Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970

Machine learning classification and biochemical characteristics in the real-time diagnosis of gastric adenocarcinoma using Raman spectroscopy

This study aimed to identify biomolecular differences between benign gastric tissues (gastritis/intestinal metaplasia) and gastric adenocarcinoma and to evaluate the diagnostic power of Raman spectroscopy-based machine learning in gastric adenocarcinoma. Raman spectroscopy-based machine learning was applied in real-time during endoscopy in 19 patients (aged 51-85 years) with high-risk for gastric adenocarcinoma. Raman spectra were captured from suspicious lesions and adjacent normal mucosa, which were biopsied for matched histopathologic diagnosis. Spectral data were analyzed using principal component analysis (PCA) and linear discriminant analysis (LDA) with leave-one-out cross-validation (LOOCV) to develop a machine learning model for diagnosing gastric adenocarcinoma. High-quality spectra (800-3300 cm⁻¹) revealed distinct patterns: adenocarcinoma tissues had higher intensities below 3150 cm⁻¹, while benign tissues exhibited higher intensities between 3150 and 3290 cm⁻¹ (p < 0.001). The model achieved diagnostic accuracy, sensitivity, specificity, and AUC values of 0.905, 0.942, 0.787, and 0.957, respectively. Biochemical correlations suggested adenocarcinoma tissues had increased protein (e.g., phenylalanine), reduced lipids, and lower water content compared to benign tissues. This study highlights the potential of Raman spectroscopy with machine learning as a real-time diagnostic tool for gastric adenocarcinoma. Further validation could establish this technique as a non-invasive, accurate method to aid clinical decision-making during endoscopy.

Impact of surgical resection on the survival in Mexican patients with gastric cancer: A meta-analysis and systematic review

BACKGROUND

Gastric cancer (GC) is one of the most frequent cancer types in Mexico. The primary method used as a treatment is surgical resection. The role of surgery in increasing survival is controversial. This study aimed to determine whether surgical resection increases the survival of patients with GC in a Mexican population.

METHODS

A systematic review of literature searches (Evidence-based MEDLINE/PubMed, Web of Science, Cochrane Library, and SciELO) and meta-analysis were performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. The published articles from 2000 to the current time were divided into cross-sectional and randomized studies. The inclusion criteria were survival, surgical resections, patients treated in Mexico, and primary GC. The effect estimation was calculated using the risk ratio (RR). The random-effects model and a confidence interval (CI) of 95% were used.

RESULTS

The RR of the pooled studies was 1.09 (95% CI, 0.71-1.67). RR of 0.82 (95% CI, 0.63-1.07) was obtained in cross-sectional studies, and randomized studies showed a RR of 2.08 (95% CI, 0.25-17.07).

CONCLUSION

This work is the first systematic study that assesses the role of surgery on the survival of patients with GC in the Mexican population, the results showed that surgical resection did not improve survival in patients with GC.

Risk of progression in patients with chronic atrophic gastritis: A retrospective study

Background

Chronic atrophic gastritis (CAG) can progress to gastric cancer (GC) thus requiring endoscopic surveillance. Here, we analyze various aspects of CAG progression, time, and mucosal background, to guide reasonable surveillance.

Methods

CAG patients with three or more endoscopies from 2010–2021 were included. All cases were analyzed for rate and time of progression, and cases with operative link on gastritis assessment (OLGA) staging, operative link on gastric intestinal metaplasia assessment (OLGIM) staging, and Kimura-Takemoto classification were further analyzed. Additional investigation of guideline-defined low-risk patients by reviewing endoscopy in the short-term (1–2 years) after baseline identified several patients as high-risk.

Results

Ninety-seven (10.4%) of the 929 CAG patients progressed to low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN), or GC, during the observation period of 36–129 months (median 53, IQR=24), including 75 (8.1%) cases of LGIN, eight (0.9%) of HGIN, and 14 (1.5%) of GC. Among 170 patients with OLGA/OLGIM at baseline, two (2/2, 100%) GC cases occurred in patients with OLGA/OLGIM III and IV. Of the 236 patients with Kimura-Takemoto classification at baseline, 5/7 (71.4%) cases of GC occurred in patients with C3–O3. Ten, 11, and 25 patients classified as low-risk on the European, British, and Chinese Guidelines, underwent additional endoscopy within 1–2 years, resulting in three (30.0%), four (36.4%), and eight (32.0%) patients being classified as high-risk on these guidelines, respectively.

Conclusion

A minority of CAG patients can progress to GC. OLGA/OLGIM III and IV staging are closely associated with progression. Disease-associated risk may be underestimated in one-third of patients classified as low-risk by initial endoscopy.

CircITGA7 Suppresses Gastric Cancer Progression Through miR-1471/MTDH Axis

In recent years, there have been reports about the involvement of circular RNAs (circRNAs) in the pathogenesis of gastric cancer (GC), but the molecular mechanism in cell proliferation, invasion, and migration is still unclear. Based on The Cancer Genome Atlas (TCGA) database, we analyzed differentially expressed circRNAs between GC and non-tumor tissues. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis were used to clarify the functional role in GC. Here, we showed that circITGA7 was lowly expressed in GC tissues based on the TCGA database. In vitro, silencing the expression of circITGA7 increased cell proliferation and metastasis, whereas overexpression did the opposite. Mechanistically, miR-1471 has circITGA7 as a sponge, and miR-1471 has metadherin (MTDH) as a target gene. Consequently, functional analysis showed that the tumor suppressor effect of circITGA7 was the result of regulating the miR-1471/MTDH axis. Overall, the circITGA7/miR-1471/MTDH signaling pathway may play a crucial role in GC, providing a new potential mechanism involved in GC progression.

Impact of surgical resection rate on survival in gastric cancer: nationwide study

Background

There are marked geographical variations in the proportion of patients undergoing resection for gastric cancer. This study investigated the impact of resection rate on survival.

Methods

All patients with potentially curable gastric cancer between 2006 and 2017 were identified from the Swedish National Register of Oesophageal and Gastric Cancer. The annual resection rate was calculated for each county per year. Resection rates in all counties for all years were grouped into tertiles and classified as low, intermediate or high. Survival was analysed using the Cox proportional hazards model.

Results

A total of 3465 patients were diagnosed with potentially curable gastric cancer, and 1934 (55.8 per cent) were resected. Resection rates in the low (1261 patients), intermediate (1141) and high (1063) tertiles were 0–50.0, 50.1–62.5 and 62.6–100 per cent respectively. The multivariable Cox analysis revealed better survival for patients diagnosed in counties during years with an intermediate versus low resection rate (hazard ratio (HR) 0.81, 95 per cent c.i. 0.74 to 0.90; P < 0.001) and high versus low resection rate (HR 0.80, 0.73 to 0.88; P < 0.001).

Conclusion

This national register study showed large regional variation in resection rates for gastric cancer. A higher resection rate appeared to be beneficial with regard to overall survival for the entire population.

Expression of Phosphoinositide 3-Kinase p110α and p110β Subunits and PIK3CA Mutation in Patients With Advanced Gastric Carcinoma

Activation of phosphoinositide 3-kinase (PI3K) is pivotal for the activity of the oncogenic PI3K/AKT signaling pathway. This study assessed the expression of 2 PI3K isoform proteins, p110α and p110β, and PIK3CA mutational status in advanced gastric carcinoma (AGC) and their correlation with clinicopathologic factors. Tissue microarray blocks were generated from 99 AGCs and immunohistochemically stained for p110α and p110β. Analysis of mutations in the PIK3CA gene, which encodes p110α, was performed using the PNAClamp PIK3CA Mutation Detection kit. Of the 99 tumors, positivity was seen in 62 (62.6%) for p110α and 97 (98.0%) for p110β with variable intensity and extent of staining. The median H-scores were 40 (range: 0 to 300) for p110α and 180 (range: 0 to 300) for p110β. Isoform p110α was more highly expressed in tumors with a lower pathologic T stage (P=0.035) and TNM stage (P=0.165), while p110β was not significantly associated with clinicopathologic factors. Samples with high p110α expression had a trend toward longer overall survival (OS) although it was not statistically significant (P=0.271), whereas high p110β expression correlated with shorter OS (P=0.016). In addition, p110β was an independent factor for poor prognosis in multivariate analysis for OS. Eight (8.1%) samples had PIK3CA mutations in exon 9. Mutational status at this locus was not significantly correlated with clinicopathologic factors. These results imply that p110β could have a more important role in the progression and aggressiveness of AGC than p110α and has potential as a prognostic biomarker in patients with AGC.

