The change of bone mineral density and bone metabolism after gastrectomy for gastric cancer: a meta-analysis

Gastric Cancer Survivorship: Multidisciplinary Management, Best Practices and Opportunities

PURPOSE

Gastric cancer is the 5th most common malignancy worldwide. As early detection increases and treatments for gastric cancer improve, the number of gastric cancer survivors grows.

METHODS

Here, we review the diagnosis and management of gastric cancer and discuss important considerations for gastric cancer survivorship including cancer surveillance, weight loss, malnutrition, fatigue, specific complications related to surgery and radiation, quality of life in gastric cancer survivorship, health behavior, and models of survivorship.

RESULTS

Multimodality therapy with chemotherapy and surgery can result in chronic toxicities in multiple organ systems. This emphasizes the need for a multidisciplinary survivorship care model including cancer surveillance, management of chronic toxicities, and optimization of modifiable risk factors with long-term involvement of appropriate providers.

CONCLUSION

Adequately caring for gastric cancer survivors requires a coordinated, multidisciplinary approach.

Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update

It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.

Micronutrient Supplementation and Bone Health After Prophylactic Total Gastrectomy in Patients With CDH1 Variants

INTRODUCTION

Patients with germline variants in CDH1 who undergo prophylactic total gastrectomy (TG) are at risk of altered nutrient and drug absorption due to modified gastrointestinal anatomy. Bone mineral density loss and micronutrient deficiencies have not been described previously in this patient population.

METHODS

In this study we included 94 patients with germline CDH1 variants who underwent prophylactic TG between October 2017 and February 2022. We examined pre- and post-gastrectomy bone mineral density (BMD); serum biomarkers including calcium, phosphorus, alkaline phosphatase, and 25 (OH)-vitamin D; and postoperative adherence to calcium and multivitamin supplementation.

RESULTS

Almost all patients (92/94, 98%) lost a substantial amount of weight post-TG, with an average weight loss of 26.5% at 12 months post-surgery. Serum biomarkers of mineral metabolism, namely calcium and phosphorus, did not change significantly after TG. However, average BMD was decreased in all patients at 12 months post-TG. Nonadherence to calcium supplementation was associated with a decrease in BMD. Nonadherence to multivitamin supplementation was associated with greater percent BMD loss in the femoral neck and total hip.

CONCLUSIONS

Appropriate micronutrient supplementation and nutritional counseling pre- and postoperatively in patients undergoing prophylactic TG are important to mitigate the long-term effects of gastrectomy on bone health.

The risk of osteoporotic fracture in gastric cancer survivors: total gastrectomy versus subtotal gastrectomy versus endoscopic treatment

PURPOSES

Previous studies have suggested that there is an increased risk of osteoporotic fracture in gastric cancer survivors. However, the data was not classified according to surgery type. This study investigated the cumulative incidence osteoporotic fracture (OF) in gastric cancer survivors according to treatment modality.

METHODS

A total of 85,124 gastric cancer survivors during 2008-2016 were included. The type of surgery was classified as total gastrectomy (TG, n = 14,428)/subtotal gastrectomy (SG, n = 52,572)/endoscopic mucosal dissection and endoscopic mucosal resection (ESD/EMR, n = 18,125). The site of osteoporotic fractures included the spine, hip, wrist, and humerus. We examined cumulative incidence using Kaplan-Meier survivor analysis and cox proportional hazards regression analysis to determine the risk factor of OF.

RESULTS

The incidence of OF per 100,000 patient year was 2.6, 2.1, 1.8 in TG, SG, ESD/EMR group. The cumulative incidence rate was 2.3% at 3 years, 4.0% at 5 years, and 5.8% at 7 years in gastrectomy group, and 1.8% at 3 years, 3.3% at 5 years in the SG group, and 4.9% at 7 years postoperatively in ESD/EMR group. TG increased the risk of OF compared to patients who underwent SG (HR 1.75, 95% confidence interval [CI] 1.57-1.94), and ESD/EMR (hazard ratio [HR] 2.23, 95% CI 2.14-2.32).

CONCLUSION

Gastric cancer survivors who underwent TG had an increased osteoporotic fracture risk than did SG or ESD/EMR in these patients. The amount of gastric resection and accompanying metabolic changes seemed to mediate such risk. Additional research is needed to establish an optimal strategy for each type of surgery.

