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Xu YF, Ma HY, Huang GL, Zhang YT, Wang XY, Wei MJ, Pei XQ. Double contrast-enhanced ultrasonography improves diagnostic accuracy of T staging compared with multi-detector computed tomography in gastric cancer patients. World J Gastroenterol 2024; 30:3005-3015. [PMID: 38946876 PMCID: PMC11212705 DOI: 10.3748/wjg.v30.i23.3005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/24/2024] [Accepted: 05/13/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Gastric cancer (GC) is the most common malignant tumor and ranks third for cancer-related deaths among the worldwide. The disease poses a serious public health problem in China, ranking fifth for incidence and third for mortality. Knowledge of the invasive depth of the tumor is vital to treatment decisions.
AIM To evaluate the diagnostic performance of double contrast-enhanced ultrasonography (DCEUS) for preoperative T staging in patients with GC by comparing with multi-detector computed tomography (MDCT).
METHODS This single prospective study enrolled patients with GC confirmed by preoperative gastroscopy from July 2021 to March 2023. Patients underwent DCEUS, including ultrasonography (US) and intravenous contrast-enhanced ultrasonography (CEUS), and MDCT examinations for the assessment of preoperative T staging. Features of GC were identified on DCEUS and criteria developed to evaluate T staging according to the 8th edition of AJCC cancer staging manual. The diagnostic performance of DCEUS was evaluated by comparing it with that of MDCT and surgical-pathological findings were considered as the gold standard.
RESULTS A total of 229 patients with GC (80 T1, 33 T2, 59 T3 and 57 T4) were included. Overall accuracies were 86.9% for DCEUS and 61.1% for MDCT (P < 0.001). DCEUS was superior to MDCT for T1 (92.5% vs 70.0%, P < 0.001), T2 (72.7% vs 51.5%, P = 0.041), T3 (86.4% vs 45.8%, P < 0.001) and T4 (87.7% vs 70.2%, P = 0.022) staging of GC.
CONCLUSION DCEUS improved the diagnostic accuracy of preoperative T staging in patients with GC compared with MDCT, and constitutes a promising imaging modality for preoperative evaluation of GC to aid individualized treatment decision-making.
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Affiliation(s)
- Yan-Fen Xu
- Department of Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Hui-Yun Ma
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Gui-Ling Huang
- Department of Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Yu-Ting Zhang
- Department of Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Xue-Yan Wang
- Department of Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Ming-Jie Wei
- Department of Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
| | - Xiao-Qing Pei
- Department of Medical Ultrasound, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China
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Liu QM, Chen Y, Fan WJ, Wu XH, Zhang ZW, Lu BL, Ma YR, Liu YY, Wu YZ, Yu SP, Wen ZQ. Value of orthogonal axial MR images in preoperative T staging of gastric cancer. Abdom Radiol (NY) 2024:10.1007/s00261-024-04322-8. [PMID: 38755454 DOI: 10.1007/s00261-024-04322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE To assess the value of orthogonal axial images (OAI) of MRI in gastric cancer T staging. METHODS This retrospective study enrolled 133 patients (median age, 63 [range, 24-85] years) with gastric adenocarcinoma who underwent both CT and MRI followed by surgery. MRI lacking or incorporating OAI and CT images were evaluated, respectively. Diagnostic performance (accuracy, sensitivity, and specificity) for each T stage, overall diagnostic accuracy and rates of over- and understaging were quantified employing pathological T stage as a reference standard. The McNemar's test was performed to compare the overall accuracy. RESULTS Among patients with pT1-pT4 disease, MRI with OAI (accuracy: 88.7-94.7%, sensitivity: 66.7-93.0%, specificity: 91.5-100.0%) exhibited superior diagnostic performance compared to MRI without OAI (accuracy: 81.2-88.7%, sensitivity: 46.2-83.1%, specificity: 85.5-99.1%) and CT (accuracy: 88.0-92.5%, sensitivity: 53.3-90.1%, specificity: 88.7-98.1%). The overall accuracy of MRI with OAI was significantly higher (83.5%) than that of MRI without OAI (67.7%) (p < .001). However, there was no significant difference in the overall accuracy of MRI with OAI and CT (78.9%) (p = .35). The over- and understaging rates of MRI with OAI (12.0, 4.5%) were lower than those of MRI without OAI (21.8, 10.5%) and CT (12.8, 8.3%). CONCLUSION OAI play a pivotal role in the T staging of gastric cancer. MRI incorporating OAI demonstrated commendable performance for gastric cancer T-staging, with a slight tendency toward its superiority over CT.
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Affiliation(s)
- Quan-Meng Liu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yan Chen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Wen-Jie Fan
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518017, China
| | - Xue-Han Wu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518017, China
| | - Zhi-Wen Zhang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Bao-Lan Lu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yu-Ru Ma
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yi-Yan Liu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yun-Zhu Wu
- MR Scientific Marketing, SIEMENS Healthineers Ltd., Shanghai, 210031, China
| | - Shen-Ping Yu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China.
| | - Zi-Qiang Wen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, No.58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China.
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Chen C, Song YL, Wu ZY, Chen J, Zhang Y, Chen L. Diagnostic value of conventional endoscopic ultrasound for lymph node metastasis in upper gastrointestinal neoplasia: A meta-analysis. World J Gastroenterol 2023; 29:4685-4700. [PMID: 37662859 PMCID: PMC10472901 DOI: 10.3748/wjg.v29.i30.4685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Upper gastrointestinal neoplasia mainly includes esophageal cancer and gastric cancer, both of which have high morbidity and mortality. Lymph node metastasis (LNM), as the most common metastasis mode of both diseases, is an important factor affecting tumor stage, treatment strategy and clinical prognosis. As a new fusion technology, endoscopic ultrasound (EUS) is becoming increasingly used in the diagnosis and treatment of digestive system diseases, but its use in detecting LNM in clinical practice remains limited. AIM To evaluate the diagnostic value of conventional EUS for LNM in upper gastrointestinal neoplasia. METHODS Using the search mode of "MeSH + Entry Terms" and according to the predetermined inclusion and exclusion criteria, we conducted a comprehensive search and screening of the PubMed, EMBASE and Cochrane Library databases from January 1, 2000 to October 1, 2022. Study data were extracted according to the predetermined data extraction form. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool, and the results of the quality assessment were presented using Review Manager 5.3.5 software. Finally, Stata14.0 software was used for a series of statistical analyses. RESULTS A total of 22 studies were included in our study, including 2986 patients. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic score and diagnostic odds ratio of conventional EUS in the diagnosis of upper gastrointestinal neoplasia LNM were 0.62 [95% confidence interval (CI): 0.50-0.73], 0.80 (95%CI: 0.73-0.86), 3.15 (95%CI: 2.46-4.03), 0.47 (95%CI: 0.36-0.61), 1.90 (95%CI: 1.51-2.29) and 6.67 (95%CI: 4.52-9.84), respectively. The area under the summary receiver operating characteristic curve was 0.80 (95%CI: 0.76-0.83). Sensitivity analysis indicated that the results of the meta-analysis were stable. There was considerable heterogeneity among the included studies, and the threshold effect was an important source of heterogeneity. Univariable meta-regression and subgroup analysis showed that tumor type, sample size and EUS diagnostic criteria were significant sources of heterogeneity in specificity (P < 0.05). No significant publication bias was found. CONCLUSION Conventional EUS has certain clinical value and can assist in the detection of LNM in upper gastrointestinal neoplasia, but it cannot be used as a confirmatory or exclusionary test.
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Affiliation(s)
- Cong Chen
- Institute of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Ya-Lan Song
- Institute of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Zhen-Yu Wu
- Institute of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Jing Chen
- Institute of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Yao Zhang
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Lei Chen
- Institute of Gastroenterology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
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Xu Z, Lin X, Zeng H, Ma X, Nabi G, Abidin ZU, Wang L, Wang L. Immune regulation in gastric adenocarcinoma is linked with therapeutic efficacy and improved recovery. Front Genet 2023; 14:1238248. [PMID: 37636266 PMCID: PMC10450621 DOI: 10.3389/fgene.2023.1238248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Adenocarcinomas are one of the most common histological types of gastric cancer. It has been ranked fifth among common cancers and is the third among death causing cancers worldwide. The high mortality rate among patients with gastric cancer is because of its silent evolution, genetic heterogeneity, high resistance to chemotherapy as well as unavailability of highly effective therapeutic strategy. Until now a number of several treatment strategies have been developed and are being practiced such as surgery, chemotherapy, radio therapy, and immunotherapy, however, further developments are required to improve the treatment responses and reduce the side effects. Therefore, novel personal therapeutic strategies based on immunological responses should be developed by targeting different check points and key immune players. Targeting macrophages and related molecular elements can be useful to achieve these goals. In this minireview, we discuss the available treatment options, molecular underpinnings and immunological regulations associated with gastric adenocarcinoma. We further describe the possible check points and immunological targets that can be used to develop novel therapeutic options.
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Affiliation(s)
- Zhenglei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, The First Affiliated Hospital, Jinan University, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Ximin Lin
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Haotian Zeng
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Xiaoxin Ma
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, The First Affiliated Hospital, Jinan University, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Ghulam Nabi
- Institute of Nature Conservation, Polish Academy of Sciences, Krakow, Poland
| | - Zain Ul Abidin
- Department of Intensive Care Unit, Kabir Medical College, Peshawar, Pakistan
| | - Luolin Wang
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, The First Affiliated Hospital, Jinan University, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Lisheng Wang
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, The First Affiliated Hospital, Jinan University, Southern University of Science and Technology, Shenzhen, Guangdong, China
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Hirata Y, Noorani A, Song S, Wang L, Ajani JA. Early stage gastric adenocarcinoma: clinical and molecular landscapes. Nat Rev Clin Oncol 2023; 20:453-469. [PMID: 37264184 DOI: 10.1038/s41571-023-00767-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/03/2023]
Abstract
Gastric adenocarcinoma, even when diagnosed at an early (localized) disease stage, poses a major health-care burden with cure rates that remain unsatisfactorily low, particularly in Western countries. This lack of progress reflects, among other aspects, the impracticality of early diagnosis, considerable variations in therapeutic approaches that is partly based on regional preferences, and the ingrained heterogeneity of gastric adenocarcinoma cells and their associated tumour microenvironment (TME). Clinical trials have long applied empirical interventions with the assumption that all early stage gastric adenocarcinomas are alike. Despite certain successes, the shortcomings of these approaches can potentially be overcome by targeting the specific molecular subsets of gastric adenocarcinomas identified by genomic and/or multi-omics analyses, including microsatellite instability-high, Epstein-Barr virus-induced, DNA damage repair-deficient, HER2-positive and PD-L1-high subtypes. Future approaches, including the availability of sophisticated vaccines, novel antibody technologies, agents targeting TME components (including fibroblasts, macrophages, cytokines or chemokines, and T cells) and novel immune checkpoint inhibitors, supported by improved tissue-based and blood-based diagnostic assays, seem promising. In this Review, we highlight current knowledge of the molecular and cellular biology of gastric adenocarcinomas, summarize the current approaches to clinical management of the disease, and consider the role of novel management and/or treatment strategies.
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Affiliation(s)
- Yuki Hirata
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ayesha Noorani
- Cancer Ageing and Somatic Mutation Group, Wellcome Sanger Institute, Hinxton, UK
- Cambridge Oesophago-gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Shumei Song
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linghua Wang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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de Nucci G, Gabbani T, Impellizzeri G, Deiana S, Biancheri P, Ottaviani L, Frazzoni L, Mandelli ED, Soriani P, Vecchi M, Manes G, Manno M. Linear EUS Accuracy in Preoperative Staging of Gastric Cancer: A Retrospective Multicenter Study. Diagnostics (Basel) 2023; 13:diagnostics13111842. [PMID: 37296694 DOI: 10.3390/diagnostics13111842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION Preoperative gastric cancer (GC) staging is the most reliable prognostic factor that affects therapeutic strategies. Contrast-enhanced computed tomography (CECT) and radial endoscopic ultrasound (R-EUS) scans are the most commonly used staging tools for GC. The accuracy of linear EUS (L-EUS) in this setting is still controversial. The aim of this retrospective multicenter study was to evaluate the accuracy of L-EUS and CECT in preoperative GC staging, with regards to depth of tumor invasion (T staging) and nodal involvement (N staging). MATERIALS AND METHODS 191 consecutive patients who underwent surgical resection for GC were retrospectively enrolled. Preoperative staging had been performed using both L-EUS and CECT, and the results were compared to postoperative staging by histopathologic analysis of surgical specimens. RESULTS L-EUS diagnostic accuracy for depth of invasion of the GC was 100%, 60%, 74%, and 80% for T1, T2, T3, and T4, respectively. CECT accuracy for T staging was 78%, 55%, 45%, and 10% for T1, T2, T3, and T4, respectively. L-EUS diagnostic accuracy for N staging of GC was 85%, significantly higher than CECT accuracy (61%). CONCLUSIONS Our data suggest that L-EUS has a higher accuracy than CECT in preoperative T and N staging of GC.
