Accuracy of Macroscopic Intraoperative Diagnosis of Serosal Invasion and Risk of Over- and Underestimation in Gastric Carcinoma

Effect of visceral adipose tissue on the accuracy of preoperative T-staging of gastric cancer

BACKGROUND

Due to the anatomical characteristics of the tumor and the specific variables of the patients, the accuracy of preoperative T-staging of gastric cancer needs to be further improved. This study investigated the effect of visceral adipose tissue (VAT) on the accuracy of clinical T-staging of gastric cancer.

METHODS

The clinical data of 455 patients who underwent gastrectomy from January 2013 to December 2018 were analyzed retrospectively. Taking the postoperative pathological results as the reference standard, the patients were divided into accurate staging group and mistaken staging group according to the comparison of clinical T stage (cT) and pathological T stage (pT). The individual characteristics of the two groups were compared, including visceral fat content at L2/L3 level calculated on computed tomography, age, sex, tumor size, tumor location (cardia, stomach body, stomach antrum), and degree of differentiation. Multivariate logistic regression was used to determine the independent factors affecting the accuracy of cT staging.

RESULTS

Among the 455 patients, 355 patients (78.0 %) had accurate preoperative cT staging and 100 patients (22.0 %) had inaccurate preoperative cT staging. The average area of VAT in the accurate staging group was (129.8 ± 72.6) cm² and that in the mistaken staging group was (74.6 ± 61.6) cm² (P < 0.001). The optimal cut-off value of VAT was 97.8 cm² calculated according to the Yoden index. Multivariate logistic regression analysis showed that VAT, tumor location and tumor size were independent predictors of cT accuracy.

CONCLUSIONS

Patients with lower visceral fat content (<97.8 cm²) based on L2/L3 level had a higher risk of false staging in preoperative clinical T staging.

The prognostic significance of macroscopic serosal change in subserosal invasion (stage T3) gastric cancer

BACKGROUND

For patients with gastric cancer intraoperative macroscopic serosal change is not always consistent with pathological T stage. We investigated whether macroscopic serosal change is associated with unfavourable prognosis of patients with gastric cancer.

METHODS

We reviewed 856 patients with stage T3 gastric cancer who underwent curative gastrectomy in our institution. All patients were classified as serosa negative and serosa positive according to the macroscopic serosal change during the operation. The prognostic difference between two groups was compared and clinicopathologic features were analysed.

RESULTS

The percentage of macroscopic serosal change accounted for 55.7% of all patients. Compared with normal serosal surface, the patients with macroscopic serosal change had larger tumour size, more extensive stomach involvement and more advanced stage N. The prognosis of stage T3 with macroscopic serosal change was significantly poorer than that of those with normal serosal surface, especially for those with stages T3N0 and T3N1. Multivariate analysis identified macroscopic serosal change as an independent factor associated with unfavourable prognosis of stage T3 cancer.

CONCLUSION

Although the depth of tumour invasion mainly depends on pathological evaluation after surgery, the prognostic significance of intraoperative macroscopic serosal change should not be ignored for those patients with subserosal invasion.

T and N Staging of Gastric Cancer Using Dual-Source Computed Tomography

Aim

This study is aimed at comparing gastric cancer T and N staging between virtual monochromatic energy images and fusion images generated by dual-source computed tomography (DSCT) dual-energy mode data acquisition prospectively while measuring the iodine concentration of gastric cancer and lymph nodes at different T and N stages from iodine map retrospectively.

Methods

A total of 71 patients (50 males and 21 females; mean age: 59 ± 11 years) confirmed with gastric cancer by endoscopic biopsy with no neoadjuvant chemotherapy were enrolled for the CT examination before surgeries. The preoperative T and N staging results were compared between groups with pathological results as the gold standard. The iodine concentrations of the gastric lesions and LNs were measured on the iodine-based material decomposition images. All iodine concentration values were normalized against those in the abdominal aorta and defined as normalized iodine concentration (nIC) values. The short axis length of LNs and nIC values were statistically analyzed.

