Nomogram-based prediction of survival in patients with advanced oesophagogastric adenocarcinoma receiving first-line chemotherapy: a multicenter prospective study in the era of trastuzumab

Is there a preferred platinum and fluoropyrimidine regimen for advanced HER2-negative esophagogastric adenocarcinoma? Insights from 1293 patients in AGAMENON-SEOM registry

BACKGROUND

The optimal chemotherapy backbone for HER2-negative advanced esophagogastric cancer, either in combination with targeted therapies or as a comparator in clinical trials, is uncertain. The subtle yet crucial differences in platinum-based regimens' safety and synergy with combination treatments need consideration.

METHODS

We analyzed cases from the AGAMENON-SEOM Spanish registry of HER2-negative advanced esophagogastric adenocarcinoma treated with platinum and fluoropyrimidine from 2008 to 2021. This study focused exclusively on patients receiving one of the four regimens: FOLFOX (5-FU and oxaliplatin), CAPOX (capecitabine and oxaliplatin), CP (capecitabine and cisplatin) and FP (5-FU and cisplatin). The aim was to determine the most effective and tolerable platinum and fluoropyrimidine-based chemotherapy regimen and to identify any prognostic factors.

RESULTS

Among 1293 patients, 36% received either FOLFOX (n = 468) or CAPOX (n = 466), 20% CP (n = 252), and 8% FP (n = 107). FOLFOX significantly increased PFS (progression free survival) compared to CP, with a hazard ratio of 0.73 (95% CI 0.58-0.92, p = 0.009). The duration of treatment was similar across all groups. Survival outcomes among regimens were similar, but analysis revealed worse ECOG-PS (Eastern Cooperative Oncology Group-Performance Status), > 2 metastatic sites, bone metastases, hypoalbuminemia, higher NLR (neutrophil-to-lymphocyte ratio), and CP regimen as predictors of poor PFS. Fatigue was common in all treatments, with the highest incidence in FOLFOX (77%), followed by FP (72%), CAPOX (68%), and CP (60%). Other notable toxicities included neuropathy (FOLFOX 69%, CAPOX 62%), neutropenia (FOLFOX 52%, FP 55%), hand-foot syndrome in CP (46%), and thromboembolic events (FP 12%, CP 11%).

CONCLUSIONS

FOLFOX shown better PFS than CP. Adverse effects varied: neuropathy was more common with oxaliplatin, while thromboembolism was more frequent with cisplatin.

Efficacy and safety of chemotherapy in young patients with advanced gastroesophageal adenocarcinoma: data from the Spanish AGAMENON-SEOM registry

BACKGROUND

Gastroesophageal adenocarcinoma in young adults (GCYA) counts for 10-15% of diagnoses. Previous studies have mainly focused on surgical outcomes in patients with resectable tumors; however, systemic therapy for advanced GCYA remains under-evaluated. This study aims to assess the efficacy-related outcomes and safety of first-line chemotherapy (CT) in younger versus older patients with advanced gastroesophageal adenocarcinoma.

METHODS

Patients with advanced gastroesophageal adenocarcinoma from the AGAMENON-SEOM registry treated with first-line polychemotherapy between January 2008 and October 2022 were included. We compared clinicopathological features, therapies received, efficacy-related outcomes, and toxicity between individuals aged < and ≥ 45 years.

RESULTS

Out of 3386 patients, 263 (7.8%) were < 45 years. Young patients exhibited a higher proportion of females affected, lower ECOG-PS ≥ 2, fewer comorbidities, and more aggressive disease-related features, such as higher proportion of diffuse subtype, signet-ring cells, plastic linitis, grade 3, peritoneal metastases and metastatic disease at diagnosis. They received more triple-agent combinations and underwent more surgeries in metastatic setting. No significant differences were observed between groups in overall response rate (53.1% vs. 52.3% in < and ≥ 45 years, respectively, p = 0.579), progression-free survival (6.1 vs. 6.83 months, p = 0.158) and overall survival (11.07 vs. 10.81 months, p = 0.82), even after adjusting for potential confounding factors. Grade 3-4 adverse events were comparable in both groups, although toxicity leading to treatment discontinuation was more frequent in older patients.

CONCLUSIONS

In the AGAMENON-SEOM registry, younger patients with GCYA exhibited more aggressive clinicopathological features, and despite receiving more aggressive treatments, similar efficacy outcomes and toxicity profiles were achieved compared to their older counterparts. In the AGAMENON-SEOM registry, GEAC in < 45 years showed more aggressive clinicopathological features and, although treated with more intense first-line CT regimens, similar efficacy outcomes and toxicity were achieved compared to older patients.

