Is there a role for palliative gastrectomy in patients with stage IV gastric cancer?

Survival benefits of palliative gastrectomy for gastric cancer patients with liver metastasis: a population-based propensity score-matched cohort analysis

Background and aims

Palliative primary tumor resection (pPTR) can benefit colorectal cancer patients with liver metastasis. Whether pPTR benefiting gastric cancer (GC) patients with liver metastasis is still controversial.

Methods

Data on patients with metastatic GC diagnosed between 2010 to 2019 was extracted from SEER database. Propensity score analysis with 1:1 matching was performed. The univariable and multivariable Cox proportional hazards regression models were used to explore prognostic factors. Kaplan-Meier method was used to analyze survival outcomes.

Results

Of 5691 GC patients with liver metastasis, 468 were included in the matched cohorts. The results showed that the median survival time was 6 months in the non-surgery groups and 14.5 months in the surgery groups (p < 0.001). Multivariable analysis showed that surgery was a protective prognostic factor for overall survival [hazard ratio (HR) = 0.416] as well as cancer-specific survival (HR = 0.417). Also, pPTR was only recommended for GC patients with isolated liver metastasis. Moreover, pPTR combined with chemotherapy brought the greatest therapeutic effect.

Conclusion

pPTR benefits GC patients with isolated liver metastasis, and GC patients with liver metastasis receiving pPTR combined with chemotherapy had the best survival outcomes than any other therapeutic model.

Gastric transcatheter chemoembolization can resolve advanced gastric cancer presenting with obstruction

Background

Gastric transcatheter chemoembolization (GTC) is an interventional minimal invasive method, which has never been mentioned in the previous literature for advanced gastric cancer with obstruction. The purpose of this study was to evaluate its safety and efficacy in treating advanced gastric cancer with obstruction.

Methods

Advanced gastric cancer patients with obstruction who underwent GTC were retrospectively analysed from June 2017 to January 2020. Baseline information, peri-intervention data, and post-intervention follow-up information were collected. Clinical data obtained before and after the GTC were compared, and the survival of all patients was analysed.

Result

Forty-Two patients were included in this study. 42 (100%) patients achieved technical success, and 22 (52.4%) achieved clinical success. The median time of the GTC was 83 (30.0–180.0) minutes, and the median time of hospitalization after GTC was 3 (1–6) days. One patient experienced abdominal pain during and after GTC. Twenty (47.6%) of the 42 patients underwent gastrectomy after intervention. The pre-intervention gastric outlet obstruction scoring system (GOOSS) was 1 (0–1) and the post-intervention GOOSS was 2 (0–3) (p = 0.000 < 0.05). The median follow-up time was 9.5 (3–35) months, and the overall survival time was 14 months. In the univariate survival analysis, a significant difference was observed between patients who did or did not undergo radical gastrectomy after GTC (p = 0.014 < 0.05).

Conclusions

GTC is a safe and effective treatment, and furthermore, it could be an alternative method in treating advanced gastric cancer with obstruction.

Survival outcomes of management in metastatic gastric adenocarcinoma patients

Chemotherapy is generally considered as the main treatment for metastatic gastric adenocarcinoma. The role of gastrectomy for metastatic gastric cancer without obvious symptoms is controversial. The objective of this study is to investigate survival outcomes of treatment modalities using a real-world data setting. A retrospective cohort study was designed using the Taiwan Cancer Registry database. We identified the treatment modalities and used Kaplan–Meier estimates and Cox regressions to compare patient survival outcomes. From 2008 to 2015, 5599 gastric adenocarcinoma patients were diagnosed with metastatic disease (M1). The median overall survival (OS) of patients with surgery plus chemotherapy had the longest survival of 14.2 months. The median OS of the patients who received chemotherapy alone or surgery alone was 7.0 and 3.9, respectively. Age at diagnosis, year of diagnosis, tumor grade, and treatment modalities are prognostic factors for survival. The hazard ratios for patients who received surgery plus chemotherapy, surgery alone, and supportive care were 0.47 (95% CI 0.44–0.51), 1.22 (95% CI 1.1–1.36), and 3.23 (95% CI 3.01–3.46), respectively, by multivariable Cox regression analysis when using chemotherapy alone as a referent. Chemotherapy plus surgery may have a survival benefit for some selected gastric adenocarcinoma patients with metastatic disease.

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

Non-curative gastrectomy for advanced gastric cancer does not result in additional risk of postoperative morbidity compared to curative gastrectomy

BACKGROUND

Non-curative gastrectomy (nCG) for gastric cancer can be considered in selected cases to relieve symptoms. The aim of this study was to evaluate postoperative morbidity and mortality in patients who underwent nCG and compare these results with an intended curative gastrectomy (CG).

MATERIALS AND METHODS

All patients who underwent both nCG and CG in the Netherlands were included from the Dutch Upper GI Cancer Audit (2011-2016). In this population-based cohort study postoperative morbidity, mortality, readmissions and short-term oncological outcomes were appraised. Propensity score matching (PSM) was applied to create comparable groups of patients who underwent nCG versus CG, using patient and tumor characteristics.

RESULTS

Of the 2202 eligible patients, 115 patients underwent nCG and 2087 underwent CG. After PSM, 115 nCG-patients were matched to 227 CG-patients. More conversions from laparoscopic to open surgery occurred during nCG (10·4 versus 2·6%, p = 0·007). Although postoperative mortality was higher after nCG in the original cohort (9·6 versus 4·8%, p = 0·026), after PSM there was no difference between groups (9·6 versus 7·0%, p = 0·415). Postoperative morbidity, re-interventions and readmission rates did not differ significantly between groups. Resection of additional organs (30·4 versus 11·5%, p < 0·001) and R+ resections (65·2 versus 12·3%, p < 0·001) occurred more frequently during nCG.

CONCLUSIONS

nCG does not lead to additional postoperative risks compared to CG in patients with similar characteristics, and may be considered in fit patients with advanced gastric cancer. However, randomized trials evaluating potential (survival) benefits of nCG should be awaited.

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.