Results

Group A was better than group B for T3 and T4 staging. No statistically significant difference in the overall accuracies for N staging was found between groups. For the late arterial and delayed phases, T3 and T4 nIC values of the extraserosal adipose tissue showed statistically significant differences. The nIC values between N0 and Nm (N1-N3) showed statistically significant differences in the portal phase only.

Conclusions

T3 and T4 nIC values of the extraserosal adipose tissue showed statistically significant differences. Hence, dual-source CT may be helpful in the differential diagnosis between T3 and T4.

Prognostic significance of intraoperative macroscopic serosal invasion finding when it shows a discrepancy in pathologic result gastric cancer

Purpose

Depth of wall invasion is an important prognostic factor in patients with gastric cancer, whereas the prognostic significance of intraoperative macroscopic serosal invasion (mSE) findings remain unclear when they show a discrepancy in pathologic findings. This study, therefore, assessed the prognostic significance of mSE.

Methods

Data from cohort of 2,835 patients with resectable gastric cancer who underwent surgery between 1990 and 2010 were retrospectively reviewed.

Results

The overall accuracy of mSE and pathologic results was 83.4%. The accuracy of mSE was 75.5% in pT2. On the other hand, the accuracy of pT3 dropped to 24.5%. According to mSE findings (+/–), the 5-year disease-specific survival (DSS) rate differed significantly in patients with pT2 (+; 74.2% vs. –; 92.0%), pT3 (+; 76.7% vs. –; 91.8%) and pT4a (+; 51.3% vs. –; 72.8%) (P < 0.001 each), but not in patients with T1 tumor. Multivariate analysis showed that mSE findings (hazard ratio [HR], 2.275; 95% confidence interval [CI], 1.148–4.509), tumor depth (HR, 6.894; 95% CI, 2.325–20.437), nodal status (HR, 5.206; 95% CI, 2.298–11.791), distant metastasis (HR, 2.881; 95% CI, 1.388–6.209), radical resection (HR, 2.002; 95% CI, 1.017–3.940), and lymphatic invasion (HR, 2.713; 95% CI, 1.424–5.167) were independent predictors of 5-year DSS rate.

Conclusion

We observed considerable discrepancies between macroscopic and pathologic diagnosis of serosal invasion. However, macroscopic diagnosis of serosal invasion was independently prognostic of 5-year DSS. It suggests that because the pathologic results could not be perfect and the local inflammatory change with mSE(+) could affect survival, a combination of mSE(+/–) and pathologic depth may be predictive of prognosis in patients with gastric cancer.

Extent of Serosal Changes Predicts Peritoneal Recurrence and Poor Prognosis After Curative Surgery for Gastric Cancer

To investigate whether the width of gastric serosal lesions in advanced gastric cancer patients have a predictive value for peritoneal recurrence and the 5-year survival rate.A total of 1109 patients with advanced noncardia primary gastric adenocarcinoma, who underwent curative gastrectomy between January 1997 and December 2007, were included. Data about tumor size, longitudinal tumor location, resection type, serum albumin concentration, lymphatic/venous invasion, lymph node metastasis status, lesion size, histological and Borrmann type of tumor, as well as the recurrence rate and width of the gastric serosal lesions were collected and analyzed.The peritoneal recurrence rate in patients with gastric serosal lesions ≤3 cm was lower than in patients with gastric serosal lesions >3 cm. Multivariate analyses of the 5-year survival rate variables for all patients revealed significant correlations with serum albumin concentrations (HR 1.382, P = 0.002, 95% CI 1.123-1.701), width of serosa changes (HR 1.377, P = 0.020, 95% CI 1.053-1.802), depth of invasion (HR 1.529, P < 0.001, 95% CI 1.288-1.814), and lymph node metastasis (HR 1.551, P < 0.001, 95% CI 1.420-1.694), whereas for recurrent patients only serum albumin concentrations (HR 2.000, P < 0.001, 95% CI 1.425-2.805), width of serosa changes (HR 1.867, P = 0.002, 95% CI 1.248-2.793), and lymph node metastasis (HR 1.521, P < 0.001, 95% CI 1.249-1.852) correlated with the 5-year survival rate.Gastric serosal lesions >3 cm may indicate a high risk for peritoneal recurrence and serve as additional indicators for preventive postoperative adjuvant chemotherapies in patients with advanced gastric cancer.

