Adjuvant capecitabine and oxaliplatin for gastric cancer after D2 gastrectomy (CLASSIC): a phase 3 open-label, randomised controlled trial

Asia Pacific Gastroesophageal Cancer Congress (APGCC) 2024 consensus statement on stage 2 and 3 locally advanced gastric and Siewert 3 junctional adenocarcinoma

BACKGROUND

While the development in multimodal therapies has helped improve treatment outcomes for patients with locally advanced gastric adenocarcinoma (LAGC), there still exist disparities in opinion with an optimal treatment plan. This consensus hopes to provide clinicians with structured guidelines to aid in the decision-making for treatment options for LAGC.

METHODS

The consensus statement was initiated by establishing a taskforce in collaboration with the Asia Pacific Gastroesophageal Cancer Congress (APGCC) and a multidisciplinary expert panel was selected. Clinical questions on LAGC where perceived variance in practice or opinion may exist were formulated. Studies involving patients with Stage 2 or 3 gastric or Siewert 3 junctional cancers with treatment arms of perioperative chemotherapy, neoadjuvant chemotherapy, adjuvant chemotherapy, immunotherapy and surgery were included. A total of two rounds of voting were performed. Consensus was determined to be reached when a single answer or a combination of either "strongly agree/agree" or "strongly disagree/disagree" responses exceeded 75%.

RESULTS

A total of thirteen clinical questions were developed. They were identified through five main categories: Distal LAGC, Proximal LAGC, Deficient mismatch repair tumors, Chemotherapy and Immunotherapy, and Elderly/Unfit patients. After two rounds of voting by our multidisciplinary expert panel, eleven out of a total thirteen clinical questions had reached consensus. No consensus was reached for two clinical questions.

CONCLUSION

The APGCC consensus statement aims to guide clinicians in the treatment options for LAGC and Siewert 3 junctional cancer and has clarified some of the roles of perioperative chemotherapy and immunotherapy.

Laparoscopic gastrectomy reduced peritoneal recurrence in Borrmann type IV gastric cancer: a retrospective cohort study with propensity score matching

BACKGROUND

Current evidence on the surgical and oncological safety of laparoscopic surgery in patients with Borrmann type IV (B-IV) advanced gastric cancer (AGC) remains insufficient. This study aimed to compare the surgical and prognostic outcomes of laparoscopic gastrectomy (LG) and open gastrectomy (OG) in patients with B-IV AGC.

METHODS

Patients with primary B-IV gastric cancer who underwent LG or OG between 2003 and 2019 were retrospectively analyzed. We conducted 1:1 propensity score matching using covariates including sex, age, body mass index, operation type, clinical T and N stages, pathological TNM stage, tumor size, and tumor location. Surgical outcomes, postoperative complications, 5-year survival and recurrence outcomes, and risk factors for peritoneal recurrence were compared between the two groups.

RESULTS

Of 401 patients enrolled, 106 from each of the LG and OG groups were matched, with all standardized differences < 0.1. The LG had significantly fewer wound infections (P = 0.029), intra-abdominal abscesses (P = 0.035) and a lower peritoneal recurrence rate (5-year cumulative incidence: 48.8% vs. 62.8%, P = 0.032; hazard ratio, 0.66; 95% confidence interval, 0.45-0.96) compared to the OG group, along with a trend toward improved 5-year overall survival (LG vs. OG: 37.0% vs. 26.2%, P = 0.174; hazard ratio, 0.78; 95% confidence interval, 0.55-1.11). Multivariate analyses revealed a 32.6% decrease in the hazard ratio for peritoneal recurrence in the LG group (P = 0.048).

CONCLUSIONS

LG significantly reduced peritoneal recurrence with fewer wound and intra-abdominal infectious complications in patients with B-IV AGC.

Adjuvant chemotherapy may have no significant survival benefit in older patients with stage II/III gastric cancer: a multicenter retrospective study

AIM

Postoperative adjuvant chemotherapy is known to enhance cure rates and is thus recommended for stages pII to pIII. However, specific guidelines for such treatment in elderly gastric cancer (GC) patients are currently lacking. This study examines the impact of adjuvant chemotherapy on the postoperative survival of these patients.

METHODS

We reviewed a total of 7749 patients with GC who underwent radical gastrectomy at Zhejiang Cancer Hospital and Fujian Cancer Hospital from January 2007 to December 2019. We conducted univariate and multivariate Cox regression analyses to investigate the impact of clinicopathological factors on overall survival (OS) and cancer-specific survival (CSS) in these patients. Additionally, we created a meta-analysis forest plot and employed propensity score matching (PSM) to mitigate confounding bias.

RESULTS

Age and adjuvant chemotherapy were independent risk factors for OS and CSS. Stratified analysis based on chemotherapy use revealed a statistically significant difference in OS and CSS between younger patients who did and did not receive adjuvant chemotherapy. In contrast, no significant differences in OS and CSS were observed between older patients with or without adjuvant chemotherapy. These findings remained consistent after propensity score matching (PSM).

CONCLUSIONS

Age and adjuvant chemotherapy are independent risk factors for OS and CSS in patients with stage II/III GC; for patients with stage II/III gastric cancer aged ≥ 75 years, shared decision-making should be made taking into account functional status and comorbidities, rather than conventional adjuvant chemotherapy.

Gastric Carcinoma Patients with Advanced Pathological Lymph Node Stage Benefit from Postoperative Radiotherapy: A Retrospective Analysis

BACKGROUND

The relationship between regional pathological lymph node status and the benefit of postoperative radiotherapy for gastric cancer remains controversial.

METHODS

This study included all surgically treated patients diagnosed with positive histology and more than 15 examined lymph nodes between January 2007 and December 2019, using data from the SEER database. Patients who received adjuvant chemotherapy were compared by propensity score matching (PSM), with overall survival (OS) as the primary endpoint and adjuvant radiotherapy (RT) as the only variable. Results of subgroup analyses are presented in a forest plot.

RESULTS

We firstly analyzed the number of patients receiving adjuvant RT and observed a gradual decline from 2000 to 2021. A total of 1882 patients were included from 2007 to 2019, with 1301 (69.1%) in the adjuvant RT group and 581 (30.9%) in the no-adjuvant RT group. After PSM, each group included 573 patients. Overall, adjuvant RT did not significantly improve 3-year OS (55.5% vs. 51.1%, p = 0.07). However, in subgroups of patients with pathologic lymph node metastasis (pN3-stage), aged 55-70 years, with tumor size > 89 mm and T3-stage, adjuvant RT was associated with improved outcome (p < 0.05). Further PSM and survival analysis based on different pathological lymph node stages suggested an association between adjuvant RT and outcomes. Improved survival outcomes were observed in pathologically lymph node positive (pN +) and pN3 groups, but no similar effects were seen in pN1 and pN2 groups. For pN0 patients, although no statistical significance was found, the data suggest that adjuvant RT may not provide additional benefit.

CONCLUSION

Adjuvant RT was associated with significantly better prognosis in pN3-stage patients. More researches are needed to further validate the role of adjuvant RT in gastric cancer.

PRMT1-catalyzed NUSAP1 methylation enhances Notch2 signaling and 5-FU resistance in gastric cancer

5-Fluorouracil (5-FU) resistance remains a significant challenge in the treatment of gastric cancer, limiting its clinical efficacy. Our study identifies NUSAP1, a nucleolar and spindle-associated protein, as a key driver of 5-FU resistance in gastric cancer. Proteomic analyses of 5-FU-resistant gastric cancer cell lines revealed that NUSAP1 is significantly upregulated, and functional studies demonstrated its essential role in promoting resistance, proliferation, migration, invasion, and tumor growth. Mechanistic investigations revealed that NUSAP1 undergoes asymmetric dimethylation (ADMA) at R418 and R422, mediated by PRMT1, with the R422 site being critical for its function. NUSAP1 interacts with the PEST domain of Notch2 through its R422 site, inhibiting Notch2 ubiquitination and stabilizing its expression, thereby activating the Notch2 signaling pathway. This pathway is closely linked to gastric cancer progression and chemoresistance. Inhibition of PRMT1 or mutation of the R422 site abrogated NUSAP1's ability to stabilize Notch2 and regulate downstream signaling. These findings unveil a novel mechanism by which NUSAP1 promotes 5-FU resistance in gastric cancer and highlight the therapeutic potential of targeting the NUSAP1-Notch2 axis or PRMT1 in overcoming chemoresistance.

Comparison of outcomes between surgery and non-surgery after conversion therapy for advanced gastric cancer with unresectable factors: a systematic review and meta-analysis

BACKGROUND

Advanced gastric cancer (AGC) with unresectable factors presents a significant treatment challenge. Conventional treatments such as systemic chemotherapy, radiotherapy, and immunotherapy can delay disease progression but often yield limited outcomes. For stage III-IV gastric cancer with unresectable factors, conversion therapy based on chemotherapy can achieve tumor downstaging, providing a subset of patients with the opportunity for curative surgery. However, the efficacy of multimodal approaches combining chemotherapy, with or without immunotherapy, and conversion surgery compared to chemotherapy alone remains controversial.

METHODS

We conducted a systematic review and meta-analysis of high-quality studies published between January 2014 and November 2024, assessing the role of surgery following conversion therapy in advanced gastric cancer. Relevant studies were retrieved from PubMed, Embase, and Web of Science databases. All included studies were observational; no randomized trials were available. Clinical data, including overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and adverse event (AE) rates, were analyzed using RevMan 5.4.

RESULTS

Twelve observational cohort studies were included. Conversion surgery(CS) was associated with improved 1-year, 3-year, and 5-year OS rates (RR 0.38, 95% CI: 0.31-0.47; RR 0.64, 95% CI: 0.54-0.76; RR 0.77, 95% CI: 0.65-0.91, respectively) and increased 1-year and 3-year PFS rates (RR 0.57, 95% CI: 0.49-0.99; RR 0.67, 95% CI: 0.57-0.78, respectively). No significant difference in AE rates was observed between groups.

CONCLUSIONS

Conversion surgery following chemotherapy in stage III-IV gastric cancer is associated with improved OS and PFS in observational studies. However, these findings may reflect inherent prognostic differences between groups, as surgery was only feasible for chemotherapy responders. Prospective trials are needed to validate causality.

