The efficacy of neoadjuvant chemotherapy is different for type 4 and large type 3 gastric cancer

Therapeutic strategies and prognostic challenges in linitis plastica

Gastric cancer ranks fifth as the most common cancer and third as the leading cause of death worldwide. Risk factors include advancing age, low-fiber diets, high salt intake and Helicobacter pylori infection. Diagnosis relies on histological examination following endoscopic biopsy with staging accomplished through various imaging modalities. Early gastric cancer is primarily managed via endoscopic resection, while non-early operable cases typically undergo surgery. Advanced cases are addressed through sequential chemotherapy lines, with initial treatment usually comprising a platinum and fluoropyrimidine combination. Linitis plastica (LP) is a rare, aggressive form of gastric cancer characterized by diffuse infiltration of the gastric wall, resulting in poor outcomes even after curative resection. The absence of a standardized definition contributes to uncertainty regarding the precise incidence of these tumors. LP is often diagnosed at advanced stages, with a reported median survival rate of approximately 4%-29%, despite "curative resection". Its distinctive biological behavior includes perineural invasion, nodal metastasis, and peritoneal dissemination. The bleak prognosis for LP patients partly stems from delayed diagnosis and its aggressive biological nature, posing significant challenges for clinical management. Currently, no specialized treatment strategy exists for LP, and clinical approaches typically align with those used for general gastric cancer treatment. Surgical resection is the primary treatment, but the optimal surgical approach remains contentious. Recent studies have investigated the efficacy of neoadjuvant chemotherapy and radiotherapy in improving survival outcomes for LP patients. However, controversies persist regarding the role of adjuvant chemotherapy and postoperative radiotherapy. LP requires a multidisciplinary approach and personalized treatment strategies tailored to each patient's condition. Further research is needed to elucidate optimal therapeutic interventions and improve outcomes for LP patients.

Treatment Modalities and Survival Outcomes in Gastric Cancer: Insights From Najran, Saudi Arabia

BACKGROUND

Gastric cancer (GC) is the fifth most prevalent cancer worldwide and the fourth leading cause of cancer-related mortality. The survival of GC patients is significantly affected by the timing of diagnosis, as late-stage detection drastically reduces survival rates. This study investigates treatment modalities, survival outcomes, and mortality factors of GC patients in Najran, Saudi Arabia.

MATERIALS AND METHODS

A retrospective analysis was conducted involving 121 patients diagnosed with GC treated at King Khaled Hospital in Najran from January 1, 2014, to December 31, 2022. Clinical and pathological parameters, treatment interventions, and survival outcomes were extracted and analyzed from medical records. The Kaplan-Meier method created survival curves and assessed survival probabilities over time. Univariate and multivariate Cox regression analyses identified independent factors associated with mortality risk, calculating hazard ratios (HR) and 95% confidence intervals (CI) to evaluate associations.

RESULTS

 The median age of the patients was 64 years, with 70 (57.9%) being over 60 years old. The cohort included 86 males (71.1%) and 35 females (28.9%), resulting in a male-to-female ratio of 2.5:1. Notably, 24 patients (19.8%) were underweight, 49 patients (40.5%) had hypertension, and 33 patients (27.3%) had diabetes. Helicobacter pylori infection was present in 18 patients (14.9%). Human epidermal growth factor receptor-2 (HER2) status was negative in 38 patients (31.4%). Elevated levels of carcinoembryonic antigen (CEA ≥ 5 ng/ml) and CA19-9 (≥ 37 U/mL) were noted in 51 patients (42.1%) and 50 patients (41.3%), respectively. Surgical intervention was performed on 72 patients (59.5%), while 49 patients (40.5%) were deemed non-resectable. Among the surgical cohort, neoadjuvant therapy was administered to 36 patients (30%), while others underwent initial or staged surgeries. Pathological findings predominantly showed 95 cases (78.5%) of intestinal-type adenocarcinomas compared to 26 cases (21.5%) of diffuse type. The most common TNM (tumor, node, metastasis) stage was IV (50 patients, 41.3%), followed by stage III (25 patients, 20.7%). During a follow-up of 41.3 ± 38.8 months, 96 patients (79.3%) were alive, while 25 patients (20.7%) had died. The median survival time was 28 months (95% CI: 20-51 months). The one-year, three-year, and five-year survival rates were 68.2% (82 patients), 42.8% (52 patients), and 37.4% (45 patients), respectively. Increased mortality was significantly associated with female gender (HR: 3.12; 95% CI: 1.56-6.24; p = 0.0013), stage IV disease (HR: 1.92; 95% CI: 1.01-3.66; p = 0.0481), and elevated CEA levels (HR: 1.95; 95% CI: 1.08-3.53; p = 0.0277). In contrast, neoadjuvant chemotherapy was linked to reduced mortality (HR: 0.55; 95% CI: 0.31-0.97; p = 0.0374).

