76, 95% confidence interval: 0.71-0.81, P < .001) compared with palliative chemotherapy. Stratified analyses by clinical nodal stage (cN) demonstrated survival benefit with palliative gastrectomy: cN0 (HR: 0.71, 95% confidence interval: 0.62-0.82), cN1 (HR: 0.68, 95% confidence interval: 0.59-0.79), cN2 (HR: 0.86, 95% confidence interval: 0.70-0.94), and cN3 (HR: 0.82, 95% confidence interval: 0.70-0.92) over palliative chemotherapy. Stratified analyses by metastasis site demonstrated that palliative gastrectomy remained superior compared with palliative chemotherapy for metastatic disease limited to liver, bone, and peritoneum, but equivalent to lung metastasis and inferior to brain metastasis.

CONCLUSION

Palliative gastrectomy appears to have a modest survival benefit over palliative chemotherapy alone. Differences in outcomes by site of metastasis warrant further research to understand tumor biology and identify specific subgroups which may benefit from palliative gastrectomy.

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

Surgical Outcomes and Survival Prognostic Factors for Palliative Gastrectomies in Stage IV Resectable Gastric Cancer Outlet Obstruction Patients

Purpose

Currently, there is no clear evidence to support any specific treatment as a principal therapy for stage IV gastric cancer outlet obstruction (GCOO) patients. This study evaluated the outcomes of palliative gastrectomies and survival prognostic factors in patients with stage IV resectable GCOO.

Materials and Methods

We retrospectively reviewed the medical records of 48 stage IV GCOO patients who underwent palliative gastrectomies between June 2010 and December 2019. Palliative gastrectomies were performed only in patients with resectable disease. Early surgical outcomes and prognostic factors were analyzed using univariate and multivariate analyses.

Results

There were no specific risk factors for postoperative complications, except for being underweight. Severe postoperative complications developed in five patients, and most of the patients underwent interventional procedures and received broad-spectrum antibiotics for intra-abdominal abscesses. The multivariate survival analysis showed that palliative chemotherapy is a positive prognostic factor, while the specific type of hematogenous and lymphatic metastasis is a negative prognostic factor.

Conclusions

We recommend that the treatment method for stage IV GCOO should be selected according to each patient's physical condition and tumor characteristics. In addition, we suggest that palliative gastrectomies can be performed in stage IV resectable GCOO patients without unfavorable prognostic factors (types of hematogenous and lymphatic metastases).

Who Will Benefit from Noncurative Resection in Patients with Gastric Cancer with Single Peritoneal Metastasis?

The value of noncurative resection for patients with gastric cancer with single peritoneal metastasis is still debatable. This study was undertaken to evaluate the survival benefit of resection in those patients. From 2006 to 2009, 119 patients with gastric cancer with single peritoneal metastasis were identified during surgery. Sixty-three of them had noncurative resection; the remainder had nonresection. Clinicopathological variables and survival were analyzed. Overall survival of patients in the noncurative resection group was longer than that in the nonresection group (14.869 vs 7.780 months). This survival advantage was still significantly better in the P1/P2 patients who underwent noncurative resection (mean survival time 21.164 vs 7.636 months, P = 0.001), but not in the P3 group ( P = 0.489). Multivariate analysis indicated that only noncurative resection retained a significant association with better prognosis in P1/P2 patients. The perioperative mortality rate in the resection group was not significantly higher than that of the noncurative group ( P = 0.747). Noncurative resection can prolong the survival of patients with gastric cancer with single P1/P2 peritoneal metastasis. This surgical approach should not be taken into account for those patients with P3 gastric cancer.

Influence of peritoneal carcinomatosis on perioperative outcome in palliative gastric bypass for malignant gastric outlet obstruction - a retrospective cohort study

Background

Malignant gastric outlet obstruction (GOO) is commonly associated with the presence of peritoneal carcinomatosis (PC) and preferably treated by surgical gastrojejunostomy (GJJ) in patients with good performance. Here, we aim to investigate the role of PC as a risk factor for perioperative morbidity and mortality in patients with GOO undergoing GJJ.

Methods

Perioperative data of 72 patients with malignant GOO who underwent palliative GJJ at our institution between 2010 and 2019 were collected within an institutional database.

To compare perioperative outcomes of patients with and without PC, extensive group analyses were carried out.

Results

A set of 39 (54.2%) patients was histologically diagnosed with concomitant PC while the remaining 33 (45.8%) patients showed no clinical signs of PC. In-house mortality due to surgical complications was significantly higher in patients with PC (9/39, 23.1%) than in patients without PC (2/33, 6.1%, p = .046). Considerable differences were observed in terms of surgical complications such as anastomotic leakage rates (2.8% vs. 0%, p = .187), delayed gastric emptying (33.3% vs. 15.2%, p = .076), paralytic ileus (23.1% vs. 9.1%, p = .113), and pneumonia (17.9% vs. 12.1%, p = .493) without reaching the level of statistical significance.

Conclusions

PC is an important predictor of perioperative morbidity and mortality patients undergoing GJJ for malignant GOO.

Clinicopathological risk factors for gastric cancer: a retrospective cohort study in China

OBJECTIVE

To examine the potential clinicopathological factors affecting the prognosis of patients with gastric cancer after surgical treatment in China.

METHODS

Between 1 January 2001 and 31 December 2012, a total of 716 patients aged 22-84 years with gastric cancer were enrolled in the study. Survival analysis techniques including log rank test and Cox proportional hazard regression model were applied to evaluate the prognostic significance of clinicopathological characteristics in terms of survival time.

RESULTS

Of the 24 demographic and pathological variables collected in the data, 16 prognostic factors of gastric cancer were found to have statistically significant influences on survival time from the unadjusted analyses. The adjusted analysis furtherly revealed that age, age square, lymph node metastasis rate group, tumour size group, surgical type II, number of cancer nodules, invasion depth group and the interaction between surgical type II and tumour size group were important prognosis and clinicopathological factors for gastric cancer in Chinese.

CONCLUSION

Our study with relatively large sample size and many potential risk factors enable us to identify independent risk factors associated with the prognosis of gastric cancer. Findings from the current study can be used to assist clinical decision-making, and serve as a benchmark for the planning of future prognosis and therapy for patients with gastric carcinoma.

Palliative Gastrectomy and Survival in Patients With Metastatic Gastric Cancer: A Propensity Score-Matched Analysis of a Large Population-Based Study

OBJECTIVES

The role of palliative gastrectomy in the management of metastatic gastric cancer remains inadequately clarified.

METHODS

We analyzed patients with metastatic gastric cancer enrolled in the Surveillance, Epidemiology, and End Results registry from January 2004 to December 2012. Propensity score (PS) analysis with 1:1 matching and the nearest neighbor matching method was performed to ensure well-balanced characteristics of the groups of patients who undergone gastrectomy and those without gastrectomy. Data were analyzed by Kaplan-Meier and Cox proportional hazards regression models to evaluate the overall survival and cancer-specific survival rates with corresponding 95% confidence intervals (CIs).