The Evolving Role of Immunotherapy for Gastroesophageal Malignancies

The incorporation of immunotherapy has transformed the treatment landscape for advanced, unresectable, or metastatic gastroesophageal cancers (GECs), with improved survival outcomes. These improvements in outcomes for advanced GECs have led to clinical trials evaluating the role of immunotherapy in patients with resectable early-stage GECs. However, there remains a high burden of morbidity and mortality, and ongoing trials utilizing novel immunotherapy agents and combinations are underway. This review summarizes the findings of previous and ongoing clinical trials related to immunotherapy for patients with early- and late-stage GECs.

Identifying beneficial gastric cancer patient on prognosis after treating with perioperative or postoperative-only chemotherapy: a single-center real-world study

BACKGROUND

This study evaluates the impact of perioperative S-1 and oxaliplatin (SOX) versus postoperative SOX or capecitabine and oxaliplatin (XELOX) on patient prognosis to identify suitable candidates for each therapy.

METHOD

A retrospective real-world cohort study was conducted using data from Zhejiang Cancer Hospital on gastric cancer patients treated between 2010 and 2019. Patients were divided into perioperative SOX and postoperative SOX or XELOX groups. Propensity score matching (PSM) was used to control for selection bias. Overall survival (OS) was the primary outcome, analyzed using the Kaplan-Meier method and Cox regression.

RESULT

A total of 816 patients were included: 293 in the perioperative SOX group and 523 in the postoperative chemotherapy group (408 SOX and 115 XELOX). In the perioperative SOX group, the tumor regression grade (TRG) 2-3 subgroup demonstrated a significantly worse overall survival (OS) compared to the postoperative XELOX group (95% CI = 1.064-3.444, P = 0.027). Subgroup analysis revealed that older patients (95% CI = 0.210-0.950, P = 0.036), and those at the cT3 (95% CI = 0.05-1.19, P = 0.008) stage experienced greater benefits from postoperative chemotherapy. When comparing the benefited populations, it was found that patients with CA125 positivity had an advantage trend with adjuvant chemotherapy compared to perioperative SOX chemotherapy.

CONCLUSION

Real-world data suggest that perioperative SOX chemotherapy does not benefit all patients with advanced gastric cancer. Patients with TRG 2-3, older age, or cT3 stage may achieve better outcomes with postoperative chemotherapy. Additionally, an exploratory analysis indicated that CA125 positivity may be associated with improved survival following adjuvant treatment.

Multi-omics analysis of Helicobacter pylori-associated gastric cancer identifies hub genes as a novel therapeutic biomarker

Helicobacter pylori infection is one of the most common gastric pathogens; however, the molecular mechanisms driving its progression to gastric cancer remain poorly understood. This study aimed to identify the key transcriptomic drivers and therapeutic targets of H. pylori-associated gastric cancer through an integrative transcriptomic analysis. This analysis integrates microarray and RNA-seq datasets to identify significant differentially expressed genes (DEGs) involved in the progression of H. pylori-associated gastric cancer. In addition to independent analyses, data were integrated using ComBat to detect consistent expression patterns of hub genes. This approach revealed distinct clustering patterns and stage-specific transcriptional changes in common DEGs across disease progression, including H. pylori infection, gastritis, atrophy, and gastric cancer. Genes such as TPX2, MKI67, EXO1, and CTHRC1 exhibited progressive upregulation from infection to cancer, highlighting involvement in cell cycle regulation, DNA repair, and extracellular matrix remodeling. These findings provide insights into molecular shifts linking inflammation-driven infection to malignancy. Furthermore, network analysis identified hub genes, including CXCL1, CCL20, IL12B, and STAT4, which are enriched in immune pathways such as chemotaxis, leukocyte migration, and cytokine signaling. This emphasizes their role in immune dysregulation and tumor development. Expression profiling demonstrated the upregulation of hub genes in gastric cancer and stage-specific changes correlating with disease progression. Finally, drug-gene interaction analysis identified therapeutic opportunities, with hub genes interacting with approved drugs like abatacept and zoledronic acid, as well as developmental drugs such as adjuvant and relapladib. These findings highlight the key role of these hub genes as biomarkers and therapeutic targets, providing a foundation for advancing precision medicine in H. pylori-associated gastric cancer. Overall, this study paves the way for advancing precision medicine in H. pylori-associated gastric cancer by providing insights into the development of early detection biomarkers, risk stratification, and targeted therapies. This supports the clinical translation of precision medicine strategies in H. pylori-associated gastric cancer.

Spatial organization of B lymphocytes and prognosis prediction in patients with gastric cancer

BACKGROUND

Within the tumor microenvironment (TME), the association of B lymphocytes (B cells) with prognosis and therapy response in gastric cancer (GC) remains poorly characterized. We investigated the predictive and prognostic value of B cells, including their spatial organization within the TME, in one of the largest multi-cohort studies to date.

METHODS

Using CD20 immunohistochemistry, we evaluated B cell density in resection specimens from 977 patients with resectable GC across three cohorts, including the randomized phase III Korean CLASSIC trial. The relationship between CD20 density, clinicopathological characteristics, and overall survival (OS) was analyzed. Digital spatial profiling of 1063 regions of interest from 15 patients was performed to characterize B cell distribution within different regions of interest (ROIs) using the NanoString GeoMx platform.

RESULTS

CD20 density was significantly higher in diffuse-type GC compared to intestinal-type (p = 0.000012). Patients with CD20-low diffuse-type GC had the shortest OS in the CLASSIC trial (median OS: 49 vs 62 months, HR: 1.9, 95% CI: 1.2-3.0, p = 0.003) and in a Japanese cohort (median OS: 49 vs 67 months, HR: 2.2, 95% CI: 1.2-4.0, p = 0.011). This survival difference was not seen in patients treated with adjuvant chemotherapy (median OS: 62 vs 63 months, HR: 1.8, 95% CI: 0.88-3.5, p = 0.108). Spatial profiling revealed significant B cell enrichment within tumor ROIs compared to the stroma, particularly in diffuse-type GC.

CONCLUSIONS

Low CD20 positivity, especially in diffuse-type GC, is linked to poor prognosis and may identify patients who could benefit from chemotherapy. These findings underscore the role of B cells in GC.

Gastric cancer

Gastric cancer remains a major health challenge worldwide, with nearly 1 million new cases annually contributing to more than 650 000 deaths. Epidemiologically, gastric cancer shows substantial geographical variation in incidence, with higher rates in Asia, South America, and eastern Europe, and a rapid increase in early-onset cases among people younger than 50 years. Key risk factors for gastric cancer include Helicobacter pylori infection, diet, obesity, smoking, and genetic predisposition. Early detection through comprehensive diagnostic procedures is crucial for optimising treatment outcomes. Standard treatment approaches for locally advanced gastric cancer include surgical resection, particularly D2 lymphadenectomy, complemented by chemotherapy and radiotherapy. There is increasing implementation of minimally invasive surgical techniques for operable disease and integration of immune checkpoint inhibitors and targeted therapies for advanced stages. Emerging therapies, such as novel targeted treatments and next-generation immunotherapies, show promise in improving survival and quality of life. Future directions in the management of gastric cancer focus on precision medicine, continued advancement in immunotherapy, novel early detection methods, and a multidisciplinary approach to care. These strategies aim to enhance the overall effectiveness of treatment and prognosis worldwide.

Robotic and laparoscopic gastrectomy for gastric cancer: comparative insights into perioperative performance and three-year survival outcomes

BACKGROUND

The primary treatment for gastric cancer (GC) is surgical resection, particularly for locally advanced cases. While laparoscopic gastrectomy (LG) has shown short- and long-term benefits, robotic gastrectomy (RG) offers enhanced precision and may lead to better outcomes, especially in advanced-stage disease.

METHODS

This retrospective study analyzed data from 1538 patients with pathological Stage I-III GC who underwent RG or LG between 2014 and 2021. Propensity score matching created 466 matched pairs. Perioperative outcomes, 3 year overall survival (OS), 3 year recurrence-free survival (RFS), and recurrence patterns were compared between RG and LG.

RESULTS

RG demonstrated significantly shorter operative time (235.5 vs. 242.5 min, p = 0.001), less blood loss (19.1 vs. 33.4 ml, p < 0.001), and shorter hospital stay (7.9 vs. 9.7 days, p < 0.001). Overall complications did not differ significantly (p = 0.183), but RG had lower rates of anastomotic leakage (p = 0.045) and pancreatic fistula (p = 0.024). No significant differences in OS were observed in the overall cohort or by stage. Similarly, RFS showed no significant differences in the overall cohort (3 year RFS: RG 86.81% vs. LG 83.04%, p = 0.1347). By stage, no differences were found in stage I or II, but in stage III, RG showed better 3 year RFS (67.52% vs. 52.97%, p = 0.0424). RG also had lower recurrence rates (9.0% vs. 14.8%, p = 0.0061), with fewer liver (p = 0.0069) and lymph node metastases (p = 0.0223).

CONCLUSION

RG demonstrated superior short-term outcomes and comparable three-year OS to laparoscopic gastrectomy, with improved three-year RFS and reduced recurrence in Stage III, likely facilitated by earlier adjuvant chemotherapy initiation.

Survival benefits of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with locally advanced gastric cancer: insights from a population-based study

BACKGROUND AND AIMS

Postoperative adjuvant chemotherapy in older adults aged ≥ 80 years with locally advanced gastric cancer (LAGC) remains debated owing to concerns over treatment tolerance and limited data. We aimed to assess the effectiveness of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with LAGC using data from the Surveillance, Epidemiology, and End Results database.

METHODS AND RESULTS

A total of 2395 patients with LAGC aged ≥ 80 years who underwent radical surgery between 2004 and 2015 were identified. Propensity score matching (1:1) was applied to pair 422 patients receiving adjuvant chemotherapy with 1973 patients who underwent surgery alone. Multivariate logistic regression identified independent predictors of adjuvant chemotherapy, including the period from 2012-2015, pN1-2 and pN3 stages, and radiation therapy. Conversely, age ≥ 85 years predicted decreased chemotherapy use. Cancer-specific survival (CSS) and overall survival (OS) were compared using multivariate Cox analysis, showing significantly longer OS and CSS in the adjuvant chemotherapy group, before and after matching. Subgroup analysis revealed that patients aged 80-84 years and those with N + stages benefited most from adjuvant chemotherapy, whereas patients aged ≥ 90 years did not show significant benefit.

