Surgical approaches to gastric cancer

Risk factors and conservative therapy outcomes of anastomotic leakage after gastrectomy: Experience of 3,926 patients from a single gastric surgical unit

Background

Anastomotic leakage (AL) after gastrectomy is one of the severest postoperative complications and is related to increasing mortality. In addition, no consensus guidelines about strategies of AL treatment have been established. This large cohort study aimed to inspect the risk factors and efficacy of the conservative treatment for AL in patients with gastric cancer.

Methods

We reviewed the clinicopathological data of 3,926 gastric cancer patients undergoing gastrectomy between 2014 and 2021. Results contained the rate, risk factors, and conservative therapy outcomes of AL.

Results

In total, 80 patients (2.03%, 80/3,926) were diagnosed with AL, and esophagojejunostomy was the most frequent AL site (73.8%, 59/80). Among them, one patient (2.5%, 1/80) died. Multivariate analysis indicated that low albumin concentration (P = 0.001), presence of diabetes (P = 0.025), laparoscopic method (P < 0.001), total gastrectomy (P = 0.003), and proximal gastrectomy (P = 0.002) were predicting factors for AL. The closure rate for the conservative treatment of AL in the first month after AL diagnosis was 83.54% (66/79), and the median time from leakage diagnosis to the closure of leakage was 17 days (interquartile range 11–26 days). Low level of plasma albumin (P = 0.004) was associated with late leakage closures. In terms of 5-year overall survival, no significant difference was observed between patients with and without AL.

Conclusion

The incidence of AL after gastrectomy is associated with low albumin concentration, diabetes, the laparoscopic method, and extent of resection. The conservative treatment is relatively safe and effective for the AL management in patients after gastric cancer surgery.

Circular RNA F-circEA-2a expression is increased in gastric adenocarcinoma and inhibits the transition from premature microRNA-3940-5p to mature microRNA-3940-5p

Circular RNA (circRNA) F-circEA-2a and micorRNA (miR)-3940-5p are two non-coding RNAs with critical roles in cancer biology. However, their participation in gastric adenocarcinoma (GA) is unclear. We predicted that miR-3940-5p could bind to F-circEA-2a and speculated that miR-3940-5p may interact with F-circEA-2a to participate in cancer biology. This study was conducted to explore the interaction between F-circEA-2a and miR-3940-5p in GA. F-circEA-2a and miR-3940-5p (mature and premature) levels in GA were detected using RT-qPCR. Their correlations were analyzed by Pearson's correlation coefficient. The role of F-circEA-2a in miR-3940-5p maturation was analyzed using overexpression assay. The direct binding of premature miR-3940-5p to F-circEA-2a was analyzed by RNA-RNA pulldown. Proliferation was analyzed with BrdU assay. We found that F-circEA-2a and premature miR-3940-5p were overexpressed in GA, while mature miR-3940-5p was under-expressed in GA. F-circEA-2a suppressed miR-3940-5p maturation in GA cells. MiR-3940-5p directly bound to F-circEA-2a wild type (-wt), but not mutant (-mut). F-circEA-2a promoted GA cell proliferation and inhibited the role of miR-3940-5p in reducing cell proliferation. Therefore, F-circEA-2a might suppress mature miR-3940-5p formation by sponging premature miR-3940-5p to promote cell proliferation in GA. Our study characterized a novel circRNA regulating miR-3940-5p maturation in GA.

The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States

BACKGROUND

Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population.

METHODS

Retrospective cohort analysis of patients with GC (2003-2018) across a multi-hospital system was performed. Associations between socioeconomic and clinicopathologic data with the presentation, treatment, and survival were examined.

RESULTS

Of 359 patients, 255 (71%) were African American and 104 (29%) Caucasian. African Americans were more likely to present at a younger age (64.0 vs 72.5, P < .001), have state-sponsored or no insurance (19.7% vs 6.9%, P = .02), reside within the lowest 2 quintiles for median income (67.4% vs 32.7%, P < .001), and have higher rates of Helicobacter pylori (14.9% vs 4.8%, P = .02). Receipt of multi-modality therapy was not impacted by race or insurance status. On multivariable analysis, only AJCC T class (HR 1.68) and node positivity (HR 2.43) remained significant predictors of disease-specific survival.

CONCLUSION

Despite socioeconomic disparities, African Americans, and Caucasians with GC had similar treatment and outcomes. African Americans presented at a younger age with higher rates of H. pylori positivity, warranting further investigation into differences in risk factors and tumor biology.

