Nodal downstaging to ypN0 after neoadjuvant chemotherapy positively impacts on survival of cT4N+ GC/GEJ patients

Body composition: a crucial factor in downstaging and postoperative complications of neoadjuvant chemotherapy for gastric cancer

Background

Postoperative complications may lower the quality of life of patients, consequently leading to a reduction in their overall survival (OS). In our previous investigations, we found that patients with gastric cancer (GC) with postoperative complications who underwent direct surgery had a significantly lower OS than patients without complications. We observed no significant difference in OS among patients who underwent neoadjuvant chemotherapy (NAC), regardless of complications. We propose that for patients who underwent reoperation following NAC, downstaging (reduction of clinical stage) and postoperative complications exerted contrasting effects on the OS. Further, we hypothesize that post-NAC downstaging and the absence of postoperative complications lead to a longer OS.

Methods

We conducted a retrospective analysis to collect the clinical data of patients with GC who underwent surgery after receiving NAC at the First Hospital of Lanzhou University from January 2016 to December 2022. Based on the presence of a post-NAC downstaging period and postoperative complications, we categorized the patients into group A (downstaging without complications), group B (downstaging with complications), group C (non-downstaging with complications), and group D (non-downstaging without complications). First, we assessed the OS disparity between the groups. Subsequently, we performed a comparative analysis of the body composition and hematological indexes of patients from the four groups.

Results

We included 295 patients in the study and categorized them into four subgroups: group A comprised 83 patients (28.1%), group B comprised 32 patients (10.8%), group C comprised 83 patients (28.1%), and group D comprised 97 patients (32.9%). Group A patients had the longest OS of 40.1 ± 20.53, whereas group C patients had the shortest OS of 32.15 ± 25.09. The OS of patients in the other two groups was between these values. Pairwise comparisons revealed significant differences between the OS of group A patients and that of groups C (32.15 ± 25.09) and D (33.06 ± 20.89) patients (p < 0.05). The skeletal mass index (SMI) and skeletal mass area (SMA) were highest in group A, lowest in group C, higher in group A (SMI: 45.05 ± 7.44, SMA: 128.88 ± 22.67) than in group C (SMI: 41.61 ± 8.17, SMA: 115.56 ± 26.67) (p < 0.05), and higher in group D (SMI: 44.94 ± 6.87, SMA: 127.05 ± 23.09) than in group C (p < 0.05). However, we observed no significant difference between the SMI and SMA of groups B (SMI: 42.91 ± 9.68, SMA: 120.76 ± 30.51) and D (p > 0.05). With respect to hematological indexes, the prognostic nutritional index (PNI) was highest in group A and lowest in group C. The PNI in group A (417.89 ± 37.58) was significantly higher than that in group C (397.62 ± 47.56) (p < 0.05), and it was also higher in group D (410.76 ± 4.28) than in group C (p < 0.05). However, we observed no significant difference between the PNI in groups B (402.57 ± 53.14) and D (p > 0.05).

Conclusion

Patients with advanced GC who experienced post-NAC downstaging and no postoperative complication had the longest OS. Patients with better body composition demonstrated more significant downstaging, fewer postoperative complications, and a longer OS.

Neoadjuvant Endocrine Therapy Compared to Neoadjuvant Chemotherapy in Node-Positive HR+, HER2- Breast Cancer (Nodal pCR and the Rate of ALND): A Systematic Review and Meta-Analysis

Introduction

Patients with hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancers have the lowest response to neoadjuvant therapy of all subtypes. The role of neoadjuvant endocrine therapy (NET) in clinically node-positive (cN+), HR+, HER2- patients is evaluated in this meta-analysis.

Methods

This study was performed between January 2010 and August 2022. We evaluated the node pathologic complete response (pCR) and axillary lymph node dissection (ALND) rates after neoadjuvant endocrine therapy (NET).

Results

18,037 HR+, HER2-, cN+ stage II and stage III breast cancer patients within eleven studies received neoadjuvant treatments. 3,707 (20.6%) patients received NET and 14,330 (79.4%) received NAC. The average age of the NET patients was higher than that of the neoadjuvant chemotherapy (NAC) patients (64.1 versus 47.6 years old, p < 0.001). 45.0% and 26.9% of the NET and the NAC groups underwent a lumpectomy. The pooled estimates of node pCR in NET and NAC groups were 8.9% and 14.9%, and the pooled proportion of ALND was 39.1% and 58.5%, respectively.

