A systematic review of patient surveillance after curative gastrectomy for gastric cancer: a brief review

Feasibility of Extended Postoperative Follow-Up in Patients With Gastric Cancer

Importance

Conventional research and guidelines on postgastrectomy follow-up for gastric cancer often restrict their focus to the first 5 years after surgery.

Objective

To evaluate the association of extended regular follow-up after 5 years postgastrectomy in patients with gastric cancer with overall and postrecurrence survival rates.

Design, Setting, and Participants

This population-based, retrospective cohort study used Korean National Health Insurance claims data extracted between January 1, 2005, and December 31, 2014, with follow-up data examined until December 31, 2021. Patients without recurrence or other cancers at 5 years postgastrectomy were divided into 2 groups: those who had extended regular follow-up visits and those who did not. The data were analyzed between August 15 and November 15, 2023.

Exposures

Regular follow-up vs irregular follow-up after 5 years postgastrectomy.

Main Outcomes and Measures

The main outcome was whether extended regular follow-up after 5 years postgastrectomy was independently associated with overall and postrecurrence survival rates using Cox proportional hazards regression. Postrecurrence survival rates were also compared across different follow-up methods and intervals.

Results

A total of 40 468 patients with gastric cancer were included, with 14 294 in the regular follow-up group (mean [SD] age, 61.3 [11.7] years; 9669 male [67.8%]) and 26 174 in the irregular follow-up group (mean [SD] age, 58.1 [11.1] years; 18 007 male [68.8%]). Late recurrence or gastric remnant cancer (GRC) was identified in 3138 patients (7.8%), including 1610 of 40 468 patients (4.0%) between 5 and 10 years postgastrectomy and 1528 of 16 287 (9.4%) patients after 10 years postgastrectomy. Regular follow-up was associated with a significantly decreased overall mortality rate after 5 years postgastrectomy (from 49.4% to 36.9% in 15-year mortality rate; P < .001), as well as significant improvement of postrecurrence survival rate after occurrence of late recurrence or GRC (from 32.7% to 71.1% in 5-year postrecurrence survival rate; P < .001). Comparison of follow-up methods revealed that the combination of endoscopy and abdominopelvic computed tomography (CT) (only abdominopelvic CT in total gastrectomy subgroup) yielded the highest 5-year postrecurrence survival rate (endoscopy alone vs abdominopelvic CT alone vs a combination of both, 54.5% vs 47.1% vs 74.5%, respectively). A time interval of more than 2 years between previous endoscopy or abdominopelvic CT and late recurrence and GRC diagnosis was associated with a significantly reduced postrecurrence survival rate (hazard ratio, 1.72 [95% CI, 1.45-2.04] and 1.48 [95% CI, 1.25-1.75], respectively).

Conclusions and Relevance

These findings suggest that extended regular follow-up after 5 years postgastrectomy should be implemented clinically and that current practice and value of follow-up protocols in postoperative care of patients with gastric cancer be reconsidered.

Clinical feasibility of the preoperative C-reactive protein-albumin-lymphocyte index to predict short- and long-term outcomes of patients with gastric cancer

BACKGROUND

Gastric cancer (GC) is a major leading cause of cancer-related death worldwide. Systemic inflammation and the nutrition-based score are feasible prognostic markers for malignancies. Emerging evidence has also revealed the C-reactive protein-albumin-lymphocyte (CALLY) index to be a prognostic marker for several cancer types. However, its clinical significance to predict surgical and oncologic outcomes of patients with GC remains unclear.

METHODS

We assessed the preoperative CALLY index in 426 patients with GC who received gastrectomy.

RESULTS

A low preoperative CALLY index was significantly correlated to all well-established clinicopathologic factors for disease development, including an advanced T stage, the presence of venous invasion, lymphatic vessel invasion, lymph node metastasis, distant metastasis, and an advanced TNM stage. A low preoperative CALLY index was also an independent prognostic factor for overall survival (hazard ratio [HR], 2.64; 95 % CI, 1.66-4.2; P < .0001) and disease-free survival (HR, 1.76; 95 % CI, 1.01-3.05; P = .045). In addition, a low preoperative CALLY index was an independent predictive factor for postoperative surgical site infection (odds ratio, 2.64; 95 % CI, 1.42-4.89; P = .002).

CONCLUSION

The preoperative CALLY index is valuable for perioperative and oncologic management of patients with GC.

Gastric Cancer Survivorship: Multidisciplinary Management, Best Practices and Opportunities

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development of nomograms for predicting the survival of intestinal-type gastric adenocarcinoma patients after surgery

Intestinal-type gastric adenocarcinoma (IGA) is a common phenotype of gastric cancer. Currently, few studies have constructed nomograms that may predict overall (OS) and cancer-specific survival (CSS) probability after surgery. This study is to establish novel nomograms for predicting the survival of IGA patients who received surgery. A total of 1814 IGA patients who received surgery between 2000 and 2018 were selected from Surveillance, Epidemiology, and End Results database and randomly assigned to the training and validating sets at a ratio of 7:3. Then univariate and multivariate cox regression analyses were performed to screen significant indictors for the construction of nomograms. The calibration curve, the area under the receiver operating characteristic (receiver operating characteristic, ROC) curve (the area under curve, AUC), C-index, net reclassification index (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA) curves were applied to assess the performance of the model. The significant outcomes of multivariate analysis revealed that ten variables (age, sex, race, surgery type, summary stage, grade, AJCC TNM stage, radiotherapy, number of regional nodes examined, number of regional nodes positive) were demonstrated to construct the nomogram for OS and ten variables (age, sex, race, surgery type, summary stage, grade, AJCC TNM stage, chemotherapy, number of regional nodes examined, number of regional nodes positive) for CSS. The calibration and AUC uncovered their favorable predictive performance. Subsequently, C-index, NRI, IDI and DCA curves further validated the predicative superiority of nomograms over 7th AJCC Stage System. The validated nomogram provides more reliable OS and CSS predictions for postoperative IGA patients with good accuracy, which can help surgeons in treatment decision-making and prognosis evaluation.

Looking for appropriateness in follow-up CT of oncologic patients: Results from a cross-sectional study

PURPOSE

The objective of this study was to assess the inappropriateness rate of oncological follow-up CT examinations.

METHODS

Out of 7.000 oncology patients referred for follow-up CT examinations between March and October 2022, a random sample of 10 % was included. Radiology residents assessed the appropriateness using the Italian Society of Medical Oncology (AIOM) guidelines, supervised by senior radiologists. Association between inappropriateness and clinical variables was investigated and variables influencing inappropriateness were analyzed through a binary logistic regression.

RESULTS

Three-hundred-eighty-eight examinations (56.1 %) were consistent with AIOM guidelines. An additional 100 (14.5  %) examinations did not follow the recommended schedule but were nevertheless considered appropriate because of suspected recurrence/progression (10.7 %) or adverse event requiring imaging assessment (3.8 %). Two-hundred-four (29.4 %) examinations were rated as inappropriate. Inappropriateness causes were as follows: CT not included in the relevant guideline (n = 47); CT extended to additional anatomical regions (n = 59); CT requested at a shorter time-interval (n = 98). No statistically significant difference was found in age, sex, scan region, and primary cancer between appropriate and inappropriate examinations. The only variable significantly associated with inappropriateness was being referred by a specific hospital unit named "unit 2" in the study (p = 0.009), which was demonstrated to be the only appropriateness independent predictor (OR 1.952).