Case Report: Severe osteoporosis misunderstood by bone metastasis after total gastrectomy and multiple metastasectomy

After radical gastrectomy for gastric cancer, patients should be monitored from two perspectives. One is local recurrence or metastasis, and the other is nutritional and metabolic side effects. Herein, we report a case of severe osteoporosis that was misunderstood for bone metastasis due to increased bone scan and positron emission tomography-computed tomography uptake in the patient who underwent total gastrectomy and consecutive multivisceral metastasectomy. She was administered bisphosphonates, calcium carbonate, and cholecalciferol. After 3 months, a follow-up bone scan revealed decreased intensity of hot-uptake lesions, healed fracture lesions, and eventually improved bone pain. This study supports the need for careful nutritional screening as well as cancer surveillance after gastrectomy for gastric cancer and the need for screening guidelines for bone metabolic diseases.

Two web-based dynamic prediction models for the diagnosis and prognosis of gastric cancer with bone metastases: evidence from the SEER database

Purpose

Our aim was to identify the clinical characteristics and develop and validate diagnostic and prognostic web-based dynamic prediction models for gastric cancer (GC) with bone metastasis (BM) using the SEER database.

Method

Our study retrospectively analyzed and extracted the clinical data of patients aged 18-85 years who were diagnosed with gastric cancer between 2010 and 2015 in the SEER database. We randomly divided all patients into a training set and a validation set according to the ratio of 7 to 3. Independent factors were identified using logistic regression and Cox regression analyses. Furthermore, we developed and validated two web-based clinical prediction models. We evaluated the prediction models using the C-index, ROC, calibration curve, and DCA.

Result

A total of 23,156 patients with gastric cancer were included in this study, of whom 975 developed bone metastases. Age, site, grade, T stage, N stage, brain metastasis, liver metastasis, and lung metastasis were identified as independent risk factors for the development of BM in GC patients. T stage, surgery, and chemotherapy were identified as independent prognostic factors for GC with BM. The AUCs of the diagnostic nomogram were 0.79 and 0.81 in the training and test sets, respectively. The AUCs of the prognostic nomogram at 6, 9, and 12 months were 0.93, 0.86, 0.78, and 0.65, 0.69, 0.70 in the training and test sets, respectively. The calibration curve and DCA showed good performance of the nomogram.

Conclusions

We established two web-based dynamic prediction models in our study. It could be used to predict the risk score and overall survival time of developing bone metastasis in patients with gastric cancer. In addition, we also hope that these two web-based applications will help physicians comprehensively manage gastric cancer patients with bone metastases.

Resistance Training for Patients with Cancer: A Conceptual Framework for Maximizing Strength, Power, Functional Mobility, and Body Composition to Optimize Health and Outcomes

There are many benefits to the addition of exercise to cancer treatment and survivorship, particularly with resistance training regimens that target hypertrophy, bone mineral density, strength, functional mobility, and body composition. These goals are best achieved through a series of individualized high-intensity compound movements that mirror functional mobility patterns and sufficiently stress the musculoskeletal system. As a result of adequate stress, the body will engage compensatory cellular mechanisms that improve the structural integrity of bones and muscles, stimulate metabolism and the immune system, optimize functional performance, and minimize mechanical injury risk. The current evidence suggests that application of the above exercise principles, practiced in a safe environment under expert observation, may offer patients with cancer an effective means of improving overall health and cancer-specific outcomes. The following article poses several important questions certified exercise specialists and physicians should consider when prescribing resistance exercise for patients with cancer.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Short and long-term outcomes of prophylactic total gastrectomy in 54 consecutive individuals with germline pathogenic mutations in the CDH1 gene

BACKGROUND

Germline mutation of CDH1 is rare and leads to hereditary diffuse gastric cancer (DGC).

METHODS

Patients (pts) with CDH1 mutation who underwent multidisciplinary counseling followed by open prophylactic total gastrectomy (PTG) by a single surgeon were reviewed.

