Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis

Surgical Options for Peritoneal Surface Metastases from Digestive Malignancies-A Comprehensive Review

The peritoneum is a common site for the dissemination of digestive malignancies, particularly gastric, colorectal, appendix, or pancreatic cancer. Other tumors such as cholangiocarcinomas, digestive neuroendocrine tumors, or gastrointestinal stromal tumors (GIST) may also associate with peritoneal surface metastases (PSM). Peritoneal dissemination is proven to worsen the prognosis of these patients. Cytoreductive surgery (CRS), along with systemic chemotherapy, have been shown to constitute a survival benefit in selected patients with PSM. Furthermore, the association of CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) seems to significantly improve the prognosis of patients with certain types of digestive malignancies associated with PSM. However, the benefit of CRS with HIPEC is still controversial, especially due to the significant morbidity associated with this procedure. According to the results of the PRODIGE 7 trial, CRS for PSM from colorectal cancer (CRC) achieved overall survival (OS) rates higher than 40 months, but the addition of oxaliplatin-based HIPEC failed to improve the long-term outcomes. Furthermore, the PROPHYLOCHIP and COLOPEC trials failed to demonstrate the effectiveness of oxaliplatin-based HIPEC for preventing peritoneal metastases development in high-risk patients operated for CRC. In this review, we discuss the limitations of these studies and the reasons why these results are not sufficient to refute this technique, until future well-designed trials evaluate the impact of different HIPEC regimens. In contrast, in pseudomyxoma peritonei, CRS plus HIPEC represents the gold standard therapy, which is able to achieve 10-year OS rates ranging between 70 and 80%. For patients with PSM from gastric carcinoma, CRS plus HIPEC achieved median OS rates higher than 40 months after complete cytoreduction in patients with a peritoneal cancer index (PCI) ≤6. However, the data have not yet been validated in randomized clinical trials. In this review, we discuss the controversies regarding the most efficient drugs that should be used for HIPEC and the duration of the procedure. We also discuss the current evidence and controversies related to the benefit of CRS (and HIPEC) in patients with PSM from other digestive malignancies. Although it is a palliative treatment, pressurized intraperitoneal aerosolized chemotherapy (PIPAC) significantly increases OS in patients with unresectable PSM from gastric cancer and represents a promising approach for patients with PSM from other digestive cancers.

Integration of Genomic Biology Into Therapeutic Strategies of Gastric Cancer Peritoneal Metastasis

The peritoneum is a common site of metastasis in advanced gastric cancer (GC). Diagnostic laparoscopy is now routinely performed as part of disease staging, leading to an earlier diagnosis of synchronous peritoneal metastasis (PM). The biology of GCPM is unique and aggressive, leading to a dismal prognosis. These tumors tend to be resistant to traditional systemic therapy, and yet, this remains the current standard-of-care recommended by most international clinical guidelines. As this is an area of unmet clinical need, several translational studies and clinical trials have focused on addressing this specific disease state. Advances in genomic sequencing and molecular profiling have revealed several promising therapeutic targets and elucidated novel biology, particularly on the role of the surrounding tumor microenvironment in GCPM. Peritoneal-specific clinical trials are being designed with a combination of locoregional therapeutic strategies with systemic therapy. In this review, we summarize the new knowledge of cancer biology, advances in surgical techniques, and emergence of novel therapies as an integrated strategy emerges to address GCPM as a distinct clinical entity.

Incidence, Risk Factors and Prognosis of T4a Gastric Cancer: A Population-Based Study

Background: T4a gastric cancer (GC) is a subtype of advanced GC (AGC), which urgently needs a comprehensive grade method for better treatment strategy choosing. The purpose of this study was to develop two nomograms for predicting the prognosis of patients with T4a GC.

Methods: A total of 1,129 patients diagnosed as T4a GC between 2010 and 2015 were extracted from the Surveillance, Epidemiology, and End Result (SEER) program database. Univariate and multivariate Cox analyses were performed to explore the independent predictors and to establish nomogram for overall survival (OS) of the patients, whereas competing risk analyses were performed to find the independent predictors and to establish nomogram for cancer-specific survival (CSS) of the patients. The area under the curve (AUC), calibration curve, decision curve analysis (DCA), and Kaplan–Meier analysis were performed to evaluate the nomograms.

Results: Older age, larger tumor size, black race, signet ring cell carcinoma (SRCC), more lymph node involvement, the absence of surgery, the absence of radiotherapy, and the absence of chemotherapy were identified as independent prognostic factors for both OS and CSS. In the training cohort, the AUCs of the OS nomogram were 0.760, 0.743, and 0.723 for 1-, 3-, and 5-year OS, whereas the AUCs of the CSS nomogram were 0.724, 0.703, and 0.713 for 1-, 3-, and 5-year CSS, respectively. The calibration curve and DCA indicated that both nomograms can effectively predict OS and CSS, respectively. The abovementioned results were also confirmed in the validation cohort. Stratification of the patients into high- and low-risk groups highlighted the differences in prognosis between the two groups both in training and in validation cohorts.

Conclusions: Age, tumor size, race, histologic type, N stage, surgery status, radiotherapy, and chemotherapy were confirmed as independent prognostic factors for both OS and CSS in patients with T4a GC. Two nomograms based on the abovementioned variables were constructed to provide more accurate individual survival predictions for them.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer with Synchronous Peritoneal Metastases: Multicenter Study of 'Italian Peritoneal Surface Malignancies Oncoteam-S.I.C.O.'

Background

The development of multimodality treatment, including cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC), has led to promising results in selected patients with peritoneal disease of gastric origin. The aim of this study was to investigate the short- and long-term outcomes of CRS/HIPEC in the treatment of synchronous peritoneal metastasis in gastric cancer.

Methods

The Italian Peritoneal Surface Malignancies Oncoteam—S.I.C.O. retrospective registry included patients with synchronous peritoneal malignancy from gastric cancer submitted to gastrectomy with CRS and HIPEC between 2005 and 2018 from 11 high-volume, specialized centers.

Results

A total of 91 patients with a median age of 58 years (range 26–75) were enrolled. The median overall survival (OS) time for the whole group of patients was 20.2 months (95% confidence interval [CI] 11.8–28.5] and the median recurrence-free survival (RFS) was 7.3 months (95% CI 4–10.6). The completeness of cytoreduction score (CCS) of 0 and Peritoneal Cancer Index (PCI) score of ≤ 6 groups showed a significantly better long-term survival (median OS 40.7 and 44.3 months, respectively) compared with the incomplete resected groups (median OS 10.7 months, p = 0.003) and PCI score of > 6 group (median OS 13.4 months, p = 0.005). A significant difference was observed in the survival rate according to neoadjuvant treatment (untreated patients: 10.7 months, 95% CI 5.1–16.2; treated patients: 35.3 months, 95% CI 2.8–67.8; p = 0.022).

Conclusions

In referral centers, CRS and HIPEC after neoadjuvant treatment significantly improved survival in selected patients. Patients with a PCI score ≤ 6, complete cytoreduction, negative nodal involvements, and negative cytology had encouraging results, showing a clinically meaningful survival.

Treatment Modality Based Survival in Gastric Carcinoma Patients with Stand-Alone Peritoneal Metastasis: a Case-Control Study

Purpose

To date, there are no promising treatments for gastric carcinoma with peritoneal metastasis. Some researchers have suggested a survival benefit of gastrectomy in select patients. This study investigated the survival of gastric carcinoma patients with stand-alone peritoneal metastasis according to the type of treatment modality.

Materials and Methods

We reviewed the data of 132 patients with gastric carcinoma and stand-alone peritoneal metastasis. We performed gastrectomy when the primary tumor was deemed resectable and systemic chemotherapy was administered. We analyzed patient survival according to the type of treatment, and the prognostic value of gastrectomy was evaluated in univariate and multivariate models.

Results

Among all patients, 70 underwent gastrectomy plus chemotherapy, 20 underwent gastrectomy alone, 36 underwent chemotherapy alone, and 6 received supportive care. The median patient survival was 13 months. Patients who underwent gastrectomy had significantly longer survival than those who did not undergo gastrectomy (14 vs. 8 months, P<0.001). Patients who received chemotherapy showed significantly longer survival than those who did not (13 vs. 7 months, P=0.032). Patients who underwent gastrectomy plus chemotherapy showed better survival than those who underwent other treatments. In multivariate analysis, gastrectomy was found to be an independent prognostic factor (hazard ratio, 0.52; 95% confidence interval, 0.33–0.82) in addition to chemotherapy.