TRP channels in gastric cancer: New hopes and clinical perspectives

Gastric cancer is a multifactorial disease associated with a combination of and environmental factors. Each year, one million new gastric cancer cases are diagnosed worldwide and two-thirds end up losing the battle with this devastating disease. Currently, surgery represents the only effective treatment option for patients with early stage tumors. However, the asymptomatic phenotype of this disease during the early stages poses as a significant limiting factor to diagnosis and often renders treatments ineffective. To address these issues, scientists are focusing on personalized medicine and discovering new ways to treat cancer patients. Emerging therapeutic options include the transient receptor potential (TRP) channels. Since their discovery, TRP channels have been shown to contribute significantly to the pathophysiology of various cancers, including gastric cancer. This review will summarize the current knowledge about gastric cancer and provide a synopsis of recent advancements on the role and involvement of TRP channels in gastric cancer as well as a discussion of the benefits of targeting TPR channel in the clinical management of gastric cancer.

Diagnosing Gastric Cancer in Chest X-ray

A 60-year-old lady presented with symptoms of chronic iron deficiency anaemia. On evaluation with routine chest X-ray, it surprisingly revealed an irregular mass-like opacity in proximal part of stomach suggesting gastric cancer. The diagnosis was later confirmed with upper GI endoscopy and CT scan abdomen. Hence, in modern era of advanced diagnostics, chest X-ray findings should not be overlooked.

Semi-end-to-end esophagojejunostomy after laparoscopy-assisted total gastrectomy better reduces stricture and leakage than the conventional end-to-side procedure: A retrospective study

BACKGROUND AND OBJECTIVE

Laparoscopy-assisted total gastrectomy (LATG) has not gained popularity due to the technical difficulty of esophagojejunostomy (EJ) and the high incidence of EJ-related complications. Herein, we compared two types of EJ for Roux-en-Y reconstruction to determine whether semi-end-to-end (SETE) EJ is more convenient than the end-to-side (ETS) procedure and is capable of reducing stricture and leakage.

METHODS

A total of 268 patients who underwent LATG with Roux-en-Y reconstruction were included in this study. Two types of EJ were applied for LATG: conventional ETS EJ and SETE EJ. The surgical outcomes and postoperative complications were compared.

RESULTS

The mean reconstruction time in the SETE group was shorter than that in the ETS group (41.6 ± 8.0 min vs 51.3 ± 9.2 min, P = 0.000). The incidences of total EJ-related complications, EJ leakage, and EJ stricture in the SETE group and ETS group were 1.1% (1/92) and 10.2% (18/176), 1.1% (1/92) and 4.0% (7/176), and 0 and 6.2% (11/176), respectively. The incidence of total EJ-related complications in the SETE group was lower than that of the ETS group (P = 0.006), and the incidence of EJ stricture in the SETE group was lower than that of the ETS group (P = 0.034).

CONCLUSIONS

SETE EJ is more convenient than the conventional ETS procedure and is associated with a shorter reconstruction time and a lower incidence of EJ stricture and leakage.

Prognostic implication of hepatoduodenal ligament lymph nodes in gastric cancer

There has been controversy regarding whether hepatoduodenal lymph node (HDLN) metastasis in gastric cancer is distant or regional metastasis. HDLN positivity was classified as distant metastasis in the 7th American Joint Committee on Cancer (AJCC) classification, but it was reclassified as regional lymph node metastasis in the 8th AJCC classification. The aim of our study is to verify prognostic significance of HDLN metastasis in gastric cancer.This retrospective study enrolled patients with gastric cancer who underwent D2 gastrectomy from January 2007 to June 2010. HDLN was classified as a regional lymph node.Total number of patients was 3175; 143 (4.5%) of them had HDLN metastasis. The HDLN positivity was significantly associated with older age, more advanced tumor stage, undifferentiated histologic type, and pathologic diagnosis of lymphatic, vascular, and perineural invasions. Five-year survival rate of HDLN-positive patients with stages I to III disease was significantly higher than that of stage IV group (59.3% vs 18.8%, P = 0.001). In patients with stage III disease, 5-year survival rate of HDLN-positive group was significantly lower than that of HDLN-negative group (51.7% vs 66.3%, P = 0.001). Multivariate analysis showed that HDLN metastasis was an independent prognostic factor.HDLN has a different prognostic significance from other regional lymph nodes in advanced stage of gastric cancer though its positivity is not considered as distant metastasis. HDLN positivity itself seems to be an independent prognostic factor in gastric cancer, and the survival outcomes of patients with stage III disease need to be reconsidered according to HDLN positivity.