Gastrectomy for Metastatic Gastric Cancer: a 15-year Experience from a Developing Country

The role of surgery in the management of metastatic gastric cancer (MGC) remains unclear. The aim of this study was to investigate the surgical and oncologic outcomes of gastrectomy in patients with MGC. The study included prospectively collected data of patients with MGC operated at four medical centers in Yerevan, Armenia, between 2000 and 2014. Armenian National Center of Oncology Registry and hospital records were used to obtain survival data. Factors associated with performing gastrectomy in patients with MGC were analyzed by using the logistic regression model. The Kaplan-Meier method was applied for survival analysis, and the Cox regression model with backward selection was used for multivariate analysis. A total number of 733 patients were operated for gastric cancer including 112 (15.3%) with MGC. Of those, 70 underwent gastrectomy, while 42 had exploratory laparotomy or bypass. Morbidity and mortality were similar after gastrectomy and exploratory laparotomy/bypass (18.6 vs 21.4%, p = 0.71 and 2.9 vs 7.1% p = 0.36, respectively). Female gender, involvement of N1 and/or N2 lymph node stations, and differentiated adenocarcinoma were associated with opting for gastrectomy. Gastrectomy with synchronous resection of distant metastases resulted in postoperative outcomes similar to those following gastrectomy without synchronous organ resection. Median follow-up was 6 months. Eighteen (16.1%) patients received chemotherapy. Median survival following gastrectomy and exploratory laparotomy/bypass were 7 and 4 months (p = 0.015), respectively. The use of chemotherapy following gastrectomy significantly improved survival compared with gastrectomy only (14 vs 6 months, p = 0.01). In the multivariable analysis, chemotherapy and nodal stage correlated with survival after gastrectomy. Gastrectomy for MGC is associated with satisfactory surgical outcomes and can be combined with synchronous resection of distant metastases in selected patients. Gastrectomy results in longer survival compared with exploratory laparotomy/bypass, especially when followed by chemotherapy.

Biodegradable pH-sensitive prospidine-loaded dextran phosphate based hydrogels for local tumor therapy

The paper focuses on the development of drug delivery systems based on hydrogels of dextran phosphate (DP) for local cancer therapy. The hydrogels were characterized by physicochemical properties including functional group content, morphology, gel fraction, pH-responsive swelling. The desirable pH-sensitive drug release behavior of these hydrogels was demonstrated by a drug release test with Prospidine-loaded hydrogels (DP-Pr hydrogels) at different pH values. In vitro degradation of the DP-Pr hydrogels was determined under simulated physiological conditions. The cytotoxicity of the blank DP hydrogels and DP-Pr hydrogels with different Pr concentrations was evaluated with HeLa and HЕр-2 cells. Investigations of antitumor efficiency in vivo showed that administration of DP-Pr hydrogels in comparison with an aqueous solution of Pr results in the increase of antitumor activity, prolongation of therapeutic action and growth of a number of animals cured. Therefore, such pH-responsive DP hydrogels could be promising candidates as drug delivery carriers.

Palliative Gastrectomy and Survival in Patients With Metastatic Gastric Cancer: A Propensity Score-Matched Analysis of a Large Population-Based Study

OBJECTIVES

The role of palliative gastrectomy in the management of metastatic gastric cancer remains inadequately clarified.

METHODS

We analyzed patients with metastatic gastric cancer enrolled in the Surveillance, Epidemiology, and End Results registry from January 2004 to December 2012. Propensity score (PS) analysis with 1:1 matching and the nearest neighbor matching method was performed to ensure well-balanced characteristics of the groups of patients who undergone gastrectomy and those without gastrectomy. Data were analyzed by Kaplan-Meier and Cox proportional hazards regression models to evaluate the overall survival and cancer-specific survival rates with corresponding 95% confidence intervals (CIs).

RESULTS

In general, receiving any kind of gastrectomy was associated with an improvement in survival in the multivariate analyses (hazard ratio [HR]os = 0.64, 95% CI = 0.59-0.70, HRcss = 0.63, 95% CI = 0.57-0.68) and PS matching (PSM) analyses (HRos = 0.63, 95% CI = 0.56-0.70, HRcss = 0.62, 95% CI = 0.55-0.70). After PSM, palliative gastrectomy was found to be associated with remarkably improved survival for patients with stage M1 with only 1 metastasis but not associated with survival of patients with stage M1 with extensive metastasis (≥2 metastatic sites).

DISCUSSION

The results obtained from the Surveillance, Epidemiology, and End Results database suggest that patients with metastatic gastric cancer might benefit from palliative gastrectomy on the basis of chemotherapy. However, a PSM cohort study of this kind still has a strong selection bias and cannot replace a properly conducted randomized controlled trial.

Long-term survival of an elderly patient with advanced gastric cancer after combination therapy: a case report and literature review

Background

Gastric cancer ranks the fifth most common cancer, and the third leading cause of cancer-related deaths worldwide. Gastric cancer with liver metastasis (GCLM) has devastating prognosis, however, optimal treatment of GCLM, especially in elderly patients, has yet to be clarified.

Case presentation

A 75-year-old man was diagnosed with advanced gastric cancer (GC), presenting with acute gastrointestinal bleeding and synchronous metastatic lesion in liver. Based on multidisciplinary team (MDT)‘s decision, this patient underwent distal palliative gastrectomy with R1 margin. Histopathological diagnosis was stage IV gastric adenocarcinoma (pT3N2M1), HER2 negative. The patient was treated with chemotherapy and argon-helium cryoablation of liver and lung metastases.HER-2 gene amplification was identified in peripheral blood at later stage of therapy. The patient had been followed-up for 39 months, in sharp contrast to a median survival time of 13.8 months for majority of advanced GC.

Conclusions

Palliative distal gastrectomy in combination with chemotherapy and cryoablation significantly prolongs overall survival of an elderly patient with GCLM.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5683-4) contains supplementary material, which is available to authorized users.

Is curative gastrectomy justified for gastric cancer with cytology positive as the only stage IV factor?

AIMS

The prognosis of patients with gastric cancer and stage IV factors is poor. However, several recent studies have identified that curative surgery followed by S-1 chemotherapy for cytology positive (CY1) only patients contributed to a better prognosis. This study was designed to compare the prognosis between curative and palliative gastrectomy followed by chemotherapy in CY1 only stage IV gastric cancer.

METHODS

Between 2001 and 2016, 1507 patients underwent gastrectomy for gastric cancer. Of these, 51 consecutive patients with only CY1 factor who underwent gastrectomy followed by chemotherapy were enrolled in this study.

RESULTS

(1) Twenty three (45%) patients underwent curative D2 or D2+ gastrectomy, and the remaining 28 (55%) patients underwent palliative gastrectomy, followed by S-1 based or another historical recommended chemotherapy postoperatively. (2) Compared with patients undergoing palliative gastrectomy, patients undergoing curative gastrectomy had a significantly better prognosis (P = 0.042; median survival time: curative vs. palliative, 22.6 months vs. 11.8 months) and a lower incidence of recurrences (P = 0.091). Two- and five-year overall survival rates of patients following curative gastrectomy were 48.2% and 18.2%, respectively. A multivariate analysis showed that venous invasion [P = 0.006; hazard ratio (HR), 3.70 (95% CI: 1.27-9.43)] and curative gastrectomy [P < 0.005; HR, 0.28 (95% CI: 0.12-0.87)] were independent prognostic factors.

CONCLUSION

Curative gastrectomy followed by chemotherapy might be justified to improve the prognosis of patients with only CY1 Stage IV gastric cancer.

