Role of staging laparoscopy with peritoneal lavage cytology in the treatment of locally advanced gastric cancer

A preoperative predictive tool to assess the need for staging laparoscopy in oesophagogastric cancer patients

INTRODUCTION

Staging laparoscopy (SL) has become commonplace in the preoperative staging pathway for oesophagogastric (OG) cancer. SL is often performed before curative treatment to examine for macroscopic peritoneal metastases (PM) or positive peritoneal cytology (PPC). The aim of this study was to develop an objective risk scoring system to predict both PM and PPC at SL.

METHODS

A prospectively collected and maintained database of all OG cancer patients treated between 2006 and 2020 was reviewed. Univariate and multivariate analyses were performed to identify risk factors for both PM and PPC at SL. A risk score was produced for both PM and PPC, and then validated internally.

RESULTS

Among 968 patients who underwent SL, 96 (9.9%) had PM and 81 (8.4%) had PPC at SL. Tumour site (p < 0.001), computed tomography (CT) T stage (p < 0.001) and N stage (p = 0.029) were significantly associated with PM at SL (p < 0.001). Tumour site (p < 0.001), biopsy histology (p = 0.041), CT T stage (p < 0.001) and N stage (p < 0.001) were significantly associated with PPC. The risk scoring model for PM included cancer site and CT T stage. This was successfully tested on the validation set (area under the receiver operating characteristic [AUROC] = 0.730). The risk scoring model for PPC included cancer site, CT T and N stage. This was successfully tested on the validation set (AUROC = 0.773).

CONCLUSIONS

The current risk scores are valid tools with which to predict the risk PM and PPC in patients undergoing SL for OG cancer and may help to avoid subjecting patients to unnecessary SL.

Efficacy and outcome of extensive intraoperative peritoneal lavage plus surgery vs surgery alone with advanced gastric cancer patients

BACKGROUND

Gastric cancer (GC) is one of the most common malignant tumors. After resection, one of the major problems is its peritoneal dissemination and recurrence. Some free cancer cells may still exist after resection. In addition, the surgery itself may lead to the dissemination of tumor cells. Therefore, it is necessary to remove residual tumor cells. Recently, some researchers found that extensive intraoperative peritoneal lavage (EIPL) plus intraperitoneal chemotherapy can improve the prognosis of patients and eradicate peritoneal free cancer for GC patients. However, few studies explored the safety and long-term outcome of EIPL after curative gastrectomy.

AIM

To evaluate the efficacy and long-term outcome of advanced GC patients treated with EIPL.

METHODS

According to the inclusion and exclusion criteria, a total of 150 patients with advanced GC were enrolled in this study. The patients were randomly allocated to two groups. All patients received laparotomy. For the non-EIPL group, peritoneal lavage was washed using no more than 3 L of warm saline. In the EIPL group, patients received 10 L or more of saline (1 L at a time) before the closure of the abdomen. The surviving rate analysis was compared by the Kaplan-Meier method. The prognostic factors were carried out using the Cox appropriate hazard pattern.

RESULTS

The basic information in the EIPL group and the non-EIPL group had no significant difference. The median follow-up time was 30 mo (range: 0-45 mo). The 1- and 3-year overall survival (OS) rates were 71.0% and 26.5%, respectively. The symptoms of ileus and abdominal abscess appeared more frequently in the non-EIPL group (P < 0.05). For the OS of patients, the EIPL, Borrmann classification, tumor size, N stage, T stage and vascular invasion were significant indicators. Then multivariate analysis revealed that EIPL, tumor size, vascular invasion, N stage and T stage were independent prognostic factors. The prognosis of the EIPL group was better than the non-EIPL group (P < 0.001). The 3-year survival rate of the EIPL group (38.4%) was higher than the non-EIPL group (21.7%). For the recurrence-free survival (RFS) of patients, the risk factor of RFS included EIPL, N stage, vascular invasion, type of surgery, tumor location, Borrmann classification, and tumor size. EIPL and tumor size were independent risk factors. The RFS curve of the EIPL group was better than the non-EIPL group (P = 0.004), and the recurrence rate of the EIPL group (24.7%) was lower than the non-EIPL group (46.4%). The overall recurrence rate and peritoneum recurrence rate in the EIPL group was lower than the non-EIPL group (P < 0.05).

CONCLUSION

EIPL can reduce the possibility of perioperative complications including ileus and abdominal abscess. In addition, the overall survival curve and RFS curve were better in the EIPL group.

Situación actual de la laparoscopía de estadificación en pacientes con cáncer gástrico en Colombia: ¿Cómo lo estamos haciendo?

Introducción. La laparoscopía de estadificación permite identificar con gran precisión el compromiso locorregional avanzado y metastásico a peritoneo en los pacientes con cáncer gástrico. Las guías internacionales aún difieren en las indicaciones para incluir este procedimiento como parte del proceso de estadificación. Métodos. Se diseñó una encuesta dirigida a cirujanos residentes en Colombia, sobre el uso de la laparoscopía de estadificación en los pacientes con cáncer gástrico. Se analizaron los resultados y con base en la evidencia disponible se proponen algunas pautas en las indicaciones y técnica del procedimiento. Resultados. Respondieron la encuesta 74 cirujanos; el 43,8 % considera que el objetivo de la laparoscopía de estadificación es descartar la carcinomatosis peritoneal. El 54,1 % realiza el procedimiento en estadios tempranos, sin embargo, el 48,6 % considera realizarla solo en pacientes con sospecha de carcinomatosis por imágenes. Las áreas evaluadas con mayor frecuencia por los cirujanos (más del 85 %) son la superficie hepática, las cúpulas diafragmáticas, los recesos parietocólicos y la pelvis. Las zonas evaluadas en menor frecuencia son la válvula ileocecal (40,5 %) y el ligamento de Treitz (39 %). El 33 % de los cirujanos no toma rutinariamente citología peritoneal. Conclusión. Este trabajo muestra la tendencia de los cirujanos en el uso de la laparoscopía de estadificación en pacientes con cáncer gástrico. A pesar de encontrar resultados muy positivos en relación con las indicaciones y técnica del procedimiento, es necesario analizar la evidencia disponible para su uso según cada escenario y mejorar la sistematización del procedimiento.

Phase 2 randomized controlled trial of intravenous or intraperitoneal paclitaxel plus mFOLFOX6 vs. mFOLFOX6 as first-line treatment of advanced gastric cancer

Objective

We conducted a phase 2 trial to compare the safety and efficacy of intravenous paclitaxel or intraperitoneal paclitaxel plus mFOLFOX6 vs. mFOLFOX6 in untreated advanced gastric cancer.

Methods

Participants with untreated advanced gastric cancer were randomly assigned (1:1:1) to: intravenous paclitaxel 135 mg/m² or intraperitoneal paclitaxel 80 mg/m² plus mFOLFOX6 omitting bolus fluorouracil; or mFOLFOX6 (oxaliplatin 85 mg/m², leucovorin 400 mg/m², fluorouracil 400 mg/m² bolus, fluorouracil 2,400 mg/m² 46-h continuous infusion). Treatment was every 14 days for up to 9 cycles followed by S-1 maintenance. The primary outcome was progression-free survival.

Results

Of 90 enrolled participants, 30 in the intravenous paclitaxel group, 29 in the intraperitoneal paclitaxel group, and 30 in the mFOLFOX6 group were included in the analyses. The median progression-free survival was 6.52, 5.83, and 4.55 months, respectively, for the intravenous paclitaxel group, intraperitoneal paclitaxel group, and mFOLFOX6 group. The hazard ratios were 0.56 (95% CI: 0.33–0.94; p = 0.026) and 0.56 (95% CI: 0.33–0.96; p = 0.037), respectively, for the intravenous paclitaxel group and the intraperitoneal paclitaxel group vs. the mFOLFOX6 group. The most common grade 3/4 adverse events for the intravenous paclitaxel group, intraperitoneal paclitaxel group, and mFOLFOX6 group, respectively, were neutropenia (30.0%, 34.5%, 33.3%), diarrhea (13.3%, 20.7%, 13.3%), and leukopenia (10.0%, 13.8%, 10.0%). No treatment-related death occurred.