CONCLUSION

This study shows that majority of oncological patients referred for follow-up CT follows standard guidelines. However, a non-negligible proportion was rated as inappropriate, mainly due to the shorter time-interval. No clinical variable was associated with inappropriateness, except for referral by a specific hospital unit.

Ultrasound-guided lymphaticovenous anastomosis without indocyanine green lymphography mapping: A preliminary report

BACKGROUND

Although indocyanine green (ICG) lymphography is the standard preoperative examination for lymphaticovenous anastomosis (LVA), it cannot be performed in patients allergic to ICG. This report aimed to clarify the effects of LVA with lymphatic ultrasound and without ICG lymphography.

METHOD

Lymphatic ultrasound was performed preoperatively on six limbs of four patients with lower limb lymphedema who were allergic to ICG to detect the lymphatic vessels. All patients were women and had secondary lymphedema after uterine cancer treatment, with a mean age of 57.0 years (range; 47-68 years). The severity of lymphedema was stage 2a in two limbs, stage 2b in three limbs, and stage 3 in one limb. During the preoperative lymphatic ultrasound, we searched for the dilated lymphatic vessels in the saphenous, lateral calf, and lateral thigh lymphosomes. The incision sites were determined based on the ultrasonographic findings, and LVA was performed under local anesthesia. The surgical results were evaluated based on the limb volume calculated from the circumferences.

RESULT

Totally, 13 skin incisions were made, and the lymphatic vessels consistent with the ultrasonographic findings were found in all locations. The mean number of the lymphatic vessels anastomosed per limb was 2.2 (range; 1-4). The mean diameter of the lymphatic vessel was 0.69 mm (range; 0.3-1.0 mm). No complications were observed in the perioperative period. The mean follow-up period was 386.8 days. The mean preoperative and postoperative limb volumes were 5468 ml (range; 4552-6378 ml) and 5027.4 ml (range; 4353-5561 ml). Limb volume decreased in all six limbs.

CONCLUSION

The effectiveness of performing LVA by identifying the lymphatic vessels using lymphatic ultrasound was demonstrated. More medical institutions will be able to perform LVA in the future, even without ICG devices.

Oncological surgery follow-up and quality of life: meta-analysis

BACKGROUND

Previous trials found that more intensive postoperative surveillance schedules did not improve survival. Oncological follow-up also provides an opportunity to address psychological issues (for example anxiety, depression, and fear of recurrence). This systematic review assessed the impact of a less intensive surveillance strategy on health-related quality of life (HRQoL), emotional well-being, and patient satisfaction.

METHODS

A systematic search was conducted in PubMed/MEDLINE, Embase, Web of Science, Cochrane database, PsycINFO, and Google Scholar to identify studies comparing different follow-up strategies after oncological surgery and their effect on HRQoL and patient satisfaction, published before 4 May 2022. A meta-analysis was conducted on the most relevant European Organisation for Research and Treatment of Cancer QLQ-C30 and Hospital Anxiety and Depression Scale subscales.

RESULTS

Thirty-five studies were identified, focusing on melanoma (4), colorectal (10), breast (7), prostate (4), upper gastrointestinal (4), gynaecological (3), lung (2), and head and neck (1) cancers. Twenty-two studies were considered to have a low risk of bias, of which 14 showed no significant difference in HRQoL between follow-up approaches. Five studies with a low risk of bias showed improved HRQoL or emotional well-being with a less intensive follow-up approach and three with an intensive approach. Meta-analysis of HRQoL outcomes revealed no negative effects for patients receiving less intensive follow-up.

CONCLUSION

Low-intensity follow-up does not diminish HRQoL, emotional well-being, or patient satisfaction.

Detection of asymptomatic recurrence following curative surgery improves survival in patients with gastric cancer: A systematic review and meta-analysis

Background

To date, there is no evidence that intensive follow-up provides survival benefit in gastric cancer patients undergoing curative gastrectomy. The aim of this study is to investigate the efficacy of detection of asymptomatic recurrence using intensive surveillance strategy in long-term survival after curative gastric cancer surgery.

Methods

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Infrastructure, Clinical Trials Registry and Google Scholar was performed up to April 2022. The primary outcomes were survival outcomes: overall survival, recurrence-free survival and post-recurrence survival. The secondary endpoints were clinicopathological features, recurrence patterns and treatment after recurrence. The registration number of this protocol is PROSPERO CRD42022327370.

Results

A total of 11 studies including 1898 participants were included. In the pooled analysis, the detection of asymptomatic recurrence was significantly associated with an improved overall survival compared to patients showing symptoms of recurrence (HR=0.67; 95%CI: 0.57-0.79; P<0.001), which was primarily driven by the prolongation of post-recurrence survival (HR=0.51; 95%CI: 0.42-0.61; P<0.001), since there was no significant difference observed in recurrence-free survival (HR=1.12; 95%CI: 0.81-1.55; P=0.48) between the two groups. Meanwhile, male sex and advanced T stage were more frequently observed in the symptomatic recurrence group. Furthermore, patients in the symptomatic recurrence group had a higher proportion of peritoneal relapse but lower proportion of distant lymph node metastasis. Additionally, patients in the symptomatic recurrence group were less likely to receive surgery treatment and post-recurrence chemotherapy.

Conclusion

The detection of asymptomatic recurrence using intensive follow-up was associated with an appreciable improvement in overall survival. However, more robust data from high-quality studies are still required to verify this issue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327370, identifier CRD42022327370.

Extragastric recurrence in patients who underwent surgical resection of stage I gastric cancer: Incidence, risk factors, and value of abdominal computed tomography as a postoperative surveillance method

Extragastric recurrence after radical resection of stage I gastric cancer is very rare. We investigated the incidence of extragastric recurrence and risk factors in patients who underwent surgical resection of stage I gastric cancer and evaluated the value of abdominal CT as a surveillance tool. This retrospective study enrolled 914 patients with stage I gastric cancer who underwent surgical resection at a single tertiary hospital. We investigated extragastric recurrence during the follow-up period, and disease-free survival (DFS) was assessed. Over a median follow-up period of 39 months, the overall incidence of extragastric recurrence was 2.2% (20/914). Risk factors for extragastric recurrence included deep submucosal invasion (SM2-3), muscularis propria invasion, and lymph node metastasis (hazard ratio [HR]=10.37, 28.101, and 6.843; P = .028, .002, and .001, respectively). Based on the number of risk factors, patients were stratified into 3 subgroups: low-risk (pT1aN0, pT1b(SM1)N0, 496/914), moderate-risk (pT1aN1, pT1b(SM1)N1, pT1b(SM2-3)N0, pT2N0, 369/914), and high-risk (pT1b(SM2-3)N1, 49/914). DFS was significantly longer in the low-risk group, followed by the moderate-risk and high-risk groups. We propose that postoperative CT surveillance should be omitted for stage 1A cases involving the mucosa and SM1 because of the extreme rarity of extragastric recurrence.

Follow-up strategy and survival for five common cancers: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the effectiveness of intensive follow-up after curative intent treatment for five common solid tumours, in terms of survival and treatment of recurrences.