The role of surgical resection before palliative chemotherapy in advanced gastric cancer

The role of palliative surgical resection in recurrent or metastatic gastric cancer is still controversial. A retrospective review was conducted on 689 patients who received palliative chemotherapy for recurrent (n = 307) or primary metastatic (n = 382) gastric cancer. Among 131 patients (89 primary metastatic and 42 recurrent) with surgical resection before chemotherpay, 75 underwent gastrectomy, 42 metastasectomy, and 14 gastrectomy with metastasectomy. The median overall survival (OS) of patients who underwent surgical resection was significantly longer than that of patients who received chemotherapy alone (18 vs. 9 months, p < 0.0001). The OS benefit of surgical resection was consistent across subgroups. In multivariate analysis, surgical resection was independently associated with favorable OS (hazard ratio = 0.42, p < 0.0001). Moreover, patients with surgical resection showed favorable OS both in univariate (p < 0.0001) and multivariate (p < 0.0001) analysis even after propensity score matching. In addition, the median OS of patients who underwent gross complete resection (n = 54) was significantly longer than that of patients who underwent incomplete resection (n = 77) (30 vs. 15 months, p = 0.002). The present study suggests that judicious use of surgical resection before chemotherapy in recurrent or metastatic gastric cancer patients may result in a favorable outcome, especially when complete resection is achievable.

Estimating the Net Survival of Patients with Gastric Cancer in Iran in a Relative Survival Framework

BACKGROUND

Iran is an Eastern Mediterranean region country with the highest rate of gastric cancer. The present study aimed to evaluate the 5-year net survival of patients with gastric cancer in Iran using a relative survival framework.

METHODS

In a cross-sectional study, using life-table estimation of relative survival, we reported 1- to 5-year relative survival regarding age, sex, disease stage, pathology, and adjuvant therapies via modeling excess mortality. All the analyses were done applying Stata 11.2 with a confidence level of 95%.

RESULTS

Data on 330 patients (aged 32-96 y), who were comprised of 228 (69.1%) men and 102 (30.1%) women with gastric cancer and were followed up for 10 years, were analyzed. Adenocarcinoma was the most common malignancy (281 [85.2%] patients), and 248 (75.1%) patients were at stage 3 or stage 4. The 1- and 5-year net survival rates after surgery were 67.96 (95% CI: 62.35-72.98) and 23.35 (95% CI: 17.94-29.28), respectively. Higher stages (P=0.001), older ages (P=0.007), and less use of adjuvant therapies (P<0.001) were independently associated with excess mortality.

CONCLUSION

It is recommended to use the relative survival framework to analyze the survival of cancer patients as an alternative approach not only to eliminate biases due to competing risks and their dependencies but also to estimate the cure at the population level concerning the most important individual characteristics. Our findings showed that the survival rate of gastric cancer in Iran is lower than that in most developed countries in terms of net survival.

Palliative gastrectomy plus chemotherapy versus chemotherapy alone for incurable advanced gastric cancer: a meta-analysis

BACKGROUND

Whether palliative gastrectomy combined with chemotherapy can improve the survival of patients with advanced gastric cancer remains controversial. We performed a meta-analysis to clarify whether palliative gastrectomy plus chemotherapy can benefit patients with incurable advanced gastric cancer and to explore the best candidates in this patient population.

METHODS

We searched the literature systematically using electronic databases including PubMed, EMBASE, and the Cochrane Library. And HRs and their 95% CIs were used to express the results for overall survival (OS) and progression-free survival (PFS).

RESULTS

One randomized controlled trial with 175 patients and 12 cohort studies with 2,193 patients were analyzed. The pooled HR for OS (HR=0.43, 95% CI=0.29-0.65, P<0.001), subgroup analysis of stage M1 (HR=0.53, 95% CI=0.40-0.72, P<0.001), peritoneal dissemination (HR=0.46, 95% CI=0.28-0.73, P=0.001), and liver metastasis (HR=0.46, 95% CI=0.33-0.65, P<0.001) all indicated the superiority of palliative gastrectomy plus chemotherapy. However, the pooled HR for PFS (HR=0.61, 95% CI=0.33-1.13, P=0.110) got separate outcome.

CONCLUSION

The results of this meta-analysis indicated that palliative gastrectomy plus chemotherapy can improve OS for incurable advanced gastric cancer. In addition, analyses based on liver metastasis and peritoneal dissemination demonstrated the advantages of palliative gastrectomy plus chemotherapy. However, the PFS of incurable advanced gastric cancer with palliative gastrectomy plus chemotherapy was no better than that under chemotherapy alone.

The Benefits of Resection for Gastric Carcinoma Patients with Non-curative Factors

The benefits of resection for gastric carcinoma patients with non-curative factors remain controversial. Thus, we evaluated the survival benefits of resection in these gastric carcinoma patients. We reviewed the hospital records of 467 gastric carcinoma patients with non-curative factors who had resection (n=305) and compared their clinicopathological findings with individuals (n=162) who underwent bypass or exploration from 1996 to 2010. The 3-year survival rate of patients who had resection was higher than was that of patients who did not (13.2 vs. 7.2%, respectively p<0.001). Cox's proportional hazard regression analysis revealed that only one factor was an independent, statistically significant prognostic parameter: the presence of peritoneal dissemination (risk ratio, 1.37; 95% confidence interval, 1.04–1.79; p<0.05). The 3-year survival rate of patients with peritoneal dissemination was higher in individuals who underwent resection compared with those who did not (9.5 vs. 4.7%, respectively; p<0.001). The current results highlight the improved survival rates of gastric carcinoma patients with non-curative factors who underwent surgery compared with those who did not. Although resection is not curative in this group of patients, we still recommend performing the procedure.

Experience of Low-Dose, Short-Course Palliative Radiotherapy for Bleeding from Unresectable Gastric Cancer

BACKGROUND/AIMS

The optimal regimen of radiotherapy (RT) for bleeding from gastric cancer (GC) has not yet been established. The aim of this study was to evaluate the usefulness of low-dose, short-course palliative RT (LSP-RT) for bleeding from GC.

MATERIAL AND METHODS

We reviewed the clinical data of 18 patients (26 courses) who received palliative RT for bleeding from GC between 2004 and 2014. The radiation dose was 6 Gy in three fractions. The total courses of RT for each patient were 1-4 (median, 1).

RESULTS

The treatment success rate of the first and the additional RT at two weeks after RT was 55% and 75%, respectively. Regarding first RT, there was a statistically significant increase in the mean hemoglobin level for one month (p = 0.009) and a significant decrease in the mean number of transfused red blood cell units for one month (p = 0.012). Toxicities were observed in two patients: one patient who received chemotherapy developed grade 3 afebrile leukocytopenia and another who had a malignant stricture suffered from a gastric obstruction. The performance status was improved in 3 of the 12 evaluable patients (25%) and dietary intake became possible one month after RT in three of the four patients who had not been able to eat before RT.

CONCLUSION

LSP-RT is expected to be not only an effective and safe treatment option for bleeding from GC, but also repeatable in cases of rebleeding. Furthermore, this treatment modality may be able to improve the patient's quality of life.