Conclusions

Our study showed that patients who underwent gastrectomy plus chemotherapy had the best survival. Although the survival benefit of gastrectomy remains uncertain, it is a favorable prognostic indicator in patients with stand-alone peritoneal metastasis.

Long term survival in patients with peritoneal metastasised gastric cancer treated with cytoreductive surgery and HIPEC: A multi-institutional cohort from PSOGI

BACKGROUND

Peritoneal metastasis (PM) of gastric cancer (GC) is relatively common (17%) and is associated with poor survival. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is still controversially discussed, as it has proven an increase in survival in selected patients, but only a small subgroup reached long-term survival. The aim of this study was to collect and analyse a worldwide cohort of patients treated with CRS and HIPEC with long-term survival in order to explore relevant patient characteristics.

METHODS

We conducted a questionnaire, which was distributed to all collaborators of the Peritoneal Surface Oncology Group International (PSOGI). Inclusion criteria were: histopathologic proven PM of GC, treated with CRS and HIPEC, and overall survival >5 years. Patient, tumour, and therapeutic details were collected and analysed.

RESULTS

From an analysis of 448 patients treated between 1994 and 2014, a total of 28 patients with a mean age of 53.0 years and mean PCI of 3.3 were included. The overall median survival was 11.0 years (min 5.0; max 27.9). The predictors completeness of cytoreduction (CC-0) and PCI<6 were present in 22/28 patients. 12/28 patients developed at a median of 9.6 years tumour recurrence, and was associated with inferior median overall survival compared to patients without recurrence (8.8 years vs. not reached; p = 0.002).

CONCLUSIONS

Long-term survival and even cure are possible in patients with PM of GC treated with CRS and HIPEC. Completeness of cytoreduction and low PCI seemed to be crucial. Further studies are needed in order to improve existing selection criteria.

Radiomics Nomogram for Prediction of Peritoneal Metastasis in Patients With Gastric Cancer

Objective: The aim of this study is to evaluate whether radiomics imaging signatures based on computed tomography (CT) could predict peritoneal metastasis (PM) in gastric cancer (GC) and to develop a nomogram for preoperative prediction of PM status.

Methods: We collected CT images of pathological T4 gastric cancer in 955 consecutive patients of two cancer centers to analyze the radiomics features retrospectively and then developed and validated the prediction model built from 292 quantitative image features in the training cohort and two validation cohorts. Lasso regression model was applied for selecting feature and constructing radiomics signature. Predicting model was developed by multivariable logistic regression analysis. Radiomics nomogram was developed by the incorporation of radiomics signature and clinical T and N stage. Calibration, discrimination, and clinical usefulness were used to evaluate the performance of the nomogram.

Results: In training and validation cohorts, PM status was associated with the radiomics signature significantly. It was found that the radiomics signature was an independent predictor for peritoneal metastasis in multivariable logistic analysis. For training and internal and external validation cohorts, the area under the receiver operating characteristic curves (AUCs) of radiomics signature for predicting PM were 0.751 (95%CI, 0.703–0.799), 0.802 (95%CI, 0.691–0.912), and 0.745 (95%CI, 0.683–0.806), respectively. Furthermore, for training and internal and external validation cohorts, the AUCs of radiomics nomogram for predicting PM were 0.792 (95%CI, 0.748–0.836), 0.870 (95%CI, 0.795–0.946), and 0.815 (95%CI, 0.763–0.867), respectively.

Conclusions: CT-based radiomics signature could predict peritoneal metastasis, and the radiomics nomogram can make a meaningful contribution for predicting PM status in GC patient preoperatively.

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

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

Gastric cancer with peritoneal metastases: Efficiency of standard treatment methods

BACKGROUND

Peritoneal metastasis (PM), arising from gastric cancer (GC), is the most common pattern of synchronous and metachronous dissemination and is generally associated with poor prognosis. New therapeutic modalities are being increasingly employed for such patients.

AIM

To develop more advanced methods, it becomes necessary to study the results of existing standard treatment methods in patients with PM in order to perform a comparative analysis of the strategies.

METHODS

A retrospective analysis of the efficiency of standard treatment methods (i.e., palliative chemotherapy, palliative gastrectomy, and the best supportive care) was performed on 200 GC patients with synchronous PM.

RESULTS

The overall survival (OS) rate in 200 GC patients with PM under standard treatment was 5.4 mo. One-year survival occurred in 18.4% of patients. In multivariate analysis, the survival rate was significantly influenced by the following factors: Presence of extraperitoneal metastases, and stage of PM according to both the Japanese Gastric Cancer Association (JGCA) and the peritoneal cancer index (PCI). The median OS and 1-year survival of patients with Р1, P2, and P3 (JGCA) carcinomatosis were 9.8 mo, 6.7 mo, and 4.0 mo, and 47.2%, 18.8%, and 5.1%, respectively. The application of the palliative gastrectomy resulted in an increase in the median OS by up to 17 mo compared to the conservative approach where the value was 8.5 mo (P = 0.05) in patients with Р1 РМ. In patients with Р3, palliative chemotherapy increased the OS by up to 5.6 mo compared to the OS of 3.2 mo (P = 0.0006) for best supportive care. The median OS and 1-year survival of patients with РCI of 1-6, 7-12 and 13+ points were 8.5 mo, 4.2 mo, and 4.1 mo, and 39.8%, 6.7%, and 5.5%, respectively. Palliative gastrectomy increased the median OS to 12.6 mo compared to conservative approach of 8.0 mo (P = 0.03) in patients with РCI of 1-6 points. In patients with РCI 13+ points, only palliative chemotherapy increased the OS to 6.0 mo compared to the OS of 3.4 mo for best supportive care (P = 0.0008).

CONCLUSION

GC patients with PM are characterized by extremely poor prognoses. Long-term survivors were found in the group with PCI of 1-6 points, and there was no survival difference in groups with PCI 7-12 vs PCI 13+ points. Palliative gastrectomy could prove effective in treating patients with early stage PM. The three standard treatment methods are equally effective for moderate stages of PM. In cases with advanced peritoneal carcinomatosis, a significant increase in prognosis was registered only after treatment with palliative chemotherapy.

Does neoadjuvant chemotherapy cancel out the negative survival impact induced by surgical complications after gastrectomy?

BACKGROUND

Postoperative infectious complications (ICs) are associated with a poor prognosis following gastric cancer surgery. Neoadjuvant chemotherapy (NAC) targeting scirrhous-type or bulky nodal disease reportedly exerts a prophylactic effect on the negative impact of ICs. However, a recent study clearly showed that NAC for scirrhous-type disease had no survival benefit. We investigated this prophylactic effect and significant interactions among subgroups of histological response, macroscopic type, and bulky nodal disease.

METHODS

We examined 115 patients who received NAC followed by radical gastrectomy between January 2008 and December 2015. The overall survival (OS) and disease-free survival (DFS) were compared between those with and without ICs. Our cohort included 62 with type 4/giant type 3, 44 with bulky nodal disease/para-aortic nodal disease, and 25 with other diseases.

RESULTS

A histological response was observed in 80 patients (69.5%). Thirty three (28.7%) developed ICs. There was no significant difference in the OS [hazard ratio (HR) 0.96; 95% confidence interval (CI) 0.47-1.99, p = 0.920] or DFS (HR 0.74; 95% CI 0.40-1.38, p = 0.342) by the presence of ICs. The HR was 1.00 in patients who had no response to NAC (grade 0/1a) and 0.95 in those who responded to NAC (grade 1b/2/3). No subgroups showed significant interactions for the OS.

CONCLUSIONS

NAC may cancel out the negative impact of morbidity on the survival in advanced gastric cancer patients. The prophylactic effects by NAC do not depend on the tumor type or histological response.

