Prognostic factors after curative resection for gastric cancer. A population-based study

Separating lymph node stations by the surgeon from the gastric cancer specimen improves the quality of nodal status evaluation

BACKGROUND

In gastric cancer (GC), the pN-stage is an important prognostic factor influencing treatment. Along with the depth of invasion of the tumor, the presence of nodal metastases is one of the most important prognostic factors guiding treatment strategies in gastric cancer. Examining a small number of lymph nodes may lead to understaging of the disease; hence, it is essential for the nodal status to be precisely assessed. In this study, we explored whether dissecting lymph node stations into separate samples by the surgeon from the gastric cancer surgical specimen affects the quality of nodal status evaluation and patient outcome.

METHODS

The clinical data of 130 GC patients treated at the Helsinki University Hospital between 2016 and 2019 was reviewed. The performed operations included 59 total and 71 subtotal gastrectomies. The processing of the surgical specimen before the pathological examination was assessed from the operation records and pathology reports. The association of the number of examined lymph nodes with other variables was assessed, and multivariate survival analysis was performed to explore the independent prognostic factors in disease-specific survival.

RESULTS

Dissecting lymph node stations into separate specimens before pathological evaluation yielded a significantly greater number of examined lymph nodes compared with a specimen without intervention (median 34.5 vs 21.0, p < 0.001). The pT-stage, the pN-stage, and the extent of lymphadenectomy were identified as independent prognostic factors, whereas dissecting the specimen's lymph node stations did not associate with survival.

CONCLUSIONS

Dissecting lymph node stations into separate specimens results in a greater number of examined lymph nodes, which has the potential to lead to a more reliable pN-stage assessment.

Role of New Anatomy, Biliopancreatic Reflux, and Helicobacter Pylori Status in Postgastrectomy Stump Cancer

Distal gastrectomy for benign gastroduodenal peptic disease has become rare, but it still represents a widely adopted procedure for advanced and, in some countries, even for early distal gastric cancer. Survival rates following surgery for gastric malignancy are constantly improving, hence the residual mucosa of the gastric stump is exposed for a prolonged period to biliopancreatic reflux and, possibly, to Helicobacter pylori (HP) infection. Biliopancreatic reflux and HP infection are considered responsible for gastritis and metachronous carcinoma in the gastric stump after oncologic surgery. For gastrectomy patients, in addition to eradication treatment for cases that are already HP positive, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the residual mucosa of any metaplastic-atrophic-dysplastic features following surgery.

Circular RNA PTK2 Accelerates Cell Proliferation and Inhibits Cell Apoptosis in Gastric Carcinoma via miR-139-3p

BACKGROUND

Gastric carcinoma (GC) is one of the most common malignant tumors. Although increasing studies have indicated that circular RNAs function as ideal biomarkers for multiple cancers, only a few researches elucidated the correlation between circular RNA PTK2 (circPTK2) and human cancers.

AIM

To further explore the expression status, biological function, and regulatory mechanism of circPTK2 in GC.

METHODS

Bioinformatics analysis and function or mechanism experiments including RT-qPCR, flow cytometry, Western blot, luciferase reporter assay, and xenografts assays were applied to investigate the function of circPTK2 and miR-139-3p.

RESULTS

High expression of circPTK2 was presented in GC tissues and cells. The circPTK2 knockdown notably suppressed cell proliferation and promoted cell apoptosis in GC. In mechanism, circPTK2 served as a sponge of miR-139-3p. Inhibition of miR-139-3p could reverse circPTK2 silence-mediated effects on GC cell proliferation and apoptosis. Furthermore, the xenograft tumor model was established to investigate the role of circPTK2 in GC tumor growth. Experimental results delineated that the reduction in tumor growth in response to circPTK2 knockdown was partly recovered by miR-139-3p inhibitor.

CONCLUSIONS

CircPTK2 promotes GC development by sponging miR-139-3p, which may function as an effective gene target for managing GC.

A qualitative classification signature for post-surgery 5-fluorouracil-based adjuvant chemoradiotherapy in gastric cancer

BACKGROUND AND PURPOSE

Currently, 5-fluorouracil (5-FU)-based adjuvant chemoradiotherapy (ACRT) is a preferred regimen for post-surgery gastric cancer (GC). However, the survival outcome of 5-FU-based ACRT varies greatly among different GC patients. Thus, it is necessary to classify which patients may benefit from 5-FU-based ACRT.

MATERIALS AND METHODS

We collected 577 GC and 84 adjacent normal samples for training and 675 GC samples for validation. Based on the within-sample relative expression orderings (REOs) of gene expression levels, reversal gene pairs were selected, and the pairs correlating with overall survival (OS) of GC patients receiving 5-FU-based ACRT were identified as candidates. Finally, an optimized set of candidate gene pairs was selected as a classification signature in training data and validated in validation data.

RESULTS

A signature consisting of 34 gene pairs was identified in training data and validated in three independent datasets. The classified low-risk group had better OS than the classified high-risk group. We also analyzed the recurrent free survival or disease free survival (RFS/DFS) of the validation datasets, and the similar results were shown. Furthermore, although the signature was identified based on the OS of GC patients receiving ACRT, it was not a prognostic signature for patients treated with surgery alone, but may be a potential signature for 5-FU-based chemotherapy alone.

CONCLUSIONS

The signature can accurately classify GC patients who may benefit from 5-FU-based ACRT, which could aid clinicians in tailoring more effective GC treatments.

Prognostic impact of Borrmann classification on advanced gastric cancer: a retrospective cohort from a single institution in western China

Background

Due to the controversy over the prognostic significance of Borrmann type in patients with gastric cancer (GC), the present study was to investigate the clinical value of Borrmann type in advanced GC.

Methods

We retrospectively evaluated 2092 patients with advanced GC and subsequently examined the clinicopathological characteristics and prognosis of patients stratified by Borrmann type.

Results

Patients were divided into three groups according to Borrmann type (Borrmann types I+II, III, and IV). Patients with Borrmann types III and IV had larger size, more poorly differentiated tumor type, more advanced tumor stage, and higher chance of involving the entire stomach. The overall survival (OS) rates were significantly different among the three groups (p < 0.001). Stratification analysis revealed significant OS rates among the three groups in tumor-node-metastasis (TNM) stage III (p < 0.001) and TNM stage IV (p = 0.008). Multivariate analysis revealed that Borrmann types, adjuvant chemotherapy, curative resection, and TNM stage were all independent predictors of OS among GC patients. The subgroup analysis indicated that Borrmann type was an independent predictor of OS among GC patients who undergone curative resection and with TNM stage III cancer. However, curative resection and postoperative chemotherapy failed to prolong the survival of patients with Borrmann type IV.

Conclusions

The clinicopathological characteristics and prognosis of patients with three Borrmann types of GC were different. Borrmann type can be simply used as a valuable factor to predict survival in advanced GC patients, especially in those TNM stage III undergoing curative resection. Additionally, more attention should be paid to the treatment for Borrmann type IV GC.

Older versus younger adults with gastric cancer receiving perioperative treatment: Results from the CRITICS trial

AIM

To evaluate treatment-related toxicity, treatment compliance, surgical complications and event-free survival (EFS) in older (≥70 years) versus younger (<70 years) adults who underwent perioperative treatment for gastric cancer.

METHODS

In the CRITICS trial, 788 patients with resectable gastric cancer were randomised before start of any treatment and received preoperative chemotherapy (3 cycles of epirubicin, cisplatin or oxaliplatin and capecitabine), followed by surgery, followed by either postoperative chemotherapy or chemoradiotherapy (45Gy + cisplatin + capecitabine).