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Affiliation(s)
- Germana de Nucci
- Gastroenterology and Digestive Endoscopy Unit, ASST Rhodense, 20094 Garbagnate Milanese, Italy
| | - Tommaso Gabbani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Giovanna Impellizzeri
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Simona Deiana
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Paolo Biancheri
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Laura Ottaviani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Surgical and Medical Sciences Department, Sant'Orsola Malpighi Hospital, 40138 Bologna, Italy
| | - Enzo Domenico Mandelli
- Gastroenterology and Digestive Endoscopy Unit, ASST Rhodense, 20094 Garbagnate Milanese, Italy
| | - Paola Soriani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
| | - Maurizio Vecchi
- Gastroenterology Unit, Major Policlinic Hospital, 20122 Milan, Italy
| | - Gianpiero Manes
- Gastroenterology and Digestive Endoscopy Unit, ASST Rhodense, 20094 Garbagnate Milanese, Italy
| | - Mauro Manno
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, 41012 Carpi, Italy
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Imtiaz S, Berger Y, Gleeson E, Williams HS, Durham DM, Mahajan D, Buseck A, Tharakan S, Zheng S, Macfie R, Labow D, Cohen NA, Golas BJ, Sarpel U, Hiotis SP. T1 Gastric Cancer is Associated With a High Incidence of Regional Lymph Node Metastases. J Surg Res 2023; 287:90-94. [PMID: 36870306 DOI: 10.1016/j.jss.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/22/2022] [Accepted: 12/14/2022] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Early stage gastric cancer, particularly T1 disease, is associated with high recurrence-free and overall survival rates following resection with curative intent. However, rare cases of T1 gastric cancer have nodal metastasis and this is associated with poor outcomes. METHODS Data from gastric cancer patients treated with surgical resection and D2 lymph node (LN) dissection at a single tertiary care institution from 2010 to 2020 were analyzed. Patients with early stage (T1) tumors were assessed in detail to identify variables associated with regional LN metastasis including histologic differentiation, signet ring cells, demographics, smoking history, neoadjuvant therapy, and clinical staging by endoscopic ultrasound (EUS). We used standard statistical techniques including Mann-Whitney U and Chi-squared tests. RESULTS Of 426 patients undergoing surgery for gastric cancer, 34% (n = 146) were diagnosed with T1 disease on surgical pathology. Among 146 T1 (T1a, T1b) gastric cancers, 24 patients [(17%) T1a (n = 4), T1b (n = 20)] had histologically confirmed regional LN metastases. The age at diagnosis ranged between 19 and 91 y and 54.8% were male. Prior smoking status was not associated with nodal positivity (P = 0.650). Of the 24 patients with positive LN on final pathology, seven patients received neoadjuvant chemotherapy. EUS was performed on 98 (67%) of the 146 T1 patients. Of these patients, 12 (13.2%) had positive LN on final pathology; however, none (0/12) were detected on preoperative EUS. There was no association between node status on EUS and node status on final pathology (P = 0.113). The sensitivity of EUS for N status was 0%, specificity was 84.4%, negative predictive value was 82.2% and positive predictive value was 0%. Signet ring cells were identified in 42% of node negative T1 tumors and 64% of node positive T1 tumors (P = 0.063). For LN positive cases on surgical pathology, 37.5% had poor differentiation, 42% had lymphovascular invasion, and regional nodal metastases were associated with increasing T stage (P = 0.003). CONCLUSIONS T1 gastric cancer is associated with a substantial risk (17%) of regional LN metastasis, when pathologically staged following surgical resection and D2 lymphadenectomy. Clinically staged N+ disease by EUS was not significantly associated with pathologically staged N+ disease in these patients.
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Affiliation(s)
- Sayed Imtiaz
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yael Berger
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hannah S Williams
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Demetrius M Durham
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Deepti Mahajan
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alison Buseck
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serena Tharakan
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serena Zheng
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebekah Macfie
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Labow
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noah A Cohen
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin J Golas
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Spiros P Hiotis
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Rossi G, Petrone MC, Healey AJ, Arcidiacono PG. Gastric cancer in 2022: Is there still a role for endoscopic ultrasound? World J Gastrointest Endosc 2023; 15:1-9. [PMID: 36686065 PMCID: PMC9846830 DOI: 10.4253/wjge.v15.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/07/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023] Open
Abstract
Gastric cancer (GC) represents the fourth leading cause of cancer death worldwide and many factors can influence its development (diet, geographic area, genetic, Helicobacter pylori or Epstein-Barr virus infections). High quality endoscopy represents the modality of choice for GC diagnosis. The correct morphologic classification during a high-resolution endoscopy is fundamental for oncologic diagnosis, staging and therapeutic decisions. Since its initial introduction in clinical practice the endoscopic ultrasound (EUS) has been considered a valuable tool for tumor (T-) and lymph nodes (N-) staging also in GC, in order to establish the best therapeutic strategy for the patient (e.g., upfront surgery vs neoadjuvant treatments). EUS tools as elastography, Doppler and contrast administration can improve diagnosis mainly in case of malignant lymph node evaluation. EUS has a marginal role in disease staging but has a fundamental role in case of a pre-endoscopic resection management and in the new era of endoscopic mucosal resection or submucosal dissection as minimally invasive surgery. Diagnosis and locoregional staging of GC with EUS are a method of inarguable value for the assessment of gastric wall involvement and presence of infiltrated paragastric lymph nodes. EUS can also have a role in disease restaging in those patients who have undergone neoadjuvant treatment. EUS can also have a role in the advanced phases of the disease, in facilitating palliative, minimally-invasive treatments, such as gastroenterostomy or biliary drainages. This review intends to discuss the modern role of EUS in GC topic.
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Affiliation(s)
- Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan 20132, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan 20132, Italy
| | - Andrew J Healey
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan 20132, Italy
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Siddiqi A, Johnston FM. The Perioperative and Operative Management of Esophageal and Gastric Cancer. Surg Oncol Clin N Am 2023; 32:65-81. [PMID: 36410922 DOI: 10.1016/j.soc.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Optimal management of esophageal and gastric cancer during the perioperative period requires a coordinated multidisciplinary treatment effort. Accurate staging guides treatment strategy. Advances in minimally invasive surgery and endoscopy have reduced risks associated with resection while maintaining oncological standards. Although the standard perioperative chemo-and radiotherapy regimens have not yet been established, randomized control trials exploring this subject show promising results.
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Affiliation(s)
- Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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10
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Intraoperative Tumor Detection Using Pafolacianine. Int J Mol Sci 2022; 23:ijms232112842. [PMID: 36361630 PMCID: PMC9658182 DOI: 10.3390/ijms232112842] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
Cancer is a leading cause of death worldwide, with increasing numbers of new cases each year. For the vast majority of cancer patients, surgery is the most effective procedure for the complete removal of the malignant tissue. However, relapse due to the incomplete resection of the tumor occurs very often, as the surgeon must rely primarily on visual and tactile feedback. Intraoperative near-infrared imaging with pafolacianine is a newly developed technology designed for cancer detection during surgery, which has been proven to show excellent results in terms of safety and efficacy. Therefore, pafolacianine was approved by the U.S. Food and Drug Administration (FDA) on 29 November 2021, as an additional approach that can be used to identify malignant lesions and to ensure the total resection of the tumors in ovarian cancer patients. Currently, various studies have demonstrated the positive effects of pafolacianine’s use in a wide variety of other malignancies, with promising results expected in further research. This review focuses on the applications of the FDA-approved pafolacianine for the accurate intraoperative detection of malignant tissues. The cancer-targeting fluorescent ligands can shift the paradigm of surgical oncology by enabling the visualization of cancer lesions that are difficult to detect by inspection or palpation. The enhanced detection and removal of hard-to-detect cancer tissues during surgery will lead to remarkable outcomes for cancer patients and society, specifically by decreasing the cancer relapse rate, increasing the life expectancy and quality of life, and decreasing future rates of hospitalization, interventions, and costs.
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11
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Predictors of Metastatic Lymph Nodes at Preoperative Staging CT in Gastric Adenocarcinoma. Tomography 2022; 8:1196-1207. [PMID: 35645384 PMCID: PMC9149869 DOI: 10.3390/tomography8030098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 12/04/2022] Open
Abstract
Background. The aim of this study was to identify the most accurate computed-tomography (CT) dimensional criteria of loco-regional lymph nodes (LNs) for detecting nodal metastases in gastric cancer (GC) patients. Methods. Staging CTs of surgically resected GC were jointly reviewed by two radiologists, considering only loco-regional LNs with a long axis (LA) ≥ 5 mm. For each nodal group, the short axis (SA), volume and SA/LA ratio of the largest LN, the sum of the SAs of all LNs, and the mean of the SA/LA ratios were plotted in ROC curves, taking the presence/absence of metastases at histopathology for reference. On a per-patient basis, the sums of the SAs of all LNs, and the sums of the SAs, volumes, and SA/LA ratios of the largest LNs in all nodal groups were also plotted, taking the presence/absence of metastatic LNs in each patient for reference. Results. Four hundred and forty-three nodal groups were harvested during surgery from 107 patients with GC, and 173 (39.1%) were metastatic at histopathology. By nodal group, the sum of the SAs showed the best Area Under the Curve (AUC), with a sensitivity/specificity of 62.4/72.6% using Youden’s index with a >8 mm cutoff. In the per-patient analysis, the sum of the SAs of all LNs in the loco-regional nodal groups showed the best AUC with a sensitivity/specificity of 65.6%/83.7%, using Youden’s index with a >39 mm cutoff. Conclusion. In patients with GC, the sum of the SAs of all the LNs at staging CT is the best predictor among dimensional LNs criteria of both metastatic invasion of the nodal group and the presence of metastatic LNs.
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12
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Zhang X, Yao J, Zhang Y, Huang X, Wang W, Huang H. Updated Evaluation of the Diagnostic Performance of Double Contrast-Enhanced Ultrasonography in the Preoperative T Staging of Gastric Cancer: A Meta-Analysis and Systematic Review. Front Oncol 2022; 12:844390. [PMID: 35356215 PMCID: PMC8959463 DOI: 10.3389/fonc.2022.844390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/08/2022] [Indexed: 01/30/2023] Open
Abstract
Objective This study aimed to systematically evaluate the diagnostic performance of double contrast-enhanced ultrasonography (DCEUS) in the preoperative T staging of gastric cancer (GC). Methods Literature searches for eligible studies were performed using MEDLINE, EMBASE, and Cochrane Library. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the summary receiver operating characteristic curve of DCEUS in the diagnosis of each T stage tumor were calculated. Meta-analyses were performed to obtain the pooled effects of risk ratio (RR) with 95% confidence interval (CI) in the comparison of DCEUS with CT/endoscopic ultrasound (EUS). Results A total of 8 studies including 1,232 patients were identified for inclusion in this meta-analysis. The pooled sensitivity and specificity were 0.78 (95% CI = 0.64–0.88) and 0.98 (95% CI = 0.96–0.99) for T1, 0.81 (95% CI = 0.76–0.86) and 0.96 (95% CI = 0.91–0.98) for T2, 0.88 (95% CI = 0.84–0.91) and 0.85 (95% CI = 0.79–0.90) for T3, and 0.81 (95% CI = 0.69–0.89) and 0.96 (95% CI = 0.93–0.97) for T4. Moreover, DCEUS demonstrated significant superiority to CT in diagnosing T1 (RR = 1.57, 95% CI = 1.20–2.05, p = 0.001) and T2 (RR = 1.41, 95% CI = 1.16–1.71, p = 0.001) and to EUS in diagnosing T3 (RR = 1.24, 95% CI = 1.08–1.42, p = 0.003) and T4 (RR = 1.40, 95% CI = 1.09–1.79, p = 0.008). However, it showed a lower diagnostic accuracy than EUS in T1 tumors (RR = 0.77, 95% CI = 0.62–0.94, p = 0.013). Conclusions DCEUS is a feasible complementary diagnostic tool for clinical T staging of GC. However, it is still far from a definitive conclusion for DCEUS to be proposed for use in routine clinical practice.