CONCLUSION

Postoperative adjuvant chemotherapy should be considered for patients aged ≥ 80 years with LAGC, especially those with lymph node involvement, as it offers significant survival benefits. However, as age approaches 90 years, the benefits of adjuvant chemotherapy may diminish, warranting more cautious application.

Neoadjuvant Chemoradiotherapy in Locally Advanced Gastric Adenocarcinoma: Long-Term Results and Statistical Algorithm to Predict Individual Risk of Relapse

BACKGROUND

The purpose of this study was to evaluate the long-term outcomes of patients with locally advanced gastric adenocarcinoma (LAGC) intended to receive induction chemotherapy, chemoradiation and surgery and to develop an algorithm to estimate the individual risk of relapse in a population-based setting.

METHODS

Patients with LAGC (cT3-4 and/or N+) were retrospectively evaluated. A pathological response was graded according to the Becker criteria. The nodal regression grade was assessed by a 4-point scale (A-D). A comprehensive analysis of 155 individual patient variables was performed, and logistic regression (LR) was utilized to develop a predictive model for relapse risk.

RESULTS

From 2010 to 2024, 48 patients were analyzed. After a median follow-up of 49 months (range, 12-212), the 5-year actuarial PFS and OS rates were 44% and 48%, respectively. Four variables were identified as the most relevant features for training the LR model. Scores for the model accuracy, sensitivity and specificity (mean +/- sd) were 0.79 +/- 0.12, 0.74 +/- 0.221 and 0.88 +/- 0.14, respectively. For a validation dataset, the figures were 0.78, 0.88 and 0.73, respectively.

CONCLUSIONS

This neoadjuvant strategy seems to correlate with a favorable long-term outcome in a subset of intestinal-type LAGA patients who achieve ypN0 features.

A novel prognostic model based on migrasome-related LncRNAs for gastric cancer

Gastric cancer (GC) represents a substantial public health challenge, characterized by elevated morbidity and mortality rates. Migrasomes, a newly discovered type of extracellular vesicle, have been highlighted as important contributors to cancer progression, though their specific role in GC remains unclear. To address this issue, we developed the first prognostic model utilizing migrasome-related long non-coding RNAs (MRLs). This model aims to deepen the understanding of GC pathogenesis and improve patient outcomes. Clinical and transcriptional data for 407 GC patients from TCGA were classified as training and testing sets. Through Pearson correlation analysis, 537 MRLs were recognized, and LASSO and Cox regression analyses further refined the list to four key lncRNAs (AC012055.1, LINC01150, AC053503.4, AC107021.2) for constructing the prognostic model. Kaplan-Meier survival analysis indicated a significantly poorer prognosis for the high-risk group. PCA confirmed the model's robustness, and univariate and multivariate analyses validated it as an independent predictor of clinical outcomes. The ROC curve and C-index evaluations further affirmed the model's predictive power. We developed a nomogram combining the MRLs signature with clinical parameters to enhance prognostic accuracy. GO, KEGG and GSEA were performed on migrasome-related genes associated with GC. Furthermore, high-risk patients exhibited increased immune cell infiltration and reduced tumor mutation burden, both associated with poorer outcomes. Additionally, twenty-nine potential therapeutic agents were identified. This novel MRLs-based model provides crucial insights into GC biology and represents a valuable tool for improving patient management and therapeutic strategies.

Proportional Correlation Between Systemic Inflammation Response Index and Gastric Cancer Recurrence Time: A Retrospective Study

BACKGROUND

Disease recurrence is the primary cause of death in patients with gastric cancer who have undergone complete surgical resection. No prognostic factors for recurrence, other than the Tumor, Node, and Metastasis stage, have been established. However, recurrence rates differ even within the same Tumor, Node, and Metastasis stage. Therefore, we aimed to develop a new prognostic confidence measure for gastric cancer recurrence and demonstrate its practical utility.

METHODS

This was a retrospective study based on the medical records of the Chungnam National University Hospital, Republic of Korea. We enrolled patients diagnosed with stage II/III gastric cancer who underwent complete surgical resection and adjuvant chemotherapy over the past 12 years. The association between seven variables, including the systemic inflammation response index (SIRI) and gastric cancer recurrence, was analyzed.

RESULTS

A total of 296 patients were enrolled in this study. Although other factors did not exhibit significant correlations, SIRI showed a significant positive correlation with gastric cancer recurrence risk, confirmed through Cox regression testing (hazard ratio, 1.231; 95% confidence interval, 1.04-1.45). Linear regression analysis revealed a significant association between higher SIRI values and shorter recurrence time (p = 0.044; β = -0.225).

CONCLUSIONS

In this study, other than SIRI, effective prognostic factors related to gastric cancer recurrence were not verified, thus indicating SIRI as a potential independent prognostic factor.

Efficacy and safety of XELOX combined with neoadjuvant radiotherapy versus neoadjuvant chemotherapy in locally advanced gastric cancer

BACKGROUND

The work aimed to compare the efficacy and safety of chemotherapy regimen (oxaliplatin + capecitabine, XELOX) combined with neoadjuvant radiotherapy (NART) and neoadjuvant chemotherapy (NACT) in locally advanced gastric cancer.

METHODS

We retrospectively analyzed clinical data from patients with locally advanced gastric cancer who underwent radical gastrectomy with D2 lymph node dissection at our center between January 2019 and December 2020. The study compared tumor markers, postoperative pathology, short-term efficacy, postoperative complications, and hospital stay between the chemoradiotherapy (CRT, XELOX + NART) group and the NACT-only group. Pearson correlation coefficients was used to analyze the correlations between clinical variables and tumor biomarkers. Inverse probability weighting (IPW) was used to adjust for confounding factors.

RESULTS

A total of 409 patients were included, with 369 (90.2%) in the NACT group and 40 (9.8%) in the CRT group. Significant correlations were found between clinical variables and tumor biomarkers, which may help identify potential prognostic factors for gastric cancer treatment. After IPW adjustment, baseline characteristics were similar between groups. The negative conversion rate of CEA-positive patients was significantly higher in the CRT group (38.1% vs. 11.8%, P < 0.001). The rate of pathological complete response was also higher in the CRT group (15.8% vs. 4.7%, P = 0.017). Postoperative pathological stages ypT0 and T1 were observed in 35.5% of the CRT group compared to 13.5% in the NACT group (P = 0.031). The CRT group had a lower average number of lymph nodes dissected (17 vs. 24, P < 0.001) but a higher ypN0 rate (60.3% vs. 39.8%, P = 0.024). The proportion of patients with tumor regression grade (TRG) 0-1 was higher in the CRT group (60.3% vs. 24.3%, P = 0.003). The R0 resection rate after IPW was 100% in the CRT group versus 96.5% in the NACT group (P = 0.001). No significant differences were found between the CRT and NACT groups in nerve invasion, vascular embolus, peritoneal invasion, bone marrow suppression, nausea, vomiting, esophagitis, diarrhea, other adverse reactions, postoperative complications, or average hospitalization time. The CRT group showed superior disease-free survival while no overall survival advantage (P < 0.05).

CONCLUSIONS

The XELOX regimen combined with neoadjuvant chemoradiotherapy provided superior downstaging, short-term pathological response, and local control benifits compared to perioperative chemotherapy alone, with similar surgical safety profiles.

Understanding metastatic patterns in gastric cancer: Insights from lymph node distribution and pathology

Gastric cancer (GC) represents a significant global health burden due to its high morbidity and mortality. Specific behaviors of GC sub-types, distinct dissemination patterns, and associated risk-factors remain poorly understood. This editorial highlights several key prognostic factors, including pathological staging and vascular invasion, that impact GC. It examines a recent study's investigation of differential metastatic lymph nodes distribution and survival in upper and lower GC sub-types, focusing on histological characterization, pathophysiology, usage of neoadjuvant chemotherapy, and additional predictive determinants. We assess the statistical robustness and clinical applicability of the findings, underscoring the importance of treating GC as a heterogeneous disease and emphasizing how tailored surgical approaches informed by lymph node distribution can optimize tumor detection while minimizing unnecessary interventions. The study's large cohort, multi-center design, and strict inclusion criteria strengthen its validity in guiding surgical planning and risk-stratification. However, integrating genetic and molecular data is critical for refining models and broadening applicability. Additionally, recurrence-metrics and infection-related factors, such as Helicobacter pylori and Epstein-Barr virus, absent in the original study, remain vital for directing future research. By bridging metastatic patterns with prospective methodologies and inclusion of diverse populations, this editorial provides a framework for advancing early detection and personalized GC care.

Evolution of Therapeutics for Locally Advanced Upper Gastrointestinal Adenocarcinoma

Upper gastrointestinal (GI) malignancies, including esophageal, gastroesophageal junction (GEJ), and gastric adenocarcinomas, remain a major global health concern, with poor overall survival and high recurrence rate despite aggressive treatment. Patients with very early tumors (cT1a) can benefit from endoscopic therapy. However, patients with locally advanced disease require multimodal therapies that may combine surgery, radiation, and systemic therapies. This review provides a comprehensive overview of recent advancements in the treatment of locally advanced upper GI adenocarcinomas. Surgical resection remains the cornerstone of curative treatment, with perioperative chemotherapy emerging as the standard of care. While preoperative chemoradiation has demonstrated some benefits in esophageal and GEJ cancers, recent data suggest a more limited role for radiation going forward. Immunotherapy has shown some promise in both the adjuvant and perioperative settings but has yet to establish definitive survival benefit. The integration of HER2-targeted therapies into treatment regimens for HER2-positive locally advanced gastroesophageal cancers has not yielded significant improvements, underscoring the need for more effective strategies. Ongoing research focuses on better predictive biomarkers, personalized treatment approaches, and potential organ preservation strategies for patients achieving a clinical complete response. Continued advancements in treatment modalities and precision medicine are critical to improving survival for patients with locally advanced upper GI adenocarcinomas.

The Influence of Lifestyle Behaviors and Body Mass Index Changes on Long-term Outcomes After Gastric Cancer Surgery: A Population-Based Cohort Study

PURPOSE

The present study investigated the impact of lifestyle behaviors and body mass index (BMI) on late recurrence, gastric remnant cancer (GRC), and long-term survival after curative gastrectomy.

MATERIALS AND METHODS

This retrospective study utilized data from the Korean National Health Insurance claims database. Among 71,014 patients with gastric cancer who underwent curative gastrectomy between January 2009 and December 2012, 23,359 remained cancer-free for five years. Of these, 7,735 patients with health examination data within 2 years before surgery and 5 years after surgery were analyzed for lifestyle behaviors, including smoking, alcohol consumption, and physical activity. Multivariable analysis was used to evaluate the independent effects of these factors and changes in BMI on late recurrence, GRC, and long-term survival.

