Consideration of the role of radiotherapy for abdominal lymph node metastases in patients with recurrent gastric cancer

Radiotherapy Combined with Chemotherapy for Regional Lymph Node Recurrence in Gastric Cancer

Purpose

Regional lymph node recurrence (RLNR) in gastric cancer is uncommon. We investigated the effects of radiotherapy combined with chemotherapy against limited RLNR and analyzed the regularity of regional lymph node recurrence and metastasis.

Patients and Methods

This retrospective study included 34 gastric cancer patients with limited RLNR after D2 lymphadenectomy between January 2012 and May 2018. All patients received systemic chemotherapy and local radiotherapy with median dose of 52.5 Gy (30–66 Gy in fractions of 1.8–3.0 Gy daily, five times weekly). All sites of recurrent and metastatic lymph nodes were collected and analyzed.

Results

The median follow-up was 19 months (range 7–60 months). After treatment, complete response and partial response were observed in 32.4% and 55.9% of patients, respectively. The median overall survival (OS) and progression-free survival (PFS) were 18 months and 13 months. On multivariate analysis, age (≤60 vs >60) was associated with a significantly better OS (p = 0.025) and radiation dose (<54 Gy vs ≥54 Gy) was considered as an independent prognostic factor for PFS (p = 0.000). During radiotherapy, three patients developed grade 3 gastrointestinal toxicity, and no deaths were related to the treatments. The most commonly metastatic lymph nodes were the No. 4, No. 3, No. 6, No. 5, No. 7, No. 9, and No. 8 nodes; the recurrent lymph nodes were mainly located in the No. 16b, No. 16a, No. 9, No. 14, No. 7, No. 13, and No. 8 nodes.

Conclusion

The selected gastric cancer patients with limited RLNR may benefit from radiotherapy combined with chemotherapy. High-dose radiotherapy (≥54 Gy) lead to better PFS and tend to extend OS. The major lymph node recurrence sites were in the gastric vascular region (especially No. 16a/b nodes).

Advances in para-aortic nodal dissection in gastric cancer surgery: A review of research progress over the last decade

Approximately 17%-40% of para-aortic lymph node (PAN) metastasis occurs in patients with advanced gastric cancer. As the third tier of lymphatic drainage of the stomach and the final station in front of the systemic circulation, PAN infiltration is defined as distant metastasis and plays a key role in the evaluation of the prognosis of advanced gastric cancer. Many clinical factors including tumor size ≥ 5 cm, pT3 or pT4 depth of tumor invasion, pN2 and pN3 stages, the macroscopic type of Borrmann III/IV, and the diffuse/mixed Lauren classification are indicators of PAN metastasis. Whether PAN dissection (PAND) should be performed on patients with or without the macroscopic PAN invasion remains unascertained, regardless of the numerous retrospective comparative studies reported on the improved prognosis over D2 alone. Another paradoxical result from many other studies showed no significant difference in the overall survival between these two lymphadenectomies. A phase II trial launched by the Japan Clinical Oncology Group indicated that two or three courses of S-1 and cisplatin preoperatively followed by radical surgery with D2 + PAND and postoperative S-1 is the current standard strategy for the treatment of patients with extensive lymph node metastasis, and this regimen could be substituted by a promising strategy with effective combination chemotherapy or suitable chemotherapy duration. This review focuses on the advances in radical gastrectomy plus PAND with or without chemotherapy for patients with advanced gastric cancer.

A clinical analysis of systemic chemotherapy combined with radiotherapy for advanced gastric cancer

This study aims to investigate the clinical efficacy of systemic chemotherapy combined with radiotherapy for advanced gastric cancer.A total of 194 advanced gastric cancer patients who were treated from 2006 to 2016 were included in this study. These patients were divided into 2 groups: chemotherapy group (n = 92) and combined chemoradiotherapy group (n = 102). The clinical efficacy of these 2 groups was compared and analyzed to explore the advantageous population and duration of radiotherapy.The remission rates in the chemotherapy group and combined chemoradiotherapy group were 73.5% and 90.6%, respectively, and median survival time was 6.7 versus 10.6 months. Furthermore, the 6-month, 1-year, and 2-year survival rates were 62% versus 83.3%, 22.8% versus 38.2%, and 7.6% versus 13.7%, respectively. All the differences were statistically significant (P < .05). In patients with distant lymph node metastasis, local advanced cancer and organ metastasis, who underwent chemotherapy + radiotherapy, the median survival time was 12.6, 11.1, and 9.8 months, respectively; and the differences were statistically significant compared with the chemotherapy group (P < .05). The median survival time in patients who received concurrent chemoradiotherapy and sequential chemoradiotherapy was 11 and 9.5 months, respectively, and the difference was not statistically significant (P > .05).Combined chemoradiotherapy significantly improved the clinical remission rate, median survival time, and the 6-month, 1-year, and 2-year survival rates in patients with advanced gastric cancer. Furthermore, the survival rate of patients with simple distant lymph node metastasis was better. Concurrent chemoradiotherapy did not significantly improve survival rate compared with sequential chemoradiotherapy.

