Role of staging laparoscopy for gastric cancer patients

The clinical implications of staging laparoscopy in the diagnostic workup of gastric cancer patients: A population based study

BACKGROUND

Since 2016, staging laparoscopy has been implemented in the diagnostic workup of patients with gastric cancer. Staging laparoscopy aims to detect incurable disease (peritoneal metastases and irresectable tumors) and to prevent futile laparotomies.

METHODS

In this population-based nationwide study, we sought patient- and tumor characteristics associated with undergoing a staging laparoscopy. Additionally, we analyzed the prevalence of synchronous peritoneal metastases, the outcome of the staging laparoscopy and its clinical impact on treatment decisions. All patients diagnosed with non-cardia gastric cancer from the Netherlands Cancer Registry between 2016 and 2021 were included.

RESULTS

Alongside tumor characteristics, patient characteristics such as younger age, absence of comorbidities and lower WHO performance status were associated with performing a staging laparoscopy. In the study period, an increase in the proportion of patients who underwent a staging laparoscopy was observed, from 19.6% in 2016 to 32.3% in 2021 (p-value<0.001). In the same period, the prevalence of synchronous peritoneal metastases increased from 25% to 31%. In 37.6% of the patients who had the outcome of their staging laparoscopy reported, had incurable disease diagnosed during staging laparoscopy. Significantly less of these patients were treated with triplet regimens as compared to patients with a negative staging laparoscopy (18.5 vs. 76.3%; p-value<0.001).

CONCLUSION

The implementation of staging laparoscopy in gastric cancer patients paralleled the increase in diagnosis of incurable disease and a decrease in the application of triplet systemic therapies in these patients.

Machine learning-based prediction of gastroparesis risk following complete mesocolic excision

BACKGROUND

Gastroparesis is a major complication following complete mesocolic excision (CME) and significantly impacts patient outcomes. This study aimed to create a machine learning model to pinpoint key risk factors before, during, and after surgery, effectively predicting the risk of gastroparesis after CME.

METHODS

The study involved 1146 patients with colon cancer, out of which 95 developed gastroparesis. Data were collected on 34 variables, including demographics, chronic conditions, pre-surgery test results, types of surgery, and intraoperative details. Four machine learning techniques were employed: extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM), and k-nearest neighbor (KNN). The evaluation involved k-fold cross-validation, receiver operating characteristic (ROC) analysis, calibration curves, decision curve analysis (DCA), and external validation.

RESULTS

XGBoost excelled in its performance for predictive models. ROC analysis showed high accuracy for XGBoost, with area under the curve (AUC) scores of 0.976 for the training set and 0.906 for the validation set. K-fold cross-validation confirmed the model's stability, and calibration curves indicated high predictive accuracy. Additionally, DCA highlighted XGBoost's superior patient benefits for intervention treatments. An AUC of 0.77 in external validation demonstrated XGBoost's strong generalization ability.

CONCLUSION

The XGBoost-fueled predictive model for post-surgery colon cancer patients proved highly effective. It underlined gastroparesis as a significant post-operative issue, associated with advanced age, prolonged surgeries, extensive intraoperative blood loss, surgical techniques, low serum protein levels, anemia, diabetes, and hypothyroidism.

Novel nomogram and risk stratification for peritoneal recurrence after curative resection in gastric cancer

Peritoneal recurrence (PR) in gastric cancer after curative resection has poor prognosis. Therefore, we aimed to construct a nomogram to predict PR, and establish PR score for risk stratification to guide adjuvant chemotherapy. A total of 315 patients with gastric cancer after radical surgery were included, and randomly stratified into training group (n = 221) and validation group (n = 94). Univariate and multivariate analyses were used to determine predictive factors of PR. The nomogram was constructed to predict the risk of PR. We utilized the time-dependent area under the receiver operating characteristic (ROC) curves (AUCs), calibration curves, and decision curve analysis (DCA) to evaluate the performance of the nomogram. Multivariate analysis showed that tumor site, N stage, preoperative CEA, and postoperative CA199 were independent predictors of PR. A nomogram was constructed to predict PR based on these factors. The AUC value was 0.755 in the training group and 0.715 in the validation group. The calibration curves showed good agreement between prediction and observation in the training and validation groups. The decision curve analysis displayed a good net benefit of the nomogram. The novel PR score was developed and patients were stratified into the low-, medium-, and high -risk groups. For the high-risk group, postoperative adjuvant chemotherapy significantly improved patients' overall survival (OS) and disease-free survival (DFS). The establishment of nomogram facilitates the prediction of PR after radical gastrectomy, and a novel PR score may help guide adjuvant chemotherapy for gastric cancer.

Safety and feasibility of "Pant-Shaped" anastomosis in laparoscopic-assisted total gastrectomy: Study of 210 cases at a single center

BACKGROUND

Advancements in laparoscopic technology have popularized laparoscopic total gastrectomy over traditional open surgery, yet postoperative complications like anastomotic leakage and stenosis persist, particularly in esophagojejunostomy. To address this, since 2017, the authors have introduced the "Pant-Shaped" esophagojejunostomy as an improvement over the classic Roux-en-Y method, especially beneficial for patients with small intestinal diameters or those with gastric body cancer or Siewert III.

OBJECTIVE

To assess the viability and safety of employing 'Pant-Shaped' anastomosis following laparoscopic-assisted total gastrectomy.

METHODS

A method of descriptive case study was used. In our department of the First Affiliated Hospital of Wannan Medical College, records of 210 patients who underwent laparoscopic-assisted total gastrectomy for gastric body cancer or adenocarcinoma at the junction of esophagus and jejunum with "Pant-Shaped" anastomosis between January 2017 and December 2022 were examined. Clinicopathological features and postoperative conditions were also examined and assessed.

RESULTS

The mean age of the 164 male and 46 female research participants was 69.2 ± 8.3 years. There was a mean estimated blood loss of 63.4 ± 29.7 ml, an anastomosis time of 25.9 ± 3.0 minutes, an operation time of 208.2 ± 40.4 minutes, and a postoperative hospital stay of 12.2 ± 8.0 days. Nine patients (4.3%) experienced postoperative problems (Clavien-Dindo > grade II), including two episodes of anastomotic leakage that were resolved with irrigation and drainage, anti-infection therapy, and nutritional assistance. After an unforeseen reoperation, two cases of duodenal stump leaking were resolved. Anastamotic hemorrhage was treated with hemostasis and blood transfusion, and the patient made a full recovery. Due to a Peterson's hernia, one patient required emergent open surgery. three months subsequent to LATG.

CONCLUSIONS

The "Pant-Shaped" anastomosis method after laparoscopic-assisted total gastrectomy is simple, easy to promote, and has fewer complications. It is a safe and feasible modified method for esophagojejunostomy, especially suitable for patients with poor intestinal dilation and contraction ability and small jejunal diameter.

Staging laparoscopy with peritoneal lavage to identify peritoneal metastases and free intraperitoneal cancer cells in the management of locally advanced gastric cancer

INTRODUCTION

Gastric cancer often presents in advanced stage with a significant risk for peritoneal dissemination. Staging laparoscopy can be used to detect peritoneal carcinomatosis (PC+) and free cancer cells in peritoneal lavage cytology (CY+). The current study aimed to present the outcomes of staging laparoscopy and the prognosis of PC+ and CY+ in a Swedish high-volume center.

MATERIALS AND METHODS

A cohort study including all consecutive patients with locally advanced gastric cancer who underwent staging laparoscopy between February 2008 and October 2022. The laparoscopy findings were categorized as PC+, PC-CY+ (positive cytology without peritoneal carcinomatosis) or negative laparoscopy (PC-CY-). The primary endpoint was overall survival (OS) stratified by laparoscopy findings. The secondary endpoint was OS within each laparoscopy finding group stratified by subsequent treatment.