RESULTS

In general, receiving any kind of gastrectomy was associated with an improvement in survival in the multivariate analyses (hazard ratio [HR]os = 0.64, 95% CI = 0.59-0.70, HRcss = 0.63, 95% CI = 0.57-0.68) and PS matching (PSM) analyses (HRos = 0.63, 95% CI = 0.56-0.70, HRcss = 0.62, 95% CI = 0.55-0.70). After PSM, palliative gastrectomy was found to be associated with remarkably improved survival for patients with stage M1 with only 1 metastasis but not associated with survival of patients with stage M1 with extensive metastasis (≥2 metastatic sites).

DISCUSSION

The results obtained from the Surveillance, Epidemiology, and End Results database suggest that patients with metastatic gastric cancer might benefit from palliative gastrectomy on the basis of chemotherapy. However, a PSM cohort study of this kind still has a strong selection bias and cannot replace a properly conducted randomized controlled trial.

[Therapeutic approach in oligometastatic gastric and esophageal cancer]

The therapeutic approach to patients with oligometastatic gastric cancer and esophageal cancer is currently undergoing a shift towards a more aggressive therapy including surgical resection. In the current German S3 guidelines surgical treatment of metastatic disease is not recommended; however, nowadays interdisciplinary tumor boards have to evaluate such patients increasingly more often. On an individual basis a radical surgical resection of the primary tumor and the metastases is considered and performed in patients who respond well to multimodal chemotherapy concepts. In this review article the currently available data from the literature are discussed and a foundation for individually extended surgical approaches is presented. Together with the currently available results of the FLOT 3 study and the mostly retrospective studies, it seems to be possible to identify patients who would profit from such an aggressive treatment. In the future randomized prospective studies, such as the RENAISSANCE/FLOT 5 study and the GASTRIPEC study will have to evaluate whether an aggressive surgical therapy within multimodal therapy concepts of metastatic gastric and esophageal carcinomas is warranted.

Palliative gastrectomy plus chemotherapy versus chemotherapy alone for incurable advanced gastric cancer: a meta-analysis

BACKGROUND

Whether palliative gastrectomy combined with chemotherapy can improve the survival of patients with advanced gastric cancer remains controversial. We performed a meta-analysis to clarify whether palliative gastrectomy plus chemotherapy can benefit patients with incurable advanced gastric cancer and to explore the best candidates in this patient population.

METHODS

We searched the literature systematically using electronic databases including PubMed, EMBASE, and the Cochrane Library. And HRs and their 95% CIs were used to express the results for overall survival (OS) and progression-free survival (PFS).

RESULTS

One randomized controlled trial with 175 patients and 12 cohort studies with 2,193 patients were analyzed. The pooled HR for OS (HR=0.43, 95% CI=0.29-0.65, P<0.001), subgroup analysis of stage M1 (HR=0.53, 95% CI=0.40-0.72, P<0.001), peritoneal dissemination (HR=0.46, 95% CI=0.28-0.73, P=0.001), and liver metastasis (HR=0.46, 95% CI=0.33-0.65, P<0.001) all indicated the superiority of palliative gastrectomy plus chemotherapy. However, the pooled HR for PFS (HR=0.61, 95% CI=0.33-1.13, P=0.110) got separate outcome.

CONCLUSION

The results of this meta-analysis indicated that palliative gastrectomy plus chemotherapy can improve OS for incurable advanced gastric cancer. In addition, analyses based on liver metastasis and peritoneal dissemination demonstrated the advantages of palliative gastrectomy plus chemotherapy. However, the PFS of incurable advanced gastric cancer with palliative gastrectomy plus chemotherapy was no better than that under chemotherapy alone.

The Role of Surgical Resection for Stage IV Gastric Cancer With Synchronous Hepatic Metastasis

BACKGROUND

With improved responses to chemotherapy and targeted treatments, the role of surgery in metastatic gastric cancer (MGC) to the liver needs to be revisited. We sought to examine whether surgical resection is associated with improvement of long-term survival.

METHODS

The National Cancer Database was queried for MGC to the liver (2010-2014). Survival analysis was performed to compare the effect of gastrectomy and perioperative chemotherapy (G-CT) to palliative chemotherapy (PCT) alone.

RESULTS

We identified 3175 patients with MGC to the liver. Most patients (94%, n = 2979) were treated with PCT, whereas 6% (n = 196 patients) underwent G-CT. Overall survival improved in patients treated with G-CT compared to PCT alone (16 versus 9.7 mo, P < 0.001). In patients undergoing G-CT, neoadjuvant chemotherapy was associated with increased overall survival compared to adjuvant chemotherapy (18.9 versus 14.8 mo, P = 0.011). Hazards of death significantly decreased with gastrectomy (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.44-0.63, P < 0.001). Negative prognostic factors included advanced age (HR: 1.10, 95% CI: 1.06-1.14, P < 0.001), treatment at nonacademic institution (HR: 1.23, 95% CI: 1.13-1.33, P < 0.001), and poorly differentiated grade (HR: 1.54, 95% CI: 1.17-2.03, P < 0.001).

CONCLUSIONS

G-CT is associated with improved survival in patients with gastric cancer and synchronous liver metastasis. Further experience with well-designed prospective trials may be warranted to confirm these findings.

Radiation Therapy for Gastric Cancer Bleeding

Aims and Background

To evaluate the outcome of palliative radiotherapy (RT) for patients with gastric cancer bleeding.

Methods

A retrospective review of 30 patients with gastric cancer bleeding who underwent palliative RT was conducted. Twenty-three patients who received a dose of ≥30 Gy in 10 fractions were eligible. The palliative effect was evaluated both in a subjective and objective manner. Subjective symptomatic relief of bleeding was determined and an objective response was evaluated by identifying the amount of transfused packed red blood cells (PRBC) and the mean hemoglobin (Hb) level of patients before and after RT.

Results

Subjective symptom relief was observed in 21 patients. The number of transfused PRBC units was 2 to 25 (median, 6) during the month before RT and 0 to 16 (median, 0) during the month after RT ( P <0.001). The average level of Hb increased from 9.1 ± 1.6 g/dL to 10.6 ± 1.6 g/dL ( P <0.001). In 9 patients whose laboratory findings were available for ≥3 months after RT, the mean Hb at one, two, and three months after RT was 10.7 ± 1.7 g/dL ( P = 0.004), 10.5 ± 1.0 g/dL ( P = 0.039), and 9.9 ± 1.0 g/dL ( P = 0.164), respectively. The median number of transfused PRBC units decreased from 6 to 0 during the three months after RT.

Conclusion

RT may be an effective treatment for gastric cancer bleeding when other modalities are not feasible. In this study, 91% of the patients experienced symptomatic palliation with an elevated Hb level and a decreased number of transfusions after RT.

