Poor prognostic factors in patients with stage I gastric cancer according to the seventh edition TNM classification: a comparative analysis of three subgroups

Association between adjuvant chemotherapy and survival in stage I gastric cancer patients after curative resection

Background

The efficacy of adjuvant chemotherapy (AC) on survival outcomes of patients with stage I gastric cancer (GC) after curative resection remains controversial. We aimed to determine whether these patients would benefit from AC.

Methods

This retrospective study included patients with pathologically confirmed stage I GC who underwent curative resection between November 2010 and December 2020. Patients were divided into AC and non-AC groups, then a 1:1 propensity score matching (PSM) analysis was performed to minimize the selection bias. Potential risk factors including age, pN stage, pT stage, lymphovascular invasion, perineural invasion, tumor size, histological type, and carcinoembryonic antigen level were used as matching covariates. The recurrence-free survival (RFS) and disease-specific survival (DSS) were compared between groups using the Kaplan-Meier method.

Results

A total of 902 consecutive patients were enrolled and 174 (19.3%) patients were treated with AC. PSM created 123 pairs of patients. Before PSM, patients receiving AC had lower 10-year RFS rates (90% vs 94.6%, P = 0.035) than those who did not receive AC; the two groups had similar 10-year DSS rates (93.8% vs 95.0%, P = 0.240). After PSM, there were no statistical differences in the 10-year RFS (90.9% vs 93.0%, P = 0.507) or DSS rates (93.5% vs 93.6%, P = 0.811) between the two groups. Similar results were found in the stage IA and IB subgroups. Moreover, these findings were not affected by AC cycles.

Conclusions

The addition of AC could not provide survival benefits for patients with stage I GC after surgery and follow-up is thus recommended. However, large-scale randomized clinical trials are required.

Meta-analysis of the relationship between lymphovascular invasion and prognosis of patients with stage I gastric cancer

Lymphovascular invasion is considered to be a high-risk pathological feature after radical resection of gastric cancer, but the relationship between lymphovascular invasion and the prognosis of stage I gastric cancer is still controversial. Therefore, we used meta-analysis to systematically evaluate the relationship between lymphovascular invasion and the prognosis of stage I gastric cancer. Up to September 2, 2021, the databases of PubMed, EMBASE, Cochrane Library, CNKI, and Wanfang were searched. According to the inclusion and exclusion criteria, 2 researchers independently completed the screening of literature, extraction of data, and quality evaluation. Meta-analysis was performed using RevMan 5.4 software merged with HR and 95%CI. A total of 7508 patients with stage I gastric cancer were included in 9 studies, and the positive rate of lymphovascular invasion was 17%. Lymphovascular invasion was significantly associated with shorter overall survival (OS) (univariate: HR = 4.05, 95%CI: 1.91-8.58; multivariate: HR = 2.10, 95%CI: 1.37-3.22) and relapse-free survival (RFS) (univariate: HR = 4.79, 95%CI: 2.30-9.99; multiple: HR = 2.17, 95%CI: 1.56-3.00). This study indicates that lymphovascular invasion is an independent risk factor affecting the prognosis of patients with stage I gastric cancer, and can be used as a reference index for postoperative adjuvant therapy.

Prognostic Nomogram for Early Gastric Cancer After Surgery to Assist Decision-Making for Treatment With Adjuvant Chemotherapy

Background: Most patients with early gastric cancer (EGC) can achieve a better 5-year survival rate after endoscopic resection or surgery. However, indications for adjuvant chemotherapy (ACT) after surgery have not yet been determined.

Methods: A total of 4,108 patients with EGC diagnosed in 2004–2016 were retrospectively analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Of these, 3,521 patients received postoperative ACT and 587 patients did not. Propensity score matching was used to balance the two groups’ confounding factors. Kaplan-Meier method was utilized to perform survival analysis. Log-rank test was used to compare the differences between survival curves. Cox proportional-hazards regression model was used to screen independent risk factors and build a nomogram for the non-ACT group. The X-tile software was employed to artificially divide all patients into low-, moderate-, and high-risk groups according to the overall survival score prediction based on the nomogram. A total of 493 patients with EGC diagnosed between 2010 and 2014 in our hospital were included for external validation.