RESULTS

Among 168 patients who underwent staging laparoscopy, 78 patients (46%) had PC-CY-, 29 patients (17%) had PC-CY+ and 61 patients (36%) had PC+. Decreased OS was observed for both PC-CY+ patients (aHR 2.14, 95% CI 1.13-4.06) and PC+ patients (aHR 5.36, 95% CI 3.21-8.93), compared to PC-CY-. Patients with PC-CY+ who converted to PC-CY- after chemotherapy and underwent tumor resection seemed to have a better prognosis compared to patients with persisting PC-CY+.

CONCLUSIONS

Staging laparoscopy is an important tool in the staging of locally advanced gastric cancer. Tumor resection for patients with PC-CY+ who convert to PC-CY- may lead to improved survival for these patients.

Stage IV gastric adenocarcinoma with enteroblastic differentiation with 5-year relapse-free survival after D2 gastrectomy and chemotherapy: A case report

BACKGROUND

Gastric adenocarcinoma with enteroblastic differentiation (GACED), a rare subtype of gastric cancer, is associated with a more aggressive behavior than conventional gastric adenocarcinomas. We report a rare case of stage IV GACED treated with D2 gastrectomy and postoperative chemotherapy.

CASE PRESENTATION

A 39-year-old woman with acute upper abdominal pain immediately underwent surgery for gastric perforation. Afterward she was diagnosed with adenocarcinoma of the pylorus. D2 gastrectomy was performed and the final pathological diagnosis was stage IV GACED with positive peritoneal cytology. Postoperative chemotherapy was initiated with S1 plus oxaliplatin for 1 year, which was ceased thereafter to enhance her quality of life. The patient survived more than 5 years without relapse after gastrectomy.

CONCLUSIONS

Stage IV GACED, determined by positive spalt-like transcription factor 4, can be successfully treated with surgery and chemotherapy.

Dynamic change in the peritoneal cancer index based on CT after chemotherapy in the overall survival prediction of gastric cancer patients with peritoneal metastasis

PURPOSE

The purpose of this research was to investigate the efficacy of the CT-based peritoneal cancer index (PCI) to predict the overall survival of patients with peritoneal metastasis in gastric cancer (GCPM) after two cycles of chemotherapy.

METHODS

This retrospective study registered 112 individuals with peritoneal metastasis in gastric cancer in our hospital. Abdominal and pelvic enhanced CT before and after chemotherapy was independently analyzed by two radiologists. The PCI of peritoneal metastasis in gastric cancer was evaluated according to the Sugarbaker classification, considering the size and distribution of the lesions using CT. Then we evaluated the prognostic performance of PCI based on CT, clinical characteristics, and imaging findings for survival analysis using multivariate Cox proportional hazard regression.

RESULTS

The PCI change ratio based on CT after treatment (ΔPCI), therapy lines, and change in grade of ascites were independent factors that were associated with overall survival (OS). The area under the curve (AUC) value of ΔPCI for predicting OS with 0.773 was higher than that of RECIST 1.1 with 0.661 (P < 0.05). Patients with ΔPCI less than -15% had significantly longer OS.

CONCLUSION

CT analysis after chemotherapy could predict OS in patients with GCPM. The CT-PCI change ratio could contribute to the determination of an appropriate strategy for gastric cancer patients with peritoneal metastasis.

Perioperative Chemotherapy for Gastro-Esophageal or Gastric Cancer: Anthracyclin Triplets versus FLOT

Background: The FLOT4-AIO trial (2019) showed improved survival with perioperative fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) compared to anthracyclin triplets in gastric cancer treatment. It is unclear whether these results extend to real-world scenarios in the Netherlands. This study aimed to compare outcomes of perioperative FLOT to anthracyclin triplets in a real-world Dutch gastric cancer population. Methods: Patients diagnosed with resectable (cT2-4a/cTxN0-3/NxM0) gastric or gastro-esophageal junction carcinoma between 2015-2021 who received neoadjuvant FLOT or anthracyclin triplets were selected from the Netherlands Cancer Registry. The primary outcome was overall survival (OS), analyzed through multivariable Cox regression. Secondary outcomes included pathological complete response (pCR), neoadjuvant chemotherapy cycle completion, surgical resection rates, and adjuvant therapy. Results: Adjusted OS showed no significant survival benefit (HR = 0.88, 95% CI 0.77-1.01, p = 0.07), even though the median OS was numerically improved by 8 months with FLOT compared to anthracyclin triplets (48.1 vs. 39.9 months, p = 0.16). FLOT patients were more likely to undergo diagnostic staging laparoscopies (74.2% vs. 44.1%, p < 0.001), had higher rates of completing neoadjuvant chemotherapy (OR = 1.35, 95% CI 1.09-1.68, p = 0.007), receiving adjuvant therapy (OR = 1.34, 95% CI 1.08-1.66, p = 0.08), and achieving pCR (OR = 1.52, 95% CI 1.05-2.20, p = 0.03). No significant differences were observed in (radical) resection rates. Conclusion(s): Real-world data showed no significant OS improvement for FLOT-treated patients compared to anthracyclin triplets, despite more staging laparoscopies. However, FLOT patients demonstrated higher rates of neoadjuvant therapy completion, proceeding to adjuvant therapy, and increased pCR rates. Therefore, we recommend the continued use of neoadjuvant FLOT therapy in the current clinical setting.

Predicting Peritoneal Carcinomatosis in Locally Advanced Gastric Cancer: The Significance of Tumor Markers in the Peritoneal Washing

PURPOSE

Gastric cancer is the fifth most common malignant tumor worldwide. Many attempts have been made over the years to investigate the relationship between tumor markers and the risk of recurrence. This study aims to explore the predictive value of tumor markers measured in peritoneal washing during staging laparoscopy, regarding peritoneal carcinomatosis and mortality within 1 year.

METHODS

Patients with locally advanced gastric cancer, staged as at least usT2anyNM0 were submitted to staging laparoscopy in a Portuguese single center. CA 19.9, CEA, CA 125, and CA 72.4 were measured in the peritoneal washing after being harvested during staging laparoscopy.

RESULTS

Thirty-eight patients were enrolled. After 1 year, 20 patients did not recur (52.5%), 11 (28.9%) developed carcinomatosis, and 7 (18.4%) had distant metastasis. Mortality reached 23.7% (n = 9). A statistically significant prediction of carcinomatosis was obtained for CA 125 (cutoff: 107.6 U/mL (p = 0.019)) and CEA (cutoff: 2.0 ng/mL (p = 0.020)) with 87.5% and 75% sensitivity, respectively. Prediction of mortality was significant for CA 125 (cutoff: 103.8 U/mL (p = 0.044)) and CA 125 + CEA (p = 0.030). CEA and CA 125 had NPVs of 87.9% and 93.1% regarding PC, respectively. NPVs of 88.9% and 89.2% were met concerning mortality, for the same tumor markers.

CONCLUSION

Performing the peritoneal liquid harvest during staging laparoscopy makes this analysis cost effective, reproducible, and does not add further morbidity. CA 125 and CEA, individually and in association, are good predictors of progression of disease and mortality within a year of staging laparoscopy in GC patients.

Timing to Surgery and Lymph Node Upstaging in Gastric Cancer: An NCDB Analysis

BACKGROUND

Prior studies have shown tumor specificity on the impact of longer time interval from diagnosis to surgery, however in gastric cancer (GC) this remains unclear. We aimed to determine if a longer time interval from diagnosis to surgery had an impact on lymph node (LN) upstaging and overall survival (OS) outcomes among patients with clinically node negative (cN0) GC.

PATIENTS AND METHODS

Patients diagnosed with cN0 GC undergoing surgery between 2004-2018 were identified in the National Cancer Database (NCDB) and divided into intervals between time of diagnosis and surgery [short interval (SI): ≥ 4 days to < 8 weeks and long interval (LI): ≥ 8 weeks]. Multivariable regression analysis evaluated the independent impact of surgical timing on LN upstaging and a Cox proportional hazards analysis and Kaplan-Meier curves evaluated survival outcomes.