RESULTS

172 (22%) patients were older adults. During preoperative chemotherapy, 131 (77%) older adults versus 380 (62%) younger adults experienced severe toxicity (p < 0.001); older adults received significantly lower relative dose intensities (RDIs) for all chemotherapeutic drugs. Equal proportions of older versus younger adults underwent curative surgery: 137 (80%) versus 499 (81%), with comparable postoperative complications and postoperative mortality. Postoperative therapy after curative surgery started in 87 (64%) older adults versus 391 (78%) younger adults (p < 0.001). Incidence of severe toxicity during postoperative chemotherapy was 22 (54%) in older adults versus 113 (59%) in younger adults (p = 0.541); older adults received significantly lower RDIs for all chemotherapeutic drugs. Severe toxicity rates for postoperative chemoradiotherapy were 22 (48%) older adults versus 89 (45%) for younger adults (p = 0.703), with comparable chemotherapy RDIs and radiotherapy dose. Two-year EFS was 53% for older adults versus 51% for younger adults.

CONCLUSION

Perioperative treatment compliance, especially in the postoperative phase, was poorer in older adults compared with younger adults. As comparable proportions of patients underwent curative surgery, future studies should focus on neo-adjuvant treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00407186. EudraCT number: 2006-00413032.

Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience

Aim

Gastric cancer is one of the most common cancers worldwide. In Turkey, stomach cancer is ranked 5th among men and 8th among women in all cancers and is located in the forefront in cancer-related deaths. Signet ring cell adenocarcinoma, which is the histopathological subtype of gastric cancer, has a poor prognosis. The incidence of signet ring cell adenocarcinoma is rising. In the present study, we aimed to describe the clinicopathologic features of signet ring cell adenocarcinoma.

Materials and Methods

A total of 79 patients with 30 being female (38%) and 49 male (62%) who were diagnosed with gastric signet ring cell adenocarcinoma in the Medical Oncology Department of Ankara Numune Training and Research Hospital between January 2004 and October 2015 were retrospectively evaluated.

Results

The baseline demographic characteristics of the patients, such as tumor localization, tumor stage, preoperative serum tumor markers, and treatment type (surgery and chemotherapy regimen), and the effects of these variables on survival and mortality were evaluated. Total surgery, stage III disease, moderate to poor grade, preoperative serum CA 19-9 and CEA levels were found as independent predictors of progression risk (p < 0.05). Each 1 ng/mL increase in preoperative serum CEA level was found to increase the risk of progression by 1.20 folds. Again, each 1 U/mL in preoperative serum CA 19-9 level was found to increase the risk of progression and mortality by 1.06 folds.

Conclusion

The clinicopathologic features of signet ring cell stomach cancer were described. Tumor localization and disease, CA 19-9 and CEA levels, and treatment type (surgery and chemotherapy regimen) were effective on survival and mortality. However, further studies with larger patient groups are needed on this issue.

How to cite this article

Altay SB, Akkurt G, Yılmaz N, et al. Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience. Euroasian J Hepato-Gastroenterol 2020;10(2):76–84.

Clinicopathological risk factors for gastric cancer: a retrospective cohort study in China

OBJECTIVE

To examine the potential clinicopathological factors affecting the prognosis of patients with gastric cancer after surgical treatment in China.

METHODS

Between 1 January 2001 and 31 December 2012, a total of 716 patients aged 22-84 years with gastric cancer were enrolled in the study. Survival analysis techniques including log rank test and Cox proportional hazard regression model were applied to evaluate the prognostic significance of clinicopathological characteristics in terms of survival time.

RESULTS

Of the 24 demographic and pathological variables collected in the data, 16 prognostic factors of gastric cancer were found to have statistically significant influences on survival time from the unadjusted analyses. The adjusted analysis furtherly revealed that age, age square, lymph node metastasis rate group, tumour size group, surgical type II, number of cancer nodules, invasion depth group and the interaction between surgical type II and tumour size group were important prognosis and clinicopathological factors for gastric cancer in Chinese.

CONCLUSION

Our study with relatively large sample size and many potential risk factors enable us to identify independent risk factors associated with the prognosis of gastric cancer. Findings from the current study can be used to assist clinical decision-making, and serve as a benchmark for the planning of future prognosis and therapy for patients with gastric carcinoma.

Prevalence of HER2 Expression and Its Correlation with Clinicopathological Parameters in Gastric or Gastroesophageal Junction Adenocarcinoma in North-East Indian Population

Objective: Human epidermal growth factor receptor 2 (erbb2/HER2) overexpression, has now been implicated in advanced gastric and gastroesophageal junction cancers. The study was conducted to determine the rate of HER2 positivity in patients with locally advanced or metastatic gastric and gastroesophageal adenocarcinoma in North-East India and to assess the impact of various demographic and clinical parameters on HER2 positivity. Methods: A total of 68 patients of age >18 years of gastric and gastroesophageal adenocarcinoma diagnosed on histopathological examination from September 2016 to February 2018 at Dr B Borooah Cancer Institute, Assam were enrolled for the observational (epidemiological) study. All patients were subjected to the HER2 immunohistochemistry test using a FDA-approved, standardized test kit. HER2 expression was correlated with various demographic and clinicopathological parameters. Results: The overall rate of HER2 positivity in the population studied was 56% (n=38). The rate was non-significantly higher in male, older age group (>60 years) and Hindu population. Similarly, HER2 positivity rate was higher in patients with well differentiated histology and was more common in patients with stage II and III diseases, but neither of the associations is statistically significant. HER2 positivity rate was significantly higher in proximal and in GEJ tumours (56% versus 44%, P=0.002). Conclusion: HER2 overexpression was evident in 56% of the North-East Indian patients with locally advanced and metastatic gastric and gastroesophageal adenocarcinoma. The overexpression correlated significantly with primary tumour site. Routine testing of gastric and gastroesophageal tumours for HER2 expression is recommended to provide a therapeutic advantage in Indian patients.

Re-emerging role of macroscopic appearance in treatment strategy for gastric cancer

Pathological outcomes are definitely the most important prognostic factors in gastric cancer, but they can be obtained only after surgical resection. Use of preoperative adjuvant chemotherapy is becoming widespread for aggressive human cancer, so clinical factors such as macroscopic features are important as they are highly predictive for patient prognosis. In gastric cancer, the macroscopic type represents a distinct prognosis; Type 0 represents early gastric cancer with excellent prognosis, but, among advanced tumors, giant Type III and Type IV tumors have a dismal prognosis. Japan Clinical Oncology Group (JCOG) Stomach Cancer Study Group adopted macroscopic features as high-risk entities in clinical trials. It makes sense for risk classification to use macroscopic phenotypes because The Cancer Genome Atlas (TCGA) Network has lately subcategorized different histologies associated with specific macroscopic types by the molecular features of the whole genome. Dismal prognosis of Type IV gastric cancer is notorious, but similar prognosis was seen in giant Type III gastric cancer defined as 8 cm or beyond, both of which are unique for their propensity of peritoneal dissemination. In this review, clinical relevance including prognosis of such macroscopic high-risk features will be separately debated in the context of precision medicine and updated prognostic outcomes will be presented under the present standard therapy of curative surgery followed by postoperative S-1 chemotherapy. Moreover, promising emerging novel therapeutic strategies including trimodal potent regimens or intraperitoneal chemotherapy will be described for such aggressive gastric cancer.

CRITICS-II: a multicentre randomised phase II trial of neo-adjuvant chemotherapy followed by surgery versus neo-adjuvant chemotherapy and subsequent chemoradiotherapy followed by surgery versus neo-adjuvant chemoradiotherapy followed by surgery in resectable gastric cancer

Background

Although radical surgery remains the cornerstone of cure in resectable gastric cancer, survival remains poor. Current evidence-based (neo)adjuvant strategies have shown to improve outcome, including perioperative chemotherapy, postoperative chemoradiotherapy and postoperative chemotherapy. However, these regimens suffer from poor patient compliance, particularly in the postoperative phase of treatment. The CRITICS-II trial aims to optimize preoperative treatment by comparing three treatment regimens: (1) chemotherapy, (2) chemotherapy followed by chemoradiotherapy and (3) chemoradiotherapy.