Results: Multivariate analysis found that age, sex, race, marital status, primary site, surgical extent, and metastatic lymph node ratio in the non-ACT group were independent prognostic factors for EGC and were included in the construction of the nomogram. The model C-index was 0.730 (95% confidence interval: 0.677–0.783). The patients were divided into three different risk groups based on the nomogram prediction score. Patients in the low-risk group did not benefit from ACT, while patients in the moderate- and high-risk groups did. External validation also demonstrated that moderate- and high-risk patients benefited from ACT.

Conclusion: The study nomogram can effectively evaluate postoperative prognosis of patients with EGC. Postoperative ACT is therefore recommended for moderate- and high-risk patients, but not for low-risk patients.

Implication of lymph node staging in migration and different treatment strategies for stage T2N0M0 and T1N1M0 resected gastric cancer: a SEER population analysis

PURPOSE

The purpose of this study was to explore the differences between stage T2N0M0 and stage T1N1M0 gastric cancer (GC) and to identify the necessity of adjuvant treatment (AT) for these stages.

METHODS

Between years 2004 and 2015, 1971 stage IB GC patients who underwent radical surgery were recruited using the Surveillance, Epidemiology and End Results database. We conducted univariate/multivariate analyses, the propensity score matching and evaluated gastric cancer-specific survival (GCSS) and overall survival (OS) with the log-rank test.

RESULTS

T1N1M0 had a significantly worse survival than T2N0M0 in both GCSS and OS before and after the propensity score matching. Examined lymph nodes (ELN) ≤ 15 and T1N1M0 were independent risk factors for worse GCSS and OS in stage IB GC. The absence of adjuvant chemotherapy (CT) was an independent risk factor for worse GCSS and OS in T1N1M0 but not in T2N0M0. AT demonstrated similar GCSS and OS with surgery alone (SA) for T2N0M0 but better survival for T1N1M0. Compared to CT and adjuvant chemoradiotherapy (CRT) group, SA demonstrated significantly worse GCSS and OS for T1N1M0. There was no significant difference between CT and CRT in both T2N0M0 and T1N1M0 stages. T2N0M0 had a better survival than T1N1M0 in ELN ≤ 15 subgroup. However, similar survival was demonstrated in ELN > 15 subgroup.

CONCLUSIONS

T2N0M0 GC has a better survival rate than T1N1M0 GC when ELN are ≤ 15. Moreover, T2N0M0 GC may not benefit from AT. T1N1M0 GC requires CT but not adjuvant radiotherapy.

Significance of Preoperative Systemic Immune Score for Stage I Gastric Cancer Patients

Background

Determining preferences regarding the benefits of adjuvant chemotherapy (AC) for stage I GC is critical.

Methods

We retrospectively reviewed 1069 patients with pathologically confirmed stage I GC who underwent R0 gastrectomy between 2006 and 2014. Univariate and multivariate survival analyses were conducted. Systemic inflammation factors were used to develop a scoring system for predicting AC benefits.

Results

With a median follow-up of 47 months (range 3–113 months), the 5-year overall survival (OS) rate was 90.5%. The patient score was 1 for either a pretreatment hypoalbuminemia or elevated derived neutrophil-lymphocyte ratio (dNLR) and was 0 otherwise. The SIS served as an independent prognostic factor for reduced OS. AC was delivered to 13.5% (144/1069) of all patients. Compared to surgery alone, AC had no significant effect on survival in both the entire cohort and the IA/IB subgroup. However, in the high-risk group (SIS = 2), patients with AC had a significantly better OS than those undergoing surgery alone.

Conclusions

Patients with SIS = 2 may benefit from AC and thus may be considered candidates for adjuvant treatment. However, to confirm our findings, future prospective studies are warranted.

Is adjuvant chemotherapy necessary in pT1N1 gastric cancer?

Background

Due to a lack of consensus on adjuvant treatments for pT1N1 gastric cancer, surgeons face a dilemma when deciding treatments for patients with pT1N1 gastric cancer after gastrectomy. The objective of this study was to determine survival benefits of adjuvant chemotherapy and risk factors for tumor recurrence in gastric cancer patients with pT1N1.

