Adjuvant and neoadjuvant therapy for gastric cancer

WYC-209 inhibited GC malignant progression by down-regulating WNT4 through RARα

Gastric cancer (GC) has been a major health burden all over the world but there are fewer promising chemotherapeutic drugs due to its multidrug resistance. It has been reported that WYC-209 suppresses the growth and metastasis of tumor-repopulating cells but the effect on GC was not explored. MTT, colony formation, and transwell assays were performed to examine the effects of WYC-209 on the proliferation, colony growth, and mobility of GC cells. Western blotting and qRT-PCR were used to detect the expression of proteins and mRNA. RNA-seq and enrichment analyses were conducted for the differentially expressed genes and enriched biological processes and pathways. The rescue experiments were carried out for further validation. Besides, we constructed xenograft model to confirm the effect of WYC-209 in vivo. The dual-luciferase reporter and Chromatin immunoprecipitation were implemented to confirm the underlying mechanism. WYC-209 exerted excellent anti-cancer effects both in vitro and in vivo. Based on RNA-seq and enrichment analyses, we found that Wnt family member 4 (WNT4) was significantly down-regulated. More importantly, WNT4 overexpression breached the inhibitory effect of WYC-209 on GC progression. Mechanically, WYC-209 significantly promoted the binding between retinoic acid receptor α (RARα) and WNT4 promoter. WYC-209 exerts anti-tumor effects in GC by down-regulating the expression of WNT4 via RARα.

WYC-209 suppresses gastric cancer by down-regulating FGF18 via inactivating the STAT3 signaling pathway

BACKGROUND

Gastric cancer (GC) is regarded as a major health burden all over the world. WYC-209 inhibits the growth and metastasis of tumor-repopulating cells (TRCs). However, its effectiveness on GC was unexplored. Herein, this study aims to investigate the effect of WYC-209 on GC and elucidate its underlying mechanism.

METHODS

We examined the effects of WYC-209 on cell survival, migration, invasion, and colony-forming capacities of two GC cell lines (AGS and HGC-27). Subsequently, RNA-seq and enrichment analyses were performed to screen the differentially expressed genes (DEGs) and the enriched signaling pathways. To further explore the underlying mechanism, loss- and gain-function experiments, Chromatin immunoprecipitation, and luciferase reporter were conducted. Finally, xenograft models were constructed to examine the effects of WYC-209 in vivo.

RESULTS

WYC-209 significantly inhibited cell motility in vitro and tumor growth in vivo. RNA-seq performed in AGS cells after WYC-209 treatment revealed that the inhibition effect of WYC-209 on GCs may be associated with the down-regulation of fibroblast growth factor-18 (FGF18), and pleasantly, FGF18 overexpression abrogated the suppression effect of the drug. In addition, we found that WYC-209 attenuated the activation of the Signal Transducer and Activator of Transcription 3 (STAT3) signaling pathway, and impeded the FGF18 levels expressed in GCs. Importantly, the WYC-209 treatment circumvented the binding of STAT3 to the FGF18 promoter, suggested that WYC-209 down-regulated FGF18 expression via the STAT3 signaling pathway.

CONCLUSION

Together, our findings presented the promise of WYC-209 in suppressing GC by down-regulating FGF18 expression through inactivating the STAT3 signaling pathway.

Correlative Analysis Between Adverse Events of Preoperative Chemotherapy and Postoperative Complications of Gastric Cancer

Background and Objectives: This study aims to explore the safety of preoperative chemotherapy and clarify whether preoperative chemotherapy with oxaliplatin + S-1 (SOX) regimen and its adverse events are associated with higher risks of postoperative complications. Methods: We included consecutive patients with gastric cancer who underwent gastrectomy in our department between July 1 2018, and January 31 2020. Patients with preoperative SOX regimen chemotherapy were included in the analysis. Results: In the 343 included patients, 77 cases underwent preoperative chemotherapy. In total, surgical complications were found in 117 patients (34.1%), and there was no significant difference between the patients with and without preoperative chemotherapy before and after propensity score matching (p > 0.05, respectively). Multivariate analysis showed that preoperative comorbidities (p = 0.026) and the preoperative cT4b (p = 0.028) were independent risk factors in postoperative complications. In patients with preoperative chemotherapy, neither the occurrence of adverse events nor their severity was associated with postoperative complications (p > 0.05). However, the patients who received five to six cycles were more prone to postoperative complications than those who received three to four cycles (62.5 vs. 27.9%, OR = 4.306, 95% Cl = 1.282-14.464, p = 0.018). Conclusions: Occurrence of postoperative complications was not influenced by preoperative SOX chemotherapy. However, increased cycles of chemotherapy may lead to higher incidence of postoperative complications.