Methods

In this multicentre phase II non-comparative study, patients with clinical stage IB-IIIC (TNM 8th edition) resectable gastric adenocarcinoma are randomised between: (1) 4 cycles of docetaxel+oxaliplatin+capecitabine (DOC), (2) 2 cycles of DOC followed by chemoradiotherapy (45Gy in combination with weekly paclitaxel and carboplatin) or (3) chemoradiotherapy. Primary endpoint is event-free survival, 1 year after randomisation (events are local and/or regional recurrence or progression, distant recurrence, or death from any cause). Secondary endpoints include: toxicity, surgical outcomes, percentage radical (R0) resections, pathological tumour response, disease recurrence, overall survival, and health related quality of life. Exploratory endpoints include translational studies on predictive and prognostic biomarkers.

Discussion

The aim of this study is to select the most promising among three preoperative treatment arms in patients with resectable gastric adenocarcinoma. This treatment regimen will subsequently be compared with the standard therapy in a phase III trial.

Trial registration

clinicaltrials.gov NCT02931890; registered 13 October 2016. Date of first enrolment: 21 December 2017.

Borrmann Type 1 Cancer is Associated with a High Recurrence Rate in Locally Advanced Gastric Cancer

BACKGROUND

This study aimed to investigate the clinicopathologic characteristics and outcomes of Borrmann type 1 gastric cancer and evaluate its clinical significance in advanced gastric cancer compared with Borrmann types 2 and 3 cancer.

METHODS

Between January 1989 and December 2013, 1949 patients with advanced gastric cancer who underwent curative gastrectomy at our institution were enrolled in the study.

RESULTS

Of the 1949 patients, 59 (3%) exhibited Borrmann type 1 cancer, characterized by a large size, rare serosal invasion, lower lymph node involvement, location in the upper third of the stomach, intestinal type, and differentiated histology. The recurrence rate was higher for Borrmann type 1 than for Borrmann types 2 and 3 cancer. In addition, more than half of the Borrmann type 1 recurrences showed a hematogenous pattern. However, overall survival did not differ significantly among the three cancer types. In the multivariate analysis, Borrmann type 1 cancer, with tumor depth, node metastasis, and vascular invasion, was an independent risk factor associated with recurrence. Particularly, Borrmann type 1 cancer showed a worse prognosis in both overall survival and recurrence-free survival than the other Borrmann types in the upper third of the stomach.

CONCLUSIONS

Borrmann type 1 gastric cancer is associated with a higher recurrence rate than Borrmann types 2 and 3, but not with a difference in the overall survival rate.

A Modified Prognostic Score for Patients with Curatively Resected Gastric Cancer

Aims and background

Gastric cancer is the second leading cause of cancer death worldwide; the risk of dying depends on several patient and disease characteristics. An existing prognostic score predicts survival in gastric cancer patients undergoing curative resection based on patient age, tumor site, extent of wall invasion and nodal status, categorized as simply as negative or positive.

Methods

Our aim was to modify the original prognostic score by incorporating information on nodal stage according to the latest TNM classification (number of involved nodes), based on a retrospective series of 610 chemotherapy-naïve gastric cancer patients recruited to a surgical clinical trial. We then tested the modified score on an independent series of 136 gastric cancer patients.

Results

Nodal stage added significant prognostic information to the nodal status classification (P <0.001), and was therefore included in the modified score. With the latter, we were able to identify three risk groups with overall five-year survival varying from more than 70% to less than 30%. The prognostic performance of the modified score was better than that achieved with the AJCC-UICC TNM staging.

Conclusions

The modified score, based on established prognostic factors, is proposed as a simple tool for prognostic grouping of gastric cancer patients undergoing curative surgery.

Lauren Histology and Lymphatic Permeation are Critical Prognostic Factors in Borrmann Type I Gastric Cancer

Macroscopic Borrmann type I is relatively rare in advanced gastric cancer, and its detailed prognostic traits are unknown. Among 5172 gastric cancer patients between 1971 and 2013, 114 cases with macroscopic Borrmann type I were identified (2.2%), among which 112 displayed clinicopathologic factors. Univariate prognostic factors with statistical significance were initially selected, which were further applied to the multivariate proportional hazards model. Recently, postoperative adjuvant chemotherapy was recommended for stage II/III gastric cancer patients. Results were as follows: (1) Five-year overall survival (OS) was 66% in Borrmann type I gastric cancer. Five-year relapse-free survival (RFS) was 100%, 87.1%, and 65.5% in stage IA, stage IB, and stage II/III, respectively. (2) Multivariate proportional hazard model for OS identified lymphatic permeation [hazard ratio (HR) = 4.8–7.5, P = 0.0021] and age (HR = 2.4, P = 0.026), while the multivariate analysis for RFS identified histology (HR = 3.5, P = 0.018) and lymphatic permeation (HR = 3.5–4.7, P = 0.049) as independent prognostic factors. (3) Recurrence was recognized more in liver of the intestinal type histology. Diffuse type histology with robust lymphatic invasion was all attributed to stage II/III, which occurred largely within 1 year and exhibited 49% RFS. Recurrence pattern of Borrmann Type I gastric cancer with intestinal type histology is unique, and patients with high risk for recurrences were enriched in diffuse type histology with robust lymphatic invasion.

Circulating microRNA-196a is an early gastric cancer biomarker

MicroRNA-196a (miRNA-196a) is associated with the development of gastric cancer and metastasis. Intestinal metaplasia and low- or high-grade dysplasia are considered to be precursors of intestinal type gastric cancer. Accordingly, we investigated the expression of plasma miRNA-196a as an early detection biomarker in precancerous gastric lesions and early cancer (pT1a/b), which is otherwise treated with endoscopic submucosal dissection. Our data showed that levels of circulating (plasma) miRNA-196a were higher in patients with precancerous lesions/early gastric adenocarcinoma than in healthy controls. The area under the receiver operating characteristic curve (AUC) for healthy controls vs. intestinal metaplasia was 0.9736; healthy controls vs. low-grade/high-grade dysplasia 0.9495; and healthy controls vs. early gastric cancer 0.9318. These results indicate that circulating miRNA-196a is a novel biomarker for detection of early gastric cancer and its precursor.

Gastroblastoma, a biphasic neoplasm of stomach: A case report

•

Gastroblastoma is a rare gastric biphasic tumor with both epithelial and mesenchymal components.

•

To the best of our knowledge only eight cases have been reported in the English literature till date.

•

Surgical excision remains the mainstay of treatment.

Introduction

Gastroblastoma is a rare gastric biphasic tumor with both epithelial and mesenchymal components. To the best of our knowledge only eight cases have been reported in the English literature till date.

Presentation of case

We report a case of a 29-year-old female, hospitalized for epigastric pain with poor general condition. An upper gastrointestinal endoscopy showed a polypoid mass in the stomach near the gastric cardia suspicious of gastrointestinal stromal tumor. The patient underwent atypical proximal gastrectomy with splenectomy. Detailed histopathological examination of the resected specimen revealed the diagnosis of gastroblastoma. After six months, the patient developed loco-regional recurrence for which surgical debulking was performed.

Discussion

Gastroblastoma is predominantly seen in young adults with non-specific complaints. They appear as submucosal lesion in the stomach mimicking gastrointestinal stromal tumor. Preoperative diagnosis is often difficult. Surgical resection remains the mainstay of treatment. On histology, they consist of mesenchymal component which stain positively for vimentin and CD10 and epithelial component which is positive for cytokeratin on immunohistochemistry.

Conclusion

Gastroblastoma is a malignant tumor with risk of local recurrence after curative resection.