Methods

Between 1996 and 2010, 510 patients who underwent curative resection for pT1N1 gastric cancer at three institutes were divided into two groups: adjuvant chemotherapy group (N = 150) and surgery-only group (N = 360). Disease-free survival rates and risk factors for tumor recurrence were analyzed.

Results

During the median follow-up of 78 months, 7.5% of patients experienced tumor recurrence (7.3% in adjuvant chemotherapy group and 7.5% in surgery-only group). The 5-year disease-free survival rate was 91.8% in the adjuvant chemotherapy group and 94.6% in the surgery-only group without significant difference between the two. In univariate analysis, older age (>65 years), male gender, body mass index <25 kg/m², elevated gross type, and differentiated histology were associated with tumor recurrence. Multivariate analysis showed that advanced age and male gender were independent risk factors for tumor recurrence. In addition, adjuvant chemotherapy showed no benefitial effect on tumor recurrence in pT1N1 gastric cancer.

Conclusions

Adjuvant chemotherapy did not show any oncologically benefitial effect on tumor recurrence, it might be unnecessary for pT1N1 gastric cancer after curative surgery.

Predictive factors for recurrence in T2N0 and T3N0 gastric cancer patients

PURPOSE

Adjuvant chemotherapy is an indispensable component of treatment for preventing recurrence in advanced gastric cancer patients after macroscopically complete tumor resection (R0). However, the efficacy of this treatment for patients with T2N0 and T3N0 gastric cancer is not well characterized.

METHODS

This study examined 1019 T1, 126 T2N0, and 67 T3N0 gastric adenocarcinoma patients who underwent gastrectomies at our institution between 1975 and 2005 to determine the predictive factors for recurrence in T2N0 and T3N0 gastric cancer patients.

RESULTS

Among 193 T2N0 and T3N0 patients, 14 patients (7.3 %) have recurred. The prevalence of ly2/3 and v2/3 was significantly higher in patients with recurrence compared with those without recurrence. The prognosis for either T2N0 or T3N0 gastric cancer patients was significantly worse than that for T1 gastric cancer patients. Multivariate analysis indicated that lymphatic and blood vessel invasion were independent prognostic indicators in T2N0 and T3N0 gastric cancer patients. Ten-year survival rates for T2N0 and T3N0 gastric cancer patients with both ly2/3 and v2/3, with either ly2/3 or v2/3, and without ly2/3 and v2/3 were 42.9, 86.1, and 96.7 %, respectively. T2N0 and T3N0 gastric cancer patients with both ly2/3 and v2/3 had a significantly worse prognosis than that of patients with either ly2/3 or v2/3 and those without ly2/3 and v2/3.

CONCLUSIONS

Our data indicate that T2N0 and T3N0 patients with both ly2/3 and v2/3 have a high risk of recurrence. Therefore, adjuvant chemotherapy should be administered to these patients.

Potential benefits of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy for cT1 upper-third gastric cancer

BACKGROUND

Few reports have compared laparoscopy-assisted proximal gastrectomy (LAPG) with laparoscopy-assisted total gastrectomy (LATG) in patients with cT1N0 gastric cancer. This study assessed the safety and feasibility of LAPG with esophagogastrostomy in these patients and compared postgastrectomy disturbances and nutritional status following LAPG and LATG.

METHODS

This study compared 40 patients who underwent LAPG with esophagogastrostomy and 59 who underwent LATG with esophagojejunostomy, both with OrVil™. Surgical outcomes, postoperative complications, nutritional status at 1 and 2 years, and relapse-free survival were compared in these two groups.

RESULTS

Operation time was significantly shorter in the LAPG group than in the LATG group (280 min vs. 365 min, P < 0.001). Although the rate of surgical complications was similar in the two groups, the rate of anastomotic stricture was significantly higher in the LAPG group than in the LATG group (28 vs. 8.4 %; P = 0.012). Rates of reflux esophagitis graded A or higher in the Los Angeles classification were 10 and 5.1 %, respectively. Hemoglobin levels 2 years after surgery, relative to baseline levels, were significantly higher in the LAPG group than in the LATG group (98.6 vs. 92.9 %, P = 0.020). Body weight, albumin and total protein concentrations, and total lymphocyte count 1 and 2 years after surgery were slightly, but not significantly, higher in the LAPG group. Relapse-free survival rates were similar, as were 5-year overall survival rates (86 vs. 79 %, P = 0.42).