METHODS

A systematic literature search was conducted, identifying comparative studies on follow-up for colorectal, lung, breast, upper gastro-intestinal and prostate cancer. Outcomes of interest were overall survival (OS), cancer specific survival (CSS), and treatment of recurrences. Random effects meta-analyses were conducted, with particular focus on studies at low risk of bias.

RESULTS

Fourteen out of 63 studies were considered to be at low risk of bias (8 colorectal, 4 breast, 0 lung, 1 upper gastro-intestinal, 1 prostate). These studies showed no significant impact of intensive follow-up on OS (hazard ratio, 95% confidence interval) for colorectal (0.99; 0.92-1.06), breast 1.06 (0.92-1.23), upper gastro-intestinal (0.78; 0.51-1.19) and prostate cancer (1.00; 0.86-1.16). No impact on CSS (hazard ratio, 95% confidence interval) was found for colorectal cancer (0.94; 0.77-1.16). CSS was not reported for other cancer types. Intensive follow-up increased the rate of curative treatment (relative risk; 95% confidence interval) for colorectal cancer recurrences (1.30; 1.05-1.61), but not for upper gastro-intestinal cancer recurrences (0.92; 0.47-1.81). For the other cancer types, no data on treatment of recurrences was available in low risk studies.

CONCLUSION

For colorectal and breast cancer, high quality studies do not suggest an impact of intensive follow-up strategies on survival. Colorectal cancer recurrences are more often treated locally after intensive follow-up. For other cancer types evaluated, limited high quality research on follow-up is available.

Evaluation of post-operative surveillance strategies for esophageal and gastric cancers: a systematic review and meta-analysis

BACKGROUND

There is no consensus or guidelines internationally to inform clinicians of how patients should be monitored for recurrence after esophagogastric resections.

AIM

This systematic review and meta-analysis summarizes the latest evidence investigating the usefulness of surveillance protocols in patients who underwent esophagectomy or gastrectomy.

METHODS

A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Articles were evaluated for the use of surveillance strategies including history-taking, physical examination, imaging modalities and endoscopy for monitoring patients post-gastrectomy or esophagectomy. Studies that compared surveillance strategies and reported detection of recurrence and post-recurrence survival were also included in the meta-analysis.

RESULTS

Fifteen studies that described a surveillance protocol for post-operative patients were included in the review. Seven studies were used in the meta-analysis. Random-effects analysis demonstrated a statistically significant higher post-recurrence survival (standardized mean difference [SMD] 14.15, 95% CI 1.40-27.26, p = 0.03) with imaging-based planned surveillance post-esophagectomy. However, the detection of recurrence (OR 1.76, 95% CI 0.78-3.97, p = 0.17) for esophageal cancers as well as detection of recurrence (OR 0.73, 95% CI 0.11-5.12, p = 0.76) and post-recurrence survival (SMD 6.42, 95% CI -2.16-18.42, p = 0.14) for gastric cancers were not significantly different with planned surveillance.

CONCLUSION

There is no consensus on whether surveillance carries prognostic survival benefit or how surveillance should be carried out. Surveillance may carry prognostic benefit for patients who underwent surgery for esophageal cancer. Randomized controlled trials are required to evaluate the survival benefits of intensive surveillance strategies, determine the ideal surveillance protocol and tailor it to the appropriate population.

Health-Related Quality of Life in Patients With Locally Advanced Gastric Cancer Undergoing Perioperative or Postoperative Adjuvant S-1 Plus Oxaliplatin With D2 Gastrectomy: A Propensity Score-Matched Cohort Study

Background

Some high-quality clinical trials have proven the efficacy and safety of perioperative and postoperative S-1 with oxaliplatin (peri-SOX and post-SOX) for patients with locally advanced gastric cancer (LAGC) undergoing D2 gastrectomy. However, little is known about how health-related quality of life (HRQOL) changes over time in patients receiving peri-SOX or post-SOX chemotherapy.

Methods

A prospective observational cohort (NCT04408859) identified 151 eligible patients with LAGC who underwent D2 gastrectomy with at least six cycles of peri-SOX or post-SOX chemotherapy from 2018 to 2020. HRQOL was assessed using the EROTC QLQ-C30 and its gastric module, QLQ-STO22, at indicated measurements, including the baseline, 1st, 3rd, 6th and 12th month after initiation of therapy. Baseline characteristics, therapeutic effects, and longitudinal HRQOL were compared between the peri-SOX and post-SOX groups after propensity score matching. HRQOL changes over time and the risk factors for scales with severe deterioration were further analyzed.

Results

No statistically significant differences in longitudinal HRQOL were observed between patients in the peri-SOX and post-SOX groups, with comparable surgical outcomes and adverse chemotherapy events. Scales of social functioning, abnormal taste, and anxiety improved earlier in the peri-SOX group than in the post-SOX group. Score changes in both groups indicated that general deterioration and slower recovery usually occurred in the scales of physical, social, and role functioning, as well as symptoms of fatigue, reflux, diarrhea, and anxiety.

Conclusion

Peri-SOX showed a longitudinal HRQOL comparable to post-SOX in patients with LAGC who underwent D2 gastrectomy. The peri-SOX group had better performance in social functioning, abnormal taste, and anxiety at some measurements.

Symptomatic Recurrence and Survival Outcomes After Curative Treatment of Gastric Cancer: Does Intensive Follow-up Evaluation Improve Survival?

BACKGROUND

Intensive surveillance after treatment of gastric cancer patients with curative intent may lead to an earlier diagnosis of disease recurrence, but its impact on survival is uncertain. This study aimed to evaluate whether early diagnosis of disease recurrence among asymptomatic patients was associated with long-term survival.

METHODS

This retrospective study analyzed patients with stages 1 to 3C gastric adenocarcinoma treated between 1999 and 2018. All recurrence events were classified as symptomatic or asymptomatic (detected by follow-up tests), and their clinicopathologic characteristics, patterns of recurrence, and survival were analyzed.

RESULTS

The cohort consisted of 669 patients treated with a total gastrectomy in 48.6% and a D2-lymphadenectomy in 88.8% of the cases. Most of the tumors were pT3-4 (46.5%), with 45.5% involving lymph node metastases and 42.3% manifesting a diffuse histology. During a median follow-up period of 80.1 months (95% confidence interval [CI], 75.3-84.8 months), 166 patients had recurrences (24.8%), 65.7% of which were symptomatic. The peritoneum was the main site of recurrence (37.2%), and peritoneal recurrence was associated with worse overall survival (OS) (hazard ratio, 1.69; 95%CI, 1.2-2.37). The median disease-free, post-recurrence survival, and OS periods in the asymptomatic and symptomatic groups were respectively 13.4 versus 17.2 months (p = 0.04), 11.9 versus 4.7 months (p < 0.001), and 29.9 versus 26.4 months (p = 0.21). When OS was analyzed among the patients with non-peritoneal recurrence, no difference was observed between the two groups (31.3 vs 31.1 months; p = 0.46).

CONCLUSION

Early diagnosis of asymptomatic disease recurrence did not affect the OS of the gastric cancer patients treated with curative intent. The use of intensive surveillance strategies in this scenario still requires further evidence.