Conclusion

The findings of this phase 2 trial suggest that adding intravenous paclitaxel or intraperitoneal paclitaxel to mFOLFOX6 for untreated advanced gastric cancer improved progression-free survival with manageable adverse events.

Prognostic value of molecular cytology by one-step nucleic acid amplification (OSNA) assay of peritoneal washings in advanced gastric cancer patients

Peritoneal dissemination is a common form of gastric cancer (GC) recurrence, despite surgery with curative intent. This study aimed to evaluate the prognostic value of intraperitoneal lavage One-Step Nucleic Acid Amplification (OSNA) assay in advanced GC patients. OSNA assay targeting CK-19 mRNA was applied to detect free cancer cells (FCC) in intraperitoneal lavage samples obtained during gastrectomy. A total of 82 GC patients were enrolled to investigate the correlation between OSNA assay and patient's prognosis. Of the 82 patients, OSNA assay was positive in 25 (30.5%) patients. The median OS in OSNA positive patients was significantly lower than in OSNA negative patients (19 vs 45 months). Positive OSNA assay result was a significant unfavourable prognostic factor in both, univariable (HR 3.45, 95% CI 0.95-12.48; p = 0.0030) and multivariable analysis (HR 3.10, 95% CI 1.22-8.54; p = 0.0298). Positive OSNA assay in intraperitoneal lavage is a valuable indicator of poor survival in advanced GC patients after multimodal treatment. After further confirmation on larger sample size, OSNA assay of peritoneal washings could be considered an adjunct tool to conventional cytology, the current gold standard, to provide precise intraoperative staging and additional prognostic information.

Usefulness of Diagnostic Staging Laparoscopy for Advanced Gastric Cancer

BACKGROUND

For advanced gastric cancer (AGC), peritoneal metastasis is the most common determinant of unresectability, but accurate preoperative diagnosis for peritoneal metastasis is challenging. Staging laparoscopy (SL) can detect unsuspected peritoneal metastasis. This study retrospectively evaluated the utility of SL and its indication in patients with AGC.

METHODS

In this study, we enrolled 114 patients with pathologically diagnosed gastric adenocarcinoma who underwent SL.

RESULTS

Of the 114 patients, 43 (37.7%) had peritoneal metastasis (P1 or CY1). Higher age, larger tumor size, type 4 GC, deeper tumor depth, elevated CA125, and ascites findings in preoperative CT were found to be significant predictors of peritoneal metastasis. In multivariate analysis, peritoneal metastasis was associated with type 4 GC (odds ratio [OR]: 6.11; 95% confidence interval [CI]: 1.87-19.8; P < .01) and ascites in CT (OR: 4.25; 95% CI: 1.48-12.1; P < .01).

CONCLUSIONS

Staging laparoscopy is an effective tool to detect peritoneal metastasis from AGC. It can increase the curative resection rate and decrease unnecessary laparotomies.

The role of laparoscopic staging for the management of gastric cancer

AİM Staging laparoscopy enables us to perform palliative treatment, neo-adjuvant therapy for curative resection or direct curative resection and making a decision with minimal morbidity by avoiding from unnecessary laparotomies. In the present study, the importance of staging lapafoscopy was retrospectively investigated by using clinical and pathologic data. METHODS Data of 70 out of 350 patients who underwent diagnostic laparoscopy due to gastric cancer at Surgical Oncology department between August 2013 and January 2020 were retrospectively analyzed. RESULTS Peritoneal biopsy was positive for malignity in 41 (58.5%) and negative in 29 (41.5%) of the patients who underwent SL. Peritoneal cytology (PC) results were negative in 32 (45.7%) patients and positive in 38 (54.3%) patients. Peritoneal biopsy and cytology results were concurrently positive in 35 patients and concurrently negative in 26 patients. CONCLUSİONS In conclusion, even the most developed imaging methods cannot provide 100% staging, therefore SL plays an important role in treatment of gastric cancer and laparoscopic staging is essential as a simple, inexpensive, safe and well tolerated method in patients who have the suspicion of peritoneal disease and who cannot be clearly evaluated with pre-operative methods.

Peritoneal Lavage Cytology Following Neoadjuvant Chemotherapy for Gastric Adenocarcinoma: Low Yield in Detecting Peritoneal Metastases

BACKGROUND

Peritoneal lavage cytology (PLC) can detect advanced disease in gastric adenocarcinoma (GC); however, routine practice remains controversial. Furthermore, the effect of neoadjuvant chemotherapy (NAC) on cytological detection of carcinomatosis is unknown.

METHODS

Using a 2012-2020 prospective database, we retrospectively reviewed patients with GC who underwent NAC followed by a staging laparoscopic peritoneal lavage with or without biopsy of suspicious peritoneal nodules. PLC results were considered discordant if they did not align with the peritoneal biopsy results. Patients with benign peritoneal cytology (Cyt-) or biopsy results who had postoperative time to carcinomatosis of <6 months were considered to have diagnostic failure of peritoneal lavage.

RESULTS

Fifty-five patients with GC who underwent NAC followed by staging diagnostic laparoscopy with peritoneal lavage were identified. The majority of the patients in the cohort had Cyt- lavage (89.1%). Of the patients who underwent resection, 76.1% had T3 or greater disease on final pathology and 66% had nodal metastases. In 23 patients (41.8%) who had both peritoneal lavage and biopsy, four cases (17.4%) had discordant results. Diagnostic failure rate was 20% at 6 months and 42.2% at 12 months. The median time to carcinomatosis in patients who were Cyt- or biopsy negative was 7.9 months.

CONCLUSION

PLC after NAC has a high diagnostic failure rate and inaccurately predicts carcinomatosis in 20% of patients with GC. Novel methods for identifying cytology positive GC after NAC should also be developed and evaluated, since the risk of peritoneal dissemination is high.

Staging laparoscopy in gastric cancer surgery. A population-based cohort study in patients undergoing gastrectomy with curative intent

BACKGROUND

Studies on the value of a staging laparoscopy in detecting metastases in gastric cancer patients show great variation. This study investigates the avoidable surgery rate in patients with and without a staging laparoscopy scheduled for surgery with curative intent.

METHODS

This population-based cohort study included all patients with an intentional resection for a potentially curable gastric adenocarcinoma, between 2011 and 2016, registered in the Dutch Upper GI Cancer audit. Patients with and without a staging laparoscopy were compared. The primary outcome was the avoidable surgery rate (detection of metastases and/or locoregional non-resectable tumor during intentional gastrectomy). Secondary outcomes were the negative predictive value, postoperative morbidity and pathology parameters.

RESULTS

2849 patients who underwent an intentional gastrectomy were included. 414 of 2849 (14.5%) patients underwent a staging laparoscopy before initiation of treatment. The avoidable surgery rate was 16.2% in the staging laparoscopy group, compared to 8.5% in the non-staging group (P < 0.001), resulting in a negative predictive value of 83.8%. The avoidable surgery rate remained significantly different after correction for possible confounders. The main reason for not executing the gastrectomy was the presence of distant metastasis in both groups. cT and cN stage were significantly higher in patients who underwent a staging laparoscopy.

CONCLUSIONS

The staging laparoscopy group had a higher cTN and pTN stage, implicating selection of patients with more advanced disease for a staging laparoscopy. Despite the staging laparoscopy, a higher rate of avoidable surgery was found, suggesting a low sensitivity for detecting metastases or locoregional non-resectability in this patient group.