Factors related to the receipt of adjuvant therapy among patients with gastric cancer in Western China

OBJECTIVE

Adjuvant therapy following curative resection has been shown to be associated with significant survival benefits in patients with gastric cancer (GC); however, this treatment is not available to some patients. The aim was to investigate factors associated with the receipt of adjuvant therapy among GC patients.

METHODS

This is a retrospective study including patients with stage IB-IIIC gastric adenocarcinoma who underwent curative resection between November 2010 and July 2014. Patients were identified using a database from West China Hospital, Sichuan University. Univariate and multivariable analyses examined factors associated with adjuvant therapy receipt.

RESULTS

A total of 1,476 patients were included. Among these, 852 patients were eligible, with 157 patients not receiving adjuvant therapy. Age, education, income, residence, medical insurance, employment status and visiting an oncologist were independently associated with adjuvant therapy receipt by univariate analysis. After adjustment for other factors, medical insurance (p = 0.005), employment status (p = 0.008) and visiting an oncologist (p < 0.001) remained significantly correlated, and income was near the threshold of a significant difference (p = 0.050).

CONCLUSION

Our study indicates that disparities do exist in determining the receipt of adjuvant therapy in GC patients according to income, insurance and employment status, and highlight the importance of visiting an oncologist postoperatively.

Predictors of survival outcome following radical gastrectomy for gastric cancer

BACKGROUND

Radical surgery with adjuvant therapy is now the standard treatment for locally advanced gastric cancer. However, the best regimen for adjuvant therapy remains controversial. We aim to determine the predictors of survival outcome of gastric cancer patients who underwent curative surgery with or without adjuvant therapy in our institution.

METHODS

All patients who received surgery for gastric cancer from years 2000 to 2015 were studied using a prospective gastric cancer database at the National University Hospital, Singapore.

RESULTS

A total of 405 patients underwent radical gastrectomy with curative intent. Seventy-eight percent received extended lymphadenectomy (≥D1). R0 resection was achieved in 377 patients (93%) with 30-day mortality rate of 1.7%. There was no significant difference in the complication rate between D1 and extended lymphadenectomy group. One hundred and forty-five patients (36%) received adjuvant therapy. With a median follow-up of 5.9 years, the 5-year disease-free survival for stage I to IV patients were 78%, 58%, 27% and 9%, respectively. Among the 141 patients with known recurrences, the first site of recurrence was 38% distant, 24% locoregional, 20% peritoneal and the rest were multiple sites. Stage of disease, adjuvant therapy, extent of lymphadenectomy, post-operative complication and approach of surgery were independent risk factors for long-term survival.

CONCLUSIONS

Stage of disease, adjuvant therapy, extent of lymphadenectomy, post-operative complication and approach of surgery are significant predictors for long-term survival. Adequate and safe surgery to allow adjuvant therapy should be the goal of all surgeons for our gastric cancer patients.

Etiologic and Clinicopathological Correlates of Gastric Carcinoma in the Egyptian Delta

We aimed at evaluation of the clinicoepidemiologic data of patients with gastric carcinoma in the Egyptian Delta as regards the etiologic factors, behavior, presenting symptoms, and tumor location, grade, and stage with highlighting of the treatment modalities, survival, and prognostic factors. Three hundred cases with gastric carcinoma were enrolled, diagnosed, and treated in a tertiary oncology center in the Egyptian Delta. Data were collected as regards the etiology, presenting symptoms, family history, comorbid conditions, treatment modalities, responses, recurrences, and survival outcomes. Univariate and multivariate analyses were done to correlate the different clinicopathologic factors with the overall and disease-free survivals. Male to female ratio was 2:1. The median age was 43 years. The main tumor location was in the gastric body. Pain was the commonest presenting symptom (36%). Most of the cases were stage IV (42.0%). Only 49% of cases were operable. On multivariate analysis, age more than 60 years, performance status 3-4, high grade, diffuse type, T4 lesions, N2 and N3, and the presence of metastasis were independently associated with worse OS. We report a clinic-epidemiologic study of gastric carcinoma in the Egyptian delta; the age at presentation was a decade earlier than that recorded in the USA and Europe; most of the cases were sporadic, located mostly at the body. Most of the cases were presented at stage IV with poor response to neoadjuvant therapy with a poorer overall survival than that recorded in the USA and Europe.

Feasibility and Effects of a Postoperative Recovery Exercise Program Developed Specifically for Gastric Cancer Patients (PREP-GC) Undergoing Minimally Invasive Gastrectomy

PURPOSE

Exercise intervention after surgery has been found to improve physical fitness and quality of life (QOL). The purpose of this study was to investigate the feasibility and effects of a postoperative recovery exercise program developed specifically for gastric cancer patients (PREP-GC) undergoing minimally invasive gastrectomy.

MATERIALS AND METHODS

Twenty-four patients treated surgically for early gastric cancer were enrolled in the PREP-GC. The exercise program comprised sessions of In-hospital Exercise (1 week), Home Exercise (1 week), and Fitness Improvement Exercise (8 weeks). Adherence and compliance to PREP-GC were evaluated. In addition, body composition, physical fitness, and QOL were assessed during the preoperative period, after the postoperative recovery (2 weeks after surgery), and upon completing the PREP-GC (10 weeks after surgery).

RESULTS

Of the 24 enrolled patients, 20 completed the study without any adverse events related to the PREP-GC. Adherence and compliance rates to the Fitness Improvement Exercise were 79.4% and 99.4%, respectively. Upon completing the PREP-GC, patients also exhibited restored cardiopulmonary function and muscular strength, with improved muscular endurance and flexibility (P<0.05). Compared to those in the preoperative period, no differences were found in symptom scale scores measured using the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and Quality of Life Questionnaire-Stomach Cancer-Specific Module (QLQ-STO22); however, higher scores for global health status and emotional functioning were observed after completing the PREP-GC (P<0.05).

CONCLUSIONS

In gastric cancer patients undergoing minimally invasive gastrectomy, PREP-GC was found to be feasible and safe, with high adherence and compliance. Although randomized studies evaluating the benefits of exercise intervention during postoperative recovery are needed, surgeons should encourage patients to participate in systematic exercise intervention programs in the early postoperative period (Registered at the ClinicalTrials.gov NCT01751880).

Intraperitoneal Hyperthermic Chemotherapy in Gastric Cancer: Rationale for a new Approach

There is preliminary evidence from experience in the treatment of various abdominal malignancies that intraperitoneal chemotherapy alone or combined with hyperthermia may attain a role in the therapeutic strategy. This paper considers the rationale for such an approach, as well as its current results and potential indications in patients with gastric cancer. The literature is critically reviewed, with special emphasis on specific topics such as patterns of tumor spread, mechanisms of local recurrence, the rationale for intraperitoneal chemotherapy and intraperitoneal hyperthermic chemotherapy, toxicity, and results from non-controlled as well as randomized clinical trials in patients with gastric cancer. There is some evidence that intraperitoneal hyperthermic chemotherapy has a favorable effect on clinical outcome in patients with limited peritoneal carcinomatosis or malignant ascitis and in those at risk of future peritoneal spread, such as patients with pT3-pT4 cancers or with positive cytology of the peritoneal fluid. Hyperthermic chemotherapy should be considered a promising approach in limited or impending peritoneal carcinomatosis, and should be included in the multidisciplinary approach to the treatment of locally advanced gastric cancer.