RESULTS

Late recurrence or GRC occurred among 628 patients (8.1%). Older age (≥60 years) and total gastrectomy were identified as risk factors. Although lifestyle behaviors and BMI changes did not directly affect recurrence, they significantly affected mortality. In the total gastrectomy group, current underweight status (hazard ratio [HR], 1.586) was associated with increased mortality. Among the partial gastrectomy group, continued smoking (HR, 1.366) and current underweight status (HR, 1.915) increased mortality risk. Conversely, regular physical activity (starting: HR, 0.674; continuing: HR, 0.699) and postoperative overweight or obesity (BMI >25 kg/m²) (HR, 0.713) were associated with reduced mortality. Changes in alcohol consumption showed inconsistent effects between the partial and total gastrectomy groups.

CONCLUSIONS

The long-term survival of post-gastrectomy patients improved with smoking cessation, regular physical activity, and maintenance of body weight.

Prospective Multicenter Observational Study on Postoperative Quality of Life According to Type of Gastrectomy for Gastric Cancer

PURPOSE

This study evaluated the postoperative quality of life (QoL) after various types of gastrectomy for gastric cancer.

MATERIALS AND METHODS

A multicenter prospective observational study was conducted in Korea using the Korean Quality of Life in Stomach Cancer Patients Study (KOQUSS)-40, a new QoL assessment tool focusing on postgastrectomy syndrome. Overall, 496 patients with gastric cancer were enrolled, and QoL was assessed at 5 time points: preoperatively and at 1, 3, 6, and 12 months after surgery.

RESULTS

Distal gastrectomy (DG) and pylorus-preserving gastrectomy (PPG) showed significantly better outcomes than total gastrectomy (TG) and proximal gastrectomy (PG) with regard to total score, indigestion, and dysphagia. DG, PPG, and TG also showed significantly better outcomes than PG in terms of dumping syndrome and worry about cancer. Postoperative QoL did not differ significantly according to anastomosis type in DG, except for Billroth I anastomosis, which achieved better bowel habit change scores than the others. No domains differed significantly when comparing double tract reconstruction and esophagogastrostomy after PG. The total QoL score correlated significantly with postoperative body weight loss (more than 10%) and extent of resection (P<0.05 for both). Reflux as assessed by KOQUSS-40 did not correlate significantly with reflux observed on gastroscopy 1 year postoperatively (P=0.064).

CONCLUSIONS

Our prospective observation using KOQUSS-40 revealed that DG and PPG lead to better QoL than TG and PG. Further study is needed to compare postoperative QoL according to anastomosis type in DG and PG.

Adjuvant chemotherapy for stage II and III gastric adenocarcinoma: A retrospective analysis with long-term follow-up

BACKGROUND

Whether adjuvant chemotherapy should be different for patients with stage II and III gastric cancer is unknown.

METHODS

We retrospectively analyzed the effects of adjuvant chemotherapy on the outcomes of 140 and 256 patients with stage II and III gastric cancer, respectively, between January 2008 and December 2018. Chemotherapies were stratified as fluoropyrimidine plus platinum versus fluoropyrimidine alone, tegafur/gimeracil/octeracil (S-1)-containing versus non-S-1-containing regimens, and S-1 plus cisplatin versus S-1 alone.

RESULTS

The median age of patients was 67.0 (range 24.6-98.8) years. With a median follow-up of 105 months, recurrence occurred in 32 (22.9%) and 130 (50.8%) patients with stage II and III disease, respectively. Adjuvant chemotherapy was administered as fluoropyrimidine monotherapy to 68 (48.6%) and 73 (28.5%) patients, fluoropyrimidine plus platinum to 9 (6.4%) and 104 (40.6%) patients, and none to 63 (45.0%) and 79 (30.9%) patients with stage II and III gastric cancer, respectively. Doublet chemotherapy was associated with longer disease-free survival (DFS) (26.5 vs. 15.2 months, P = 0.001) and overall survival (OS) (41.2 vs. 22.0 months, P < 0.001) than fluoropyrimidine monotherapy for stage IIIB-IIIC disease. Furthermore, S-1-containing regimens prolonged DFS (57.4 vs. 21.9 months, P = 0.044) and OS (81.4 vs. 28.6 months, P = 0.023) compared with non-S-1-containing chemotherapy in stage III disease.

CONCLUSION

Although fluoropyrimidine monotherapy is feasible for stage II-IIIA disease, doublet chemotherapy is significantly associated with longer survival than monotherapy for stage IIIB-IIIC disease. S-1-containing regimens might lead to longer survival than non-S-1-containing chemotherapy in stage III gastric cancer.

Pathological response guides adjuvant 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy in surgically resected gastro-oesophageal cancer (SPACE-FLOT): international cohort study

BACKGROUND

Many patients with locally advanced gastro-oesophageal cancers are unable to complete adjuvant 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy, raising questions about its therapeutic utility. The aim of this study was to examine whether pathological response to neoadjuvant FLOT can guide its adjuvant use.

METHODS

Patients with non-metastatic gastro-oesophageal adenocarcinoma who received neoadjuvant FLOT and underwent surgery from 1 January 2017 to 1 January 2022 from 43 hospitals across 12 countries were analysed. Pathological response was assessed using tumour regression grading systems, trichotomized into minimal responders (MR; worst category), complete responders (CR; pCR), and partial responders (PR; between MR and CR). Survival outcomes of patients who did and did not receive adjuvant FLOT were compared using Kaplan-Meier, Cox regression, propensity score matched, and sensitivity analysis.

RESULTS

A total of 1887 patients (459 MR, 221 CR, and 1207 PR) were evaluated. The median follow-up was 25.5 (interquartile range 15.0-39.1) months. In the MR group, there was no difference in disease-free survival (DFS; HR 1.03 (95% c.i. 0.78 to 1.36), P = 0.836) between those who did and did not receive adjuvant FLOT. Whilst there was a difference in non-adjusted OS, this became statistically non-significant after adjusting for baseline characteristics (HR 0.96 (95% c.i. 0.70 to 1.30), P = 0.801). In the CR group, there was no difference in DFS (HR 0.88 (95% c.i. 0.41 to 1.85), P = 0.724) or OS (HR 0.69 (95% c.i. 0.31 to 1.54), P = 0.343) between those who did and did not receive adjuvant FLOT. In the PR group, adjuvant FLOT conferred a significant DFS (HR 0.68 (95% c.i. 0.55 to 0.86), P < 0.001) and OS (HR 0.55 (95% c.i. 0.44 to 0.69), P < 0.001) benefit.

CONCLUSION

Pathological response to neoadjuvant FLOT may guide the use of adjuvant FLOT, enabling personalized approaches to treatment.

Post-recurrence survival in patients with stage III gastric cancer who received adjuvant chemotherapy; post-hoc analysis of the JACCRO GC-07 study

BACKGROUND

As adjuvant chemotherapy for stage III gastric cancer, the phase III (JACCRO GC-07) trial showed that docetaxel plus S-1 (DS) was superior to S-1 in terms of recurrence-free and overall survival. However, whether adding docetaxel to S-1 in the adjuvant setting affects survival after recurrence remains unclear. The optimal treatment strategy for patients who develop recurrence during or after DS has also been controversial.

METHODS

We used results from JACCRO GC-07 to investigate post-recurrence survival (PRS) in patients who developed recurrence during or after completing adjuvant chemotherapy. PRS was compared between adjuvant groups and among post-recurrence chemotherapeutic regimens.

RESULTS

During 5 years of follow-up after surgery, 161 of 441 patients in the DS group and 216 of 452 patients in the S-1 group developed recurrence, with median PRS of 12.6 and 11.4 months, respectively (hazard ratio [HR] 0.98, 95 % confidence interval [CI] 0.79-1.22; p = 0.84). Among patients with recurrence, 115 patients in the DS group and 165 patients in the S-1 group received chemotherapy, and median PRS was 14.5 and 13.7 months, respectively (HR 1.04, 95 %CI 0.81-1.34; p = 0.76). Platinum-based chemotherapy resulted in longer PRS than non-platinum chemotherapy, regardless of the adjuvant chemotherapeutic regimen or time of recurrence.

CONCLUSIONS

PRS was similar between patients who received adjuvant chemotherapy with DS or with S-1 alone. PRS was also similar between groups of patients who received chemotherapy after recurrence. Platinum-based chemotherapy might be the optimal treatment for patients who develop recurrence after completing adjuvant DS, regardless of the time of recurrence.

Phase 2 study of neoadjuvant durvalumab plus docetaxel, oxaliplatin, and S-1 with surgery and adjuvant durvalumab plus S-1 for resectable locally advanced gastric cancer

BACKGROUND

Based on the phase 3 PRODIGY study, neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) have emerged as a viable treatment option for Asian patients with resectable locally advanced gastric cancer (LAGC). This phase 2 study evaluated the efficacy and safety of combining neoadjuvant durvalumab with DOS, followed by surgery and adjuvant durvalumab plus S-1 chemotherapy, for resectable LAGC.

METHODS

Patients with LAGC with cT2/3N+or cT4Nany tumors were enrolled in this study. Patients with proficient mismatch repair protein (pMMR) tumors received three cycles of neoadjuvant durvalumab plus DOS, administered every 3 weeks, followed by surgery and adjuvant S-1 plus durvalumab (main study arm). The primary endpoints were the rate of pathologic complete regression (pCR) and safety. An exploratory arm evaluated patients with deficient mismatch repair protein (dMMR) tumors, who received three cycles of neoadjuvant durvalumab and tremelimumab, followed by surgery and adjuvant durvalumab.

RESULTS

In the main study arm, 50 pMMR patients were enrolled, and received at least one dose of neoadjuvant treatment. The median age was 63 years, with 72.0% being men. 18 and 32 patients presented with clinical stage II and III tumors, respectively. 49 (98.0%) underwent surgery, with 45 achieving R0 resection. A pCR rate of 30.0% was observed, meeting the prespecified primary efficacy endpoint. With a median follow-up of 21.8 months, the 3-year progression-free survival and overall survival rates were 69.9% and 88.1%, respectively. 10% of patients experienced predefined unacceptable severe toxicities, including febrile neutropenia (n=3) and persistent G4 neutropenia (n=2) lasting more than 7 days, thereby meeting the primary safety endpoint. Nine patients with dMMR tumors were enrolled in the exploratory arm. All nine underwent surgery, with a pCR rate of 22.2%.