Peritoneal dissemination of breast cancer diagnosed by laparoscopy

The accuracy of modern imaging techniques for the diagnosis of peritoneal carcinomatosis is poor. A breast cancer patient with a high serum CA15-3 level did not receive a definitive diagnosis of peritoneal dissemination by imaging examination and then underwent laparoscopy. Pathological examination showed peritoneal dissemination of breast cancer, but the biological markers were different from the primary lesion: ER(−), PgR(−), and Her2:3 +. T-DM1 therapy was very effective, and her systemic symptoms disappeared. Since biomarkers of metastatic lesions may sometimes change, laparoscopic biopsy is very important and useful.

Gastric Cancer with Radiographically Occult Metastatic Disease: Biology, Challenges, and Diagnostic Approaches

Gastric adenocarcinoma is an aggressive cancer that demonstrates heterogeneous biology depending on patient ethnicity, tumor location, tumor type, and genetic profile. It remains the third leading cause of cancer deaths worldwide and was estimated to result in 782,000 deaths in 2018. Challenges exist in accurately assessing the disease burden, as available radiological staging often underestimates metastatic disease. This diagnostic handicap, along with the poor understanding of the heterogeneous biology of gastric cancer, has hindered the development of effective therapeutic solutions and thus halted improvement in patient outcomes over the last few decades. The management of occult peritoneal disease is complicated, as most patients are understaged by standard imaging studies and therefore thought to have local diseases. In this article, we systematically review recent literature on the limitations that are associated with standard radiographic staging, discuss recent molecular biology advances to better identify and diagnose occult peritoneal disease, and propose possible management strategies to approach this complicated clinical problem.

Diagnostic Laparoscopy and Abdominal Cytology Reliably Detect Peritoneal Metastases in Patients with Urachal Adenocarcinoma

BACKGROUND

Urachal adenocarcinoma (UrAC) is a rare malignancy that can cause peritoneal metastases (PM). Analogous to other enteric malignancies, selected patients with limited PM of UrAC can be treated by cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

OBJECTIVE

The aim of this study was to address the value of diagnostic laparoscopy (DLS) and abdominal cytology (ACyt) for the detection and evaluation of the extent of PM in patients with UrAC.

METHODS

A consecutive series of cN0M0 patients with UrAC who underwent DLS with or without ACyt at a tertiary referral center between 2000 and 2018 was assessed. Patients were staged with computed tomography (CT) and/or positron emission tomography (PET)/CT or bone scan. DLS was performed to rule out PM and to evaluate the extent and resectability of PM if seen on imaging. Sensitivity and specificity values were calculated for imaging, DLS, ACyt, and the combination of DLS and ACyt.

RESULTS

Thirty-two patients with UrAC underwent DLS. ACyt was obtained in 19 patients. Four patients had suspicion of PM on imaging. In the 28 patients who were PM-negative on imaging, DLS and ACyt revealed PM in 6 (21%) patients, of whom 5 had macroscopically visible PM; 1 patient had positive ACyt without visible PM. Sensitivity of combined DLS/ACyt for the detection of PM was 91%, with a specificity of 100%, whereas sensitivity of imaging was 36%. DLS correctly predicted resectability in all patients.

CONCLUSION

Combined DLS/ACyt proved an effective tool to detect occult PM and to evaluate the extent of PM to select UrAC patients for possible treatment with CRS/HIPEC.

Effect of early body cavity continuous circulation hyperthermia perfusion chemotherapy combined with systemic chemotherapy (and nursing) on survival rate and serum tumor markers in patients with advanced gastric cancer

This study was designed to investigate the effects of early coelom continued circulatory hyperthermic perfusion chemotherapy combined with systemic chemotherapy on the survival and serum tumor markers. A total of 128 patients with advanced gastric carcinoma who have received surgical treatments were selected and were randomly divided into study group (receiving early circulatory intraperitoneal hyperthermic perfusion chemotherapy combined with systemic chemotherapy postoperatively) and control group (receiving chemotherapy alone postoperatively), with 64 cases in each. Comparison of serum tumor markers (CA724, CA242), vascular endothelial growth factor (VEGF), matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9), immune function indexes (CD3+, CD4+, CD8+), and 5-year survival rate was assessed. Before treatment, there was no significant difference in the serum tumor markers (CA724 and CA242) as well as the serum VEGF, MMP-2, and MMP-9 levels among the two groups ( P > 0.05). However, the above parameters in the study group were significantly lower than control group 8 weeks after the treatment ( P < 0.05). Before treatment, there was no significant difference in CD3+, CD4+, CD8+ and CD4+/CD8+ between the two groups ( P > 0.05). Eight weeks after the treatment, the CD3+, CD4+ and CD4+/CD8+ in the study group were significantly higher than those in the control group ( P < 0.05), while the CD8+ levels was significantly lower than the latter group ( P < 0.05). The 2-year recurrence rate in the study group was lower than the control group ( P < 0.05). Furthermore, survival rates (1-year, 3-year and 5-year) of the study group were all higher than control group ( P < 0.05). Early circulatory hyperthermia perfusion chemotherapy combined with systemic chemotherapy contributed to the decrease in the serum tumor markers (CA724, CA242) as well as the serum VEGF, MMP-2, and MMP-9 levels, improved the immune functions. This therapeutic regimen prolonged the long-term survival conditions of the patients as well as proved the safety and effectiveness.

Genomewide Expression Profiling Identifies a Novel miRNA-Based Signature for the Detection of Peritoneal Metastasis in Patients With Gastric Cancer

OBJECTIVE

This study aimed to conduct a genomewide transcriptomic profiling to develop a microRNA (miRNA)-based signature for the identification of peritoneal metastasis (PM) in patients with gastric cancer (GC).

SUMMARY BACKGROUND DATA

Even though PM in patients with GC has long been recognized to associate with poor prognosis, currently there is lack of availability of molecular biomarkers for its robust diagnosis.

METHODS

We performed a systematic biomarker discovery by analyzing miRNA expression profiles in primary tumors from GC patients with and without PM, and subsequently validated the expression of candidate miRNA biomarkers in 3 independent clinical cohorts of 354 patients with advanced GC.

RESULTS

Five miRNAs (miR-30a-5p, -134-5p, -337-3p, -659-3p, and -3917) were identified during the initial discovery phase; three of which (miR-30a-5p, -659-3p, and -3917) were significantly overexpressed in the primary tumors from PM-positive patients in the testing cohort (P = 0.002, 0.04, and 0.007, respectively), and distinguished patients with versus without peritoneal metastasis with the value of area under the curve (AUC) of 0.82. Furthermore, high expression of these miRNAs also associated with poor prognosis (hazard ratio = 2.18, P = 0.04). The efficacy of the combination miRNA signature was subsequently validated in an independent validation cohort (AUC = 0.74). Finally, our miRNA signature when combined together with the macroscopic Borrmann's type score offered a much superior diagnostic in all 3 cohorts (AUC = 0.87, 0.76, and 0.79, respectively).

CONCLUSIONS

We have established an miRNA-based signature that have a potential to identify peritoneal metastasis in GC patients.

Conversion Surgery for Gastric Cancer with Peritoneal Metastasis Based on the Diagnosis of Second-Look Staging Laparoscopy

BACKGROUND

Patients with positive peritoneal cytology (CY1) or peritoneal dissemination (P1) have significantly poor prognosis. We performed pre-therapeutic staging laparoscopy (SL) to diagnose peritoneal metastasis for patients with advanced gastric cancer. When peritoneal metastasis disappears by chemotherapy for patients with CY1 or P1, we have intention to perform conversion surgery (CS). This study aims to clarify the clinical significance of CS for such patients.

METHODS

We retrospectively analyzed clinical outcomes of 115 patients with advanced gastric cancer (large type 3, type 4, serosa-invasion) who underwent SL between 2005 and 2014. Disappearance of peritoneal metastasis was confirmed by second-look SL.