Surgical palliation of gastric outlet obstruction in advanced malignancy

Gastric outlet obstruction (GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract. Palliative treatment of patients’ symptoms who present with GOO is an important aspect of their care. Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life. Palliative treatment for GOO includes operative (open and laparoscopic gastrojejunostomy) and non-operative (endoscopic stenting) options. The performance status and medical condition of the patient, the extent of the cancer, the patients prognosis, the availability of a curative procedure, the natural history of symptoms of the disease (primary and secondary), the durability of the procedure, and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy. Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.

A Prognostic Model in Metastatic or Recurrent Gastric Cancer Patients with Good Performance Status Who Received First-Line Chemotherapy

PURPOSE: Good performance status is widely known as a superior prognostic predictor. However, some patients have large survival differences despite having good performance status that are influenced by certain prognostic factors. The purpose of this study was to explore baseline host- or tumor-related factors and to establish a prognostic model for metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy. METHODS: A total of 310 metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy were enrolled. Prognostic significance was determined using multivariate Cox regression analysis. Incorporating all pretreatment indicators, a prognostic model was established. Overall survival outcomes were compared with different risk groups using the Kaplan-Meier method and log-rank test. RESULTS: In multivariate analysis, no previous gastrectomy [hazard ratio (HR) = 1.42; 95% confidence interval (CI) = 1.08-1.85], number of distant metastatic sites (HR = 1.47; 95% CI = 1.11-1.96), bone metastasis (HR = 2.20; 95% CI = 1.16–4.18), liver metastasis (HR = 1.77; 95% CI = 1.31-2.39), and an elevated neutrophil lymphocyte ratio (HR = 1.37; 95% CI = 1.04-1.79) were independent prognostic factors of overall survival. Patients were categorized into three risk groups according to their risk scores. Median survival times for the low-risk (0 point), intermediate-risk (1-3 points), and high-risk (≥ 4 points) groups were 19.7, 10.7 and 5.1 months, respectively (P < .001). CONCLUSIONS: A prognostic model was developed that could facilitate risk stratification for metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy to help clinicians choose an applicable treatment based on the estimated prognosis.

Comparison of Therapeutic Efficacy between Gastrectomy with Transarterial Chemoembolization Plus Systemic Chemotherapy and Systemic Chemotherapy Alone in Gastric Cancer with Synchronous Liver Metastasis

BACKGROUND

Systemic chemotherapy (SC) is the recommended treatment for gastric cancer with liver metastasis. However, the improvement in survival has been disappointing. The aim of this study was to compare the therapeutic efficacy of gastrectomy with transarterial chemoembolization plus SC (GTC) and SC alone for gastric cancer with synchronous liver metastasis.

METHODS

From January 2008 to December 2013, 107 gastric cancer patients with synchronous liver metastasis attending the four participating centers were enrolled in this multicenter, ambispective, controlled cohort study. Patients who underwent GTC (n = 32) were compared with controls who were received SC alone (n = 75). The primary endpoints of the study were overall survival (OS) and progression-free survival (PFS). The secondary endpoints were response rate to treatment and treatment-related adverse effects.

RESULTS

The median OS was 14.0 months (95% confidence interval [CI ]: 13.1-14.9 months) in the GTC treatment group and 8.0 months (95% CI : 6.6-9.4 months) in SC group, this difference being statistically significant (P < 0.001). The median PFS was significantly longer in the GTC than in the SC group (5 months, 95% CI : 2.2-7.8 months vs. 3 months, 95% CI : 2.3-3.4 months, respectively) (P < 0.001). The rate of response to treatment was significantly better in the GTC than the SC group (59.4% vs. 37.4%, respectively) (P = 0.035). According to multivariate analysis, OS in patients receiving combination treatment was significantly correlated with the size (P = 0.037) and extent of liver metastases (P < 0.001). PFS was also correlated with the extent of liver metastases (P = 0.003).

CONCLUSIONS

GTC is more effective than SC alone in patients with gastric cancer with synchronous liver metastasis. GTC therapy prolongs the survival of selected gastric cancer patients with synchronous liver metastasis.

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.

Role of Surgery in the Management for Gastric Cancer with Synchronous Distant Metastases

Optimal treatment of patients with gastric cancer with synchronous distant metastases is palliative chemotherapy. However, occasionally gastrectomy should be selected due to control bleeding from tumors, perforation, or obstruction. The aim of this study is to evaluate the survival benefits of non-curative gastrectomy for patients with synchronous distant metastasis. Total 78 gastric cancer patients with synchronous distant metastasis treated in our hospital between 2003 and 2012 were enrolled in this study. Of these, 74 patients (95 %) received S1 based chemotherapy. During the treatment, 37 patients (47.4 %) underwent palliative gastrectomy because of bleeding from tumors (n = 15), tumor perforation (n = 6), and obstruction (n = 16). Survival benefits were compared in resected and non-resected patients, retrospectively. The two groups were clinicopathologically similar. Palliative gastrectomy was performed safely (morbidity: 10.8 % and mortality: 0) in resection group. However, resection showed survival benefits only in 13 patients (16.7 %) with single metastasis and without peritoneal metastasis. Their 2-year survival rate was 40 % and their median survival was 19 months. Non-curative gastrectomy with precise surgical techniques followed careful postoperative nutrition management may improve survival only for patients with a single metastatic site, except for peritoneal dissemination.

Metastatic gastric cancer (MGC) patients: Can we improve survival by metastasectomy? A systematic review and meta-analysis

BACKGROUND

Prognosis with current management strategies continues to be dismal in metastatic gastric cancer (MGC) patients. We aimed to evaluate the role of metastasectomy in improving survival.

METHODS

A comprehensive search of MEDLINE, EMBASE, SCOPUS, and Cochrane central databases (1965 to present) was performed. All comparative studies measuring survival in MGC patients undergoing metastasectomy versus other therapies were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for survival at 1, 3, and 5 years.

RESULTS

Sixteen studies with 1712 patients (378 patients in metastasectomy, 1334 patients in other therapies) were eligible for the final meta-analysis. Median age was 63 years. For patients undergoing metastasectomy, a significant survival advantage was observed at 1 year (RR 0.52, CI 0.43-0.62), 3 year (RR 0.75 CI 0.67-0.83), and 5 year (RR 0.82, CI 0.74-0.91); mean increased difference in survival conferred by metastasectomy averaged between 9.3 and 15.7 months; P < 0.001 for all results. Age, ECOG status, and STROBE score did not contribute to differences in survival.

CONCLUSION

Metastasectomy is associated with increased survival at 1, 3, and 5 years in MGC patients. Large prospective randomized controlled trials are critically needed to evaluate the role of metastasectomy in MGC.

Chemoresponse after non-curative gastrectomy for M1 gastric cancer

Background

M1 gastric cancer has a poor oncologic outcome with a median survival of less than 1 year despite aggressive chemotherapy. Recent trials include chemotherapy combined non-curative gastrectomy. This study evaluated the chemoresponse after non-curative gastrectomy in M1 gastric cancer and the survival benefit.