Prognostic value of Serum and Tumor Tissue CA 72-4 Content in Gastric Cancer

To date no general agreement has been reached regarding the prognostic significance of CEA, CA 19-9 and CA 72-4 as serum markers in gastric cancer, and only scattered information is available on the predictive value of marker expression in tumor tissue. Therefore, a longitudinal study was designed to analyze the presurgical serum and tumor tissue content of CA 72-4, CEA and CA 19-9 in 166 patients at different stages of gastric cancer, and to evaluate the possible correlation with clinicopathological features in respect to prognostic information on relapse-free survival. The results obtained showed that 48.4% of patients with tumor recurrence had positive presurgical CA 72-4 levels compared to approximately 24% of patients who remained free of disease. Furthermore, the median presurgical serum CA 72-4 levels were significantly elevated in relapsing patients. Serosa and lymph node involvement as well as positive presurgical serum CA 72-4 levels had independent prognostic value in predicting recurrence. A significant association between disease-free survival and lymph node involvement, depth of invasion and tumor tissue content of CA 72-4 was also demonstrated. We may therefore conclude that CA 72-4 antigen can be considered the marker of choice in the follow-up of gastric cancer patients and may be used as a prognostic indicator of relapse.

Five-year Survival Rate for Gastric Cancer in Yazd Province, Central Iran, from 2001 to 2008

BACKGROUND

The number of patients with gastric cancer is growing worldwide. In Iran (in 2009) of 74067 new cases of cancer, 6886 were diagnosed as having gastric cancer. This study was conducted to investigate 5-year survival rate for gastric cancer in Yazd province, central Iran.

METHODS

In this descriptive study, the medical records of patients with gastric cancer were collected from the archives of Yazd hospitals from 2001 to 2008. The data gathered included age, sex, type of histopathology, site of involvement, cancer staging, and mode of treatment, which were analyzed using SPSS software version 11.5. To investigate the survival and the factors influencing the survival time of patients, which are the main objectives of this study, Kaplan-Meier method was used and Cox proportional hazards model was fitted to the data. To compare survival function in different subgroups, the log rank test or generalized Wilcoxon test was used.

RESULTS

295 cases of gastric cancer were enrolled in the study. The mean age of the subjects was 59.3 ± 9 years. 5-year survival rate of the patients was calculated as 18% where the highest rate was 39% for the age group of 50-60 years and the lowest was 3% for the age group of above 80 years. 5-year survival rates in different groups were as follows: 32% in women, 13% in men; 16% in adenocarcinoma, 46% in other pathologies; 16% in gastric cardia involvement, 17% in antrum; 59% in stage 1, 31% in stage 2, 13% in stage 3, and 3% in stage 4.

CONCLUSION

The results of this study showed that age, stage of the cancer, mode of therapy, and type of histopathology affected the survival rate of gastric cancer. No significant association was found between the site of involvement and survival rate. In general, the survival rate for gastric cancer was low, which might be due to slow but steady progress of the disease and delayed referral of the patients.

Understanding the diagnostic yield of current endoscopic biopsy for gastric neoplasm: A prospective single-center analysis based on tumor characteristics stratified by biopsy number and site

Although there are general guidelines on endoscopic biopsy for diagnosing gastric neoplasms, they are predominantly based on outdated literature obtained with fiberscopes without analyses specific to tumor characteristics.This study aims to comprehensively characterize the contemporary endoscopic biopsy by determining the diagnostic yield across different lesion morphologies and histological stages, especially exploring how the number and site of biopsy may influence the overall yield.Biopsy samples from suspected gastric neoplasms were collected prospectively from May 2011 to August 2014 in a tertiary care medical center. A standardized methodology was used to obtain a total of 6 specimens from 2 defined sites per lesion. Rate of positive diagnosis based on the biopsy number and site was assessed for specific gastric lesion morphologies and histological stages.A total of 1080 biopsies from 180 pathologically diagnosed neoplastic lesions in 176 patients were obtained during the study. For depressed/ulcerative and polypoid lesions, the yield was already >99% by the fourth biopsy without further gain from additional biopsies. Lower overall yield was observed for infiltrative lesions (57.1% from 4 biopsies). The site of biopsy did not influence the diagnostic yield except for with infiltrative lesions in which biopsies from thickened mucosal folds were of higher yield than erosive regions.Obtaining 4 specimens may be sufficient for accurate diagnosis of a depressed/ulcerative or polypoid gastric lesion regardless of its histological stage. For infiltrative lesions, at least 5 to 6 biopsies per lesion with more representative sampling from thickened mucosal folds may be preferable.

The Essentials of Locoregional Control in the Treatment of Gastric Cancer

Gastric cancer is the fourth most frequent cancer in the world. For curative treatment and local control of gastric cancer, surgery is essential. The extent of the lymph node dissection is still under debate. Only one available trial showed significantly increased overall survival, whereas in all other randomised trials no significant difference could be found.

As surgery alone often is not sufficient in the curative treatment in gastric cancer, different (neo)adjuvant treatment strategies have extensively been studied. The recently published MAGIC trial showed downstaging, downsizing and an improved overall survival for patients treated with perioperative chemotherapy, compared to surgery alone (difference 13%, p = 0.009). The INT 0116 trial on the other hand, demonstrated the benefit of postoperative chemoradiotherapy compared to surgery alone for patients with a curative resection of gastric cancer. However, the quality of resections in this trial was poor, illustrating the importance of standardisation by quality control. This could be done by the Maruyama index, which quantifies the likelihood of unresected disease.

In the Netherlands, the CRITICS trial has recently been launched, which will be a quality controlled trial comparing postoperative chemoradiotherapy and chemotherapy on survival and/or locoregional control in patients who receive neoadjuvant chemotherapy followed by a D1+ gastric resection.

DWI as a Quantitative Biomarker in Predicting Chemotherapeutic Efficacy at Multitime Points on Gastric Cancer Lymph Nodes Metastases

The purpose of the hypothesis testing is to determine that apparent diffusion coefficient (ADC) as an early biomarker can predict the metastatic lymph nodes' (LNs) response to neoadjuvant chemotherapy in advanced gastric cancer (GC) in early stage. From March 2011 to June 2015, 106 patients with advanced GC were enrolled in the study. Patients underwent conventional magnetic resonance imaging and functional diffusion weighted imaging before and 3 days, 7 days, 30 days, and 60 days following the standard chemotherapy. After surgery, among 3034 detected LNs, the positive group was divided into complete response (CR) group, partial response (PR) group, and stable disease (SD) group in accordance to the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Mean ADCs, short/long diameters of LNs before chemotherapy between the whole positive and the negative LNs were compared by t test. Changes of mean ADCs in 3 groups were analyzed by 1-way ANOVA. The mean ADC of the whole positive LNs was (1.145 ± 0.014) × 10⁻³ mm²/s, which was significantly lower than that of the whole negative LNs ([1.491 ± 0.010] × 10⁻³ mm²/s; P < 0.05). The means of both short/long diameters in the whole positive LNs were significantly longer than those in the whole negative LNs (P < 0.05). In CR, PR, and SD groups, the mean ADC of metastatic LNs on the 3rd day, 7th day, 13th day, and 16th day following the chemotherapy were all higher than that of LNs before chemotherapy, respectively (all P < 0.05). In addition, significant difference was found between mean ADCs in any 2 time points (all P < 0.05), except between mean ADCs in the 3rd day and in the 7th day of the chemotherapy. In conclusion, ADC can be used as an early biomarker to predict the metastatic LNs' response to neoadjuvant chemotherapy in advanced GC in early stage.