RESULTS

Of 1824 patients with cN0 GC, 71.8% had a SI to surgery and 28.1% had a LI to surgery. LN upstaging was seen more often in the SI group when compared to LI group (82% versus 76%, p = 0.004). LI to surgery showed to be an independent factor protective against LN upstaging [adjusted odds ratio = 0.62, 95% CI: (0.39-0.99)]. Multivariate Cox regression analysis indicated that time to surgery was not associated with a difference in overall survival [hazard ratio (HR) = 0.91, 95% CI: (0.71-1.17)], however uncontrolled Kaplan-Meier curves showed OS difference between the SI and LI to surgery groups (p = 0.037).

CONCLUSION

Timing to surgery was not a predictor of LN upstaging or overall survival, suggesting that additional medical optimization in preparation for surgery and careful preoperative staging may be appropriate in patients with node negative early stage GC without affecting outcomes.

Evaluating staging laparoscopy indications for pancreatic cancer based on resectability classification and treatment strategies for patients with positive peritoneal washing cytology

Introduction

The prognosis of pancreatic ductal adenocarcinoma (PDAC) in patients with positive peritoneal washing cytology (CY1) is poor. We aimed to evaluate the results of staging laparoscopy (SL) and treatment efficacy in CY1 patients based on a resectability classification.

Methods

We retrospectively reviewed 250 patients with PDAC who underwent SL before the initial treatment between 2017 and 2023 at the University of Toyama.

Results

The breakdown of cases by resectability classification was resectable (R):borderline resectable (BR):unresectable locally advanced (UR-LA) = 131:48:71 cases. The frequency of CY1 increased in proportion to the degree of local progression (R:BR:UR-LA = 20:23:34%), but the frequencies of liver metastasis or peritoneal dissemination were comparable (R:BR:UR-LA = 6.9:6.3:8.5%). Most CY1 patients received gemcitabine along with nab-paclitaxel therapy. The CY-negative conversion rates (R:BR:UR-LA = 70:64:52%) and conversion surgery rates (R:BR:UR-LA = 40:27:9%) were inversely proportional to the degree of local progression.Comparing H0P0CY1 factors for each classification, patients with H0P0CY1 had significantly more pancreatic body or tail carcinoma and tumor size ≥32 mm in R patients, whereas in BR patients, duke pancreatic monoclonal antigen type 2 (DUPAN-2) ≥ 230 U/mL was a significant factor. In contrast, no significant factors were observed in UR-LA patients.

Conclusion

The CY1 rates, CY-negative conversion rates, and conversion surgery rates varied according to local progression. In the case of R and BR, SL could be considered in patients with pancreatic body or tail carcinoma, large tumor size, or high DUPAN-2 level. In UR-LA, SL might be considered for all patients.

Techniques of staging laparoscopy and peritoneal fluid assessment in gastric cancer: a systematic review

BACKGROUND

Staging laparoscopy for gastric cancer is recommended to assess the tumor's locoregional extension and exclude peritoneal disease. As there is no consensus on optimizing the procedure's diagnostic accuracy, we aimed to systematically review the literature on operative techniques, followed by peritoneal lavage fluid assessment in gastric cancer patients. Specifically, we sought to indicate the most common characteristics of the procedure and cytological evaluation.

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol for this systematic review was registered on PROSPERO database (CRD: 42022306746). On September 2022, a search was carried out using Embase, Medline ALL, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection.

RESULTS

The search identified 1632 studies on staging laparoscopy and 2190 studies on peritoneal fluid assessment. Some 212 studies were included. Open Hasson was the method of choice in accessing the peritoneal cavity in 65% of the studies, followed by establishing a pneumoperitoneum at 10-12 mmHg in 52% of reports. Most frequently, the patient was positioned supine (70%), while a 30° scope and three ports were used to assess the peritoneal cavity clockwise (72%, 77%, and 85%, respectively). Right and left upper abdomen quadrants were the predominant area of laparoscopic exploration (both 65%), followed by the primary tumor region (54%), liver and pelvis (both 30%), and small bowel and spleen (19% and 17%, respectively). Regions of peritoneal lavage and aspiration were limited to the pelvis (50%), followed by right and left upper abdomen quadrants (37.5% and 50%, respectively). No studies compared different methods of operative techniques or analysis of ascites/fluid.

CONCLUSIONS

This study indicates a high heterogeneity in the technique of staging laparoscopy and peritoneal fluid assessment in gastric cancer patients. Further research and initiatives to reach a consensus on the standardization of the procedure are warranted.

Systematic review of diagnostic tools for peritoneal metastasis in gastric cancer-staging laparoscopy and its alternatives

BACKGROUND

Gastric cancer is one of the leading causes of cancer burden and mortality, often resulting in peritoneal metastasis in advanced stages with negative survival outcomes. Staging laparoscopy has become standard practice for suspected cases before a definitive gastrectomy or palliation. This systematic review aims to compare the efficacy of other diagnostic modalities instead of staging laparoscopy as the alternatives are able to reduce cost and invasive staging procedures. Recently, a radiomic model based on computed tomography and positron emission tomography (PET) has also emerged as another method to predict peritoneal metastasis.

AIM

To determine if the efficacy of computed tomography, magnetic resonance imaging and PET is comparable with staging laparoscopy.

METHODS

Articles comparing computed tomography, PET, magnetic resonance imaging, and radiomic models based on computed tomography and PET to staging laparoscopies were filtered out from the Cochrane Library, EMBASE, PubMed, Web of Science, and Reference Citations Analysis (https://www.referencecitationanalysis.com/). In the search for studies comparing computed tomography (CT) to staging laparoscopy, five retrospective studies and three prospective studies were found. Similarly, five retrospective studies and two prospective studies were also included for papers comparing CT to PET scans. Only one retrospective study and one prospective study were found to be suitable for papers comparing CT to magnetic resonance imaging scans.

RESULTS

Staging laparoscopy outperformed computed tomography in all measured aspects, namely sensitivity, specificity, positive predictive value and negative predictive value. Magnetic resonance imaging and PET produced mixed results, with the former shown to be only marginally better than computed tomography. CT performed slightly better than PET in most measured domains, except in specificity and true negative rates. We speculate that this may be due to the limited F-fluorodeoxyglucose uptake in small peritoneal metastases and in linitis plastica. Radiomic modelling, in its current state, shows promise as an alternative for predicting peritoneal metastases. With further research, deep learning and radiomic modelling can be refined and potentially applied as a preoperative diagnostic tool to reduce the need for invasive staging laparoscopy.

CONCLUSION

Staging laparoscopy was superior in all measured aspects. However, associated risks and costs must be considered. Refinements in radiomic modelling are necessary to establish it as a reliable screening technique.

Application of Circulating Tumor Cells and Interleukin-6 in Preoperative Prediction of Peritoneal Metastasis of Advanced Gastric Cancer

Background

The purpose of this study was to explore the clinical significance of circulating tumor cells (CTCs) and cytokines in peripheral blood in preoperative prediction of peritoneal metastasis (PM) in advanced gastric cancer (AGC).

Methods

The clinicopathological characteristics of 282 patients with AGC were retrospectively analyzed. The patients were divided into training and validation groups according to the time of receiving treatment. We used univariate analysis and multivariate logistic regression analysis to screen out the independent risk factors of PM in AGC. Then, we incorporated independent risk factors into the nomogram, and evaluated the discriminative ability.

Results

The levels of CTCs and interleukin-6 (IL-6) of AGC patients with PM were higher than those without PM (P<0.05). Moreover, the levels of CTCs and IL-6 in the occult peritoneal metastasis (OPM) group and the CT-positive PM group were higher than those in the negative PM (P<0.05). Multivariate logistic regression analysis showed that IL-6 > 12.22 pg/mL, CTCs > 4/5mL, CA724 > 6 IU/mL, CA125 > 35 U/mL and tumor size > 5 cm were independent risk factors for PM of AGC. The area under the ROC curve of the nomogram were 0.898 and 0.926 in the training and validation sets, respectively. The clinical decision curve showed that the nomogram had good clinical utility.