Conclusion

The rate of node pCR was lower among cN+ patients who received NET compared to the NAC group. The rate of ALND among cN+ NET patients was lower than the NAC group, revealing more patients with residual nodal disease do not get ALND in the NET group. Further prospective studies are required to compare survival outcomes as a more reliable surrogate.

Efficacy and safety of neoadjuvant sintilimab in combination with FLOT chemotherapy in patients with HER2-negative locally advanced gastric or gastroesophageal junction adenocarcinoma: an investigator-initiated, single-arm, open-label, phase II study

BACKGROUND

The addition of immune checkpoint inhibitors to neoadjuvant chemotherapy in operable advanced gastric or gastroesophageal junction (G/GEJ) cancer aroused wide interest. This study was designed to assess the efficacy and safety of neoadjuvant sintilimab, a programmed cell death protein-1 (PD-1) inhibitor, in combination with fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy for HER2-negative locally advanced G/GEJ cancer.

METHODS

Eligible patients with clinical stage cT4 and/or cN+M0 G/GEJ cancer were enroled in this phase II study. Patients received neoadjuvant sintilimab (200 mg every 3 weeks) for three cycles plus FLOT (50 mg/m 2 docetaxel, 80 mg/m 2 oxaliplatin, 200 mg/m 2 calcium levofolinate, 2600 mg/m 2 5-fluorouracil every 2 weeks) for four cycles before surgery, followed by four cycles of adjuvant FLOT with same dosages after resection. The primary endpoint was the pathological complete response (pCR) rate.

RESULTS

Thirty-two patients were enroled between August 2019 and September 2021, with a median follow-up of 34.8 (95% CI, 32.8-42.9) months. Thirty-two (100%) patients received neoadjuvant therapy, and 29 underwent surgery with an R0 resection rate of 93.1%. The pCR (TRG0) was achieved in 5 (17.2%; 95% CI, 5.8-35.8%) patients, and the major pathological response was 55.2%. Twenty-three (79.3%) patients had T downstaging, 21 (72.4%) had N downstaging, and 19 (65.5%) had overall TNM downstaging. Six (20.7%) patients experienced recurrence. Patients achieving pCR showed better event-free survival (EFS), disease-free survival (DFS), and overall survival (OS) than non-pCR. The estimated 3-year EFS rate, 3-year DFS rate, and 3-year OS rate were 71.4% (95% CI, 57.2-89.2%), 78.8% (95% CI, 65.1-95.5%), and 70.9% (95% CI, 54.8-91.6%), respectively. The objective response rate and disease control rate were 84.4% (95% CI, 68.3-93.1%) and 96.9% (95% CI, 84.3-99.5%), respectively. Twenty-five (86.2%) received adjuvant therapy. The main grade ≥3 treatment-related adverse events (TRAEs) were lymphopenia (34.4%), neutropenia (28.1%), and leukopenia (15.6%). no patients died from TRAE. The LDH level exhibited a better predictive value to pathological responses than PD-L1 and MSI status.

CONCLUSIONS

The study demonstrated an encouraging efficacy and manageable safety profile of neoadjuvant sintilimab plus FLOT in HER2-negative locally advanced G/GEJ cancer, which suggested a potential therapeutic option for this population.

Study on the diagnostic value of MDCT extramural vascular invasion in preoperative N staging of gastric cancer patients

BACKGROUND

To explore the diagnostic value of multidetector computed tomography (MDCT) extramural vascular invasion (EMVI) in preoperative N Staging of gastric cancer patients.

METHODS

According to the MR-defined EMVI scoring standard of rectal cancer, we developed a 5-point scale scoring system to evaluate the status of CT-detected extramural vascular invasion(ctEMVI), 0-2 points were ctEMVI-negative status, and 3-4 points were positive status for ctEMVI. Patients were divided into ctEMVI positive group and ctEMVI negative group. The correlation between ctEMVI and clinical features was analyzed. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of ctEMVI for pathological metastatic lymph nodes and N staging, The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of pathological N staging using ctEMVI and short-axis diameter were generated and compared.

