What studies are appropriate and necessary for staging gastric adenocarcinoma? Results of an international RAND/UCLA expert panel

Diagnosis of gastric cancer by MDCT gastrography: diagnostic characteristics and management potential

Background

Gastric cancer is regarded as the fifth most frequent tumor globally but the third most common fatal illness. As early as possible, we diagnose cancer stomach especially at early stages, the higher the rate of life. Nevertheless, most cases are diagnosed at late cases where surgery is not of the same benefit at early stages because of clinically indefinite symptoms. The prospective study goal is to estimate the role of MDCT in diagnosis and staging of cancer stomach.

Results

In our study, it was found that there was a high relationship between pathological and CT staging by using MPR. CT with MPR was specific and accurate in diagnosis of all stages of gastric cancer with specificity ranged between 93 and 97% and accuracy ranged between 90 and 92.5%. However, it showed lowest sensitivity in diagnosis of stage 1 of gastric cancer. On the other hand, it showed highest sensitivity (90%) in diagnosis of stage IV as well as we found that MPR and VR of MDCT are much more accurate (92.5%) than multi-detector computed tomography axial images (80%) in the diagnosis of all stages of gastric cancer with the difference between the two sequences was significant (P = 0.009).

Conclusion

Our results demonstrate that preoperative MDCT with contrast filling technique for abdomen and pelvis evaluates the local disease process of gastric cancer as well as the potential areas of spread. This information is vital in choosing between palliative or radical surgery. MPR and VR help in the assessment of tumor extension and considered as a highly representative prognostic value. Making it the imaging modality of choice in diagnosis and staging of gastric cancers.

Significance of Gastric Wall Thickening Detected in Abdominal CT Scan to Predict Gastric Malignancy

Background

Early diagnosis of gastric cancer is one of the most important parameters affecting the survival of the disease. In this study, we aimed to stress the importance of antrum wall thickness in CT examination.

Method

The study included 111 patients between ages of 18 and 95 who had antral wall thickening in computed tomography and also had endoscopic evaluation performed in the same clinic. The patients were divided into two groups as benign and malignant according to the pathology results. The thickness of the antrum wall in computed tomography, hemoglobin and albumin levels, and age was compared among these two groups. Parameters with significant differences were further analyzed by multivariate analysis using logistic regression analysis.

Results

Of the 111 patients included in the study, 57 were male and 54 were female. Mean age was 65 years. Fifty-one patients were classified as benign and 60 patients as malignant. Mean age of the malignant patients was 70, while that of benign patients was 59 (p < 0.05). Antrum wall thickness was 13.68 ± 3.27 mm in malignant patients and 9.22 ± 2.17 mm in benign patients (p < 0.05). Similarly, hemoglobin level was significantly different in malignant and benign patients (10.78 ± 1.57 g/dl and 12.64 ± 1.43 g/dl, respectively; p < 0.05). Albumin levels were 3.36 ± 0.57 mg/dl in malignant patients and 3.97 ± 0.57 mg/dl in benign patients (p < 0.05).

Conclusion

Evaluation of antrum wall thickness, age, hemoglobin, and albumin values together may contribute to distinguishing the benign and malignant pathologies involving this region in patients with suspected stomach wall thickening in abdominal CT scan.

Pre-operative laparoscopic staging of gastric cancer in patients who are candidates for neo-adjuvant chemotherapy: A Cross Sectional Study

Objective The aim of this study is to evaluate the laparoscopic method in gastric cancer staging before surgery in patients undergoing Neo-adjuvant chemotherapy. Methods This was a cross-sectional study on patients with T3-T4 and node positive non-metastatic gastric adenocarcinoma who was candidates for neo-adjuvant chemotherapy. The patients were excluded from the study when they were not in the condition to continue the study. All eligible patients underwent metastases work up by abdominal, pelvic and chest CT scans and then received neo-adjuvant chemotherapy. Pre-operative laparoscopy was performed before definitive surgery. The collected data was analyzed using SPSS software. The statistical significance, sensitivity, specificity and predictive values were calculated from this data. Results In this study, out of 50 patients, 26 (52%) were male. The mean age of the patients was 62.44 ± 12.136 years. Most tumors were located in one-third distal of stomach (21 patients, 42%). The accuracy of the laparoscopic method, to determine the degree of involvement of the lymph nodes, revealed that the method had a sensitivity of 84%, a specificity of 47.62%, a positive likelihood ratio (PLR) of 1.6, a negative likelihood ratio (NLR) of 0.33%, a positive predictive value of 65.62% and a negative predictive value of 71.43%. The accuracy of the laparoscopic method, regarding determining the presence or absence of metastasis, revealed that the method had a sensitivity, specificity, positive predictive value, and a negative predictive value of 100%. Conclusion Based on the evidence of this study, and other studies in this field, it seems that the use of a step-by-step combination methods in gastric cancer staging would be logical. Alone, no singular method would be sufficient in providing the physician with sufficient information to successfully stage the tumor and thus determine the appropriate treatment. Therefore, the combination of methods should be used which, in view of the economic constraints of health systems, would be recommended for high-risk patients for metastasis (N+/ T3-T4), diagnostic pre-operative laparoscopy.

Is Accurate N - Staging for Gastric Cancer Possible?

Node stage (N stage) is of paramount importance for gastric cancer staging. Radiologically node status implies detection and characterization of suspect malignant lymph nodes. Clinically it might determine survival and alter therapeutic plans. A number of modalities, including computerized tomography, MRI, PET and endoscopic ultrasound are currently available. Using a multimodality strategy, accuracy ranges between 50-90% across various studies. Specificity and sensitivity varies with respect to method, number of positive lymph nodes, their location and other characteristics. Restaging after neoadjuvant therapy and staging of recurrence presents its own, particular challenges. Each method has its advantages and limitations and none of them alone is adequate enough for staging. While most of them are clinically well established, they are also active research topics. To overcome the aforementioned limitations a multidisciplinary, multimodality approach with emphasis on clinical staging and treatment plans is proposed.