Conclusion

CTCs and IL-6 in peripheral blood are promising biomarkers for predicting the risk of PM in AGC. The nomogram constructed from five risk factors can effectively assess the risk of PM in AGC patients individually.

The Role of Staging Laparoscopy for Gastric Cancer Patients: Current Evidence and Future Perspectives

A significant proportion of patients diagnosed with gastric cancer is discovered with peritoneal metastases at laparotomy. Despite the continuous improvement in the performance of radiological imaging, the preoperative recognition of such an advanced disease is still challenging during the diagnostic work-up, since the sensitivity of CT scans to peritoneal carcinomatosis is not always adequate. Staging laparoscopy offers the chance to significantly increase the rate of promptly diagnosed peritoneal metastases, thus reducing the number of unnecessary laparotomies and modifying the initial treatment strategy of gastric cancer. The aim of this review was to provide a comprehensive summary of the current literature regarding the role of staging laparoscopy in the management of gastric cancer. Indications, techniques, accuracy, advantages, and limitations of staging laparoscopy and peritoneal cytology were discussed. Furthermore, a focus on current evidence regarding the application of artificial intelligence and image-guided surgery in staging laparoscopy was included in order to provide a picture of the future perspectives of this technique and its integration with modern tools in the preoperative management of gastric cancer.

Peritoneal regression grading score (PRGS): first evidence for independent predictive and prognostic significance

Objectives

The peritoneal regression grading score (PRGS) is a four-tied pathologic score measuring tumor regression in biopsies from patients with peritoneal metastasis (PM) receiving chemotherapy.

Methods

This retrospective analysis of a prospective registry (NCT03210298) analyses 97 patients with isolated PM under palliative chemotherapy. We examined the predictive value of the initial PRGS for overall survival (OS) and the prognostic value of PRGS in repeated peritoneal biopsies.

Results

The 36 (37.1 %) patients with an initial mean PRGS≤2 had a longer median OS (12.1 months, CI 95 % 7.8-16.4) vs. 8.0 months (CI 95 % 5.1-10.8 months) in 61 (62.9 %) patients with PRGS≥3 (p=0.02) After stratification, the initial PRGS was an independent predictor of OS (Cox-regression, p<0.05). Out of 62 patients receiving≥two chemotherapy cycles, 42 (67.7 %) had a histological response (defined as a lower or stable mean PRGS in successive therapy cycles), and 20 (32.3 %) progressed (defined as an increasing mean PRGS). PRGS response was associated with a longer median OS (14.6 months, CI 5-95 % 6.0-23.2) vs. 6.9 (CI 5-95 % 0.0-15.9) months. PRGS response was prognostic in the univariate analysis (p=0.017). Thus, PRGS had both a predictive and prognostic significance in patients with isolated PM receiving palliative chemotherapy in this patient cohort.

Conclusions

This is the first evidence for the independent predictive and prognostic significance of PRGS in PM. These encouraging results need validation in an adequately powered, prospective study.

STAGING LAPAROSCOPY IS STILL A VALUABLE TOOL FOR OPTIMAL GASTRIC CANCER MANAGEMENT

BACKGROUND

Complete surgical resection is the main determining factor in the survival of advanced gastric cancer patients, but is not indicated in metastatic disease. The peritoneum is a common site of metastasis and preoperative imaging techniques still fail to detect it.

AIM

The aim of this study was to evaluate the role of staging laparoscopy in the staging of advanced gastric cancer patients in a Western tertiary cancer center.

METHODS

A total of 130 patients with gastric adenocarcinoma who underwent staging laparoscopy from 2009 to 2020 were evaluated from a prospective database. Clinicopathological characteristics were analyzed to identify factors associated with the presence of peritoneal metastasis and were also evaluated the accuracy and strength of agreement between computed tomography and staging laparoscopy in detecting peritoneal metastasis and the change in treatment strategy after the procedure.

RESULTS

The peritoneal metastasis was identified in 66 (50.76%) patients. The sensitivity, specificity, and accuracy of computed tomography in detecting peritoneal metastasis were 51.5, 87.5, and 69.2%, respectively. According to the Kappa coefficient, the concordance between staging laparoscopy and computed tomography was 38.8%. In multivariate analysis, ascites (p=0.001) and suspected peritoneal metastasis on computed tomography (p=0.007) were statistically correlated with peritoneal metastasis. In 40 (30.8%) patients, staging and treatment plans changed after staging laparoscopy (32 patients avoided unnecessary laparotomy, and 8 patients, who were previously considered stage IVb by computed tomography, were referred to surgical treatment).

CONCLUSION

The staging laparoscopy demonstrated an important role in the diagnosis of peritoneal metastasis, even with current advances in imaging techniques.

Staging LaParoscopy to Assess Lymph NOde InvoLvement in Advanced GAstric Cancer (POLA)-Study protocol for a single-arm prospective observational multicenter study

INTRODUCTION

In the era of neoadjuvant chemotherapy in advanced gastric cancer (GC), the role of staging laparoscopy (SL) will become more established. However, despite guidelines recommendations, SL for optimal preoperative staging remains underutilized. Diagnostic value of near-infrared (NIR) / indocyanine green (ICG) guided sentinel node (SN) mapping in GC confirmed its technical feasibility, however no data exist regarding its potential role in pathological nodal staging. To the best of our knowledge, current study is the first to evaluate the role of ICG in nodal staging of advanced GC patients undergoing SL.

MATERIALS AND METHODS

This single-arm prospective observational multicenter study was approved by the Bioethical Committee of Medical University of Lublin (Ethic Code: KE-0254/331/2018). The protocol is registered at clinicaltrial.gov (NCT05720598), and the study results will be reported according to the Strengthening of Reporting of Observational Studies in Epidemiology (STROBE) statement. The primary endpoint of this study is the identification rate of ICG-guided SN in advanced GC patients. The secondary endpoints include pathological and molecular assessment of retrieved SNs and other pretreatment clinical variables potentially associated with SL: pattern of perigastric ICG distribution according to patients' pathological and clinical characteristics, neoadjuvant chemotherapy compliance, 30-day morbidity, and mortality.

CONCLUSION

POLA study is the first to investigate the clinical value of ICG-enhanced sentinel node biopsy during staging laparoscopy in advanced GC patients in a Western cohort. Identifying pN status before multimodal treatment will improve GC staging process.

Situación actual de la laparoscopía de estadificación en pacientes con cáncer gástrico en Colombia: ¿Cómo lo estamos haciendo?

Introducción. La laparoscopía de estadificación permite identificar con gran precisión el compromiso locorregional avanzado y metastásico a peritoneo en los pacientes con cáncer gástrico. Las guías internacionales aún difieren en las indicaciones para incluir este procedimiento como parte del proceso de estadificación. Métodos. Se diseñó una encuesta dirigida a cirujanos residentes en Colombia, sobre el uso de la laparoscopía de estadificación en los pacientes con cáncer gástrico. Se analizaron los resultados y con base en la evidencia disponible se proponen algunas pautas en las indicaciones y técnica del procedimiento. Resultados. Respondieron la encuesta 74 cirujanos; el 43,8 % considera que el objetivo de la laparoscopía de estadificación es descartar la carcinomatosis peritoneal. El 54,1 % realiza el procedimiento en estadios tempranos, sin embargo, el 48,6 % considera realizarla solo en pacientes con sospecha de carcinomatosis por imágenes. Las áreas evaluadas con mayor frecuencia por los cirujanos (más del 85 %) son la superficie hepática, las cúpulas diafragmáticas, los recesos parietocólicos y la pelvis. Las zonas evaluadas en menor frecuencia son la válvula ileocecal (40,5 %) y el ligamento de Treitz (39 %). El 33 % de los cirujanos no toma rutinariamente citología peritoneal. Conclusión. Este trabajo muestra la tendencia de los cirujanos en el uso de la laparoscopía de estadificación en pacientes con cáncer gástrico. A pesar de encontrar resultados muy positivos en relación con las indicaciones y técnica del procedimiento, es necesario analizar la evidencia disponible para su uso según cada escenario y mejorar la sistematización del procedimiento.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Predicting peritoneal carcinomatosis of gastric cancer: A simple model to exempt low-risk patients from unnecessary staging laparoscopy

Background

Peritoneal carcinomatosis (PC) of gastric cancer indicates a poor outcome and is mainly diagnosed by staging laparoscopy (SL). This study was designed to develop a risk stratification model based on the number of risk factors to exempt low-risk patients from unnecessary SL.