RESULTS

CY0P0, CY1P0, and P1 were found in 56, 26, and 33 patients, respectively. In patients with CY1P0, 12 patients (66.7%) underwent CS (R0) as peritoneal cytology turned negative. All cases received S-1-based regimens, with median five treatment courses. The survival of patients with CS was significantly longer than those without CS (median survival time (MST); 41 vs. 11 months, respectively, P < 0.001). We observed no difference in overall survival between patients who underwent CS and patients with CY0P0 at the first SL (P = 0.913). All patients with P1 received chemotherapy. As peritoneal metastasis of five patients (15.2%) disappeared by chemotherapy, those patients underwent the CS (R0). The survival of patients who underwent CS was significantly longer than those who did not (MST; 31 vs. 10 months, respectively, P = 0.034).

CONCLUSION

This study suggests that conversion surgery contributes to improvement in survival of patients with peritoneal metastasis.

Role of staging laparoscopy for gastric cancer patients

Staging laparoscopy (SL) is frequently carried out in patients with advanced gastric cancer. However, some clinical questions are being debated and consensus must be obtained. With this aim, a literature search of PubMed/MEDLINE was carried out using the keywords "gastric cancer," "SL," and "diagnostic laparoscopy". Articles published online up to February 2019 were analyzed, focusing on the following questions. (i) What is an adequate indication for SL? (ii) How do you carry out SL? (iii) Does SL provide accurate information about peritoneal dissemination? (iv) Is the yield of SL different by tumor location? (v) Is SL a safe procedure? (vi) Is "repeat SL" needed? (vii) Does SL provide oncological benefit? Results provided the following responses: (i) In Western countries, clinically resectable advanced tumor is an indication for SL. Terms to be introduced for adequate indication include "location," "type 4 (linitis feature)," "large tumor," "equivocal computed tomography (CT] findings," and "lymph node swelling". (ii) Exploration of the entire peritoneal cavity is preferable. (iii) Detection rate of peritoneal disease is 43%-52% in Japanese institutions and 7.8%-40% in other countries. False-negative findings during SL were 0%-17%, and 10%-13% when limited to cytology. (iv) Yield of SL was higher in gastric cancer compared with esophagogastric junctional tumor. (v) SL-related complications were estimated to occur in 0.4%. (vi) Repeat SL is important after treatment. (vii) If the efficacy of neoadjuvant chemotherapy for patients with P0CY1 is established, SL can provide oncological benefit. SL can be carried out safely and effectively. Considering the prevalence of neoadjuvant treatment, the role of SL will become more important.

Utilidad de la laparoscopia de estadificación frente a la tomografía axial computarizada para detectar metástasis peritoneales en el adenocarcinoma gástrico avanzado

  Introducción. El adenocarcinoma gástrico es una de las neoplasias más frecuentes. La tomografía computarizada abdominal con contraste es el método estándar para la estadificación; tiene una sensibilidad del 30 al 73 % y una especificidad del 83 al 100 %. La laparoscopia detecta hasta el 30 % de los casos de enfermedad metastásica que no se haya observado en los estudios de imágenes. En la Clínica Universitaria Colombia se realiza estadificación rutinaria con tomografía y laparoscopia más lavado peritoneal. Objetivos. Determinar la utilidad de la laparoscopia para detectar la carcinomatosis peritoneal en los pacientes con adenocarcinoma gástrico avanzado en un centro de referencia. Materiales y métodos. Se llevó a cabo un estudio descriptivo y retrospectivo, en el cual se analizaron todas las historias clínicas de los pacientes con cáncer gástrico atendidos en la Clínica Universitaria Colombia entre el 2013 y el 2016. Se confrontó el hallazgo de la laparoscopia con el de la tomografía abdominal, buscando falsos negativos para la enfermedad peritoneal. Resultados. Se incluyeron 94 pacientes con adenocarcinoma gástrico. La localización en el cuerpo gástrico fue la más frecuente (47,9 %). La tomografía reportó estadio T3 en el 56,4 %, N0 en el 55,3 % y M0 en el 97,9 % de los casos. La laparoscopia reportó estadio T3 en el 43,6 %, ganglios comprometidos en el 56,4 % y carcinomatosis peritoneal (M1) en el 11,7 %. Discusión. Un radiólogo experimentado detecta una gran proporción de las enfermedades peritoneales, pero la laparoscopia detecta hasta 11 % de aquellas que no son evidentes en los exámenes de imágenes. El lavado peritoneal no prolonga el tiempo quirúrgico ni incrementa la morbilidad, lo cual favorece su realización rutinaria. Se puede recomendar la laparoscopia en aquellos pacientes con resultados tomográficos negativos, evitando la cirugía cuando la neoplasia es irresecable. La laparoscopia tiene un impacto positivo en el manejo integral del cáncer gástrico, acorde con la literatura mundial.

Effects of CO2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells

BACKGROUND

The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO₂ pneumoperitoneum.

METHODS

We established simulated CO₂ pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO₂ pneumoperitoneum treatment group and 15 mmHg CO₂ pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention.

RESULTS

Cell culture pH value of each subgroup in CO₂ group decreased significantly after exposed in CO₂ pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO₂ group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO₂ 1 h subgroup and 15 mmHg CO₂ 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO₂ pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO₂ group 24 h after exposure to CO₂. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO₂ group and decreased in 3-h subgroup of 15 mmHg CO₂ group 72 h after exposure to CO₂. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO₂ group compared to that in 3-h subgroup of control group.

CONCLUSIONS

The routine pressure and duration of CO₂ pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.

"Four-Step Procedure" of laparoscopic exploration for gastric cancer in West China Hospital: a retrospective observational analysis from a high-volume institution in China

BACKGROUND

The preoperative work-up has limitations on finding peritoneal dissemination (PD) in gastric cancer patients. Laparoscopic exploration (LE) can discover radiographically occult PD, obtain accurate stage and avert futile laparotomy. The aim of our study was to introduce "Four-Step Procedure" LE in West China Hospital and further evaluate its safety and feasibility.

METHODS

We conducted a retrospective analysis on 165 patients from July 2016 to December 2017 who underwent "Four-Step Procedure" LE in gastrointestinal surgery department of West China Hospital. All the patients were diagnosed with gastric adenocarcinoma without explicit distant metastasis through Computed Tomography and/or Gastrointestinal Ultrasonography. Peritoneal lavage cytological examination (CY) was routinely performed during LE in our research. The "Four-Step" technical process of LE was introduced comprehensively. The clinicopathologic features and the presence of PD or CY at LE were analyzed, and the stratified analysis by cT and cN stages on the proportion of P1 and/or CY1 was also reported in this study.

RESULTS

Total of 165 patients accepted LE in our study, among these patients: 27 (16.4%) patients with P1 and/or CY1: 19 (11.5%) patients were found PD (P1), 17 (10.3%) patients with positive cytological examination (CY1) and 9 (3.6%) patients with P1Cy1. The stratified analysis by cT stage indicated that there was no P1 and/or Cy1 in cT1-cT2 stages, 1 (2.7%) patient with P1 and 1 (2.7%) with Cy1 in cT3 stage, 18 (20.0%) patients with P1 and 16 (17.8%) with Cy1 in cT4 stage. After LE, there were 74 (44.8%) patients underwent laparoscopic assistant gastrectomy, 25 (15.2%) patients with open gastrectomy, 50 (30.3%) patients with neoadjuvant chemotherapy and 16 (9.7%) patients with palliative chemotherapy and/or conversion therapy.

CONCLUSION

"Four-Step Procedure" LE is reliable and feasible for gastric cancer. From our study, LE has unique superiority on ascertaining PD and cytological examination and LE should be recommended in cT4 stage gastric cancer before resection.