Development and Validation of a Nomogram to Predict the Risk of Tinnitus Severity in Patients With Unilateral Subjective Tinnitus

Purpose: To develop and validate a nomogram for predicting the risk of tinnitus severity in patients with unilateral subjective tinnitus. Methods: The objective of this study was to establish and validate a nomogram specifically designed for patients with unilateral subjective tinnitus. We collected data on unilateral subjective tinnitus from the Air Force Medical Center, including 146 participants between January 2021 and June 2022. Risk factors for unilateral subjective tinnitus severity were evaluated by least absolute shrinkage and selection operator (LASSO) and binary logistic regression analysis. Internal verification was used to evaluate the performance of the nomogram. The discriminative ability was measured by the consistency index (C-indices) and the area under the curve (AUC) of the receiver operating characteristic (ROC) curves. Results: All included patients were randomized according to a 7:3 ratio into the training cohort (104 patients) and the validation cohort (42 patients). The LASSO regression model identified sex, tinnitus loudness, and hearing loss as candidate variables. Binary logistic regression analysis showed that gender (OR: 0.76; 95% CI: 0.6-0.95; P = 0.021) and tinnitus loudness (OR: 1.37; 95% CI: 1.09-1.72; P = 0.009) were significant predictors of unilateral subjective tinnitus severity, while age, tinnitus matching frequency, and tinnitus duration were not. The significant predictors were included in the nomogram. Hearing loss was included in the nomogram based on prior clinical experience and previous studies. The training and validation cohorts C-indexes were 0.707 (95% CI: 0.607-0.806) and 0.706 (95% CI: 0.548-0.863), respectively. The training and validation cohort's AUC of the ROC curves were 0.692 and 0.705, respectively. Conclusion: We have developed and validated a nomogram based on gender, hearing loss, and tinnitus loudness, which can effectively predict the risk of tinnitus severity in patients with unilateral subjective tinnitus. The nomogram provides personalized prediction results for patients with unilateral subjective tinnitus, which is beneficial for clinical decision-making and treatment plan development.

The AGAMENON-SEOM model for prediction of survival in patients with advanced HER2-positive oesophagogastric adenocarcinoma receiving first-line trastuzumab-based therapy

Background

Trastuzumab and chemotherapy is the standard first-line treatment in human epidermal growth factor receptor 2 (HER2)-positive advanced gastro-oesophageal cancer. The objective was to develop a predictive model for overall survival (OS) and progression-free survival (PFS) in patients treated with trastuzumab.

Methods

Patients with HER2-positive advanced gastro-oesophageal adenocarcinoma (AGA) from the Spanish Society of Medical Oncology (SEOM)-AGAMENON registry and treated first line with trastuzumab and chemotherapy between 2008 and 2021 were included. The model was externally validated in an independent series (The Christie NHS Foundation Trust, Manchester, UK).

Results

In all, 737 patients were recruited (AGAMENON-SEOM, n = 654; Manchester, n = 83). Median PFS and OS in the training cohort were 7.76 [95% confidence interval (CI), 7.13-8.25] and 14.0 months (95% CI, 13.0-14.9), respectively. Six covariates were significantly associated with OS: neutrophil-to-lymphocyte ratio, Eastern Cooperative Oncology Group performance status, Lauren subtype, HER2 expression, histological grade and tumour burden. The AGAMENON-HER2 model demonstrated adequate calibration and fair discriminatory ability with a c-index for corrected PFS/OS of 0.606 (95% CI, 0.578-0.636) and 0.623 (95% CI, 0.594-0.655), respectively. In the validation cohort, the model is well calibrated, with a c-index of 0.650 and 0.683 for PFS and OS, respectively.

Conclusion

The AGAMENON-HER2 prognostic tool stratifies HER2-positive AGA patients receiving trastuzumab and chemotherapy according to their estimated survival endpoints.

Machine learning models for predicting one-year survival in patients with metastatic gastric cancer who experienced upfront radical gastrectomy

Tumor metastasis is a common event in patients with gastric cancer (GC) who previously underwent curative gastrectomy. It is meaningful to employ high-volume clinical data for predicting the survival of metastatic GC patients. We aim to establish an improved machine learning (ML) classifier for predicting if a patient with metastatic GC would die within 12 months. Eligible patients were enrolled from a Chinese GC cohort, and the complete detailed information from medical records was extracted to generate a high-dimensional dataset. Appropriate feature engineering and feature filter were conducted before modeling with eight algorithms. A 10-fold cross validation (CV) nested in a holdout CV (8:2) was employed for hyperparameter tuning and model evaluation. Model selection was based on the area under the receiver operating characteristic (AUROC) curve, recall, and precision. The selected model was globally explained using interpretable surrogate models. Of the total 399 cases (median survival of 8.2 months), 242 patients survived less than 12 months. The linear discriminant analysis (LDA), support vector machine (SVM), and random forest (RF) model had the highest AUROC (0.78 ± 0.021), recall (0.93 ± 0.031), and precision (0.80 ± 0.026), respectively. The LDA model created a new function that generally separated the two classes. The predicted probability of the SVM model was interpreted using a linear regression model visualized by a nomogram. The predicted class of the RF model was explained using a decision tree model. In summary, analyzing high-volume medical data by ML is helpful to produce an improved model for predicting the survival in patients with metastatic GC. The algorithm should be carefully selected in different practical scenarios.