Methods

This was a retrospective cohort study based on a single institution between January 2015 and December 2019. SL is indicated for patients of advanced locoregional stage, and clinicopathologic characteristics of 535 consecutive patients were included. PC-associated variables were identified by logistic regression analysis. A risk stratification model based on the number of risk factors was constructed, and we defined its predictive value with a receiver operating characteristic (ROC) curve and negative predictive value.

Results

In total, 15.9% of included patients were found to have PC during SL. Borrmann type IV, elevated CA125, and tumour diameter ≥5 cm were independent risk factors of PC. These three factors combined with cT4 were selected as predictive factors, and the number of predictive variables was significantly related to the possibility of PC (2.0%, 12.8%, 20.0%, 54.2%, and 100%, respectively). When the cutoff value is more than one predictive factor, the negative predictive value is 98.0%, with an area under the curve of 0.780. This model could exempt 29.8% of unnecessary SL compared to the indication of the current NCCN guideline.

Conclusions

We constructed a simple model to predict the probability of PC using the number of predictive factors. It is recommended that patients without any of these factors should be exempt from SL.

Efficacy Evaluation of 64-Slice Spiral Computed Tomography Images in Laparoscopic-Assisted Distal Gastrectomy for Gastric Cancer under the Reconstruction Algorithm

This study was aimed to analyze the application value of the filtered back-projection (FBP) reconstruction algorithm of computed tomography (CT) images in laparoscopic-assisted distal gastrectomy. In this study, 56 patients with gastric cancer were selected as research subjects and randomly divided into the control group (CT-guided laparoscopic radical gastrectomy) and the observation group (CT-guided laparoscopic radical gastrectomy with the FBP reconstruction algorithm), with 28 patients in each group. Fourier transform and iterative reconstruction were introduced for comparison, and finally, the postoperative curative effect and adverse events were compared between the two groups. The results showed that the CT image quality score processed by the FBP reconstruction algorithm (4.31 ± 0.31) was significantly higher than that of the iterative reconstruction method (3.5 ± 0.29) and the Fourier transform method (3.97 ± 0.38) (P < 0.05). The incidences of postoperative wound infection and gastric motility disorder (5.88% and 8.16%, respectively) in the observation group were significantly lower than those in the control group (8.21% and 10.82%, respectively) (P < 0.05). The levels of serum interleukin-6 (IL-6) (280.35 ± 15.08 ng/L) and tumor necrosis factor-α (TNF-α) (144.32 ± 10.32 ng/L) in the observation group after the treatment were significantly lower than those in the control group, which were 399.71 ± 14.19 ng/L and 165.33 ± 10.08 ng/L, respectively (P < 0.05). In conclusion, the FBP reconstruction algorithm was better than other algorithms in the processing of gastric cancer CT images. The FBP reconstruction algorithm showed a good reconstruction effect on CT images of gastric cancer; CT images based on this algorithm helped to formulate targeted surgical treatment plans for gastric cancer, showing a high clinical application value.

Development of the PERI-Gastric (PEritoneal Recurrence Index) and PERI-Gram (Peritoneal Recurrence Index NomoGRAM) for predicting the risk of metachronous peritoneal carcinomatosis after gastrectomy with curative intent for gastric cancer

BACKGROUND

A model that quantifies the risk of peritoneal recurrence would be a useful tool for improving decision-making in patients undergoing curative-aim gastrectomy for gastric cancer (GC).

METHODS

Five Italian centers participated in this study. Two risk scores were created according to the two most widely used pathologic classifications of GC (the Lauren classification and the presence of signet-ring-cell features). The risk scores (the PERI-Gastric 1 and 2) were based on the results of multivariable logistic regressions and presented as nomograms (the PERI-Gram 1 and 2). Discrimination was assessed with the area under the curve (AUC) of receiver operating curves. Calibration graphs were constructed by plotting the actual versus the predicted rate of peritoneal recurrence. Internal validation was performed with a bootstrap resampling method (1000 iterations).

RESULTS

The models were developed based on a population of 645 patients (selected from 1580 patients treated from 1998 to 2018). In the PERI-Gastric 1, significant variables were linitis plastica, stump GC, pT3-4, pN2-3 and the Lauren diffuse histotype, while in the PERI-Gastric 2, significant variables were linitis plastica, stump GC, pT3-4, pN2-3 and the presence of signet-ring cells. The AUC was 0,828 (0.778-0.877) for the PERI-Gastric 1 and 0,805 (0.755-0.855) for the PERI-Gastric 2. After bootstrap resampling, the PERI-Gastric 1 had a mean AUC of 0.775 (0.721-0.830) and a 95%CI estimate for the calibration slope of 0.852-1.505 and the PERI-Gastric 2 a mean AUC of 0.749 (0.693-0.805) and a 95%CI estimate for the slope of 0.777-1.351. The models are available at www.perigastric.org .

CONCLUSIONS

We developed the PERI-Gastric and the PERI-Gram as instruments to determine the risk of peritoneal recurrence after curative-aim gastrectomy. These models could direct the administration of prophylactic intraperitoneal treatments.

Indication of Hyperthermic Intraperitoneal Chemotherapy in Gastric Cancer (Gastripec, Gastrichip)

<b><i>Background:</i></b> Gastric cancer (GC) is associated with a poor prognosis mostly due to peritoneal metastasis, which will develop in time during the patient’s disease history. To prevent and treat peritoneal metastasis, different kinds of treatment regimens have been described. <b><i>Summary:</i></b> In this review, we addressed two main topics – prophylaxis and treatment of peritoneal metastasis in GC. Prevention should be directed towards diminishing cancer cell spillage and reducing adherence of cancer cells to the abdominal cavity. Postoperative washing of the abdomen with or without chemotherapy and additional heat are herein discussed. <b><i>Key Messages:</i></b> Treatment of existing peritoneal metastasis is effective in patients with limited disease and tumour spread. Cytoreductive surgery including resection of peritoneal metastasis followed directly with hyperthermic intraperitoneal chemotherapy can increase overall survival and progression-free survival in selected patients. Drugs, duration and time schedules of intraperitoneal chemotherapy are reviewed and presented. Intraperitoneal chemotherapy seems to improve the prognosis of patients with GC and peritoneal metastasis after complete resection of both primary and metastatic tumours.

Clinical impact of gastrectomy for gastric cancer patients with positive lavage cytology without gross peritoneal dissemination

BACKGROUND

The prognosis of gastric cancer patients with positive lavage cytology without gross peritoneal dissemination (P0CY1) is poor. The survival benefit of gastrectomy for these patients has not been established.