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Affiliation(s)
- Xin Zhang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jun Yao
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yu Zhang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xin Huang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Weijun Wang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Hejing Huang
- Department of Ultrasound, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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13
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Ajani JA, D'Amico TA, Bentrem DJ, Chao J, Cooke D, Corvera C, Das P, Enzinger PC, Enzler T, Fanta P, Farjah F, Gerdes H, Gibson MK, Hochwald S, Hofstetter WL, Ilson DH, Keswani RN, Kim S, Kleinberg LR, Klempner SJ, Lacy J, Ly QP, Matkowskyj KA, McNamara M, Mulcahy MF, Outlaw D, Park H, Perry KA, Pimiento J, Poultsides GA, Reznik S, Roses RE, Strong VE, Su S, Wang HL, Wiesner G, Willett CG, Yakoub D, Yoon H, McMillian N, Pluchino LA. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:167-192. [PMID: 35130500 DOI: 10.6004/jnccn.2022.0008] [Citation(s) in RCA: 605] [Impact Index Per Article: 302.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the third leading cause of cancer-related deaths worldwide. Over 95% of gastric cancers are adenocarcinomas, which are typically classified based on anatomic location and histologic type. Gastric cancer generally carries a poor prognosis because it is often diagnosed at an advanced stage. Systemic therapy can provide palliation, improved survival, and enhanced quality of life in patients with locally advanced or metastatic disease. The implementation of biomarker testing, especially analysis of HER2 status, microsatellite instability (MSI) status, and the expression of programmed death-ligand 1 (PD-L1), has had a significant impact on clinical practice and patient care. Targeted therapies including trastuzumab, nivolumab, and pembrolizumab have produced encouraging results in clinical trials for the treatment of patients with locally advanced or metastatic disease. Palliative management, which may include systemic therapy, chemoradiation, and/or best supportive care, is recommended for all patients with unresectable or metastatic cancer. Multidisciplinary team management is essential for all patients with localized gastric cancer. This selection from the NCCN Guidelines for Gastric Cancer focuses on the management of unresectable locally advanced, recurrent, or metastatic disease.
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Affiliation(s)
| | | | - David J Bentrem
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Prajnan Das
- The University of Texas MD Anderson Cancer Center
| | - Peter C Enzinger
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | | | | | - Farhood Farjah
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | | | - Rajesh N Keswani
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Samuel J Klempner
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Jill Lacy
- Yale Cancer Center/Smilow Cancer Hospital
| | | | | | - Michael McNamara
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Mary F Mulcahy
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Haeseong Park
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Kyle A Perry
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Scott Reznik
- UT Southwestern Simmons Comprehensive Cancer Center
| | - Robert E Roses
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | | | | | - Danny Yakoub
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
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14
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Chen ZD, Zhang PF, Xi HQ, Wei B, Chen L, Tang Y. Recent Advances in the Diagnosis, Staging, Treatment, and Prognosis of Advanced Gastric Cancer: A Literature Review. Front Med (Lausanne) 2021; 8:744839. [PMID: 34765619 PMCID: PMC8575714 DOI: 10.3389/fmed.2021.744839] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/30/2021] [Indexed: 01/06/2023] Open
Abstract
Gastric cancer is one of the most common cause of cancer related deaths worldwide which results in malignant tumors in the digestive tract. The only radical treatment option available is surgical resection. Recently, the implementation of neoadjuvant chemotherapy resulted in 5-year survival rates of 95% for early gastric cancer. The main reason of treatment failure is that early diagnosis is minimal, with many patients presenting advanced stages. Hence, the greatest benefit of radical resection is missed. Consequently, the main therapeutic approach for advanced gastric cancer is combined surgery with neoadjuvant chemotherapy, targeted therapy, or immunotherapy. In this review, we will discuss the various treatment options for advanced gastric cancer. Clinical practice and clinical research is the most practical way of reaching new advents in terms of patients' characteristics, optimum drug choice, and better prognosis. With the recent advances in gastric cancer diagnosis, staging, treatment, and prognosis, we are evident that the improvement of survival in this patient population is just a matter of time.
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Affiliation(s)
- Zhi-da Chen
- Department of General Surgery, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Peng-Fei Zhang
- Department of Oncology, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Hong-Qing Xi
- Department of General Surgery, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Bo Wei
- Department of General Surgery, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Lin Chen
- Department of General Surgery, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Yun Tang
- Department of General Surgery, First Medical Center of Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
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15
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Kim J, Jang J, Cho DW. Controlling Cancer Cell Behavior by Improving the Stiffness of Gastric Tissue-Decellularized ECM Bioink With Cellulose Nanoparticles. Front Bioeng Biotechnol 2021; 9:605819. [PMID: 33816446 PMCID: PMC8009980 DOI: 10.3389/fbioe.2021.605819] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/10/2021] [Indexed: 12/14/2022] Open
Abstract
A physiologically relevant tumor microenvironment is favorable for the progression and growth of gastric cancer cells. To simulate the tumor-specific conditions of in vivo environments, several biomaterials engineering studies have investigated three-dimensional (3D) cultures. However, the implementation of such cultures remains limited because of challenges in outlining the biochemical and biophysical characteristics of the gastric cancer microenvironment. In this study, we developed a 3D cell printing-based gastric cancer model, using a combination of gastric tissue-specific bioinks and cellulose nanoparticles (CN) to provide adequate stiffness to gastric cancer cells. To create a 3D gastric tissue-specific microenvironment, we developed a decellularization process for a gastric tissue-derived decellularized extracellular matrix (g-dECM) bioink, and investigated the effect of the g-dECM bioink on promoting the aggressiveness of gastric cancer cells using histological and genetic validation methods. We found that incorporating CN in the matrix improves its mechanical properties, which supports the progression of gastric cancer. These mechanical properties are distinguishing characteristics that can facilitate the development of an in vitro gastric cancer model. Further, the CN-supplemented g-dECM bioink was used to print a variety of free-standing 3D shapes, including gastric rugae. These results indicate that the proposed model can be used to develop a physiologically relevant gastric cancer system that can be used in future preclinical trials.
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Affiliation(s)
- Jisoo Kim
- School of Interdisciplinary Bioscience and Bioengineering, Pohang University of Science and Technology, Pohang, South Korea
| | - Jinah Jang
- School of Interdisciplinary Bioscience and Bioengineering, Pohang University of Science and Technology, Pohang, South Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, South Korea
- Department of Convergence IT Engineering, Pohang University of Science and Technology, Pohang, South Korea
- Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - Dong-Woo Cho
- School of Interdisciplinary Bioscience and Bioengineering, Pohang University of Science and Technology, Pohang, South Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, South Korea
- Institute of Convergence Science, Yonsei University, Seoul, South Korea
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16
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Aversa JG, Diggs LP, Hagerty BL, Dominguez DA, Ituarte PHG, Hernandez JM, Davis JL, Blakely AM. Multivisceral Resection for Locally Advanced Gastric Cancer. J Gastrointest Surg 2021; 25:609-622. [PMID: 32705611 PMCID: PMC9274296 DOI: 10.1007/s11605-020-04719-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Locally advanced gastric cancer (LAGC) presents a therapeutic dilemma, particularly as it often involves adjacent organs through desmoplasia or true pathologic invasion. To obtain a margin-negative resection, these tumors require en bloc gastrectomy with multivisceral resection (G+MVR), and contention remains regarding its safety and oncologic benefit. METHODS We used the National Cancer Database to retrospectively evaluate the short- and long-term outcomes of patients with LAGC treated in the USA between 2004 and 2016. Associations with margin status and perioperative outcomes were calculated using logistic regression. Survival was estimated using Cox proportional hazards regression and the Kaplan-Meier method. RESULTS Overall, 785 pathologic stage T4b (pT4b) patients diagnosed with LAGC underwent gastrectomy (n = 438) or G+MVR (n = 347). There was no association between G+MVR and short- or long-term mortality. Positive resection margins (HR 1.68, 95% CI 1.40-2.03), the presence of nodal disease (HRs 1.46-1.50), treatment at a high-volume center (HR 0.76, 95% CI 0.68-0.85), and the receipt of adjuvant chemotherapy (HR 0.64, 95% CI 0.51-0.80) were independently associated with overall survival. Diffuse-type histology was associated with higher rates of an R1 resection (OR 3.60, 95% CI 2.20-5.87). Perioperative and long-term survival metrics were comparable between patients with pT4a and pT4b LAGC who underwent a margin-negative G+MVR. Undergoing a margin-negative G+MVR imparted a 6-month survival benefit over non-curative gastrectomy alone (p < 0.001). CONCLUSIONS Our study demonstrates the safety and long-term feasibility of G+MVR for disease clearance in well-selected patients with LAGC, and we advocate for their referral to high-volume centers for optimal care.
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Affiliation(s)
- John G Aversa
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Laurence P Diggs
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brendan L Hagerty
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dana A Dominguez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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17
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Cummings D, Wong J, Palm R, Hoffe S, Almhanna K, Vignesh S. Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors. Cancers (Basel) 2021; 13:582. [PMID: 33540736 PMCID: PMC7867245 DOI: 10.3390/cancers13030582] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.
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Affiliation(s)
- Donelle Cummings
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Medical College, New York City Health and Hospitals Corporation-Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, USA;
| | - Joyce Wong
- Division of Surgery, Mid Atlantic Kaiser Permanente, 700 2nd St. NE, 6th Floor, Washington, DC 20002, USA;
| | - Russell Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Khaldoun Almhanna
- Division of Hematology/Oncology, Lifespan Cancer Institute, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy St, George 312, Providence, RI 02903, USA;
| | - Shivakumar Vignesh
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Health Sciences University, MSC 1196, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
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18
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Moslim MA, Minarich MJ, Deng M, Handorf E, Greco SH, Reddy SS, Farma JM. Treatment at an Academic Cancer Center Confers Better Survival by Stage for Signet-Ring Cell and Non-signet-Ring Cell Gastric Cancer. Ann Surg Oncol 2021; 28:4423-4432. [PMID: 33393048 DOI: 10.1245/s10434-020-09424-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/10/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND The literature lacks large-scale population studies comparing survival outcomes between signet-ring cell gastric carcinoma (SRGC) and non-SRGC (NSRGC) when treatment is delivered at academic versus community cancer centers. METHODS The National Cancer Database (NCDB) from 2004 to 2016 was queried to examine the association between treatment facility category and overall survival of patients who underwent gastrectomy for resectable gastric adenocarcinoma (GAC). RESULTS The study investigated 22,871 patients. Upstaging of resectable GAC to pathologic stage 4 was more evident at community centers (3.5%) than at academic centers (2.8%) for the NSRGC variant (p = 0.211), whereas it was comparable between the two facility categories for the SRGC variant (5.9% vs 6%, respectively). Patients with pathologic stage 1 or 3 NSRGC who underwent gastrectomy at academic programs had better overall survival (OS) (hazard ratio [HR], 0.68; p < 0.0001) than those who underwent gastrectomy at community centers (HR, 0.79; p < 0.0065). Similarly, patients with stage 2 SRGC had better OS when treated at academic versus community centers (HR, 0.54; p = 0.0019). No statistically significant improvement in OS was observed between patients with stage 2 NSRGC (HR, 0.84; p = 0.083) and those with stage 3 SRGC (HR, 0.78; p = 0.054) who were treated at academic centers. No survival benefit was demonstrated for stage 1 SRGC when academic and community centers were compared (p = 0.56). CONCLUSIONS This is the first study based on a large-scale database in the Western population that addressed the overall survival-by-stage of two distinct GAC histologic variants. Treatment at academic centers was associated with significant improvements in OS.
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Affiliation(s)
- Maitham A Moslim
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Michael J Minarich
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mengying Deng
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elizabeth Handorf
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stephanie H Greco
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Sanjay S Reddy
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection. Gastric Cancer 2021; 24:145-155. [PMID: 32572791 DOI: 10.1007/s10120-020-01100-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasonography is a reliable diagnostic modality for determining indications of endoscopic submucosal dissection for early gastric cancer. We aimed to clarify the clinical significance of endoscopic ultrasonography in the invasion depth diagnosis of early gastric cancer. METHODS We retrospectively assessed 1598 consecutive patients with 2001 early gastric cancers who underwent EUS before ESD or surgery between October 2010 and April 2019 at our institution. Lesions were classified according to endoscopic ultrasonography-determined invasion depth as EUS-M/SM1 (lesions confined to sonographic layers 1 and 2 or lesions with changes in sonographic layer 3; depth, < 1 mm) and EUS-SM2 (lesions with changes in sonographic layer 3; depth, ≥ 1 mm). We evaluated the invasion depth determination accuracy of endoscopic ultrasonography and analyzed the clinicopathological features of misdiagnosed early gastric cancer cases. RESULTS The invasion depth determination accuracy was as follows: EUS-M/SM1: pathological T1a/T1b1 early gastric cancer, 97%; EUS-SM2: pathological T1b2 early gastric cancer, 79%. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 95%, 98%, 69%, 97%, and 79%, respectively. In EUS-M/SM1 early gastric cancer, tumor size of ≥ 15 mm, presence of ulceration, and undifferentiated histological type were significantly associated with endoscopic ultrasonography accuracy. In EUS-SM2 early gastric cancer, tumor size of ≥ 30 mm was significantly associated with endoscopic ultrasonography accuracy. CONCLUSIONS Endoscopic ultrasonography is a useful modality in accurately determining the invasion depth of early gastric cancer before endoscopic submucosal dissection.