Intensified neoadjuvant multimodal approach in synchronous liver metastases from gastric cancer: a single institutional experience

BACKGROUND

Synchronous liver metastases (LM) from gastric (GC) or esophagogastric junction (EGJ) adenocarcinoma are a rare events. Several trials have evaluated the role of liver surgery in this setting, but the impact of preoperative therapy remains undetermined.

METHODS

Patients with synchronous LM from GC/EGJ adenocarcinoma who achieved disease control after induction chemotherapy (ICT) and were subsequently scheduled to chemoradiotherapy (CRT) to the primary tumor and surgery assessment were retrospectively analyzed. Pathological response, patterns of relapse, progression-free survival (PFS), and overall survival (OS) were calculated. From July 2002 to September 2012, 16 patients fulfilling the inclusion criteria were identified.

RESULTS

Primary tumor site was GC (nine patients) or EGJ (seven patients). LM were considered technically unresectable in nine patients. Radiological response to the whole neoadjuvant program was achieved in 13 patients. Eight patients underwent surgical resection of the primary tumor; in five of these LM were resected. A complete pathological response in the primary or in the LM was found in four and three patients, respectively. The most frequent site of relapse/progression was systemic (eight patients). Local and liver-only relapses were observed in two patients each. After a median follow-up of 91 months, the median OS and PFS were 23.0 (95% CI 13.2-32.8) and 17.0 months (95% CI 11.7-22.3). 5-year actuarial PFS is 17.6%.

CONCLUSION

Our results suggest that an intensified approach using ICT followed by CRT in synchronous LM from GC/EGJ adenocarcinoma is feasible and may translate into prolonged survival times in selected patients.

Does surgery have a role in managing incurable gastric cancer?

Although the incidence of gastric cancer is decreasing, the outcomes of this disease are among the poorest of all solid-organ tumours, predominantly due to the frequent presence of stage IV metastatic disease at primary presentation. Stage IV gastric cancer is incurable and carries a very poor prognosis (5-year survival rate of ∼4%); palliative chemotherapy remains the standard of care, but increasing evidence indicates that palliative surgery can provide a prognostic and symptomatic benefit, particularly in combination with chemotherapy and/or radiotherapy. Ongoing prospective trials should further clarify the efficacy of palliative surgery in comparison with other treatment modalities. Until such data are available, surgery should not be offered as a standard first-line treatment, but can be considered in selected cases after thorough multidisciplinary discussions involving the patient. Patient selection for both gastrectomy and nonresectional surgery must include consideration of various factors that predict quality of life after surgery. This Perspectives summarizes the available evidence and discusses the utility of palliative surgery in relation to other therapeutic modalities in the management of incurable gastric cancer.

Concurrent involved-field radiotherapy and XELOX versus XELOX chemotherapy alone in gastric cancer patients with postoperative locoregional recurrence

PURPOSE

To compare the treatment outcomes of concurrent involved-field radiotherapy and XELOX (oxaliplatin and capecitabine) versus XELOX chemotherapy alone in gastric adenocarcinoma patients with locoregional recurrence.

MATERIALS AND METHODS

From 2004 to 2008, 79 patients with recurrent locoregional gastric cancer after curative resection of gastric tumor were enrolled. Among them, 41 patients received involved-field radiotherapy (median dose 50 Gy) by a 3-dimensional conformal radiotherapy technique and concurrent XELOX chemotherapy, and 38 patients were treated with XELOX chemotherapy alone (oxaliplatin 130 mg/m, capecitabine 1000 mg/m, twice daily, 3 wk each cycle).