Serine-arginine protein kinase 1 (SRPK1) is elevated in gastric cancer and plays oncogenic functions

Serine-arginine protein kinase 1 (SRPK1) phosphorylates proteins involved in the regulation of several mRNA processing pathways including alternative splicing. SRPK1 has been reported to be over-expressed in multiple cancers including prostate, breast, lung and glioma. Several studies further identified that inhibition of SRPK1 showed tumor-suppressive effects, thus raising SRPK1 as a novel candidate chemotherapy target. Interestingly, SRPK1 plays tumor suppressing role in mouse embryonic fibroblasts, on that SRPK1-silencing induces cell transformation. Therefore, the effect of SRPK1 seems heterogeneously in different cell types and tissues. The existence and role of SRPK1 in gastric cancer (GC) hasn't been reported. Here we investigated the expression pattern of SRPK1 in GC by immunohistochemistry and found that it was up-regulated in tumor tissues, where its expression was correlated with tumor grade and prognosis. Further, we explored the signaling mechanism of SRPK1 in promoting GC progression, which revealed that both PP2A and DUSP6 phosphatases impaired the oncogenic effects of SRPK1. However, we didn't find any direct interaction between SRPK1 with PP2A or DUSP6, indicating PP2A and DUSP6 function by regulating the downstream effectors of SRPK1. Our study not only revealed the clinical significance of SRPK1 in GC, but also provided new evidence for its signaling modulation which is invaluable for novel chemotherapy development.

Upregulation of circulating cytokeratin 20, urokinase plasminogen activator and C-reactive protein is associated with poor prognosis in gastric cancer

Gastric cancer is one of the most common types of cancer, with a high mortality rate. The aim of this study was to investigate the role of several key molecules, including cytokeratin (CK) 19 and CK20, urokinase plasminogen activator (uPA), C-reactive protein (CRP) and matrix metalloproteinase (MMP)-9, which are involved in cancer invasion and metastasis, in order to determine whether they may be considered as novel prognostic factors for gastric cancer. Peripheral blood was collected from 165 patients with gastric adenocarcinoma who underwent curative surgical resection at Zhejiang Cancer Hospital (Hangzhou, China) between 2010 and 2011. The mRNA levels of CK19, CK20, uPA and MMP-9 were detected by reverse transcription-quantitative polymerase chain reaction. The protein expression of CRP was measured by immunoturbidimetry. The Students t-test was used in the univariate analyses and the Kaplan-Meier method was used to analyze the survival curves. The relative mRNA expression of CK19 and MMP-9 was not found to be significantly associated with gender, age or cancer stage, whereas that of CK20 and uPA was associated with gastric cancer stage: The low-expression group was associated with early-stage and the high-expression group with more advanced-stage disease (P<0.05). The CRP protein level was associated with gender and cancer stage: The low-expression group was predominantly associated with male gender and early-stage disease, whereas the high-expression group was associated with female gender and advanced-stage disease (P<0.05). The expression of CK19, CK20, uPA and CRP, but not MMP-9, was negatively associated with overall survival (OS): The OS rate in the high-expression groups was significantly lower compared with that in the low-expression groups (P<0.05). In conclusion, the upregulation of CK20, uPA and CRP was found to be a negative prognostic factor for gastric cancer.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Decreased expression of Bauhinia purpurea lectin is a predictor of gastric cancer recurrence

PURPOSE

Molecular markers as indicators for gastric cancer recurrence are urgently required. The aim of this study was to identify lectins that can be used to predict gastric cancer recurrence after gastrectomy.

METHODS

We created lectin expression profiles by microarray analysis for 60 patients, who underwent surgery for gastric cancer at the Oita University Hospital between January, 2005 and December, 2007. Lectin expression and clinicopathological factors in patients who suffered gastric cancer recurrence and those who did not were compared by univariate and multivariate analyses.

RESULTS

Thirteen lectins showed a significant increase in binding to cancer tissues, whereas 11 lectins showed a significant decrease in binding to cancer tissues, when compared with binding to normal epithelia. Multivariate analysis revealed that lymph node metastasis and low Bauhinia purpurea lectin (BPL)-binding signals were independent predictive factors for recurrence. All patients with low BPL expression had significantly worse relapse-free survival than those with high BPL expression.

CONCLUSIONS

Our results using a novel lectin microarray system provide the first solid evidence that BPL expression is a predictor of gastric cancer recurrence.

The distance of proximal resection margin dose not significantly influence on the prognosis of gastric cancer patients after curative resection

Purpose

It is well known that the curative resection with an adequate proximal margin length is the most effective treatment in gastric cancer. However, despite surgeon's effort to achieve a sufficient proximal margin length, it is often difficult to obtain a recommended proximal margin length in some cases. Therefore, this study was planned to investigate the impact of the length of proximal margin on prognosis of overall survival.

Methods

Between June 1992 and December 2010, 1,888 gastric cancer patients who underwent gastrectomy with curative intent were reviewed. According to tumor's location (total vs. subtotal gastrectomy), pathologic T staging, and differentiation, univariate and multivariate analyses were performed to evaluate the impact of the discrepancies of proximal margin length on overall survival. Also, the impact of the discrepancies of proximal margin length on local recurrence was assessed.

Results

The 5-year survival rate of positive proximal margin group was 5.9%. In negative proximal margin groups, multivariate analysis showed that the discrepancies of proximal margin length have no impact on overall survival. Kaplan-Meier analyses showed that there is no association between discrepancy of proximal margin length and local recurrence.

Conclusion

It takes effort to secure a negative proximal margin in the surgical treatment of gastric cancer because of the poor prognosis of positive proximal margin. In negative proximal margin patients, there's no need to achieve an additional proximal margin length for long-term survival benefit because there was no impact of proximal margin length on overall survival and local recurrence.

Gastric cancer arising from the remnant stomach after distal gastrectomy: A review

Gastric stump carcinoma was initially reported by Balfore in 1922, and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology, carcinogenesis, Helicobacter pylori (H. pylori) infection, Epstein-Barr virus infection, clinicopathologic characteristics and endoscopic treatment. In particular, it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition, endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast, many issues concerning gastric stump carcinoma remain to be clarified, including molecular biological characteristics and the carcinogenesis of H. pylori infection. We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.

Surgical treatment of gastric cancer in a community hospital in Brazil: who are we treating and how?

PURPOSE

Surgical treatment of gastric cancer has risks, and the current trend in developed countries is to centralize cases in high-volume centers. Many countries, however, particularly the developing ones, have to rely in low-volume centers for the most part of gastric cancer operations. We aimed to verify the characteristics of the patients and tumors as well as the in-hospital outcomes in a community hospital in Brazil treating gastric cancer.

METHODS

This is a retrospective study on patients undergoing surgical treatment of gastric adenocarcinoma at a community hospital in Brazil. The authors reviewed demographic, clinical, pathological, and perioperative data.

RESULTS

A total of 28 patients were operated on during the study period. Mean age was 69.5 years, 53.6% were male, 67.9% had anemia, 78.5% had ASA score ≥ 3, 89.3% were at nutritional risk, intestinal/diffuse ratio was 1.6, 68.5% had tumor ≥ 6 cm, involvement of lower/middle third of the stomach occurred in 96.4%, 73.7% had serosal invasion, 79% had stage III disease, median number of dissected nodes was 23, median operative time was 255 min, 21.4% had urgent procedures, 67.8% had curative surgery, 50% had distal gastrectomy, 43.5% had a Billroth I, median length of stay was 17 days, 53.6% had some admission to the intensive care unit, 21.4% required relaparotomy, 25% had wound infection/dehiscence, and mortality was 66.7/18.2% (urgent/non-urgent surgery).

CONCLUSION

We treat elderly malnourished patients with multiple comorbidities and advanced cancer. Improvement is required in lymph node dissection, non-surgical therapies, and critical care.

The high-sensitivity modified Glasgow prognostic score is superior to the modified Glasgow prognostic score as a prognostic predictor in patients with resectable gastric cancer

AIM

The aim of the present study was to evaluate the superiority of the high-sensitivity modified Glasgow prognostic score (HS-mGPS) before surgery in patients with gastric cancer.

