Rationale for gastrectomy with D2 lymphadenectomy in the treatment of gastric cancer

Do all the European surgeons perform the same D2? The need of D2 audit in Europe

Although D2 lymphadenectomy is the standard of care for radical intent surgical treatment of gastric cancer, the real compliance with D2 dissection in Europe is still unknown. The aim of the present study is to analyze the variation in lymph-node harvesting reported after D2 dissection in European series and to present a European project aiming at evaluating the real compliance with D2 lymphadenectomy. A PubMed search for papers using the key words "D2 lymphadenectomy" and "gastric cancer" from 2008 to 2017 was undertaken. Only studies by European authors in English language reporting the number of retrieved lymph nodes after D2 lymphadenectomy were included. The results of literature review were descriptively reported. The literature survey yielded 16 studies: 2 RCTs, 3 observational multicentre studies, and 11 observational monocentric studies. A large variability was found in the number of retrieved nodes, which, overall, was the lowest in the surgical series from Eastern Europe (16.6 and 19.9 in the Lithuanian and Hungarian series, respectively) and the highest in an Italian RCT. The within-study variability was also quite high, especially in multicentre RCTs and observational studies. Sample size tended to have a larger effect on the variability of lymph nodes retrieved than on its actual value. However, in both cases, the relation was not significant, due to the low number of studies considered. There is a large variability in the number of retrieved nodes after D2 dissection in European series. This reflects, at least partly, different approaches to D2 lymphadenectomy by European surgeons and may be responsible of the different outcomes observed in patients with gastric cancer across Europe. Therefore, there is the need to standardize the practice of D2 gastrectomy in Europe and to define possible variations of D2 procedures according to tumour's characteristics.

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

BACKGROUND

The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer.

METHODS

Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated.

RESULTS

Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10, >0.10-0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (>0.25: hazard ratio 2.3; all P < .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P < .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio >0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P < .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P > .05).

CONCLUSION

Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio >0.25).

Surgical outcomes in patients with locally advanced gastric cancer treated with S-1 and oxaliplatin as neoadjuvant chemotherapy

BACKGROUND

We wished to evaluate the impact of S-1 combined with oxaliplatin (SOX regimen) as neoadjuvant chemotherapy on surgical outcomes after gastrectomy with D2 lymphadenectomy.

METHODS

From February 2012 to September 2013, 170 patients with American Joint Committee on Cancer (AJCC) stage II-III gastric cancer were assessed retrospectively. Eighty patients underwent neoadjuvant chemotherapy before radical gastrectomy, and 90 patients received surgical treatment with adjuvant chemotherapy. Patients received S-1 (80 mg/m(2)/day; days 1-14) and oxaliplatin (130 mg/m(2); day 1) as neoadjuvant or adjuvant chemotherapy, and this schedule was repeated every 3 weeks. Gastrectomy with D2 lymphadenectomy was standard therapy for each patient. Surgical outcomes between the two groups were analyzed statistically.

RESULTS

There was no significant difference in the total prevalence of complications between neoadjuvant and adjuvant groups (18.8% vs. 22.2%, P = 0.704). The most common postoperative complications were surgical site infection (6.5%) and gastrointestinal motility disorders (3.5%). The clinical response rate was 68.8%, and ten patients (12.5%) had a pathological complete response after neoadjuvant chemotherapy. The SOX regimen as neoadjuvant chemotherapy for AJCC stage II/III gastric cancer can be effective without increasing the risk of postoperative complications.

CONCLUSIONS

The SOX regimen could be a neoadjuvant chemotherapy for advanced gastric cancer worldwide in the future.

Long term follow up and retrospective study on 533 gastric cancer cases

Background

Gastric cancer (GC) is the third leading cause of cancer death in China and the outcome of GC patients is poor. The aim of the research is to study the prognostic factors of gastric cancer patients who had curative intent or palliative resection, completed clinical database and follow-up.

Methods

This retrospective study analyzed 533 GC patients from three tertiary referral teaching hospitals from January 2004 to December 2010 who had curative intent or palliative resection, complete clinical database and follow-up information. The GC-specific overall survival (OS) status was determined by the Kaplan-Meier method, and univariate analysis was conducted to identify possible factors for survival. Multivariate analysis using the Cox proportional hazard model and a forward regression procedure was conducted to define independent prognostic factors.