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Margalit O, Shacham-Shmueli E, Yang YX, Lawerence YR, Levy I, Reiss KA, Golan T, Halpern N, Aderka D, Giantonio B, Mamtani R, Boursi B. Prognostic Implications of Tumor Differentiation in Clinical T1N0 Gastric Adenocarcinoma. Oncologist 2020; 26:e111-e114. [PMID: 32969129 PMCID: PMC7794188 DOI: 10.1002/onco.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/17/2020] [Indexed: 11/25/2022] Open
Abstract
Background Current guidelines recommend neoadjuvant chemotherapy in patients with locoregional gastric adenocarcinoma. Patients diagnosed with early stage gastric adenocarcinoma are usually managed with upfront surgical intervention. However, pathologic staging in a subset of these clinically staged patients identifies more advanced locoregional disease requiring adjuvant treatment. Therefore, identifying these patients prior to surgical intervention is critical to ensure employment of the appropriate treatment paradigm. The aim of the current study was to define patient characteristics associated with clinical understaging in early gastric cancer. Methods Using the National Cancer Database (2004–2014) we identified 3,892 individuals with clinical T1N0 gastric adenocarcinoma who underwent upfront definitive surgery, had negative surgical margins, and did not receive preoperative chemotherapy or radiotherapy. Patient characteristics were compared between those with pathologic stage T1N0 disease and those who were upstaged upon surgery. Results Twenty‐seven percent of clinical T1N0 gastric adenocarcinomas had a change in stage because of pathologically defined ≥T2 disease or positive lymph nodes. Individuals who were upstaged had a higher tumor grade compared with those with pathologic stage T1N0 disease. Specifically, 41.9% (530/1,264) of individuals with a poorly differentiated tumor were upstaged, compared with only 10.7% (70/656) with a well‐differentiated tumor. Approximately 75% of cases involved upstaging because of T misclassification. The highest percentage of upstaging was shown for tumors located at the fundus and body of the stomach. Conclusion Upstaging of clinical T1N0 gastric adenocarcinoma is characterized by higher tumor grade and is mostly a result of a change in T stage. These findings mandate thorough workup in order to identify patients with clinically staged T1N0 disease requiring preoperative chemotherapy. Implications for Practice Upstaging of clinical T1N0 gastric adenocarcinoma is characterized by higher tumor grade and is mostly a result of a change in T stage. These findings mandate thorough workup in order to identify patients with clinically staged T1N0 disease requiring preoperative chemotherapy. This article evaluates the frequency of upstaging following surgery among cT1N0 gastric cancer and defines the corresponding patient characteristics, with the goal of better identifying those patients who require preoperative chemotherapy.
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Affiliation(s)
- Ofer Margalit
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Einat Shacham-Shmueli
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Yu-Xiao Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yaacov R Lawerence
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel.,Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Idan Levy
- Department of Gastroenterology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Kim A Reiss
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Talia Golan
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Naama Halpern
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Dan Aderka
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel
| | - Bruce Giantonio
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronac Mamtani
- Department of Gastroenterology, Sheba Medical Center, Tel-Hashomer, Israel.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ben Boursi
- Department of Oncology, Sheba Medical Center, Tel-Hashomer, Israel.,Tel-Aviv University, Tel-Aviv, Israel.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Newton AD, Predina JD, Frenzel-Sulyok LG, Low PS, Singhal S, Roses RE. Intraoperative Molecular Imaging Utilizing a Folate Receptor-Targeted Near-Infrared Probe Can Identify Macroscopic Gastric Adenocarcinomas. Mol Imaging Biol 2020; 23:11-17. [PMID: 33033941 DOI: 10.1007/s11307-020-01549-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Current methods of assessing disease burden in gastric adenocarcinoma are imperfect. Improved visualization during surgery with intraoperative molecular imaging (IMI) could improve gastric adenocarcinoma staging and guide surgical decision-making. The goal of this study was to evaluate if IMI with a folate receptor-targeted near-infrared fluorescent agent, OTL38, could identify gastric adenocarcinomas during surgery. PROCEDURES Five patients were enrolled in an IMI clinical trial. Patients received a folate receptor-targeted near-infrared dye (OTL38) 1.5-6 h prior to surgery. During staging laparoscopy and gastric resection, IMI was utilized to identify the primary tumor and any fluorescent lymph nodes. Resected tumors were analyzed for folate receptor alpha (FRα) and CD68 expression using immunohistochemistry. Microscopic OTL38 accumulation was examined with immunofluorescence. RESULTS Four out of five patients underwent total or subtotal gastrectomy; one had a staging laparoscopy only. All four patients who underwent gastric resection had invasive gastric adenocarcinoma; three had fluorescent tumors, mean tumor to background ratio (TBR) 4.1 ± 2.9. The one patient with a non-fluorescent tumor had a T1a tumor with two 0.4 cm tumor foci within a larger polyp. In each case with a fluorescent tumor, the fluorescence was evident from the exterior of the stomach. Two of the fluorescent tumors had modest FRα expression and no CD68 expression. One fluorescent tumor had high CD68 expression and no FRα expression. CONCLUSIONS Intraoperative molecular imaging of gastric adenocarcinoma with OTL38 is feasible. Further studies should evaluate the clinical utility of this technique.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lydia G Frenzel-Sulyok
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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22
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Hester SC, Kuriakose M, Nguyen CD, Mallidi S. Role of Ultrasound and Photoacoustic Imaging in Photodynamic Therapy for Cancer. Photochem Photobiol 2020; 96:260-279. [PMID: 31919853 PMCID: PMC7187279 DOI: 10.1111/php.13217] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022]
Abstract
Photodynamic therapy (PDT) is a phototoxic treatment with high spatial and temporal control and has shown tremendous promise in the management of cancer due to its high efficacy and minimal side effects. PDT efficacy is dictated by a complex relationship between dosimetry parameters such as the concentration of the photosensitizer at the tumor site, its spatial localization (intracellular or extracellular), light dose and distribution, oxygen distribution and concentration, and the heterogeneity of the inter- and intratumoral microenvironment. Studying and characterizing these parameters, along with monitoring tumor heterogeneity pre- and post-PDT, provides essential data for predicting therapeutic response and the design of subsequent therapies. In this review, we elucidate the role of ultrasound (US) and photoacoustic imaging in improving PDT-mediated outcomes in cancer-from tracking photosensitizer uptake and vascular destruction, to measuring oxygenation dynamics and the overall evaluation of tumor responses. We also present recent advances in multifunctional theranostic nanomaterials that can improve either US or photoacoustic imaging contrast, as well as deliver photosensitizers specifically to tumors. Given the wide availability, low-cost, portability and nonionizing nature of US and photoacoustic imaging, together with their capabilities of providing multiparametric morphological and functional information, these technologies are thusly inimitable when deployed in conjunction with PDT.
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Affiliation(s)
- Scott C. Hester
- Department of Biomedical EngineeringTufts UniversityMedfordMA
| | - Maju Kuriakose
- Department of Biomedical EngineeringTufts UniversityMedfordMA
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23
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Kersy O, Loewenstein S, Lubezky N, Sher O, Simon NB, Klausner JM, Lahat G. Omental Tissue-Mediated Tumorigenesis of Gastric Cancer Peritoneal Metastases. Front Oncol 2019; 9:1267. [PMID: 31803630 PMCID: PMC6876669 DOI: 10.3389/fonc.2019.01267] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/01/2019] [Indexed: 12/21/2022] Open
Abstract
The peritoneal cavity, especially the omentum, is a common site for gastric cancer metastasis, representing advanced disease stage and poor prognosis. Here, we studied the effects of omental tissue on gastric cancer tumor progression in vitro and in vivo. Utilizing in vitro models, we found that omental tissue secreted factors increased gastric cancer cellular growth (by 30–67%, P < 0.05), motility (>8-fold, P < 0.05), invasiveness (>7-fold, P < 0.05) and chemoresistance to platinum-based chemotherapeutic agents (>1.2-fold for oxaliplatin and >1.6-fold for cisplatin, P < 0.05). Using a robust proteomic approach, we identified numerous molecules secreted into the omental tissue conditioned medium (CM) which may promote gastric cancer cellular aggressiveness (i.e., IL-6, IL-8, MMP9, FN1, and CXCL-5). Next, an in vivo xenograft mouse model showed an increased human gastric adenocarcinoma tumor volume of cells co-cultured with human omental tissue secreted factors; 1.6 ± 0.55 vs. 0.3 ± 0.19 cm3 (P < 0.001), as well as increased angiogenesis. Finally, exosomes were isolated from human omental tissue CM of gastric cancer patients. These exosomes were taken up by gastric cancer cells enhancing their growth (>8-fold, P < 0.01) and invasiveness (>8-fold, P < 0.001). Proteomic analysis of the content of these exosomes identified several established cancer- related proteins (i.e., IL-6, IL-8, ICAM-1, CCl2, and OSM). Taken together, our findings imply that the omentum play an active role in gastric cancer metastasis. The data also describe specific cytokines that are involved in this cross talk, and that omental tissue- derived exosomes may contribute to these unique cellular interactions with gastric cancer cells. Further studies aimed at understanding the biology of gastric cancer intra peritoneal spread are warranted. Hopefully, such data will enable to develop future novel therapeutic strategies for the treatment of metastatic gastric cancer.
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Affiliation(s)
- Olga Kersy
- Laboratory of Surgical Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Division of Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Shelly Loewenstein
- Laboratory of Surgical Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Division of Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Nir Lubezky
- Division of Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Osnat Sher
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.,Institute of Pathology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Natalie B Simon
- College of Arts and Sciences, University of Virginia, Charlottesville, VA, United States
| | - Joseph M Klausner
- Division of Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.,The Nikolas and Elizabeth Shlezak Cathedra for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Guy Lahat
- Laboratory of Surgical Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Division of Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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24
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Chen J, Zhou C, He M, Zhen Z, Wang J, Hu X. A Meta-Analysis And Systematic Review Of Accuracy Of Endoscopic Ultrasound For N Staging Of Gastric Cancers. Cancer Manag Res 2019; 11:8755-8764. [PMID: 31632135 PMCID: PMC6774993 DOI: 10.2147/cmar.s200318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic ultrasonography (EUS) is widely used as a staging modality for gastric cancer. However, the results of studies on the use of EUS for N staging in gastric cancer vary. This study aimed at studying the overall diagnostic accuracy of EUS for N staging of gastric cancer. METHODS Published studies were identified through searching the MEDLINE, Web of Science, EMBASE, SpringerLink and ScienceDirect databases. A bivariate random effect model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A hierarchical summary receiver operating characteristic curves (HSROC) based on the pooled data was also computed. RESULTS Fifty studies (5223 patients) were included in this analysis. The pooled sensitivity, specificity, PLR, NLR and DOR of EUS for N staging were 0.82 (95% CI 0.78 to 0.85), 0.68 (0.63 to 0.73), 2.6 (2.2 to 3.0), 0.27 (0.22 to 0.32), and 10 (8 to 12), respectively. The area under the HSROC was 0.83. CONCLUSION The EUS may provide a clinically useful tool to guide physicians in the N staging of gastric cancer. However, physicians must note that the EUS has a relatively low specificity.
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Affiliation(s)
- Jiafei Chen
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Chaoyang Zhou
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Min He
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Zhiming Zhen
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Jie Wang
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Xiaofei Hu
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
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25
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Ma M, Lu S, Liu Y, Kong P, Long Z, Wan P, Zhang Y, Wang Y, Xu D. Identification and external validation of a novel miRNA signature for lymph node metastasis prediction in submucosal-invasive gastric cancer patients. Cancer Med 2019; 8:6315-6325. [PMID: 31486298 PMCID: PMC6797584 DOI: 10.1002/cam4.2530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/24/2022] Open
Abstract
Endoscopic resection (ER) has been increasingly performed in the treatment of early gastric cancer (GC). However, lymph node metastasis (LNM) can cause treatment failure with ER, especially in T1b patients. Here, we attempted to develop a miRNA‐based classifier to detect LNM in T1b patients. Based on high‐throughput data from The Cancer Genome Atlas, we identified 20 miRNAs whose expression significantly changed in T1‐2 GC with LNM vs T1‐2 GC without LNM. We then developed a miRNA signature to predict LNM of T1b GC using the LASSO model and backward step wise elimination approach in a training cohort. Furthermore, the predictive accuracy of this classifier was validated in both an internal testing group of 63 patients and an external independent group of 114 patients. This systematic and comprehensive in silico study identified a 7‐miRNA signature with an area under the receiver operating characteristic curve (AUROC) value of 0.843 in T1‐2 GC and 0.911 in T1 EGC. The backward elimination was further used to develop a 4‐miRNA (miR‐153‐3p, miR‐708, miR‐940 and miR‐375) risk‐stratification model in the training cohort with an AUROC value of 0.898 in cohort 2. When pathologic results were used as a reference, the risk model yielded AUROC values of 0.829 and 0.792 in two cohorts of endoscopic biopsy specimens. This novel miRNA‐LNM classifier works better than the currently used pathologic criteria of ER in T1b EGC. This classifier could individualize the management of T1b patients and facilitate treatment decisions.