Survival benefits of gastrectomy in gastric cancer patients with stage IV: a population-based study

Objective

The aim of the current study is to investigate the role of gastrectomy for survival among metastatic gastric cancer patients.

Results

We finally identified 12,986 eligible patients with stage IV GC between 2004 and 2012, including 1,981 (15.3%) patients with gastrectomy and 11,005 (84.7%) without surgery. The median overall survival time for patients with and without surgery were 9.0 (95%, 8.3–9.7) and 4.0 (95%, 3.9–4.1) months respectively. Patients who received gastrectomy had a significantly better survival outcome compared with those without surgery (P < 0.05). In the multivariate Cox analysis, gastrectomy was associated with decreased overall mortality (HR, 0.47, 95% CI 0.44–0.49, P < 0.001) and cancer-specific mortality (HR, 0.46, 95% CI 0.44–0.50, P < 0.001). The survival benefits associated with surgery persisted even after performing the propensity score matching analysis (overall survival, HR, 0.47, 95% CI 0.43–0.50, cancer-specific survival, HR, 0.47, 95% CI 0.44–0.50).

Conclusions

Based on population-based study, we demonstrated that there was a survival advantage of gastrectomy in stage IV GC patients. Further prospective trials need to verify our findings.

Materials and Methods

We included an eligible cohort of stage IV gastric cancer (GC) patients in the Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2012. The survival difference of patients with and without gastrectomy were assessed by Kaplan–Meier analysis and log-rank test. Multivariate Cox analyses were performed to analyze the effect of gastrectomy on overall and cancer-specific mortality. Furthermore, we performed propensity score matching (PSM) to reduce the potential selection bias.

Cross-Sectional Location of Gastric Cancer Affects the Long-Term Survival of Patients as Tumor Invasion Deepens

BACKGROUND

The prognosis of gastric cancer is generally determined by tumor depth and lymph node metastasis, while the effect of cross-sectional tumor location on prognosis remains unclear.

METHODS

This study recruited patients who had been diagnosed with gastric cancer and who underwent gastrectomy from 1989 to 2012. The cross-sectional locations of the gastric cancers were classified into four regions: the lesser (LC) and greater curvatures (GC), and anterior (AW) and posterior walls (PW).

RESULTS

Overall, 4820 patients were enrolled in this study. The most common site of gastric cancer among the four cross-sectional locations was the LC (46.4%), while the proportions of PW (19.9%), AW (18.4%), and GC (15.4%) were similar. Overall survival differed statistically (p = 0.013) according to the cross-sectional location, and the 5-year overall survival of those with tumors with a GC location was significantly worse (p = 0.003) than for the other three locations. In subgroup multivariate analysis, GC location was an independent prognostic indicator for a worse clinical outcome at T stage 3-4b (hazard ratio 1.365, 95% confidence interval 1.150-1.620, p < 0.001). In addition, a GC gastric cancer had a higher recurrence rate in terms of peritoneal seeding compared with other locations.

CONCLUSIONS

The cross-sectional location of gastric cancer is associated with long-term survival. A GC location predicts a worse prognosis, especially in gastric cancer patients with deeper T stages.

Effect of age on rates of palliative surgery and chemotherapy use in patients with locally advanced or metastatic gastric cancer

BACKGROUND

This study assessed trends in the treatment and survival of palliatively treated patients with gastric cancer, with a focus on age-related differences.

METHODS

For this retrospective, population-based, nationwide cohort study, all patients diagnosed between 1989 and 2013 with non-cardia gastric cancer with metastasized disease or invasion into adjacent structures were selected from the Netherlands Cancer Registry. Trends in treatment and 2-year overall survival were analysed and compared between younger (age less than 70 years) and older (aged 70 years or more) patients. Analyses were done for five consecutive periods of 5 years, from 1989-1993 to 2009-2013. Multivariable logistic regression analysis was used to examine the probability of undergoing surgery. Multivariable Cox regression analysis was used to identify independent risk factors for death.

RESULTS

Palliative resection rates decreased significantly in both younger and older patients, from 24·5 and 26·2 per cent to 3·0 and 5·0 per cent respectively. Compared with patients who received chemotherapy alone, both younger (21·6 versus 6·3 per cent respectively; P < 0·001) and older (14·7 versus 4·6 per cent; P < 0·001) patients who underwent surgery had better 2-year overall survival rates. Multivariable analysis demonstrated that younger and older patients who received chemotherapy alone had worse overall survival than patients who had surgery only (younger: hazard ratio (HR) 1·22, 95 per cent c.i. 1·12 to 1·33; older: HR 1·12, 1·01 to 1·24). After 2003 there was no association between period of diagnosis and overall survival in younger or older patients.

CONCLUSION

Despite changes in the use of resection and chemotherapy as palliative treatment, overall survival rates of patients with advanced and metastatic gastric cancer did not improve.

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.

Is noncurative gastrectomy always a beneficial strategy for stage IV gastric cancer?

Purpose

The purpose of this study is to suggest a treatment strategy for stage IV gastric cancer by investigating the behavioral difference between initially and recurrent metastatic disease.

Methods

We reviewed the medical records of the patients who underwent chemotherapy alone for metastatic gastric cancer between January 2006 and September 2013. Patients were divided into those who underwent chemotherapy for metastatic disease since initial diagnosis (IM group) and for metastatic recurrence after curative surgery (RM group). Survival and causes of death were compared between the 2 groups, and significant prognostic factors were also investigated.

Results

A total of 170 patients were enrolled in this study. Of these patients, 104 were included in the IM group and 66 in the RM group. Overall survival of the IM group did not differ from that of RM (P = 0.569). In the comparison of the causes of death, the IM group had a greater tendency to die from bleeding (P = 0.054) and pneumonia (P = 0.055). In multivariate analysis, bone metastasis (P < 0.001; HR = 2.847), carcinoma peritonei (P = 0.047; HR = 1.766), and the frequency of chemotherapy (P < 0.001; HR = 0.777) were significantly associated with overall survival of IM group.

Conclusion

Disease-burden mainly contributes to the prognosis of metastatic gastric cancer, although noncurative gastrectomy may be helpful in reducing the mortality of initially metastatic disease. Therefore, disease-burden should be also prioritized in determining the treatment strategies for stage IV gastric cancer.

Significant Role of Palliative Gastrectomy in Selective Gastric Cancer Patients with Peritoneal Dissemination: A Propensity Score Matching Analysis

OBJECTIVE

The aim of this study was to explore whether palliative gastrectomy is suitable for gastric cancer patients with peritoneal metastasis, and for patients in whom the type of peritoneal metastasis should be selected to receive palliative gastrectomy.

METHODS

A total of 747 patients diagnosed with gastric adenocarcinoma with peritoneal metastasis at our centers between January 2000 and April 2014 were retrospectively analyzed. After propensity score matching, the clinicopathologic characteristics and clinical outcomes of patients with peritoneal dissemination were analyzed.