Does HER2 status influence in the benefit of ramucirumab and paclitaxel as second line treatment of advanced gastro-esophageal adenocarcinoma? Data from the AGAMENON-SEOM registry

PURPOSE

This study aimed to compare ramucirumab-paclitaxel versus chemotherapy in second-line (2L) advanced gastroesophageal cancer (aGEC) based on HER2 status and analyze prognostic factors.

METHODS

The study includes patients from the AGAMENON-SEOM registry with aGEC and known HER2 status who received 2L between 2016 and 2021. The Kaplan-Meier method was used to calculate progression-free survival (PFS) and overall survival (OS) and multivariable Cox regression analysis was done to adjust for confounding variables.

RESULTS

Of the 552 patients who met the selection criteria, 149 (26.9%) had HER2-positive aGEC, 89 were treated with chemotherapy, and 60 with ramucirumab-paclitaxel, and 403 had an HER2-negative aGEC, 259 were treated with chemotherapy, and 144 with ramucirumab-paclitaxel. In the whole sample, 2L PFS was 3.0 months (95% CI 2.8-3.2), 2L OS, 5.7 months (5.2-6.3), and ramucirumab-paclitaxel versus chemotherapy was associated with increased PFS (HR 0.64, 95% CI 0.53-0.78, p < 0.0001) and OS (HR 0.68, 0.55-0.83, p = 0.0002). Median PFS of ramucirumab- paclitaxel versus chemotherapy was 3.5 vs 2.8 months (HR 0.67, 0.54-0.83, p = 0.0004) in HER2-negative, and 4.7 vs 2.7 months (HR 0.57, 0.40-0.82, p = 0.0031) in HER2-positive aGEC, respectively. Median OS for ramucirumab-paclitaxel versus chemotherapy was 6.6 vs 5 months (HR 0.67, 0.53-0.85, p = 0.0007) in HER2-negative, and 7.4 vs 5.6 months (HR 0.70, 0.53-1.04, p = 0.083) in HER2-positive aGEC, respectively. ECOG-PS, tumor burden, Lauren subtype, and neutrophil-lymphocyte ratio were prognostic factors.

CONCLUSIONS

In patients with an aGEC from the AGAMENON-SEOM registry, 2L treatment with ramucirumab-paclitaxel was superior to chemotherapy in PFS, OS and response rate, independent of HER2 status.

Sex and gender disparities in patients with advanced gastroesophageal adenocarcinoma: data from the AGAMENON-SEOM registry

Background

Recommendations for research articles include the use of the term sex when reporting biological factors and gender for identities or psychosocial or cultural factors. There is an increasing awareness of incorporating the effect of sex and gender on cancer outcomes. Thus, these types of analyses for advanced gastroesophageal adenocarcinoma are relevant.

Patients and methods

Patients with advanced gastroesophageal adenocarcinoma from the Spanish AGAMENON-SEOM registry treated with first-line combination chemotherapy were selected. Epidemiology, characteristics of the disease, treatment selection, and results were examined according to sex.

Results

This analysis included 3274 advanced gastroesophageal adenocarcinoma patients treated with combination chemotherapy between 2008 and 2021: 2313 (70.7%) men and 961 (29.3%) women. Tumors in females were more frequently HER2-negative (67.8% versus 60.8%; P < 0.0001), grade 3 (45.4% versus 36.8%; P < 0.001), diffuse (43.3% versus 26.5%; P < 0.0001), and signet ring cell histology (40.5 versus 23.9%; P < 0.0001). Peritoneal spread was more common in women (58.6% versus 38.9%; P < 0.0001), while liver burden was lower (58.9% versus 71.1%; P < 0.0001). There were no significant differences in treatment recommendation. Treatment doses, density, and duration were comparable between sexes. Women experienced more diarrhea (46% versus 37%; P < 0.0001), neutropenia (51% versus 43%; P < 0.0001), and anemia (62% versus 57%; P < 0.0001). After a median 59.6-month follow-up [95% confidence interval (CI) 54.5-70.8], there were no statistically significant differences between the sexes in progression-free survival [6.21 months (95% CI 5.8-6.5 months) versus 6.08 months (95% CI 5.8-6.3 months); log-rank test, χ² = 0.1, 1 df, P = 0.8] or in overall survival [10.6 months (95% CI 9.8-11.1 months) versus 10.9 months (95% CI 10.4-11.4 months); log-rank test: χ² = 0.6, 1 df, P = 0.5].