Systematic review on quality of life outcomes after gastrectomy for gastric carcinoma

BACKGROUND

Despite advances in chemotherapy and radiotherapy, gastrectomy is the only curative intervention for gastric carcinoma. This study reviews post-operative health-related quality of life (HRQOL) after gastrectomy.

METHODS

A literature search was conducted on PubMed for all studies published after January 2000 matching strict eligibility criteria. Bibliographies of included studies were also reviewed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesised by narrative review according to PRISMA guidelines with full tabulation of results of all included studies.

RESULTS

A total of 21 studies (3,575 patients) were included. Post-operative HRQOL improvements were demonstrated across most or all domains in different HRQOL instruments. Patients experienced declines in HRQOL 1 month after surgery, but reached at least pre-operative levels with recovery by 1 year. The greatest improvements were demonstrated in the emotional health domain with favourable functional benefits. Partial gastrectomy appears to be superior to total gastrectomy in physical, emotional and functional health domains. However, patients remain susceptible to gastrointestinal symptoms following surgery, which negatively impact upon HRQOL. Post-operative complications did not appear to affect HRQOL. Most studies were prospective, but data is heterogeneous.

CONCLUSIONS

Gastrectomy results in significant HRQOL benefits across a broad range of health domains. This is critical outcome of surgery and an important consideration in pre-operative decision making.

Adjuvant chemoradiotherapy in gastric cancer: a pooled analysis of the AIRO gastrointestinal group experience

BACKGROUND

Given the poor compliance with adjuvant chemoradiotherapy (CRT) in gastric cancer reported in previous studies, a survey was conducted among 18 Italian institutions within the AIRO Gastrointestinal Group to investigate current treatment modalities, toxicities, and compliance with adjuvant CRT.

PATIENTS AND METHODS

Data from 348 patients operated on for gastric cancer were collected retrospectively from September 2000 to June 2008 and analyzed. The adjuvant treatments included CRT according to center guidelines. In multivariate analysis, acute hematological, gastrointestinal, and renal toxicity (according to the RTOG Acute Radiation Morbidity Scoring Criteria) and compliance with treatment were studied, as well as risk factors for local control, metastasis-free survival, disease-free survival, and overall survival.

RESULTS

Compliance with treatment was excellent: 95.7% of patients completed CRT. During CRT, acute G3-G4 ­hematological toxicity was 3.7% and acute G3-G4 gastrointestinal toxicity 4%. 78.4% of patients completed chemotherapy (CT), either before or after CRT. During CT acute G3-G4 hematological toxicity was 5.4% and acute G3-G4 gastrointestinal toxicity 6%. Overall, 74.1% of patients completed the prescribed treatment (CRT and CT). Doses greater than 4500 cGy did not compensate for more aggressive disease. The 5-year overall survival was 51%.

CONCLUSIONS

The adjuvant treatment of gastric cancer within the AIRO group was diverse, but radiotherapy treatment was homogeneous (in terms of technique) and well tolerated. Toxicity was low and compliance with treatment was good during CRT; these results may be due to the radiotherapy technique applied. This survey could be used as a benchmark for further studies.

Overexpression of phosphorylated 4E-binding protein 1 and its clinicopathological significances in gastric cancer

Multiple intracellular transforming signals regulate eukaryotic translation initiation factor 4E (eIF4E)-binding protein (4E-BP1). The signals result in hierarchical phosphorylation of 4E-BP1, resulting in release of eIF4E, relieving translational repression and enhancing oncogenic protein synthesis. This study assessed the expression of phosphorylated 4E-BP1 (p-4E-BP1) in gastric cancer and its correlation with clinicopathological parameters and patient survival. Tissue microarray blocks were generated from 179 gastric carcinomas and immunohistochemically stained for p-4E-BP1. The expression of p-4E-BP1 was higher in tumors that were intestinal-type (P=0.028); had a diameter smaller than 5cm (P=0.001); were lower pathological T stage (P<0.001), N stage (P=0.004), or TNM stage (P<0.001); did not have distant metastasis (P=0.027). High p-4E-BP1 expression significantly correlated with prolonged overall survival (P=0.046) and disease-free survival (P=0.035), but was not an independent prognostic factor in multivariate analysis. Our results indicate that p-4E-BP1 is more highly expressed in early gastric cancers than in advanced ones, and has limited potential as an independent prognostic biomarker in patients with gastric cancer. Larger well-controlled studies with molecular validation are warranted to elucidate more exact prognostic significance and working mechanism of p-4E-BP1 in gastric cancer.

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BACKGROUND

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

METHOD

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

RESULTS

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

CONCLUSION

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

Concomitant PIK3CA amplification and RASSF1A or PAX6 hypermethylation predict worse survival in gastric cancer

OBJECTIVES

A large number of genetic and epigenetic alterations have been found in gastric cancer, but there is remarkably little consensus on the value of individual biomarker in diagnosis and prognosis of this cancer. This study was designed to illustrate the value of PIK3CA amplification in combination with promoter methylation of RASSF1A and PAX6 genes in early diagnosis and prognosis of gastric cancer.

DESIGN AND METHODS

Using real-time quantitative PCR, quantitative methylation-specific PCR (Q-MSP), and methylation-specific PCR (MSP) assays, we examined PIK3CA amplification and promoter methylation of RASSF1A and PAX6 genes in a cohort of gastric cancers, and explored the association of various (epi)genotypes with clinical outcomes of gastric cancer patients.

RESULTS

We demonstrated that PIK3CA gene was specifically amplified in gastric cancers, but not in normal gastric tissues. Moreover, frequent methylation of RASSF1A and PAX6 was also found in gastric cancers. Given the patients harboring diverse (epi)genotypes, we thus investigated the effect of various (epi)genotypes on poor prognosis in gastric cancer. The data showed that concomitant PIK3CA amplification and RASSF1A or PAX6 methylation were closely associated with poor clinical outcomes, particularly survival, as compared to other (epi)genotypes in gastric cancer.

CONCLUSIONS

We found frequent PIK3CA amplification and promoter methylation of RASSF1A and PAX6 genes in gastric cancers, and demonstrated that concomitant PIK3CA amplification and promoter methylation in any one of these two genes were significantly associated with worse survival in gastric cancer. Collectively, such (epi)genotypes may be strong and independent poor prognostic factors for gastric cancer patients.

Trends in clinical features, postoperative outcomes, and long-term survival for gastric cancer: a Western experience with 1,278 patients over 30 years

BACKGROUND

The aim of the present study was to identify temporal trends in long-term survival and postoperative outcomes and to analyze prognostic factors influencing the prognosis of patients with gastric cancer (GC) treated in a 30-year interval in a tertiary referral Western institution.

METHODS

Between January 1980 and December 2010, 1,278 patients who were diagnosed with GC at the Digestive Surgery Department, Catholic University of Rome, Italy, were identified. Among them, 936 patients underwent surgical resection and were included in the analysis.

RESULTS

Over time there was a significant improvement in postoperative outcomes. Morbidity and mortality rates decreased to 19.4% and 1.6%, respectively, in the last decade. By contrast, the multivisceral resection rate steadily increased from 12.7% to 29.6%. The overall five-year survival rate steadily increased over time, reaching 51% in the last decade, and 64.5% for R0 resections. Multivariate analysis showed a higher probability of overall survival for early stages (I and II), extended lymphadenectomy, and R0 resections.

CONCLUSIONS

Over three decades there was a significant improvement in perioperative and postoperative care and a steady increase in overall survival.