CONCLUSIONS

The findings of this study indicate a five-year survival rate of 37.4% (95% CI: 29.3-47.8%) among GC patients in Najran. Notably, female gender, advanced disease stage, and elevated CEA levels emerged as significant predictors of increased mortality. Conversely, the administration of neoadjuvant chemotherapy was associated with a reduced mortality risk. These results emphasize the critical need for personalized treatment strategies and robust risk assessments to improve patient outcomes, particularly high-risk ones.

Oncological similarities between large type 3 and type 4 tumors in patients with resectable gastric cancer: a propensity score-matched analysis of a multi-institutional dataset

BACKGROUND

Large type 3 (diameter ≥ 8 cm) and type 4 gastric cancers have been arbitrarily combined in Japan as a single entity. However, whether these two types are oncologically similar remain unclear. This study aimed to clarify this issue.

METHODS

In this retrospective study, we analyzed a database of 3,575 patients from nine institutions who underwent gastrectomy between 2010 and 2014. Using propensity scores to balance significant variables, we compared prognoses and tumor recurrences.

RESULTS

Of patients with clinical T3/T4 who underwent R0 resection, 75 and 73 had large type 3 and 4 tumors, respectively. Patients with type 4 tumors had significantly lower overall survival rates than those of patients with large type 3 tumors (hazard ratio [HR] 1.77; 95% confidence interval [CI] 1.14-2.74). However, among the large type 3 tumors, a remarkable difference in prognosis was observed between the differentiated and undifferentiated histological types. A comparison was made between large type 3 with undifferentiated phenotype and type 4, each with 39 patients after propensity score matching. Outcomes in both groups were similar in terms of overall survival (HR 1.28; 95% CI 0.73-2.25) and relapse-free survival (HR 1.34; 95% CI 0.80-2.27). No statistically significant differences were observed in the incidence of peritoneal recurrence (35.9% vs. 46.1%, P = 0.36) and lymph node recurrence (25.6% vs. 12.8%, P = 0.15).

CONCLUSIONS

Large type 3 tumors with undifferentiated phenotype and type 4 tumors were oncologically similar. This subgroup could be considered as a new entity for future clinical trials.

Perioperative systemic and prophylactic intraperitoneal chemotherapy for type 4/large type 3 gastric cancer: DRAGON-10

Large type 3 and type 4 gastric cancers (GC) have a significantly poor prognosis, primarily due to their high predisposition for peritoneal dissemination. The application of intraperitoneal chemotherapy has emerged as a viable therapeutic strategy for managing GC patients with peritoneal metastasis. This study is planned to enroll 37 resectable large type 3 or type 4 GC patients. These patients are scheduled to undergo a treatment comprising preoperative chemotherapy with paclitaxel, oxaliplatin and S-1, followed by D2 gastrectomy, and concluding with postoperative treatments that include prophylactic intraperitoneal chemotherapy. The study's primary objective is to evaluate the 3-year peritoneal recurrence rate. Secondary objectives are to assess the 3-year disease-free survival, 3-year overall survival and to monitor the adverse events.Clinical trial registration number: ChiCTR2400083253 (https://www.chictr.org.cn).