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Affiliation(s)
- Mingzhe Ma
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shixun Lu
- Department of Pathology, Sun Yat-sen University Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Yinhua Liu
- Department of Pathology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Pengfei Kong
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ziwen Long
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ping Wan
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yan Zhang
- Department of Gastroenterology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yanong Wang
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Dazhi Xu
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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26
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Chen D, Chen G, Jiang W, Fu M, Liu W, Sui J, Xu S, Liu Z, Zheng X, Chi L, Lin D, Li K, Chen W, Zuo N, Lu J, Chen J, Li G, Zhuo S, Yan J. Association of the Collagen Signature in the Tumor Microenvironment With Lymph Node Metastasis in Early Gastric Cancer. JAMA Surg 2019; 154:e185249. [PMID: 30698615 DOI: 10.1001/jamasurg.2018.5249] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Lymph node status is the primary determinant in treatment decision making in early gastric cancer (EGC). Current evaluation methods are not adequate for estimating lymph node metastasis (LNM) in EGC. Objective To develop and validate a prediction model based on a fully quantitative collagen signature in the tumor microenvironment to estimate the individual risk of LNM in EGC. Design, Setting, and Participants This retrospective study was conducted from August 1, 2016, to May 10, 2018, at 2 medical centers in China (Nanfang Hospital and Fujian Provincial Hospital). Participants included a primary cohort (n = 232) of consecutive patients with histologically confirmed gastric cancer who underwent radical gastrectomy and received a T1 gastric cancer diagnosis from January 1, 2008, to December 31, 2012. Patients with neoadjuvant radiotherapy, chemotherapy, or chemoradiotherapy were excluded. An additional consecutive cohort (n = 143) who received the same diagnosis from January 1, 2011, to December 31, 2013, was enrolled to provide validation. Baseline clinicopathologic data of each patient were collected. Collagen features were extracted in specimens using multiphoton imaging, and the collagen signature was constructed. An LNM prediction model based on the collagen signature was developed and was internally and externally validated. Main Outcomes and Measures The area under the receiver operating characteristic curve (AUROC) of the prediction model and decision curve were analyzed for estimating LNM. Results In total, 375 patients were included. The primary cohort comprised 232 consecutive patients, in whom the LNM rate was 16.4% (n = 38; 25 men [65.8%] with a mean [SD] age of 57.82 [10.17] years). The validation cohort consisted of 143 consecutive patients, in whom the LNM rate was 20.9% (n = 30; 20 men [66.7%] with a mean [SD] age of 54.10 [13.19] years). The collagen signature was statistically significantly associated with LNM (odds ratio, 5.470; 95% CI, 3.315-9.026; P < .001). Multivariate analysis revealed that the depth of tumor invasion, tumor differentiation, and the collagen signature were independent predictors of LNM. These 3 predictors were incorporated into the new prediction model, and a nomogram was established. The model showed good discrimination in the primary cohort (AUROC, 0.955; 95% CI, 0.919-0.991) and validation cohort (AUROC, 0.938; 95% CI, 0.897-0.981). An optimal cutoff value was selected in the primary cohort, which had a sensitivity of 86.8%, a specificity of 93.3%, an accuracy of 92.2%, a positive predictive value of 71.7%, and a negative predictive value of 97.3%. The validation cohort had a sensitivity of 90.0%, a specificity of 90.3%, an accuracy of 90.2%, a positive predictive value of 71.1%, and a negative predictive value of 97.1%. Among the 375 patients, a sensitivity of 87.3%, a specificity of 92.1%, an accuracy of 91.2%, a positive predictive value of 72.1%, and a negative predictive value of 96.9% were found. Conclusions and Relevance This study's findings suggest that the collagen signature in the tumor microenvironment is an independent indicator of LNM in EGC, and the prediction model based on this collagen signature may be useful in treatment decision making for patients with EGC.
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Affiliation(s)
- Dexin Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, Fujian Normal University, Fuzhou, Fujian, People's Republic of China
| | - Gang Chen
- Department of Pathology, Fujian Provincial Cancer Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Wei Jiang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Meiting Fu
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Wenju Liu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Pathology, Fujian Provincial Cancer Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Jian Sui
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Gastrointestinal Surgery, Fujian Provincial Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Shuoyu Xu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China
| | - Zhangyuanzhu Liu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Xiaoling Zheng
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Endoscopy Center, Fujian Provincial Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Liangjie Chi
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Gastrointestinal Surgery, Fujian Provincial Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Dajia Lin
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Gastrointestinal Surgery, Fujian Provincial Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Kai Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Weisheng Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Ning Zuo
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, Fujian Normal University, Fuzhou, Fujian, People's Republic of China
| | - Jianping Lu
- Department of Pathology, Fujian Provincial Cancer Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | - Jianxin Chen
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, Fujian Normal University, Fuzhou, Fujian, People's Republic of China
| | - Guoxin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Shuangmu Zhuo
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, Fujian Normal University, Fuzhou, Fujian, People's Republic of China
| | - Jun Yan
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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Wang L, Liu Z, Kou H, He H, Zheng B, Zhou L, Yang Y. Double Contrast-Enhanced Ultrasonography in Preoperative T Staging of Gastric Cancer: A Comparison With Endoscopic Ultrasonography. Front Oncol 2019; 9:66. [PMID: 30809510 PMCID: PMC6380108 DOI: 10.3389/fonc.2019.00066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 01/24/2019] [Indexed: 12/15/2022] Open
Abstract
Objective: To compare the precision of double contrast-enhanced ultrasonography (DCEUS) to endoscopic ultrasonography (EUS) in preoperative T staging of gastric cancers. Methods: This retrospective study consisted of 158 pathologically confirmed gastric cancer patients. All patients underwent DCEUS (intravenous contrast-enhanced ultrasonography combined with oral contrast-enhanced ultrasonography) and endoscopic ultrasonography (EUS) preoperatively. The histopathological findings of resected specimens were compared with the results of DCEUS and EUS retrospectively. Results: The accuracy of DCEUS and EUS in evaluating the T staging of gastric cancer were 82.3% (T1 62.5%,T2 84.4%,T3 87.9%,T4 91.3%) and 76.6% (T1 84.4%,T2 82.2%,T3 72.4%,T4 65.2%), respectively. There were no significant differences between the methods for the overall T staging accuracy (χ2 = 1.569, P = 0.210). But EUS was superior to DCEUS for T1 stage (χ2 = 3.925, P = 0.048) and DCEUS was superior to EUS for T3 stage (χ2 = 4.393, P = 0.036) and T4 stage (χ2 = 4.600, P = 0.032). Conclusion: DCEUS is a convenient and noninvasive method with high precision, which can be used as the primary imaging technique for advanced gastric cancer T staging. In early gastric cancer, we should prefer EUS. Two methods are complementary for assessing tumor invasion depth of gastric cancer.
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Affiliation(s)
- Liang Wang
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhe Liu
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Wenzhou Institute of Biomaterials and Engineering, Chinese Academy of Sciences, Wenzhou, China
| | - Hongju Kou
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huiliao He
- Wenzhou Institute of Biomaterials and Engineering, Chinese Academy of Sciences, Wenzhou, China
| | - Bo Zheng
- Department of Gastroenterology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingling Zhou
- Department of Pathology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Yang
- Department of Ultrasound, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Molina JC, Al-Hinai A, Gosseling-Tardif A, Bouchard P, Spicer J, Mulder D, Mueller CL, Ferri LE. Multivisceral Resection for Locally Advanced Gastric and Gastroesophageal Junction Cancers-11-Year Experience at a High-Volume North American Center. J Gastrointest Surg 2019; 23:43-50. [PMID: 29663302 DOI: 10.1007/s11605-018-3746-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 03/13/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The oncologic benefit of multivisceral en bloc resections for T4 gastroesophageal tumors has been questioned, given the increased morbidity associated. We thus sought to investigate the surgical and oncologic outcomes of curative-intent en bloc multivisceral resections for T4 gastroesophageal carcinomas. METHODS Between 2005 and 2016, 35 of the 525 patients who had gastric or EGJ carcinomas underwent curative-intent multivisceral resections for direct invasion or adhesion to adjacent organs. RESULTS Postoperative complications occurred in 16(46%), 10 of which were Clavien-Dindo ≥ 3 (29%). Ninety-day mortality was 3%. The R0 resection rate was 94% (33). Direct organ invasion (pT4b) was confirmed on pathological analysis in 14 (40%) and did not affect survival. The majority (28, 80%) had lymph node involvement with a high nodal disease burden and was associated with decreased survival. Overall 5-year survival rate was 34%, and the vast majority of recurrences were distant/peritoneal (81%). On multivariate analysis, positive lymph nodes (H.R. 21.2; 95%CI 2.34-192) and R1 resection (H.R. 5.6; 95%CI 1.02-30.9) were predictors of survival. CONCLUSION Multivisceral resections for T4 gastric and GEJ adenocarcinomas, in combination with effective systemic therapy, result in prolonged long-term survival with acceptable morbidity. Complete resection to negative margins should remain a mainstay of curative-intent treatment in carefully selected patients.
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Affiliation(s)
- J C Molina
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada.
| | - A Al-Hinai
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - A Gosseling-Tardif
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - P Bouchard
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - J Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D Mulder
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - C L Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - L E Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
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Costa JM, Gonçalves B, Miguel Gomes M, Fernandes D, Gonçalves R, Soares JB. Accuracy of endoscopic ultrasound in gastric adenocarcinoma patient selection for neoadjuvant therapy. United European Gastroenterol J 2018; 7:278-286. [PMID: 31081829 DOI: 10.1177/2050640618818942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022] Open
Abstract
Background Recent studies demonstrated the positive impact of neoadjuvant treatment in locally advanced gastric cancer. Objective To assess the accuracy of endoscopic ultrasound (EUS) in the selection of patients with gastric adenocarcinoma for neoadjuvant therapy (T ≥ 2 and/or N+). Methods Retrospective analysis of patients with an anatomopathological diagnosis of gastric adenocarcinoma between January 2011 and June 2017, who had EUS for staging and underwent surgery as a first therapeutic attempt. The concordance (k) and accuracy (area under the curve (AUC)) of EUS for T ≥ 2 and/or N+ were assessed using the anatomopathological staging of the resected surgical specimen as the gold standard. Results The final sample included 152 patients (66.4% male, 67.1 ± 12.2 years). The concordance, accuracy, sensitivity and specificity of the EUS for T ≥ 2 and/or N+ were 0.72, 0.86 ± 0.03, 88.5% and 83.1%, respectively. The results were higher in proximal (k = 0.93, AUC = 0.96 ± 0.05, sensitivity (S) = 99.0% and specificity (E) = 90.9%) compared with distal lesions (k = 0.67, AUC = 0.84 ± 0.04, S = 85.7% and E = 81.5%), and in intestinal subtype (k = 0.77, AUC = 0.88 ± 0.04, S = 92.6% and E = 84.1%) compared with diffuse (k = 0.58, AUC = 0.79 ± 0.10, S = 85.0% and E = 72.7%) or mixed-subtype tumours (k = 0.65, AUC = 0.84 ± 0.10, S = 76.9% and E = 90.0%). Conclusion In one of the largest series of patients, we showed that EUS has overall high agreement and accuracy in the selection of patients with gastric adenocarcinoma for neoadjuvant therapy, although the agreement and accuracy are greater for proximal and intestinal lesions.