RESULTS

Fifty-four pts with a median age of 41 years (16-70 years) underwent PTG between 2006 and 2021. Median operative time was 161 min, and median hospital stay was 7 days (range 6-12). There were 5 complications (9.2%) within 30 days, and two complications (pulmonary embolism and pancreatitis) required readmission. There were no anastomotic leaks. The pathologic analysis of the first 10 pts included the entire gastric mucosa, revealing a median of 15 foci of DGC (range 5-136). The subsequent 44 pts with more limited analysis had a median of 2 foci (range 0-5), and two pts (3.7%) had no foci identified. Median maximum weight loss was 19%. In long-term follow-up (median 4.6 years) of 20 pts, median global QOL was 2.0 (very good), the majority had persistent difficulty with certain foods or liquids, and all stated they would again elect PTG over surveillance endoscopy.

CONCLUSIONS

PTG can be performed safely at high-volume referral centers with very good QOL but nutritional sequelae persist.

Prognostic significance of preoperative osteopenia on outcomes after gastrectomy for gastric cancer

Aim

Osteopenia, characterized by low bone mineral density, is a potential prognostic factor for patients with cancer. The aim of this study was to clarify the impact of preoperative osteopenia in patients with gastric cancer (GC) after gastrectomy.

Methods

We included 224 patients with GC who underwent gastrectomy between August 2013 and May 2022. Osteopenia was evaluated by measuring the pixel density in the mid-vertebral core of the 11th thoracic vertebra using computed tomography.

Results

Osteopenia was identified in 68 patients (30%). The osteopenia group had significantly worse overall survival (OS) and disease-free survival (DFS) than the non-osteopenia group (P < .01, P < .01, respectively). The postoperative hospital stay was significantly longer, and the occurrence of postoperative complications (Clavien-Dindo grade ≥ III) was significantly higher in the osteopenia group (P = .04, P < .01, respectively). In multivariate analysis, osteopenia (P < .01), stage ≥II (P < .01), and R1 or R2 curability (P < .01) were independent and significant predictors of DFS. Additionally, osteopenia (P < .01), intraoperative blood loss (P = .04), stage ≥II (P < .01), and R1 or R2 curability (P < .01) were independent and significant predictors of OS.

Conclusion

Preoperative osteopenia was independently associated with a poor prognosis and recurrence in patients who underwent gastrectomy for GC.

Functional tooth number in the posterior region associated serum ucOC levels

Purpose

The purpose of this study was to investigate serum undercarboxylated osteocalcin (ucOC) levels in partially edentulous patients scheduled to receive implant treatment and determine the association between ucOC levels, vegetable intake, vitamin K, dietary fiber intake, and functional tooth number in the posterior region (p-FTN).

Methods

A total of 46 patients (20 male and 26 female, 61.9 ± 12.7 years old) were included. The association among serum ucOC levels, vegetable intake, vitamin K and dietary fiber intake was assessed using Spearman’s rank correlation coefficient and binary logistic regression analysis.

Results

In total, 35% of patients (16/46 subjects) showed an abnormally high ucOC level (≧ 4.5 ng/mL). p-FTN showed a weak positive correlation with vegetable intake, vitamin K and dietary fiber intake (r = 0.28, 0.21, and 0.14, respectively) and a significant negative correlation with ucOC levels (r = − 0.51). Multivariate analysis demonstrated that p-FTN as well as vitamin K intake showed a significant negative association with serum ucOC levels.

Conclusions

More than one-third of patients showed abnormally high ucOC levels. p-FTN showed a negative association with serum ucOC levels, which indicated the possibility that oral status affected bone quality.

International Delphi consensus guidelines for follow-up after prophylactic total gastrectomy: the Life after Prophylactic Total Gastrectomy (LAP-TG) study

BACKGROUND

Prophylactic total gastrectomy (PTG) remains the only means of preventing gastric cancer for people with genetic mutations predisposing to Hereditary Diffuse Gastric Cancer (HDGC), mainly in the CDH1 gene. The small but growing cohort of people undergoing PTG at a young age are expected to have a life-expectancy close to the general population, however, knowledge of the long-term effects of, and monitoring requirements after, PTG is limited. This study aims to define the standard of care for follow-up after PTG.

METHODS

Through a combination of literature review and two-round Delphi consensus of major HDGC/PTG units and physicians, and patient advocates, we produced a set of recommendations for follow-up after PTG.