RESULTS

After propensity score matching, the median overall survival (OS) of patients in the gastrectomy group was longer than that for patients in the non-gastrectomy group (11.87 vs. 9.27 months; p = 0.020). Patients who received first-line chemotherapy had a significantly longer median OS than those who did not (11.97 vs. 7.03 months; p < 0.001); among these patients, those undergoing more than eight periods of first-line chemotherapy benefited the most (p < 0.001). Subgroup analyses revealed that patients classified as P1 who were undergoing chemotherapy benefited from gastrectomy (p = 0.024), and patients without multisite metastasis also benefited from gastrectomy with regard to OS (p = 0.007). In the multivariate survival analysis, multisite distant metastasis was the independent poor prognostic factor (p < 0.001), while palliative gastrectomy (p = 0.006) and a period of first-line chemotherapy (p < 0.001) were good prognostic factors. Morbidity rates in the gastrectomy and non-gastrectomy groups were 10.4 and 1.0 %, respectively (p = 0.003); however, no difference in mortality was noted between the two groups (p = 0.590).

CONCLUSIONS

Palliative gastrectomy can prolong the survival of P1 patients without multisite distant metastasis when combined with more than five periods, and particularly more than eight periods, of first-line chemotherapy.

Modest overall survival improvements from 1998 to 2009 in metastatic gastric cancer patients: a population-based SEER analysis

BACKGROUND

An increasing fraction of gastric cancer patients present with distant metastases at diagnosis. The objective of the present 11-year population-based trend analysis was to assess the survival rates in patients who underwent and in patients who did not undergo palliative gastrectomy.

METHODS

Patients with metastatic gastric cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2009. Time trend and impact of palliative gastrectomy on survival were assessed by both a multivariate Cox proportional hazards model and propensity score matching.

RESULTS

We identified 8249 patients with stage IV gastric cancer. The rate of metastatic disease increased from 31.0 % in 1998 to 37.5 % in 2009 (P < 0.001). The palliative gastrectomy rate dropped from 18.8 to 10.2 % (P = 0.004). The median survival for patients who underwent palliative gastrectomy (N = 1445, 17.4 %) and for patients who did not undergo palliative gastrectomy (N = 6804, 82.4 %) was 7 and 3 months, respectively. There was an increase in median overall survival from 2 months (1998) to 3 months (2009) in the no-gastrectomy group, and from 6.5 to 8 months in the gastrectomy group. The 3-year cancer-specific survival rates were 2.1 % (95 % confidence interval 1.7-2.5 %) for patients who did not undergo palliative gastrectomy and 9.4 % (95 % confidence interval 7.8-11.2 %) for patients who underwent palliative gastrectomy (P < 0.001). Palliative gastrectomy was associated with an increased cancer-specific survival in propensity-score-adjusted Cox regression analyses (hazard ratio 0.50, 95 % confidence interval 0.46-0.55, P < 0.001).

CONCLUSION

On a population-based level, only modest improvements in prognosis for metastatic gastric cancer were observed in patients who underwent and in patients who did not undergo palliative gastrectomy. Considering the low rate of midterm survivors in both groups, only a small subgroup of patients benefits from palliative gastrectomy.

Primary Tumor Resection and Survival in Patients with Stage IV Gastric Cancer

Purpose

The aim of this study was to determine whether surgical resection of the primary tumor contributes to survival in patients with metastatic gastric cancer.

Materials and Methods

A total of 288 patients with metastatic gastric cancer from the Akdeniz University, Antalya Training and Research Hospital, and the Meram University of Konya database were retrospectively analyzed. The effect of primary tumor resection on survival of patients with metastatic gastric cancer was investigated using the log-rank test. Kaplan-Meier survival estimates were calculated. Multivariate analysis was performed using Cox proportional hazards regression modeling.

Results

The median overall survival was 12.0 months (95% confidence intewrval [CI], 10.4~13.6 months) and 7.8 months (95% CI, 5.5~10.0 months) for patients with and without primary tumor resection, respectively (P<0.001). The median progression-free survival was 8.3 months (95% CI, 7.1~9.5 months) and 6.2 months (95% CI, 5.8~6.7 months) for patients with and without primary tumor resection, respectively (P=0.002).

Conclusions

Non-curative gastrectomy in patients with metastatic gastric cancer might increase their survival rate regardless of the occurrence of life-threatening tumor-related complications.

Gastrectomy plus chemotherapy versus chemotherapy alone for advanced gastric cancer with a single non-curable factor (REGATTA): a phase 3, randomised controlled trial

BACKGROUND

Chemotherapy is the standard of care for incurable advanced gastric cancer. Whether the addition of gastrectomy to chemotherapy improves survival for patients with advanced gastric cancer with a single non-curable factor remains controversial. We aimed to investigate the superiority of gastrectomy followed by chemotherapy versus chemotherapy alone with respect to overall survival in these patients.

METHODS

We did an open-label, randomised, phase 3 trial at 44 centres or hospitals in Japan, South Korea, and Singapore. Patients aged 20-75 years with advanced gastric cancer with a single non-curable factor confined to either the liver (H1), peritoneum (P1), or para-aortic lymph nodes (16a1/b2) were randomly assigned (1:1) in each country to chemotherapy alone or gastrectomy followed by chemotherapy by a minimisation method with biased-coin assignment to balance the groups according to institution, clinical nodal status, and non-curable factor. Patients, treating physicians, and individuals who assessed outcomes and analysed data were not masked to treatment assignment. Chemotherapy consisted of oral S-1 80 mg/m(2) per day on days 1-21 and cisplatin 60 mg/m(2) on day 8 of every 5-week cycle. Gastrectomy was restricted to D1 lymphadenectomy without any resection of metastatic lesions. The primary endpoint was overall survival, analysed by intention to treat. This study is registered with UMIN-CTR, number UMIN000001012.

FINDINGS

Between Feb 4, 2008, and Sept 17, 2013, 175 patients were randomly assigned to chemotherapy alone (86 patients) or gastrectomy followed by chemotherapy (89 patients). After the first interim analysis on Sept 14, 2013, the predictive probability of overall survival being significantly higher in the gastrectomy plus chemotherapy group than in the chemotherapy alone group at the final analysis was only 13·2%, so the study was closed on the basis of futility. Overall survival at 2 years for all randomly assigned patients was 31·7% (95% CI 21·7-42·2) for patients assigned to chemotherapy alone compared with 25·1% (16·2-34·9) for those assigned to gastrectomy plus chemotherapy. Median overall survival was 16·6 months (95% CI 13·7-19·8) for patients assigned to chemotherapy alone and 14·3 months (11·8-16·3) for those assigned to gastrectomy plus chemotherapy (hazard ratio 1·09, 95% CI 0·78-1·52; one-sided p=0·70). The incidence of the following grade 3 or 4 chemotherapy-associated adverse events was higher in patients assigned to gastrectomy plus chemotherapy than in those assigned to chemotherapy alone: leucopenia (14 patients [18%] vs two [3%]), anorexia (22 [29%] vs nine [12%]), nausea (11 [15%] vs four [5%]), and hyponatraemia (seven [9%] vs four [5%]). One treatment-related death occurred in a patient assigned to chemotherapy alone (sudden cardiopulmonary arrest of unknown cause during the second cycle of chemotherapy) and one occurred in a patient assigned to chemotherapy plus gastrectomy (rapid growth of peritoneal metastasis after discharge 12 days after surgery).