RESULTS

The concurrent radiochemotherapy group showed better overall response (including complete response and partial response) when compared with the chemotherapy group (87.8% vs. 63.0%, P=0.01). The control rates for pain, bleeding, and dysphagia/obstruction were 89.5% (17/19), 81.8% (9/11), and 80% (8/10), respectively, in the radiochemotherapy group and 58.8% (10/17), 50% (5/10), and 57.1% (4/7), respectively, in the chemotherapy group. The concurrent radiochemotherapy group showed better overall symptom-control rate when compared with the chemotherapy group (55.9% vs. 85%, P=0.006). Patients receiving concurrent radiochemotherapy trended toward a better median overall survival when compared with those receiving chemotherapy alone (13.4 vs. 5.4 mo, P=0.06). In addition, there were no significant differences in the rates of toxicity or adverse reactions between the 2 groups.

CONCLUSIONS

Concurrent involved-field radiotherapy and XELOX showed better responses and overall symptom-control rates compared with XELOX chemotherapy alone in gastric cancer patients with postoperative locoregional recurrence. A trend of survival benefit from radiochemotherapy was also observed but needs to be further explored.

Docetaxel, capecitabine and concurrent radiotherapy for gastric cancer patients with postoperative locoregional recurrence

AIMS AND BACKGROUND

This study aimed to assess the efficacy of concurrent chemoradiotherapy (CCRT) with docetaxel and capecitabine versus docetaxel and capecitabine chemotherapy for gastric cancer patients with postoperative locoregional recurrence.

METHODS

From 2008 to 2011, 81 patients with locoregional recurrence after curative resection of gastric cancer were enrolled. Thirty-nine (CCRT group) received involved-field radiotherapy with oral capecitabine (twice daily, 5 days/week) and intravenous infusion of docetaxel (once weekly). The remaining 42 patients (chemotherapy group) were treated with oral capecitabine (twice daily, days 1-14) followed by intravenous infusion of docetaxel (days 1 and 8). The overall response rate, overall symptom control rate, toxicity or adverse reactions, and overall survival (OS) were compared.

RESULTS

The overall response rate (CR+PR) was significantly higher in the CCRT group (79.5%) than the chemotherapy group (54.8%). In CCRT individuals, the control rates for bleeding, pain, and dysphagia/obstruction were 87.5%, 75%, and 71.4%, respectively, versus 63.2%, 50%, and 28.6% in the chemotherapy group. CCRT patients had a better symptom control rate than the chemotherapy group (52.5% vs. 80%). Adverse reactions were nonsignificantly more severe in CCRT patients. Finally, median OS was longer in the CCRT vs. chemotherapy group (14.2 vs. 6.4 months).

CONCLUSIONS

Involved-field radiotherapy with docetaxel and capecitabine was effective and well tolerated. These findings provide further insight into the role of CCRT in gastric cancer. However, this was not a randomized controlled study and the number of patients was relatively small, suggesting that cautious interpretation of cumulative estimates is warranted.

Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer

OBJECTIVES

This retrospective study aimed to compare the efficacy and safety of combination treatment with high-intensity focused ultrasound (HIFU) and chemotherapy to those of chemotherapy alone for treatment of the abdominal lymph node metastasis from gastric cancer.

METHODS

A total of 185 patients with gastric cancer and abdominal lymph node metastasis were enrolled and divided into 2 groups: group A received chemotherapy alone (n = 102); group B received HIFU combined with chemotherapy (n = 83). The clinical efficacy and safety of the groups were then analyzed.

RESULTS

The overall response rates of groups A and B were 34.3% and 47.0%, respectively (P = .046). The pain relief rates in groups A and B were 51.6% and 75.0% (P = .039). At the data cutoff, the median survival times of groups A and B were 8.6 and 11.9 months (P < .05). The adverse reactions in the groups did not show significant differences (P > .05). Among the patients treated with HIFU and chemotherapy, those with small abdominal lymph nodes (diameter <3 cm) had a better prognosis than those with large nodes (diameter ≥3 cm).

CONCLUSIONS

In patients with gastric cancer and abdominal lymph node metastasis, the combination of HIFU and chemotherapy can provide clinical benefits. High-intensity focused ultrasound could effectively facilitate treatment of abdominal lymph node metastasis from gastric cancer.

Acute histopathological responses of testicular tissues after different fractionated abdominal irradiation in rats

PURPOSE

To compare the effects of different fractionated doses of abdominal radiation therapy on acute histopathological responses of testicular tissues in rats.