A novel nomogram based on cardia invasion and chemotherapy to predict postoperative overall survival of gastric cancer patients

Background

We aimed to establish and externally validate a nomogram to predict the 3- and 5-year overall survival (OS) of gastric cancer (GC) patients after surgical resection.

Methods

A total of 6543 patients diagnosed with primary GC during 2004–2016 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. We grouped patients diagnosed during 2004–2012 into a training set (n = 4528) and those diagnosed during 2013–2016 into an external validation set (n = 2015). A nomogram was constructed after univariate and multivariate analysis. Performance was evaluated by Harrell’s C-index, area under the receiver operating characteristic curve (AUC), decision curve analysis (DCA), and calibration plot.

Results

The multivariate analysis identified age, race, location, tumor size, T stage, N stage, M stage, and chemotherapy as independent prognostic factors. In multivariate analysis, the hazard ratio (HR) of non-cardia invasion was 0.762 (P < 0.001) and that of chemotherapy was 0.556 (P < 0.001). Our nomogram was found to exhibit excellent discrimination: in the training set, Harrell’s C-index was superior to that of the 8th American Joint Committee on Cancer (AJCC) TNM classification (0.736 vs 0.699, P < 0.001); the C-index was also better in the validation set (0.748 vs 0.707, P < 0.001). The AUCs for 3- and 5-year OS were 0.806 and 0.815 in the training set and 0.775 and 0.783 in the validation set, respectively. The DCA and calibration plot of the model also shows good performance.

Conclusions

We established a well-designed nomogram to accurately predict the OS of primary GC patients after surgical resection. We also further confirmed the prognostic value of cardia invasion and chemotherapy in predicting the survival rate of GC patients.

Urgent Surgery for Gastric Adenocarcinoma: A Study of the National Cancer Database

BACKGROUND

Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer.

MATERIALS AND METHODS

Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant.

RESULTS

Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]).

CONCLUSIONS

Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.

Preoperative controlling nutritional status (CONUT) score as a predictor of long-term outcome after curative resection followed by adjuvant chemotherapy in stage II-III gastric Cancer

BACKGROUND

The prognostic value of preoperative controlling nutritional status (CONUT) has been reported in many malignancies. In present study, we aimed to clarify the prognostic impact of CONUT in gastric cancer (GC) receiving curative resection and adjuvant chemotherapy.

METHODS

We retrospectively reviewed 697 consecutive patients undergoing curative surgery followed by adjuvant chemotherapy for Stage II-III GC between November 2000 and September 2012. Patients were classified into high (≥3) and low (≤2) CONUT groups according to the receiver operating characteristic (ROC) analysis.

RESULTS

Of the included patients, 217 (31.1%) belonged to the high CONUT group. The high CONUT group had a significantly lower 5-year cancer-specific survival (CSS) rate than the low CONUT group (39.3 vs. 55.5%, P < 0.001). High CONUT score was significantly associated with larger tumor size, more lymph node metastasis, and poorer nutritional status, including lower body mass index (BMI), higher prognostic nutritional index (PNI) and the presence of preoperative anemia (all P < 0.05). Multivariate analysis revealed that CONUT score was an independent prognostic factor (HR: 1.553; 95% CI: 1.080-2.232; P = 0.017). Of note, in the low PNI group, CONUT score still effectively stratified CSS (P = 0.016). Furthermore, the prognostic significance of CONUT score was also maintained when stratified by TNM stage (all P < 0.05).

CONCLUSIONS

CONUT score is considered a useful nutritional marker for predicting prognosis in stage II-III GC patients undergoing curative resection and adjuvant chemotherapy, and may help to facilitate the planning of preoperative nutritional interventions.

Preoperative CT texture analysis of gastric cancer: correlations with postoperative TNM staging

AIM

To explore the role of computed tomography (CT) texture analysis in predicting pathologic stage of gastric cancers.