The efficacy of treatment options for patients with gastric cancer and peritoneal metastasis

BACKGROUND

Patients with peritoneal metastases of gastric cancer have a poor prognosis and median survival of 7 months. This study compared treatment options and outcomes based on the Peritoneal Cancer Index (PCI).

METHODS

This retrospective analysis included patients with gastric cancer treated between August 2008 and December 2017 with synchronous peritoneal metastases only diagnosed by laparoscopy. The three treatments were as follows: (1) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with pre- and postoperative systemic chemotherapy (n = 58), (2) laparotomy/laparoscopy without CRS, but HIPEC in combination with pre- and postoperative systemic chemotherapy (n = 11), and (3) systemic chemotherapy only (n = 19).

RESULTS

A total of 88 patients aged 54.6 ± 10.9 years with mean PCI of 14.3 ± 11.3 were included. The PCI was significantly lower in group 1 (8.3 ± 5.7) than in group 2 (23.9 ± 11.1, p < 0.001) and group 3 (27.3 ± 9.3, p < 0.001). Mean time from diagnosis to laparoscopy was 5.2 ± 2.9 months. The median overall survival was 9.8 ± 0.7 for group 1, 6.3 ± 3.0 for group 2 and 4.9 ± 1.9 months for group 3 (p < 0.001). Predictors for deteriorated overall patient survival included > 4 cycles of preoperative chemotherapy (HR 4.49, p < 0.001), lymph-node metastasis (HR 3.53, p = 0.005), PCI ≥ 12 (HR 2.11, p = 0.036), and incompleteness of cytoreduction (HR 4.30, p = 0.001) in patients treated with CRS and HIPEC.

CONCLUSION

CRS and HIPEC showed convincing results in selected patients with PCI < 12 and complete cytoreduction. Prolonged duration (> 4 cycles) of preoperative intravenous chemotherapy reduced patient survival in patients suitable for CRS and HIPEC.

The Diagnostic and Prognostic Value of Digital Rectal Examination in Gastric Cancer Patients with Peritoneal Metastasis

Background: Peritoneal metastasis (PM) is the most common cause of death in gastric cancer (GC) patients. However, diagnosis of PM is still difficult in clinical practice. This study aimed to explore the diagnostic and prognostic value of digital rectal examination (DRE) in GC. Methods: 247 GC patients with PM confirmed by operation were included. The diagnostic yield of DRE compared with computed tomography (CT) was calculated. In another group of 1330 cases receiving radical gastrectomy, 38 cases with DRE (+) postoperatively were analyzed to identify risk factors. A nomogram was constructed to predict postoperative DRE (+). Results: The specificity, positive predictive value and positive likelihood ratio of DRE in diagnosis of PM was 99.8%, 91.2% and 58.4, higher than CT (97.6%, 64.9% and 10.4). Though the sensitivity of DRE (12.6%) was lower than CT (24.7%), 17 of 31 patients with DRE (+) could not be found by CT. Moreover, the overall survival of confirmed PM patients with DRE (+) (PM-DRE (+)) was much lower than PM-DRE (-) patients (P<0.001). In addition, the nomogram to predict postoperative DRE (+) had a bootstrap-corrected concordance index of 0.73 and was well calibrated. Conclusions: GC patients with DRE (+) could be regarded as a special subtype of stage IV ones with poorer prognosis. Supply of palliative care and chemotherapy rather than unnecessary operation might be a better alternative for these patients. DRE was an effective supplement for CT and should be generally recommended for GC patients.

Pressurized intraperitoneal aerosol chemotherapy and its effect on gastric-cancer-derived peritoneal metastases: an overview

This manuscript aspires to portray a review of the current literature focusing on manifest peritoneal metastasis (PM) derived from gastric cancer and its treatment options. Despite the development of chemotherapy and multimodal treatment options during the last decades, mortality remains high worldwide. After refreshing important epidemiological considerations, the molecular mechanisms currently accepted through which PM occurs are revised. Palliative chemotherapy is the only recommended treatment option for patients with PM of gastric cancer according to the National Comprehensive Cancer Network guidelines, although cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy demonstrated promising results in selected patients with regional PM and localized intraabdominal tumor spread. A novel treatment named pressurized intraperitoneal aerosol chemotherapy may have a promising future in improving overall survival with an acceptable postoperative complication rate and stabilizing quality of life during treatment. Additionally, the procedure has been proved to be safe for the patient and medical personnel and a feasible, repeatable method to deter metastatic proliferation. This overview comprehensively addresses this novel and promising treatment in the context of a scientifically and clinically challenging disease.

Pathologic analyses of peritoneal nodules in gastric cancer patients during surgery-A single cancer center experience with diagnostic pitfalls

BACKGROUND

Gastric carcinoma (GC) is the second most common cause of cancer-related deaths worldwide. During operations, nodular lesions of the peritoneum are often sent for frozen section (FS). For pathologists, FS of the peritoneum is challenging due to sparse and discohesive tumor cells in a fibrotic background.

METHODS

To explore diagnostic accuracy and diagnostic pitfalls of FS in this setting, we retrospectively collected 252 peritoneal biopsies in cases with GC from January 2006 to May 2017 and compared corresponding permanent sections and patient prognosis. After review, 6 cases (2.4%) were discrepant: positive conversion was identified in 5 cases due to scarce tumor cells associated with severe fibrosis and inflammation; negative conversion was identified in one case due to papillary mesothelial cell proliferation masquerading as carcinoma.

RESULTS

Two hundred cases were finally confirmed as positive for tumor cells. Of these, 185 (92.5%) patients died of GC, with survival times ranging from 7 to 3574 (mean 415) days after operation. Fifty-two (20.6%) cases were negative for tumor, and pathologic findings included chronic inflammation with fibrosis (N = 25: associated with previous operation, 10; idiopathic, 15) and papillary mesothelial cell proliferation (N = 9). All 5 patients with frozen diagnosis converted to positive results died of GC during follow up. A total of 19 patients with peritoneal nodules diagnosed as benign on FS died with GC (79.0%), and their survival times ranged from 87 to 3649 (mean 833) days.

CONCLUSIONS

Peritoneal biopsies in patients with GC were mostly carcinoma, followed by chronic inflammation with fibrosis and papillary mesothelial cell proliferation. Deeper sections or intradepartmental consultations were helpful to reduce false negative diagnosis on FS.

Prophylactic effect of neoadjuvant chemotherapy in gastric cancer patients with postoperative complications

BACKGROUND

The occurrence of postoperative complications may have a significant negative impact on the prognosis of patients with gastrointestinal cancers. The inflammatory response releases systemic cytokines, which may induce residual cancer cell growth. Recently, neoadjuvant chemotherapy (NAC) was found to improve the prognosis of advanced gastric cancer (GC). We hypothesize that when postoperative complications occur after gastrectomy, NAC treatment of micrometastases can prevent residual cancer cell growth.

METHODS

This study included 101 patients who underwent curative resection after NAC for GC from 2005 to 2015. Clinical data, including intraoperative parameters, were collected retrospectively. Overall survival (OS) and relapse-free survival (RFS) were compared between the patients with complications and those without complications.

RESULTS

Of the 101 patients, 35 (34.7%) had grade 2 or higher complications. Among those with complications, the 3- and 5-year OS rates were 63.5 and 58.2% and the 3- and 5-year RFS rates 41.7 and 41.7%, respectively. Among those without complications, the 3- and 5-year OS rates were 65.9 and 56.3% and the 3- and 5-year RFS rates 51.1 and 43.9%, respectively. There was no significant difference in prognosis between the patients with complications and those without complications.

CONCLUSION

Our study is the first to demonstrate the potential of NAC to abolish the poor prognosis induced by postoperative complications after curative resection for GC.