Treatment of peritoneal metastases from gastric carcinoma

Patients with advanced gastric cancer and positive peritoneal cytology and/or peritoneal dissemination are deemed to be incurable and to hold dismal prognosis. So far, the only treatment option for these patients has been palliative systemic (chemo)therapy. However, for the last three decades, great progress has been made in attempts to treat (potential) peritoneal dissemination by means of complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) after preoperative systemic therapy. This review is focused on the recent achievements of this multimodal strategy. Additionally, the review stands as background for the 4th International Conference “Advances in Surgical Oncology” that was held at the Medical University of Lublin (Poland) in November 2017, and dedicated to cytoreductive surgery and HIPEC for advanced gastric cancer.

Regional variation in the management of metastatic gastric cancer in Ontario

BACKGROUND

Geographic variation in cancer care is common when clear clinical management guidelines do not exist. In the present study, we sought to describe health care resource consumption by patients with metastatic gastric cancer (gc) and to investigate the possibility of regional variation.

METHODS

In this population-based cohort study of patients with stage iv gastric adenocarcinoma diagnosed between 1 April 2005 and 31 March 2008, chart review and administrative health care data were linked to study resource utilization outcomes (for example, clinical investigations, treatments) in the province of Ontario. The study took a health care system perspective with a 2-year time frame. Chi-square tests were used to compare proportions of resource utilization, and analysis of variance compared mean per-patient resource consumption between geographic regions.

RESULTS

A cohort of 1433 patients received 4690 endoscopic investigations, 12,033 computed tomography exams, 12,774 radiography exams, and 5059 ultrasonography exams. Nearly all patients were seen by a general practitioner (98%) and a specialist (99%), and were hospitalized (95%) or visited the emergency department (87%). Fewer than half received chemotherapy (43%), gastrectomy (37%), or radiotherapy (28%). The mean number of clinical investigations, physician visits, hospitalizations, and instances of patient accessing the emergency department or receiving radiotherapy or stent placement varied significantly by region.

CONCLUSIONS

Variations in health care resource utilization for metastatic gc patients are observed across the regions of Ontario. Whether those differences reflect differential access to resources, patient preference, or physician preference is not known. The observed variation might reflect a lack of guidelines based on high-quality evidence and could partly be ameliorated with regionalization of gc care to high-volume centres.

MRI of the stomach: a pictorial review with a focus on oncological applications and gastric motility

The purpose of this pictorial review is to demonstrate gastric pathology seen on magnetic resonance imaging (MRI) and discuss the essential MRI sequences for the evaluation of benign and malignant gastric pathologies. Common tumors of the stomach, polyposis syndromes, iatrogenic conditions, as well as other conditions of the stomach will be reviewed. The utility of MRI in the evaluation of patients with gastric malignancies and disorders of gastric motility will also be discussed.

Multidetector computed tomography in the preoperative staging of gastric adenocarcinoma

Objective

To evaluate the role of multidetector computed tomography in the preoperative investigation of tumor invasion depth and lymph node and metastatic involvement according to the TNM classification, in patients with gastric adenocarcinoma.

Materials and Methods

Fifty-four patients with biopsy-confirmed gastric cancer underwent preoperative staging with 64-channel multidetector computed tomography. Two independent radiologists analyzed the images and classified the findings. Sensitivity, specificity, accuracy and overall accuracy were calculated for each observer. The interobserver agreement was also evaluated.

Results

The accuracy in the classification of categories T ranged from 74% to 96% for observer 1 and from 80% to 92% for observer 2. The overall accuracy was 70% for both observers. The weighted kappa index was 0.75, consistent with a significant interobserver agreement. The accuracy in the classification of lymph node involvement (category N) ranged from 55% to 79% for observer 1 and from 73% to 82% for observer 2. The evaluation of metastatic involvement showed an overall accuracy of 89.6% for both observers.

Conclusion

64-channel multidetector computed tomography demonstrated clinically relevant accuracy in the preoperative staging of gastric adenocarcinoma as regards invasion depth (T category) and metastatic involvement (M category).

Breast Implant-associated Anaplastic Large Cell Lymphoma: Updated Results from a Structured Expert Consultation Process

Background:

Despite increased cases published on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), important clinical issues remain unanswered. We conducted a second structured expert consultation process to rate statements related to the diagnosis, management, and surveillance of this disease, based on their interpretation of published evidence.

Methods:

A multidisciplinary panel of 12 experts was selected based on nominations from national specialty societies, academic department heads, and recognized researchers in the United States.

Results:

Panelists agreed that (1) this disease should be called “BIA-ALCL”; (2) late seromas occurring >1 year after breast implantation should be evaluated via ultrasound, and if a seroma is present, the fluid should be aspirated and sent for culture, cytology, flow cytometry, and cell block to an experienced hematopathologist; (3) surgical removal of the affected implant and capsule (as completely as possible) should occur, which is sufficient to eradicate capsule-confined BIA-ALCL; (4) surveillance should consist of clinical follow-up at least every 6 months for at least 5 years and breast ultrasound yearly for at least 2 years; and (5) BIA-ALCL is generally a biologically indolent disease with a good prognosis, unless it extends beyond the capsule and/or presents as a mass. They firmly disagreed with statements that chemotherapy and radiation therapy should be given to all patients with BIA-ALCL.

Conclusions:

Our assessment yielded consistent results on a number of key, incompletely addressed issues regarding BIA-ALCL, but additional research is needed to support these statement ratings and enhance our understanding of the biology, treatment, and outcomes associated with this disease.