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Affiliation(s)
- Juliana M Costa
- Department of Gastroenterology, Hospital of Braga, Braga, Portugal
| | - Bruno Gonçalves
- Department of Gastroenterology, Hospital of Braga, Braga, Portugal
| | | | - Dália Fernandes
- Department of Gastroenterology, Hospital of Braga, Braga, Portugal
| | - Raquel Gonçalves
- Department of Gastroenterology, Hospital of Braga, Braga, Portugal
| | - João B Soares
- Department of Gastroenterology, Hospital of Braga, Braga, Portugal
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Xiao H, Wang Y, Quan H, Ouyang Y. Incidence, Causes and Risk Factors for 30-Day Unplanned Reoperation After Gastrectomy for Gastric Cancer: Experience of a High-Volume Center. Gastroenterology Res 2018; 11:213-220. [PMID: 29915632 PMCID: PMC5997474 DOI: 10.14740/gr1032w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 05/09/2018] [Indexed: 02/03/2023] Open
Abstract
Background To investigate the incidence, causes and risk factors for unplanned reoperation because of early complications within 30 days of radical gastrectomy for gastric cancer. Methods The study cohort comprised 1,948 patients who underwent radical gastrectomy for gastric cancer between November 2010 and April 2017. The incidence, causes and outcomes of unplanned reoperation were examined and the risk factors were identified using univariate and multivariate analyses. Results In total, 24 patients (1.2%) underwent unplanned reoperations because of early complications after radical gastrectomy. The main causes more frequently requiring reoperation were adhesive intestinal obstruction (eight cases, 33.3%), intra-abdominal bleeding (five cases, 20.8%), wound dehiscence (five cases, 20.8%), anastomotic leakage and intra-abdominal infection (five cases, 20.8%), and iatrogenic common bile duct injury (one case). Multivariate analysis identified that only combined multi-organ resection (odds ratio (OR) = 4.060, 95% confidence interval (CI): 1.645 - 10.023, P = 0.002) was an independent risk factor. Two patients (8.3%) who underwent reoperation died from disseminated intravascular coagulation or sepsis, respectively, which was significantly higher than the remaining 1,924 patients who did not require reoperation (six cases, 0.3%, P < 0.001). Moreover, patients who underwent reoperation experienced higher morbidity rates (37.5% vs. 6.8%, P < 0.001), requiring intensive care (20.8% vs. 2.4%, P < 0.001) and longer postoperative hospital stays (33.6 days vs. 11.0 days, P < 0.001) compared with patients required no reoperation. Conclusions Combined multi-organ resection was an independent risk factor for unplanned reoperation following radical gastrectomy. Avoiding multi-organ resection as possible will decrease the likelihood of patients requiring reoperation.
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Affiliation(s)
- Hua Xiao
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
| | - Yu Wang
- Department of Breast and Thyroid Surgery, The Second Xiangya Hospital of Central South University, 410011 Changsha, Hunan, China
| | - Hu Quan
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
| | - Yongzhong Ouyang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, 410013 Changsha, Hunan, China
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Clinicopathologic score predicting lymph node metastasis in T1 gastric cancer. Surgery 2018; 163:889-893. [DOI: 10.1016/j.surg.2017.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 02/06/2023]
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Ikoma N, Blum M, Estrella JS, Das P, Hofstetter WL, Fournier KF, Mansfield P, Ajani JA, Badgwell BD. Evaluation of the American Joint Committee on Cancer 8th edition staging system for gastric cancer patients after preoperative therapy. Gastric Cancer 2018; 21. [PMID: 28643144 PMCID: PMC7703858 DOI: 10.1007/s10120-017-0743-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Joint Committee on Cancer (AJCC) recently released its 8th edition staging system, which created a separate staging system for gastric cancer patients who have undergone preoperative therapy (ypStage). The objective of this retrospective study was to apply the new ypStage to patients who have undergone preoperative therapy and potentially curative gastrectomy. METHODS We collected data from a prospectively maintained institutional database of gastric cancer patients who underwent potentially curative gastrectomy after preoperative therapy (1995-2015). Kaplan-Meier survival estimations and log-rank tests were performed to compare survival. Univariable and multivariable analyses were performed to determine risk factors for overall survival. RESULTS A total of 354 patients met our criteria. Most patients completed planned preoperative therapy (94%; 332/354) and received chemoradiation therapy (75%; 265/354). Although clinical stage (cStage) provided a poor discrimination of survival, postneoadjuvant pathological stage (ypStage) identified significant variation in survival (p < 0.001). Multivariable analysis showed the following factors were associated with survival after adjustment for ypStage: Asian race (HR 0.52; p = 0.028), linitis plastica (HR 1.66; p = 0.037), and R1 resection (HR 1.91; p = 0.016). Survival was not longer in ypT0N0 patients than in ypStage I patients (HR 1.29; p = 0.377). CONCLUSIONS The AJCC 8th edition staging system for gastric cancer demonstrated reasonable survival prediction by ypStage, but not cStage, in patients who had undergone preoperative therapy. ypT0N0 patients, although not defined in the 8th edition, may be considered for inclusion in the ypStage I group.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S. Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L. Hofstetter
- Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F. Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
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Chen XL, Pu H, Yin LL, Li JR, Li ZL, Chen GW, Hou NY, Li H. CT volumetry for gastric adenocarcinoma: association with lymphovascular invasion and T-stages. Oncotarget 2017; 9:12432-12442. [PMID: 29552323 PMCID: PMC5844759 DOI: 10.18632/oncotarget.23478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/13/2017] [Indexed: 02/05/2023] Open
Abstract
Purpose To determine whether gross tumor volume of resectable gastric adenocarcinoma on multidetector computed tomography could predict presence of lymphovascular invasion and T-stages. Results Gross tumor volume increased with the lymphovascular invasion (r = 0.426, P < 0.0001) and T stage (r = 0.656, P < 0.0001). Univariate analysis showed gross tumor volume could predict lymphovascular invasion (P < 0.0001). Multivariate analyses indicated gross tumor volume as an independent risk factor of lymphovascular invasion (P = 0.026, odds ratio = 2.284). The Mann-Whitney U test showed gross tumor volume could distinguish T2 from T3, T1 from T2–T4a, T1–T2 from T3–T4a and T1–T3 from T4a (P = 0.000). In the development cohort, gross tumor volume could predict lymphovascular invasion (cutoff, 15.92 cm3; AUC, 0.760), and distinguish T2 from T3 (cutoff, 10.09 cm3; AUC, 0.828), T1 from T2-T4a (cutoff, 8.20 cm3; AUC, 0.860), T1-T2 from T3-T4a (cutoff, 15.88 cm3; AUC, 0.883), and T1-T3 from T4a (cutoff, 21.53 cm3; AUC, 0.834). In validation cohort, gross tumor volume could predict presence of lymphovascular invasion (AUC, 0.742), and distinguish T2 from T3 (AUC, 0.861), T1 from T2-T4a (AUC, 0.859), T1–T2 from T3–T4a (AUC, 0.875), and T1–T3 from T4a (AUC, 0.773). Materials and Methods 360 consecutive patients with gastric adenocarcinoma were retrospectively identified. Gross tumor volume was evaluated on multidetector computed tomography images. Statistical analysis was performed to determine whether gross tumor volume could predict presence of lymphovascular invasion and T-stages. Cutoffs of gross tumor volume were first investigated in 212 patients and then validated in an independent 148 patients using area under the receiver operating characteristic curve (AUC) for predicting lymphovascular invasion and T-stages. Conclusions Gross tumor volume of resectable gastric adenocarcinoma at multidetector computed tomography demonstrated capability in predicting lymphovascular invasion and distinguishing T-stages.
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Affiliation(s)
- Xiao-Li Chen
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Hong Pu
- Department of Radiology, Affiliated Hospital of Medical School, University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Long-Lin Yin
- Department of Radiology, Affiliated Hospital of Medical School, University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Jun-Ru Li
- Department of Out-Patient, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zhen-Lin Li
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Guang-Wen Chen
- Department of Radiology, Affiliated Hospital of Medical School, University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Neng-Yi Hou
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Qingyang District, Chengdu, Sichuan, China
| | - Hang Li
- Department of Radiology, Affiliated Hospital of Medical School, University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
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Strong VE, Russo A, Yoon SS, Brennan MF, Coit DG, Zheng CH, Li P, Huang CM. Comparison of Young Patients with Gastric Cancer in the United States and China. Ann Surg Oncol 2017; 24:3964-3971. [DOI: 10.1245/s10434-017-6073-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Ikoma N, Lee JH, Bhutani MS, Ross WA, Weston B, Chiang YJ, Blum MA, Sagebiel T, Devine CE, Matamoros A, Fournier K, Mansfield P, Ajani JA, Badgwell BD. Preoperative accuracy of gastric cancer staging in patient selection for preoperative therapy: race may affect accuracy of endoscopic ultrasonography. J Gastrointest Oncol 2017; 8:1009-1017. [PMID: 29299361 DOI: 10.21037/jgo.2017.04.04] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Over the last 15 years, large randomized controlled studies have validated the benefit of preoperative therapy for patients with resectable gastric cancer. Computed tomography (CT) and endoscopic ultrasonography (EUS) are commonly used to select patients for preoperative treatment, but studies of preoperative staging accuracy that focus on patient selection for preoperative therapy are rare; therefore, whether CT or EUS can reliably identify patients eligible for preoperative therapy is still unclear. Our purpose was to determine the accuracy of EUS and CT for preoperative staging of gastric cancer and to identify factors that may affect their usefulness in selecting patients for preoperative therapy. Methods We reviewed the medical records of 8,260 patients with gastric or gastroesophageal adenocarcinoma treated at our institution from 1995 to 2013, identifying those who underwent gastrectomy without preoperative treatment. We compared T stage and N status from preoperative EUS and CT reports with those drawn from surgical pathology reports. Clinicopathologic and demographic variables associated with incorrect preoperative staging were investigated using univariate and multivariate analyses. Results We identified 187 patients who underwent preoperative staging by EUS (n=145) and/or CT (n=134) before gastrectomy. The accuracy, sensitivity, and specificity of EUS in distinguishing stage T1 from more advanced tumors were 82%, 78%, and 85%, respectively. Variables associated with underestimation of EUS T stage were lymphovascular invasion [odds ratio (OR), 7.51; 95% confidence interval (CI), 1.91-29.50; P<0.01] and white race (OR, 3.75; 95% CI, 1.31-10.75; P=0.01). The accuracies, sensitivities, and specificities for determining N status were, respectively, 65%, 49%, and 79% with CT and 66%, 29%, and 95% with EUS. Lymphovascular invasion was associated with a false negative result (OR, 3.79; 95% CI, 1.34-10.70; P=0.01), and well- or moderately differentiated histology was associated with a false positive result for CT N status (OR, 7.14; 95% CI, 2.00-25.44; P<0.01). Conclusions EUS is accurate in distinguishing T1 from T2-T4 lesions; both CT and EUS have low sensitivities and high specificities in determining N status. These accuracies and variables associated with inaccurate staging, including race, should be considered when selecting gastric cancer patients for preoperative therapy.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William A Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Weston
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela A Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tara Sagebiel
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine E Devine
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aurelio Matamoros
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Xiao H, Ma M, Xiao Y, Ouyang Y, Tang M, Zhou K, Hong Y, Tang B, Zuo C. Incomplete resection and linitis plastica are factors for poor survival after extended multiorgan resection in gastric cancer patients. Sci Rep 2017; 7:15800. [PMID: 29150634 PMCID: PMC5694005 DOI: 10.1038/s41598-017-16078-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022] Open
Abstract
The aim of this retrospective study was to analyze the morbidity, mortality, and survival rates of extended multiorgan resection (EMR) for locally advanced gastric cancer patients compared to gastrectomy alone and a palliative operation. 893 locally advanced gastric cancer patients without distant metastasis had surgery including gastrectomy alone (GA group, n = 798), EMR resection (EMR group, n = 75), and palliative operation (palliative gastrectomy or gastrojejunostomy (PO group, n = 20)). Postoperative mortality and complication rates in the EMR group were significantly higher than in the GA group (2.7% vs 0.4%, P = 0.010 and 25.3% vs 8.1%, P < 0.001, respectively), but similar in the PO group. The median survival time of the EMR group was significantly longer than in the PO group (27 months vs 11 months, P = 0.020), but significantly worse (P = 0.020) than in the GA group (44 months). Incompleteness of resection (R1) and linitis plastica were independent prognostic factors for survival in the EMR group. Three different gastric cancer surgeries led to different postoperative mortality and complication rates. EMR had a better survival rate compared with PO while GA had the longest survival time with the lowest mortality and complication rates.
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Affiliation(s)
- Hua Xiao
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Min Ma
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yanping Xiao
- Department of Admissions and Employment, Changsha Health Vocational College, Changsha, 410010, China
| | - Yongzhong Ouyang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Ming Tang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Kunyan Zhou
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yuan Hong
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Bo Tang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Chaohui Zuo
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China.