Results

By the last follow-up, the median follow-up time of 533 GC patients was 38.6 mo (range 6.9-100.9 mo), and the median GC-specific OS was 25.3 mo (95% CI: 23.1-27.4 mo). The estimated 1-, 2-, 3- and 5-year GC-specific OS rates were 78.4%, 61.4%, 53.3% and 48.4%, respectively. Univariate analysis identified the following prognostic factors: hospital, age, gender, cancer site, surgery type, resection type, other organ resection, HIPEC, LN status, tumor invasion, distant metastases, TNM stage, postoperative SAE, systemic chemotherapy and IP chemotherapy. In multivariate analysis, seven factors were identified as independent prognostic factors for long term survival, including resection type, HIPEC, LN status, tumor invasion, distant metastases, postoperative SAE and systemic chemotherapy.

Conclusions

Resection type, HIPEC, postoperative SAE and systemic chemotherapy are four independent prognostic factors that could be intervened for GC patients for improving survival.

Lymph node ratio is a better prognosticator than lymph node status for gastric cancer: A retrospective study of 138 cases

To study the clinical significance of lymph node ratio (LNR) in gastric cancer (GC), this study analyzed 613 patients with GC who underwent surgical resection. Of 613 patients with GC, 138 patients who had >15 lymph nodes (LNs) resected and radical resection were enrolled into the final study. All major clinicopathological data were entered into a central database. LNR was defined as the ratio of the number of metastatic LNs to the number of removed LNs. In order to determine the best cut-off points for LNR, the log-rank test and X-tile were used. LNR was then substituted for lymph node status (pN) in the 7th American Joint Committee on Cancer tumor-node-metastases (TNM) staging system and this was defined as the tumor-node ratio-metastases (TRM) staging system. Pearson's correlation coefficient (r) was used to study the correlations among the number of removed LNs, pN and LNR. The Kaplan-Meier survival curve was used to study the survival status, and the log-rank test and Cox proportional hazards model were used to identify the independent factors for survival. Receiver operating characteristic curve analysis was used to determine the predictive value of the parameters. By the time of last follow-up (median follow-up period, 38.3 months; range, 9.9-97.7 months), the median overall survival (OS) was 23.9 months [95% confidence interval (CI), 18.8-29.0 months]. The 1-, 2-, 3- and 5-year survival rates were 76.8, 57.2, 50.0 and 46.4%, respectively. The cut-off points were 0, 0.5 and 0.8 (R0, LNR=0; R1, LNR ≤0.5; R2, 0.5> LNR ≤0.8; and R3, LNR >0.8). Univariate and multivariate analyses revealed that both LNR and pN were independent prognostic factors for GC. LNR could better differentiate OS in patients than LN. In addition, the TRM staging system was better at predicting the clinical outcomes than the TNM staging system, and LNR was better than pN. In conclusion, LNR was a better prognosticator than pN for GC.

Pathological complete response of locally advanced gastric cancer after four courses of neoadjuvant chemotherapy with paclitaxel plus cisplatin: report of a case

We report a case of advanced gastric carcinoma treated successfully by four courses of neoadjuvant chemotherapy (NAC) with paclitaxel and cisplatin. The patient was a 43-year-old man with advanced gastric cancer, clinically diagnosed as P0H0M0CY0T3N2, which had invaded the upper body of the stomach and esophagus. He was entered into a clinical trial and received the following NAC regimen: paclitaxel 80 mg/m(2), and cisplatin 25 mg/m(2), on days 1, 8, and 15, followed by a rest on day 22, as one course. The lymph nodes had reduced in size to 59% after two courses and to 40% after four courses, with no sign of severe toxicity. Subsequently, he underwent D2 total gastrectomy with pancreatico-splenectomy. On microscopic examinations, no tumor cells were detected in the ulcer scar of the resected stomach or the regional lymph nodes. Thus, we discuss the potential of long-term NAC, especially for responders to two initial courses.

Adjuvant chemotherapy: an option for Asian patients only?