Methods

Between January 2000 and December 2010, 660 patients received chemotherapy for gastric cancer at the Department of Hemato-Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea. Data was collected retrospectively from the medical records. Patients who received preoperative or adjuvant chemotherapy, who underwent other surgeries like gastrojejunal bypass or exploratory laparotomy, who died within 3 months due to seriously advanced gastric cancer, who were lost to follow-up, or whose medical records were unsuitable for data collection were excluded. The remaining 101 patients had received chemotherapy only (CTx group, n = 76) or chemotherapy after non-curative gastrectomy (NCG + CTx group, n = 25). Clinicopathologic characteristics, chemoresponse, and overall survival were compared between the two groups.

Results

There were no significant differences between the two groups in clinicopathologic characteristics including age, sex, body mass index (BMI), comorbidity, histologic differentiation, tumor location, clinical T stage, and initial site of distant metastasis. Chemoresponse was checked on two separate occasions from the initiation of chemotherapy: first chemotherapy regimen and until the third regimen change. The NCG + CTx group showed more favorable chemoresponse than the CTx group in both checks (60% and 72% vs. 18.4% and 23.7%). The NCG + CTx group showed longer overall survival than the CTx group (26 vs. 11 months).

Conclusions

Non-curative gastrectomy in M1 gastric cancer could improve chemoresponse and extend overall survival.

Identification of prognostic factors and surgical indications for metastatic gastric cancer

BACKGROUND

The treatment of metastatic gastric cancer is not uniform, and the prognostic factors and indications for surgery are currently unclear. This retrospective study aimed to identify the prognostic factors and clinical indications for surgery in patients with metastatic gastric cancer.

METHODS

A total of 123 consecutive patients with gastric cancer and synchronous distant metastasis treated between January 1999 and December 2011 were reviewed. Patient, tumor, laboratory, surgical, and chemotherapy factors were analyzed, with overall survival as the endpoint. Univariate analyses were performed using the log-rank test, multivariate analyses were performed using the Cox proportional hazards model, and Kaplan-Meier curves were used to estimate survival. Significance was set at p<0.05.

RESULTS

The median overall survival time was 13.1 months. Ninety-eight patients received chemotherapy. Twenty-eight patients underwent gastrectomy with metastasectomy and 55 underwent gastrectomy without metastasectomy. The median overall survival time for patients who underwent gastrectomy with metastasectomy, gastrectomy without metastasectomy, and no surgical intervention was 21.9 months, 12.5 months, and 7.2 months, respectively (p<0.001). Multivariate analysis identified gastrectomy with or without metastasectomy, performance status (PS) ≥ 3, neutrophil-to-lymphocyte ratio (NLR) >3.1, and carbohydrate antigen 19-9 (CA19-9) level >37 U/mL as predictors of poor survival. NLR and CA19-9 level were also independent prognostic factors in the group of patients who underwent surgery.

CONCLUSIONS

High pretreatment NLR, CA19-9 level, and PS are predictors of poor prognosis in patients with metastatic gastric cancer. In selected patients, gastrectomy can be performed safely, and may be associated with longer survival.

Gastrectomy in advanced gastric cancer effectively palliates symptoms and may improve survival in select patients

BACKGROUND

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

METHODS

We reviewed 210 locally advanced or metastatic gastric cancers (1992-2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N = 99), exploration without resection (N = 66), and no surgery (N = 45).

RESULTS

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p < 0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR = 0.175). Resolution of symptoms (p < 0.001, Hazards Ratio (HR) = 0.09) and preoperative nausea/vomiting (p = 0.017, HR = 0.55) improved survival, while linitis plastica (p = 0.035, HR = 4.05) and spindle cell morphology (p = 0.011, HR = 1.98) were predictors of poor survival in patients undergoing resection.

CONCLUSIONS

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.

The role of palliative radiotherapy for haemostasis in unresectable gastric cancer: a single-institution experience

Purpose:

To evaluate the outcomes of patients with gastric cancer bleeding who had been treated with palliative radiotherapy with haemostatic intent.

Methods and materials:

Fifty-two gastric cancer patients aged 52–92 years (median 78 years) with active bleeding or anaemia resulting from inoperable gastric cancer were treated with short-course radiotherapy. Responses to radiotherapy treatment were evaluated based on the changes of haemoglobin level, number of transfusions received before and after radiotherapy, and overall median survival.

Results:

Thirty-nine (75%) patients received single 8 Gy fraction, and 13 (25%) patients received 20 Gy in five daily fractions. The need for transfusion was evaluable in 44 patients, and the response rate was 50%, with less requirement for blood transfusions within four weeks of radiotherapy. There was also an increase in mean haemoglobin level (0.66 ± 1.12 g/dl, p < 0.01) after radiotherapy in 35 evaluable patients. The overall median survival (calculated from last day of treatment to date of death) was 160 days (95% CI of 119–201 days), making actuarial 12-month survival 15%.

Conclusion:

Palliative short-course radiotherapy is a reasonably effective treatment that can provide durable palliation of bleeding in gastric cancer.

The role of non-curative surgery in incurable, asymptomatic advanced gastric cancer

Background

Although general agreement exists on palliative surgery with intent of symptom palliation in advanced gastric cancer (AGC), the role of non-curative surgery for incurable, asymptomatic AGC is hotly debated. We aim to clarify the role of non-curative surgery in patients with incurable, asymptomatic AGC under the first-line chemotherapy.

Methods

A total of 737 patients with incurable, asymptomatic advanced gastric adenocarcinoma between January 2008 and May 2012 at the Sun Yat-sen University Cancer Center were retrospectively analyzed, comprising 414 patients with non-curative surgery plus first-line chemotherapy, and 323 patients with first-line chemotherapy only. The clinicopathologic data, survival, and prognosis were evaluated, with propensity score adjustment for selection bias.

Results

The median overall survival (OS) outcomes significantly favored non-curative surgery group over first-line chemotherapy only group in entire population (28.00 versus 10.37 months, P = 0.000), stage 4 patients (23.87 versus 10.37 months, P = 0.000), young patients (28.70 versus 10.37 months, P = 0.000) and elderly patients (23.07 versus 10.27 months, P = 0.031). The median OS advantages of non-curative surgery over first-line chemotherapy only were also maintained when the analyses were restricted to single organ metastasis (P = 0.001), distant lymph node metastasis (P = 0.002), peritoneal metastasis (P = 0.000), and multi-organ metastasis (P = 0.010). Significant OS advantages of non-curative surgery over chemotherapy only were confirmed solid by multivariate analyses before and after adjustment on propensity score (P = 0.000). Small subsets of patients with surgery of single metastatic lesion after previous curative gastrectomy, and with surgery of both primary and single metastatic sites showed sound median OS.

Conclusions

There is a role for non-curative surgery plus first-line chemotherapy for incurable, asymptomatic AGC, in terms of survival. Randomized controlled trials are warranted to fill a gap in knowledge about the value of metastectomy and patient selection strategies.