METHODS

Thirty-three 3-week-old Wistar albino rats were randomized into 6 groups: group 1 (n = 5), control; group 2 (n = 4), hypofractionated total abdominal irradiation (TAI) of 6 Gy/1 fraction/day for 2 days; group 3 (n = 6), hypofractionated TAI of 4 Gy/1 fraction/day for 3 days; group 4 (n = 6), hypofractionated TAI of 3 Gy/1 fraction/day for 4 days; group 5 (n = 6), conventionally fractionated TAI of 2 Gy/1 fraction/day for 6 days; group 6 (n = 6), conventionally fractionated TAI of 1.7 Gy/1 fraction/day for 7 days. Mean epithelial length and diameter of seminiferous tubules of testicular tissues were determined after euthanasia.

RESULTS

Initially, a highly significant decrease in both the mean tubular diameter and epithelial height of the seminiferous tubules was demonstrated in all irradiated rats compared with the control group. No significant differences regarding both damage parameters were found between different hypofractionated radiation therapies. Both conventional radiation therapies reduced the epithelial height and mean diameter of the seminiferous tubules to a lesser extent when compared with 6 Gy/1 fraction/day hypofractionated therapy. It was further shown that parameter values were comparable between rats that received 3 Gy/day hypofractionated therapy and rats that received either of the two conventional therapies. Furthermore, although 4 Gy/day hypofractionation decreased tubular diameter and epithelial length to a greater degree compared with the conventional therapy of 1.7 Gy/1 fraction/day, no statistically significant difference was found when compared with conventional therapy of 2 Gy/1 fraction/day. Additionally, no statistically significant difference was demonstrated between the two types of conventional radiotherapy application.

CONCLUSION

The present study demonstrated that hypofractionated abdominal irradiation leads to more prominent tissue damage in the testes than conventional irradiation.

Role of salvage radiotherapy for regional lymph node recurrence after radical surgery in advanced gastric cancer

PURPOSE

To evaluate the role of salvage radiotherapy (RT) for the treatment of regional lymph node recurrence (RLNR) after radical surgery in advanced gastric cancer.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 26 patients who underwent salvage treatment after diagnosis of RLNR between 2006 and 2011. Patients with peritoneal seeding or distant metastasis were excluded. Eighteen patients received RT with or without chemotherapy and the other 8 did chemotherapy only without RT. A three-dimensional conformal RT was performed with median dose of 56 Gy (range, 44 to 60 Gy). Sixteen patients had fluoropyrimidine-based chemotherapy, 5 did taxane-based chemotherapy, and irinotecan was applied in 4.

RESULTS

With a median follow-up of 20 months (range, 5 to 57 months), median overall survival (OS) and progression-free survival (PFS) after diagnosis of RLNR were 29 months and 12 months in the entire patients, respectively. Radiotherapy (p = 0.007) and disease-free interval (p = 0.033) were statistically significant factors for OS in multivariate analysis. Median OS was 36 months in patients who received RT and 16 months in those who did not. Furthermore, delivery of RT (p < 0.001), complete remission after salvage treatment (p = 0.040) and performance status (p = 0.023) were associated with a significantly better PFS. Gastrointestinal toxicities from RT were mild in most patients.

CONCLUSION

Salvage RT combined with systemic chemotherapy may be an effective treatment managing RLNR from advanced gastric cancer.

Computed tomography-guided permanent brachytherapy for locoregional recurrent gastric cancer

BACKGROUND

Locoregional recurrence is the typical pattern of recurrence in gastric cancer, and cannot be removed by surgery in most of the patients. We aimed to evaluate the feasibility and efficacy of computed tomography (CT)-guided brachytherapy for patients with locoregional recurrent gastric cancer.

MATERIALS AND METHODS

We reviewed the case histories of 28 patients with locoregional recurrent gastric cancer that were selected for CT- guided brachytherapy by a multidisciplinary team. The clinical data of the patients including patient characteristics, treatment parameters, short-term effects, and survival data were collected and analyzed.