Imaging peritoneal metastasis of gastric cancer with 18F-fluorothymidine positron emission tomography/computed tomography: a proof-of-concept study

OBJECTIVE

Peritoneal metastasis (PM) is the most frequent form of metastasis in gastric cancer (GC). The sensitivity of detecting PM by pre-operative imaging modalities is low. Utility of positron emission tomography (PET) with ¹⁸F-fluodeoxyglucose (FDG) for GC is limited, because diffuse-type tumors are not FDG-avid. ¹⁸F-fluothymidine ([F-18]FLT) is a radiotracer that reflects cellular proliferation and the utility of [F-18]FLT-PET in GC has been reported. In this proof-of-concept study, we explored the ability of [F-18]FLT-PET/CT to detect PM of GC previously identified by other imaging modalities.

METHODS

The key eligibility criteria were as follows; (i) histologically proven gastric adenocarcinoma; (ii) evident PM detected by CT performed within 4 weeks prior to registration; (iii) no prior treatment of PM within 4 weeks before registration. [F-18]FLT-PET/CT was performed at National Cancer Center Hospital, and [F-18]FLT-PET/CT images were evaluated independently by two radiologists. Safety assessments were carried out before and after [F-18]FLT-PET/CT. The primary end point was the detection sensitivity of PM.

RESULTS

A total of 19 eligible patients were analyzed, of which 15 (78.9%) had diffuse-type histology. Detection sensitivity of PM, primary lesion, and lymph node metastasis were 73.7% [maximum standardized uptake value (SUVmax): 1.697-13.21], 100% (SUVmax: 2.71-22.01), and 72.7% (SUVmax: 2.079-12.61), respectively. No patients experienced adverse events during or after [F-18]FLT-PET/CT.

CONCLUSION

This proof-of-concept study shows that [F-18]FLT-PET/CT is a sensitive method for detecting PM in GC, and paves the way for future studies investigating the clinical utility of this approach for the detection of clinically non-evident PM in GC. Advances in knowledge: This proof-of-concept study found that [F-18]FLT-PET/CT is a sensitive method for detecting peritoneal metastases in GC.

Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis

BACKGROUND

Peritoneal cytology has been used as a part of the cancer staging of gastric cancer patients. The primary aim of this systematic review was to evaluate the value of peritoneal cytology as part of the staging of gastric cancer and survival prediction. The second aim was to establish if positive cytology may be modified by neoadjuvant therapy, to improve prognosis.

METHODS

An electronic literature search was performed using Embase, Medline, Web of Science, and Cochrane library databases up to January 2016. The logarithm of the hazard ratio (HR) with 95% confidence intervals (CI) was used as the primary summary statistic. Comparative studies were used, and the outcome measure was survival in three groups: (1) positive versus negative cytology at staging laparoscopy immediately preceding surgery; (2) effect of neoadjuvant therapy on cytology and survival; and (3) positive cytology in the absence of macroscopic peritoneal disease was compared with obvious macroscopic peritoneal disease.

RESULTS

Pooled analysis demonstrated that positive cytology was associated with significantly reduced overall survival (HR, 3.46; 95% CI, 2.77-4.31; P < 0.0001). Interestingly, negative cytology following neoadjuvant chemotherapy was associated with significantly improved overall survival (HR, 0.42; 95% CI, 0.31-0.57; P < 0.0001). The absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved overall survival (HR, 0.64; 95% CI, 0.56-0.73; P < 0.0001).

CONCLUSION

This study suggests that patients with initial positive cytology may have a good prognosis following neoadjuvant treatment if the cytology results change to negative after treatment.

Stage IV gastric cancer successfully treated by multidisciplinary therapy including chemotherapy, immunotherapy, and surgery: a case report

BACKGROUND

The prognosis of stage IV gastric cancer (GC) still remains unfavorable. Multidisciplinary approaches should therefore be considered to improve the survival of patients with stage IV GC. We report here a case of primary GC with potentially unresectable metastasis, successfully treated by a multidisciplinary approach including chemotherapy, immunotherapy, and surgery.

CASE PRESENTATION

A 74-year-old man presented with multiple left neck masses. Abdominal computed tomography showed a thickened gastric wall and multiple lymphadenopathies including left supraclavicular lymph node. Gastroenterological endoscopy revealed tumor lesions in the gastric cardia. Tumor biopsy indicated a pathological diagnosis of poorly differentiated adenocarcinoma. Open left cervical lymph node biopsy showed histological features identical with the gastric tumor, indicating left clavicle lymph node metastasis of GC. After 2 years of chemo-immunotherapy with S-1/CDDP, paclitaxel, and cytokine-activated killer cells, lesions other than the stomach lesion had regressed to undetectable on imaging studies. The patient then underwent laparoscopy-assisted total gastrectomy with Roux-en-Y reconstruction followed by adjuvant chemo-immunotherapy with paclitaxel and S-1 for 1 year, and immunotherapy with tumor lysate-pulsed dendritic cell-activated killer cells for 5 years. The patient remained well after 5 years and 6 months of follow-up, with no signs of recurrence.

CONCLUSION

Therapeutic combinations including immunotherapy may thus allow surgery to be performed in patients previously considered unsuitable for surgical intervention, potentially leading to a clinical cure, as in the current case.

The Yield of Staging Laparoscopy in Gastric Cancer is Affected by Racial and Ethnic Differences in Disease Presentation

BACKGROUND

Gastric cancer is a heterogeneous disease with variable presentation between racial and ethnic groups. Staging laparoscopy (SL) detects occult metastases not visible on cross-sectional imaging and therefore improves staging. It remains unclear how differences in race and ethnicity affect disease presentation and the yield of SL.

METHODS

We performed a retrospective review of a prospectively maintained database to identify patients with gastric cancer treated with curative intent at our institutions from 2008 to 2015.

RESULTS

Hispanic patients presented at an earlier mean age (55.5 ± 11.9 years) compared with Asian (59.8 ± 13.9 years), African American (61.0 ± 10.0 years), and white patients (61.7 ± 12.5 years; p = 0.046) and with more locally advanced disease (clinical stage T3/T4 or node positive; Hispanic 87%; African American 79%; white 68%, Asian 55%; p = 0.03). SL identified 42 patients (34%) with occult metastatic disease. Hispanics were more likely to have a positive SL (44%) than white patients (21%; p = 0.04). On univariate analysis, Hispanic ethnicity, clinical T3/T4, positive nodal disease, signet ring cells, and poor differentiation were predictors of a positive SL. On multivariable analysis, clinical T3/T4, signet ring cells, and poor differentiation independently predicted radiographically occult disease.

CONCLUSIONS

Hispanic patients presented with more locally advanced disease and were more likely to have occult disease found on SL compared with white patients. Laparoscopy should be used routinely as part of the pretreatment staging evaluation for patients with locally advanced disease as it alters the management in a significant proportion of patients.

Yield of Staging Laparoscopy for Incurable Factors in Chinese Patients with Advanced Gastric Cancer

BACKGROUND

Although the role of staging laparoscopy (SL) in detecting radiologically occult M1 disease has been widely recognized, it is seldom used in China and its clinical value based on Chinese population has been rarely reported. The aim of this study is to identify the yield of SL for Chinese patients with advanced gastric cancer (AGC) and determine the proportions of patients in whom treatment plan is altered.

MATERIALS AND METHODS

The clinical data were retrospectively collected from 879 AGC patients who underwent SL without any definite signs of disseminated disease on imaging examination. The primary outcomes were the proportions of patients whose laparoscopy identified incurable factors (including M1 diseases and unresectable T4b diseases), and who had their treatment plan altered.

RESULTS

SL revealed incurable factors in 130 (14.8%) patients, including macroscopic peritoneal metastasis (n = 92), positive peritoneal cytology (n = 10), liver metastasis (n = 12), para-aortic lymph node metastasis (n = 1), and unresectable T4b tumor (n = 18). After SL, treatment plans were altered in 123 (14.0%) patients, among which 82 (63.1%) patients were not offered any further procedure and referred for chemotherapy. Among 749 M0 patients who immediately proceeded to radical gastrectomy after SL, new incurable factors were found at subsequent operations in 21 (2.8%) patients. Multivariate analysis showed that tumor size ≥8 cm, Borrmann type III and IV, and tumor invasion of T4a and T4b in preoperative imaging examination were the predictive factors for peritoneal metastasis.