PATIENTS AND METHODS

In this population-based cohort study, we investigated the impact of radical gastrectomy with lymph node dissection for P0CY1 patients. Patients who were diagnosed with Stage IV gastric cancer from 2008 to 2015 in all nine cancer-designated hospitals in a tertiary medical area were listed. Patients who were diagnosed with histologically proven adenocarcinoma in both the primary lesion and lavage cytology during the operation or a diagnostic laparoscopic examination were enrolled. Patients with a gross peritoneal lesion or other metastatic lesions were excluded. The primary outcome was the adjusted hazard ratio (aHR) of gastrectomy for overall survival. We also evaluated the survival time in patients who underwent gastrectomy or chemotherapy in comparison to patients managed without primary surgery or with best supportive care.

RESULTS

One hundred patients were enrolled. The aHR (95% confidence interval) of gastrectomy was 0.677 (0.411-1.114, p = 0.125). The median survival time in patients who received gastrectomy (n = 74) was 21.7, while that in patients managed without primary surgery (n = 30) was 20.5 months (p = 0.155). The median survival time in patients who received chemotherapy (n = 76) was 23.0 months, while that in patients managed without chemotherapy was 8.6 months (p < 0.001).

CONCLUSION

Gastrectomy was not effective for improving the survival time in patients with P0CY1 gastric cancer. Surgeons should prioritize the performance of chemotherapy over surgery as the initial treatment.

OUP accepted manuscript

We performed the accurate diagnosis and complete surgical resection of a gastrointestinal stromal tumor at the mesentery of the small bowel. Computed tomography (CT) in a 62-year-old man at 2 years after gastrectomy for gastric cancer showed a mesenteric tumor, with no other tumors noted. Positron emission tomography-computed tomography (PET-CT) showed a maximum standardized uptake value (SUV max) of 2.9 at the tumor. The presence of a single and low SUV max tumor allowed us to perform laparoscopic surgery. Partial resection of the tumor with an adequate margin was performed. The pathological findings showed c-kit positivity and a low Ki-67 proliferation index (<5%). In the present case, PET-CT and laparoscopic assessments were useful for accurately evaluating the surgical resectability of the mesenteric tumor after distal gastrectomy for gastric cancer. The low SUV max and laparoscopic findings led to complete surgical resection of a mesenteric tumor.

18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC)

Importance

The optimal staging for gastric cancer remains a matter of debate.

Objective

To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer.

Design, Setting, and Participants

This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020.

Exposures

All patients underwent an FDG-PET/CT and/or SL in addition to initial staging.

Main Outcomes and Measures

The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay.

Results

Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days.

Conclusions and Relevance

This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.

The Burden of Peritoneal Metastases from Gastric Cancer: A Systematic Review on the Incidence, Risk Factors and Survival

The peritoneum is a common metastatic site in gastric cancer. This systematic review provides an overview of the incidence, risk factors and survival of synchronous peritoneal metastases from gastric cancer. A systematic search was performed to identify studies wherein the incidence, risk factors and survival of gastric cancer with peritoneal metastases were investigated. Of all 38 potentially eligible studies, 17 studies were included based on the eligibility criteria. The incidence of synchronous gastric peritoneal metastases was reviewed for population-based studies (10–21%), for observational cohort studies (2–15%) and for surgical cohort studies (13–40%). Potential risk factors for synchronous gastric peritoneal metastases were younger age, non-cardia gastric cancer, female sex, signet ring cell carcinoma, diffuse type histology or linitis plastica, T4 stage, Hispanic ethnicity and more than one metastatic location. Synchronous peritoneal metastases are commonly diagnosed in patients with gastric cancer with an incidence up to 21% in recent population-based studies. Furthermore, prognosis of patients with gastric peritoneal metastases is poor with median overall survival ranging from 2 to 9 months. The high incidence and poor prognosis require intensive research on diagnostic features and effective treatment options to improve survival.

Staging laparoscopy in patients with advanced gastric cancer: A single center cohort study

BACKGROUND

Most studies exploring the role of staging laparoscopy in gastric cancer are limited by low sample size and are predominantly conducted in Asian countries. This study sets out to determine the value of staging laparoscopy in patients with advanced gastric cancer in a Western population.

METHODS

All patients with gastric cancer from a tertiary referral center without definite evidence of non-curable disease after initial staging, and who underwent staging laparoscopy between 2013 and 2020, were identified from a prospectively maintained database. The proportion of patients in whom metastases or locoregional non-resectability was detected during staging laparoscopy was established. Secondary outcomes included the avoidable surgery rate (detection of non-curable disease during gastrectomy with curative intent) and diagnostic accuracy (sensitivity, specificity, accuracy, negative and positive predictive value).

RESULTS

A total of 216 patients were included. Staging laparoscopy revealed metastatic disease in 46 (21.3 %) patients and a non-resectable tumor in three (1.4 %) patients. During intended gastrectomy, non-curable disease was revealed in 13 (8.6 %) patients. Overall sensitivity, specificity and diagnostic accuracy were 76.6 %, 100 % and 92.6 %, respectively. The positive predictive value was 100 % and the negative predictive value was 90.3 %.

CONCLUSION

Staging laparoscopy is valuable in the staging process of gastric cancer with a high accuracy in detecting non-curable disease, thereby preventing futile treatment and its associated burden.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

Prognostic impact of surgery after chemotherapy for type 4 gastric cancer

PURPOSE

To assess the clinical indications for, and prognostic impact of surgery after, chemotherapy for type 4 gastric cancer.

METHODS

The subjects of this retrospective study were 67 patients who received chemotherapy for type 4 gastric cancer. The patients were grouped into those with progressive disease (PD group) and those without PD (non-PD group), according to the tumor response to chemotherapy.

RESULTS

Distant metastases developed in 58 patients. With regard to tumor response, there were 16 patients in the PD group and 51 patients in the non-PD group. The prognosis of the PD group patients was significantly poorer than that of the non-PD group patients (p < 0.0001). R0 resection was performed for 21 of 23 patients who underwent surgery after chemotherapy. Multivariate analysis revealed tumor response and surgery as independent prognostic factors (p = 0.0001 and p = 0.0009, respectively). Moreover, multivariate analysis of the surgery group revealed that metastatic nodal status (N0-1 vs. N2-3) and residual tumor status (R0 vs. R1-2) were significant independent prognostic factors (p = 0.0258 and p = 0.0458, respectively).

CONCLUSION

The findings of this study suggest that surgery after chemotherapy for type 4 gastric cancer may improve the prognosis of responders with N0-1 status, who undergo curative R0 resection.

Lymph Node Involvement in Advanced Gastric Cancer in the Era of Multimodal Treatment-Oncological and Surgical Perspective

Simple Summary

Gastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Therefore, further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.

Abstract

Gastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. A favourable prognostic impact for ypN0 patients is observed, either due to truly negative LN before the start of therapy or because preoperative therapy achieved a pathologically complete nodal response. Ongoing trials investigating the extent of lymphadenectomy after neoadjuvant therapy will standardise the LN dissection from the multimodal therapy perspective. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.

Influence of positive margins on tumour recurrence and overall survival after gastrectomy for gastric cancer

BACKGROUND

Incidence of positive surgical margins after curative gastrectomy ranges from 1% to 20%. It has been suggested that positive surgical margin is an adverse prognosis factor, with a higher local recurrence and worse overall survival (OS). However, the management of these patients remains unclear.

METHODS

A total of 267 patients who underwent gastrectomy with curative intent between January 2010 and December 2018 in our centre were enrolled in this study. Post-operative histological analysis revealed positive resection margins in 18 patients (8%). Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared.

RESULTS

Patients with positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, whole stomach involved and poorly differentiated tumours. Local recurrence was described in 50% of cases with positive margins. The multivariate analysis demonstrated that the TNM stage was the only independent prognostic factor associated with recurrence. OS for positive margins at 1, 3 and 5 years was 75%, 57% and 26%, respectively. The median survival in patients with positive margins was 38.33 versus 81.17 months for R0 patients (p = 0.027). Multivariate analysis showed that age (hazard ratio [HR] 1.041, 95% confidence interval [CI] 1.02-1.07, sex (HR 2.00, 95% CI 1.22-3.30) and TNM stage (p < 0.001) were independent factors of OS.