Clinical significance of palliative gastrectomy on the survival of patients with incurable advanced gastric cancer: a systematic review and meta-analysis

Background

Palliative gastrectomy for patients with advanced gastric cancer remains controversial. The objective of the present meta-analysis was to analyze survival outcomes and establish a consensus on whether palliative gastrectomy is suitable for patients with incurable advanced gastric cancer and which type of patients should be selected to receive palliative gastrectomy.

Methods

A literature search was conducted in PubMed, EMBASE and the Cochrane Library. The results for overall survival in the meta-analysis are expressed as hazard ratios (HRs) with 95% confidence intervals (CIs).

Results

Of 1647 articles and abstracts reviewed, 14 studies with 3003 patients were eligible for the final analysis. The meta-analysis revealed that palliative gastrectomy is associated with a significantly improvement in overall survival (HR 0.56; 95%CI 0.39–0.80; p < 0.002) compared that of patients treated without palliative gastrectomy. An improvement in survival was also observed in patients with stage M1 gastric cancer who received palliative gastrectomy (HR 0.62; 95%CI 0.49–0.78; p < 0.0001), especially those with peritoneal dissemination (HR = 0.76, 95%CI 0.63–0.92), liver metastasis (HR = 0.41, 95%CI 0.30–0.55), or distant lymph-node metastasis (HR = 0.36, 95%CI 0.23–0.59). Combined hepatic resection may be beneficial for patients who under palliative gastrectomy (HR 0.30; 95%CI 0.15–0.61; p = 0.0008). The overall survival of patients who underwent palliative gastrectomy combined with chemotherapy was significantly improved (HR 0.63; 95%CI 0.47–0.84; p = 0.002).

Conclusions

From the results of the meta-analysis, palliative gastrectomy for patients with incurable advanced gastric cancer may be associated with longer survival, especially for patients with stage M1 gastric cancer. Combined hepatic resection for patients with liver metastasis and chemotherapy may be beneficial factors compared to simple palliative gastrectomy.

Gastric outlet obstruction in gastric cancer: a comparison of three palliative methods

BACKGROUND

Gastric outlet obstruction (GOO) commonly occurs in advanced gastric cancer. Our aim was to evaluate the results of endoscopic stenting (ES), palliative resection (PR), and gastrojejunostomy (GJ) as palliation of GOO.

METHODS

A total of 97 patients (50 ES, 26 PR, 21 GJ) were included in this retrospective study. All the patients had primary gastric cancer and symptoms of GOO.

RESULTS

Compared to surgery, ES resulted in a faster improvement on oral intake and symptom relief (P < 0.001) and a shorter hospitalization (P < 0.001). Complication rates, hospital re-admissions, occurrence of biliary obstruction, and the number of patients receiving chemotherapy were similar. The median symptom-free and overall survival were longest in the PR group (P < 0.001). In multivariate survival analysis, independent prognostic factors were age, BMI, pre-procedure GOOSS, palliative resection as treatment modality, and chemotherapy.

CONCLUSIONS

In gastric cancer and GOO, the clinical condition of the patient before treatment affects survival and should be taken into account in determining the treatment. PR seems to provide a survival benefit and should be considered as treatment option for patients suitable for surgery. For patients unfit for surgery, ES provides rapid and efficient palliation. Chemotherapy also seems to improve survival in gastric cancer and GOO.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

SPan-1 is a useful prognostic marker for patients with stage IV gastric cancer who underwent palliative gastrectomy: a retrospective multivariate study

BACKGROUND

We retrospectively investigated prognostic factors to be used in selecting the patients with stage IV gastric cancer (GC) who have an unfavorable prognosis after palliative gastrectomy.

METHODS

A total of 146 GC patients at stage IV who had undergone palliative gastrectomy were enrolled. Various clinicopathological parameters were evaluated for prognosis.

RESULTS

Surgical morbidity and hospital mortality occurred in 35 (23.9 %) and 4 (2.7 %) patients, respectively. The overall 5-year survival rate and the median survival time were 11.2 % and 13.2 months, respectively. Of the 146 patients, 64 had uncomfortable symptoms associated with GC and 76 had no such symptoms. Of the 64 patients with uncomfortable symptoms, 60 (93.7 %) experienced relief of these symptoms after palliative surgery. Multivariate analysis for patients without uncomfortable symptoms associated with GC revealed that the number of incurable factors and serum SPan-1 level were independent prognostic factors.

CONCLUSIONS

Patients with stage IV GC who had multiple incurable factors and a high level of serum SPan-1 might not be candidates for palliative gastrectomy for the purpose of prognostic benefit.

Assessment of advanced gastric cancer management in the United States

BACKGROUND

Increasing attention is being placed on utilization of treatment for advanced malignancies. Though some suggest it is futile, recent reports have advocated noncurative surgery for advanced gastric cancer. Our objectives were to (1) assess treatment trends, (2) identify predictors of surgery, and (3) evaluate the effect of treatment on outcomes.

METHODS

Patients with stage IV gastric adenocarcinoma were identified from the National Cancer Data Base (1998-2007). Patients who underwent emergent surgery were excluded. Models were developed to identify factors associated with treatment receipt and to compare adjusted overall survival by treatment group.

RESULTS

Twenty-four percent (n = 22,430) of patients presented with stage IV gastric adenocarcinoma; 1.5 % (n = 414) underwent emergent surgery. Of the remaining 21,039 patients, 62.4 % underwent treatment (87.0 % chemotherapy with or without radiotherapy (C ± RT), 5.6 % surgery, 7.2 % combined surgery and C ± RT). Over the decade, surgery rates increased by 43 %, and C ± RT use increased by 16 % while receipt of no treatment decreased by 26 % (all p < 0.001). Patients who were younger, white, and insured, as well as those with distal tumors were more likely to undergo surgery. Reasons for receiving no treatment were multifactorial but were most strongly associated with advanced age and being uninsured. Median survival was longest for patients selected to undergo surgery and C ± RT (13.5 months) versus C ± RT alone (6.1 months), surgery alone (4.8 months), or no treatment (1.7 months, all p < 0.001).

CONCLUSIONS

Utilization of nonemergent surgical treatment and C ± RT for metastatic gastric adenocarcinoma has increased considerably over time, especially in certain patient populations; however, the true utility and cost of these treatments remain unknown.

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.

Significant prognostic factors in patients with Stage IV gastric cancer with special reference to the curability of surgery

PURPOSES

The purpose of this study was to determine an effective treatment strategy for patients with Stage IV gastric cancer.

METHODS

We analyzed the significant prognostic factors in 74 patients who underwent surgery between 1989 and 2005, and were finally determined to have Stage IV gastric cancer. These patients were classified as curability A (n = 0), B (n = 29) and C (n = 45) according to the criteria outlined by Japanese Gastric cancer society. Anti-tumor drugs were used after surgery in some cases. There were 32 patients who received either no treatment or an oral anti-tumor drug, and 42 patients who received new chemotherapeutic regimens.