Intraoperatively assessed macroscopic serosal changes in patients with curatively resected advanced gastric cancer: clinical implications for prognosis and peritoneal recurrence

BACKGROUND

This study aimed to validate the prognostic relevance of macroscopic serosal changes in patients with resected gastric cancer. Prospectively collected databases of two multicenter randomized phase III trials of adjuvant chemotherapy were analyzed.

METHODS

For this study, 655 patients in the control groups of AMC 0101 and 0201 trials were selected. Macroscopic serosal changes were determined according to disruptions in serosal continuity, such as changes in color or nodular texture by the operating surgeon. Correlations with recurrence-free survival (RFS), overall survival (OS), and time to peritoneal recurrence were analyzed.

RESULTS

Macroscopic serosal changes were identified intraoperatively in 432 patients (66 %) and found to be significantly associated with multifocal or diffuse involvement (p = 0.001), Borrmann type 4 (p = 0.005), advanced pathologic T (p < 0.001), N (p < 0.001), overall stage (p < 0.001), and total gastrectomy (p < 0.001). In multivariate analyses, which included prognostic factors of localized gastric cancer, macroscopic serosal changes were significantly associated with poor RFS [hazard ratio (HR) 2.0; 95 % confidence interval (CI), 1.4-2.7; p < 0.001] and OS (HR 2.1; 95 % CI 1.5-3.0; p < 0.001). The changes also were significantly related to shorter time to peritoneal recurrence (HR 2.9; 95 % CI 1.7-5.0; p < 0.001).

CONCLUSIONS

Intraoperatively assessed macroscopic serosal changes confer a poor prognosis and increased peritoneal recurrence for patients with curatively resected gastric cancer. Macroscopic assessment of serosal changes may be a useful indicator that allows better risk stratification of patients with resected gastric cancer in terms of prognosis and peritoneal recurrence.

Impact of Intraoperative Macroscopic Diagnosis of Serosal Invasion in Pathological Subserosal (pT3) Gastric Cancer

Purpose

The macroscopic diagnosis of tumor invasion through the serosa during surgery is not always distinct in patients with gastric cancer. The prognostic impact of the difference between macroscopic findings and pathological diagnosis of serosal invasion is not fully elucidated and needs to be re-evaluated.

Materials and Methods

A total of 370 patients with locally advanced pT2 to pT4a gastric cancer who underwent curative surgery were enrolled in this study. Among them, 155 patients with pT3 were divided into three groups according to the intraoperative macroscopic diagnosis of serosal invasion, as follows: serosa exposure (SE)(-) (no invasion, 72 patients), SE(±) (ambiguous, 47 patients), and SE(+) (definite invasion, 36 patients), and the clinicopathological features, surgical outcomes, and disease-free survival (DFS) were analyzed.

Results

A comparison of the 5-year DFS between pT3_SE(-) and pT2 groups and between pT3_SE(+) and pT4a groups revealed that the differences were not statistically significant. In addition, in a subgroup analysis of pT3 patients, the 5-year DFS was 75.1% in SE(-), 68.5% in SE(±), and 39.4% in SE(+) patients (P<0.05). In a multivariate analysis to evaluate risk factors for tumor recurrence, macroscopic diagnosis (hazard ratio [HR], SE(-) : SE(±) : SE(+)=1 : 1.01 : 2.45, P=0.019) and lymph node metastasis (HR, N0 : N1 : N2 : N3=1 : 1.45 : 2.20 : 9.82, P<0.001) were independent risk factors for recurrence.

Conclusions

Gross inspection of serosal invasion by the surgeon had a strong impact on tumor recurrence in gastric cancer patients. Consequently, the gross appearance of serosal invasion should be considered as a factor for predicting patients' prognosis.