CONCLUSIONS

This study met its primary efficacy and safety endpoints. The combination of neoadjuvant durvalumab plus DOS, followed by surgery and adjuvant durvalumab plus S-1 chemotherapy, warrants further investigation in a phase 3 trial for Asian patients with LAGC.

CLINICAL TRIAL INFORMATION

04221555.

Comparison of PSOX (paclitaxel, oxaliplatin, S-1) and SOX (oxaliplatin, S-1) as postoperative adjuvant chemotherapy for stage II-III gastric cancer

BACKGROUND

Adjuvant chemotherapy is the conventional treatment for stage II and III gastric cancer(GC). Postoperative doublet chemotherapy has consistently shown improved survival outcomes in advanced-stage GC patients compared to single-agent regimens. Triplet regimens have shown significant survival benefits in the perioperative settings. This retrospective study evaluated the efficacy and safety of paclitaxel/S-1/oxaliplatin (PSOX) compared to S-1/oxaliplatin (SOX) as postoperative adjuvant chemotherapy in stage II-III GC patients following D2 gastrectomy.

METHODS

A retrospective review was conducted on patients with histologically confirmed stage II-III gastric cancer who underwent D2 gastrectomy at Jiangsu Cancer Hospital, categorizing them into two groups. A total of 75 patients were included in PSOX group and 81 patients in the SOX group between April 2018 and August 2021. Patients in PSOX group received paclitaxel (120 mg/m2), oxaliplatin (100 mg/m2) and S-1 (80 - 60 mg/d) per cycle, while those patients in SOX group were administrated oxaliplatin (130 mg/m2) and S-1 (80-120 mg/d) per cycle. Patients from both groups were matched in a 1:1 ratio using propensity scores to assess differences in disease-free survival (DFS) and safety.

RESULTS

The 3-year DFS rate was 78.2% for the PSOX group and 74.0% for the SOX group (P = 0.355), with a hazard ratio for peritoneal relapse of 0.287 (95% CI, 0.090-0.915; P = 0.035). Subgroup analysis indicated that stage IIIC GC patients in the PSOX group had a higher DFS rate than those in the SOX group(P = 0.032). Grade 3 or 4 adverse events, as per the National Cancer Institute Common Toxicity Criteria, such as leucopenia (10.6% vs. 4.5%), neutropenia (10.6% vs. 9.1%), nausea/vomiting (4.5% vs. 3.0%), and diarrhea (4.5% vs. 3.0%) were relatively common in the PSOX group compared to the SOX group, with no statistically significant differences between the two groups.

CONCLUSION

Our findings suggested that adjuvant PSOX chemotherapy offers superior survival benefits compared to the SOX regimen in patients with staged IIIC GC after D2 gastrectomy. The incidence of adverse events with PSOX chemotherapy was comparable to that of SOX chemotherapy.

Perioperative versus adjuvant chemotherapy for resectable gastric cancer: a meta-analysis of randomized controlled trials

Objectives

To report the latest systematic review and meta-analysis of randomized controlled trials (RCT) to compare perioperative versus adjuvant chemotherapy for resectable gastric cancer.

Methods

We conducted a systematic literature retrieval via PubMed, Embase, Web of Science, and Cochrane until April, 2024 for RCT which compared perioperative versus adjuvant chemotherapy for resectable gastric cancer. Outcomes measured were overall survival (OS) and progression-free survival (PFS).

Results

5 RCTs including 2,735 patients were included for meta-analysis. Meta-analysis revealed a significant longer PFS in the neoadjuvant chemotherapy (NAC) group (HR: 0.77; 95% CI: 0.69, 0.85; P<0.00001) compared with adjuvant chemotherapy (AC) group. Subgroup analysis found that there was still a significant superiority of NAC in female (HR: 0.53; 95% CI: 0.40, 0.70; P<0.0001) and cN+ (HR: 0.77; 95% CI: 0.67, 0.89; P=0.0005) patients, while the superiority disappeared in male (HR: 0.87; 95% CI: 0.74, 1.01; P=0.07) and cN- patients (HR: 0.91; 95% CI: 0.46, 1.78; P=0.77). In addition, meta-analysis observed a trend towards improved OS with NAC (HR: 0.86; 95% CI: 0.70, 1.07; P = 0.17), and sensitivity analysis demonstrated instability in OS.

Conclusions

NAC can significantly prolong PFS in patients with resectable gastric cancer compared to AC, and the benefit is more significant in women and cN+ patients. Besides, our analysis indicated that NAC has a potential to improve OS compared with AC.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024546165.

Perioperative or postoperative adjuvant oxaliplatin with S-1 versus adjuvant oxaliplatin with capecitabine in patients with locally advanced gastric or gastro-oesophageal junction adenocarcinoma undergoing D2 gastrectomy (RESOLVE): final report of a randomised, open-label, phase 3 trial

BACKGROUND

The multicentre RESOLVE trial examined the efficacy of perioperative and postoperative S-1 and oxaliplatin (SOX) compared with postoperative capecitabine and oxaliplatin (CapOx) in gastric or gastro-oesophageal junction cancer. Initial analyses did not encompass overall survival owing to the immature data. This paper provides an updated analysis of the survival data from the RESOLVE trial.

METHODS

In this randomised, open-label, phase 3 study, participants aged 18 years or older with cT4a N+ M0 or cT4b Nany M0 gastric or gastro-oesophageal junction adenocarcinoma who were feasible for D2 lymphadenectomy and had a Karnofsky performance score of 70 or higher were enrolled. Participants were randomly assigned in a 1:1:1 ratio via an interactive web response system, stratified by participating centres and Lauren classification, to receive adjuvant CapOx (eight postoperative cycles of intravenous oxaliplatin 130 mg/m2 on day 1 of each 21-day cycle plus oral capecitabine 1000 mg/m2 twice a day on days 1-14, adjuvant SOX (eight postoperative cycles of intravenous oxaliplatin 130 mg/m2 on day 1 of each 21-day cycle plus oral S-1 40-60 mg twice a day on days 1-14), or perioperative SOX (intravenous oxaliplatin 130 mg/m2 on day 1 of each 21-day cycle plus oral S-1 40-60 mg twice a day for three cycles preoperatively and five cycles postoperatively followed by three cycles of S-1 monotherapy. The primary endpoint, assessed in the modified intention-to-treat population, was 3-year disease-free survival to assess the superiority of perioperative-SOX compared with adjuvant-CapOx and the non-inferiority (hazard ratio [HR] non-inferiority margin of 1·33) of adjuvant-SOX compared with adjuvant-CapOx, and has been reported previously. This final report focuses on the secondary endpoint of 5-year overall survival, also assessed in the modified intention-to-treat population. Other secondary endpoints-R0 resection rate and safety-were not updated in this analysis. The study is registered at ClinicalTrials.gov, NCT01534546, and is complete.

FINDINGS

Between Aug 15, 2012, and Feb 28, 2017, 1094 patients were enrolled and randomly assigned, of whom 1022 participants were included in the modified intention-to-treat population: 345 (259 male, 86 female) in the adjuvant-CapOx group, 340 (238 male, 102 female) in the adjuvant-SOX group, and 337 (271 male, 66 female) in the perioperative-SOX group. As of April 7, 2022, the median duration of follow-up was 62·8 months (IQR 52·0-75·1). The 5-year overall survival rates were 52·1% (95% CI 46·3-57·5) for the adjuvant-CapOx group, 61·0% (55·3-66·2) for the adjuvant-SOX group, and 60·0% (54·2-65·3), for the perioperative-SOX group. Overall survival was significantly prolonged with perioperative-SOX (HR 0·79; 95% CI 0·62-1·00, p=0·049) and adjuvant-SOX (HR 0·77, 0·61-0·98, p=0·033), compared with adjuvant-CapOx.

INTERPRETATION

Consistent with the initial analysis of 3-year disease-free survival, the extended 5-year overall survival analysis from the RESOLVE trial confirmed the survival advantage of perioperative-SOX and adjuvant-SOX compared with the standard adjuvant-CapOx regimen. The SOX regimen, given perioperatively or as an adjuvant treatment, emerges as a potential standard treatment modality for locally advanced gastric or gastro-oesophageal junction cancer management in Asian patients.

FUNDING

The National Key Research and Development Program of China, the National Natural Science Foundation of China, the Capital's Funds for Health Improvement and Research, the Beijing Natural Science Foundation, National Natural Science Foundation of China, the Beijing Natural Science Foundation, Taiho, Hengrui Pharmaceutical and Sanofi-Aventis.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

How do I treat dMMR/MSI gastro-oesophageal adenocarcinoma in 2025? A position paper from the EORTC-GITCG gastro-esophageal task force

In less than a decade, immune checkpoint inhibitors (ICIs) have transformed the management of mismatch repair-deficient (dMMR) and microsatellite instability-high (MSI) cancers. However, beyond colorectal cancer (CRC), much of the evidence is mostly derived from non-randomized phase II studies or post-hoc analyses of broader clinical trials. dMMR/MSI tumours represent a specific subgroup of gastro-esophageal adenocarcinomas (GEA), accounting for approximately 9 % of cases, with a higher prevalence in early-stage compared to advanced-stage disease and older female patients. These tumours are predominantly sporadic, often linked to MLH1 promoter methylation, and rarely exhibit HER2 overexpression/ERBB2 amplification or other oncogenic drivers. The treatment landscape for early stage dMMR/MSI GEA is likely to change substantially soon, as ICIs have shown high pathological complete response (pCR) rates in small phase II trials, raising questions on optimisation of neoadjuvant therapy, and paving the way for organ preservation. The standard of treatment for untreated patients with advanced dMMR/MSI GEA is chemotherapy + ICI irrespectively of PDL-1 status. However, the role of chemotherapy-free regimen consisting of CTLA-4 plus PD-1 inhibitors remains undetermined. This review addresses these and other emerging questions, offering expert opinions and insights into the future therapeutic landscape for dMMR/MSI GEA.