RESULTS

According to a univariate analysis, the postoperative mean survival times were significantly different; tumor size ≤ 12 cm, a tumor without lymphatic involvement, more than D2 lymphadenectomy, and classification as curability B were favorable prognostic factors. The multivariate analysis revealed that tumor size, lymphadenectomy and curability were independent prognostic factors. In curability B patients, venous involvement was an independent prognostic factor. In curability C patients, both the tumor size and postoperative chemotherapy affected their prognosis.

CONCLUSIONS

In patients with curable Stage IV gastric cancer, at least a D2 gastrectomy to reduce the absolute volume of tumor cells, followed by adjuvant chemotherapy, may be essential to improve their prognosis. In incurable cases, aggressive new chemotherapeutic regimens should be the treatment of choice for the prolongation of survival.

Survival in patients with stage IV noncardia gastric cancer - the influence of DNA ploidy and Helicobacter pylori infection

Background

Palliative surgery followed by postoperative chemotherapy is a challenging approach in the treatment of stage IV gastric cancer yet patients must be carefully selected on the basis of likely clinical benefit.

Methods

The records of 218 patients with histological diagnosis of gastric adenocarcinoma who underwent palliative surgery followed by postoperative chemotherapy were retrospectively reviewed. Twelve potential prognostic variables including tumour DNA index and serum IgG anti- Helicobacter pylori (HP) antibodies were evaluated for their influence on overall survival by multivariate analysis.

Results

The median survival was 13.25 months [95% Confidence Interval (CI) 12.00, 14.50]. Three factors were found to have an independent effect on survival: performance status (PS) [PS 60–70 vs. 90–100 Hazard Ratio (HR) 1.676; CI 1.171-2.398, p = 0.005], liver metastases (HR 1.745; CI 1.318-2.310, p < 0.001), and DNA Index as assessed by Image cytometry (2.2-3.6 vs. >3.6 HR 3.059; CI 2.185-4.283, p < 0.001 and <2.2 vs. >3.6 HR; 4.207 CI 2.751-6.433 <0.001). HP infection had no statistically significant effect on survival by either univariate or multivariate analysis.

Conclusion

Poor pre-treatment PS, the presence of liver metastasis and high DNA Index were identified factors associated with adverse survival outcome in patients with Stage IV gastric cancer treated with palliative gastrectomy and postoperative chemotherapy. HP infection had no influence on survival of these patients.

Does non-curative gastrectomy improve survival in patients with metastatic gastric cancer?

BACKGROUND

The role of non-curative or palliative gastrectomy remains controversial. Our aim was to compare retrospective patients who have undergone non-curative gastrectomy to the patients with surgical exploration only.

METHODS

Between years 2000 and 2009, 488 patients with gastric adenocarcinoma were treated at the Department of Surgery, Helsinki University Central Hospital. Fifty-five patients had metastatic disease but their symptoms were not severe enough to require palliative surgery. Thirty-two of them underwent operative exploration (Group A), and 23 non-curative gastrectomy (Group B). All operations were initiated with curative intent.

RESULTS

The difference in median survival between Groups A and B was insignificant (5.7 months in Group A and 10.8 months in Group B, P = 0.152). However, 33 patients with postoperative chemotherapy had significantly better median survival than the others (14.2 months vs. 1.9 months, P < 0.001). No significant differences were observed between Groups A and B in the rate of late postoperative gastrointestinal obstruction or bleeding.

CONCLUSIONS

Non-curative gastrectomy does not improve survival in patients with metastatic gastric cancer, nor reduces the rate of late occlusions. There is no need for prophylactic palliative gastrectomy in patients with gastric cancer who do not have bleeding or obstruction preoperatively. Among those patients, postoperative chemotherapy seems to improve survival.

Non-curative gastric resection for patients with stage 4 gastric cancer--a single center experience and current review of literature

PURPOSE

The majority of patients with gastric cancer present with an advanced stage and, therefore, may not be eligible for curative treatment. The role of non-curative gastric resection in situations other than emergency treatment for life threatening tumor-related complications is still under discussion.

METHODS

Data from 290 consecutive patients with advanced gastric cancer who were treated in our hospital were analyzed. A total of 48 patients underwent primary non-curative gastric resection.

RESULTS

The overall survival in the non-curatively resected group was 15 months and 6 months for non-resected patients, respectively (p < 0.001). The incidence of tumor-related complications which required intervention was 63% in non-resected patients as compared to 12% in patients who underwent primary non-curative resection. Younger age, less than three tumor locations, and chemotherapy have been identified as prognostic factors for improved survival by univariate analysis. D3 lymph node involvement and chemotherapy were independent prognostic factors in the multivariate analysis. Peritoneal carcinosis did not significantly influence survival in resected patients. Non-curative resection in combination with chemotherapy resulted in longer overall survival than resection alone.

CONCLUSIONS

Primary non-curative gastric resection can reduce the incidence of severe tumor-related complications and can prolong overall survival in selected subgroups. In particular, younger patients with no more than two tumor locations should be considered for this procedure.

Influence of a positive proximal margin on oral intake in patients with palliative gastrectomy for far advanced gastric cancer

BACKGROUND

Resection margin involvement is one of the most significant risk factors for local recurrence in curative gastrectomy, and local recurrence results in anastomotic stenosis. In the present study, the effects of a positive resection margin in palliative gastrectomy on the symptoms of anastomotic stenosis and the amount of oral intake were analyzed.

METHODS

Between September 2002 and December 2009, 2,228 patients underwent resection for gastric cancer at Shizuoka Cancer Center, Japan, of whom 18 underwent palliative gastrectomy with a positive proximal margin because of urgent symptoms such as tumor bleeding, stenosis, or perforation. These 18 patients were analyzed retrospectively in this study.

RESULTS

Twelve patients had a positive proximal margin, and six patients had both proximal and distal margin involvement. Anastomotic leakage occurred in 2 patients. The median overall survival was 7.5 months, and the median time from operation to a decrease in oral intake was 5.5 months. Anastomotic recurrence developed in 3 patients, and in all of them, anastomotic stricture was found 2-3 months after gastrectomy. One of these patients, who was in good general condition, was treated by endoscopic balloon dilatation. The other 2 patients did not undergo balloon dilatation because their general condition was poor, with peritonitis carcinomatosa.

CONCLUSIONS

It does not appear necessary for palliative gastrectomy to achieve a negative proximal margin, because salvage therapies resulted in maintaining a tolerable oral intake in patients who were in good general condition.

Outcome of palliative total gastrectomy for stage IV proximal gastric cancer

BACKGROUND

A few studies have investigated the outcome of palliative total gastrectomy (PTG) in stage IV proximal gastric cancer. In this study, we tried to summarize the outcome of PTG in stage IV proximal gastric cancer.