INTERPRETATION

Since gastrectomy followed by chemotherapy did not show any survival benefit compared with chemotherapy alone in advanced gastric cancer with a single non-curable factor, gastrectomy cannot be justified for treatment of patients with these tumours.

FUNDING

The Ministry of Health, Labour and Welfare of Japan and the Korean Gastric Cancer Association.

The effect of the gastrectomy on survival in patients with metastatic gastric cancer: a study of ASMO

AIM

To investigate the role of surgical resection of primary tumor on overall survival (OS) in advanced gastric cancer patients at the time of diagnosis.

PATIENTS & METHODS

The survival rates of metastatic gastric cancer patients whose gastric primary tumor was resected at time of diagnosis were compared with metastatic gastric cancer patients whose primary tumor was nonresected.

RESULTS

The median progression-free survival and OS in operated and nonoperated group were 10 versus 6, 14 versus 9 months, respectively (p < 0.001). In multivariate analysis, gastric resection of primary tumor, Eastern Cooperative Oncology Group performance status, second-line chemotherapy had a significant effect on OS (hazard ratio [HR]: 0.52 [95% CI: 0.38-0.71], HR: 0.57 [95% CI: 0.42-0.78], HR: 1.48 [1.09-2.01]; p ≤ 0.001, p = 0.001 and p = 0.012, respectively).

CONCLUSION

Subpopulations of patients with metastatic gastric cancer might benefit from surgical removal of primary tumor.

Analysis of surgery for incurable gastric cancer

BACKGROUND

It is important to evaluate the curability of and avoid unnecessary exploratory surgery for gastric cancer preoperatively. However, no related research has been reported until now. The aim of this study was to evaluate the factors influencing surgery for incurable gastric cancer.

METHODS

310 cases of T3-4 gastric cancer patients were analyzed retrospectively, including 141 cases with radical surgery and 169 with surgery for incurable gastric cancer. The incurable factors were categorized as T status (unresectable T4 tumor), N status (unresectable lymph node), peritoneal metastasis, and distant metastasis. χ (2) test and logistic regression were performed to analyze the associations between curability, T status, N status, peritoneal metastasis, or distant metastasis and clinicopathological data.

RESULTS

Esophageal involvement and T grade were associated with curability. Cardia involvement and Borrmann type were associated with T status. Esophageal involvement and T grade were associated with N status. Gastric body involvement, esophageal involvement, and T grade were associated with peritoneal metastasis. Gastric antrum involvement was associated with distant metastasis.

CONCLUSIONS

The influencing factors of surgery for incurable gastric cancer should be analyzed preoperatively. Resectability should be evaluated according to these influencing factors combined with imaging analysis.

The Value of Palliative Gastrectomy for Gastric Cancer Patients With Intraoperatively Proven Peritoneal Seeding

The aim of this study was to evaluate the survival benefit of palliative gastrectomy for gastric cancer patients with peritoneal seeding proven intraoperatively and to identify positive predictive factors for improving survival.The value of palliative resection for gastric cancer patients with peritoneal metastasis is controversial.From 2006 to 2013, 267 gastric cancer patients with intraoperatively identified peritoneal dissemination were retrospectively analyzed. Patients were divided into resection group and nonresection group according to whether a palliative gastrectomy was performed. Clinicopathologic variables and survival were compared. Subgroup analyses stratified by clinicopathologic factors and multivariable analysis for overall survival were also performed.There were 114 patients in the resection group and 153 in nonresection group. The morbidities in the resection and nonresection groups were 14.91% and 5.88%, respectively (P = 0.014). There, however, was no difference in mortality between the 2 groups. The median survival time of patients in the resection group was longer than in nonresection group (14.00 versus 8.57 months, P = 0.000). The median survivals among the patients with different classifications of peritoneal metastasis were statistically significant (P = 0.000). Patients undergoing resection followed by chemotherapy had a significantly longer median survival, compared with that of patients who had chemotherapy alone, those who had resection alone, or those who had not received chemotherapy or resection (P = 0.000). Results of subgroup analyses showed that except for P3 patients and patients with multisite distant metastases, overall survival was significantly better in patients with palliative gastrectomy, compared with the nonresection group. In multivariate analysis, P3 disease (P = 0.000), absence of resection (P = 0.000), and lack of chemotherapy (P = 0.000) were identified as independently associated with poor survival.Palliative gastrectomy might be beneficial to the survival of gastric cancer patients with intraoperatively proven P1/P2 alone, rather than P3. Postoperative palliative chemotherapy could improve survival regardless of operation and should be recommended.

Role of Surgery in the Management for Gastric Cancer with Synchronous Distant Metastases

Optimal treatment of patients with gastric cancer with synchronous distant metastases is palliative chemotherapy. However, occasionally gastrectomy should be selected due to control bleeding from tumors, perforation, or obstruction. The aim of this study is to evaluate the survival benefits of non-curative gastrectomy for patients with synchronous distant metastasis. Total 78 gastric cancer patients with synchronous distant metastasis treated in our hospital between 2003 and 2012 were enrolled in this study. Of these, 74 patients (95 %) received S1 based chemotherapy. During the treatment, 37 patients (47.4 %) underwent palliative gastrectomy because of bleeding from tumors (n = 15), tumor perforation (n = 6), and obstruction (n = 16). Survival benefits were compared in resected and non-resected patients, retrospectively. The two groups were clinicopathologically similar. Palliative gastrectomy was performed safely (morbidity: 10.8 % and mortality: 0) in resection group. However, resection showed survival benefits only in 13 patients (16.7 %) with single metastasis and without peritoneal metastasis. Their 2-year survival rate was 40 % and their median survival was 19 months. Non-curative gastrectomy with precise surgical techniques followed careful postoperative nutrition management may improve survival only for patients with a single metastatic site, except for peritoneal dissemination.

Metastatic gastric cancer (MGC) patients: Can we improve survival by metastasectomy? A systematic review and meta-analysis

BACKGROUND

Prognosis with current management strategies continues to be dismal in metastatic gastric cancer (MGC) patients. We aimed to evaluate the role of metastasectomy in improving survival.

METHODS

A comprehensive search of MEDLINE, EMBASE, SCOPUS, and Cochrane central databases (1965 to present) was performed. All comparative studies measuring survival in MGC patients undergoing metastasectomy versus other therapies were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for survival at 1, 3, and 5 years.