Prognostic Significance of Signet-Ring Cell Components in Patients With Gastric Carcinoma of Different Stages

Background: Gastric carcinoma (GC), which contains signet ring cell (SRC) components are frequently observed in postoperative pathological assessment. This study aims to study the prognostic significance of SRC components in GC patients.

Methods: From 2003 to 2017, surgically resected primary GC patients were retrospectively reviewed. All enrolled patients were divided into three groups according to the proportion of SRC. The overall survival (OS) and disease-free survival (DFS) of GC patients with different tumor stages were analyzed.

Results: Patients with SRC or mixed-SRC were more associated with female, younger age, middle or lower third of the stomach, larger tumor, higher pN stage, and more lymphovascular invasion. For GC patients in stage I, multivariate survival analysis showed that age >60, SRC components >50%, and pT stage were independent prognostic factors for OS (all p < 0.05). The 5-year OS of patients with SRC were higher than that of patients with pure adenocarcinoma (p = 0.021). For GC patients in stage II/III, multivariate survival analysis showed that age >60, SRC proportion, surgical types, Borrmann's type, pT stage, pN stage, and lymphovascular invasion were independent prognostic factors for OS (all p < 0.05). The 5-year OS/DFS of patients with SRC were lower than that of patients with pure adenocarcinoma (p < 0.001).

Conclusions: SRC seemed to be a favorable prognostic factor in GC patients in stage I. However, for GC patients in stage II/III, the SRC components were associated with poor prognosis, independent of other clinicopathological factors.

Cancer-related FGFR2 overexpression and gene amplification in Japanese patients with gastric cancer

OBJECTIVE

Fibroblast growth factor receptor 2 (FGFR2) has been proposed as a novel druggable target in unresectable gastric cancer. FGFR2 alteration has been reported as associated with poor prognosis even in patients with gastric cancer who received systemic chemotherapy. This study aimed to evaluate the frequency of FGFR2 overexpression and gene amplification in clinical specimens from Japanese patients with recurrent or unresectable gastric cancer.

METHODS

This observational study enrolled patients who were histologically or cytologically confirmed with unresectable HER2-negative or unknown gastric or gastroesophageal junctional adenocarcinoma treated with at least one previous chemotherapy. FGFR2 overexpression and gene amplification in the specimens were evaluated by immunohistochemical staining and fluorescence in situ hybridization methods, respectively.

RESULTS

In a total of 173 eligible cases, FGFR2 immunohistochemistry score was evaluated as 0, 1, 2, 3 and 4 for 20, 80, 35, 28 and 10 cases, respectively. In 151 evaluable cases with FGFR2 immunohistochemistry scores of 1-4, FGFR2 copy number expressed as fluorescence in situ hybridization signals were detected as <4, ≥4 < 10 and ≥10 copies for 123, 16 and 12 cases, respectively. FGFR2 copy number showed an increasing tendency along with higher FGFR2 immunohistochemistry scores in the corresponding specimen. The response rate and time to treatment failure for first line chemotherapy did not have any obvious relationship to FGFR2 immunohistochemistry score and FGFR2 copy number.

CONCLUSIONS

Although FGFR2 overexpression and gene amplification were shown in Japanese patients with unresectable gastric cancer, these alterations did not impact the effects of cytotoxic agents as first line chemotherapy.

Adequate period of surveillance in each stage for curatively resected gastric cancer: analyzing the time and rates of recurrence

BACKGROUND

Surveillance after curative surgery for gastric cancer is conventionally performed for 5 years. However, the appropriate follow-up period remains controversial.

METHODS

This study retrospectively compiled a clinicopathological database of patients who underwent curative gastrectomy between 1975 and 2010 at Toranomon Hospital and were reviewed until March 2020. Analyzing the follow-up rate and recurrence rate for each stage in each postoperative year, we set each follow-up endpoint when the subsequent recurrence rate fell below 1%.

RESULTS

A total of 5235 patients were eligible for inclusion in the study. The rate of patients followed up for 5 years was 90.3%. The rates of follow-up were 52.7% at 10 years, 38.3% at 15 years, and 10.3% at 20 years. Recurrence was confirmed in 850 patients in total (16.2%) and in 50 patients beyond 5 years. The adequate follow-up endpoints according to stage (with < 1% recurrence risk) were 2 years for stage IA, 4 years for IB, 6 years for IIA, 9 years for IIB, 7 years for IIIA, and 8 years for IV (curative). For stage IIIB and IIIC, the recurrence risk remained.

CONCLUSIONS

The adequate surveillance duration of resected gastric cancer might be different in each stage. Although the follow-up duration for stage I disease could be reduced to less than 5 years, advanced gastric cancer such as stage III or IV disease has risk of recurrence beyond 5 years and therefore additional follow-up is required. These results could help decide the strategy for surveillance.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Risk of Second Primary Malignancies among Patients with Early Gastric Cancer Exposed to Recurrent Computed Tomography Scans

Simple Summary

Cancer risk after radiation exposure during childhood has been extensively documented in the literature, although cancer risk associated with recurrent computed tomography (CT) scans during adulthood is less understood. We found a significant relationship between the frequency of CT scans and the subsequent incidence of secondary primary malignancies in patients who have undergone curative resection for early gastric cancer (EGC). On the basis of the low incidence of extragastric recurrence and the risk of radiation exposure, we suggest that overzealous CT surveillance should be avoided in adult patients with EGC.

Abstract

Although computed tomography (CT) scans are very useful for identification or surveillance of malignancy, they are also associated with the risk of cancer caused by ionizing radiation. We investigated the risk of second primary malignancies (SPMs) after frequent abdominopelvic CT scans in a cohort of Korean patients with early gastric cancer (EGC). We performed a cohort study of 11,072 patients who underwent resection for EGC at Samsung Medical Center and validated the results using data from 7908 patients in a Korean National Health Insurance Service cohort. Cox proportional hazards regression model was used to estimate hazard ratios (HRs) for intra-abdominal SPM. During 43,766.5 person-years of the follow-up at our center, 322 patients developed intra-abdominal SPMs. Patients who underwent receiving >8 abdominopelvic CT scans had a significantly greater risk of developing SPM (HR, 2.73; 95% CI, 1.66–4.50; p < 0.001) than those who had with ≤8 scans. For each additional abdominopelvic CT scan, the adjusted HR for SPM was 1.09 (95% confidence interval (CI), 1.03–1.14). Similar results were observed in the Korean National Health Insurance Service cohort (adjusted HR, 1.14; 95% CI, 1.07–1.22). Significantly elevated risk of SPM was still observed when considering a 2-year latency period (adjusted HR, 2.43; 95% CI, 1.37–4.48) and a 3-year latency period (adjusted HR, 2.17; 95% CI, 1.06–4.47). Frequent abdominopelvic CT scans are associated with an elevated risk of SPMs after the treatment of EGC. Thus, physicians need to weigh carefully the clinical benefits of CT examinations against the potential risks of radiation exposure.

Stratification of Postsurgical Computed Tomography Surveillance Based on the Extragastric Recurrence of Early Gastric Cancer

OBJECTIVE

To stratify the postsurgical computed tomography (CT) surveillance based on a risk-scoring system for predicting extragastric recurrence after surgical resection of early gastric cancer (EGC).