LGALS9B stabilizes EEF1D protein and activates the PI3K/AKT signaling pathway to promote gastric cancer occurrence and metastasis

Gastric cancer ranks among the most prevalent malignancies globally, characterized by limited treatment efficacy and high recurrence rates. Effective management of this disease requires a comprehensive understanding of its underlying pathogenic mechanisms. Galectins have emerged as promising targets in gastric cancer therapy, with Galectin-9 (LGALS9) receiving considerable attention in recent years. However, Galectin-9B (LGALS9B) remains relatively under-explored in gastric cancer research. Our study investigates the role of LGALS9B in gastric cancer progression, demonstrating that its over-expression enhances cellular proliferation, migration, and invasion, while its knockdown inhibits these processes both in vitro and in vivo. We further elucidate that LGALS9B competes with the E3 ligase HERC5 for binding to eukaryotic translation elongation factor 1 delta (EEF1D), thereby preventing its protein degradation. This interaction results in the enrichment of EEF1D, which activates the PI3K/AKT signaling pathway and ultimately promotes gastric cancer progression. These findings highlight the regulatory role of LGALS9B in the pathogenesis of gastric cancer, offering valuable insights into potential novel therapeutic strategies for managing this challenging disease.

Tremelimumab and durvalumab as neoadjuvant or non-operative management strategy of patients with microsatellite instability-high resectable gastric or gastroesophageal junction adenocarcinoma: the INFINITY study by GONO

BACKGROUND

In resectable gastric/gastroesophageal junction adenocarcinoma, microsatellite instability-high (MSI-H) confers improved survival, but limited benefit from chemotherapy. Immunotherapy may eliminate the need for chemotherapy or surgery.

PATIENTS AND METHODS

INFINITY is a multicenter, multicohort phase II trial (NCT04817826) investigating in cohort 1 the activity and safety of tremelimumab + durvalumab (T300/D) as neoadjuvant treatment of mismatch repair deficient/MSI-H, resectable gastric/gastroesophageal junction adenocarcinoma. Primary endpoint was pathologic complete response (pCR) rate; Secondary endpoints: progression-free survival (PFS), overall survival (OS), quality of life, and translational analyses. In cohort 2, the activity and safety of T300/D was explored as definitive treatment in patients achieving clinical complete response (cCR). Primary endpoint was 2-year cCR rate, and secondary endpoints were PFS, OS, quality of life, gastrectomy-free survival and translational analyses.

RESULTS

In cohort 1, 18 patients were recruited and 15 evaluable. pCR and major pathologic response-pCR were 60% and 80%, respectively. Since pCR rate in T4 tumors was 17%, this subgroup of patients was excluded from enrollment in cohort 2. At 28.1 months median follow-up, 24-month gastric cancer-specific PFS and OS rates were 85% and 92%, respectively. In cohort 2, 18 patients were enrolled and 17 assessable, and 13 had cCR and started non-operative management. At 11.5 months median follow-up, one patient had local regrowth and underwent salvage surgery; 12-month gastrectomy-free survival was 64.2%.

CONCLUSIONS

The INFINITY study provided promising activity results of a chemo-free T300/D combination regimen as preoperative treatment in mismatch repair deficient/MSI gastric/gastroesophageal junction adenocarcinoma and the first available feasibility results of a non-operative management strategy in this disease setting, worthy of further validation in larger cohorts.

Clinical Value of Nomograms Integrating Circulating Lipid and Inflammation Risk Score in Predicting Long-Term Outcomes After Radical Gastrectomy in Gastric Cancer: A Multicenter Real-World Study

BACKGROUND

The clinical value of incorporating lipid and inflammatory factors to predict long-term survival in patients with gastric cancer (GC) is unreported. This study aimed to investigate the clinical value of nomograms integrating the Circulating Lipid and Inflammation Risk Score (CLIRS) for predicting the long-term outcome of patients with GC.

METHODS

A retrospective analysis included patients with GC who underwent radical resection at four tertiary medical centers. Patients were divided into training and validation cohorts, with least absolute shrinkage and selection operator regression selecting optimal lipid and inflammatory indicators related to GC prognosis. The CLIRS was developed from six indicators: lymphocyte, triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B.

RESULTS

Overall, 2534 patients were studied, including 1910 in the training cohort and 624 in the validation cohort. The CLIRS was an independent risk factor for overall survival (OS; hazard ratio [HR] 1.529, 95% confidence interval [CI] 1.271-1.839; p < 0.001) and disease-free survival (DFS; HR 1.511, 95% CI 1.267-1.801; p < 0.001) in GC patients. The OS nomogram (area under the receiver operating characteristic curve 0.823 vs. 0.785; p < 0.05) and DFS nomogram (AUC 0.804 vs. 0.770; p < 0.05) based on the CLIRS outperformed pTNM stage. High-risk patients had earlier and more sustained recurrence, with higher rates of local, peritoneal, and distant recurrences (p < 0.05).

CONCLUSIONS

The CLIRS, combining circulating lipid and inflammatory factors, is an independent prognostic factor for patients with GC. Nomograms incorporating the CLIRS are superior to pTNM stage in predicting postoperative survival and recurrence in patients with GC.

Effect of Adjuvant Chemotherapy Cycles on Patients with Node-Negative Gastric Cancer Following Neoadjuvant Chemotherapy: Multicenter Cohort Study

BACKGROUND

Research investigating the potential impact of postoperative adjuvant chemotherapy cycles on patients with lymph node-negative gastric cancer following neoadjuvant chemotherapy is currently sparse. This study aims to explore the effect of adjuvant chemotherapy cycles on the prognosis of this specific patient group.

PATIENTS AND METHODS

We analyzed clinicopathological data from patients at four institutions between 2010 and 2020. Independent risk factors associated with 3-year overall survival (OS) were identified using a Cox proportional hazards regression model.

RESULTS

We enrolled a total of 219 patients in this study. Patients with lymph node-negative gastric cancer who received neoadjuvant chemotherapy and underwent at least five cycles of adjuvant chemotherapy (AC ≥ 5) after surgery had a significantly higher 3-year overall survival rate of 86.8% compared with those who received fewer than five cycles (AC < 5) with a survival rate of 68.1% (P = 0.016). Multivariate analysis identified several factors, including AC ≥ 5 (HR 0.367, 95% CI 0.166-0.815, P = 0.014), ypT stage ≥ 2 (HR 2.779, 95% CI 1.199-6.438, P = 0.017), and poorly differentiated tumors (HR 2.501, 95% CI 1.385-4.517, P = 0.002), as independently associated with 3-year OS in this patient group. Stratified analysis further revealed that AC ≥ 5 significantly enhanced long-term outcomes in patients with ypT stage ≥2 (3-year OS, 82.5% vs. 62.6%, P = 0.025) and in those with poorly differentiated tumors (3-year OS, 82.6% vs. 53.3%, P = 0.021).

CONCLUSION

Patients who have lymph node-negative gastric cancer following neoadjuvant chemotherapy, with either ypT stage ≥ 2 or poorly differentiated gastric cancers, may experience benefits from undergoing at least five cycles of adjuvant chemotherapy.

Adjuvant chemotherapy for node-negative gastric adenocarcinoma after neoadjuvant chemotherapy and gastrectomy: A propensity score matched analysis study

INTRODUCTION

The long term survival of patients undergoing curative resection for gastric cancer remains poor owing to high recurrence rates. The use of adjuvant chemotherapy in node positive gastric cancer to prolong survival and prevent recurrence is widely accepted. However, the role for adjuvant chemotherapy in node negative gastric cancer is less clear, particularly in the era of neoadjuvant chemotherapy.

OBJECTIVE

To determine the association of adjuvant chemotherapy with survival in patients undergoing pathologically node negative gastric cancer resection, following neoadjuvant chemotherapy.

METHODS

We examined a national cancer database containing patients who had undergone neoadjuvant chemotherapy and pathologically node negative curative gastrectomy. We divided these patients into those who had undergone adjuvant chemotherapy versus those who had not. Using a propensity score matched analysis, we analyzed the survival of these patients between the 2 groups.

RESULTS

5309 patients who had undergone curative gastrectomy were identified from the database and 806 of these patients were given adjuvant chemotherapy. Following propensity score matched analysis, patients who had been given adjuvant chemotherapy had an increased median survival of 150 vs 125 months (5-year 68 % vs 62 %, p < 0.001).

CONCLUSION

There is a small, but statistically significant survival benefit for adjuvant chemotherapy in patients with node negative gastric cancer who had undergone neoadjuvant chemotherapy. Further studies are required to examine the role of adjuvant chemotherapy in this subset of patients.

Postoperative adjuvant chemotherapy in patients with gastric cancer based on the Nationwide Gastric Cancer Registry in Japan

The nationwide registry of the Japanese Gastric Cancer Association contains data related to the efficacy of adjuvant chemotherapy and prognostic factors across this patient population; elderly patients with advanced resectable gastric cancer are especially prevalent. Here, we analyzed data from 34,931 patients, who were treated between 2011 and 2013 at 421 hospitals in Japan. Although adjuvant chemotherapy was effective overall, 75 years or older elderly patients had a worse prognosis compared to younger patients. The most administered adjuvant chemotherapy was S-1 monotherapy. Adjuvant S-1 monotherapy was also effective for patients with pT1N2, pT1N3, and pT3N0 stage II tumors, as well as patients with other stage II and III malignancies. Independent prognostic factors for poor overall and relapse-free survival in patients at both stage II and stage III were age 75 or older, male, preoperative Eastern Cooperative Oncology Group performance status (ECOG-PS) 1 or more, preoperative renal dysfunction, undifferentiated adenocarcinoma, undergoing total gastrectomy, open laparotomy, no adjuvant chemotherapy, D1 lymphadenectomy, residual tumor R1 or R2, and Clavien-Dindo classification grade II or higher. Age 75 or older, renal dysfunction, ECOG-PS 1 and total gastrectomy were also significant risk factors for postoperative complications and lower compliance with adjuvant chemotherapy. Our analysis also revealed that adjuvant chemotherapy after resection of cancer of gastric remnant and postoperative chemotherapy against CY1 gastric cancer were also effective. We conclude that adjuvant chemotherapy is effective for all stage II and III patients including age 75 or older gastric cancer patients, in addition to distal gastrectomy, proximal gastrectomy, and pylorus-preserving surgery to avoid total gastrectomy may improve surgical outcomes and quality of life for elderly patients.

Chemotherapy Options for Locally Advanced Gastric Cancer: A Review

Cancers represent a significant global health burden, affecting millions of individuals each year [...].