RESULTS

Sixteen studies with 1712 patients (378 patients in metastasectomy, 1334 patients in other therapies) were eligible for the final meta-analysis. Median age was 63 years. For patients undergoing metastasectomy, a significant survival advantage was observed at 1 year (RR 0.52, CI 0.43-0.62), 3 year (RR 0.75 CI 0.67-0.83), and 5 year (RR 0.82, CI 0.74-0.91); mean increased difference in survival conferred by metastasectomy averaged between 9.3 and 15.7 months; P < 0.001 for all results. Age, ECOG status, and STROBE score did not contribute to differences in survival.

CONCLUSION

Metastasectomy is associated with increased survival at 1, 3, and 5 years in MGC patients. Large prospective randomized controlled trials are critically needed to evaluate the role of metastasectomy in MGC.

Identification of prognostic factors and surgical indications for metastatic gastric cancer

BACKGROUND

The treatment of metastatic gastric cancer is not uniform, and the prognostic factors and indications for surgery are currently unclear. This retrospective study aimed to identify the prognostic factors and clinical indications for surgery in patients with metastatic gastric cancer.

METHODS

A total of 123 consecutive patients with gastric cancer and synchronous distant metastasis treated between January 1999 and December 2011 were reviewed. Patient, tumor, laboratory, surgical, and chemotherapy factors were analyzed, with overall survival as the endpoint. Univariate analyses were performed using the log-rank test, multivariate analyses were performed using the Cox proportional hazards model, and Kaplan-Meier curves were used to estimate survival. Significance was set at p<0.05.

RESULTS

The median overall survival time was 13.1 months. Ninety-eight patients received chemotherapy. Twenty-eight patients underwent gastrectomy with metastasectomy and 55 underwent gastrectomy without metastasectomy. The median overall survival time for patients who underwent gastrectomy with metastasectomy, gastrectomy without metastasectomy, and no surgical intervention was 21.9 months, 12.5 months, and 7.2 months, respectively (p<0.001). Multivariate analysis identified gastrectomy with or without metastasectomy, performance status (PS) ≥ 3, neutrophil-to-lymphocyte ratio (NLR) >3.1, and carbohydrate antigen 19-9 (CA19-9) level >37 U/mL as predictors of poor survival. NLR and CA19-9 level were also independent prognostic factors in the group of patients who underwent surgery.

CONCLUSIONS

High pretreatment NLR, CA19-9 level, and PS are predictors of poor prognosis in patients with metastatic gastric cancer. In selected patients, gastrectomy can be performed safely, and may be associated with longer survival.

Role of metastasectomy on overall survival of patients with metastatic gastric cancer

PURPOSE

The role of metastasectomy has been debatable and unclear in the treatment for patients with metastatic gastric cancer. Therefore, this study was designed to evaluate the role of metastasectomy on the overall survival of these patients.

MATERIALS AND METHODS

In 2,406 patients who underwent gastrectomy for gastric cancer between 1998 and 2010, 188 (7.8%) patients had their first surgery for metastatic gastric cancer. To minimize the bias of systemic chemotherapy, 99 patients who received postoperative chemotherapy (fewer than 2 cycles) were excluded. The primary gastrectomy or metastasectomy had not been enforced in the following cases. Patients with far advanced peritoneal dissemination, multiple liver and lung metastasis (more than 2), and a poor general condition (Eastern Cooperative Oncology Group>2) were excluded. Based on the metastasectomy, the patients were classified into two groups, gastrectomy with metastasectomy and gastrectomy only group.

RESULTS

There was no significant difference between both groups in clinicopathological characteristics except for the mean age (P=0.047). The univariate analysis for overall survival show statistical significances in metastasectomy (P=0.026), distal gastrectomy (P=0.047), and combined resection of another organ (P=0.047) group. With a multivariate analysis, metastasectomy was a significant factor in patient survival after surgery (odds ratio 1.679; P=0.034).

CONCLUSIONS

Based on our results, we assume that a detailed strategy for surgery is needed to improve the overall survival of patients with metastatic gastric cancer. Therefore, we suggest that a metastasectomy can help prolong overall survival in some patients with metastatic gastric cancer.

The role of non-curative surgery in incurable, asymptomatic advanced gastric cancer

Background

Although general agreement exists on palliative surgery with intent of symptom palliation in advanced gastric cancer (AGC), the role of non-curative surgery for incurable, asymptomatic AGC is hotly debated. We aim to clarify the role of non-curative surgery in patients with incurable, asymptomatic AGC under the first-line chemotherapy.

Methods

A total of 737 patients with incurable, asymptomatic advanced gastric adenocarcinoma between January 2008 and May 2012 at the Sun Yat-sen University Cancer Center were retrospectively analyzed, comprising 414 patients with non-curative surgery plus first-line chemotherapy, and 323 patients with first-line chemotherapy only. The clinicopathologic data, survival, and prognosis were evaluated, with propensity score adjustment for selection bias.

Results

The median overall survival (OS) outcomes significantly favored non-curative surgery group over first-line chemotherapy only group in entire population (28.00 versus 10.37 months, P = 0.000), stage 4 patients (23.87 versus 10.37 months, P = 0.000), young patients (28.70 versus 10.37 months, P = 0.000) and elderly patients (23.07 versus 10.27 months, P = 0.031). The median OS advantages of non-curative surgery over first-line chemotherapy only were also maintained when the analyses were restricted to single organ metastasis (P = 0.001), distant lymph node metastasis (P = 0.002), peritoneal metastasis (P = 0.000), and multi-organ metastasis (P = 0.010). Significant OS advantages of non-curative surgery over chemotherapy only were confirmed solid by multivariate analyses before and after adjustment on propensity score (P = 0.000). Small subsets of patients with surgery of single metastatic lesion after previous curative gastrectomy, and with surgery of both primary and single metastatic sites showed sound median OS.

Conclusions

There is a role for non-curative surgery plus first-line chemotherapy for incurable, asymptomatic AGC, in terms of survival. Randomized controlled trials are warranted to fill a gap in knowledge about the value of metastectomy and patient selection strategies.

Clinical significance of palliative gastrectomy on the survival of patients with incurable advanced gastric cancer: a systematic review and meta-analysis

Background

Palliative gastrectomy for patients with advanced gastric cancer remains controversial. The objective of the present meta-analysis was to analyze survival outcomes and establish a consensus on whether palliative gastrectomy is suitable for patients with incurable advanced gastric cancer and which type of patients should be selected to receive palliative gastrectomy.

Methods

A literature search was conducted in PubMed, EMBASE and the Cochrane Library. The results for overall survival in the meta-analysis are expressed as hazard ratios (HRs) with 95% confidence intervals (CIs).