MATERIALS AND METHODS

Preoperative enhanced CT images of 153 patients (112 men, 41 women) with gastric cancers were reviewed retrospectively. Regions of interest (ROIs) were manually drawn along the margin of the lesion on the section where it appeared largest on the arterial and venous CT images, which yielded texture parameters, including mean, maximum frequency, mode, skewness, kurtosis, and entropy. Correlations between texture parameters and pathological stage were analysed with Spearman's correlation test. The diagnostic performance of CT texture parameters in differentiating different stages was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

Maximum frequency in the arterial phase and mean, maximum frequency, mode in the venous phase correlated positively with T stage, N stage, and overall stage (all p<0.05) of gastric cancer. Entropy in the venous phase also correlated positively with N stage (p=0.009) and overall stage (p=0.032). Skewness in the arterial phase had the highest area under the ROC curve (AUC) of 0.822 in identifying early from advanced gastric cancers. Multivariate analysis identified four parameters, including maximum frequency, skewness, entropy in the venous phase, and differentiation degree from biopsy, for predicting lymph node metastasis of gastric cancer. The multivariate model could distinguish gastric cancers with and without lymph node metastasis with an AUC of 0.892.

CONCLUSION

Multiple CT texture parameters, especially those in the venous phase, correlated well with pathological stage and hold great potential in predicting lymph node metastasis of gastric cancers.

Preoperative Nutritional Deficiency Is a Useful Predictor of Postoperative Outcome in Patients Undergoing Curative Resection for Gastric Cancer

BACKGROUND: Preoperative nutritional deficiency (ND) has been shown to be a valuable prognostic factor in urologic malignancies. We aimed to investigate the prognostic value of ND in patients with gastric cancer (GC). METHODS: A single-center cohort of 1026 GC patients undergoing curative resection between 2003 and 2012 was categorized to ND and nutritionally replete (NR) groups. Patients with body mass index <18.5 kg/m², preoperative albumin <35 g/l, or preoperative weight loss ≥5% of body weight were defined as ND. RESULTS: Of the 1026 patients included in the study, 585 (57.0%) were categorized as ND. Overall survival (OS) at 5 years was 68.5% for ND patients and 44.0% for NR patients (P < .001). Multivariate analysis revealed that ND was a significant predictor of OS (hazard ratio: 1.954; 95% confidence interval: 1.552-2.460; P < .001). In stage-stratified analysis, it was still independently associated with OS in tumor-nodes-metastasis stage II and III (P = .004 and P < .001, respectively). Of note, the prognostic significance of ND was still maintained when stratified by age, sex, anemia, and adjuvant chemotherapy (all Ps < .05). CONCLUSION: Preoperative ND is a novel predictor of outcome in GC, especially in stage II to III GC, and may help clinicians identify high-risk patients for proactive nutritional interventions.

The role of adjuvant chemotherapy for patients with stage II and stage III gastric adenocarcinoma after surgery plus D2 lymph node dissection: a real-world observation

Background

The influence of adjuvant chemotherapy on the survival of gastric adenocarcinoma patients in a stage-specific manner is controversial.

Methods

To further explore this topic, we retrospectively analyzed the impact of adjuvant chemotherapy on the clinical outcomes of 77 stage II and 117 stage III patients diagnosed between January 2008 and December 2012.

Results

All 194 patients underwent radical operation plus D2 dissection, and were followed a median time of 23.3 (range 0.4–80.2) months. Median patient age was 67.7 (range 33.9–97.5) years. Adjuvant chemotherapy prolonged the relapse-free survival [22.9 (95 % confidence interval 9.4–36.4) vs. 14.2 (95 % CI 8.6–19.8) months, P = 0.009] and overall survival [32.3 (95 % CI 22.6–42.0) vs. 13.4 (95 % CI 9.5–17.2) months, P < 0.001] for patients with stage III, but not stage II, disease. Higher overall survival from adjuvant chemotherapy in stage II patients with node involvement did not reach the level of statistical significance (P = 0.102). To reduce the selection bias, 142 patients aged <75 years were included in a subgroup analysis in which the benefit of adjuvant chemotherapy on relapse-free survival and overall survival were demonstrated for patients with stage III disease.

Conclusions

Adjuvant chemotherapy prolongs relapse-free and overall survival for patients with stage III gastric cancer in a real-world situation. Tailoring therapy based on different characteristics for patients with stage II gastric cancer may produce better outcomes.

Adjuvant radiochemotherapy for gastric cancer: Should we use prognostic factors to select patients?