Addition of peritonectomy to gastrectomy can predict good prognosis of gastric adenocarcinoma patients with intraoperatively proven single P1/P2 carcinomatosis

This study was to evaluate the prognosis of peritonectomy following gastrectomy for gastric adenocarcinoma patients with intraoperatively proven single P1/P2 carcinomatosis and to define the best therapeutic strategy of the patient cohort. The patients with intraoperatively proven single P1/P2 carcinomatosis from a prospectively maintained database were divided into resection group and non-resection group based on complete gross resection of peritoneal carcinomatosis. From 2005 to 2012, there were 103 patients in the resection group and 122 patients in the non-resection group. There was no difference in morbidity and mortality between groups. The patients did not have improved median survival in P1 carcinomatosis compared to P2 carcinomatosis (15.53 vs 14.80 months, p = 0.450). The median survival was significantly improved in the resection group compared to the patients in the non-resection group (21.07 vs 13.37 months, p < 0.001). The patients undergoing complete gross peritonectomy plus postoperative chemotherapy had a significantly longer median survival than patients who had complete gross peritonectomy alone, patients receiving postoperative chemotherapy alone, and patients receiving neither peritonectomy nor postoperative chemotherapy (27.33 vs 12.00 vs 16.00 vs 10.33 months, p < 0.001). In the multivariate analysis, poor performance status ( p = 0.036), absence of complete gross peritonectomy ( p < 0.001), and lack of postoperative chemotherapy ( p < 0.001) were identified as independently associated with poor survival. The data indicate complete gross peritonectomy following gastrectomy confers a survival benefit to gastric cancer patients with intraoperatively proven single P1/P2 carcinomatosis. In addition, postoperative chemotherapy improves survival regardless of resection of peritoneal carcinomatosis and should be recommended.

Survival benefit of gastrectomy for gastric cancer with peritoneal carcinomatosis: a propensity score-matched analysis

Peritoneal carcinomatosis (PC) is the most frequent pattern of metastasis in stage IV gastric cancer (GC). The study aims to investigate the efficacy of gastrectomy in GC with PC. Clinicopathological data of 518 stage IV GC patients were retrospectively collected in Nanfang Hospital. Among all cases, 312 GC patients with PC (without other site of metastasis) were eligible. Univariate and multivariate analyses were performed to identify the independent prognostic factors. Propensity score matching analysis was performed to balance the characteristics and treatment‐related factors. There was a significantly improved overall survival in gastrectomy group (148 patients) compared with nonresection group (164 patients) (P < 0.001). The 1‐year and 2‐year survival rates were 49.8% and 21.5% in gastrectomy group, whereas 28.8% and 9.7% in nonresection group, respectively. Further analysis showed that gastrectomy had also improved survival in P1 (P = 0.017) and P2 stage patients (P < 0.001), but not P3 stage (P = 0.495). The modality of gastrectomy plus chemotherapy plus hyperthermic intraperitoneal chemotherapy (HIPEC) showed an optimum survival. In addition, P3 disease, nongastrectomy, nonchemotherapy, non‐HIPEC, and age ≥ 60 years were independently associated with poor survival. The gastrectomy plus chemotherapy plus HIPEC modality showed a significant survival benefit for gastric adenocarcinoma patients, particularly in those with P1 and P2 diseases.

The Multidisciplinary Team Conference's Decision on M-Staging in Patients with Gastric- and Gastroesophageal Cancer is not Accurate without Staging Laparoscopy

BACKGROUND

The implementation of the multidisciplinary team conference has been shown to improve treatment outcome for patients with gastric- and gastroesophageal cancer. Likewise, the staging laparoscopy has increased the detection of patients with disseminated disease, that is, patients who do not benefit from a surgical resection. The aim of this study was to compare the multidisciplinary team conference's decision in respect of M-staging with the findings of the following staging laparoscopy.

METHODS

Patients considered operable and resectable within the multidisciplinary team conference in the period 2010-2012 were retrospectively reviewed. Patient data were retrieved by searching for specific diagnosis and operation codes in the in-house system. The inclusion criteria were as follows: biopsy-verified cancer of the esophagus, gastroesophageal junction or stomach, and no suspicion of peritoneal carcinomatosis or liver metastases on multidisciplinary team conference before staging laparoscopy. Furthermore, an evaluation with staging laparoscopy was required.

RESULTS

In total, 222 patients met the inclusion criteria. Most cancers were located in the gastroesophageal junction, n = 171 (77.0%), and most common with adenocarcinoma histology, n = 196 (88.3%). The staging laparoscopy was M1-positive for peritoneal carcinomatosis in eight patients (16.7%) with gastric cancer versus nine patients (5.3%) with gastroesophageal junction cancer. Furthermore, liver metastases were evident in zero patients (0.0%) and four patients (2.3%) with gastric- and gastroesophageal junction cancer, respectively. The staging laparoscopy findings regarding peritoneal carcinomatosis were significantly different between gastric- and gastroesophageal junction cancers, p = 0.01. No significant differences were found regarding T-/N-stage or histological tumor characteristics between the positive- and negative-staging laparoscopy group.

CONCLUSION

The M-staging of the multidisciplinary team conference without staging laparoscopy lacks accuracy concerning peritoneal carcinomatosis. Staging laparoscopy remains an essential part of the preoperative detection of disseminated disease in patients with gastric- and gastroesophageal cancer.

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

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

Combined targeting of high-mobility group box-1 and interleukin-8 to control micrometastasis potential in gastric cancer

Micrometastasis is the major cause of treatment failure in gastric cancer (GC). Because epithelial-to-mesenchymal transition (EMT) is considered to develop prior to macroscopic metastasis, EMT-promoting factors may affect micrometastasis. This study aimed to evaluate the role of extracellular high-mobility group box-1 (HMGB1) in EMT and the treatment effect of combined targeting of HMGB1 and interleukin-8 (IL-8) at early-stage GC progression through interrupting EMT promotion. Extracellular HMGB1 was induced by human recombinant HMGB1 and pCMV-SPORT6-HMGB1 plasmid transfection. EMT activation was evaluated by immunoblotting, immunofluorescence and immunohistochemistry. Increased migration/invasion activities were evaluated by in vitro transwell migration/invasion assay using all histological types of human GC cell lines (N87, MKN28 SNU-1 and KATOIII), N87-xenograft BALB/c nude mice and human paired serum-tissue GC samples. HMGB1-induced soluble factors were measured by chemiluminescent immunoassay. Inhibition effects of tumor growth and EMT activation by combined targeting of HMGB1 and IL-8 were evaluated in N87-xenograft nude mice. Serum HMGB1 increases along the GC carcinogenesis and reaches maximum before macroscopic metastasis. Overexpressed extracellular HMGB1 promoted EMT activation and increased cell motility/invasiveness through ligation to receptor for advanced glycation end products. HMGB1-induced IL-8 overexpression contributed the HMGB1-induced EMT in GC in vitro and in vivo. Blocking HMGB1 caused significant reduction of tumor growth, and addition of human recombinant IL-8 rescues this antitumor effects. Our results imply the role of HMGB1 in EMT through IL-8 mediation, and a potential mechanism of GC micrometastasis. Our observations suggest combination strategy of HMGB1 and IL-8 as a promising diagnostic and therapeutic target to control GC micrometastasis.

Incidence, time course and independent risk factors for metachronous peritoneal carcinomatosis of gastric origin--a longitudinal experience from a prospectively collected database of 1108 patients

Background

Comprehensive evidence on the incidence, time course and independent risk factors of metachronous peritoneal carcinomatosis (metaPC) in gastric cancer patients treated with curative intent in the context of available systemic combination chemotherapies is lacking.

Methods

Data from a prospectively collected single-institutional Center Cancer Registry with 1108 consecutive patients with gastric adenocarcinoma (GC), clinical, histological and survival data were analyzed for independent risk factors and prognosis with focus on the development of metaPC. Findings were then stratified to the time periods of treatment with surgery alone, 5-Fluorouracil-only and contemporary combined systemic perioperative chemotherapy strategies, respectively.

Results

Despite R0 D2 gastrectomy (n = 560), 49.6% (±5.4%) of the patients were diagnosed with tumour recurrence and 15.5% (±1.8%) developed metaPC after a median time of 17.7 (15.1-20.3) months after surgery resulting in a tumour related mortality of 100% with a median survival of 3.0 months (2.1 – 4.0). Independent risk factors for the development of metaPC were serosa positive T-category, nodal positive-status, signet cell and undifferentiated gradings (G3/G4). Contemporary systemic combination chemotherapy did not improve the incidence and prognosis of metaPC (p = 0.54).

Conclusions

Despite significant improvements in the overall survival for the complete cohort with gastric cancer over time, those patients with metaPC did not experience the same benefits. The lack of change in the incidence, and persistent poor prognosis of metaPC after curative surgery expose the need for further prevention and/or improved treatment options for this devastating condition.