Results

Of 1647 articles and abstracts reviewed, 14 studies with 3003 patients were eligible for the final analysis. The meta-analysis revealed that palliative gastrectomy is associated with a significantly improvement in overall survival (HR 0.56; 95%CI 0.39–0.80; p < 0.002) compared that of patients treated without palliative gastrectomy. An improvement in survival was also observed in patients with stage M1 gastric cancer who received palliative gastrectomy (HR 0.62; 95%CI 0.49–0.78; p < 0.0001), especially those with peritoneal dissemination (HR = 0.76, 95%CI 0.63–0.92), liver metastasis (HR = 0.41, 95%CI 0.30–0.55), or distant lymph-node metastasis (HR = 0.36, 95%CI 0.23–0.59). Combined hepatic resection may be beneficial for patients who under palliative gastrectomy (HR 0.30; 95%CI 0.15–0.61; p = 0.0008). The overall survival of patients who underwent palliative gastrectomy combined with chemotherapy was significantly improved (HR 0.63; 95%CI 0.47–0.84; p = 0.002).

Conclusions

From the results of the meta-analysis, palliative gastrectomy for patients with incurable advanced gastric cancer may be associated with longer survival, especially for patients with stage M1 gastric cancer. Combined hepatic resection for patients with liver metastasis and chemotherapy may be beneficial factors compared to simple palliative gastrectomy.

Gastric outlet obstruction in gastric cancer: a comparison of three palliative methods

BACKGROUND

Gastric outlet obstruction (GOO) commonly occurs in advanced gastric cancer. Our aim was to evaluate the results of endoscopic stenting (ES), palliative resection (PR), and gastrojejunostomy (GJ) as palliation of GOO.

METHODS

A total of 97 patients (50 ES, 26 PR, 21 GJ) were included in this retrospective study. All the patients had primary gastric cancer and symptoms of GOO.

RESULTS

Compared to surgery, ES resulted in a faster improvement on oral intake and symptom relief (P < 0.001) and a shorter hospitalization (P < 0.001). Complication rates, hospital re-admissions, occurrence of biliary obstruction, and the number of patients receiving chemotherapy were similar. The median symptom-free and overall survival were longest in the PR group (P < 0.001). In multivariate survival analysis, independent prognostic factors were age, BMI, pre-procedure GOOSS, palliative resection as treatment modality, and chemotherapy.

CONCLUSIONS

In gastric cancer and GOO, the clinical condition of the patient before treatment affects survival and should be taken into account in determining the treatment. PR seems to provide a survival benefit and should be considered as treatment option for patients suitable for surgery. For patients unfit for surgery, ES provides rapid and efficient palliation. Chemotherapy also seems to improve survival in gastric cancer and GOO.

Palliative treatment and the role of surgical resection in gastric cancer

Adenocarcinoma of the stomach is often diagnosed in the late stages of the disease. Surgical resection of all gross and microscopic disease is essential for curative treatment. Complete resection is often not achievable when patients present with advanced stage IV cancer. In the absence of symptoms, chemotherapy without resection has been the standard of care in most major centers. With improvements in response to chemotherapy and less invasive surgical approaches, patients with metastatic gastric cancer have had better survival outcomes than in the past. The challenge today when treating these patients is in defining who will benefit from more aggressive interventions. Reviewing the literature for guidance is difficult because the goals of treatment are often not clearly defined. Finding the proper balance of aggressiveness needed to extend survival while preserving and maximizing quality of life is a decision that clinicians have to make with increasing frequency. This review will attempt to provide a framework to aid in determining what role, if any, gastrectomy has in the management of patients with stage IV gastric cancer.

Palliative radiotherapy in patients with a poor performance status: the palliative effect is correlated with prolongation of the survival time

Background

The purpose of this study was to analyze the efficacy and tolerability of palliative radiotherapy (RT) in patients with a poor performance status (PS) and to evaluate the relationship between the palliative effect and survival time.

Methods

One hundred and thirty-three patients with a poor PS (Eastern Cooperative Oncology Group 3 or 4) were treated with palliative RT using the three-dimensional conformal technique and retrospectively analyzed. Each patient's primary symptom treated with palliative RT as the major cause of the poor PS was evaluated using the second item of the Support Team Assessment Schedule (STAS) at the start and one week after the completion of palliative RT.

Results

One hundred and fourteen (86%) of the 133 patients completed the planned palliative radiation dose. Grade 3 acute toxicity was observed in two patients (2%) and Grade 2 acute toxicity was observed in 10 patients (9%). No Grade 2 or higher late toxicities were observed, except for Grade 3 radiation pneumonitis in one patient. Improvement in the STAS scores between pre- and post-palliative RT was recorded in 76 (61%) of the 125 patients with available scores of STAS. A significant improvement in the mean STAS score between pre- and post-palliative RT was recognized (p < 0.0001). Improvement in the STAS score was found to be the most statistically significant prognostic factor for overall survival after palliative RT in both the multivariate and univariate analyses. The median overall survival time in the patients with an improvement in the STAS score was 6.4 months, while that in the patients without improvement was 2.4 months (p < 0.0005).

Conclusions

Palliative RT in patients with a poor PS provides symptomatic benefits in more than half of patients without inducing severe toxicities. The palliative effect is strongly correlated with prolongation of the survival time and may contribute to improving the remaining survival time in patients with metastatic/advanced cancer with a poor PS.

SPan-1 is a useful prognostic marker for patients with stage IV gastric cancer who underwent palliative gastrectomy: a retrospective multivariate study

BACKGROUND

We retrospectively investigated prognostic factors to be used in selecting the patients with stage IV gastric cancer (GC) who have an unfavorable prognosis after palliative gastrectomy.

METHODS

A total of 146 GC patients at stage IV who had undergone palliative gastrectomy were enrolled. Various clinicopathological parameters were evaluated for prognosis.

RESULTS

Surgical morbidity and hospital mortality occurred in 35 (23.9 %) and 4 (2.7 %) patients, respectively. The overall 5-year survival rate and the median survival time were 11.2 % and 13.2 months, respectively. Of the 146 patients, 64 had uncomfortable symptoms associated with GC and 76 had no such symptoms. Of the 64 patients with uncomfortable symptoms, 60 (93.7 %) experienced relief of these symptoms after palliative surgery. Multivariate analysis for patients without uncomfortable symptoms associated with GC revealed that the number of incurable factors and serum SPan-1 level were independent prognostic factors.

CONCLUSIONS

Patients with stage IV GC who had multiple incurable factors and a high level of serum SPan-1 might not be candidates for palliative gastrectomy for the purpose of prognostic benefit.

Survival benefit of palliative gastrectomy in gastric cancer patients with peritoneal metastasis

BACKGROUND

The survival benefit of palliative gastrectomy in patients with peritoneal metastasis as a single incurable factor remains unclear.

METHODS

A total of 148 gastric cancer patients with peritoneal metastasis underwent gastrectomy or chemotherapy at the Shizuoka Cancer Center between September 2002 and December 2008 and were included in this study. The effects of gastrectomy and chemotherapy on their long-term outcome were investigated. Multivariate analysis was also performed to identify independent prognostic factors.