CONCLUSION

Positive resection margin was an indication of advanced and more aggressive disease rather than an independent prognosis factor for OS or recurrence in gastric cancer.

Evaluation of the Implementation of FDG-PET/CT and Staging Laparoscopy for Gastric Cancer in The Netherlands

BACKGROUND

The role of 18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) has increased in the preoperative staging of gastric cancer. Dutch national guidelines have recommended the use of FDG-PET/CT and SL for patients with locally advanced tumors since July 2016.

OBJECTIVE

The aim of this study was to evaluate the implementation of FDG-PET/CT and SL in The Netherlands.

METHODS

Between 2011 and 2018, all patients who underwent surgery for gastric cancer were included from the Dutch Upper GI Cancer Audit. The use of FDG-PET/CT and SL was evaluated before and after revision of the Dutch guidelines. Outcomes included the number of non-curative procedures (e.g. palliative and futile procedures) and the association of FDG-PET/CT and SL, with waiting times from diagnosis to the start of treatment.

RESULTS

A total of 3310 patients were analyzed. After July 2016, the use of FDG-PET/CT (23% vs. 61%; p < 0.001) and SL (21% vs. 58%; p < 0.001) increased. FDG-PET/CT was associated with additional waiting time to neoadjuvant therapy (4 days), as well as primary surgical treatment (20 days), and SL was associated with 8 additional days of waiting time to neoadjuvant therapy. Performing SL or both modalities consecutively in patients in whom it was indicated was not associated with the number of non-curative procedures.

CONCLUSION

During implementation of FDG-PET/CT and SL after revision of the guidelines, both have increasingly been used in The Netherlands. The addition of these staging methods was associated with increased waiting time to treatment. The number of non-curative procedures did not differ after performing none, solely one, or both staging modalities.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer]

BACKGROUND

Gastric cancer with peritoneal metastases is associated with an extremely poor prognosis. Developed multimodal treatment concepts, which include a combination of perioperative systemic treatment and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), show promising results with respect to improvement of the long-term survival.

METHODS

This article contains a review of the literature of published studies on the topic of gastric cancer and peritoneal metastasis.

RESULTS

The prognosis of patients with gastric cancer peritoneal carcinomatosis shows an extremely limited median survival of 7 months under palliative second-line systemic treatment. The median survival time increased to 12 months with cytoreductive surgery and in combination with HIPEC showed a positive effect on survival in individual studies.

EXPERT OPINION

Treatment recommendations for patients with peritoneal metastases of gastric cancer should be carried out by experts in surgical reference centers.

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors

Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Multidisciplinary team consultation for resectable Gastric Cancer: A propensity score matching analysis

Purpose: Previous studies proposed that the multidisciplinary team (MDT) consultation could improve tumor staging accuracy and outcomes of patients with gastric malignancy. However, evidence-based reports remain limited. This study aimed to determine the effectiveness of MDT for tumor staging accuracy and outcomes of patients with resectable gastric cancer, and to explore the potential factors affecting its effectiveness. Methods: This retrospective study enrolled 719 gastric cancer patients who underwent gastrectomy in our hospital. After propensity score matching, 378 patients were selected, including 189 in the non-MDT group and 189 in the MDT group. Data regarding baseline characteristics, staging, treatments, and survival were analyzed. Results: The data showed that the staging accuracy in the MDT group and non-MDT group was comparable (53% vs 61% for T stage, 46.1% vs 35.3% for N stage, and 78.3% vs 78.7% for M stage). The MDT group had a higher proportion of preoperative chemotherapy (39.2% vs 28%, p=0.03) and laparoscopic surgery (82.5% vs 72%, p=0.02) than the non-MDT group. However, the achievement of R0 resection was similar in the two groups (93.7% vs 88.9%, p=0.73). There was no significant difference in the 1-year and 3-year overall survival rates between the two groups. Moreover, we observed poor patient compliance when the MDT recommended further examinations, radiotherapy, or chemotherapy before surgical interventions. Conclusion: MDT consultation has limited effects on improving the staging accuracy and treatment outcomes including survival of patients with resectable gastric cancer. Poor patient compliance may be a factor affecting the effectiveness of MDT consultation.

Noninvasive Prediction of Occult Peritoneal Metastasis in Gastric Cancer Using Deep Learning

IMPORTANCE

Occult peritoneal metastasis frequently occurs in patients with advanced gastric cancer and is poorly diagnosed with currently available tools. Because the presence of peritoneal metastasis precludes the possibility of curative surgery, there is an unmet need for a noninvasive approach to reliably identify patients with occult peritoneal metastasis.

OBJECTIVE

To assess the use of a deep learning model for predicting occult peritoneal metastasis based on preoperative computed tomography images.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter, retrospective cohort study, a deep convolutional neural network, the Peritoneal Metastasis Network (PMetNet), was trained to predict occult peritoneal metastasis based on preoperative computed tomography images. Data from a cohort of 1225 patients with gastric cancer who underwent surgery at Sun Yat-sen University Cancer Center (Guangzhou, China) were used for training purposes. To externally validate the model, data were collected from 2 independent cohorts comprising a total of 753 patients with gastric cancer who underwent surgery at Nanfang Hospital (Guangzhou, China) or the Third Affiliated Hospital of Southern Medical University (Guangzhou, China). The status of peritoneal metastasis for all patients was confirmed by pathological examination of pleural specimens obtained during surgery. Detailed clinicopathological data were collected for each patient. Data analysis was performed between September 1, 2019, and January 31, 2020.

MAIN OUTCOMES AND MEASURES

The area under the receiver operating characteristic curve (AUC) and decision curve were analyzed to evaluate performance in predicting occult peritoneal metastasis.

RESULTS

A total of 1978 patients (mean [SD] age, 56.0 [12.2] years; 1350 [68.3%] male) were included in the study. The PMetNet model achieved an AUC of 0.946 (95% CI, 0.927-0.965), with a sensitivity of 75.4% and a specificity of 92.9% in external validation cohort 1. In external validation cohort 2, the AUC was 0.920 (95% CI, 0.848-0.992), with a sensitivity of 87.5% and a specificity of 98.2%. The discrimination performance of PMetNet was substantially higher than conventional clinicopathological factors (AUC range, 0.51-0.63). In multivariable logistic regression analysis, PMetNet was an independent predictor of occult peritoneal metastasis.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that the PMetNet model can serve as a reliable noninvasive tool for early identification of patients with clinically occult peritoneal metastasis, which will inform individualized preoperative treatment decision-making and may avoid unnecessary surgery and complications. These results warrant further validation in prospective studies.

Video-Assisted Jejunostomy Tube Placement With Two Portals: Surgical Technique in Ten Steps

Objectives. Endoscopic gastrostomy occasionally presents limitations such as costs, availability of equipment and special materials, and difficult access to the gastric cavity in the setting of obstructive esophageal tumors. Open jejunostomies present high rates of postoperative complications and limited capacity for abdominal evaluation due to reduced incision size. Thus, to reduce procedure-related complications and overall costs and provide a thorough intraoperative evaluation of the peritoneal cavity, we present the following simplified technique. Methods. Video-assisted jejunostomy in ten steps. Results. The use of this Video-assisted laparoscopic technique proves to be a safe, viable alternative, with cost reduction, decreased use of disposable materials, shortened operative time, and accelerated recovery, in addition to increased technical ease and wide applicability across a variety of hospital settings.

The impact of peritoneal lavage cytology in biliary tract cancer (KHBO1701): Kansai Hepato-Biliary Oncology Group

Background

Only few studies in literature have analyzed the clinical effects of peritoneal lavage status in biliary tract cancers.

Aim

We aimed to assess the effect of cytology‐positive peritoneal lavage on survival for patients with biliary tract cancer who underwent curative resection.