CONCLUSIONS

SL detects additional incurable factors in Chinese AGC patients with potentially resectable disease and optimizes their treatments. A systematic and painstaking inspection of the whole abdominal cavity, including routine entry into the bursa omentalis, is necessary for improving the yield of SL.

Depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis

Objective

Diagnostic laparoscopy is recommended for the pretherapeutic staging of gastric cancer to detect any unexpected or unconfirmed intra-abdominal metastasis. The aim of this study was to evaluate the role and indications of diagnostic laparoscopy in the detection of intra-abdominal metastasis.

Methods

Standard diagnostic laparoscopy with peritoneal cytology examination was performed prospectively on patients who were clinically diagnosed with primary local advanced gastric cancer (cT≥2M0). We calculated the rate of intra-abdominal metastases identified by diagnostic laparoscopy, and examined the relationship between peritoneal dissemination (P) and cytology results (CY). Split-sample method was applied to find clinical risk factors for intra-abdominal metastasis. Multivariate logistic regression analysis and receiver-operator characteristic (ROC) analysis were performed in training set to find out risk factors of intra-abdominal metastasis, and then validate it in testing set.

Results

Out of 249 cM0 patients, 51 (20.5%) patients with intra-abdominal metastasis were identified by diagnostic laparoscopy, including 20 (8.0%) P1CY1, 17 (6.8%) P0CY1 and 14 (5.6%) P1CY0 patients. In the training set, multivariate logistic regression analysis and ROC analysis showed that the depth of tumor invasion on computer tomography (CT) scan ≥21 mm and tumor-occupied ≥2 portions of stomach are predictive factors of metastasis. In the testing set, when diagnostic laparoscopy was performed on patients who had one or two of these risk factors, the sensitivity and positive predictive value for detecting intra-abdominal metastasis were 90.0% and 32.1%, respectively.

Conclusions

According to our results, depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis.

Detection value of free cancer cells in peritoneal washing in gastric cancer: a systematic review and meta-analysis

Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells is still unclear, leading to a lack of consensus in the management of gastric cancer. The aim of the present study is to perform a systematic review and meta-analysis to analyze intraperitoneal free cancer cells-positive patients with regard to tumor oncologic stage, recurrence, grade of cellular differentiation, and survival rates and to analyze the clinical significance of intraperitoneal free cancer cells with regard to prognosis. Databases were searched up to January 2016 for prognostic factors associated with intraperitoneal free cancer cells, including oncologic stage, depth of neoplasm invasion, lymph nodal spread, differentiation grade of the tumor, and recurrence and survival rates. A total of 100 studies were identified. Meta-analysis revealed a clear association between intraperitoneal free cancer cells and a poor prognosis. intraperitoneal free cancer cells -positive patients had higher rates of nodal spread (risk difference: 0.29; p<0.01), serosal invasion (risk difference: 0.43; p<0.01), recurrence (after 60 months of follow-up, risk difference: 0.44; p<0.01), and mortality (after 60 months of follow-up, risk difference: 0.34; p<0.01). Intraperitoneal free cancer cells are associated with a poor outcome in gastric cancer. This surrogate biomarker should be used to guide therapy both prior to and after surgery.

Greater Omental Milky Spot Examination for Diagnosis of Peritoneal Metastasis in Gastric Cancer Patients

OBJECTIVE

To evaluate the diagnostic value of cytological greater omental milky spot examination for the diagnosis of peritoneal metastasis in gastric cancer patients.

METHODS

A total of 136 patients diagnosed with gastric cancer and without distant metastasis were enrolled in our study. All patients underwent laparoscopy and CH40 suspension liquid dye of peritoneal lymph nodes preoperatively as well as ascites or peritoneal lavage fluid collections and excisions of marked greater omental milky spot tissues perioperatively.

RESULTS

According to the laparoscopic results, the patients were divided into T1-T2 stage (n = 56) without and into T3-T4 stage (n = 80) with tumor invasion into the serosal layer. Among the T1-T2-stage patients, tumor cells could be detected in peritoneal lavage fluids in 2 cases, whereas with greater omental milky spot examination, peritoneal metastasis was detected in 8 cases. Among the 80 cases in the T3-T4 stage, tumor cells could be detected in 28 cases via peritoneal lavage cytology and in 43 cases by greater omental milky spot examinations, and 4 cases had cancer cell infiltration also in nonmilky spot omental areas. The statistical analysis showed that the staging accuracy rate of exfoliative cytology examination was superior to that of the laparoscopic exploration (P < .05), but its sensitivity was significantly lower than that obtained with cytological greater omental milky spot examinations (P < .05).

CONCLUSIONS

The laparoscopic exploration could make a preliminary diagnosis of peritoneal metastasis via serosal layer invasion detection. For further analyses, cytological examinations of greater omental milky spots were more sensitive than exfoliative cytology.

Real-time optical diagnosis of gastric cancer with serosal invasion using multiphoton imaging

A real-time optical biopsy, which could determine tissue histopathology, would be of extraordinary benefit to staging laparoscopy for gastric cancer with serosal invasion (T4) that requires downstage treatment. We investigated the feasibility of using multiphoton imaging to perform a real-time optical diagnosis of gastric cancer with or without serosal invasion. First, a pilot study was performed to establish the optical diagnostic features of gastric cancer with or without serosal invasion using multiphoton imaging compared with hematoxylin-eosin staining and Masson’s trichrome staining. Second, a blinded study was performed to compare the diagnostic sensitivity, specificity, and accuracy of multiphoton imaging and endoscopic ultrasonography (EUS) for T4 gastric cancer. In the pilot study, multiphoton imaging revealed collagen loss and degradation and cellular and nuclear pleomorphism in gastric cancer with serosal invasion. The collagen content in gastric cancer with or without serosal invasion was 0.36 ± 0.18 and 0.79 ± 0.16 (p < 0.001), respectively. In the blinded study, the sensitivity, specificity, and accuracy of EUS and multiphoton imaging for T4 gastric cancer were 70% and 90% (p = 0.029), 66.67% and 96.67% (p = 0.003), and 68.33% and 93.33% (p = 0.001), respectively. It is feasible to use multiphoton imaging to make a real-time optical diagnosis of gastric cancer with or without serosal invasion.

Staging Laparoscopy for Patients with cM0, Type 4, and Large Type 3 Gastric Cancer

BACKGROUND

Staging laparoscopy (SL) is considered useful for detecting peritoneal metastasis, a task that is difficult using conventional imaging modalities. However, indications for the procedure remain unclear, with differences evident across reports. The present study aimed to clarify the effectiveness and limitations of SL for patients with type 4 and large type 3 gastric cancer.

METHODS

We included 88 patients with cM0, type 4 or large type 3 gastric cancer who underwent SL at the Shizuoka Cancer Center from August 2008 to June 2014, to determine the detection rate of peritoneal metastasis by SL. In addition, we calculated the false-negative rate of SL by recruiting patients who were diagnosed as P0 at SL and underwent laparotomy within 28 days after the SL.

RESULTS

P0CY0, P0CY1, P1CY0, and P1CY1 were diagnosed in 41 (46.6 %), 15 (17.0 %), 15 (17.0 %), and 17 (19.3 %) patients, respectively. Accordingly, clinically non-evident peritoneal metastasis was found in 36.3 % of patients, and 53.4 % of patients were diagnosed with stage IV. In addition, 29 patients diagnosed as P0 at SL underwent laparotomy within 28 days after the SL. Among them, peritoneal metastasis was found in five patients. Thus, the false-negative rate was 17.2 % (5/29, 95 % CI 7.6-34.6 %).