RESULTS

15-75 125I seeds were implanted into each patient to produce a minimal peripheral dose (MPD) 100-160 Gy. Median day 0 dosimetry was significant for the following: V100 (the volume treated with the prescription dose) 95.8% (90.2-120.5%) and D90 (prescription dose received by at least 90% of the volume) 105.2% (98.0-124.6%) of prescription dose. No serious complications occurred during the study. Two months after brachytherapy, complete response, partial response and progressive disease were observed in 50.0%, 28.6% and 21.4% of patients, respectively. The median survival time was 22.0 ± 5.2 months, and the 1, 2,and 3-year survival rate was 89 ± 6%, 52 ± 10% and 11 ± 7%, respectively. A univariate analysis showed that the tumor size was a significant predictor of overall survival (P = 0.034). Patients with tumors <3 cm had relatively higher complete response rate (66.7%), compared to those with tumors >3 cm (30.8%). The PTV (planning target volume) smaller than 45 cm3 was significantly correlated with achieving complete tumor eradication in the treated region (P = 0.020).

CONCLUSIONS

For selected patients with limited locoregional recurrent gastric cancer, CT-guided brachytherapy using 125I seeds implantation can provide a high local control rate, with minimal trauma.

Management strategies for locoregional recurrence in early-stage gastric cancer: retrospective analysis and comprehensive literature review

OBJECTIVE

To present a comprehensive account and literature review addressing the anatomical distribution, natural history, and management strategies for locoregional recurrence in early-stage gastric cancer (EGC).

PATIENTS AND METHODS

Retrospective chart review of patients presenting with EGC recurrence at King Hussein Cancer Center (Amman, Jordan) between July 2006 and May 2009. A literature review of publications addressing recurrence following surgery for EGC was undertaken via a systematic search of PUBMED database and National Comprehensive Cancer Network (NCCN) guideline updates.

RESULTS

Seventeen patients presented with EGC, three of whom (17.6%) were pathologically staged as T2N1 [1/33 lymph nodes (LNs)], T1N0, and T1N0 were afflicted by recurrence following R0 partial gastrectomy. Literature review yielded 18 studies specifically addressing recurrence in EGC. Several management strategies have been proposed for isolated recurrence following gastrectomy in EGC. NCCN clinical practice guideline updates do not take into consideration whether the recurrence is isolated or widespread and whether the initial stage is early or advanced.

CONCLUSIONS

While acknowledging the limitations of this study, including the small sample size and the short follow-up period, it appears clear that oncologic treatment is possible for EGC recurrence, particularly, in patients with isolated relapse. Guideline updates should differentiate between management strategies suitable for recurrence occurring in early versus advanced initial cancer stage.

Management of advanced gastric cancer

The management of advanced gastric cancer has only evolved a little over the last 15 years: platinum and fluoropyrimidine chemotherapy remains the backbone of therapy with ongoing debate as to the benefit of triplet therapy with either an anthracycline or taxane. Recently published trials of biological agents, in particular those targeting the Her2 receptor, have provided some signs of improvement. This article summarizes the relevant literature, discusses the role of these agents, as well as geographical variations in use, and provides recommendations regarding both 'standard chemotherapy' and the role of biological agents in advanced gastric cancer. Given the relative lack of progress for gastric cancer over the last 15 years, the focus for the next 5 years should be on an improved understanding of the molecular basis of gastric cancer, thus allowing rational integration of new molecular agents.

Clinical characteristics and treatment outcomes of gastric cancer patients with isolated para-aortic lymph node involvement

BACKGROUND

Although gastric cancer with isolated para-aortic lymph node (PAN) involvement is considered an advanced disease, the clinical characteristics of it have not been comprehensively elucidated.

PATIENTS AND METHODS

We reviewed the medical records of 1,277 patients received palliative chemotherapy with advanced gastric cancer according to metastatic sites: PAN-only metastasis, single organ metastasis other than PAN, and multiple organ metastasis. Time to other organ metastasis (TTOM) was determined only in PAN-only metastasis group as the time interval between initial diagnosis of recurrence or de novo metastasis and confirming distant metastasis beyond PAN area.

RESULTS

The median overall survival (OS) of patients with PAN-only metastasis was significantly longer than that of patients with single organ metastasis other than PAN or multiple organ metastasis (13.8 months vs. 11.4 months vs. 8.4 months; P < 0.001). In the PAN-only metastasis group, patients with recurrent diseases showed longer TTOM beyond the PAN area (10.7 vs. 7.7 months; P = 0.037) and OS (23.8 vs. 12.8 months; P = 0.010) than those with de novo metastatic disease and it was validated by multivariate analysis.

CONCLUSION

Patients with isolated PAN metastasis showed an excellent prognosis compared with patients with metastasis at other sites and it was primarily evident in patients with recurrent PAN metastasis.