Methods

The KHBO1701 study was a multi‐institutional retrospective study that assessed the clinical effects of peritoneal lavage cytology in biliary tract cancers. Using clinicopathological data from 11 Japanese institutions, we compared long‐term outcomes between patients with cytology‐positive and cytology‐negative peritoneal lavage.

Results

Of 169 patients who underwent curative resection, 164 were cytology‐negative, and five were cytology‐positive. The incidence of portal invasion and preoperative carbohydrate antigen 19‐9 levels were higher in the cytology‐positive group than in the cytology‐negative group. The incidence of peritoneal metastatic recurrence was also higher, and overall survival tended to be worse in the cytology‐positive group. In contrast, recurrence‐free survival was similar between the cytology‐negative and cytology‐positive groups.

Conclusions

The positive status of peritoneal lavage cytology could moderately affect the survival of patients with biliary tract cancers. Given that surgical resection is the only curative treatment option, it may be acceptable to resect biliary tract cancers without other non‐curative factors, regardless of peritoneal lavage cytology status.

Peritoneal dissemination of breast cancer diagnosed by laparoscopy

The accuracy of modern imaging techniques for the diagnosis of peritoneal carcinomatosis is poor. A breast cancer patient with a high serum CA15-3 level did not receive a definitive diagnosis of peritoneal dissemination by imaging examination and then underwent laparoscopy. Pathological examination showed peritoneal dissemination of breast cancer, but the biological markers were different from the primary lesion: ER(−), PgR(−), and Her2:3 +. T-DM1 therapy was very effective, and her systemic symptoms disappeared. Since biomarkers of metastatic lesions may sometimes change, laparoscopic biopsy is very important and useful.

New insights in diagnostic laparoscopy

The basic concept of Diagnostic Laparoscopy (DL) is old but not old-fashioned. – Before the rise of tomography and ultrasound there was just the direct look into the abdomen and onto the affected organ available. As open surgery comes along with trauma, blood loss and infection, every effort have been made to improve the access strategies. Finally, due to innovation in optics, video technology and computer science, the look into the abdomen through a “keyhole” is a standard procedure today. – In this review we give an overview of history, implications and cost-effectiveness of DL, attempting an extrapolation of its future role.

The additive value of restaging-CT during neoadjuvant chemotherapy for gastric cancer

INTRODUCTION

Computed tomography (CT) is used for restaging of gastric cancer patients during neoadjuvant chemotherapy (NAC). The treatment strategy could be altered after detection of distant interval metastases, possibly leading to a reduction in unnecessary chemotherapy cycles, its related toxicity, and surgical procedures. The aim of this study was to evaluate the additive value of restaging-CT during NAC in guiding clinical decision making in gastric cancer.

MATERIALS AND METHODS

This retrospective, multicenter cohort study identified all patients with surgically resectable gastric adenocarcinoma (cT1-4a-x, N0-3-x, M0-x), who started NAC with curative intent. Restaging-CT was performed after 2 out of 3 cycles of NAC. The primary outcome was treatment alterations made based on restaging-CT by a multidisciplinary tumor board. Confirmation of metastases was obtained by surgery or biopsy.

RESULTS

Between 2007 and 2015, CT-restaging was performed in 122 out of 152 included patients and timed after 2 cycles (n = 76) or after 3 cycles (n = 46) of NAC. Restaging-CT revealed a metastasis in 1 out of 122 restaged patients (1%) after which surgical resection was omitted, whereas 4 patients (3%) with distant interval metastases were not identified by restaging-CT and underwent a futile laparotomy. In 5 out of 76 patients (7%) disease progression was detected while undergoing NAC, leading to omission of the 3rd cycle of chemotherapy.

CONCLUSION

The additive value of restaging-CT during NAC in gastric cancer is limited in guiding clinical decision making and therefore not recommended. Further studies may identify subgroups that may benefit of alternative diagnostic modalities.

Analysis and external validation of a nomogram to predict peritoneal dissemination in gastric cancer

OBJECTIVE

Peritoneal dissemination is difficult to diagnose by conventional imaging technologies. We aimed to construct a nomogram to predict peritoneal dissemination in gastric cancer (GC) patients.

METHODS

We retrospectively analyzed 1,112 GC patients in Sun Yat-sen University Cancer Center between 2001 and 2010 as the development set and 474 patients from The Sixth Affiliated Hospital, Sun Yat-sen University between 2010 and 2016 as the validation set. The clinicopathological variables associated with gastric cancer with peritoneal dissemination (GCPD) were analyzed. We used logistic regression analysis to identify independent risk factors for peritoneal dissemination. Then, we constructed a nomogram for the prediction of GCPD and defined its predictive value with a receiver operating characteristic (ROC) curve. External validation was performed to validate the applicability of the nomogram.

RESULTS

In total, 250 patients were histologically identified as having peritoneal dissemination. Logistic regression analysis demonstrated that age, sex, tumor location, tumor size, signet-ring cell carcinoma (SRCC), T stage, N stage and Borrmann classification IV (Borrmann IV) were independent risk factors for peritoneal dissemination. We constructed a nomogram consisting of these eight factors to predict GCPD and found an optimistic predictive capability, with a C-index of 0.791, an area under the curve (AUC) of 0.791, and a 95% confidence interval (95% CI) of 0.762-0.820. The results found in the external validation set were also promising.

CONCLUSIONS

We constructed a highly sensitive nomogram that can assist clinicians in the early diagnosis of GCPD and serve as a reference for optimizing clinical management strategies.

Gastric Cancer with Radiographically Occult Metastatic Disease: Biology, Challenges, and Diagnostic Approaches

Gastric adenocarcinoma is an aggressive cancer that demonstrates heterogeneous biology depending on patient ethnicity, tumor location, tumor type, and genetic profile. It remains the third leading cause of cancer deaths worldwide and was estimated to result in 782,000 deaths in 2018. Challenges exist in accurately assessing the disease burden, as available radiological staging often underestimates metastatic disease. This diagnostic handicap, along with the poor understanding of the heterogeneous biology of gastric cancer, has hindered the development of effective therapeutic solutions and thus halted improvement in patient outcomes over the last few decades. The management of occult peritoneal disease is complicated, as most patients are understaged by standard imaging studies and therefore thought to have local diseases. In this article, we systematically review recent literature on the limitations that are associated with standard radiographic staging, discuss recent molecular biology advances to better identify and diagnose occult peritoneal disease, and propose possible management strategies to approach this complicated clinical problem.

Consensus statement of the Hellenic and Cypriot Gastric Cancer Study Group on the diagnosis, staging and management of gastric cancer

Gastric Cancer epidemics have changed over recent decades, declining in incidence, shifting from distal to proximal location, transforming from intestinal to diffuse histology. Novel chemotherapeutic agents combined with modern surgical operations hardly changed overall disease related survival. This may be attributed to a substantial inherent geographical variation of disease genetics, but also to a failure to standardize and implement treatment protocols in clinical practice. To overcome these drawbacks in Greece and Cyprus, a Gastric Cancer Study Group under the auspices of the Hellenic Society of Medical Oncology (HeSMO) and Gastrointestinal Cancer Study Group (GIC-SG) merged their efforts to produce a consensus considering ethnic parameters of healthcare system and the international proposals as well. Utilizing structured meetings of experts, a consensus was reached. To achieve further consensus, statements were subjected to the Delphi methodology by invited multidisciplinary national and international experts. Sentences were considered of high or low consensus if they were voted by ≥ 80%, or < 80%, respectively; those obtaining a low consensus level after both voting rounds were rejected. Forty-five statements were developed and voted by 71 experts. The median rate of abstention per statement was 9.9% (range: 0-53.5%). At the end of the process, one statement was rejected, another revised, and all the remaining achieved a high consensus. Forty-four recommendations covering all aspects of the management of gastric cancer and concise treatment algorithms are proposed by the Hellenic and Cypriot Gastric Cancer Study Group. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and individualization are emphasized.