RESULTS

There were 42 first round, and 62 second round, responses from clinicians, allied health professionals and patient advocates. The guidelines include recommendations for timing of assessments and specialties involved in providing follow-up, micronutrient supplementation and monitoring, bone health and the provision of written information.

CONCLUSION

While the evidence supporting the guidelines is limited, expert consensus provides a framework to best manage people following PTG, and could support the collection of information on the long-term effects of PTG.

Vitamin D—The Nutritional Status of Post-Gastrectomy Gastric Cancer Patients—Systematic Review

Gastric cancer is a malignant neoplasm of the gastrointestinal tract, with one of the standard treatment methods remaining gastrectomy. The authors conducted a systemic review of the Medline and Embase databases concerning the serum vitamin D level in post-gastrectomy gastric cancer patients, regarding all articles published until 22 May 2022 according to the PRISMA guidelines. 18 studies with a total number of 908 gastric cancer survivors were included in the analysis. The initial rate of vitamin D deficiency in gastric cancer patients undergoing gastrectomy appears to be similar to the global population deficiency. In post-gastrectomy survivors, the level of 25(OH)D may remain stable or decrease, while the level of 1, 25(OH)₂D remains normal. Supplementation with vitamin D results in an improvement in its serum concentration and positively affects bone mineral density, which is gradually reduced in post-gastrectomy survivors. Combining vitamin D supplementation with calcium and bisphosphonates enables us to obtain better results than vitamin D and calcium only. The type of surgery influences the level of serum vitamin D and its metabolites, with total or partial gastrectomy and maintenance of the duodenal food passage remaining the most important factors. There is a strong need for randomized, controlled trials that would investigate this matter in the future.

Emerging Adults Carrying A CDH1 Pathogenic or Likely Pathogenic Variant Face Diet and Lifestyle Challenges After Total Gastrectomy

Emerging adults with a CDH1 pathogenetic or likely pathogenetic variant face a life altering decision to undergo prophylactic total gastrectomy (PTG) or to have frequent endoscopies for gastric cancer risk management. They are in a unique life stage with distinct characteristics, such as identity finding, career seeking, relationship exploring, establishing financial independence and planning for or pursuing pregnancy. Research has shown these emerging adults heavily weighed dietary and nutrition concerns after PTG on their decision making for both timing of surgery and whether they should or should not undergo the surgery. These concerns are valid because of the significant dietary and lifestyle modification that emerging adults need to commit to prevent common sequelae after PTG, which include early satiety, nausea, dumping syndrome, bile reflux, excessive weight loss, micronutrient deficiencies and metabolic bone disorders. Thus, working with a multidisciplinary team with expertise in CDH1 and hereditary diffuse gastric cancer, including a registered dietitian nutritionist, is essential for this population.

Prediction of risk of osteoporosis after gastrectomy for gastric cancer

Introduction

There are few guidelines for screening of osteoporosis in patients who have undergone gastrectomy. This study aimed to develop and validate a nomogram to predict the risk of osteoporosis after gastrectomy in patients with gastric cancer.

Methods

Bone densitometry results for 522 patients with gastric cancer and 2088 individuals from a health-promotion centre were compared using propensity score matching to develop a nomogram to predict osteoporosis after gastrectomy. External validation was performed using an independent data set.

Results

In the 10 years after gastrectomy 53.5 per cent of patients developed osteoporosis. In multivariable analysis, the odds ratios of subtotal gastrectomy and total gastrectomy were 5.46 and 8.69 (P < 0.001 for both). Seven risk factors (type of gastrectomy, age, sex, BMI, and serum levels of albumin, creatinine and phosphorus) were incorporated into the nomogram. The prediction accuracy of the nomogram in the development set was 0.830 (area under the curve (AUC)); (95 per cent c.i. 0.812 to 0.848). In the validation set, the AUC was 0.807 (95 per cent c.i. 0.741 to 0.873).

Conclusion

Gastrectomy was a risk factor for osteoporosis, and its incidence in the first 10 years after surgery was high. This nomogram can help clinicians to identify patients with gastric cancer most at risk of developing osteoporosis after surgery.

Nutritional management of gastric cancer

Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of "post-gastrectomy syndromes", the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.

Nutritional management of gastric cancer

Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs (Enhanced Recovery after Surgery) is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of «post-gastrectomy syndromes», the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.