PATIENTS AND METHODS

The participants of this retrospective study comprised 552 patients with gastric cancer who underwent gastrectomy at the Fukuoka University Hospital. The HS-mGPS was calculated before surgery based on cutoff values of 0.3 mg/dl for C-reactive protein and 3.5 g/dl for albumin, and correlations between the HS-mGPS and the clinicopathological parameters and prognosis were evaluated. In addition, the superiority of the HS-mGPS to the mGPS as a prognostic indicator was examined in detail.

RESULTS

The mGPS was 0 in 494 patients, 1 in 24 patients and 2 in 34 patients. In contrast, the HS-mGPS was 0 in 411 patients, 1 in 75 patients and 2 in 66 patients. Both the mGPS (p < 0.0001) and HS-mGPS (p < 0.0001) were good prognostic predictors in gastric cancer patients who underwent gastrectomy. Of the 494 patients with an mGPS of 0 before surgery, 51 and 32 exhibited an HS-mGPS of 1 and 2, respectively. The patients who exhibited migration in the HS-mGPS demonstrated a significantly more unfavorable prognosis than the patients with an HS-mGPS of 0 (p < 0.0001). The prognostic impact of the HS-mGPS was especially clear in stage I and IV patients (p = 0.0027, p = 0.017). The HS-mGPS was found to be a superior prognostic predictor compared to the mGPS in a multivariate analysis (p = 0.0002).

CONCLUSIONS

The HS-mGPS before surgery is a superior prognostic predictor in patients with gastric cancer.

Clinical significance of lymph node metastasis in gastric cancer

Gastric cancer, one of the most common malignancies in the world, frequently reveals lymph node, peritoneum, and liver metastases. Most of gastric cancer patients present with lymph node metastasis when they were initially diagnosed or underwent surgical resection, which results in poor prognosis. Both the depth of tumor invasion and lymph node involvement are considered as the most important prognostic predictors of gastric cancer. Although extended lymphadenectomy was not considered a survival benefit procedure and was reported to be associated with high mortality and morbidity in two randomized controlled European trials, it showed significant superiority in terms of lower locoregional recurrence and disease related deaths compared to limited lymphadenectomy in a 15-year follow-up study. Almost all clinical investigators have reached a consensus that the predictive efficiency of the number of metastatic lymph nodes is far better than the extent of lymph node metastasis for the prognosis of gastric cancer worldwide, but other nodal metastatic classifications of gastric cancer have been proposed as alternatives to the number of metastatic lymph nodes for improving the predictive efficiency for patient prognosis. It is still controversial over whether the ratio between metastatic and examined lymph nodes is superior to the number of metastatic lymph nodes in prognostic evaluation of gastric cancer. Besides, the negative lymph node count has been increasingly recognized to be an important factor significantly associated with prognosis of gastric cancer.

Prognostic significance of overexpression of EZH2 and H3k27me3 proteins in gastric cancer

The enhancer of zeste homolog 2 (EZH2) methyl transferase and histone 3 lysine 27 (H3K27me3) protein can repress gene transcription, and their aberrant expression has been observed in various human cancers. This study determined their expression levels in gastric cancer tissues with reference to clinicopathological features and patient survival. We collected 117 gastric cancer and corresponding normal tissues for immunohistochemistry analysis. In gastric cancers, 82/117 (70.1%) were positive for EZH2 and 66/117 (56.4%) for H3K27me3 proteins in contrast to only 5.41% and 7.25% of normal gastric mucosa specimens, respectively. Kaplan-Meier survival data showed the average overall and disease-free survival of EZH2 high expression patients was 25.2 and 20.2 months, respectively, shorter than that with EZH2 low expression (40.5 and 35.9 months). The average overall survival and disease-free survival of high H3K27me3 expression patients was 23.4 and 17.4 months, shorter than without H3K27me3 expression (37.6 and 34.5 months). The average overall survival and disease-free survival of patients with both EZH2 and H3K27me3 expression was 18.8 and 12.9 months, respectively, shorter than that with either alone (34.7 and 31.2 months) or with low levels of both (43.9 and 39.9 months). Multivariate Cox regression analysis showed that H3K27me3 and EZH2 expression, tumor size differentiation and clinical stage were all independent prognostic factors for predicting patient survival. This study demonstrated that detection of both EZH2 and H3K27me3 proteins can predict poor survival of gastric cancer patients, superior to single protein detection. In addition, H3K27me3 and EZH2 protein expression could predict lymph node metastasis.

Adjuvant chemotherapy for elderly patients with gastric cancer after D2 gastrectomy

BACKGROUND

A phase III clinical trial has already shown the survival benefits of postoperative chemotherapy in gastric cancer. However, there are limited published data concerning the elderly. This study aims to investigate the use of adjuvant chemotherapy for gastric cancer after D2 gastrectomy among the elderly and identify its impact on survival.

METHODS

We retrospectively reviewed 360 patients who had undergone D2 gastrectomy, aged 65 years or older, with non-metastatic gastric cancer in a single institution. We analyzed the predictors and survival benefits of adjuvant chemotherapy use in the elderly. Further, we analyzed the survival benefits of adjuvant chemotherapy by dividing the patients into groups according to disease stages and chemotherapeutic regimens.

RESULTS

Among the 360 patients, only 34.7% of patients received adjuvant chemotherapy. Age, tumor location, lymph node involvement and tumor invasion were associated with the receipt of adjuvant chemotherapy. Adjuvant chemotherapy improved the overall survival for non-metastatic elderly patients (HR 0.60, 95%CI 0.42-0.83, P = 0.003). Significant survival benefits were found with adjuvant chemotherapy in stage III patients (HR 0.67, 95%CI 0.47-0.97, P = 0.033), but not in stage I patients or in stage II patients (HR 0.52, 95%CI 0.21-1.30 P = 0.161). Compared to adjuvant chemotherapy without platinum, no significant survival benefits were observed with platinum-containing chemotherapy (HR 0.84, 95%CI 0.49-1.45, P = 0.530). Besides adjuvant chemotherapy, other independent prognostic factors of survival included tumor location, tumor size, histologic grade, depth of tumor invasion, and lymph node status.

CONCLUSIONS

This study demonstrated the survival benefits of adjuvant fluoropyrimidine-based chemotherapy among the elderly patients with non-metastatic gastric cancer after D2 gastrectomy. However, due to the limitations of this study, further well-designed prospective studies with large populations are needed to confirm these findings and identify the patients that can tolerate and benefit from adjuvant chemotherapy.

Retinoid receptors in gastric cancer: expression and influence on prognosis

BACKGROUND

Gastric cancer is frequently lethal despite aggressive multimodal therapies, and new treatment approaches are therefore needed. Retinoids are potential candidate drugs: they prevent cell differentiation, proliferation and malignant transformation in gastric cancer cell lines. They interact with nuclear retinoid receptors (the retinoic acid receptors [RARs] and retinoid X receptors [RXRs]), which function as transcription factors, each with three subclasses, α, β and γ. At present, little is known about retinoid expression and influence on prognosis in gastric cancers.

PATIENTS AND METHODS

We retrospectively analyzed the expression of the subtypes RARα, RARβ, RARγ, RXRα, RXRβ, RXRγ by immunohistochemistry in 147 gastric cancers and 51 normal gastric epithelium tissues for whom clinical follow-up data were available and correlated the results with clinical characteristics. In addition, we quantified the expression of retinoid receptor mRNA using real- time PCR (RT-PCR) in another 6 gastric adenocarcinoma and 3 normal gastric tissues. From 2008 to 2010, 80 patients with gastric cancers were enrolled onto therapy with all-trans-retinoic acid (ATRA).