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Bohle W, Zachmann R, Zoller WG. Sequential endoscopic ultrasound identifies predictive variables for relapse-free follow-up after neoadjuvant chemotherapy in gastric cancer. Scand J Gastroenterol 2017; 52:754-761. [PMID: 28355948 DOI: 10.1080/00365521.2017.1303845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The accuracy of endosonographic tumor staging after neoadjuvant therapy is less reliable than in primary staging. Therefore, the value of sequential endosonographic examinations after neaodjuvant chemotherapy in gastro-esophageal cancer is discussed controversially. Previous data suggest, that endoscopic ultrasound (EUS) after neoadjuvant treatment using other variables than classic uTN-criteria may identify patients with a better prognosis. METHODS In 67 patients with locally advanced gastric cancer treated in curative intent, we performed EUS before and after neoadjuvant chemotherapy. Endosonographic yTN-stage was compared to pathohistological yTN-stage after curative resection. The uTN-stage, yuTN-stage, maximal tumor thickness and maximal lymph node diameter as well as the shift of these variables after neoadjuvant therapy were analyzed for their usefulness to predict recurrence-free follow-up. RESULTS Accuracy of EUS for yTN-staging after neoadjuvant therapy was poor, especially in lower tumor stages. However, three heavily correlated variables analyzed by sequential EUS could be used for the prediction of prognosis: low endosonographic tumor stage (yuT0-2) after neoadjuvant chemotherapy, a decrease of two or more steps in uT-stage and a maximal tumor thickness of <15 mm after chemotherapy were significantly associated with recurrence-free follow-up. Endosonographic T-stage before neoadjuvant therapy, as well as lymph node variables before or after chemotherapy, were of no predictive value. CONCLUSION In spite of poor concordance between endosonographic and pathohistological TN-stage after neoadjuvant treatment, sequential EUS, performed before and after neoadjuvant therapy, possibly identify patients at risk for tumor relapse after multimodal treatment in gastric cancer. This finding should be validated in a larger patient cohort.
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Affiliation(s)
- Wolfram Bohle
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
| | - Ruben Zachmann
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
| | - Wolfram G Zoller
- a Department of Gastroenterology , Katharinenhospital , Klinikum Stuttgart , Germany
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Merkow RP, Herrera G, Goldman DA, Gerdes H, Schattner MA, Markowitz AJ, Strong VE, Brennan MF, Coit DG. Endoscopic Ultrasound as a Pretreatment Clinical Staging Tool for Gastric Cancer: Association with Pathology and Outcome. Ann Surg Oncol 2017; 24:3658-3666. [PMID: 28815443 DOI: 10.1245/s10434-017-6050-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is a guideline-recommended diagnostic test to estimate pretreatment clinical stage in gastric cancer. The impact of EUS to discriminate long-term outcomes has not been established. OBJECTIVES The objectives of our study were to (1) evaluate the association between EUS and pathologic stage; (2) evaluate the ability of EUS to predict disease-specific survival (DSS); and (3) determine how neoadjuvant chemotherapy (NCT) affects these relationships. METHODS A prospective gastric cancer database at a tertiary care cancer center identified 734 patients who underwent curative intent resection. Patients were separated into EUS low-risk (T1-2, N0) and EUS high-risk (T3-4 Nany, or Tany N+) groups. Agreement statistics and 5-year DSS were estimated stratified by NCT. RESULTS Between 1987 and 2015, 68% (502/734) of patients were not treated with NCT. Among these patients, percentage agreement between EUS and pathology was moderate (individual T stage: 52%; N stage: 70%; risk group: 73%). EUS accurately estimated pathologic risk group in 73% (365/502) of patients, whereas it overestimated pathologic risk group in 19% (93/502) of patients and underestimated risk in 8% (41/502) of patients. EUS in non-NCT staging was able to discriminate DSS for T stage (hazard ratio [HR] 5.07, p < 0.05), N stage (HR 3.58, p < 0.05), and risk group (HR 6.35, p < 0.05). Among patients treated with NCT, EUS was unable to discriminate DSS for T stage (HR 0.94, p > 0.05), N stage (HR 1.46, p > 0.05) and risk group (HR 0.50, p > 0.05). CONCLUSIONS Pretreatment clinical staging based on EUS alone could lead to over- or under treatment in 27% of patients and can discriminate DSS in NCT-naive patients. EUS should be used in the context of other validated clinical risk tools.
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Affiliation(s)
- Ryan P Merkow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabriel Herrera
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Debra A Goldman
- Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Gerdes
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark A Schattner
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arnold J Markowitz
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel G Coit
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Intra-abdominal infection after radical gastrectomy for gastric cancer: Incidence, pathogens, risk factors and outcomes. Int J Surg 2017; 48:195-200. [PMID: 28751223 DOI: 10.1016/j.ijsu.2017.07.081] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 07/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical site infection, particularly intra-abdominal infection (IAI), remains a clinically important event after gastrectomy for gastric cancer. The aim of this retrospective study was to clarify the incidence, pathogens, risk factors and outcomes of IAI following gastrectomy for gastric cancer. METHODS The study cohort was 1835 patients who underwent gastrectomy for gastric cancer from January 2011 through December 2016. The incidence, pathogens, and treatment outcomes of IAI were examined, and the risk factors were identified using univariate and multivariate analyses. RESULTS In total, 73 patients (4.0%) developed IAI after radical gastrectomy. Bacterial culture in these patients showed that Gram-negative bacilli, such as Escherichia coli and Klebsiella pneumonia were the most common pathogens. Multivariate analysis identified that combined multi-organ resection (Odds Ratio [OR] = 2.262, 95% confidence interval [CI]: 1.114-4.596, P = 0.024), and body mass index (BMI) ≥ 25 kg/m2 (OR = 1.968, 95% CI: 1.107-3.500, P = 0.021) were independent risk factors. Three patients (4.1%) developed IAI who died from sepsis and/or multiple-organ failure, which was significantly higher than in the remaining 1762 patients without IAI (5 cases, 0.3%, P = 0.003). Moreover, IAI required more re-operations (5.5% vs 0.8%, P = 0.005) and longer post-operative hospital stays (23.3 days vs 11.2 days, P < 0.001) compared without IAI. CONCLUSIONS IAI is a major complication after radical gastrectomy for gastric cancer, and associated with combined multi-organ resection and a BMI ≥ 25 kg/m2; thus, meticulous surgical procedures need to be performed in patients with these specific risk factors.
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Han C, Lin R, Shi H, Liu J, Qian W, Ding Z, Hou X. The role of endoscopic ultrasound on the preoperative T staging of gastric cancer: A retrospective study. Medicine (Baltimore) 2016; 95:e4580. [PMID: 27603347 PMCID: PMC5023869 DOI: 10.1097/md.0000000000004580] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasonography (EUS) is used for preoperative assessment of gastric cancer. However, recent studies suggested that EUS staging accuracy is lower than previously thought. We aimed to assess EUS efficacy and image characteristics in preoperative gastric cancer T staging.A retrospective review of clinical and imaging features of 232 gastric carcinoma patients who underwent preoperative EUS assessment of T stage was performed. Only cases with tumor-free resection margin status and no metastases were enrolled. Comparisons of preoperative EUS and postoperative histopathological stagings were also performed to identify vital EUS image features for evaluating gastric carcinoma.EUS accuracy for T staging was 64.2% (149/232) with the highest accuracy for T3 (75.0%). Enlarged lymph nodes, well differentiated histological type and Borrmann IV type were associated with diagnostic accuracy in predicting tumor invasion. Although no factors were associated with overstaging, circumferential lesions ≥1/2, signet ring cell adenocarcinoma, and Borrmann IV type had significantly higher risks of understaging. Gastric wall outer edge irregularity was also an indicator of serosal involvement with a sensitivity of 82.0%. The pancreas and colon were more frequent disease extension sites than previously predicted.Although EUS is likely the best and most accurate option that we have used to stage gastric cancer, the finding that factors including circumferential lesions, signet ring cell adenocarcinoma, and Borrmann IV type carcinoma were more frequently related to incorrect staging warrants attention.
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Affiliation(s)
| | | | | | | | | | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Correspondence: Zhen Ding, Associate Professor, Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 JieFang Avenue, Wuhan, 430022, China (e-mail: )
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Real-time optical diagnosis of gastric cancer with serosal invasion using multiphoton imaging. Sci Rep 2016; 6:31004. [PMID: 27499365 PMCID: PMC4976383 DOI: 10.1038/srep31004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/11/2016] [Indexed: 12/16/2022] Open
Abstract
A real-time optical biopsy, which could determine tissue histopathology, would be of extraordinary benefit to staging laparoscopy for gastric cancer with serosal invasion (T4) that requires downstage treatment. We investigated the feasibility of using multiphoton imaging to perform a real-time optical diagnosis of gastric cancer with or without serosal invasion. First, a pilot study was performed to establish the optical diagnostic features of gastric cancer with or without serosal invasion using multiphoton imaging compared with hematoxylin-eosin staining and Masson’s trichrome staining. Second, a blinded study was performed to compare the diagnostic sensitivity, specificity, and accuracy of multiphoton imaging and endoscopic ultrasonography (EUS) for T4 gastric cancer. In the pilot study, multiphoton imaging revealed collagen loss and degradation and cellular and nuclear pleomorphism in gastric cancer with serosal invasion. The collagen content in gastric cancer with or without serosal invasion was 0.36 ± 0.18 and 0.79 ± 0.16 (p < 0.001), respectively. In the blinded study, the sensitivity, specificity, and accuracy of EUS and multiphoton imaging for T4 gastric cancer were 70% and 90% (p = 0.029), 66.67% and 96.67% (p = 0.003), and 68.33% and 93.33% (p = 0.001), respectively. It is feasible to use multiphoton imaging to make a real-time optical diagnosis of gastric cancer with or without serosal invasion.
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Randle RW, Swords DS, Levine EA, Fino NF, Squires MH, Poultsides G, Fields RC, Bloomston M, Weber SM, Pawlik TM, Jin LX, Spolverato G, Schmidt C, Worhunsky D, Cho CS, Maithel SK, Votanopoulos KI. Optimal extent of lymphadenectomy for gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative. J Surg Oncol 2016; 113:750-5. [PMID: 26996496 DOI: 10.1002/jso.24227] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/09/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The optimal extent of lymphadenectomy in the treatment of gastric adenocarcinoma is debated. We compared gastrectomy outcomes following limited (D1) or extended (D2) lymphadenectomy. METHODS Using the multi-institutional US Gastric Cancer Collaborative database, we reviewed the morbidity, mortality, recurrence, and overall survival (OS) of patients receiving D1 or D2 lymphadenectomies. RESULTS Between 2000 and 2012, 266 and 461 patients received a D1 and D2 lymphadenectomy, respectively. ASA class, mean number of comorbidities, grade, and stage were similar between groups. While major morbidity was similar (P = 0.85), mortality was worse for those receiving a D1 lymphadenectomy (4.9% vs. 1.3%, P = 0.004). D2 lymphadenectomy was associated with improved median OS in stage I (4.7 years for D1 vs. not reached for D2, P = 0.003), stage II (3.6 years for D1 vs. 6.3 for D2, P = 0.42), and stage III patients (1.3 years for D1 vs. 2.1 for D2, P = 0.01). After adjusting for predictors of OS, D2 lymphadenectomy remained a significant predictor of improved survival (HR 1.5, 95%CI 1.1-2.0, P = 0.008). CONCLUSIONS D2 lymphadenectomy can be performed without increased risk of morbidity and mortality. Additionally, D2 lymphadenectomy is associated with improved survival especially in early stages, and should be considered for gastric adenocarcinoma patients. J. Surg. Oncol. 2016;113:750-755. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Reese W Randle
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Douglas S Swords
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward A Levine
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora F Fino
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Mark Bloomston
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy M Pawlik
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Gaya Spolverato
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - David Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Serrano OK, Huang K, Ng N, Yang J, Friedmann P, Libutti SK, Kennedy TJ. Correlation between preoperative endoscopic ultrasound and surgical pathology staging of gastric adenocarcinoma: A single institution retrospective review. J Surg Oncol 2016; 113:42-5. [PMID: 26784562 DOI: 10.1002/jso.24098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 11/07/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent evidence validates the effectiveness of neoadjuvant chemotherapy in the treatment of gastric adenocarcinoma. Endoscopic ultrasonographic (EUS) staging has been proposed as a useful adjunct in this setting. METHODS We performed a retrospective review of patients treated at our institution for gastric adenocarcinoma between July 2005 and January 2014. We identified patients referred for EUS before surgery as part of a prospective treatment plan. Histopathologic staging was compared to EUS staging, with a focus on T- and N-stage. Agreement between the two modalities was examined using kappa-statistics. RESULTS We identified 614 patients with biopsy-proven gastric adenocarcinoma; 145 underwent curative-intent surgery. Surgical pathology and EUS results were available from 69 patients. The accuracy of EUS for the evaluation of T- and N-stage was 44.9% and 56.5%, respectively. EUS demonstrated greater concordance with histopathology at evaluating T-stage (κ = 0.3469) than N-stage (κ = 0.1316). EUS underestimated T- and N-stage in 40.8% and 30.4% of patients, respectively. CONCLUSION EUS seems to correlate poorly with pathology in the preoperative staging of gastric adenocarcinoma. In the majority of inaccurate cases, EUS underestimates T-stage and N-stage, limiting its utility in the neoadjuvant setting.