CONCLUSIONS

LAPG with esophagogastrostomy using OrVil™ was safe and feasible for patients with cT1N0 gastric cancer. LAPG may have nutritional advantages over LATG, but the rate of anastomotic stricture was significantly higher for LAPG than for LATG.

The expression of claudin 1 correlates with β-catenin and is a prognostic factor of poor outcome in gastric cancer

Claudin 1 is one of the tight junction proteins, which are critical in the maintenance of epithelial integrity. Aberrant regulation of CLDN1 and its correlation with β-catenin have been discovered in malignant tumors. The present study aimed to investigate the expression profile and clinical relevance of CLDN1 and β-catenin. The protein levels of CLDN1 and β-catenin were examined using immunohistochemical staining. The characteristics of expression profile and prognostic value were analyzed using Pearson's χ² test and Kaplan-Meier analysis, respectively. β-catenin overexpression and knockdown were used to investigate its role in regulating CLDN1 expression. We showed that CLDN1 was overexpressed in intestinal-type, presence of lymph node metastasis, higher TNM stage in gastric cancer patients and correlated with decreased overall survival. The characteristics of CLDN1 expression were associated with that of β-catenin. CLDN1 and β-catenin showed similar prognostic value in intestinal-type gastric cancers. β-catenin knockdown and overexpression in cell models revealed a positive relation between CLDN1 and β-catenin. Our study demonstrated that CLDN1 is a biomarker for intestinal-type gastric cancer with shorter survival. The expression of CLDN1 was strongly associated with β-catenin in gastric cancer patients and a gastric cancer cell model.

Prognostic impact of lymph node retrieval and ratio in gastric cancer: a U.S. single center experience

INTRODUCTION

Increased lymph node (LN) retrieval for gastric cancer has been associated with improved overall survival (OS). This study examines the impact of number of examined LN (eLN) and lymph node ratio.

METHODS

Patients referred for surgical care of gastric cancer were stratified by number of eLN, positive LNs (LN+), and lymph node ratio (LN+/eLN). Clinicopathologic factors were compared; OS and disease-free survival (DFS) were the primary endpoints.

RESULTS

From 1997 to 2012, 222 patients, median age 67 (range, 17-92) years, were analyzed. Of 220 (99 %) explored, 164 (74 %) underwent resection. Median OS was 22 (range, 0.3-140) months. Perineural and lymphovascular invasion and poor differentiation adversely affected OS, p < 0.05. A median 14 eLN (range, 0-45), with median 1 LN+ (range, 0-31), was observed. There were no OS or DFS differences when comparing the eLN groups. Both OS and DFS were impacted by LN+. Lymph node ratio demonstrated worse median OS with increasing ratio: 49 months (0) to 37 months (0.01-0.2), 27 months (0.21-0.5), and 12 months (>0.5), p < 0.0001. DFS was similar: 35 months (0), decreasing to 22 months (0.01-0.2), 13 months (0.21-0.5), and 7 months (>0.5), p < 0.0001.

CONCLUSION

Number of eLN did not impact survival, while LN+ adversely affected survival. Lymph node ratio may predict prognosis better than number of eLN or LN+ in gastric cancer.

Slit2 expression and its correlation with subcellular localization of β-catenin in gastric cancer

Gastric cancer is the fourth most common cancer worldwide. Several signaling pathways are involved in gastric cancer development and progression. Slit2 was recently found to be involved in cancer; however, its expression pattern in gastric cancer has not been discovered yet. In the present study, we investigated the expression of Slit2 in human gastric cancer and its correlation with the expression and subcellular localization of β-catenin. Immunohistochemistry (IHC) staining revealed that Slit2 was highly expressed in human gastric cancer tissues, while it was low or weakly expressed in normal gastric tissues. The differences in clinicopathological features between different groups were determined using Pearson's χ2 test. Slit2 levels were significantly associated with differentiation, Lauren's classification, lymph node metastasis and TNM staging. Slit2 levels were positively correlated with β-catenin level in gastric cancer tissues and cell lines. High levels of Slit2 were correlated with the membrane localization of β-catenin, and low levels of Slit2 were correlated with nuclear translocation of β-catenin in both gastric cancer tissues and cell lines assayed by IHC and immunofluorescence staining, respectively. Our data suggest that Slit2 was highly expressed in gastric cancer patients with less advanced clinicopathological features. Slit2 levels were correlated with β-catenin level and subcellular localization.