Rates and patterns of recurrence after curative intent resection for gastric cancer: a United States multi-institutional analysis

BACKGROUND

Reports on recurrence and outcomes of US patients with gastric cancer are scarce. The aim of this study was to determine incidence and pattern of recurrence after curative intent surgery for gastric cancer.

STUDY DESIGN

Using the multi-institutional US Gastric Cancer Collaborative database, we identified 817 patients undergoing curative intent resection for gastric cancer between 2000 and 2012. Patterns and rates of recurrence along with associated risk factors were identified using adjusted regression analysis. Recurrences were classified as locoregional, peritoneal, or hematogenous.

RESULTS

Median patient age was 65.8 years (interquartile range [IQR] 56.4, 74.7); the majority of patients were male (n = 462, 56.6%) and white (n = 511, 62.5%). At the time of surgery, the majority of patients underwent a partial gastrectomy (n = 481, 59.2%) with a complete R0 resection achieved in 91.6% (n = 748) of patients. At the time of last follow-up, 244 (29.9%) of 817 patients developed a recurrence; 163 (66.8%) patients had recurrence at only a single site; the remaining 81 (33.2%) had multiple sites of initial recurrence. Among patients who recurred at a single site, recurrence was most common at a distant location and included hematogenous (n = 57, 23.4%) or peritoneal (n = 47, 19.3%) only metastasis. Tumors at the gastroesophageal junction (odds ratio [OR] 3.18, 95% CI 1.08 to 9.40; p = 0.04) were associated with higher risk of locoregional recurrence, while the presence of multiple lesions (OR 10.82, 95% CI 3.56 to 32.85; p < 0.001) remained associated with an increased risk of distant hematogenous recurrence after adjusted analysis. Recurrence was associated with worse survival, with a median recurrence-free survival of 10.8 months (IQR 8.9, 12.8) among those who experienced a recurrence.

CONCLUSIONS

Nearly one-third of patients experienced recurrence after gastric cancer surgery. The most common site of recurrence was distant.

Chemotherapy for patients with gastric cancer after complete resection: A network meta-analysis

AIM: To conduct a network meta-analysis to evaluate the effectiveness of different chemotherapy regimens for patients with gastric cancer.

METHODS: PubMed (1966-2011.12), the Cochrane Library (2011 Issue 2) and EMBASE (1974-2011.12) were searched with the terms “gastric cancer” and “chemotherapy”, as well as the medical subject headings. References from relevant articles and conferences were also included. Patients who had previous gastric surgery, radiation before or after surgery or chemotherapy before surgery were excluded. In this study, only randomized controlled trials (RCTs) were considered, and the end-point was the overall mortality. Direct comparisons were performed using traditional meta-analysis whereas indirect comparisons were performed using network meta-analysis.

RESULTS: In total, 31 RCTs with 7120 patients were included. Five chemotherapy regimens, fluorouracil (FU) + BCNU, FU + methyl-CCNU (mCCNU), FU + cisplatin, FU + anthracyclines and FU + mitomycin c (MMC) + cytarabine (Ara-c), were found to be less beneficial in terms of overall mortality. In contrast, four chemotherapy regimens were effective for the patients after surgery, including FU + MMC + adriamycin (FMA), FU + MMC (FM), Tegafur and MMC, There was no significant difference in terms of overall mortality among these regimens. The evidence for the FM regimen and MMC regimen was poor. Additionally, the FMA regimen, which includes a variety of chemotherapy drugs and causes many side effects, was not better than the Tegafur regimen.

CONCLUSION: Although the four chemotherapy regimens were effective in patients with gastric cancer after surgery and the overall mortality revealed no significant difference among them in the network meta-analysis, thorough analysis of the results recommends Tegafur as the first-line adjuvant chemotherapy regimen for patients after complete resection.

High lactate dehydrogenase 5 expression correlates with high tumoral and stromal vascular endothelial growth factor expression in gastric cancer

BACKGROUND

Lactate dehydrogenase 5 (LDH5) is a major lactate dehydrogenase isoenzyme catalyzing the transformation of pyruvate to lactate to provide anaerobic energy. Vascular endothelial growth factor (VEGF) is expressed in both tumor and stromal cells in gastric cancer. Our aim was to study the prognostic effect of LDH5, and tumoral and stromal expression of the angiogenic factor VEGF in gastric cancer, and the intercorrelation of tissue expression of both factors.

METHODS

Tissue microarray analysis of 382 consecutive gastric cancer resection specimens was used for immunohistochemistry of LDH5 and VEGF, and expression of LDH5, tumoral VEGF, and stromal VEGF was categorized into low and high groups.

RESULTS

High expression was observed for LDH5 in 57.9% (219/378), tumoral VEGF in 35.7% (136/381), and stromal VEGF in 58.5% (223/381) of the specimens. Regarding high expression of LDH5 and VEGF, significant associations with intestinal type, advanced gastric cancer, lymph node metastasis, higher TNM stage, and upper-third location were noted. Positive intercorrelations occurred among the expression of LDH5 and VEGF. Results of survival analyses revealed a significant association of high expression of LDH5 and VEGF with lower survival (overall and disease-free survival). Five-year survival rates were significantly lower in tumors with high LDH5 and tumoral VEGF expression in diffuse- or mixed-type cancers and high expression of stromal VEGF in intestinal-type cancer.

CONCLUSION

The results of our study showed that high LDH5 and VEGF expression in both tumor and stroma was a prognostic factor for patients with gastric cancers, especially diffuse- or mixed-type cancers. Therefore, LDH5 expression may play a role in the regulation of tumoral and stromal VEGF expression in gastric cancer. Our results suggest the potential use of LDH5 expression as a biomarker for response to VEGF-targeted therapy.

Mixture and non-mixture cure fraction models based on the generalized modified Weibull distribution with an application to gastric cancer data

The cure fraction models are usually used to model lifetime time data with long-term survivors. In the present article, we introduce a Bayesian analysis of the four-parameter generalized modified Weibull (GMW) distribution in presence of cure fraction, censored data and covariates. In order to include the proportion of "cured" patients, mixture and non-mixture formulation models are considered. To demonstrate the ability of using this model in the analysis of real data, we consider an application to data from patients with gastric adenocarcinoma. Inferences are obtained by using MCMC (Markov Chain Monte Carlo) methods.

Risk factors for double primary malignancies and their clinical implications in patients with sporadic gastric cancer

AIMS

We carried out a large scale study to identify the risk factors for double primary malignancy (DPM) development in gastric cancer patients and to evaluate the clinical implications for these patients.

METHODS

A total of 2593 patients who underwent gastrectomy for primary gastric cancer from January 2005 to November 2010 were reviewed with regard to DPM. We compared the clinicopathological characteristics, risk factors for developing DPM, and prognosis between the DPM+ group and the DPM- group.

RESULTS

Of the 2593 patients, 152 (5.9%) were diagnosed with DPM. The most common accompanying malignancies were colorectal, lung and thyroid. Multivariate analysis indicated that age (p = 0.016) and MSI status (p = 0.002) were associated with a higher frequency of DPM. 30.3% of patients were diagnosed with DPM within 1 year around perioperative period and 53.3% of patients had DPM detected during 5 years of post-operative follow up periods. Although there was no significant difference in overall survival between the DPM+ and DPM- group, DPM+ patients had a worse prognosis than DPM- patients in stage I gastric cancer.

CONCLUSIONS

Gastric cancer patients over the age of 60 or with a MSI-high status had an increased risk for developing DPM. Further, in stage I gastric cancer, the presence of DPM was associated with a worse prognosis. Therefore, careful pre- and postoperative surveillance is especially important in these patients.