New analysis reexamines the value of cancer care in the United States compared to Western Europe

Despite sharp increases in spending on cancer treatment since 1970 in the United States compared to Western Europe, US cancer mortality rates have decreased only modestly. This has raised questions about the additional value of US cancer care derived from this additional spending. We calculated the number of US cancer deaths averted, compared to the situation in Western Europe, between 1982 and 2010 for twelve cancer types. We also assessed the value of US cancer care, compared to that in Western Europe, by estimating the ratio of additional spending on cancer to the number of quality-adjusted life-years saved. Compared to Western Europe, for three of the four costliest US cancers-breast, colorectal, and prostate-there were approximately 67,000, 265,000, and 60,000 averted US deaths, respectively, and for lung cancer there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer-amounts that exceed most accepted thresholds for cost-effective medical care. The United States lost quality-adjusted life-years despite additional spending for lung cancer: -$19,000 per quality-adjusted life-year saved. Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers.

Entirely Laparoscopic Gastrectomy and Colectomy for Remnant Gastric Cancer with Gastric Outlet Obstruction and Transverse Colon Invasion

It is well known that gastrectomy with curative intent is the best way to improve outcomes of patients with remnant gastric cancer. Recently,several investigators reported their experiences with laparoscopic gastrectomy of remnant gastric cancer. We report the case of an 83-year-old female patient who was diagnosed with remnant gastric cancer with obstruction. She underwent an entirely laparoscopic distal gastrectomy with colectomy because of direct invasion of the transverse colon. The operation time was 200 minutes. There were no postoperative complications. The pathologic stage was T4b (transverse colon) N0M0. Our experience suggests that laparoscopic surgerycould be an effective method to improve the surgical outcomes of remnant gastric cancer patients.

Clinical characteristics of hepatoduodenal lymph node metastasis in gastric cancer

AIM

To assess the clinical features of hepatoduodenal lymph node (HDLN) metastasis and to clarify the optimal indication of HDLN dissection.

METHODS

We investigated a total of 276 patients who underwent gastrectomy with extended lymphadenectomy, including HDLN dissection, for gastric cancer between 1999 and 2012. Of these, 26 patients (9.4%) had HDLN metastasis. First, we investigated the clinicopathological characteristics, their perioperative clinical outcomes, such as postoperative complications, and prognostic outcomes between patients with and without HDLN metastasis. Second, we detected the prognostic factors, particularly in patients with HDLN metastasis. Third, we assessed the therapeutic value of HDLN dissection to determine its optimal indication.

RESULTS

The five-year overall survival rate of the patients with HDLN metastasis was 29%. Univariate and multivariate logistic regression analyses revealed that the tumour location (the middle or lower stomach [P = 0.005, OR = 5.88 (95%CI: 1.61-38.1)] and pT category [T3 or T4, P = 0.017, OR = 4.45 (95%CI: 1.28-21.3)] were independent risk factors for HDLN metastasis. Cox proportional hazard analysis identified pN3 as an independent poor prognostic factor in the patients with HDLN metastasis [P = 0.021, HR = 5.17 (95%CI: 1.8-292)]. For patients who underwent radical HDLN dissection, HDLN metastasis was a prognostic indicator in pN3 gastric cancer (P < 0.0001), but not pN1-2 (P = 0.602). Furthermore, the index of therapeutic value of HDLN dissection for gastric cancer in the middle or lower stomach and the upper stomach was 3.4 and 0.0, respectively.

CONCLUSION

We suggest that HDLN dissection should be indicated for pN1 or pN2 gastric cancers located at the middle or lower stomach.

Risk Factors for Anastomotic Leakage: A Retrospective Cohort Study in a Single Gastric Surgical Unit

Purpose

Although several studies report risk factors for anastomotic leakage after gastrectomy for gastric cancer, they have yielded conflicting results. The present retrospective cohort study was performed to identify risk factors that are consistently associated with anastomotic leakage after gastrectomy for stomach cancer.

Materials and Methods

All consecutive patients who underwent gastrectomy at a single gastric surgical unit between May 2003 and December 2012 were identified retrospectively. The associations between anastomotic leakage and 23 variables related to patient history, diagnosis, and surgery were assessed and analyzed with logistic regression.

Results

In total, 3,827 patients were included. The rate of anastomotic leakage was 1.88% (72/3,827). Multiple regression analysis showed that male sex (P=0.001), preoperative/intraoperative transfusion (P<0.001), presence of cardiovascular disease (P=0.023), and tumor location (P<0.001) were predictive of anastomotic leakage. Patients with and without leakage did not differ significantly in terms of their 5-year survival: 97.6 vs. 109.5 months (P=0.076).