RESULTS

RARα, RARβ, RARγ and RXRγ positively correlated with each other (p<0.001) and demonstrated significantly lower levels in the carcinoma tissue sections (p<0.01), with lower RARβ, RARγ and RXRα expression significantly related to advanced stages (p<=0.01). Tumors with poor histopathologic grade had lower levels of RARα and RARβ in different histological types of gastric carcinoma (p<0.01). Patients whose tumors exhibited low levels of RARa expression had significantly lower overall survival compared with patients who had higher expression levels of this receptor (p<0.001, HR=0.42, 95.0% CI 0.24-0.73), and patients undergoing ATRA treatment had significantly longer median survival times (p=0.007, HR=0.41, 95.0% CI 0.21-0.80).

CONCLUSIONS

Retinoic acid receptors are frequently expressed in epithelial gastric cancer with a decreased tendency of expression and RARa may be an indicator of a positive prognosis. This study provides a molecular basis for the therapeutic use of retinoids against gastric cancer.

Clinicopathologic characteristics and outcomes of surgery of middle-third gastric cancer

Many issues of middle-third gastric cancer need to be address for obtaining preferably clinical treatment. The objective of this retrospective study was to analyze clinicopathologic characteristics and results of surgery for 113 middle-third gastric cancer patients admitted to our hospital. Retrospective cohort analyses of clinicopathologic data and postoperative prognosis of 113 middle-third gastric cancer patients who underwent curative resection between January 1997 and December 2003 were reviewed. Compared with lower-third gastric cancer patients, middle-third gastric cancer patients had significantly lower 5-year survival rate (P < 0.001) and higher recurrence rate (P < 0.001). With the Cox proportional hazards model analysis, the types of gastrectomy (hazard ratio (HR) = 0.495, P = 0.012) and ratio between metastatic and dissected lymph nodes (RML) (HR = 1.681, P < 0.001) were identified as the independent predictors of overall survival (OS) of middle-third gastric cancer patients. Besides, only RML (HR = 3.026, P < 0.001) was an independent predictor of recurrence for middle-third gastric cancer patients after surgery identified using the logistic regression analysis. The prognosis of middle-third gastric cancer was significantly worse than lower-third gastric cancer. RML was a key indicator for OS and recurrence of middle-third gastric cancer.

Computed tomography-guided permanent brachytherapy for locoregional recurrent gastric cancer

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of response and prognosis by a score including only pretherapeutic parameters in 410 neoadjuvant treated gastric cancer patients

BACKGROUND

Response to neoadjuvant chemotherapy is an independent prognostic factor in locally advanced gastric cancer. However, no prospectively tested pretherapeutic parameters predicting response and/or survival in gastric cancer are available in clinical routine.

METHODS

We evaluated the prognostic significance of various clinical pathologic parameters in 410 patients who were treated with neoadjuvant chemotherapy followed by gastrectomy. Clinical and histopathologic response evaluation was performed by using standardized criteria. A prognostic score was created on the basis of the variables identified in the multivariate analysis.

RESULTS

Three pretherapeutic parameters were identified as positive predictive factors for response and prognosis: tumor localization in the middle third of the stomach (P=0.001), well-differentiated tumors (P=0.001), and intestinal tumor type according to Laurén classification (P=0.03). A prognostic index was constructed, dividing the patients into three risk groups: low (n=73), intermediate (n=274), and high (n=63). The three groups had significantly different clinical (P=0.007) and histopathologic response rates (P=0.001) and survival times, with a median survival time that was not reached in the low-risk group, 39.2 months in the intermediate-risk group, and 20.5 months in the high-risk group. The corresponding 5-year survival rates were 65.3, 41.2, and 21.2% (P<0.001), respectively.

CONCLUSIONS

A simple scoring system based on three clinicopathologic parameters accurately predicts response and prognosis in neoadjuvant treated gastric cancer. This system provides additional useful information that could be applied to select gastric cancer patients pretherapeutically for different treatment approaches. Prospective testing of the score in an independent patient cohort is warranted.

Comparison of the clinicopathological characteristics of young and elderly patients with gastric carcinoma: a meta analysis

To evaluate the relationship between age and clinicopathological characteristics in gastric carcinoma patients, we performed the meta-analysis based on nine retrospective clinical trials. Comparing elderly patients with young patients it showed lower male/female ratio, more diffuse GC, more Borrmann type IV, more poorly differentiated carcinoma, more peritoneal metastasis, less vascular invasion, fewer partial resections, and better 5-year survival rate. These particular age-related characteristics need to be further investigated.

Characterization of gastric cancer models from different cell lines orthotopically constructed using improved implantation techniques

AIM: To develop orthotopic gastric cancer mouse models from different cell lines and characterize the tumor features to assist further in preclinical trials and clinical treatment strategies.

METHODS: Human gastric cancer SGC-7901 and BGC-823 cell suspensions were injected subcutaneously into nude mice to develop solid tumors, and tumor tissue pieces were then implanted under the serous coat of the stomach. An autopsy was performed on all animals of the SGC-7901 and BGC-823 models to observe the primary tumor growth and metastases using pathological and immunohistochemical methods.

RESULTS: Both models showed large tumors in situ resulting in pressure and infiltration of the adjacent organs. The gastric cavity became smaller, along with stenosis of the cardia or pylorus. There were biological and statistical differences between the two models. The metastasis rate in involved organs (lymph nodes, kidney, spleen, testis) was significantly higher in the BGC-823 model compared to the SGC-7901 model (P < 0.05 or P < 0.01). The median survival of the BGC-823 model was shorter than that of SGC-7901 (23 d vs 84 d, P < 0.05). Histopathologically, the primary tumor and metastatic lesions of the two models showed obvious atypia and mucus in the cytoplasm. Compared with the SGC-7901 model, BGC-823 appeared more poorly differentiated (absence of adenoid structure), had a smaller volume, and richer capillary structure. Immunohistochemical staining revealed cytokeratin 20 and epithelial membrane antigen expression was positive in the SGC-7901 tumors, while negative in BGC-823 ones.

CONCLUSION: Models using the SGC-7901 and BGC-823 cell lines were established which could function in gastric cancer research on carcinogenesis mechanism and drug discovery. The two models showed different tumor behavior and the latter was more malignant than the former.

Prediction of response and prognosis by a score including only pretherapeutic parameters in 410 neoadjuvant treated gastric cancer patients

INTRODUCTION

Response to neoadjuvant chemotherapy (NAC) is an independent prognostic factor in locally advanced gastric cancer. However, no prospectively tested pretherapeutic parameters predicting response and/or survival in gastric cancer are available in clinical routine.

PATIENTS AND METHODS

We evaluated the prognostic significance of various clinicopathologic parameters in 410 patients who were treated with NAC followed by gastrectomy. Clinical and histopathological response evaluation was performed using standardized criteria. A prognostic score was created on the basis of the variables identified in the multivariate analysis.

RESULTS

Multivariate analysis identified three pretherapeutic parameters as positive predictive factors for response and prognosis: tumor localization in the middle third of the stomach (p = 0.001), well differentiated tumors (p = 0.001) and intestinal tumor type according to Laurén's classification (p = 0.03). From the obtained data a prognostic index was constructed, dividing the patients into three risk groups: low (n = 73), intermediate (n = 274), and poor (n = 63). The three groups had significantly different clinical (p = 0.007) and histopathological response rates (p = 0.001) and survival times, with a median survival time that was not reached in the low-risk group, 39.2 months in the intermediate-risk group and 20.5 months in the poor-risk group. The corresponding 5-year survival rates were 65.3, 41.2, and 21.2 % (p < 0.001), respectively.

CONCLUSION

A simple scoring system based on three clinicopathologic parameters, accurately predicts response and prognosis in neoadjuvant treated gastric cancer. This system provides additional useful information that could be applied to select gastric cancer patients pretherapeutically for different treatment approaches. Prospective testing of the score in an independent patient cohort is warranted.

Clinicopathological features and outcomes of young patients with hepatocellular carcinoma after hepatectomy

BACKGROUND

There are few reports about hepatectomy for young patients with hepatocellular carcinoma (HCC), and the significance of resection for young patients remains unknown. The present study aimed to investigate retrospectively the clinicopathological features and outcomes after hepatectomy of young HCC patients.