SUMMARY OF BACKGROUND DATA

Postsurgical CT surveillance should not be routinely performed in all patients because of the low incidence of extragastric recurrence and potential risk of radiation exposure.

METHODS

Data from 3162 patients who underwent surgical resection for EGC were reviewed to develop a risk-scoring system to predict extragastric recurrence. Risk scores were based on the predictive factors for extragastric recurrence, which were determined using Cox proportional hazard regression model. The risk-scoring system was validated by Uno censoring adjusted C-index. External validation was performed using an independent dataset (n = 430).

RESULTS

The overall incidence of extragastric recurrence was 1.4% (44/3162). Five risk factors (lymph node metastasis, indications for endoscopic resection, male sex, positive lymphovascular invasion, and elevated macroscopic type), which were significantly associated with extragastric recurrence, were incorporated into the risk-scoring system, and the patients were categorized into 2 risk groups. The 10-year extragastric recurrence-free survival differed significantly between low- and high-risk groups (99.7% vs 96.5%; P < 0.001). The predictive accuracy of the risk-scoring system in the development cohort was 0.870 [Uno C-index; 95% confidence interval (95% CI), 0.800-0.939]. Discrimination was good after internal (0.859) and external validation (0.782, 0.549-1.000).

CONCLUSION

This risk-scoring system might be useful to predict extragastric recurrence of EGC after curative surgical resection. We suggest that postsurgical CT surveillance to detect extragastric recurrence should be avoided in the low-risk group.

Surveillance and outcomes after curative resection for gastroesophageal adenocarcinoma

Background

The goal of surveillance testing is to enable curative salvage therapy through early disease detection, however supporting evidence in gastroesophageal adenocarcinoma is limited. We evaluated frequency of successful salvage therapy and outcomes in patients who underwent surveillance.

Methods

A single‐site, retrospective cohort study was conducted to identify all patients who received curative resection for gastroesophageal adenocarcinoma. Surveillance testing were those investigations not triggered by abnormal symptoms, physical examination, or blood tests. Successful salvage therapy was any potentially curative therapy for disease recurrence which resulted in postrecurrence disease‐free survival ≥2 years. Time‐to‐event data were analyzed using the Kaplan‐Meier method and log rank tests.

Results

Between 2011 and 2016, 210 consecutive patients were reviewed. Esophageal (14%), gastroesophageal junction (40%), and gastric adenocarcinomas (45%) were treated with surgery alone (29%) or multimodality therapy (71%). Adjuvant therapy was administered in 35%. At median follow‐up of 38.3 months, 5‐year overall survival (OS) rate was 56%. Among 97 recurrences, 53% were surveillance‐detected, and 46% were symptomatic. None was detected by surveillance endoscopy. Median time‐to‐recurrence (TTR) was 14.8 months. Recurrences included locoregional only (4%), distant (86%), and both (10%). Salvage therapy was attempted in 15 patients, 4 were successful. Compared to symptomatic recurrences, patients with surveillance‐detected recurrences had longer median OS (36.2 vs 23.7 months, P = .004) and postrecurrence survival (PRS, 16.5 vs 4.6 months, P < .001), but similar TTR (16.2 vs 13.3 months, P = .40) and duration of palliative chemotherapy (3.9 vs 3.3 months, P = .64).

Conclusions

Among patients surveyed, 96% of recurrences were distant, and salvage therapy was successful in only 1.9% of patients. Longer OS in patients with surveillance‐detected compared to symptomatic recurrences was not associated with significant earlier disease detection, and may be contributed by differences in disease biology. Further prospective data are warranted to establish the benefit of surveillance testing in gastroesophageal adenocarcinoma.

Nomogram for predicting the survival of gastric adenocarcinoma patients who receive surgery and chemotherapy

Background

Surgery is the only way to cure gastric adenocarcinoma (GAC), and chemotherapy is the basic adjuvant management for GAC. A significant prognostic nomogram for predicting the respective disease-specific survival (DSS) rates of GAC patients who receive surgery and chemotherapy has not been established.

Objective

We were planning to establish a survival nomogram model for GAC patients who receive surgery and chemotherapy.

Methods

We identified 5764 GAC patients who had received surgery and chemotherapy from the record of Surveillance, Epidemiology, and End Results (SEER) database. About 70% (n = 4034) of the chosen GAC patients were randomly assigned to the training set, and the rest of the included ones (n = 1729) were assigned to the external validation set. A prognostic nomogram was constructed by the training set and the predictive accuracy of it was validated by the validation set.

Results

Based on the outcome of a multivariate analysis of candidate factors, a nomogram was developed that encompassed age at diagnosis, number of regional lymph nodes examined after surgery, number of positive regional lymph nodes, sex, race, grade, derived AJCC stage, summary stage, and radiotherapy status. The C-index (Harrell’s concordance index) of the nomogram model was some larger than that of the traditional seventh AJCC staging system (0.707 vs 0.661). Calibration plots of the constructed nomogram displayed that the probability of DSS commendably accord with the survival rate. Integrated discrimination improvement (IDI) revealed obvious increase and categorical net reclassification improvement (NRI) showed visible enhancement. IDI for 3-, 5- and 10- year DSS were 0.058, 0.059 and 0.058, respectively (P > 0.05), and NRI for 3-, 5- and 10- year DSS were 0.380 (95% CI = 0.316–0.470), 0.407 (95% CI = 0.350–0.505), and 0.413 (95% CI = 0.336–0.519), respectively. Decision curve analysis (DCA) proved that the constructed nomogram was preferable to the AJCC staging system.

Conclusion

The constructed nomogram supplies more credible DSS predictions for GAC patients who receive surgery and chemotherapy in the general population. According to validation, the new nomogram will be beneficial in facilitating individualized survival predictions and useful when performing clinical decision-making for GAC patients who receive surgery and chemotherapy.

Cancer Survivorship in Primary Care

With the early detection of cancer and improvement in cancer therapy, the number of cancer survivors is rapidly increasing. This number is expected to reach 2 million by the end of 2019. Cancer survivors struggle with not only cancer-related health problems but also diverse acute and chronic diseases. These health issues make cancer survivorship more complex, and proper care coordination is necessary. This study aimed to summarize the definition of cancer experience and management of cancer survivors, specifically focused on gastric, colorectal, lung, breast, thyroid, prostate, and cervical cancers. Furthermore, it aimed to discuss the role of primary care in cancer survivorship and survivorship care models and the National Policy for Cancer Survivors and Future Challenges.