CONCLUSIONS

SL is useful for detecting previously unsuspected peritoneal metastasis and for avoiding unnecessary laparotomy, although the high false-negative rate cannot be ignored. Patients with cM0, type 4, and large type 3 gastric cancer are considered suitable candidates for SL.

Staging laparoscopy improves treatment decision-making for advanced gastric cancer

AIM: To evaluate the clinical value of staging laparoscopy in treatment decision-making for advanced gastric cancer (GC).

METHODS: Clinical data of 582 patients with advanced GC were retrospectively analyzed. All patients underwent staging laparoscopy. The strength of agreement between computed tomography (CT) stage, endoscopic ultrasound (EUS) stage, laparoscopic stage, and final stage were determined by weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. A χ² test was used to analyze the correlation between peritoneal metastasis or positive cytology and clinical characteristics.

RESULTS: Among the 582 patients, the distributions of pathological T classifications were T2/3 (153, 26.3%), T4a (262, 45.0%), and T4b (167, 28.7%). Treatment plans for 211 (36.3%) patients were changed after staging laparoscopy was performed. Two (10.5%) of 19 patients in M1 regained the opportunity for potential radical resection by staging laparoscopy. Unnecessary laparotomy was avoided in 71 (12.2%) patients. The strength of agreement between preoperative T stage and final T stage was in almost perfect agreement (Kw = 0.838; 95% confidence interval (CI): 0.803-0.872; P < 0.05) for staging laparoscopy; compared with CT and EUS, which was in fair agreement. The strength of agreement between preoperative M stage and final M stage was in almost perfect agreement (Kw = 0.990; 95% CI: 0.977-1.000; P < 0.05) for staging laparoscopy; compared with CT, which was in slight agreement. Multivariate analysis revealed that tumor size (≥ 40 mm), depth of tumor invasion (T4b), and Borrmann type (III or IV) were significantly correlated with either peritoneal metastasis or positive cytology. The best performance in diagnosing P-positive was obtained when two or three risk factors existed.

CONCLUSION: Staging laparoscopy can improve treatment decision-making for advanced GC and decrease unnecessary exploratory laparotomy.

Prognosis of gastric adenocarcinoma patients with various burdens of peritoneal metastases

BACKGROUND

Peritoneal metastases (PM) in patients with gastric adenocarcinoma (GAC) may be identified by diagnostic laparoscopy (DL) or imaging (I). Although prognosis is poor, some patients have excellent outcome. We compared the overall survival (OS) of patients in 3 groups: those with positive cytology (CY+) by DL (DL-CY+), those with gross PM (GPM) by DL (DL-GPM+) and with GPM obvious on I (I-GPM+).

METHODS

146 GAC patients were identified. The Kaplan-Meier analysis, univariate, and multivariate Cox proportional hazards regression models were employed.

RESULTS

Patients were primarily men (67%), with good ECOG scores (0-1; 89%), had DL (84%), had poorly differentiated GAC (92%), and had received chemotherapy (89%). The median OS for all patients was 15 months (5% CI, 12.9-18.2 months). The DL-CY+ group had median OS of 22.5 months (95% CI, 15-29.3 months). Patients with I-GPM+ had four times the risk of death than those with DL-CY+ (P < 0.001) and patients with DL-GPM+ had two times the risk of death than those with DL-CY+ (P = 0.001). At 36 months, all DL-GPM+ and I-GPM+ had died but 8 patients with DL-CY+ remained alive.

CONCLUSIONS

Some GAC patients with DL-CY+ have long OS; therefore, novel strategies to further prolong their OS are needed.

Surgical management of advanced gastric cancer: An evolving issue

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

State-of-the-art methods in clinical diagnosis and treatment of peritoneal metastasis of gastric cancer

Gastric cancer is one of the most common malignant tumors and presents a very high mortality. The main reason for this situation is metastasis after curative resection, with the most common type being peritoneal metastasis, which accounts for more than 50% of all cases. Once peritoneal carcinomatosis (PC) happens, the pathological stage is stage IV and there is a grim prognosis. Accordingly, early effective prevention and treatment of PC have extremely important clinical significance for the improvement of the prognosis of patients with gastric cancer. This article describes the pathogenesis, clinical diagnosis using serum biomarkers and image examinations, as well as multimodality treatment of peritoneal metastasis of gastric cancer by neoadjuvant intraperitoneal-systemic chemotherapy (NIPS), cytoreductive surgery+hyperthermic intraperitoneal chemotherapy (CRS+HIPEC), early postoperative intraperitoneal chemotherapy (EPIC), extensive intraoperative peritoneal lavage (EIPL), molecular targeting therapy, and usage of drug delivery systems.

A systematic review and meta-analysis of gastric cancer treatment in patients with positive peritoneal cytology

Gastric cancer patients with positive peritoneal cytology as the only marker of metastatic disease have poor prognoses. There is no universal consensus on the most appropriate treatment regimen for this particular patient group. We reviewed and analyzed published data to determine the optimal treatment regimen for patients with peritoneal cytology-positive gastric adenocarcinomas. Six electronic databases were explored [PubMed, Cochrane (Systematic Reviews and Controlled Trials), PROSPERO, DARE, and EMBASE]. The primary outcome was overall survival with secondary outcomes including patterns of recurrence and treatment-related morbidity. Six studies were included for data extraction. There was no significant heterogeneity between studies. The use of S1 monotherapy was associated with a significant survival benefit (HR 0.48; 95% CI 0.32-0.70; p = 0.0002). Intraoperative intraperitoneal chemotherapy (IIPC) with adjuvant chemotherapy showed a trend toward improvement in overall survival (HR 0.70; 9 % CI 0.47-1.04; p = 0.08). A recent randomized controlled trial examining extensive intraperitoneal lavage (EIPL) with IIPC showed a significant improvement in overall survival (5-year overall survival, 43.8% for EIPL-IPC group compared with 4.6% for IPC group). However, these promising results need to be validated in larger prospective randomized trials.

The clinical significance of potentially curative resection for gastric cancer following the clearance of free cancer cells in the peritoneal cavity by induction chemotherapy

PURPOSE

The aim of this study was to evaluate the significance of the conversion of the peritoneal cytology from positive to negative following induction chemotherapy in relation to the prognosis after subsequent resection for gastric cancer.

METHODS

This retrospective study was conducted using a prospectively maintained database. A total of 47 patients with free cancer cells in the peritoneal cavity, as evaluated by staging laparoscopy, but no other evidence of distant metastasis, who underwent induction chemotherapy followed by surgery were enrolled in the study. Then, the clinicopathological factors and survival in the study subjects were assessed.

RESULTS

The median survival time and 5-year overall survival rate of the 47 study participants were 20.4 months and 25.0 %, respectively. In 23 of the patients, the peritoneal cytology converted from positive to negative after the induction chemotherapy, and a microscopically margin-negative gastrectomy was performed. The median survival time of 30.4 months and the 5-year survival rate of 34.6 % of these patients was significantly more favorable than the corresponding values of 15.0 months and 17.6 % in the patients who had persistently positive cytology (P = 0.03).

CONCLUSION

Based on our findings, the clearance of free cancer cells in the peritoneal cavity by induction chemotherapy improves the prognosis of patients following subsequent gastrectomy.

Test execution variation in peritoneal lavage cytology could be related to poor diagnostic accuracy and stage migration in patients with gastric cancer

PURPOSE

Peritoneal lavage cytology is part of the routine staging workup for patients with advanced gastric cancer. However, no quality assurance study has been conducted to show variations or biases in peritoneal lavage cytology results. The aim of this study was to demonstrate a test execution variation in peritoneal lavage cytology between investigating surgeons.