Conclusions

Male sex, cardiovascular disease, perioperative transfusion, and tumor location in the upper third of the stomach were associated with an increased risk of anastomotic leakage. Although several studies have reported that an anastomotic complication has a negative impact on long-term survival, this association was not observed in the present study.

Lymphadenectomy extent and survival of patients with gastric carcinoma: a systematic review and meta-analysis of time-to-event data from randomized trials

BACKGROUND

The extent of lymph node dissection in patients with resectable non-metastatic primary carcinoma of the stomach is still a controversial matter of debate, with special regard to its effect on survival.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of time-to-event data from randomized controlled trials (RCTs) comparing the three main types of lymphadenectomy (D1, D2, and D3) for gastric cancer. Hazard ratio (HR) was considered the effect measure for both overall (OS), disease-specific (DSS) and disease-free survival (DFS). The quality of the available evidence was assessed using the GRADE system.

RESULTS

Eight RCTs enrolling 2515 patients were eligible. The meta-analysis of four RCTs (n=1599) showed a significant impact of D2 versus D1 lymphadenectomy on DSS (summary HR=0.807, CI: 0.705-0.924, P=0.002), the corresponding number-to-treat being equal to ten. This effect remained clinically valuable even after adjustment for postoperative mortality. However, the quality of evidence was graded as moderate due to inconsistency issues. When OS and DFS were considered, the meta-analysis of respectively five (n=1653) and three RCTs (n=1332) found no significant difference between D2 and D1 lymph node dissection (summary HR=0.911, CI: 0.708-1.172, P=0.471, and summary HR=0.946, CI: 0.840-1.066, P=0.366, respectively). However, at subgroup analysis D2 type resulted superior to D1 type lymphadenectomy in terms of OS considering the two RCTs carried out in Eastern countries (summary HR=0.627, CI: 0.396-0.994, P=0.047). As regards the D3 vs D2 comparison, the meta-analysis of the three available RCTs (n=862) showed no significant impact of more extended lymphadenectomy on OS (summary HR=0.990, CI: 0.814-1.205, P=0.924).

CONCLUSIONS

Our findings support the superiority of D2 versus D1 lymphadenectomy in terms of survival benefit. However, this advantage is mainly limited to DSS, the level of evidence is moderate, and the interaction with other factors affecting patient survival (such as complementary medical therapy) remains to be elucidated.

Three cases of laparoscopic total gastrectomy with intracorporeal esophagojejunostomy for gastric cancer in remnant stomach

Gastric cancer in remnant stomach is a rare tumor but with poor prognosis. Compared with conventional open surgery, laparoscopic gastrectomy has potential benefits for these patients due to advantages resulting from its minimally invasive approach. Herein, we report on three patients with gastric cancer in remnant stomach who underwent laparoscopic total gastrectomy with intracorporeal esophagojejunostomy successfully. The operative time was 280, 250 and 225 minutes, the estimated blood loss was 100, 80 and 50 ml and the length of postoperative hospital stay was seven, eight and nine days respectively. Our experience has suggested that laparoscopic total gastrectomy with intracorporeal esophagojejunostomy can be a safe, feasible and promising option for patients with gastric cancer in remnant stomach.

Length of negative resection margin does not affect local recurrence and survival in the patients with gastric cancer

AIM: To investigate the influence of the resection margin on local recurrence and survival in gastric cancer patients.

METHODS: We reviewed the medical records of 1788 patients who had undergone gastrectomy for gastric cancer at the Seoul National University Bundang Hospital, South Korea, between May 2003 and July 2009. The patients were divided into early and advanced gastric cancer groups. In each group, we analyzed the relationship between clinicopathologic factors and survival outcomes, and compared the hazard rates of event occurrence between patients with resection margins above and below the cut-off value, using a Cox proportional hazard model.

RESULTS: The early and advanced gastric cancer groups included 1001 and 787 patients, respectively. The hazard rates of event occurrence did not significantly differ between the patients with resection margins above the cut-off value and those with resection margins below the cut-off value (P > 0.05, in all comparisons). Based on the multivariable analyses, the proximal and distal resection margins were not significantly associated with survival outcomes and local recurrence (P > 0.05, in all analyses).

CONCLUSION: The proximal or distal resection margins did not affect the prognosis of patients with gastric cancer if the margins were pathologically negative.