Neoadjuvant chemotherapy combined with antiangiogenic therapy and immune checkpoint inhibitors for the treatment of locally advanced gastric cancer: a real - world retrospective cohort study

Background

Although immune checkpoint inhibitors (ICIs) and anti-angiogenic drugs have demonstrated effectiveness in treating advanced gastric cancer (GC), their role in neoadjuvant or conversion therapy remains uncertain. This study aimed to evaluate the efficacy and safety of combining neoadjuvant chemotherapy with anti-angiogenesis and ICIs in patients with locally advanced GC (LAGC).

Methods

In this cohort study, we reviewed our prospectively maintained GC database and included individuals diagnosed with clinical stage II-III GC who received neoadjuvant therapy followed by surgery between January 2022 and August 2023. The treatment protocol combined ICIs, anti-angiogenic therapy (specifically apatinib), and chemotherapy (S-1 with oxaliplatin). A systematic approach was used to document patients' clinical and pathological characteristics, pathological findings, and survival outcomes, which were subsequently analyzed in detail.

Results

A total of 38 individuals met the study's inclusion criteria, with the majority (32 patients, 84.2%) having clinical stage III GC. All participants underwent surgery, resulting in a notable R0 resection rate of 97.4%. The rates of major pathological response (MPR) and pathological complete response (pCR) were 47.4% and 23.7%, respectively. Post-surgery, 36 patients (92.1%) received adjuvant chemotherapy. With a median follow-up of 22 months, ten patients experienced disease recurrence, including three who died from tumor relapse. The 1-year overall survival (OS) rate stood at 100%, and the disease-free survival (DFS) rate was 94.7%, with median OS and DFS yet to be reached. The neoadjuvant therapy regimen was generally well-tolerated, with no grade 5 treatment-related adverse events (TRAEs) reported. Only one patient experienced a grade 4 TRAE (immune-related hepatitis), while the most common grade 3 TRAEs included thrombocytopenia, elevated aminotransferase levels, and neutropenia.

Conclusions

The combination of neoadjuvant chemotherapy, anti-angiogenic therapy, and ICIs has proven effective in treating LAGC patients, achieving high pCR rates and favorable survival outcomes while maintaining an acceptable safety profile.

Cross-Lagged Panel Network Analysis of Symptoms in Patients with Gastric Cancer Undergoing Postoperative Chemotherapy

OBJECTIVES

To develop temporal symptom networks at three postoperative chemotherapy time points and investigate the longitudinal relationships between 18 symptoms in patients with gastric cancer undergoing postoperative chemotherapy in China.

METHODS

Symptom prevalence and severity were measured using the M. D. Anderson Symptom Inventory (MDASI) and Gastrointestinal Cancer Module of the MDASI (MDASI-GI) at T1, T2, and T3 on the day after the first, third, and sixth chemotherapy sessions, respectively. Cross-lagged panel network (CLPN) models were employed to examine the temporal dynamics of the 18 symptoms and their interrelationships.

RESULTS

In total, 379 participants were included. Dry mouth had the highest out-prediction (r = 0.101) and out-strength (r = 0.863) values during T1→T2. The strongest direct effect was observed for the change in taste → lack of appetite (β = 0.38) during T2→T3. Feeling bloated had the highest values for out-strength (r = 0.910), out-prediction (r = 0.215), and bridge strength (r = 1.010) during the T2→T3 period. The two CLPNs showed medium to high stability based on the centrality stability coefficients of out-strength and in-strength.

CONCLUSIONS

Lack of appetite can be improved during chemotherapy by managing vomiting and taste changes. Attention should be paid to the dry mouth and feeling bloated, as they are the strongest predictors in the early and middle stages of treatment.

IMPLICATIONS FOR NURSING

Understanding the relationship between symptoms during chemotherapy in patients with postoperative gastric cancer can help clinicians identify targets for intervention at different times.

Resectable gastric cancer: should we apply a tailored surgical strategy according to microsatellite status?

BACKGROUND

High microsatellite instability (MSI) represents a small subgroup of gastric cancer (GC) with favorable prognostic and predictive significance. This study aimed to investigate locoregional lymph node (LN) involvement, overall survival (OS), disease-free survival (DFS), and the interplay between molecular subtypes and histologic profiles regarding survival outcomes in MSI GC vs microsatellite stability (MSS) GC.

METHODS

This study included 72 patients with GC who underwent surgery with or without chemotherapy from 2017 to 2023. Clinicopathologic characteristics, OS, and DFS were compared between LN-positive and LN-negative patients stratified by microsatellite status, treatments, molecular profiles, and tumor cell types.

RESULTS

MSI GC was more common in older patients (79.0 vs 70.2 years; P <.001), more common in females (73.68% vs 43.32%; P =.023), and associated with intestinal-type histology (94.5% vs 49.0%; P =.002). Positive LN involvement and lymphovascular invasion (LVI) were lower in the MSI group than in the MSS group (positive LN: 2.73 vs 4.15, respectively; P =.366; LVI: 36.8% vs 64.5%, respectively; P =.039). Patients with MSI showed slightly better OS and DFS than those with MSS (OS: 84.20% vs 66.00%, respectively; P =.108; DFS: 84.62% vs 63.89%, respectively; P =.120). In addition, compared with patients with MSS GC, those with MSI GC had improved OS and DFS in the LN-positive group (OS: 72.7% vs 61.3%, respectively; P =.255; DFS: 75.0% vs 50.0%, respectively; P =.148) and LN-negative group (OS: 100.0% vs 85.7%, respectively; P =.149; DFS: 100.0% vs 85.7%, respectively; P =.376). In patients not receiving chemotherapy, the MSI/intestinal-type group had the highest OS and DFS (77.0% and 87.5%, respectively; P =.024), whereas the MSS/mixed-type group had the lowest OS and DFS (25.0% and 100.0%, respectively; P =.290). In patients receiving chemotherapy, the MSI/intestinal-type group had the highest OS and DFS (100.0% and 100.0%, respectively; P =.741), whereas the MSS/mixed-type group had the lowest OS and DFS (66.7% and 50.0%, respectively; P =.397).

CONCLUSION

First, patients with MSI GC have a significantly lower risk of locoregional LN involvement and better OS and DFS than those with MSS GC. Second, treatment responses differ based on MSI status: patients with MSI tumors benefit more from upfront surgical interventions, whereas those with MSS, particularly mixed histotypes, demonstrate improved outcomes with preoperative chemotherapy. These results advocate for a tailored therapeutic approach that considers microsatellite status, Lauren classification, and patient clinical conditions.

Evolving Strategies in the Management of Microsatellite Instability-High/Mismatch Repair Deficient Esophagogastric Adenocarcinoma

PURPOSE OF REVIEW

This review addresses the current treatment paradigm and new advancements in the management of microsatellite instability-high/mismatch repair deficient (MSI-H/dMMR) esophagogastric cancer (EGC).

RECENT FINDINGS

While chemotherapy and surgery remain the cornerstone of EGC treatment, MSI-H/dMMR tumors harbor high tumor mutational burden and represent a subset of patients who benefit from immune checkpoint inhibitors (ICI). ICI has been incorporated in the front line setting with and without chemotherapy for advanced disease. Recently, ICI has been studied in the perioperative setting for resectable disease. Though perioperative ICI results in improved response rates, it is not yet clear whether this translates to a survival benefit. Despite high response rates with ICI in this patient population, many do not respond to therapy, representing a major challenge in treatment. Preclinical studies have highlighted potential mechanisms of resistance which will guide drug development and clinical trials.

Differences in efficacy of biweekly irinotecan plus cisplatin versus irinotecan alone in second-line treatment of advanced gastric cancer with or without prior gastrectomy

BACKGROUND

Biweekly irinotecan plus cisplatin combination therapy (BIRIP) and irinotecan monotherapy (IRI) are both expectable second-line chemotherapy (SLC) options for treating advanced gastric cancer (AGC). Although many patients receiving SLC have undergone gastrectomy, the impact of gastrectomy on SLC remains unclear, and the impact of gastrectomy may vary from regimen to regimen.

PATIENTS AND METHODS

A total of 290 eligible patients registered in two randomized phase III trials evaluating BIRIP (IRI, 60 mg/m2; CDDP, 30 mg/m2, q2w) or IRI (150 mg/m2, q2w) for patients with AGC was classified into the prior gastrectomy subgroup (PGG) or the no gastrectomy subgroup (NGG). We performed a subgroup analysis to evaluate the impact of gastrectomy on second-line BIRIP and IRI.

RESULTS

The BIRIP demonstrated significantly longer OS (11.1 vs. 6.8 months; HR 0.64; P = 0.026) and PFS (3.7 vs. 2.3 months; HR 0.54; P = 0.003) than the IRI, as well as better ORR (23.5% vs. 7.1%, P = 0.046) and DCR (74.5% vs. 47.6%, P = 0.010) in NGG. Although in PGG, the BIRIP failed to demonstrate differences in OS (13.8 vs. 13.8 months; HR 0.94; P = 0.722), PFS (4.9 vs. 4.5 months; HR 0.82; P = 0.194), ORR (18.3% vs. 20.5%) and DCR (70.4% vs. 65.1%). The incidence of grade 3 or worse adverse events did not differ except for a high incidence of anemia in the BIRIP group in PGG.

CONCLUSIONS

BIRIP was an effective treatment option that may improve survival outcomes among patients with AGC without previous gastrectomy.

CLINICAL TRIAL REGISTRATION

UMIN000025367.

Multimodality Treatment for Locally Advanced Gastric Adenocarcinoma

Gastric cancer is prevalent worldwide and is a leading cause of cancer-related death. Patients with GC often present at advanced stages at diagnosis. Patients with locally advanced diseases experience poor survival rates with surgery alone. Multimodality therapy, including peri-operative therapy and adjuvant therapy, has improved outcomes. However, there is no consensus on the optimal treatment approach. Molecular characteristics of GC may help guide treatment choices and studies are currently underway to evaluate other treatment modalities including immunotherapy and targeted therapy.

Lymphadenectomy for Gastric Cancer

Current treatment for gastric cancer includes a multidisciplinary approach of systemic therapy and surgery. While retrospective, prospective, and randomized trials have demonstrated conflicting results on the need for extended lymphadenectomy, current guidelines dictate a recommendation for the retrieval of at least 16 lymph nodes to accurately stage patients. The "D1" lymph nodes along the major gastric and epiploic vessels may provide adequate lymph node harvest, though "D2" lymphadenectomy along the celiac axis and its branches may be necessary. Performing a distal pancreatectomy and splenectomy to maximize the D2 nodal harvest is not necessary and leads to increased morbidity.