METHODS

Among 610 patients who underwent curative hepatectomy for HCC between January 1987 and December 2007, 13 patients younger than 40 years of age were defined as the young group. Because none of the young group had hepatitis C virus antibodies (HCVAb), 246 patients aged above 40 years without HCVAb were defined as the older group. The clinicopathological findings and outcomes after hepatectomy were compared between the two groups.

RESULTS

In the young group, 7 patients had hepatitis B surface antigen and 3 other patients had hepatitis B core antibodies. The young group had better liver function but more advanced HCC, with a large tumor size and a high incidence of portal vein invasion compared with the older group. Major hepatectomy was more frequently chosen in the young group than in the older group. There was no significant difference in the incidences of postoperative complications. The overall survival tended to be better in the young group than in the older group (p=0.057).

CONCLUSIONS

Hepatitis B virus-related HCC was common in the younger group of patients reported here. Although the young patients had advanced HCC, there were no significant differences in the complication rate and the overall survival rate of the young and older groups. Aggressive hepatic resection for young patients would contribute to improved survival and should be recommended.

Survival trends in gastric cancer patients of Northeast China

AIM: To describe survival trends in patients in Northeast China diagnosed as gastric cancer.

METHODS: A review of all inpatient and outpatient records of gastric cancer patients was conducted in the First Affiliated Hospital of China Medical University. All the gastric cancer patients who satisfied the inclusion criteria from January 1, 1980 through December 31, 2003 were included in the study. The main outcomes were based on median survival and 3-year and 5-year survival rates, by decade of diagnosis.

RESULTS: From 1980 through 2003, the median survival for patients with gastric cancer (n = 1604) increased from 33 mo to 49 mo. The decade of diagnosis was not significantly associated with patient survival for gastric cancer (P = 0.084 for overall survival, and P = 0.150 for 5-year survival); however, the survival rate of the 2000s was remarkably higher than that of the 1980s (P = 0.019 for overall survival, and P = 0.027 for 5-year survival).

CONCLUSION: There was no significant difference of survival among each period; however, the survival rate of the 2000s was remarkably higher than that of the 1980s.

Prognostic factors and survival in stomach cancer - analysis of 15 years of data from a referral hospital in iran and evaluation of international variation

BACKGROUND

Stomach cancer is the most common cancer among Iranian men. We studied survival rates and prognostic factors of stomach cancer in a referral hospital in Tehran, Iran.

PATIENTS AND METHODS

We followed 367 stomach cancer patients hospitalized between 1991 and 2007 in the Baqyiatallah Hospital. We estimated survival rates overall and among operable patients exclusively. Hazard ratios (HR) for the different prognostic factors were estimated with the Cox regression model. Furthermore, we studied international variations in stage distribution and 5 year survival for stomach cancer.

RESULTS

Overall, 5 year survival of stomach cancer was low (14%), and the majority of patients (53%) were diagnosed at stage IV. Stage, tumor size, age, and gender were statistically significant prognostic factors. Relative risk of mortality in stage IV compared to stage IA was 9.9 (95% confidence interval 5.8-16.9). The highest 5 year survival was reported from Japan, particularly among screening detected patients (89.4%). Among operable patients, 5 year survival was 32.6% in France, 26% in the USA, and 30.5% in China, which was close to the rates estimated in our study (24%).

CONCLUSIONS

Due to stomach cancer being frequently diagnosed in advanced stages, its prognosis is poor in Iran. Early diagnosis and downstaging strategies need to be prioritized to improve the prognosis of stomach cancer.

Meta-analysis on the relationship between nonsteroidal anti-inflammatory drug use and gastric cancer

Although nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, show chemopreventive effects on several types of cancer, their role in the development of gastric cancer remains controversial. The objective of this study is to assess the quantitative association between NSAIDs and gastric cancer by meta-analysis using both crude data and adjusted data. A search of Medline, Embase, Web of science, and citations from relevant articles was conducted for eligible articles published up to March 2009. A meta-analysis was developed. Pooled risk ratio and odds ratio with 95% confidence intervals were calculated, based on both crude and adjusted data from the selected studies and using random or fixed effects models based on heterogeneity analysis. Overall, 21 individual epidemiological studies (13 case-control studies with 29 560 participants and 8 cohort studies with 2 199 227 participants) were examined. The summary crude and adjusted risk ratios were 0.89 (0.83-0.97) and 0.81 (0.73-0.89) when the case-control and cohort studies were pooled, respectively. Significant protective effects of NSAIDs against gastric cancer appeared in all subgroups (study design, type of drug, site of cancer, and sample source), but only the site of cancer and sample source can substantially influence the estimate of effect. The chemopreventive effect of NSAIDs in gastric cancer was stronger based on the adjusted data than that based on crude data. Therefore, we conclude that NSAID use is associated with a decrease in the development of gastric cancer. The associations were more obvious after we adjusted for several risk factors that are known to contribute to the development of gastric cancer.

Trends in incidence, management, and survival of gastric and cardia carcinomas in the area of Finistere (France) between 1984 and 2003

OBJECTIVE

The aim of this study was to evaluate trends in incidence and prognosis of gastric and cardia carcinomas in the area of Finistère (France) between 1984 and 2003.

METHODS

The Digestive Tumor Registry of Finistère recorded all new cases of gastric and cardia carcinomas from January 1, 1984 to December 31, 2003. Raw incidence data were standardized using the direct method based on the reference world population. The data and survival rates were studied in univariate and multivariate analyses.

RESULTS

Between 1984-1988 and 1999-2003 the standardized incidence of distal gastric carcinomas decreased (10.74 ± 0.39-5.68 ± 0.27/year/100 000 inhabitants, P < 0.001). There was no significant increase in the incidence of cardia carcinomas (0.83 ± 0.11-1.25 ± 0.14/year/100 000 inhabitants). The frequency of macroscopically infiltrating tumors doubled (P < 0.001) and linitis plastica increased from 9 to 16.2% (P < 0.001). Overall survival rates increased only for patients with metastatic carcinomas of both locations (P < 0.001) and with advanced tumors of distal stomach (P < 0.001) receiving therapy.

CONCLUSION

This study showed a significant decrease over time in the incidence of distal gastric carcinomas but no significant increase in the incidence of cardia carcinomas. Despite improvement in the management of patients, prognosis remains dismal, probably because of an increased incidence of poor prognosis of histological and anatomical types.

Evaluation of dose coverage to target volume and normal tissue sparing in the adjuvant radiotherapy of gastric cancers: 3D-CRT compared with dynamic IMRT

Purpose:

To assess the potential advantage of intensity-modulated radiotherapy (IMRT) over 3D-conformal radiotherapy (3D-CRT) planning in postoperative adjuvant radiotherapy for patients with gastric carcinoma.

Methods and materials:

In a retrospective study, for plan comparison, dose distribution was recalculated in 15 patients treated with 3D-CRT on the contoured structures of same CT images using an IMRT technique. 3D-conformal plans with three fields and four-fields were compared with seven-field dynamic IMRT plans. The different plans were compared by analyzing the dose coverage of planning target volume using TV₉₅, D_mean, uniformity index, conformity index and homogeneity index parameters. To assess critical organ sparing, D_mean, D_max, dose to one-third and two-third volumes of the OARs and percentage of volumes receiving more than their tolerance doses were compared.

Results:

The average dose coverage values of PTV with 3F-CRT and 4F-CRT plans were comparable, where as IMRT plans achieved better target coverage(p<0.001) with higher conformity index value of 0.81±0.07 compared to both the 3D-CRT plans. The doses to the liver and bowel reduced significantly (p<0.001) with IMRT plans compared to other 3D-CRT plans. For all OARs the percentage of volumes receiving more than their tolerance doses were reduced with the IMRT plans.