MATERIALS AND METHODS

A prospective cohort study was designed for determination of the positive rate of peritoneal lavage cytology using a liquid-based preparation method in patients with potentially curable advanced gastric cancer (cT2~4/N0~2/M0). One hundred thirty patients were enrolled and underwent laparotomy, peritoneal lavage cytology, and standard gastrectomy, which were performed by 3 investigating surgeons. Data were analyzed using the chi-square test and a logistic regression model.

RESULTS

The overall positive peritoneal cytology rate was 10.0%. Subgroup positive rates were 5.3% in pT1 cancer, 2.0% in pT2/3 cancer, 11.1% in pT4a cancer, and 71.4% in pT4b cancer. In univariate analysis, positive peritoneal cytology showed significant correlation with pT stage, lymphatic invasion, vascular invasion, ascites, and the investigating surgeon. We found the positive rate to be 2.1% for surgeon A, 10.2% for surgeon B, and 20.6% for surgeon C (P=0.024). Multivariate analysis identified pT stage, ascites, and the investigating surgeon to be significant risk factors for positive peritoneal cytology.

CONCLUSIONS

The peritoneal lavage cytology results were significantly affected by the investigating surgeon, providing strong evidence of test execution variation that could be related to poor diagnostic accuracy and stage migration in patients with advanced gastric cancer.

The clinical importance of a transcription reverse-transcription concerted (TRC) diagnosis using peritoneal lavage fluids in gastric cancer with clinical serosal invasion: a prospective, multicenter study

PURPOSE

We have developed a novel molecular method of diagnosis using the technique of transcriptase-reverse transcriptase concerted reaction (TRC) for the detection of cancer micrometastasis. This study prospectively examined the clinical importance of the TRC diagnosis with peritoneal lavage fluids collected from gastric cancer operations at multiple institutes.

METHODS

TRC amplification targeting carcinoembryonic antigen mRNA was applied to detect gastric cancer cells in peritoneal lavage fluids obtained during gastric cancer resections from nine different hospitals. A total of 137 patients with a clinical diagnosis of serosa-invading neoplasms were enrolled to investigate the correlation between the TRC diagnosis and patient prognosis.

RESULTS

Of the 137 patients, 27 (20%) were positive by cytologic examination. In contrast, TRC targeting carcinoembryonic antigen mRNA was positive in 59 of 137 (54%) patients. TRC positivity was associated with a poorer overall survival in all patients and in the 104 patients who underwent a curative operation. TRC positivity also was associated with the peritoneal recurrence-free survival rate in the 104 curative cases. Multivariate analysis showed that TRC positivity and the pathologic N factor were prognostic factors for the overall survival time.

CONCLUSION

Our prospective multicenter study showed that the TRC test using peritoneal lavage fluids could be a potential prognostic factor to predict patient survival and peritoneal recurrence with clinically diagnosed, serosa-invading gastric cancer.

Incidental complete excision of appendiceal gastric cancer metastasis

Gastric cancer is a common malignancy with high recurrence rates following surgical resection. A common site of disease recurrence is the peritoneum. We report the case of a 73-year-old female who had previously undergone a total gastrectomy for gastric cancer who presented acutely with features classical of acute appendicitis and underwent open appendectomy. Histological analysis showed metastasis of gastric cancer with clear resection margins. The patient recovered fully and has remained disease-free for 14 months following presentation. Peritoneal metastasis is associated with difficulty in treatment and poor prognosis. The unplanned excision of this patient’s peritoneal metastasis has yielded a favourable clinical outcome in a difficult clinical situation.

Role of staging laparoscopy in gastric malignancies - our institutional experience

AIM: To investigate the value of staging laparoscopy with laparoscopic ultrasound (LUS) and peritoneal lavage cytology in patients with newly-diagnosed gastric tumours in our department.

METHODS: Retrospective review of prospectively-collected data was conducted in all patients with newly-diagnosed gastric tumours on oesophagogastroduodenoscopy between December 2003 and July 2008. All the patients had a pre-treatment histological diagnosis and were discussed at the hospital multidisciplinary tumour board meeting for their definitive management. Computed tomography scan was performed in all patients as a part of standard preoperative staging work up. Staging laparoscopy was subsequently performed in selected patients and staging by both modalities was compared.

RESULTS: Twenty seven patients were included. Majority of patients had cardio-oesophageal junction adenocarcinoma. Thirteen patients (48%) were upstaged following staging laparoscopy and one patient was downstaged (3.7%). None of the patients had procedure-related complications. None of the patients with metastasis detected at laparoscopy underwent laparotomy. Gastrectomy after staging laparoscopy was performed in 13 patients (9 R0 resections, 3 R1 resections and 1 R2 resection). Only one patient did not have gastrectomy at laparotomy because of extensive local invasion. Three patients were subjected to neoadjuvant therapy following laparoscopy but only one patient subsequently underwent gastrectomy.

CONCLUSION: In this small series reflecting our institutional experience, staging laparoscopy appears to be safe and more accurate in detecting peritoneal and omental metastases as compared to conventional imaging. Peritoneal cytology provided additional prognostic information although there appeared to be a high false negative rate.

A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of gastric cancer

BACKGROUND

Despite improved preoperative imaging techniques, patients with incurable or unresectable gastric cancer are still subjected to non-therapeutic laparotomy. Diagnostic laparoscopy (DL) has been advocated by some to be essential in decision-making in gastric cancer. We aimed to identify and synthesize findings on the value of DL for patients with gastric cancer, in this era of improved preoperative imaging.

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. We calculated the change in management and avoidance of laparotomy based on the addition of DL and laparoscopic ultrasound (LUS). The accuracy, agreement (kappa), sensitivity, and specificity of DL in assessing tumor extent, nodal involvement, and the presence of metastases with respect to the gold standard (pathology) were also calculated.

RESULTS

Twenty-one articles were included. DL showed moderate to substantial agreement with final pathology for T stage, but only fair agreement for N stage. For M staging, DL had an overall accuracy, sensitivity, and specificity ranging from 85-98.9%, 64.3-94%, and 80-100%, respectively. The use of DL altered treatment in 8.5-59.6% of cases, avoiding laparotomy in 8.5-43.8% of cases. LUS provided additional benefit in 5.8-7.2% of cases.

CONCLUSIONS

Despite evolving preoperative imaging techniques, diagnostic laparoscopy continues to be of substantial value in staging patients with gastric cancer and in avoiding unnecessary laparotomy. The current data support DL for all patients with advanced gastric cancer.

Clinicopathological analysis and prognostic significance of peritoneal cytology in Chinese patients with advanced gastric cancer

BACKGROUND

The influence of peritoneal cytology on survival of patients with gastric cancer has not been consistent. This study was to identify risk factors for positive peritoneal cytology and to evaluate the predictive value of positive cytology among Chinese patients with advanced gastric cancer.

METHODS

The study included 139 patients with gastric cancer macroscopically invading the serosa, who underwent gastrectomy and intra-operative peritoneal cytological examination. In these patients, the relationship between cytological positivity and various clinicopathological features was analysed, and survival analysis was performed to identify independent prognostic factors of significance.

RESULTS

Thirty-eight (27.3%) of 139 patients had positive peritoneal cytology. Although tumour size, lymphovascular invasion, depth of tumour invasion, lymph node metastasis and peritoneal metastasis were correlated with positive cytology, multivariate analysis revealed the depth of tumour invasion and peritoneal metastasis as the independent features affecting the cytology. Patients with a positive cytology result were confirmed to have a greater risk for recurrence in the pattern of peritoneal carcinomatosis and a significant inferior prognosis. Multivariate analysis indicated that positive peritoneal cytology was an independent prognostic factor among the curatively resected patients with advanced gastric cancer and was the prognostic factor most predictive of death for these patients (risk ratio = 2.74).

CONCLUSIONS

Positive peritoneal cytology correlated with advanced features of gastric cancer. It is an independent poor prognostic factor, and it may serve as a guide for adjuvant therapeutic options to improve the survival of gastric cancer.

The role of laparoscopic surgery in gastric cancer

The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.