Radiotherapy has a not well-established role in the pre-operative and in the post-operative setting in gastric cancer (GC) patients. Randomized trials report controversial outcomes and impact on survival. In the D2 loco-regional node resection era, after a well-performed radical surgery, local treatment using radiotherapy combined to chemotherapy should be considered for locally advanced GC. Prognostic factors could help the better selection of subgroups that present high risk of loco-regional recurrence. Then, the addition of radiotherapy could improve the disease-free survival and also quality of life. There are no large prospective studies that have assessed specific factors predicting for recurrence or survival, but only retrospective series, some of them including high number of patients with homogeneous characteristics. In locally advanced GC adding radiotherapy to the post-operative chemotherapy seems to improve outcomes and quality of life. Prognostic factors such as T-stage, N-status, nodal ratio, and other histological factors should be considered to submit patients to post-operative combined treatment. Larger prospective series are necessary to investigate the role of combined chemoradiation after radical D2-resection, especially in locally advanced GC. Further prospective investigations are needed to suggest prognostic factors that have significant impact on survival and recurrence, improving the management and outcomes, particularly in locally advanced GC patients.

Prognostic Significance of Carcinoembryonic Antigen Staining in Cancer Tissues of Gastric Cancer Patients

PURPOSE

The aim of this study was to assess the significance of the correlation among tissue carcinoembryonic antigen (CEA) expression with serum CEA (sCEA) levels and long-term survival to highlight the clinical prognostic significance of tissue CEA expression in gastric cancer patients.

METHODS

Immunohistological method and radioimmunoassay were used to assess tissue and sCEA expression, respectively. Univariate and multivariate analyses were performed to determine correlations, and the Kaplan-Meier method was used to investigate the prognostic significance.

RESULTS

Our results demonstrate that tissue CEA in gastric cancer is significantly correlated with preoperative sCEA levels (p = 0.031), depth of invasion (p = 0.001), lymph node metastasis (p < 0.001), distant metastasis (p = 0.001), and TNM staging (p < 0.001). The 5-year survival rates were 67.6, 53.9, and 40.1 % for negatively, moderately, and intensely positively stained tissues (p < 0.001), and 57.0 and 37.9 % for serum with normal and elevated CEA expression (p = 0.031). Multivariate analysis revealed that tissue CEA can be considered an independent prognostic factor. Further analysis illustrated that patients with negative expression in both tissue and serum had better prognosis compared with those positively expressing CEA in both tissue and serum and/or those positively expressing CEA in either tissue or serum (p < 0.001). Our results also demonstrated that patients with negative tissue CEA staining and elevated sCEA expression had a better 5-year survival.

CONCLUSION

Tissue CEA expression in gastric cancer is directly correlated with sCEA levels and long-term prognosis. Thus, tissue CEA expression can be considered as a useful biomarker to improve the interpretation of sCEA levels in predicting long-term survival.

Gastric cancer and the epoch of immunotherapy approaches

The incidence of gastric cancer (GC) fell dramatically over the last 50 years, but according to IARC-Globocan 2008, it is the third most frequent cause of cancer-related deaths with a case fatality GC ratio higher than other common malignancies. Surgical resection is the primary curative treatment for GC though the overall 5-year survival rate remains poor (approximately 20%-25%). To improve the outcome of resectable gastric cancer, different treatment strategies have been evaluated such as adjuvant or perioperative chemotherapy. In resected gastric cancer, the addition of radiotherapy to chemotherapy does not appear to provide any additional benefit. Moreover, in metastatic patients, chemotherapy is the mainstay of palliative therapy with a median overall survival of 8-10 mo and objective response rates of merely 20%-40%. Therefore, the potential for making key beneficial progress is to investigate the GC molecular biology to realize innovative therapeutic strategies, such as specific immunotherapy. In this review, we provide a panoramic view of the different immune-based strategies used for gastric cancer treatment and the results obtained in the most significant clinical trials. In detail, firstly we describe the therapeutic approaches that utilize the monoclonal antibodies while in the second part we analyze the cell-based immunotherapies.

Adjuvant chemotherapy for elderly patients (aged 70 or older) with gastric cancer after a gastrectomy with D2 dissection: A single center experience in Korea

AIMS

Adjuvant chemotherapy is recommended for gastric cancer after a gastrectomy with D2 dissection. However, its survival benefit in elderly patients is unclear. Here we investigated the use of adjuvant chemotherapy in patients ≥70 years old with stage II or III gastric cancer.

METHODS

Patients ≥70 years old diagnosed with stage II or III gastric cancer at Ulsan University Hospital were identified. A retrospective analysis of electronic and paper patient records was performed.