METHODS

Between January 1991 and January 2005, complete clinical data of 197 patients with stage IV proximal gastric cancer undergoing PTG, 642 patients undergoing curative total gastrectomy (CTG), 152 nonsurgical patients, 102 patients undergoing explorative laparotomy, and 78 patients undergoing jejunostomy were enrolled in this study. Survival rates, median survival, complication rates, and mortality were analyzed.

RESULTS

The 1-year, 3-year, and 5-year survival rates were 61.3%, 8.9%, and 6.4% in the PTG group, respectively, and 92.3%, 58.5%, and 48.9% in the CTG group, respectively (P < .05). The median survival periods in the PTG, no surgery, laparotomy, and jejunostomy groups were 16.4, 5.5, 4.7, and 5.8 months, respectively. The median survival in the PTG group was significantly longer than that in the other 3 groups (P < .05). The postoperative complication rate and mortality rate were, respectively, 24.3% and 3.0% in the PTG group and 13.5% and 2.3% in the CTG group (P > .05).

CONCLUSIONS

PTG for stage IV proximal gastric cancer when compared with no surgery, laparotomy, and jejunostomy is associated with prolonged survival time and improved quality of life. However, despite the feasibility and safety of PTG, patients with stage IV proximal gastric cancer who are suitable for this treatment should be selected, and thoughtful preparation should be made in the perioperative period.

Survival benefit of gastrectomy ± metastasectomy in patients with metastatic gastric cancer receiving chemotherapy

BACKGROUND

This study was performed to investigate the role of surgery in patients with gastric cancer and distant metastases who had received systemic chemotherapy.

METHODS

Patients with newly diagnosed gastric cancer and synchronous distant metastases who had received chemotherapy (n = 274) were categorized into 3 groups according to the surgical treatment rendered: complete gross resection of both primary and metastatic sites (group A; n = 42); debulking gastrectomy (group B; n = 47); and chemotherapy without debulking (group C; n = 185).

RESULTS

The median overall survival of all patients was 11.8 months. The median overall survival and 3-year survival rates were 28.0, 15.5, and 9.0 months and 42.8, 8.1, and 3.5% in groups A, B, and C, respectively. In group A, patients with peritoneal seeding, intra-abdominal distant lymph nodes, or ovarian or hepatic metastases underwent complete gross resection, and 12 (29%) were disease-free at the time of the last analysis (median follow-up duration, 29.1 months). On multivariate analysis, the adjusted hazard ratios for death were 0.27 (P < 0.001) and 0.64 (P = 0.024) for groups A and B, respectively, as compared to group C.

CONCLUSIONS

Our study suggests survival benefits of debulking gastrectomy or gastrectomy plus metastasectomy in gastric cancer patients with distant metastases receiving systemic chemotherapy. Prolonged disease-free survival was observed after complete resection (gastrectomy plus metastasectomy) that may lead to cure in some patients. Well-designed prospective trials of the role of multidisciplinary approaches combining chemotherapy and surgery are needed to confirm the observations of our study.

Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: a retrospective analysis

OBJECTIVE

Most patients with gastric cancer present with locally advanced or metastatic disease and usually receive palliative therapy. We sought to identify factors influencing overall survival in patients with stage IV gastric cancer receiving palliative chemotherapy.

PATIENTS AND METHODS

The records of 311 patients with histological diagnosis of gastric adenocarcinoma were retrospectively reviewed and 17 clinicopathological and therapeutic parameters were evaluated for their influence on overall survival.

RESULTS

In multivariate analysis nine factors were found to independently influence survival: no previous palliative gastrectomy [Hazard ratio (HR, 12; CI 7.969-18.099)], single agent chemotherapy instead of combination chemotherapy (HR, 1.35; CI 1.068-1.721), histological grade III (HR, 1.39; 95% CI 1.098-1.782), the presence of hepatic (HR, 1.6; 95% CI 1.246-2.073) and abdominal metastasis (HR, 1.33; 95% CI 1.039-1.715), CA 72-4 > 7 U/L (HR, 1.39; 95% CI 1.026-1.887), LDH > 225 U/L (HR, 1.72; 95% CI 1.336-2.236], need for blood transfusions (HR, 1.58; 95% CI 1.213-2.082), and weight loss > 5% (HR, 1.96; 95% CI 1.352-2.853) at the time of initial diagnosis. Patients were stratified as low (0-2 factors), intermediate (3-6 factors) and high (7-9 factors) risk and the median survival was 76, 40 and 11 weeks, respectively.

CONCLUSION

Nine clinical and laboratory factors that adversely affect survival in patients with stage IV gastric cancer who receive chemotherapy were identified. Their concurrent presence seems to have an additive effect as patients with seven to nine factors have the worse prognosis. Palliative gastrectomy and combination chemotherapy appear to be associated with improved survival.

Tratamento paliativo do adenocarcinoma gástrico

INTRODUÇÃO: Embora decrescendo nos países do chamado primeiro mundo, o adenocarcinoma gástrico mantém-se como terceiro tumor mais frequente no sexo masculino mundialmente. Sua mortalidade é muito elevada, fruto do diagnóstico tardio em lesões muito avançadas, o que frequentemente torna paliativo seu tratamento, motivos pelos quais se justificam estudos no sentido de melhorar estes resultados. MÉTODO: Revisão da literatura através do portal de periódicos da CAPES indicados por busca no sites da Bireme e PubMed. Além disso, foram consultados os sumários do 8º Congresso Internacional de Câncer Gástrico em 2009. Foi apresentada uma sugestão de algoritmo de atendimento destes pacientes. CONCLUSÕES: O surgimento de novas drogas anticancer, mais efetivas, está propiciando novas alternativas para a ressecção gástrica como tratamento paliativo. Novos protocolos estão surgindo mostrando boas perspectivas para melhorar os resultados desta doença.

Potential benefit of resection for stage IV gastric cancer: a national survey

INTRODUCTION

Controversy exists as to whether patients with stage IV gastric cancer should undergo surgical resection. We examined the association of gastrectomy with survival in this population.

METHODS

Stage IV gastric cancer diagnoses were identified using the SEER database (1988-2005). Analyses examined three subgroups divided on the basis of whether cancer-directed surgery was recommended and performed. Univariate analyses included chi-square and Kaplan-Meier survival analyses. Cox proportional hazards modeling was performed to assess independent determinants of survival.

RESULTS

Of 66,751 identified gastric cancer patients, 23,830 had stage IV disease. Resected patients had a significant survival advantage; survival outcomes of patients who had been recommended for, but had not undergone, surgery were identical to that of patients who had not been recommended (3 months vs. 9 months for resected, p < 0.0001). Furthermore, resection status was the most significant independent predictor of increased risk of death (hazard ratios 2.0 for non-cancer-directed surgery groups).

CONCLUSIONS

Patients with stage IV gastric cancer who undergo resection, a highly selected population, have significantly greater survival than unresected patients, including those who were recommended for, but did not receive, resection. Stage IV gastric cancer patients who are reasonable operative candidates should be offered resection.