RESULTS

The occurrence rate of lymphovascular invasion (LVI) and proportion of tumors with a greatest diameter > 6 cm in the ctEMVI positive group was higher than that in the ctEMVI negative group (P < 0.05). Spearman correlation analysis showed a positive correlation between ctEMVI and LVI, N stage, and tumor size (P < 0.05). For ctEMVI scores ≥ 3,The AUC of ctEMVI for diagnosing lymph node metastasis, N stage ≥ N2, and N3 stage were 0.857, 0.802, and 0.758, respectively. The sensitivity, NPV and accuracy of ctEMVI for diagnosing N stage ≥ N2 were superior to those of short-axis diameter (P < 0.05), while sensitivity, specificity, PPV, NPV, and accuracy of ctEMVI for diagnosing N3 stage were superior to those of short-axis diameter (P < 0.05).

CONCLUSION

ctEMVI has important value in diagnosing metastatic lymph nodes and advanced N staging. As an important imaging marker, ctEMVI can be included in the preoperative imaging evaluation of patients, providing important assistance for clinical guidance and treatment.

Does the ypTNM-stage adequately predict long-term survival rates in gastric cancer patients receiving neoadjuvant chemotherapy followed by radical resection?

BACKGROUND

Following neoadjuvant chemotherapy (NAC) for resectable gastric cancer, the prognostic adequacy of the UICC staging system needs to be investigated. In particular to explore whether the ypTNM curves for radically resected gastric cancer patients receiving NAC follow the stage-matched survival curves of radically resected chemo-naïve patients (pTNM). Further, to disclose any interaction between the TNM-response mode to NAC and stage-specific survival rates, i.e., whether survival for a particular pathological disease stage was dependent on whether this was reached through a downstaging or as stable disease following NAC.

MATERIAL AND METHODS

Retrospective study on radically resected patients ≤ 75 years of age with gastric adenocarcinoma stages I-III diagnosed during 2001-2016. The patients constitute two population-based cohorts; the SURG-group with n = 121 patients treated before 2007 when NAC was introduced, and the NAC-group with n = 126 patients diagnosed since early 2007, receiving NAC and subsequent radical resection.

RESULTS

Long-term survival rates were similar when specific ypTNM-stages were compared to their corresponding pTNM chemo-naïve counterparts. The dichotomised N0 vs. N + had a substantial impact on the long-term survival rates in both groups, however, no discrepancy in long-term survival rates between pN0 vs. ypN0, and pN + vs. ypN + was found. The pathological stage determined long-term survival rates irrespective of the baseline disease stage, as no interaction between the response mode and stage-specific survival rates was found.

CONCLUSIONS

Survival curves for specific ypTNM-stages following NAC did not differ from the corresponding survival curves of their chemo-naïve pTNM counterparts. The interpretation is that NAC affected the gastric cancer, lymph nodes, and micrometastases, in such a way that the final ypTNM-stage provided similar prognostic information as the chemo-naïve pTNM-stages. Survival rates were contingent on the final ypTNM-stages alone, and not influenced by the response mode to reach that particular disease stage, or predetermined by the original clinical TNM-stage.

UICC Staging after Neoadjuvant/Perioperative Chemotherapy Reveals No Significant Survival Differences Compared to Primary Surgery for Locally Advanced Gastric Cancer

Background: The applicability of UICC TNM staging for gastric cancer (GC) patients treated with neoadjuvant chemotherapy (nCTX) and surgery was not yet analyzed in comparison to patients undergoing primary surgery (PS). The purpose of this analysis was to analyze if the prognostic impact of TNM staging after nCTx is comparable with PS. Methods: Data for patients having been treated for GC with or without nCTx between 1990 and 2016 were analyzed. Uni-(URA) and multivariable regression analyses (MRA) were performed to identify predictors. Survival according to the UICC 8th edition stages was analyzed by the Kaplan−Meier method and cox regression analysis. Propensity score matching (PSM) was performed to balance for confounders. Results: 1149 patients with GC were eligible for primary analysis. URA demonstrated age (p < 0.0001), tumor localization (p < 0.0001), clinical UICC-stage, complications, UICC stage 0, IIB-IIIC, Lauren subtype, grading, and R-stage to be significantly associated with OS. MRA revealed that age, distal tumor localization, more than 25 dissected lymph nodes, UICC stage 0, IIB-IIIC, and Lauren subtype were significantly and independently related to OS. After PSM, survival analyses revealed only a significant difference for pN2/ypN2 (p = 0.03), while all other T and N stages were comparable. Conclusion: UICC dependent survival stages do not change significantly after nCTx treatment for GC. Therefore, UICC staging in its present version is applicable to patients undergoing nCTx.