Expression of ALDH1A1 and CD133 is associated with the prognosis and effect of different chemotherapeutic regimens in gastric cancer

Gastric cancer (GC) is one of the most common malignant tumors worldwide. Previous studies have reported that aldehyde dehydrogenase-1A1 (ALDH1A1) and cluster of differentiation (CD)-133 are considered to be cancer stem cell markers in GCs. The present study immunohistochemically examined the distribution and expression of two tumor stem cell markers, CD133 and ALDH1A1, in both primary tumors and para-tumor tissues. In 91 cases with stage III, 57 (62%) were positive for ALDH1A1 and 60 (66%) were positive for CD133. ALDH1A1 was detected in para-tumors and cancerous tissues of the stomach, and the immunoreactivity of the tumors was stronger than that in para-tumor tissues. CD133 was only detected in tumors. The expression of ALDH1A1 was significantly associated with advanced T/N stage (T stage, P=0.012; N stage, P=0.023) and poor differentiation (P=0.020), while CD133 was associated with advanced T stage (P=0.007). Univariate and multivariate Cox proportional hazards analysis revealed that tumor stage, CD133 expression, vascular invasion and sex were independent predictors of disease-free survival (DFS) time, and tumor size, vascular invasion and sex were independent predictors of overall survival (OS) time in patients with GC. Patients with CD133⁺ GC had poorer DFS (P=0.042), while ALDH1A1⁺ GC was not associated with poorer DFS. In regard to chemotherapy, improvements in survival were not observed after the addition of taxane compared with two-drug therapy. However, the subgroup analysis indicated that in the ALDH1A1⁻ subgroup, and CD133⁺ and ALDH1A1⁻ subgroups, an increased OS was observed in two-drug therapy (P=0.043). The results of the present study indicate that ALDH1A1 and CD133 may play an important role in tumor invasion, metastasis and prognosis, and ALDH1A1⁻ expression does not benefit the taxane-based triple chemotherapeutic regimen in patients with GC.

Are We Choosing Surveillance Imaging in Gastric and Pancreatic Cancers Wisely? A Population-Based Study

BACKGROUND/OBJECTIVE

Although gastric and pancreatic cancers are aggressive, there is no evidence that early detection of recurrence improves overall survival. We aimed to measure the frequency of surveillance imaging in patients after curative resection for gastric and pancreatic cancers.

METHODS

We performed a population-based cohort study on patients in Ontario, Canada, with a first diagnosis of gastric and pancreatic cancer in 2003-2013. Health administrative databases were linked using unique encoded identifiers to record demographics, imaging frequency, and health resource utilization.

RESULTS

The cohort comprised 2930 patients (2151 gastric, 779 pancreatic). The median age was 69 (38% female). The cumulative incidence of CT imaging overall was 74.3% after 1 year and 82.8% by 3 years. Imaging was more likely for pancreatic cancer compared to gastric cancer (p < 0.0001). On multivariate analysis, imaging was less likely for females and older patients and varied significantly by health district. Imaging frequency increased over the study period.

CONCLUSIONS

Significant and increasing numbers of patients received surveillance imaging after resection of gastric or pancreatic cancers despite lack of data to show its benefit. This data shows the need for the Choosing Wisely Canada recommendations (published after the study period) and serve as a baseline for future analyses.

The clinical outcomes of S-1 plus cisplatin for patients with advanced gastric cancer: A meta-analysis and systematic review

BACKGROUND

To evaluate the clinical outcomes of S-1 plus cisplatin (SC) for the treatment of patients with advanced gastric cancer (AGC).

METHODS

A systematic literature search was conducted by searching PubMed, the Cochrane Library, Embase, China Biology Medicine disc (CBMdisc), China National Knowledge Infrastructure (CNKI), and WanFang Database, for all year up to January 2017. Pooled analyses of overall survival (OS), progress-free survival rates, and adverse events were performed.

RESULTS

A total of 8 random controlled trails (RCTs) consisting of 2699 patients with AGC were selected and included in this meta-analysis. The results of our meta-analysis showed that AGC patients who treated with SC regimen receive a similar OS (HR = 1.01, 95%CI: 0.86-1.18, P = .928), PFS (HR = 0.89, 95%CI: 0.72-1.09, P = .263), and overall response rate (HR = 0.88, 95%CI: 0.70-1.11, P = .283). However, SC regimen may increase the risk of 1 to 2 grade (OR = 1.128, 95%CI: 1.075-1.184, P = .000) and 3 to 4 grade (OR = 1.24, 95%CI: 1.01-1.52, P = .039) adverse events.

CONCLUSION

SC chemotherapy showed no difference in survival compared with 5-FU- and S-1-based other therapy, but has a higher rate of adverse events compared with other chemotherapy regimens.

Identification of a high-risk subtype of intestinal-type Japanese gastric cancer by quantitative measurement of the luminal tumor proportion

Background

We hypothesized that the relative proportion of tumor (PoT) at the luminal surface can predict gastric cancer (GC) patient survival.

Methods

We measured the luminal PoT in resection specimens from 231 GC patients with stage II/III disease who had surgery at the Kanagawa Cancer Center, Yokohama, Japan. Tissue microarrays were used to assess the extent of immune cell infiltration by CD45 immunohistochemistry. Results were related to histopathological features and patient overall survival (OS).

Results

PoT was significantly lower in diffuse‐type (30%) compared to intestinal‐type GC (41%), P = 0.03. Patients with low PoT intestinal‐type GC survived significantly longer than patients with high PoT intestinal‐type GC (5 years OS: 78% vs 47%, P = 0.0112). Low PoT was an independent favorable prognostic factor in multivariate analysis in intestinal‐type GC. Low PoT was correlated with high content of CD45‐positive immune cells (P = 0.035). There was no relationship between PoT and survival in diffuse‐type GC.

Conclusions

This is the first study to identify a subgroup of patients with stage II/III intestinal‐type GC at high risk of recurrence by measuring PoT at the luminal surface. The relationship between PoT and immune cell content provides an initial insight into potential underlying biological mechanisms.

Is endoscopic surveillance necessary for patients who undergo total gastrectomy for gastric cancer?

There have been only a few reports investigating the clinical efficacy of follow-up endoscopy for detection of recurrent gastric cancer after total gastrectomy (TG). We reviewed the records of 747 patients undergoing TG from 2003 to 2012 and enrolled 267 patients (70 with early gastric cancer (EGC) and 197 with advanced gastric cancer (AGC)), who received one or more follow-up endoscopy and contrast abdominal computed tomography (CT) scan. We found no tumor recurrence in the 70 EGC patients during the mean follow-up periods of 42.1 ± 18 and 43.2 ± 19 months by endoscopy and contrast abdominal CT scan. In 197 AGC patients, 59 patients (29.8%) had confirmed tumor recurrence during mean follow-up periods of 40.5 ± 21 and 45.3 ± 22 months. The most common pattern of tumor recurrence was distant metastasis (n = 35) followed by peritoneal metastasis (n = 11). Among the other 13 cases with loco-regional recurrence, seven cases were regional lymph node metastases, four were anastomosis site recurrences, and two were duodenal stump and jejunal loop site recurrences. Three of the four cases of anastomosis site recurrence were found by both endoscopy and contrast abdominal CT scan; one case was missed by contrast abdominal CT scan. However, the two cases with duodenal stump and jejunal loop recurrences were detected by contrast abdominal CT scan only. An annual follow-up endoscopy for gastric cancer after TG might have a limited role in the detection of tumor recurrence, especially in patients with EGC. Contrast abdominal CT scan may be sufficient as a follow-up method for recurrent gastric cancer after TG.

Postoperative follow-up programs improve survival in curatively resected gastric and junctional cancer patients: a propensity score matched analysis

BACKGROUND

To date there is no evidence that more intensive follow-up after surgery for esophagogastric adenocarcinoma translates into improved survival. This study aimed to evaluate the impact of standardized surveillance by a specialized center after resection on survival.