Serum ENA78/CXCL5, SDF-1/CXCL12, and their combinations as potential biomarkers for prediction of the presence and distant metastasis of primary gastric cancer

BACKGROUND

Chemokines play important roles in cancer development and progression. Epithelial-derived neutrophil-activating peptide-78 (ENA78/CXCL5) and stromal cell-derived factor (SDF-1/CXCL12) supposedly contribute to gastric cancer (GC) development and progression. This study aims to evaluate serum levels of ENA78/CXCL5 and SDF-1/CXCL12 along the GC carcinogenesis, and analyze their clinical significance, and diagnostic potentials through human serum samples.

METHODS

A total of 300 subjects were enrolled in this study. Serum levels of ENA78/CXCL5 and SDF-1/CXCL12, measured by chemiluminescent immunoassay, were compared among 4 disease groups; normal, high-risk (intestinal metaplasia and adenoma), early GC (EGC), and advanced GC (AGC) groups in both training (n=25 per group) and validation dataset (n=70, 30, 50, 50, respectively) by ANOVA test (post hoc Bonferroni). Correlations between serum ENA78/CXCL5 or SDF-1/CXCL12 levels and clinicopathological parameters of GC patients were evaluated (Spearman's correlation; γs). To validate the diagnostic accuracy, receiver operating characteristic (ROC) curve and logistic regression analysis was performed.

RESULTS

Serum ENA78/CXCL5 and SDF-1/CXCL12 levels were significantly higher in AGC groups than EGC, high-risk and normal groups in both training and validation dataset (Bonferroni, from p<0.01 to p<0.001). Clinicopathologically, serum ENA78/CXCL5 was correlated with T-stage (γs=0.231, p=0.021) and distant metastasis (γs=0.357, p<0.001), while serum SDF-1/CXCL12 was correlated with lymph node (γs=0.220, p=0.029) and distant (γs=0.425, p<0.001) metastasis. ROC curve and logistic regression demonstrated that serum ENA78/CXCL5 and SDF-1/CXCL12 showed higher diagnostic accuracy compared with carcinoembryonic antigen (CEA) in predicting GC. Serum ENA78/CXCL5 could predict both the presence of GC and distant metastasis, while serum SDF-1/CXCL12 could mainly predict its distant metastasis. All combination of serum ENA78/CXCL5, SDF-1/CXCL12, and CEA achieved 92.8% specificity at 75.0% sensitivity to predict distant metastasis of GC.

CONCLUSIONS

Combinations of initial serum ENA78/CXCL5, SDF-1/CXCL12, and CEA before any treatment for GC can produce valuable serum biomarker panels to predict the presence and distant metastasis of GC.

Photoimmunotherapy of gastric cancer peritoneal carcinomatosis in a mouse model

Photoimmunotherapy (PIT) is a new cancer treatment that combines the specificity of antibodies for targeting tumors with the toxicity induced by photosensitizers after exposure to near infrared (NIR) light. We performed PIT in a model of disseminated gastric cancer peritoneal carcinomatosis and monitored efficacy with in vivo GFP fluorescence imaging. In vitro and in vivo experiments were conducted with a HER2-expressing, GFP-expressing, gastric cancer cell line (N87-GFP). A conjugate comprised of a photosensitizer, IR-700, conjugated to trastuzumab (tra-IR700), followed by NIR light was used for PIT. In vitro PIT was evaluated by measuring cytotoxicity with dead staining and a decrease in GFP fluorescence. In vivo PIT was evaluated in a disseminated peritoneal carcinomatosis model and a flank xenograft using tumor volume measurements and GFP fluorescence intensity. In vivo anti-tumor effects of PIT were confirmed by significant reductions in tumor volume (at day 15, p<0.0001 vs. control) and GFP fluorescence intensity (flank model: at day 3, PIT treated vs. control p<0.01 and peritoneal disseminated model: at day 3 PIT treated vs. control, p<0.05). Cytotoxic effects in vitro were shown to be dependent on the light dose and caused necrotic cell rupture leading to GFP release and a decrease in fluorescence intensity in vitro. Thus, loss of GFP fluorescence served as a useful biomarker of cell necrosis after PIT.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and five-year survival rates are poor, therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately, in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-, intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index (e.g., Charlson comorbidity index), assessment of nutritional status (e.g., short nutritional assessment questionnaire, nutritional risk screening - 2002) and frailty assessment (Groningen frailty indicator, Edmonton frail scale, Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential. Implementation of fast-track or enhanced recovery after surgery programs is showing promising results, although future studies have to determine what the exact optimal strategy is. Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection. Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far. Advances in postoperative care include optimal timing of oral diet, which has been shown to reduce hospital stay. In general, hospital volume, i.e., centralization, and clinical audits might further improve the outcome in gastric cancer surgery. In conclusion, progress has been made in improving the surgical treatment of gastric cancer. However, gastric cancer treatment is high risk surgery and many areas for future research remain.

Peritoneal carcinomatosis of gastric origin: a population-based study on incidence, survival and risk factors

Peritoneal carcinomatosis (PC) is an important cause of morbidity and mortality among patients with gastric cancer. The aim of the current study was to provide reliable population-based data on the incidence, risk factors and prognosis of PC of gastric origin. All patients diagnosed with gastric cancer in the area of the Eindhoven Cancer Registry between 1995 and 2011 were included. Incidence and survival were computed and risk factors for peritoneal carcinomatosis were determined using multivariate logistic regression analysis. In total, 5,220 patients were diagnosed with gastric cancer, of whom 2,029 (39%) presented with metastatic disease. PC was present in 706 patients (14%) of whom 491 patients (9%) had PC as the only metastatic site. Younger age (<60 years), female gender, advanced T- and N-stage, primary tumor of signet ring cells or linitis plastica and primary tumors covering multiple anatomical locations of the stomach were all associated with a higher odds ratios of developing PC. Median survival of patients without metastases was 14 months, but only 4 months for patients with PC. PC is a frequent condition in patients presenting with gastric cancer, especially in younger patients with advanced tumor stages. Given the detrimental influence of PC on survival, efforts should be undertaken to further explore the promising results that were obtained in preventing or treating this condition with multimodality strategies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of surgery for non-curative gastric cancer

BACKGROUND

Most gastric cancer patients present with advanced stage disease precluding curative surgical treatment. These patients may be considered for palliative resection or bypass in the presence of major symptoms; however, the utility of surgery for non-curative, asymptomatic advanced disease is debated and the appropriate treatment strategy unclear.

PURPOSE

To evaluate the non-curative surgical literature to better understand the limitations and benefits of non-curative surgery for advanced gastric cancer.

METHODS

A literature search for non-curative surgical interventions in gastric cancer was conducted using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases from 1 January 1985 to 1 December 2009. All abstracts were independently rated for relevance by a minimum of two reviewers. Outcomes of interest were procedure-related morbidity, mortality, and survival.

RESULTS

Fifty-nine articles were included; the majority were retrospective, single institution case series. Definitions describing the treatment intent for gastrectomy were incomplete in most studies. Only five were truly performed with relief of symptoms as the primary indication for surgery, while the majority were considered non-curative or not otherwise specified. High rates of procedure-related morbidity and mortality were demonstrated for all surgeries across the majority of studies and treatment-intent categories. Median and 1-year survival were poor, and values ranged widely within surgical approaches and across studies.

CONCLUSIONS

A lack of transparent documentation of disease burden and symptoms limits the surgical literature in non-curative gastric cancer. Improved survival is not evident for all patients receiving non-curative gastrectomy. Further prospective research is required to determine the optimal intervention for palliative gastric cancer patients.

The progression potential of peritoneal dissemination nodules from gastrointestinal tumors

It is necessary to examine the characteristics of the dissemination nodules to establish a therapeutic strategy for peritoneal dissemination from digestive malignancy. Ki-67 expression as a proliferation marker in peritoneal dissemination nodules was investigated. The subjects were 15 patients with gastrointestinal cancers who underwent resection of the primary tumor and disseminated nodules. The expression of Ki-67 in both primary tumor and peritoneal dissemination nodule from each patient was evaluated by immunohistochemistry. Ki-67 labeling index in the original tumor was higher than that in the disseminated nodule in 13 of 15 patients (P < 0.0001). The mean value of Ki-67 labeling index was 42.2% in the 15 original tumors and 18.7% in the 15 disseminated nodules. Proliferative activity in the disseminated nodules was lower than that in the primary tumors. Further examination about characteristics of cancer dissemination is needed to treat patients with peritoneal metastasis.