Differential expression of histone deacetylase and acetyltransferase genes in gastric cancer and their modulation by trichostatin A

Gastric cancer is still the second leading cause of cancer-related death worldwide, even though its incidence and mortality have declined over the recent few decades. Epigenetic control using histone deacetylase inhibitors, such as trichostatin A (TSA), is a promising cancer therapy. This study aimed to assess the messenger RNA (mRNA) levels of three histone deacetylases (HDAC1, HDAC2, and HDAC3), two histone acetyltransferases (GCN5 and PCAF), and two possible targets of these histone modifiers (MYC and CDKN1A) in 50 matched pairs of gastric tumors and corresponding adjacent nontumors samples from patients with gastric adenocarcinoma, as well as their correlations and their possible associations with clinicopathological features. Additionally, we evaluated whether these genes are sensitive to TSA in gastric cancer cell lines. Our results demonstrated downregulation of HDAC1, PCAF, and CDKN1A in gastric tumors compared with adjacent nontumors (P < 0.05). On the other hand, upregulation of HDAC2, GCN5, and MYC was observed in gastric tumors compared with adjacent nontumors (P < 0.05). The mRNA level of MYC was correlated to HDAC3 and GCN5 (P < 0.05), whereas CDKN1A was correlated to HDAC1 and GCN5 (P < 0.05 and P < 0.01, respectively). In addition, the reduced expression of PCAF was associated with intestinal-type gastric cancer (P = 0.03) and TNM stages I/II (P = 0.01). The increased expression of GCN5 was associated with advanced stage gastric cancer (P = 0.02) and tumor invasion (P = 0.03). The gastric cell lines treated with TSA showed different patterns of histone deacetylase and acetyltransferase mRNA expression, downregulation of MYC, and upregulation of CDKN1A. Our findings suggest that alteration of histone modifier genes play an important role in gastric carcinogenesis, contributing to MYC and CDKN1A deregulation. In addition, all genes studied here are modulated by TSA, although this modulation appears to be dependent of the genetic background of the cell line.

Incidence of microscopically positive proximal margins in adenocarcinoma of the gastroesophageal junction

Aim

To investigate the incidence and risk factors of microscopically positive proximal margins in Chinese patients with adenocarcinoma of the gastroesophageal junction.

Methods

The medical records of 483 patients, who underwent surgical treatment with curative intent for adenocarcinoma of the gastroesophageal junction in a single high-volume tertiary medical center, were reviewed. Demographic, radiographic, endoscopic, pathologic, and treatment-related variables were evaluated. All proximal margins were re-evaluated by two experienced pathologists, and a positive proximal margin was defined as the microscopic presence of invasive tumor cells seen at the esophageal transaction margin submitted en face on final paraffin sections.

Results

The incidence of positive proximal margins was 23.81% in this series. Siewert type, depth of tumor invasion, lymph node involvement, presence of vascular or lymphatic invasion, and presence of perineural invasion were significantly associated with positive proximal margins. On multivariate analysis, the presence of vascular or lymphatic invasion and advanced-stage disease were independent risk factors for positive proximal margins in patients with adenocarcinoma of the gastroesophageal junction.

Conclusion

Residual cancer at proximal resection margins remains a major issue for the surgical treatment of adenocarcinoma of the gastroesophageal junction in China.

Laparoscopic gastrectomy for gastric cancer with simultaneous organ resection

OBJECTIVES

Simultaneous organ resection is performed in 10% of laparoscopic gastrectomies for gastric cancer. The purpose of this study is to investigate the feasibility and safety of simultaneous organ resection with laparoscopic gastrectomy for gastric cancer.

SUBJECTS AND METHODS

We retrospectively reviewed the medical records from a prospectively collected database of patients who underwent laparoscopic gastrectomy from May 2003 to April 2012 in a single center. The patients were classified into three groups: a gastrectomy-only (no simultaneous resection [NS]) group as a control, a combined resection (CB) group characterized by additional resection due to tumor invasion and extensive lymphadenectomy, and a concomitant resection (CC) group, including patients with other pathologic conditions. The clinical outcomes, in particular morbidity and mortality, were compared among the three groups.

RESULTS

The NS, CB, and CC groups included 1883 (90.1%), 66 (3.2%), and 140 (6.7%) patients, respectively. Mean operation time was longer in CB and CC patients than in NS patients (233.0 ± 59.3, 227.4 ± 100.9, and 180.1 ± 54.0 minutes, respectively; P<.001), and mean hospital stay was longer in the CB and CC groups than in the NS group (9.6 ± 5.2, 8.3 ± 4.7, and 6.9 ± 4.4 days, respectively; P<.001). However, there were no statistically significant differences among the groups in the incidence of complications (P=.185), complications more severe than grade II (P=.077), and mortality (P=1.000).

CONCLUSIONS

Laparoscopic simultaneous organ resection during laparoscopic gastrectomy for gastric cancer prolonged the operation time and hospital stay but did not increase morbidity and mortality.