METHODS

Data of 587 patients were analyzed who underwent curative surgery for esophagogastric adenocarcinoma in our institution. Based on their postoperative surveillance, patients were assigned to either standardized follow-up (SFU) by the National Center for Tumor Diseases (SFU group) or individual follow-up by other physicians (non-SFU group). Propensity score matching (PSM) was performed to compensate for heterogeneity between groups. Groups were compared regarding clinicopathological findings, recurrence, and impact on survival before and after PSM.

RESULTS

Of 587 patients, 32.7% were in the SFU and 67.3% in the non-SFU group. Recurrence occurred in 39.4% of patients and 92.6% within the first 3 years; 73.6% were treated, and of those 17.1% underwent resection. In recurrent patients overall and post-recurrence survival (OS/PRS) was influenced by diagnostic tools (p < 0.05), treatment (p ≤ 0.001), and resection of recurrence (p ≤ 0.001). Standardized follow-up significantly improved OS (84.9 vs. 38.4 months, p = 0.040) in matched analysis and was an independent positive predictor of OS before and after PSM (p = 0.034/0.013, respectively).

CONCLUSION

After PSM, standardized follow-up by a specialized center significantly improved OS. Cross-sectional imaging and treatment of recurrence were associated with better outcome. Regular follow-up by cross-sectional imaging especially during the first 3 years should be recommended by national guidelines, since early detection might help select patients for treatment of recurrence and even resection in few designated cases.

Follow-up after curative resection for gastric cancer: Is it time to tailor it?

There is still no consensus on the follow-up frequency and regimen after curative resection for gastric cancer. Moreover, controversy exists regarding the utility of follow-up in improving survival, and the recommendations of experts and societies vary considerably. The main reason to establish surveillance programs is to diagnose tumor recurrence or metachronous cancers early and to thereby provide prompt treatment and prolong survival. In the setting of gastric malignancies, other reasons have been put forth: (1) the detection of adverse effects of a previous surgery, such as malnutrition or digestive sequelae; (2) the collection of data; and (3) the identification of psychological and/or social problems and provision of appropriate support to the patients. No randomized controlled trials on the role of follow-up after curative resection of gastric carcinoma have been published. Herein, the primary retrospective series and systematic reviews on this subject are analyzed and discussed. Furthermore, the guidelines from international and national scientific societies are discussed. Follow-up is recommended by the majority of institutions; however, there is no real evidence that follow-up can improve long-term survival rates. Several studies have demonstrated that it is possible to stratify patients submitted to curative gastrectomy into different classes according to the risk of recurrence. Furthermore, promising studies have identified several molecular markers that are related to the risk of relapse and to prognosis. Based on these premises, a promising strategy will be to tailor follow-up in relation to the patient and tumor characteristics, molecular marker status, and individual risk of recurrence.

Adjuvant therapy for locally advanced gastric cancer

D2 gastrectomy is now the globally accepted surgical standard for locally advanced gastric cancer. However, since 2000, different evidence has emerged regarding the efficacy of adjuvant chemoradiation, perioperative adjuvant chemotherapy, and postoperative chemotherapy for locally advanced gastric cancer. This review summarizes the background, current status, and future perspectives of adjuvant therapy for locally advanced gastric cancer. The Intergroup 0116 study was the first to show the significant overall survival benefits of adjuvant (chemoradiation) therapy for gastric cancer. The second study was the MAGIC trial, which showed the efficacy of perioperative adjuvant chemotherapy. Although the findings from the Intergroup 0116 study and the MAGIC trial were positive, recent studies, such as the ARTIST and EORTC 40954 studies, found no survival benefit for patients who had undergone D2 gastrectomy for gastric cancer. Regarding the adjuvant chemotherapy strategy, two pivotal phase III trials: the ACTS-GC and the CLASSIC, demonstrated the efficacy of postoperative adjuvant chemotherapy following D2 gastrectomy. However, more intensive chemotherapy is necessary to improve the survival rate. Several studies have analyzed the effectiveness of molecular-targeted therapy against metastatic gastric or gastroesophageal junction carcinoma. Further studies should focus on the survival benefit of more-intensive adjuvant therapy with D2 resection, or with concurrent molecular-targeted therapy.

Postgastrectomy follow-up in the West: evidence base, guidelines, and daily practice

Follow-up after gastrectomy for gastric cancer has several purposes, including management of side effects of surgery, oncological recurrence surveillance, psychological support, and data collection for research. How follow-up after gastrectomy, and especially recurrence surveillance, is performed differs immensely between different Western countries, despite guidelines from Western oncological organizations quite unanimously advocating symptom-driven surveillance, without scheduled cross-sectional imaging, endoscopies, or analysis of tumor markers. Given a complete lack of randomized data, the available body of observational data does not support intensive routine surveillance for recurrent disease. Moreover, studies of other cancers have shown a negative emotional impact of routine surveillance. There is an apparent need for randomized controlled trials to address the issue of optimized strategies for postgastrectomy recurrence surveillance.

Report from the 17th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Edmonton, Alberta; 11-12 September 2015

The 17th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Edmonton, Alberta, 11-12 September 2015. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of gastric cancer.

Clinical outcomes of recurrent gastric cancer detected by upper endoscopy after curative total gastrectomy

BACKGROUND/AIMS

Endoscopically detected tumor recurrence after curative total gastrectomy is very rare. We reviewed the clinicopathological and endoscopic findings together with the clinical outcomes of these patients.

METHODS

Seventeen patients with recurrent gastric cancer detected by upper gastrointestinal endoscopy who underwent curative total gastrectomy between January 1990 and May 2011 at the Asan Medical Center were analyzed retrospectively.

RESULTS

Of the 17 patients, 5 were resectable at the time of diagnosis of recurrence and 12 were unresectable. The median interval between total gastrectomy and diagnosis of recurrence was 20.2 months (interquartile range 12.4-42.1 months). The tumors were located in the anastomotic area in 8 patients, in the proximal part of the afferent or efferent loop in 7, and in the stump of the afferent loop in 2 patients. With regard to the endoscopic findings, a mass was found in 8 cases, an ulcer in 2, stricture in 4, and nodularities in 3. Operations were performed in 3 patients, chemotherapy in 10 (including 2 receiving adjuvant chemotherapy), and conservative management in 6. Fourteen patients died from progression of the disease and the median survival period from recurrence for all 17 patients was 5.3 months (interquartile range 1.2-7.7 months).

CONCLUSIONS

Local recurrence of gastric cancer detected by upper gastrointestinal endoscopy after curative total gastrectomy has a poor prognosis.

Characterising timing and pattern of relapse following surgery for localised oesophagogastric adenocarcinoma: a retrospective study

Background

Oesophagogastric adenocarcinoma (OGA) has a poor prognosis, even for patients with operable disease. However, the optimal surveillance strategy following surgery is unknown.

Methods

We performed a retrospective review of all patients with OGA who had undergone surgery with radical intent at the Royal Marsden between January 2001 and December 2010.

Results

Of the 360 patients with OGA who underwent potentially curative surgery, 100/214 patients (47 %) with oesophageal/gastro-oesophageal junction (GOJ) adenocarcinoma and 47/146 patients (32 %) with gastric adenocarcinoma developed recurrent disease. 51, 79 and 92 % of relapses occurred within 1, 2 and 3 years respectively and the majority of patients relapsed at distant sites. Of the patients who relapsed, 67 % (67/100) with oesophageal/GOJ adenocarcinoma and 72 % of patients with gastric cancer (34/47) were symptomatic at the time of relapse. The majority of asymptomatic relapses were first detected by a rise in tumour markers. There was no difference in disease-free survival between asymptomatic and symptomatic patients, but asymptomatic patients were more likely to receive further treatment and had a longer survival beyond relapse.