RESULTS

From 2008 to 2012, 277 patients ≥70 years old underwent gastrectomy with D2 dissection. Of these patients, 94 were pathologically diagnosed with stage II or III; 55 of these patients (58.5%) received adjuvant chemotherapy and 39 received regular checkups without chemotherapy. Fluoropyrimidine-alone regimens, including TS-1 composed of tegafur, gimestat and otastat potassium (n = 26) and doxifluridine (n = 22), were more commonly used than fluoropyrimidine-platinum combination regimens (n = 7). With a median follow-up of 30.9 (range 0.8-65.5) months, the median relapse-free survival of patients with adjuvant chemotherapy or regular follow-up only was 35.5 and 20.4 months, respectively (P = 0.030). Multivariate analysis revealed that adjuvant chemotherapy is associated with longer relapse-free survival (hazard ratio 0.50; 95% confidence interval 0.27-0.96). There was a trend toward an improved overall survival in the adjuvant chemotherapy group compared with the follow-up only group (P = 0.242).

CONCLUSIONS

Although well-designed prospective studies are required, adjuvant chemotherapy may confer a potential survival benefit in elderly patients (aged 70 or older) with stage II or III gastric cancer after a gastrectomy with D2 dissection.

Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis

BACKGROUND

Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy.

METHODS

Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate.

RESULTS

Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null.

CONCLUSION

These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.

Cost-effectiveness analysis of adjuvant chemotherapies in patients presenting with gastric cancer after D2 gastrectomy

Background

To analyze and compare the economic outcomes of adjuvant chemotherapy with capecitabine plus oxaliplatin (referred to as the XELOX strategy) and of S-1 (the S-1 strategy) for gastric cancer patients after D2 gastrectomy.

Methods

A Markov model was developed to simulate the lifetime disease course associated with stage II or III gastric cancer after D2 gastrectomy. The lifetime quality-adjusted life years (QALYs), associated costs, and incremental cost-effectiveness ratios (ICERs) were estimated. The clinical data were derived from the results of pilot studies. Direct costs were estimated from the perspective of the Chinese healthcare system, and the utility data were measured from end-point observations of Chinese patients. Sensitivity analyses were used to explore the impact of uncertainty on the model’s outcomes.

Results

The combined adjuvant chemotherapy strategy with XELOX yielded the greatest increase in QALYs over the course of the disease (8.1 QALYs compared with 7.8 QALYs for the S-1 strategy and 6.2 for surgery alone). The incremental cost per QALY gained using the XELOX strategy was significantly lower than that for the S-1 strategy ($3,502 vs. $6,837, respectively). The results were sensitive to the costs of oxaliplatin and the hazard ratio of relapse-free survival.

Conclusion

The observations reported herein suggest that adjuvant therapy with capecitabine plus oxaliplatin is a highly cost-effective strategy and more favorable treatment option than the S-1 strategy in patients with stage II or III gastric cancer who have undergone D2 gastrectomy.

A phase II trial of post-operative chemoradiotherapy for completely resected gastric cancer with D2 lymphadenectomy

The optimal post-operative adjuvant treatment for completely resected gastric cancer with D2 lymphadenectomy remains controversial. The present study was a phase II trial on post-operative chemoradiotherapy in 30 patients with gastric cancer. Patients with stage II to IV (M0) gastric cancer received two cycles of chemotherapy prior to and following chemoradiotherapy. The chemotherapy consisted of a 2-h infusion of oxaliplatin (100 mg/m²) and folinic acid (100 mg/m²), which was followed by a 46-h continuous infusion of 5-fluorouracil (5-FU; 2,400 mg/m²) through a portable pump, repeated every 3 weeks. The chemoradiotherapy consisted of 45 Gy of radiotherapy for 5 weeks and 5-FU continuous infusion (350 mg/m²/day). In total, 30 patients were enrolled in this study. All patients underwent the chemoradiotherapy treatment as planned. A total of 10 (33.3%) patients relapsed; two (6.7%) locoregional relapses and mediastinum metastases, four (13.3%) peritoneal relapses, and four (13.3%) distant metastases. The three-year overall survival and disease-free survival rates were 72.7 and 65%, respectively. The toxicities of chemotherapy and radiotherapy, consisting of neutropenia, nausea and hand-foot syndrome, were observed. In conclusion, post-operative chemoradiotherapy following complete resection of gastric cancer with D2 lymphadenectomy is feasible in a significant subset of patients.