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Affiliation(s)
- Oscar K Serrano
- Department of Surgery, Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.,Albert Einstein College of Medicine, New York, New York
| | - Kevin Huang
- Albert Einstein College of Medicine, New York, New York
| | - Nicole Ng
- Albert Einstein College of Medicine, New York, New York
| | - Julie Yang
- Albert Einstein College of Medicine, New York, New York.,Department of Gastroenterology, Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | | | - Steven K Libutti
- Department of Surgery, Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.,Albert Einstein College of Medicine, New York, New York
| | - Timothy J Kennedy
- Department of Surgery, Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.,Albert Einstein College of Medicine, New York, New York
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National Trends in Utilization of Endoscopic Ultrasound for Gastric Cancer: a SEER-Medicare Study. J Gastrointest Surg 2016; 20:154-63; discussion 163-4. [PMID: 26553265 DOI: 10.1007/s11605-015-2988-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 10/10/2015] [Indexed: 01/31/2023]
Abstract
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.
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Newton AD, Datta J, Loaiza-Bonilla A, Karakousis GC, Roses RE. Neoadjuvant therapy for gastric cancer: current evidence and future directions. J Gastrointest Oncol 2015; 6:534-43. [PMID: 26487948 DOI: 10.3978/j.issn.2078-6891.2015.047] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Although surgical resection remains the only potentially curative treatment for gastric cancer (GC), poor long-term outcomes with resection alone compel a multimodality approach to this disease. Multimodality strategies vary widely; while adjuvant approaches are typically favored in Asia and the United States (USA), a growing body of evidence supports neoadjuvant and/or perioperative strategies in locally advanced tumors. Neoadjuvant approaches are particularly attractive given the morbidity associated with surgical management of GC and the substantial risk of omission of adjuvant therapy. The specific advantages of chemoradiotherapy (CRT) compared to chemotherapy have not been well defined, particularly in the preoperative setting and trials aimed at determining the optimal elements and sequencing of therapy are underway. Future studies will also define the role of targeted and biologic therapies.
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Affiliation(s)
- Andrew D Newton
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jashodeep Datta
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Arturo Loaiza-Bonilla
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Tran TB, Worhunsky DJ, Norton JA, Squires MH, Jin LX, Spolverato G, Votanopoulos KI, Schmidt C, Weber S, Bloomston M, Cho CS, Levine EA, Fields RC, Pawlik TM, Maithel SK, Poultsides GA. Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative. Ann Surg Oncol 2015; 22 Suppl 3:S840-7. [PMID: 26148757 DOI: 10.1245/s10434-015-4694-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Resection of an adjacent organ during gastrectomy for gastric cancer is occasionally necessary to achieve margin clearance. The short- and long-term outcomes of this approach remain unclear. METHODS Patients who underwent gastric cancer resection in seven U.S. academic institutions from 2000 to 2012 were evaluated to compare perioperative morbidity, mortality, and survival outcomes, stratified by the need for and type of multivisceral resection (MVR). RESULTS Of 835 patients undergoing curative-intent gastrectomy, 159 (19 %) had MVR. The most common adjacent organs resected were the spleen (48 %), pancreas (27 %), liver segments 2/3 (14 %), and colon (13 %). As extent of resection increased (gastrectomy only, n = 676; MVR without pancreatectomy, n = 116; and MVR with pancreatectomy, n = 43), perioperative morbidity was higher: any complication (45, 60, 59 %, p = 0.012), major complication (17, 31, 33 %, p = 0.001), anastomotic leak (5, 11, 19 %, p < 0.001), and respiratory failure (9, 15, 22 %, p = 0.012). However, perioperative mortality did not significantly increase (30-day: 3, 4, 2 %, p = 0.74; 90-day: 6, 8, 9 %, p = 0.61). Overall survival after resection decreased as extent of resection increased (5-year: 42, 28, 6 %). After controlling for age, race, T stage, N stage, grade, margin status, perineural invasion, adjuvant therapy, and blood transfusion, MVR with pancreatectomy (HR 1.67, p = 0.044), but not MVR without pancreatectomy (HR 0.97, p = 0.759), remained an independent predictor of poor survival. CONCLUSION In this modern, multi-institutional cohort of gastric cancer patients, multivisceral resection was associated with higher perioperative morbidity but not significantly higher perioperative mortality. If concomitant pancreatectomy is anticipated, patients should be selected with extreme caution because long-term survival remains poor.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - David J Worhunsky
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Malcolm Hart Squires
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Linda X Jin
- Department of Surgery, Barnes Jewish Hospital and The Alvin J. Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | | - Carl Schmidt
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Mark Bloomston
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Ryan C Fields
- Department of Surgery, Barnes Jewish Hospital and The Alvin J. Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - George A Poultsides
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.
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Fairweather M, Jajoo K, Sainani N, Bertagnolli MM, Wang J. Accuracy of EUS and CT imaging in preoperative gastric cancer staging. J Surg Oncol 2015; 111:1016-20. [PMID: 25872753 DOI: 10.1002/jso.23919] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/19/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant therapy is recommended for locally advanced gastric cancer patients (stage IB-IIIC). The objective of this study is to evaluate the accuracy of endoscopic ultrasound (EUS) and computed tomography (CT) in identifying patients with locally advanced gastric cancer. METHODS Patients with gastric adenocarcinoma who underwent gastrectomy at our institution were reviewed. Preoperative EUS and CT staging were compared with pathologic staging to determine accuracy. RESULTS Between 2001 and 2013, 280 patients were identified. Forty-nine patients (18%) who underwent preoperative staging by EUS were analyzed. The accuracy of EUS in identifying individual T stage and N stage was 41.0% and 42.9%, respectively. EUS had moderate accuracy in differentiating locally advanced from early (stage 0-IA) disease (75.5%, area under curve (AUC) 0.772). For individual T stage and N stage, the accuracy of CT was 4.0% and 56%, respectively. CT had relatively poor accuracy in differentiating locally advanced from early disease (60.0%, AUC 0.649). CONCLUSIONS EUS and CT had poor performance in identifying individual T and N stage although EUS demonstrated moderate accuracy in identifying patients with locally advanced disease. A combined staging approach, in addition to further optimization of staging modalities, is required for accurate staging for patients with gastric cancer.
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Affiliation(s)
- Mark Fairweather
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kunal Jajoo
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nisha Sainani
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Monica M Bertagnolli
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jiping Wang
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, Massachusetts
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Endoscopic ultrasound may misclassify the nodal status of a small subset of patients with early gastric cancer: in reply to Chen and colleagues. J Am Coll Surg 2015; 220:373-4. [PMID: 25700903 DOI: 10.1016/j.jamcollsurg.2014.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 11/18/2014] [Indexed: 11/22/2022]
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Chen XZ, Huang ZX, Hu JK. Sensitivity of endoscopic ultrasound in detecting N+ disease among early gastric cancer patients needs to be underlined. J Am Coll Surg 2015; 220:372-3. [PMID: 25700901 DOI: 10.1016/j.jamcollsurg.2014.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 11/18/2014] [Indexed: 11/26/2022]
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Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev 2015; 2015:CD009944. [PMID: 25914908 PMCID: PMC6465120 DOI: 10.1002/14651858.cd009944.pub2] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is proposed as an accurate diagnostic device for the locoregional staging of gastric cancer, which is crucial to developing a correct therapeutic strategy and ultimately to providing patients with the best chance of cure. However, despite a number of studies addressing this issue, there is no consensus on the role of EUS in routine clinical practice. OBJECTIVES To provide both a comprehensive overview and a quantitative analysis of the published data regarding the ability of EUS to preoperatively define the locoregional disease spread (i.e., primary tumor depth (T-stage) and regional lymph node status (N-stage)) in people with primary gastric carcinoma. SEARCH METHODS We performed a systematic search to identify articles that examined the diagnostic accuracy of EUS (the index test) in the evaluation of primary gastric cancer depth of invasion (T-stage, according to the AJCC/UICC TNM staging system categories T1, T2, T3 and T4) and regional lymph node status (N-stage, disease-free (N0) versus metastatic (N+)) using histopathology as the reference standard. To this end, we searched the following databases: the Cochrane Library (the Cochrane Central Register of Controlled Trials (CENTRAL)), MEDLINE, EMBASE, NIHR Prospero Register, MEDION, Aggressive Research Intelligence Facility (ARIF), ClinicalTrials.gov, Current Controlled Trials MetaRegister, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), from 1988 to January 2015. SELECTION CRITERIA We included studies that met the following main inclusion criteria: 1) a minimum sample size of 10 patients with histologically-proven primary carcinoma of the stomach (target condition); 2) comparison of EUS (index test) with pathology evaluation (reference standard) in terms of primary tumor (T-stage) and regional lymph nodes (N-stage). We excluded reports with possible overlap with the selected studies. DATA COLLECTION AND ANALYSIS For each study, two review authors extracted a standard set of data, using a dedicated data extraction form. We assessed data quality using a standard procedure according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. We performed diagnostic accuracy meta-analysis using the hierarchical bivariate method. MAIN RESULTS We identified 66 articles (published between 1988 and 2012) that were eligible according to the inclusion criteria. We collected the data on 7747 patients with gastric cancer who were staged with EUS. Overall the quality of the included studies was good: in particular, only five studies presented a high risk of index test interpretation bias and two studies presented a high risk of selection bias.For primary tumor (T) stage, results were stratified according to the depth of invasion of the gastric wall. The meta-analysis of 50 studies (n = 4397) showed that the summary sensitivity and specificity of EUS in discriminating T1 to T2 (superficial) versus T3 to T4 (advanced) gastric carcinomas were 0.86 (95% confidence interval (CI) 0.81 to 0.90) and 0.90 (95% CI 0.87 to 0.93) respectively. For the diagnostic capacity of EUS to distinguish T1 (early gastric cancer, EGC) versus T2 (muscle-infiltrating) tumors, the meta-analysis of 46 studies (n = 2742) showed that the summary sensitivity and specificity were 0.85 (95% CI 0.78 to 0.91) and 0.90 (95% CI 0.85 to 0.93) respectively. When we addressed the capacity of EUS to distinguish between T1a (mucosal) versus T1b (submucosal) cancers the meta-analysis of 20 studies (n = 3321) showed that the summary sensitivity and specificity were 0.87 (95% CI 0.81 to 0.92) and 0.75 (95% CI 0.62 to 0.84) respectively. Finally, for the metastatic involvement of lymph nodes (N-stage), the meta-analysis of 44 studies (n = 3573) showed that the summary sensitivity and specificity were 0.83 (95% CI 0.79 to 0.87) and 0.67 (95% CI 0.61 to 0.72), respectively.Overall, as demonstrated also by the Bayesian nomograms, which enable readers to calculate post-test probabilities for any target condition prevalence, the EUS accuracy can be considered clinically useful to guide physicians in the locoregional staging of people with gastric cancer. However, it should be noted that between-study heterogeneity was not negligible: unfortunately, we could not identify any consistent source of the observed heterogeneity. Therefore, all accuracy measures reported in the present work and summarizing the available evidence should be interpreted cautiously. Moreover, we must emphasize that the analysis of positive and negative likelihood values revealed that EUS diagnostic performance cannot be considered optimal either for disease confirmation or for exclusion, especially for the ability of EUS to distinguish T1a (mucosal) versus T1b (submucosal) cancers and positive versus negative lymph node status. AUTHORS' CONCLUSIONS By analyzing the data from the largest series ever considered, we found that the diagnostic accuracy of EUS might be considered clinically useful to guide physicians in the locoregional staging of people with gastric carcinoma. However, the heterogeneity of the results warrants special caution, as well as further investigation for the identification of factors influencing the outcome of this diagnostic tool. Moreover, physicians should be warned that EUS performance is lower in diagnosing superficial tumors (T1a versus T1b) and lymph node status (positive versus negative). Overall, we observed large heterogeneity and its source needs to be understood before any definitive conclusion can be drawn about the use of EUS can be proposed in routine clinical settings.
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Affiliation(s)
- Simone Mocellin
- Meta-Analysis Unit, Department of Surgery,Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, Padova, Veneto, 35128, Italy. .
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