[Current S3 guidelines on surgical treatment of gastric carcinoma]

The current S3 guidelines on the diagnosis and treatment of gastric carcinoma including those of the esophagogastric junction describe optimal clinical practice based on a high level of evidence and expert consensus from different medical disciplines. Endoscopy and performance of multiple biopsies is the standard approach to detect malignant tumors in the upper gastrointestinal tract. Further diagnostic procedures are necessary to evaluate the tumor stage. With the exception of mucosal carcinomas, surgical therapy is the cornerstone of curative treatment in all potentially resectable stages. In locally advanced carcinomas perioperative chemotherapy should be carried out and in high-seated tumors preoperative radiochemotherapy might be an alternative option. Palliative surgical resection should be avoided in disseminated asymptomatic stages. In a palliative situation complications of the tumor should primarily be treated by interventional or conservative procedures.

Laparoscopic hyperthermic intraperitoneal chemotherapy: indications, aims, and results: a systematic review of the literature

PURPOSE

To evaluate laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with neoadjuvant, adjuvant, or palliative purpose in order to discuss potential clinical implications.

METHODS

A systematic search of PubMed's Medline through August 2011 using the keywords laparoscopic, hyperthermic, and chemotherapy.

RESULTS

Eight studies encompassing a total of 183 patients were considered. The indications for laparoscopic HIPEC was neoadjuvant in 5 patients, adjuvant in 102 patients, and palliative in 76 patients. There were 13 minor complications not requiring repeat operation, and no deaths related to procedure were recorded. When performed to treat refractory malignant ascites, the procedure was effective in 95 % of cases.

CONCLUSIONS

Laparoscopic HIPEC appears to be a safe and effective procedure when performed to treat malignant ascites refractory to less aggressive treatments. The effectiveness of laparoscopy to perform HIPEC with neoadjuvant or adjuvant purpose needs to be confirmed by further studies.

Clinical significance of Zinc finger E-box Binding homeobox 1 (ZEB1) in human gastric cancer

BACKGROUND AND OBJECTIVES

Zinc finger E-box Binding homeobox 1 (ZEB1) encodes a transcription factor and is one of the epithelial-mesenchymal transition (EMT)-inducible genes that play a key role in tumor progression in various cancers. The aim of this study is to clarify the clinical significance of ZEB1 expression in gastric cancer patients.

METHODS

One hundred thirty-four patients who underwent surgery for gastric cancer were evaluated. We analyzed ZEB1 mRNA levels by real-time reverse transcription PCR in gastric cancer tissue and adjacent normal mucosa. ZEB1 protein expression in primary cancer and in peritoneal dissemination samples was measured using immunohistochemical analysis.

RESULTS

Expression of the ZEB1 gene was significantly higher in cancerous tissue than in adjacent normal mucosa. Increased ZEB1 expression was significantly associated with peritoneal dissemination, and was an independent prognostic factor. Logistic regression analysis revealed that increased ZEB1 expression was an independent risk factor for peritoneal dissemination. Immunohistochemical analysis indicated that ZEB1 was intensely expressed in both primary cancer and peritoneal dissemination samples.

CONCLUSIONS

ZEB1 is an independent factor for peritoneal dissemination in patients with gastric cancer, and may therefore play a key role in the progression to peritoneal dissemination in gastric cancer patients.

Laparoscopic staging in gastric cancer: An essential step in its management

AIM:

The role of laparoscopy in staging of gastric cancer is widely accepted; however, in Malaysia its usage has been limited. Patients can be classified as resectable or unresectable, which helps in avoiding an unwanted laparotomy and the morbidities associated with it. The aim of this study was to assess the value of laparoscopy in staging of gastric cancer in comparison with CT scan.

MATERIALS AND METHODS:

Patients with carcinoma of the stomach after a complete preoperative work-up underwent laparoscopy prior to surgical exploration. TNM staging was used to compare laparoscopy with CT, with the histopathological report used as the gold standard.

RESULTS:

Forty cases were included in this study. The sensitivity of laparoscopy for T3 tumours appears to be significant when compared to that of CT. Laparoscopy detected 90.3% of the cases as against the 58% detected with CT. There was not much difference in the N factor. With regard to M factor, the sensitivity was 100% for laparoscopy in comparison with CT.

CONCLUSIONS:

Laparoscopy has been shown to be sensitive in detecting metastasis in gastric cancer in comparison to CT, thus helping in avoiding unwanted laparotomy and thus providing a more systemic approach in managing gastric cancers.

Surgical management of gastric cancer: review and consideration for total care of the gastric cancer patient

Surgical therapy remains the most effective modality in the treatment of gastric cancer. Staging laparoscopy with laparoscopic ultrasound may increase the accuracy of staging and prevent patients with unresectable gastric cancer from undergoing unnecessary operations. Resection of proximal and distal gastric cancer is best accomplished with an appropriate gastrectomy that ensures adequate resection margins. A D2 lymphadenectomy can be performed safely and facilitates the resection of the minimum 15 lymph nodes required for adequate staging. Adjacent organ resection should be used only in highly selected patients with R0 resection as the goal. Palliative operations offer improved quality of life and symptom relief in patients with metastatic disease. Appreciation of postoperative quality of life after gastric resection facilitates appropriate and effective preoperative counseling. Surgical outcomes may be influenced by hospital volume and rate of adequate lymph node assessment.

Predictive factors improving survival after gastrectomy in gastric cancer patients with peritoneal carcinomatosis

BACKGROUND

The aim of this study was to review prognosis following gastrectomy for gastric cancer patients with synchronous peritoneal carcinomatosis and to identify predictive factors for improving survival after gastrectomy in this setting.

METHODS

Records of all patients who underwent gastrectomy for gastric cancer with peritoneal dissemination in our center between 1993 and 2004 were reviewed.

RESULTS

Data of 101 patients who underwent gastrectomy for gastric cancer with peritoneal dissemination were available. Peritoneal dissemination was classified as P1, metastasis to the adjacent peritoneum in 34 patients; P2, a few scattered metastases to the adjacent peritoneum in 13 patients; and P3, numerous metastases in 54 patients. Nineteen patients sustained 21 adverse events. Overall survival was significantly improved for those in the P1 and P2 groups compared with that for the P3 group (median of 18 months and 15 months vs. 9 months; P < 0.001). Seven factors were significant for overall survival: peritoneal carcinomatosis, peritoneal lavage cytology, macroscopic type, resection margin, extent of lymph node dissection, curative potential of gastric resection, and chemotherapy, including perioperative and postrecurrent chemotherapy. In multivariate analysis, two factors were identified as independently associated with poor survival: P3 disease (P = 0.002) and absence of chemotherapy (P = 0.009). Univariate analysis of gastric cancer patients with P1 or P2 carcinomatosis revealed only tumor differentiation to be significant.

CONCLUSIONS

Gastric cancer patients with P1/P2 carcinomatosis and well/moderately differentiated tumors are likely to have an improved survival after gastrectomy. We emphasize that patients with good performance status and P1/P2 carcinomatosis should be considered appropriate surgical candidates before embarking on palliative systemic chemotherapy alone.