RESULTS

Gastrectomy was performed in 82 patients and subsequent chemotherapy was administered to 55. Chemotherapy was selected as an initial treatment for 66 patients. Median survival time (MST) was identical between patients with and without gastrectomy (13.1 vs. 12.0 months; P = 0.410). Conversely, MST was significantly longer in patients who received chemotherapy (13.7 months) than those who did not (7.1 months; P = 0.048). According to the results of multivariate analysis, chemotherapy (hazards ratio [HR] = 0.476; 95 % CI = 0.288-0.787) was selected as an independent prognostic factor, while gastrectomy was not.

CONCLUSIONS

The results of the present study did not show a survival benefit of palliative gastrectomy in selected patients with peritoneal metastasis. Instead, chemotherapy has to be considered as an initial treatment for these patients.

The clinical value of non-curative resection followed by chemotherapy for incurable gastric cancer

BACKGROUND

The clinical value of a non-curative resection for gastric cancer is still controversial. We analyzed the clinical outcomes of patients who underwent non-curative gastric resection.

METHODS

Data from a total of 178 patients who underwent non-curative resection for advanced gastric cancer at Seoul St. Mary's hospital were reviewed. Factors related to the incurability were classified as peritoneal metastasis (P), liver metastasis (H), extra-abdominal metastasis (X), direct adjacent organ invasion that was unresectable (T). The clinicopathologic data, survival, and quality of life of patients were evaluated.

RESULTS

The overall median survival time was 12.1 months, and that for the patients with gastrectomy with chemotherapy was 14.3 months. Operation-related complications occurred in 20 patients (11.2 %). Five patients (2.8 %) died of postoperative complications within 30 days, and 43 patients (24.2 %) had symptoms and signs of gastric outlet obstruction or uncontrolled bleeding. The mean duration of postoperative hospital stay was 15.9 days for those symptomatic patients, and the symptom-relieved period was 8.6 months.

CONCLUSIONS

There might be a role for non-curative resection followed by chemotherapy for incurable gastric cancer, in terms of survival, and this treatment approach should be carefully considered because of the high mortality rate associated with the disease. A large, randomized, prospective study is warranted to prove the benefit of non-curative resection in patients with incurable gastric cancer.

Outcomes of surgery aiming at curative resection in good responder to induction chemotherapy for gastric cancer with distant metastases

BACKGROUND

The aim of this study is to analyze the outcome of surgery with curative intent in good responder to induction chemotherapy for gastric cancer with distant metastases (M1 gastric cancer).

MATERIALS AND METHODS

We reviewed M1 gastric cancer patients in whom radiologic evaluation suggests disappearance of metastatic lesion after chemotherapy and received operation from January 2000 to December 2009. Clinicopathologic variables and oncologic outcomes were evaluated.

RESULTS

Of the 34 patients who underwent surgery with curative intent after chemotherapy, overall R0 resection rate was 76.5% (26/34). R0 resection rate was 88.0% (22/25) in initial one metastatic site and 44.4% (4/9) in two metastatic sites (P = 0.017). Postoperative morbidity and mortality rate were 14.7% and 0%. Recurrence rate was 61.5% (16/26) after R0 resection. Median survival was 22.9 and 7.8 months according to R0 versus non-R0 resection (P = 0.033). After R0 resection, 3-year overall survival was 51.7% in ypN0-2 stage group.

CONCLUSION

The present study provides evidence that in patients with M1 gastric cancer which confined to one site who respond well to induction chemotherapy, a higher rate of R0 resection and longer survival can be expected. A multicenter cohort study is needed to explore this concept further.

Palliative resection for advanced gastric and junctional adenocarcinoma: which patients will benefit from surgery?

BACKGROUND

Whereas palliative chemotherapy offers a median survival of approximately 10 months in advanced gastric and junctional adenocarcinoma (AGJA), the survival impact of primary tumor resection is controversial. Our purpose was to identify which AGJA patients benefit from palliative resection.

METHODS

In 3,202 AGJA patients scheduled for surgery in 21 French centers between 1997 and 2010, prognostic factors were identified in palliative group and the impact of each combination of these factors on survival was studied.

RESULTS

Surgery was defined as palliative due to solid organ metastasis (5.6 %), localized (4.6 %) or diffuse (2.3 %) peritoneal carcinomatosis (PC), or incomplete tumoral resection (12.8 %). Median survival of AGJA patients resected with a palliative intent (n = 677) was longer than in nonresected patients (n = 532; 11.9 vs. 8.5 months, P < 0.001). Multivariable analyses identified ASA score III-IV (P < 0.001) as a predictor of postoperative mortality and solid organ metastasis (P = 0.009), localized PC (P = 0.004), diffuse PC (P = 0.046), and signet ring cell histology (SRC; P = 0.02) as predictors of survival. Only ASA I-II patients with incomplete resection without metastasis or PC, one site solid organ metastasis without PC, or localized PC without SRC had a survival benefit after palliative surgery with median survivals from 12.0 to 18.3 months. Nonresected ASA I-II patients with same risk factors had median survivals from 3.5 to 8.8 months (P < 0.05 for each).

CONCLUSIONS

In AGJA, patient and tumor-related factors should be used to select candidates for palliative surgery in association with chemotherapy.

Effective palliation and quality of life outcomes in studies of surgery for advanced, non-curative gastric cancer: a systematic review

BACKGROUND

Relief of symptoms should be the primary focus of palliative treatment as defined by the World Health Organization. Evaluating the effectiveness of palliative interventions should incorporate this goal and include quality of life (QOL) outcome assessments. A systematic review of the surgical gastric cancer literature was performed to summarize the effectiveness of palliative surgical interventions in addressing QOL.

METHODS

An electronic literature search of EMBASE, Medline, and the Cochrane Database of Controlled Trials was performed from January 1, 1985 to December 1, 2009. English language abstracts and articles were reviewed independently by two reviewers. A systematic approach to data abstraction and presentation was followed.

RESULTS

No articles were identified as reporting true QOL outcomes using reliable, validated QOL instruments in surgically managed, advanced gastric cancer patients. Nine articles were identified as reporting outcomes measuring effectiveness of palliation. Commonly reported pre-procedure symptoms were weight loss, abdominal pain, vomiting, obstruction, and bleeding. Time to oral intake was reported in 5 of 9 studies, ranging from a mean of 2.9 days (laparoscopic gastrojejunostomy) to 8 days (surgical bypass). Length of postoperative inpatient stay ranged from a mean of 7 days (gastrojejunostomy) to 28 days (surgical bypass). Other measures of effective palliation included measures of clinical success, hospital re-admission rates, and post-procedure analgesic intake.

CONCLUSION

A paucity of literature exists regarding the QOL of surgically managed gastric cancer patients. Prospectively designed studies using credible QOL measures are necessary to better inform the treatment decision-making process for these patients.