Conclusion:

This study showed that a better target coverage and significant dose reduction to OARs could be achieved with the IMRT plans. The IMRT can be preferred with caution for organ motion. The authors are currently studying organ motion in the upper abdomen to use IMRT for patient treatment.

Effect of age on surgical outcomes of extended gastrectomy with D2 lymph node dissection in gastric carcinoma: prospective cohort study

BACKGROUND AND PURPOSE

As a life expectancy increases, the proportion of aged patients diagnosed with gastric cancer has increased over the past decades, but the optimal surgical approach to these patients remains a dilemma because of the presumed risk associated with extended surgery.

METHODS

A total of 383 consecutive patients who underwent gastrectomy with D2 lymph node dissection in 2008 and 2009 were enrolled onto this study. Patients were divided into two age groups (<70 vs. > or =70 years) and were prospectively evaluated with respect to postoperative complications and hospital courses.

RESULTS

The cohort consisted of 101 elderly and 282 nonelderly patients. No statistically significant differences were evident between the two groups with respect to clinicopathological parameters and operations performed, except for preoperative comorbidity rates and mean American Society of Anesthesiologists scores. Surgical complication rates in the elderly and nonelderly groups were 18.8 and 17.4%, respectively (P = 0.746), and medical complication rates were 5.0 and 1.8%, respectively (P = 0.137). The two groups were not statistically significantly different in terms of mean length of hospital stays, times to diet start, or required transfusion. Multivariate analysis showed that body mass index, male sex, and distal pancreatectomy were independent risk factors of a surgical complication, and that comorbidity and operating time were independently associated with a medical complication.

CONCLUSIONS

This study shows that age neither increased postoperative morbidity nor negatively affected hospital courses after gastrectomy with D2 lymph node dissection. Accordingly, chronologic age alone should not preclude standard gastrectomy with extended lymph node dissection in gastric carcinoma.

Radiologist performance in differentiating polypoid early from advanced gastric cancer using specific CT criteria: emphasis on dimpling sign

OBJECTIVE

The purpose of this study was to retrospectively determine whether there are specific CT features that can be used to differentiate polypoid early from advanced gastric cancer and to assess the performance of radiologists using specific CT findings for differentiation.

MATERIALS AND METHODS

A review of medical records yielded the cases of 46 patients, 27 with polypoid early gastric cancer and 19 with polypoid advanced gastric cancer, whose CT scans were available for review. Two radiologists retrospectively reviewed the CT images for the presence and depth of dimpling at the tumor base, the presence of vessel invagination at the dimpling site, thickening of the low-attenuating outer layer, perigastric infiltration, and transmural full-thickness enhancement of the lesion. Individual CT findings relevant as predictors were determined with univariate and multivariate analyses. Individual review of CT scans subsequently was performed by two other radiologists, who were blinded to tumor stage but aware of the results of univariate and multivariate analyses. Individual performance was evaluated with receiver operating characteristic analysis.

RESULTS

The presence of severe dimpling greater than 3.5 mm at the base of the tumor (odds ratio, 31.3) had the highest odds ratio for differentiating early from advanced gastric cancer, followed by vessel invagination (odds ratio, 12.3), the presence of dimpling (odds ratio, 9.8), perigastric infiltration (odds ratio, 5.2), and transmural full-thickness enhancement (odds ratio, 4.8). Multivariate analysis showed that the presence of dimpling greater than 3.5 mm was the only independent variable that differentiated polypoid advanced gastric cancer from polypoid early gastric cancer (p = 0.001). Subsequent differentiation of advanced from early gastric cancer with the described CT findings was very good, yielding areas under the receiver operating characteristic analysis curves of 0.827 and 0.811 for the two observers.

CONCLUSION

Greater than 3.5 mm dimpling and other ancillary CT findings are helpful in differentiating polypoid advanced gastric cancer from polypoid early gastric cancer and contribute to good individual accuracy for differentiation.

Enhancement the prediction of postoperative survival in gastric cancer by combining the negative lymph node count with ratio between positive and examined lymph nodes

BACKGROUND

The purpose of this study was to evaluate the impact of the negative lymph node (NLN) count on the prognostic prediction of the ratio between positive and examined lymph nodes (RML) in gastric cancer after curative resection.

METHODS

The positive and negative node counts were determined for 456 patients who underwent curative resection for gastric cancer. Overall survival was examined according to clinicopathologic variables. The correlation between the NLN count and the aforementioned best variable for prediction the disease-specific overall survival was examined.

RESULTS

The NLN count cutoffs were designed as 0-9, 10-14, and > or =15, with the 5-year survival rate 4.1, 30.7, and 74.8%, respectively. RML of 98 patients who had an NLN count of nine or fewer was > or =40%. The median survival of these patients was 12 months. Of 88 patients who had 10 to 14 NLN count, 7 had 74-month median survival with 0.1-10% RML, 52 had 47-month median survival with 10.1-40% RML, and 29 had 22-month median survival with >40% RML. Of 270 patients who had > or =15 NLN count, 157 had 114-month median survival without positive nodes, 62 had 98-month median survival with 0.1-10% RML, 45 had 40-month median survival with 10.1-40% RML, and 6 had 14-month median survival with >40% RML.

CONCLUSIONS

The NLN count is a key factor for improvement of survival prediction of RML in gastric cancer.

Incidence and survival of stomach cancer in a high-risk population of Chile

AIM: To study the incidence and survival rate of stomach cancer (SC) and its associated factors in a high risk population in Chile.

METHODS: The population-based cancer registry of Valdivia, included in the International Agency for Research on Cancer system, covers 356 396 residents of Valdivia Province, Southern Chile. We studied all SC cases entered in this Registry during 1998-2002 (529 cases). Population data came from the Chilean census (2002). Standardized incidence rates per 100 000 inhabitants (SIR) using the world population, cumulative risk of developing cancer before age 75, and rate ratios by sex, age, ethnicity and social factors were estimated. Relative survival (Ederer II method) and age-standardized estimates (Brenner method) were calculated. Specific survival rates (Kaplan-Meier) were measured at 3 and 5 years and survival curves were analyzed with the Logrank and Breslow tests. Survival was studied in relation to demographics, clinical presentation, laboratory results and medical management of the cases. Those variables significantly associated with survival were later included in a Cox multivariate model.

RESULTS: Between 1998 and 2002, 529 primary gastric cancers occurred in Valdivia (crude incidence rate 29.2 per 100 000 inhabitants). Most cases were male (69.0%), residents of urban areas (57.5%) and Hispanic (83.2%), with a low education level (84.5% < 8 school years). SC SIR was higher in men than women (40.8 and 14.8 respectively, P < 0.001), risk factors were low education RR 4.4 (95% CI: 2.9-6.8) and 1.6, (95% CI: 1.1-2.1) for women and men respectively and Mapuche ethnicity only significant for women (RR 2.2, 95% CI: 1.2-3.7). Of all cases, 76.4% were histologically confirmed, 11.5% had a death certificate only (DCO), 56.1% were TNM stage IV; 445 cases (84.1%) were eligible for survival analysis, all completed five years follow-up; 42 remained alive, 392 died of SC and 11 died from other causes. Specific 5-year survival, excluding cases with DCO, was 10.6% (95% CI: 7.7-13.5); 5-year relative survival rate was 12.3% (95% CI: 9.1-16.1), men 10.9% (95% CI: 7.4-15.2) and women 16.1% (95% CI: 9.5-24.5). Five-year specific survival was higher for patients aged < 55 years (17.3%), with intestinal type of cancer (14.6%), without metastasis (22.2%), tumor size < 4 cm (60.0%), without lymphatic invasion (77.1%), only involvement of the mucous membrane (100%). Statistically significant independent prognostic factors were: TNM staging, diffuse type, metastasis, supraclavicular adenopathy, palpable tumor, and hepatitis or ascites.

CONCLUSION: Social determinants are the main risk factors for SC, but not for survival. An advanced clinical stage at consultation is the main cause of poor SC survival.