Conclusion

The majority of relapses occur within the first 3 years and at distant sites. Monitoring of tumour markers should be considered as part of a surveillance program.

National Trends in Utilization of Endoscopic Ultrasound for Gastric Cancer: a SEER-Medicare Study

INTRODUCTION

Accurate preoperative staging is important for patients with gastric cancer. This study identifies the rate of utilization of endoscopic ultrasound (EUS) and its associated factors in Medicare patients with gastric adenocarcinoma.

METHODS

The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare claims database was queried from 1996 to 2009 for patients with gastric cancer who underwent gastric resection. Analysis with univariate, multivariate, and Cochran-Armitage trend tests were performed.

RESULTS

In 5826 patients with gastric cancer with an average age of 76.9 ± 6.62 years, 59.1% had regionalized spread of cancer. EUS utilization increased significantly during the study period from 2.6% to 22% (p < 0.0001). EUS patients were more likely to be male, white, married, have higher education and income quartiles, and live in large metropolitan areas compared to non-EUS patients (p < 0.0001). Even after controlling for confounding factors, patients who underwent EUS were more likely to have >15 lymph nodes examined (odds ratio (OR) 1.26, 95% confidence interval (CI) 1.04-1.53) and have the administration of both pre- and postoperative chemotherapy (OR 1.27, 95% CI 1.03-1.57).

CONCLUSION

EUS is currently under-utilized but increasing. Patients who underwent EUS (12.9%) were more likely to receive other NCCN-recommended care, including perioperative chemotherapy and adequate nodal retrieval.

Systematic review on quality of life outcomes after gastrectomy for gastric carcinoma

BACKGROUND

Despite advances in chemotherapy and radiotherapy, gastrectomy is the only curative intervention for gastric carcinoma. This study reviews post-operative health-related quality of life (HRQOL) after gastrectomy.

METHODS

A literature search was conducted on PubMed for all studies published after January 2000 matching strict eligibility criteria. Bibliographies of included studies were also reviewed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesised by narrative review according to PRISMA guidelines with full tabulation of results of all included studies.

RESULTS

A total of 21 studies (3,575 patients) were included. Post-operative HRQOL improvements were demonstrated across most or all domains in different HRQOL instruments. Patients experienced declines in HRQOL 1 month after surgery, but reached at least pre-operative levels with recovery by 1 year. The greatest improvements were demonstrated in the emotional health domain with favourable functional benefits. Partial gastrectomy appears to be superior to total gastrectomy in physical, emotional and functional health domains. However, patients remain susceptible to gastrointestinal symptoms following surgery, which negatively impact upon HRQOL. Post-operative complications did not appear to affect HRQOL. Most studies were prospective, but data is heterogeneous.

CONCLUSIONS

Gastrectomy results in significant HRQOL benefits across a broad range of health domains. This is critical outcome of surgery and an important consideration in pre-operative decision making.

Efficacy of docetaxel plus S-1 as neoadjuvant chemotherapy for operable advanced gastric cancer

AIM: To evaluate the efficacy of preoperative chemotherapy with docetaxel plus S-1 (DS regimen) for resectable advanced gastric cancer.

METHODS: Two hundred and twenty patients with operable locally advanced gastric cancer were collected and equally divided into two groups (A and B). In group A, patients received docetaxel (35 mg/m²) on day 1 for 2 h and daily oral administration of S-1 [80 mg/(m²•d)] on days 1-14 every 4 wk for two cycles, and prophylactic administration of antiemetic medication at a standard doses was routinely used to prevent nausea and vomiting. Then gastrectomy with D2 lymphadenectomy was performed. In group B, patients received only gastrectomy with D2 lymphadenectomy. The R0 resection rate, pathological complete response (pCR), postoperative complications, local recurrence rate and survival rate were compared between the two groups.

RESULTS: Treatment-related death or operative mortality was not found in this study. Because of economic reasons, only 107 (97.3%) patients underwent surgery. There was no significant difference in the incidence of anastomotic leakage (1.8% vs 2.7%, P > 0.05) or poor healing of incision (5.6% vs 4.5%, P > 0.05). There were significant differences in R0 radical resection rate (99.06% vs 92.73%, P < 0.05), pCR rate (8.41% vs 1.81%, P < 0.05) and local recurrence rate (18.6% vs 31.8%, P < 0.05) between the two groups. The 3- (55.7% vs 40.6%, P < 0.05) and 5-year survival rates (31.3% vs 21.8%, P < 0.05) also differed significantly between the two groups.

CONCLUSION: DS regimen as neoadjuvant chemotherapy for operable locally advanced gastric cancer can increase the rates of R0 radical resection, pCR and survival, and decrease the recurrence rate, without increasing the rate of complications.

Follow-up: the evidence

There is currently no consensus on the best strategy for the follow-up of patients who have undergone surgical treatment with curative intent for gastric cancer. The wide variation in recommendations for surveillance among international experts and hospital schedules clearly reflects a lack of an established body of evidence on this subject. Consequently, most of the international guidelines aimed at early detection of disease recurrence gloss over details concerning the mode, duration, and intensity of surveillance since they cannot be based on an acceptable grade of recommendation. Very few report anything other than the detection of recurrences or death as the primary endpoints, and, given the poor survival of patients with recurrent gastric cancer, the prognostic effect of early detection seems doubtful. In recent years, an increasing focus on evidence-based medicine, which has coincided with a growing concern about costs and efficiency in medicine, has caused a reevaluation of most surveillance practices. In this paper, we review and discuss the current body of evidence and follow-up practices after curative resection of gastric cancer.

Neoadjuvant chemotherapy for gastric cancer in Japan: a standing position by comparing with adjuvant chemotherapy

Adjuvant chemotherapy aims to eradicate micrometastatic tumor cells before and after curative surgery. Many Phase III trials have been conducted to study the efficacy of postoperative adjuvant chemotherapy; however, most trials have failed to show any survival benefit because of their low statistical power and/or poor patient compliance. Since 2000, two pivotal Phase III trials, the ACTS-GC and the CLASSIC, have demonstrated the efficacy of postoperative adjuvant chemotherapy following D2 gastrectomy. Although treatment with S-1 for 1 year or combination therapy with capecitabine and oxaliplatin for 6 months is effective, more intensive chemotherapy is necessary to further improve the survival rates. In Europe, two Phase III trials, the MAGIC and the FNCLCC/FFCD, have produced results that strongly suggest that neoadjuvant chemotherapy is beneficial. The advantages of neoadjuvant chemotherapy include a high rate of R0 resection, tumor regression, high compliance and the avoidance of unnecessary surgery. The disadvantage of neoadjuvant chemotherapy is over-diagnosis. In Japan, the Japan Clinical Oncology Group has conducted several clinical trials using neoadjuvant chemotherapy to target extensive nodal disease and/or scirrhous carcinomas. The optimal courses and regimens of neoadjuvant chemotherapy should, therefore, be clarified in the future.