Type IV collagen levels are elevated in the serum of patients with peritoneal dissemination of gastric cancer

Type III procollagen (amino-terminal propeptide of procollagen type III) and type IV collagen are considered to be reliable serum markers for monitoring the progression of liver fibrosis. The peritoneal dissemination of gastric cancer is also characterised by abundant collagen deposition in the peritoneum. The present study was performed to investigate the potential of serum type III procollagen and IV collagen as biomarkers for peritoneal dissemination in gastric cancer. The study population consisted of 117 patients with gastric cancer: 32 patients had peritoneal dissemination which was pathologically diagnosed by laparotomy or laparoscopic examination, while 85 patients (45/40, early/advanced gastric cancer) had no peritoneal dissemination. We measured the serum levels of type III procollagen and type IV collagen in comparison to the commonly accepted tumor markers carcinoembryonic (CEA), carbohydrate antigen (CA)19-9 and CA125. The median type III procollagen levels showed no significant differences between the two groups, whereas the median type IV collagen levels were significantly (201 ng/ml) higher in patients with than in those without peritoneal dissemination (early/advanced gastric cancer, 124/136 ng/ml) (P<0.05). In receiver operating characteristic (ROC) curve analysis, type IV collagen had the largest area under the curve (0.83), followed by CA125 (0.72), CA19-9 (0.64), CEA (0.59) and type III procollagen (0.48). Type IV collagen was an independent marker (P<0.0001, odds ratio 15.7) for predicting peritoneal dissemination along with CA125 (P=0.0086, odds ratio 9.4) based on multivariate logistic regression. In conclusion, serum type IV collagen levels may be significant in the early detection and management of patients with peritoneal dissemination of gastric cancer.

Método laparoscópico no diagnóstico e extensão da carcinomatose peritoneal

INTRODUÇÃO: O método laparoscópico é efetivo no diagnóstico e verificação do estádio das neoplasias malignas intra-abdominais e permite a exploração do comprometimento da serosa gástrica, folhetos peritoneais parietal e visceral, fígado, epíplons, cavidade pélvica e outros órgãos da cavidade abdominal, e coleta de líquido ascítico. OBJETIVO: Relatar a técnica do método videolaparoscópico e como realizá-lo com vistas à carcinomatose peritoneal. MÉTODO: Após a introdução sob visão direta do trocarte na região da cicatriz umbilical, esvazia-se a ascite ao máximo. Coleta-se fluido peritoneal para realização de exame citológico, evitando-se contaminação com sangue para não diminuir a sensibilidade do método. Se não houver ascite, pode-se realizar o lavado peritoneal. As liberações de bridas e aderências podem ser realizadas previamente à exploração da cavidade e também várias biópsias do peritônio parietal, diafragma, omento e cavidade pélvica para confirmação. Para se determinar se o paciente é candidato à peritoniectomia e/ou quimioterapia hipertérmica intra-abdominal, realiza-se o índice de carcinomatose peritoneal, tendo-se por base a distribuição e o tamanho dos nódulos. Para que isto ocorra é essencial a utilização de mesa operatória com capacidade de se mover para as posições de Trendelenburg, proclive e laterais. CONCLUSÃO: O método laparoscópico apresenta-se bom para se avaliar ascite, metástases hepática e peritoneal, podendo atingir eficiência, sensibilidade e especificidade de até 100% para os referidos atributos. Ele deve ser realizado quando existir suspeita clínica de difusão intraperitoneal da neoplasia não confirmada pelos métodos diagnósticos por imagem.

Prognostic significance of free peritoneal tumor cells in the peritoneal cavity before and after neoadjuvant chemotherapy in patients with gastric carcinoma undergoing potentially curative resection

BACKGROUND

Free peritoneal tumor cells (FPTCs) are an independent prognostic factor in patients undergoing curative resection for gastric carcinoma. Whether neoadjuvant chemotherapy (NAC) can eliminate FPTCs in the peritoneal lavage remains unclear. The aim of the study was to determine the effect of NAC on FPTCs.

METHODS

From 1994 to 2000, data from a total of 61 patients with resectable gastric cancer were analyzed. Peritoneal cytology was performed before NAC at laparoscopy and at tumor resection. A minimum of 6 weeks of NAC, consisting of cisplatin, folinic acid, and fluorouracil, was administered. FPTCs were detected immunohistochemically with Ber-EP4 antibody.

RESULTS

No FPTCs could be detected in 42 patients (69%), compared to 19 (31%) with FPTCs before NAC. During chemotherapy, 10 (24%) of 42 patients developed FPTCs, and 7 (37%) of 19 patients reverted from positive to negative. Patients who became FPTC negative (n = 7) showed an improved median survival (36.1 months) and a longer 2-year survival (71.4%) compared to FPTC-positive patients before and after NAC (n = 12), with a median survival of 9.2 months and a 2-year survival rate of 25%. In contrast, patients who reverted from FPTC negative to positive during NAC (n = 10) had a median survival of 18.5 months and a 2-year survival of only 20%. Multivariate analysis identified ypN category and FPTC change as independent prognostic factors.

CONCLUSIONS

NAC for patients with positive cytology could lead to FPTC negativity in a subset of patients and improve their prognosis. However, NAC might be a risky strategy for almost one-quarter of patients whose disease develops positive cytology.

A third-generation herpesvirus is effective against gastroesophageal cancer

BACKGROUND

Gastroesophageal cancer remains a leading cause of cancer deaths and is uniformly fatal in patients presenting with metastases and recurrence. This study sets out to determine the effect of a third-generation, replication-competent, oncolytic herpes simplex type 1 virus containing transgenes encoding for a fusogenic membrane glycoprotein and Fcy::Fur, against gastroesophageal cancer.

METHODS

The cytotoxic effect of the virus was tested on human gastroesophageal cancer cell lines OCUM-2MD3, MKN-45, AGS, MKN-1, MKN-74, and BE-3 at sequential multiplicities of infection (MOI). Cytotoxicity was measured using a lactate dehydrogenase assay. Viral replication was tested by serially diluting supernatants from viral infections and titering on VERO cells via standard plaque assay. Correlations of cytotoxicity and viral replication were also investigated.

RESULTS

All cell lines were susceptible to viral infection and demonstrated a dose-dependent effect, with greater and faster cytotoxicity at higher MOIs. Viral replication was supported in the cell lines tested, with peak titers by d 5, some supporting as high as >40,000× amplification. Cell lines with longer doubling times (>30 h) also achieved higher viral titers at a MOI of 0.1. Cell lines with shorter doubling times achieved 50% cell kill in fewer days, with an average of 2.3 d for cell lines with doubling times under 30 h compared with 4.4 d for cell lines with doubling times over 30 h.

CONCLUSION

These results suggest that this third-generation oncolytic herpesvirus can effectively infect and lyse gastroesophageal cancer cells and may provide a novel therapy against gastroesophageal cancer.

Surgical outcome after docetaxel-based neoadjuvant chemotherapy in locally-advanced gastric cancer

AIM: To investigate feasibility, morbidity and surgical mortality of a docetaxel-based chemotherapy regimen randomly administered before or after gastrectomy in patients suffering from locally-advanced resectable gastric cancer.

METHODS: Patients suffering from locally-advanced (T3-4 any N M0 or any T N1-3 M0) gastric carcinoma, staged with endoscopic ultrasound, bone scan, computed tomography, and laparoscopy, were assigned to receive four 21 d/cycles of TCF (docetaxel 75 mg/m² day 1, cisplatin 75 mg/m² day 1, and fluorouracil 300 mg/m² per day for days 1-14), either before (Arm A) or after (Arm B) gastrectomy. Operative morbidity, overall mortality, and severe adverse events were compared by intention-to-treat analysis.

RESULTS: From November 1999 to November 2005, 70 patients were treated. After preoperative TCF (Arm A), thirty-two (94%) resections were performed, 85% of which were R0. Pathological response was complete in 4 patients (11.7%), and partial in 18 (55%). No surgical mortality and 28.5% morbidity rate were observed, similar to those of immediate surgery arm (P = 0.86). Serious chemotherapy adverse events tended to be more frequent in arm B (23% vs 11%, P = 0.07), with a single death per arm.

CONCLUSION: Surgery following docetaxel-based chemotherapy was safe and with similar morbidity to immediate surgery in patients with locally-advanced resectable gastric carcinoma.

Signet ring cell histology is an independent predictor of poor prognosis in gastric adenocarcinoma regardless of tumoral clinical presentation

OBJECTIVE

To test the hypothesis that signet ring cell (SRC) histology has a negative prognostic value in patients with gastric adenocarcinoma (ADC).

SUMMARY BACKGROUND DATA

In western countries, gastric ADC with SRC often occurs after the disease has advanced. Consequently, the prognosis of SRC is generally regarded as poor, although survival studies comparing SRC and non-SRC have yielded inconsistent results.