Evaluating survival outcomes and treatment recommendations in resectable gastric cancer

No consensus exists on the optimal therapy for resectable gastric cancer (GC) and gastroesophageal junction (GEJ) tumors, including the effectiveness of chemoradiotherapy versus perioperative chemotherapy (PC). Our study aimed to compare overall survival (OS) outcomes associated with the recommended treatment modalities for GC and GEJ tumors and evaluate treatment trends from 2010 to 2020. A national registry cohort identified patients with ≥ cT2 nonmetastatic GC and GEJ cancer. Treatment modalities were classified as neoadjuvant chemotherapy (NC), neoadjuvant chemoradiotherapy (NCR), PC, adjuvant chemotherapy (AC), and adjuvant chemoradiation (ACR). Kaplan-Meier curve and multivariable Cox regression models evaluated factors associated with OS. A cohort of 7665 patients were included. Patients who received PC had the highest OS (median 86.80 months, 95% CI 73.40-NE), while chemoradiotherapy in the neoadjuvant and adjuvant settings had worse OS than PC and NC (NCR median 47.15 months, 95% CI 44.58-52.27, and ACR median 52.67 months, 95%CI 42.78-63.93). The Cox proportional hazards model showed that NCR and NC had worse survival than PC (HR 1.74, 95% CI 1.50-2.02, p < 0.001 and HR 1.26, 95% CI 1.10-1.44, p = 0.0008, respectively). Additionally, the most utilized modality during 2020 was NC (35.8%), followed by PC (28.0%) and NCR (24.9%). The utilization of PC and NC had the most substantial rise between 2010 and 2020, increasing by 11.0%. The study demonstrates the association of PC with improved OS outcomes for nonmetastatic GC and GEJ tumors. Therapies combining radiation with chemotherapy and extended lymph node dissection correlated with a worse prognosis compared to PC and NC. Despite the association with improved outcomes, national data reveals low utilization rates for PC.

The impact of delayed adjuvant chemotherapy on survival in gastric cancer patients with and without preoperative chemotherapy

Aim

Adjuvant chemotherapy (AC) is the standard treatment for patients with advanced gastric cancer (GC), yet the optimal timing for its initiation remains unclear. Besides, no studies have definitively established when AC should begin in patients receiving preoperative chemotherapy (PC). This study aimed to determine the optimal timing for initiating AC in patients with GC who underwent curative gastrectomy, either with or without PC.

Methods

A total of 446 patients who underwent curative gastrectomy were evaluated, including 140 who received AC: 72 without PC and 68 with PC. Patients were categorized into two groups based on when they began AC: the early initiation group (within 8 weeks post‐surgery), and the late initiation group (8 weeks or later post‐surgery).

Results

In the non‐PC cohort, the 3‐year relapse‐free survival (RFS) rates were 71% in the early group versus 56% in the late group (p = 0.49), while the 3‐year overall survival (OS) rates were 94% versus 73% (p = 0.003). Similar trends were observed in the PC cohort; the 3‐year RFS rates were 59% versus 19% (p = 0.002), and the 3‐year OS rates were 69% versus 48% (p = 0.02). Multivariate analysis identified pretherapeutic distant metastasis (p < 0.001) and delayed AC initiation (≥8 weeks) (p = 0.001) as independent predictors of worse prognosis.

Conclusion

Delayed initiation of AC is associated with significantly poorer postoperative survival in patients with GC, irrespective of whether PC was administered. These findings emphasize the importance of timely AC initiation to improve long‐term outcomes in this patient population.

SIGLEC11 promotes M2 macrophage polarization through AKT-mTOR signaling and facilitates the progression of gastric cancer

BACKGROUND

Sialic acid-binding immunoglobulin-like lectins (SIGLECs) are widely expressed on immune cell surfaces, play an important role in maintaining immune homeostasis and regulating inflammatory responses, and are increasingly emerging as potential targets for tumor immunotherapy. However, the expression profile and crucial role of SIGLEC11 in gastric cancer (GC) remain unclear. This study aimed to elucidate the prognostic relevance of SIGLEC11 expression and its role in the immune microenvironment in patients with GC.

METHODS

SIGLEC11 expression profile was analyzed using bioinformatics, immunohistochemistry, and immunofluorescence staining. Flow cytometry, mouse tumor models, patient-derived tumor organoid models, and RNA sequencing were used to explore the potential functions with the underlying mechanisms of SIGLEC11 in a coculture system of macrophages and GC cells.

RESULTS

We demonstrated that SIGLEC11 was predominantly expressed in normal tissues. However, tumor-infiltrating SIGLEC11+ cells in the high SIGLEC11 expression subgroups showed poor overall survival, which was associated with the expression of an immunosuppressive regulator. Our results showed that SIGLEC11 was predominantly expressed in monocytes and macrophages and selectively upregulated in tumor-associated macrophages. Furthermore, SIGLEC11 promoted macrophage M2 polarization via AKT-mTOR signaling. In addition, SIGLEC11+ macrophages accelerate GC progression.

CONCLUSIONS

The abundance of SIGLEC11+ M2-like macrophage-infiltrating tumors may serve as a biomarker for identifying immunosuppressive subtypes of GC. Thus, the potential role of SIGLEC11+ M2 macrophages as therapeutic targets warrants further investigation.

A prognostic nomogram to predict the cancer-specific survival of patients with initially diagnosed metastatic gastric cancer: a validation study in a Chinese cohort

BACKGROUND

Few studies have been designed to predict the survival of Chinese patients initially diagnosed with metastatic gastric cancer (mGC). Therefore, the objective of this study was to construct and validate a new nomogram model to predict cancer-specific survival (CSS) in Chinese patients.

METHODS

We collected 328 patients with mGC from Northern Jiangsu People's Hospital as the training cohort and 60 patients from Xinyuan County People's Hospital as the external validation cohort. Multivariate Cox regression was used to identify risk factors, and a nomogram was created to predict CSS. The predictive performance of the nomogram was evaluated using the consistency index (C-index), the calibration curve, and the decision curve analysis (DCA) in the training cohort and the validation cohort.

RESULTS

Multivariate Cox regression identified differentiation grade (P < 0.001), T-stage (P < 0.05), N-stage (P < 0.001), surgery (P < 0.05), and chemotherapy (P < 0.001) as independent predictors of CSS. Nomogram of chemotherapy regimens and cycles was also designed by us for the prediction of mGC. Thus, these factors are integrated into the nomogram model: the C-index value was 0.72 (95% CI 0.70-0.85) for the nomogram model and 0.82 (95% CI 0.79-0.89) and 0.73 (95% CI 0.70-0.86) for the internal and external validation cohorts, respectively. Calibration curves and DCA also demonstrated adequate fit and ideal net benefit in prediction and clinical applications.

CONCLUSIONS

We established a practical nomogram to predict CSS in Chinese patients initially diagnosed with mGC. Nomograms can be used to individualize survival predictions and guide clinicians in making therapeutic decisions.

Effect of Minimally Invasive Gastrectomy on Return to Intended Oncologic Therapy for Gastric Cancer

BACKGROUND

Adjuvant chemotherapy offers survival benefit to patients with gastric cancer. Only 50-65% of patients who undergo neoadjuvant chemotherapy and gastrectomy are able to receive adjuvant therapy. It is optimal to start adjuvant therapy within 8 weeks after gastrectomy. We compared the rate of return to intended oncologic therapy (RIOT) between minimally invasive gastrectomy (MIG) and open gastrectomy (OG).

METHOD

Retrospectively, we analyzed patients who underwent gastrectomy within a multi-hospital university-based health system (2019-2022). Data on patient demographics, comorbid conditions, operative approach, and postoperative outcomes were assessed with univariate analysis and multivariable analysis (MVA) to determine the association with RIOT.

RESULTS

Among 87 eligible patients, 33 underwent MIG and 54 underwent OG. There were no differences in demographics, performance status, comorbid conditions, or type of gastrectomy between the two groups. MIG patients were significantly more likely to RIOT compared with OG patients (87.9% vs. 63%, p = 0.003), with 73.1% of MIG patients starting adjuvant therapy within 8 weeks compared with 53.1% of OG patients. Factors associated with higher odds of RIOT included MIG and age <65 years, while major postoperative complications (Clavien-Dindo grade ≥IIIa) was associated with lower odds of RIOT. On MVA, MIG was independently associated with higher odds of RIOT compared with OG (odds ratio 6.05, 95% confidence interval 1.47-24.78, p = 0.008).

CONCLUSION

The minimally invasive approach may benefit patients undergoing gastrectomy, irrespective of the extent of gastric resection for adenocarcinoma. MIG is associated with a higher likelihood of (1) RIOT and (2) starting adjuvant therapy within the optimal time period after gastrectomy.

Advantages of adjuvant chemotherapy using S-1 following minimally invasive gastrectomy for gastric cancer versus open surgery: a propensity score-matched analysis

BACKGROUND

It is essential to ensure optimal adherence to adjuvant chemotherapy regimens following gastric cancer surgery. However, treatment intensity for S-1 as adjuvant chemotherapy has not as yet been compared between minimally invasive (MI) and open (Open) surgery.

METHODS

We retrospectively compared dose modification of adjuvant S-1 between MI and Open surgery in patients undergoing R0 gastrectomy for gastric or esophago-gastric junction cancer at the Cancer Institute Hospital Tokyo, Japan, during the period from 2012 to 2022, and receiving S-1 for pStage II or S-1 plus docetaxel for pStage III as adjuvant chemotherapy. Propensity score matching (PSM) was conducted to adjust for possible confounders.

RESULTS

In total, 323 patients were initially included. After PSM, 158 patients remained, 79 in each group. The adjuvant chemotherapy completion rates were similar in the two groups. However, the proportion of patients who required S-1 dose reduction was significantly lower in the MI than in the Open group (43.0% vs. 65.8%, p = 0.004). In addition, the MI group had significantly fewer patients requiring suspension of S-1 than the Open group (46.8% vs. 64.6%, p = 0.025). Moreover, the frequency of adverse events of grade ≥ 3 was significantly lower in the MI than in the Open group (17.7% vs. 31.7%, p = 0.042).

CONCLUSIONS

In adjuvant chemotherapy for gastric cancer, minimally invasive surgery may offer better treatment intensity for oral S-1 administration than open surgery.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.