Lymphovascular and perineural invasion as selection criteria for adjuvant therapy in intrahepatic cholangiocarcinoma: a multi-institution analysis

OBJECTIVES

Criteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.

METHODS

A total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).

RESULTS

Median OS was 23.0 months. Median tumour size was 6.5 cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6 months vs. 32.7 months (P= 0.020) and 10.7 months vs. 32.7 months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7 months vs. 30.0 months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1 months vs. 10.7 months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio 4.07, 95% confidence interval 1.60-10.40; P= 0.003).

CONCLUSIONS

Lymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy.

Impact of lymphatic and/or blood vessel invasion in stage II gastric cancer

AIM: To determine the prognostic value of lymphatic and/or blood vessel invasion (LBVI) in patients with stage II gastric cancer.

METHODS: From January 2001 to December 2006, 487 patients with histologically confirmed primary gastric adenocarcinoma were diagnosed with stage II gastric cancer according to the new 7th edition American Joint Committee on Cancer stage classification at the Department of Gastric Cancer and Soft Tissue Surgery, Fudan University Shanghai Cancer Center. All patients underwent curative gastrectomy with standard lymph node (LN) dissection. Fifty-one patients who died in the postoperative period, due to various complications or other conditions, were excluded. Clinicopathological findings and clinical outcomes were analyzed. Patients were subdivided into four groups according to the status of LBVI and LN metastases. These four patient groups were characterized with regard to age, sex, tumor site, pT category, tumor grading and surgical procedure (subtotal resection vs total resection), and compared for 5-year overall survival by univariate and multivariate analysis.

RESULTS: The study was composed of 320 men and 116 women aged 58.9 ± 11.5 years (range: 23-88 years). The 5-year overall survival rates were 50.7% and the median survival time was 62 mo. Stage IIa cancer was observed in 334 patients, including 268 T3N0, 63 T2N1, and three T1N2, and stage IIb was observed in 102 patients, including 49 patients T3N1, 51 T2N2, one T1N3, and one T4aN0. The incidence of LBVI was 28.0% in stage II gastric cancer with 19.0% (51/269) and 42.5% (71/167) in LN-negative and LN-positive patients, respectively. In 218 patients (50.0%), there was neither a histopathologically detectable LBVI nor LN metastases (LBVI⁻/LN⁻, group I); in 51 patients (11.7%), LBVI with no evidence of LN metastases was detected (LBVI⁺/LN⁻, group II). In 167 patients (38.3%), LN metastases were found. Among those patients, LBVI was not determined in 96 patients (22.0%) (LBVI⁻/LN⁺, group III), and was determined in 71 patients (16.3%) (LBVI⁺/LN⁺, group IV). Correlation analysis showed that N category and the number of positive LNs were significantly associated with the presence of LBVI (P < 0.001). The overall 5-year survival was significantly longer in LN-negative patients compared with LN-positive patients (56.1% vs 42.3%, P = 0.015). There was a significant difference in the overall 5-year survival between LBVI-positive and LBVI-negative tumors (39.6% vs 54.8%, P = 0.006). Overall 5-year survival rates in each group were 58.8% (I), 45.8% (II), 45.7% (III) and 36.9% (IV), and there was a significant difference in overall survival between the four groups (P = 0.009). Multivariate analysis in stage II gastric cancer patients revealed that LBVI independently affected patient prognosis in LN-negative patients (P = 0.018) but not in LN-positive patients (P = 0.508).

CONCLUSION: In LN-negative stage II gastric cancer patients, LBVI is an additional independent prognostic marker, and may provide useful information to identify patients with poorer prognosis.