METHODS

: An intent to treat analysis was performed among 215 patients with gastric ADC scheduled for surgical resection from 1996 to 2007. Of these, 180 patients underwent the resection and 35 were not resected due to diffuse metastatic illness. From 59 resected patients with SRC (SRC group), control non-SRC resected patients matched by age, gender, American Society of Anaesthesiologists (ASA) classification, tumoral location, and pTNM stage were randomly selected by computer (non-SRC group: n = 100) during the same study period.

RESULTS

The overall median survival was 21 months, which was significantly higher in resected compared to non-resected patients (31 vs. 5 months, P < 0.001). In non-resected patients, SRC histological subtype was associated with higher rates of diffuse peritoneal carcinomatosis (90.1% vs. 62.5%, P = 0.053) and neoplastic ascitis (63.6% vs. 34.7%, P = 0.059) and poorer median survival (5 vs. 7 months, P = 0.062). For resected patients, the 2 groups (SRC and non-SRC) were comparable regarding matching variables, demographic variables, and postoperative course. The median survival was significantly lower for SRC patients (21 vs. 44 months, P = 0.004). SRC resected patients exhibited higher rates of localized peritoneal carcinomatosis (P = 0.013) and lymph node involvement (P < 0.001) at diagnosis, lower R0 resection rate (P = 0.019) and earlier tumor relapse (P = 0.009), which was generally in a peritoneal carcinomatosis form (P = 0.011). By multivariate analysis, we concluded that SRC histology was independently associated with a dismal prognosis after adjustment on confounding variables (hazard ratio = 1.5, 95% confidence interval 1.1-2.0, P = 0.004). The prognostic role of SRC was maintained after exclusion of patients with advanced stage at initial diagnosis such as localized peritoneal carcinomatosis or lymph node invasion.

CONCLUSIONS

This study is currently the best evidence showing that SRC is a major and independent predictor of poor prognosis due to specific characteristics such as more infiltrating tumors showing affinity for lymphatic tissue accompanied by a higher rate of peritoneal carcinomatosis. Our results suggest the need for a specific therapeutic strategy for such tumors.

Rectal cancer with macroscopic peritoneal involvement--clinical challenges and consequences

OBJECTIVE

In gastrointestinal cancer, serosal involvement indicates advanced disease. We looked at the possible role of clinical peritoneal involvement (CPI) in local recurrences (LRs) and the overall survival of patients with rectal cancer (RC).

METHOD

Between 1993 and 2002, 6404 patients were diagnosed with RC. Based on macroscopic findings at surgery and corresponding histological findings, 166 patients (3%) had CPI. Surgery was stratified according to type and extent of operation: as resective or nonresective surgery and as curative (R0) or noncurative (R1 or R2) resection.

RESULTS

The presence of CPI was a negative factor for survival with a median of 15 months (95% CI, 12-19) in the presence of CPI compared with 65 months (95% CI, 61-70) without it (P < 0.001). In R0 resections, the median survival was 97 months (95% CI, 90-102) in patients without CPI compared with 48 months (95% CI, 22-74) in patients with CPI (P < 0.001). In R1 or R2 resections, the median survival was 16 months (95% CI, 15-17) in the absence of CPI and 9 months (95% CI, 8-10) in the presence of CPI. The LR rate in patients without CPI was 10.2% compared with 15.7% in patients with CPI (P = 0.022).

CONCLUSIONS

Clinical peritoneal involvement is a significant detrimental prognostic factor for the LR of RC and survival in the absence of metastases. Observations from this large national cohort add to what is known about peritoneal involvement. Diagnosed CPI should be taken into consideration when adjuvant treatment strategies are addressed.

Peritoneal metastasis: detection with 16- or 64-detector row CT in patients undergoing surgery for gastric cancer

PURPOSE

To retrospectively measure the diagnostic performance of prospective computed tomographic (CT) results obtained by using 16- or 64-detector row scanners in the detection of peritoneal metastases (PMs) in patients with advanced gastric cancer.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and waived the need to obtain patient consent. In 498 patients with gastric cancer (stage >or= T2) who were undergoing surgery, the presence of PM was prospectively rated as grade 0 (absent), grade 1 (equivocal), or grade 2 (present) on CT scans (0.67 or 2 mm thick) that were interpreted by interactively adjusting the viewing thickness and viewing plane. The CT readings were retrospectively compared with surgical and pathologic findings. In patients in whom the presence of PM was rated as grade 1 or less, factors predictive of PM were identified by testing variables, including patient and tumor characteristics, with univariate tests and multivariate logistic regression analysis.

RESULTS

Fifty-three patients (10.6%) had confirmed PM. When only grade 2 was considered to indicate a positive CT reading, sensitivity and specificity were 28.3% (15 of 53) and 98.9% (440 of 445), respectively. With the threshold of grade 1 or greater indicating a positive reading, sensitivity and specificity were 50.9% (27 of 53) and 96.2% (428 of 445), respectively. In the patients with grades of 1 or less, the significant factors predictive of PM were greater tumor size and T stage.

CONCLUSION

The sensitivity of PM detection is limited, even with modern CT techniques. In patients whose CT results are not definitely positive for PM, staging laparoscopy is still recommended if the aforementioned two predictive factors (greater tumor size and T stage) are suspected.

Induction of anti-tumor immunity by trifunctional antibodies in patients with peritoneal carcinomatosis

Peritoneal carcinomatosis (PC) from epithelial tumors is a fatal diagnosis without efficient treatment. Trifunctional antibodies (trAb) are novel therapeutic approaches leading to a concerted anti-tumor activity resulting in tumor cell destruction. In addition, preclinical data in mouse tumor models demonstrated the induction of long lasting tumor immunity after treatment with trAb. We describe the induction of anti-tumor specific T-lymphocytes after intraperitoneal administration of trAb in patients with PC.

9 patients with progressive PC from gastric (n = 6) and ovarian cancer (n = 2), and cancer of unknown primary (n = 1) received 3 escalating doses of trAb after surgery and/or ineffective chemotherapy. The trAb EpCAM × CD3 (10, 20, 40 μg) or HER2/neu × CD3 (10, 40, 80 μg) were applicated by intraperitoneal infusion. Four weeks after the last trAb application, all patients were restimulated by subdermal injection of trAb + autologous PBMC + irradiated autologous tumor cells. Immunological reactivity was tested by analyzing PBMC for specific tumor reactive CD4+/CD8+ T lymphocytes using an IFN-γ secretion assay.

In 5 of 9 patients, tumor reactive CD4+/CD8+ T-lymphocytes increased significantly, indicating specific anti-tumor immunity. A clinical response (stable disease, partial regression) has been observed in 5 of 9 patients, with a mean time to progression of 3.6 months. Follow-up showed a mean survival of 11.8 months (median 8.0 months) after trAb therapy.

TrAb are able to induce anti-tumor immunity after intraperitoneal application and restimulation. The induction of long-lasting anti-tumor immunity may provide an additional benefit of the intraperitoneal therapy with trAb and should be further elevated in larger clinical trials.

Preoperative imaging for metastasectomy

For most solid neoplasms, medical imaging is a vital component of tumor staging and surveillance. Imaging strategies vary according to the type and grade of primary neoplasm, tumor stage at diagnosis, tumor markers, previous therapies, and patient symptoms. In this article, we address imaging of individual organs (lung, liver, adrenals) and outline imaging strategies for specific types of neoplasms.

Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of malignant ascites secondary to unresectable peritoneal carcinomatosis from advanced gastric cancer

AIMS

To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications.

METHODS

From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60-90min with an inflow temperature of 45 degrees C.

RESULTS

Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication.

CONCLUSIONS

Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

The role of minimal access surgery for metastasectomy and cytoreduction

This article summarizes findings about the applicability of minimal-access techniques for thoracic and upper gastrointestinal cancers, including those affecting the lung, liver, stomach, and adrenal gland. If metastasectomy and cytoreductive surgery are rapidly evolving, minimal-access surgery in this setting is in its introductory stages. Nevertheless, minimal-access metastasectomy and cytoreductive surgery harbor great potential for selected patients, but further clinical studies are needed.

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis (Br J Surg 2006; 93: 1530–1535)

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