Heat shock protein 70 (HSP70) expression is associated with poor prognosis in intestinal type gastric cancer

Heat shock protein 70 (HSP70) is a molecular chaperone which plays an important role in cellular protection against various stressful stimuli and in the regulation of cellular growth and apoptosis. This study was conducted in gastric carcinoma (GC) to assess correlations of HSP70 expression with clinicopathological parameters and overall survival (OS). Tissue microarray blocks were constructed from 172 GCs and immunohistochemically stained for HSP70. Low HSP70 expression was found in 122 GCs (71 %), whereas 50 (29 %) had high expression. HSP70 expression was higher in tumours in the cardia (p = 0.008), with non-signet ring cell histology (p < 0.001), of intestinal type (p = 0.045) and of higher pathological T stage (p = 0.026). When considering the cohort as a whole, HSP70 expression did not correlate with OS (p = 0.092). In intestinal type carcinomas, however, high HSP70 expression significantly correlated with worse OS (p = 0.034). These results suggest that HSP70 expression might be an unfavourable prognostic factor in patients with GC, especially of intestinal type.

The survival benefit of lymph node dissection at the time of removal of kidney, prostate and urothelial carcinomas: what is the evidence?

INTRODUCTION

Lymph node dissection (LND) has been advocated by oncologic surgeons to completely eradicate cancer. However, evidence for that strategy is solely based on poor quality data. Some randomized studies done outside the field of urology failed to show any benefit to LND. Our objective was to evaluate whether LND at the time of removal of prostate, kidney and urothelial carcinomas results in a survival benefit.

METHODS

For that purpose, we performed a systematic literature review.

RESULTS

For kidney cancer, LND might be able to cure some patients with N+ disease. In N0 patients, although a randomized trial has been completed, the value of LND remains uncertain. LND at the time of radical prostatectomy can be useful in some patients with lymph node invasion. However, studies on the impact of LND in pN0 patients are retrospective and conflictive. Extended LND has been recommended when performing a radical cystectomy based on improved outcomes observed in retrospective studies. However, these studies are limited by selection biases and results of ongoing randomized trials will specify the template and the advantages of LND when removing a bladder cancer. Recent data of large series of radical nephro-ureterectomies for upper tract urothelial carcinomas are conflicting. Some found a benefit of LND in N0 patients while others did not.

CONCLUSION

The studies that support LND at the time of surgery for prostate, kidney and urothelial carcinomas have low level of evidence. This should encourage urologists to design and perform well-designed randomized trials to assess the potential survival impact of a commonly done procedure.

L-Dopa decarboxylase (DDC) constitutes an emerging biomarker in predicting patients' survival with stomach adenocarcinomas

PURPOSE

Stomach adenocarcinoma represents a major health problem and is regarded as the second commonest cause of cancer-associated mortality, universally, since it is still difficult to be perceived at a curable stage. Several lines of evidence have pointed out that the expression of L-Dopa decarboxylase (DDC) gene and/or protein becomes distinctively modulated in several human neuroendocrine neoplasms as well as adenocarcinomas.

METHODS

In order to elucidate the clinical role of DDC on primary gastric adenocarcinomas, we determined qualitatively and quantitatively the mRNA levels of the gene with regular PCR and real-time PCR by using the comparative threshold cycle method, correspondingly, and detected the expression of DDC protein by immunoblotting in cancerous and normal stomach tissue specimens.

RESULTS

A statistically significant association was disclosed between DDC expression and gastric intestinal histotype as well as tumor localization at the distal third part of the stomach (p = 0.025 and p = 0.029, respectively). Univariate and multivariate analyses highlighted the powerful prognostic importance of DDC in relation to disease-free survival and overall survival of gastric cancer patients. According to Kaplan-Meier curves, the relative risk of relapse was found to be decreased in DDC-positive (p = 0.031) patients who, also, exhibited higher overall survival rates (p = 0.016) than those with DDC-negative tumors.

CONCLUSIONS

This work is the first to shed light on the potential clinical usefulness of DDC, as an efficient tumor biomarker in gastric cancer. The provided evidence underlines the propitious predictive value of DDC expression in the survival of stomach adenocarcinoma patients.

The value of expression of M2-PK and VEGF in patients with advanced gastric cancer

Glycolytic pyruvate kinase isoenzyme type M2 (M2-PK) plays a key role in tumor metabolism and energy production. Vascular endothelial growth factor (VEGF) is critical in regulating angiogenesis which is an essential process required for tumor growth and metastasis. These two genes may function in accordance with tumor development. The purpose of this study was to investigate the relationship between the expression of M2-PK and VEGF, and their association with clinicopathological features in patients with advanced gastric cancer. Expression of M2-PK and VEGF were examined in 142 cases of paraffin-embedded tissue blocks from patients with advanced gastric cancer. M2-PK expression was found to strongly correlate with that of VEGF (r = 0.718). In addition, expression of M2-PK and VEGF correlates with tumor size (p = 0.0001, and p = 0.0017, respectively), depth of invasion (p = 0.0024, and p = 0.0261, respectively), and lymph node metastasis (p = 0.036, and p = 0.028, respectively). The high expression levels of M2-PK and VEGF may indicate poor prognosis in patients with advanced gastric cancer.

Sentinel lymph node mapping and biopsy using radioactive tracer in gastric cancer

BACKGROUND

Lymph node metastasis is one of the most important prognostic factors in gastric cancer survival. Sentinel lymph node (SLN) mapping and biopsy may reduce the extension of lymph node dissection by determination of lymph node involvement. The current study prospectively evaluates the feasibility and reliability of SLN biopsy in gastric cancer.

METHODS

A total of 30 patients with gastric cancer with a preoperative imaging stage of T1-T2 or T3, N0 and M0 were enrolled in the study. Furthermore, 2-16 h prior to each operation, (99m) Tc-sulphur colloid solution (0.5 mL, 2 mCi/mL) was endoscopically injected into the submucosal layer around the primary lesion. Lymph nodes were examined using a hand-held gamma probe. Subsequently, a total or subtotal gastrectomy and D2 lymphadenectomy was performed in each patient.

RESULTS

The success rate of SLN biopsy was 100%. Sensitivity, specificity, positive predictive value and negative predictive value were 91.7%, 100%, 100% and 75%, respectively. Both of the two false-negative cases were in the T3 group. In cases of T2 tumours, the sensitivity was 100%.

DISCUSSION

SLN biopsy using a gamma probe in early stage gastric cancer seems to be a safe, feasible and accurate procedure with high sensitivity in predicting regional lymph node involvement.

WITHDRAWN: Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach

BACKGROUND

Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer.

OBJECTIVES

To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer.

SEARCH METHODS

We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field. For the updated review, the Cochrane Library, M EDLINE , E MBASE and LILACS were searched from 2001 to April 2009.

SELECTION CRITERIA

Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons.

MAIN RESULTS

Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different.

AUTHORS' CONCLUSIONS

D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Gastric cancer: tumor markers as predictive factors for preoperative staging

INTRODUCTION

CEA, CA 19-9, and CA 72-4 are tumor markers commonly used for gastric neoplasms. The clinical importance of the preoperative serum levels of these tumor markers in gastric cancer (GC) is not well known. Even less is known about the predictive value of the preoperative serum levels of the β-subunit of human chorionic gonadotropin (hCGβ).

AIMS AND METHODS

We designed a prospective study to evaluate the significance of the preoperative values of these tumor markers in GC. The serum levels that we considered as positive are as follows: CA 72-4, >4 U/ml; CEA, >5 ng/ml; CA 19-9, >37 U/ml; hCGβ-free subunit, <5 mUI/ml. These levels were correlated by pathological stage, lymph node status, and histology.

RESULTS

We studied 66 (42 male and 24 female) patients prospectively. Twenty-seven patients had stage I and stage II GCs, while 39 patients had stage III and stage IV GCs. Two patients tested positive for hCGβ. The preoperative positivity rates of CA 72-4 in patients at the early stages (stages I and II) and in patients with advanced disease (stages III and IV) were 0 and 28 patients, respectively. The preoperative positivity rates of CEA/CA 19.9 were 0/5 and 7/12 patients in early stages and advanced disease, respectively. The serum levels of these markers were not correlated with the histological type or tumoral grade of GC.