Survival rates following curative resection for gastric cancer are higher in East Asia than in Europe and the US. The aggressive surgical approach adopted in East Asia may explain these observations. In Japan and Korea, gastrectomy with extended lymphadenectomy (D2 gastrectomy) has been standard of care for many years, whereas gastrectomy with lymphadenectomy of the perigastric lymph nodes (D1 surgery) has been favored in Europe and the US until recently. D2 surgery is now recommended globally based on the 15-year findings from the large Dutch D1D2 study, which showed a reduction in cancer-related deaths with D2 versus D1 surgery. Improved outcomes are now being reported in the US and Europe as D2 surgery becomes more widely used. In addition to surgery, systemic therapy is also required to control recurrences, although the preferred regimen differs by region. Given that some of the studies on which these preferences are based predate the widespread acceptance of D2 surgery, the optimal regimen should be considered carefully. Recent studies from East Asia support the use of adjuvant chemotherapy after D2 surgery. Adjuvant chemotherapy should also be considered a valid approach in other regions now that the benefits of D2 surgery have been demonstrated unequivocally.

Meta-analysis of D1 versus D2 gastrectomy for gastric adenocarcinoma

OBJECTIVES

To conduct a meta-analysis of randomized controlled trials evaluating the efficacy and drawbacks of limited (D1) versus extended lymphadenectomy (D2) for proven gastric adenocarcinoma.

METHODS

A search of Cochrane, Medline, PubMed, Embase, Science Citation Index and Current Contents electronic databases identified randomized controlled trials published in the English language between 1980 and 2008 comparing the outcomes of D1 versus D2 gastrectomy for gastric adenocarcinoma. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses statement. The 6 outcome variables analyzed included length of hospital stay; overall complication rate; anastomotic leak rate; reoperation rate; 30-day mortality rate and 5-year survival rate. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD).

RESULTS

Six trials totaling 1876 patients (D1 = 946, D2 = 930) were analyzed. In 5 of the 6 outcomes the summary point estimates favored D1 over D2 group with a statistically significant reduction of (i) 6.37 days reduction in hospital stay (WMD -6.37, confidence interval [CI] -10.66, -2.08, P = 0.0036); (ii) 58% reduction in relative odds of developing postoperative complications (OR 0.42, CI 0.27, 0.66, P = 0.0002); (iii) 60% reduction in anastomotic breakdown (OR 0.40, CI 0.25, 0.63, P = 0.0001); (iv) 67% reduction in reoperation rate (OR 0.33, CI 0.15, 0.72, P = 0.006); and (v) 41% reduction in 30-day mortality rate (OR 0.59, CI 0.40, 0.85, P = 0.0054). Lastly there was no significant difference in the 5-year survival (OR 0.97, CI 0.78, 1.20, P = 0.7662) between D1 and D2 gastrectomy patients.

CONCLUSIONS

On the basis of this meta-analysis we conclude that D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complication rate, reoperation rate, decreased length of hospital stay and 30-day mortality rate. Finally, the 5-year survival in D1 gastrectomy patients was similar to the D2 cohort.

A phase II study of preoperative chemotherapy with S-1 plus cisplatin followed by D2/D3 gastrectomy for clinically serosa-positive gastric cancer (JACCRO GC-01 study)

AIMS

Clinically serosa-positive (T3-4) gastric cancer has a poor prognosis. This phase II trial explored the feasibility and safety of preoperative chemotherapy followed by D2 or D3 gastrectomy in this type of gastric cancer.

METHODS

Patients with T3-4 gastric cancer received one course of S-1 (80mg/m(2) daily for 3 weeks) and cisplatin (60mg/m(2) on day 8) chemotherapy and then underwent D2 or D3 gastrectomy with curative intent. Primary endpoint was toxicities.

RESULTS

Of 50 patients enrolled, 49 were eligible and received the treatment protocol. Chemotherapy-related toxicities were mild; grade 3 neutropenia in 2 patients, anorexia in 3, and nausea in 2, and no grade 4 toxicities. Clinical response was achieved in 13 of 34 evaluable patients. Of the 49 patients, 39 underwent D2 or D3 dissection. There was no surgical mortality. Operative morbidity occurred in 5 of 49 patients, including pancreatic fistula in 1 and abdominal abscess in 2.

CONCLUSION

This multi-modality treatment seems to be feasible and safe for T3-4 gastric cancer.