CONCLUSION

The preoperative serum level of CA 72-4 has the best predictive value in indicating advanced disease in patients diagnosed with GC. A combination of these four markers is better in predicting this situation.

The diagnosis and management of gastric cancer: expert discussion and recommendations from the 12th ESMO/World Congress on Gastrointestinal Cancer, Barcelona, 2010

Well-recognized experts in the field of gastric cancer discussed during the 12th European Society Medical Oncology (ESMO)/World Congress Gastrointestinal Cancer (WCGIC) in Barcelona many important and controversial topics on the diagnosis and management of patients with gastric cancer. This article summarizes the recommendations and expert opinion on gastric cancer. It discusses and reflects on the regional differences in the incidence and care of gastric cancer, the definition of gastro-esophageal junction and its implication for treatment strategies and presents the latest recommendations in the staging and treatment of primary and metastatic gastric cancer. Recognition is given to the need for larger and well-designed clinical trials to answer many open questions.

Significance of SUV on Follow-up F-18 FDG PET at the Anastomotic Site of Gastroduodenostomy after Distal Subtotal Gastrectomy in Patients with Gastric Cancer

PURPOSE

The aim of this study was to characterize the patterns of fluorodeoxyglucose (FDG) uptake on F-18 FDG positron emission tomography/computed tomography (FDG PET/CT) at the anastomotic site of gastroduodenostomy after distal subtotal gastrectomy in patients with gastric cancer.

METHODS

From May 2007 to May 2010, two or more follow-up measurements using FDG PET/CT scans were done for 19 patients (11 men, 8 women; mean age, 62.0 ± 10.3 years) who underwent distal subtotal gastrectomy with gastroduodenostomy between February 2006 and March 2008 for detecting gastric cancer recurrence at our medical center. The FDG PET/CT images were retrospectively reviewed. Patients with local recurrence, regional nodal metastasis or distant metastasis on follow-up studies were excluded. CT and endoscopy were done within 1 month before or after the FDG PET/CT scan. Eight patients had two follow-ups of FDG PET/CT, and 11 patients had three follow-ups. The mean interval between surgery and the first follow-up FDG PET/CT was 12.9 ± 0.8 months (n = 19); between the first and second it was 12.3 ± 1.0 months (n = 19); between the second and third it was 11.6 ± 0.7 months (n = 11). The F-18 FDG uptakes at the anastomotic site and fundus in the remnant stomach were measured by maximum standardized uptake value (SUVmax) using a region of interest technique.

RESULTS

The SUVmax at the anastomotic site was significantly higher than that of the fundus on all series of first, second and third follow-up studies (3.3 ± 1.1 vs. 2.1 ± 0.7, p < 0.001: 3.1 ± 0.9 vs. 2.2 ± 0.7, p = 0.001: 3.0 ± 0.6 vs. 2.1 ± 0.7, p = 0.006, respectively). The SUVmax for the anastomotic site and fundus, and SUVmax ratio for the anastomotic site over the fundus were not significantly different throughout the series.

CONCLUSION

The SUVmax at the anastomotic site is significantly higher than that of the fundus and does not decrease significantly over time. Therefore, the local recurrence of gastric cancer after surgery could not be definitely differentiated from physiologic uptake or postoperative inflammatory change.

Assessment of quality of life after gastrectomy using EORTC QLQ-C30 and STO22

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Cancer (QLQ-C30) and the site-specific module for gastric cancer (QLQ-STO22) have seldom been used to measure the postoperative health-related quality of life (HRQOL) in Japanese gastric cancer patients. The aim of this study was to evaluate the HRQOL after gastrectomy using these instruments and to compare various aspects of HRQOL among surgical procedures.

METHODS

A total of 98 patients who underwent gastrectomy and had no recurrence were evaluated. Among them, we compared the differences between major surgical procedures consisting of open total gastrectomy (TG, n=8), open distal gastrectomy (DG, n=24), and laparoscopy-assisted distal gastrectomy (LADG, n=44). Questionnaires were completed at baseline and at 1, 3, 6 and 12 months postoperatively.

RESULTS

The worst scores for most of the items were observed at 1 month after surgery and usually improved thereafter. Scores after TG were the worst of all surgical procedures across all dimensions throughout the period. Scores after LADG were generally superior to those after DG at 1 and 3 months postoperatively but not at 12 months.

CONCLUSIONS

EORTC QLQ-C30 and STO22 detected differences in several aspects of HRQOL among patients treated by the three surgical procedures. The laparoscopic approach resulted in superior short-term outcomes, whereas TG continued to affect the HRQOL in several items 12 months after surgery.

Patients' experiences of the recovery period 12 months after upper gastrointestinal surgery

The aim of this study was to describe and explore participants' experiences of their recovery from upper gastrointestinal surgery and being recovered or not 12 months following their operations. A hermeneutic approach was used to understand participants' experiences and situations. Fifteen participants were interviewed at 12 months postoperatively. According to participants, the year that had passed was experienced as being "pale and gray." Themes that were identified included feelings of doubtfulness, others' concern, and disappointment; never feeling quite well and having to adapt to new circumstances; feelings of being changed; and feelings of becoming free from illness and regaining strength. Being trapped in suffering meant that participants' lives had lost meaningful values. They felt disappointed because of physical discomforts and thoughts about disease and death. Recovery was felt when their physical discomforts decreased, and they felt free from doubts and "difficult" thoughts about illness and death. The recovery process can be understood as a movement between darkness and light.

Over-expression of Ephb4 is associated with carcinogenesis of gastric cancer

BACKGROUND

Gastric cancer is one of the most frequently diagnosed malignancies in the world. The gene expression profile and molecular grouping of gastric cancer has been a challenging task due to its inherent complexity and variation among individuals.

AIMS

To determine the molecular mechanism associated with gastric carcinogenesis.

METHODS

We analyzed the gene expression profiles of 20 cancerous tissues and their tumor-adjacent tissue from patients with gastric cancer by using a 14 K cDNA microarray. The differentially expressed genes and their products were verified by semiquantitative reverse transcription PCR (RT-PCR), western blotting and immunohistochemistry of gastric cancer and normal tissue samples.

RESULTS

A total of 69 genes were found to be differentially regulated in the cancerous tissue. Among them, genes such as CDH17, ETV4, S100A6, S100A11, Ephb4, and KLK10 were confirmed by RT-PCR to be up-regulated, while genes such as NK4 and PPP2R1B were down-regulated. Western blotting and immunohistochemistry indicated that Ephb4 was over-expressed and localized to the cytoplasm of gastric cancer cells. Moreover, Ephb4 protein was observed as being significantly related to tumor size and pN category (p = 0.001 and 0.007, respectively).

CONCLUSIONS

These newly identified genes might provide a valuable resource for understanding the molecular mechanism associated with the carcinogenesis of gastric cancer and for finding potential diagnostic markers of gastric cancer.

Prognostic significance of host- and tumor-related factors in patients with gastric cancer

BACKGROUND

Various factors regarding the biological state of tumors or the nutritional status of patients have been reported individually to correlate with prognosis. Identification of defined patient groups based on a prognostic score may improve the prediction of survival and individualization of therapy. The aim of the present study was to identify clinically useful parameters obtainable before treatment that could be used for predicting clinical outcomes in patients with gastric cancer.

METHODS

In 357 consecutive patients who had been treated for potentially curable gastric cancer, we retrospectively analyzed the following clinicopathological factors: sex, age, body mass index, body weight changes, hemoglobin, white blood cell count, neutrophil to lymphocyte (N/L) ratio, serum C-reactive protein (CRP), serum albumin, serum cholinesterase, tumor location, tumor size, histology, and clinical tumor node metastasis (TNM) stage. Factors related to prognosis were evaluated by univariate and multivariate analysis.

RESULTS

From univariate analysis, significant differences in survival were found for age, hemoglobin, N/L ratio, serum CRP, serum albumin, serum cholinesterase, tumor size, and clinical T and N grouping. N/L ratio, tumor size, and clinical T grouping were identified as independent prognostic indicators in multivariate analysis. A prognostic score was constructed using these variables to estimate the probability of death. The model gave an area under the receiver operating characteristic curve of 0.85 for prediction of death at 5 years.

CONCLUSIONS

This model based on N/L ratio, tumor size, and clinical T grouping before treatment offers a very informative scoring system for predicting prognosis of gastric cancer.

Impact of the extent of surgery and postoperative chemoradiotherapy on recurrence patterns in gastric cancer

PURPOSE

The Intergroup 0116 trial has demonstrated that postoperative chemoradiotherapy (CRT) improves survival in gastric cancer. We retrospectively compared survival and recurrence patterns in two phase I/II studies evaluating more intensified postoperative CRT with those from the Dutch Gastric Cancer Group Trial (DGCT) that randomly assigned patients between D1 and D2 lymphadenectomy.

PATIENTS AND METHODS

Survival and recurrence patterns of 91 patients with adenocarcinoma of the stomach who had received surgery followed by radiotherapy combined with fluorouracil and leucovorin (n = 5), capecitabine (n = 39), or capecitabine and cisplatin (n = 47) were analyzed and compared with survival and recurrence patterns of 694 patients from the DGCT (D1, n = 369; D2, n = 325). For both groups, the Maruyama Index of Unresected Disease (MI) was calculated and correlated with survival and recurrence patterns.

RESULTS

With a median follow-up of 19 months in the CRT group, local recurrence rate after 2 years was significantly higher in the surgery only (DGCT) group (17% v 5%; P = .0015). Separate analysis of CRT patients who underwent a D1 dissection (n = 39) versus DGCT-D1 (n = 369) showed fewer local recurrences after chemoradiotherapy (2% v 8%; P = .001), whereas comparison of CRT-D2 (n = 25) versus DGCT-D2 (n = 325) demonstrated no significant difference. CRT significantly improved survival after a microscopically irradical (R1) resection. The MI was found to be a strong independent predictor of survival.

CONCLUSION

After D1 surgery, the addition of postoperative CRT had a major impact on local recurrence in resectable gastric cancer.

The clinical significance of ascitic fluid CEA in advanced gastric cancer with ascites

BACKGROUND

This study was carried out to evaluate the clinical significance of ascitic fluid carcinoembryonic antigen (CEA) in advanced gastric cancer patients with ascites.

PATIENTS AND METHODS

From November 2001 to February 2008, 119 gastric cancer patients with concurrent ascites who were clinically diagnosed with carcinomatosis, were retrospectively reviewed with regard to ascitic fluid cytology and clinicopathological parameters. Serum CEA (sCEA) and ascitic fluid CEA (aCEA) were measured using a chemiluminescent enzyme immunoassay.

RESULTS

The patients' median age was 50 years (range 23-80 years). The median value of aCEA was significantly higher than sCEA [130.5 ng/ml (range 0.2-12.211 ng/ml) vs. 2.1 ng/ml (range 0.02-8.152 ng/ml), p < 0.001]. Sixty-five patients (54.6%) had positive ascitic fluid cytology. The median overall survival of all patients was 3.0 months (95% CI 2.0-4.0 months). The patients with low aCEA (<5 ng/ml) had a significantly longer overall survival compared to patients with high aCEA (>or=5 ng/ml) (7.4 months vs. 2.3 months, p = 0.003). However, we found no difference in overall survival according to ascitic fluid cytology (median, 3.0 months vs. 2.5 months, p = 0.530). Multivariate analysis also demonstrated that aCEA levels of more than 5 ng/ml were associated with poor prognosis (HR = 2.88; 95% CI 1.45-5.74; p = 0.003), while sCEA levels were not associated with poor prognosis (HR = 1.15; 95% CI 0.67-2.03; p = 0.622).

CONCLUSION

These results suggest that aCEA levels can be used as a prognostic marker for advanced gastric cancer patients with ascites.

Application of the Bayesian dynamic survival model in medicine

The Bayesian dynamic survival model (BDSM), a time-varying coefficient survival model from the Bayesian prospective, was proposed in early 1990s but has not been widely used or discussed. In this paper, we describe the model structure of the BDSM and introduce two estimation approaches for BDSMs: the Markov Chain Monte Carlo (MCMC) approach and the linear Bayesian (LB) method. The MCMC approach estimates model parameters through sampling and is computationally intensive. With the newly developed geoadditive survival models and software BayesX, the BDSM is available for general applications. The LB approach is easier in terms of computations but it requires the prespecification of some unknown smoothing parameters. In a simulation study, we use the LB approach to show the effects of smoothing parameters on the performance of the BDSM and propose an ad hoc method for identifying appropriate values for those parameters. We also demonstrate the performance of the MCMC approach compared with the LB approach and a penalized partial likelihood method available in software R packages. A gastric cancer trial is utilized to illustrate the application of the BDSM.

Optimal surgery for advanced gastric cancer

Locoregional control remains a major problem after surgery, although a curative resection is still the only treatment to offer a cure for patients with gastric cancer. Despite the results of major randomized trials, the extent of nodal dissection continues to be debated. If there is a survival benefit to be gained by extended lymphadenectomy, added operative mortality should be eliminated. A pancreas and spleen-preserving D2 lymphadenectomy provides superior staging information and may provide a survival benefit while avoiding its excess morbidity. Splenectomy during gastric resection for tumors not adjacent to or invading the spleen increases morbidity and mortality without improving survival. Therefore, splenectomy should not be performed unless there is direct tumor extension. The Maruyama Index and nomograms that predict disease-specific survival may help to discriminate between patients with a high risk of relapse and select those patients who will be most likely to benefit from tailored multimodality treatment. There is growing evidence that gastric cancer surgery should be performed in high-volume centers with experienced specialists to reduce morbidity and operative mortality and to achieve better survival results.

Comparison of colorectal and gastric cancer: survival and prognostic factors

BACKGROUND/AIMS

Gastric and colorectal cancers are the most common gastrointestinal malignancies in Iran. We aim to compare the survival rates and prognostic factors between these two cancers.

METHODS

We studied 1873 patients with either gastric or colorectal cancer who were registered in one referral cancer registry center in Tehran, Iran. All patients were followed from their time of diagnosis until December 2006 (as failure time). Survival curves were calculated according to the Kaplan-Meier Method and compared by the Log-rank test. Multivariate analysis of prognostic factors was carried out using the Cox proportional hazard model.

RESULTS

Of 1873 patients, there were 746 with gastric cancer and 1138 with colorectal cancer. According to the Kaplan-Meier method 1, 3, 5, and 7-year survival rates were 71.2, 37.8, 25.3, and 19.5%, respectively, in gastric cancer patients and 91.1, 73.1, 61, and 54.9%, respectively, in patients with colorectal cancer. Also, univariate analysis showed that age at diagnosis, sex, grade of tumor, and distant metastasis were of prognostic significance in both cancers (P < 0.0001). However, in multivariate analysis, only distant metastasis in colorectal cancer and age at diagnosis, grade of tumor, and distant metastasis in colorectal cancer were identified as independent prognostic factors influencing survival.

CONCLUSIONS

According to our findings, survival is significantly related to histological differentiation of tumor and distant metastasis in colorectal cancer patients and only to distant metastasis in gastric cancer patients.