Conclusion

This sex analysis of patients with advanced gastroesophageal adenocarcinoma from the AGAMENON-SEOM registry receiving first-line polychemotherapy found no differences in survival. Although women had worse prognostic histopathology, metastatic disease pattern, and greater toxicity, treatment allocation and compliance were equivalent.

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Sex and gender are determinants of health inequalities and may affect treatments, tolerability, and therapeutic outcomes.

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According to sex, subtle biological and clinical differences exist in advanced gastroesophageal adenocarcinoma.

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Women with advanced gastroesophageal adenocarcinoma experience greater toxicity with therapeutic results comparable with men.

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Stratification and analysis by sex in studies of gastroesophageal adenocarcinoma should be considered.

Identification of Thrombosis-Related Genes in Patients with Advanced Gastric Cancer: Data from AGAMENON-SEOM Registry

Advanced gastric cancer is one of the most thrombogenic neoplasms. However, genetic mechanisms underlying this complication remain obscure, and the molecular and histological heterogeneity of this neoplasm hinder the identification of thrombotic biomarkers. Therefore, our main objective was to identify genes related to thrombosis regardless of Lauren subtypes. Furthermore, in a secondary exploratory study, we seek to discover thrombosis-associated genes that were specific to each TCGA molecular subtype. We designed a nested case-control study using the cohort of the AGAMENON national advanced gastric cancer registry. Ninety-seven patients were selected—48 with and 49 without venous thromboembolism (using propensity score matching to adjust for confounding factors)—and a differential gene expression array stratified by Lauren histopathological subtypes was carried out in primary tumor samples. For the secondary objective, the aforementioned differential expression analysis was conducted for each TCGA group. Fifteen genes were determined to be associated with thrombosis with the same expression trend in both the intestinal and diffuse subtypes. In thrombotic subjects, CRELD1, KCNH8, CRYGN, MAGEB16, SAA1, ARL11, CCDC169, TRMT61A, RIPPLY3 and PLA2G6 were underexpressed (adjusted-p < 0.05), while PRKD3, MIR5683, SDCBP, EPS8 and CDC45 were overexpressed (adjusted-p < 0.05), and correlated, by logistic regression, with lower or higher thrombotic risk, respectively, in the overall cohort. In each TCGA molecular subtype, we identified a series of genes differentially expressed in thrombosis that appear to be subtype-specific. We have identified several genes associated with venous thromboembolism in advanced gastric cancer that are common to Lauren intestinal and diffuse subtypes. Should these genetic factors be validated in the future, they could be complemented with existing clinical models to bolster the ability to predict thrombotic risk in individuals with advanced gastric adenocarcinoma.

Development and validation of a prognostic scoring model for mortality risk stratification in patients with recurrent or metastatic gastric carcinoma

Background

Survival times differ among patients with advanced gastric carcinoma. A precise and universal prognostic evaluation strategy has not yet been established. The current study aimed to construct a prognostic scoring model for mortality risk stratification in patients with advanced gastric carcinoma.

Methods

Patients with advanced gastric carcinoma from two hospitals (development and validation cohort) were included. Cox proportional hazards regression analysis was conducted to identify independent risk factors for survival. A prognostic nomogram model was developed using R statistics and validated both in bootstrap and external cohort. The concordance index and calibration curves were plotted to determine the discrimination and calibration of the model, respectively. The nomogram score and a simplified scoring system were developed to stratify patients in the two cohorts.

Results

Development and validation cohort was comprised of 401 and 214 gastric cancer patients, respectively. Mucinous or non-mucinous histology, ECOG score, bone metastasis, ascites, hemoglobin concentration, serum albumin level, lactate dehydrogenase level, carcinoembryonic antigen level, and chemotherapy were finally incorporated into prognostic nomogram. The concordance indices were 0.689 (95% CI: 0.664 ~ 0.714) and 0.673 (95% CI: 0.632 ~ 0.714) for bootstrap and external validation. 100 and 200 were set as the cut-off values of nomogram score, patients in development cohort were stratified into low-, intermediate- and high-risk groups with median overall survival time 15.8 (95% CI: 12.2 ~ 19.5), 8.4 (95% CI: 6.7 ~ 10.2), and 3.9 (95% CI: 2.7 ~ 5.2) months, respectively; the cut-off values also worked well in validation cohort with different survival time in subgroups. A simplified model was also established and showed good consistency with the nomogram scoring model in both of development and validation cohorts.

Conclusion

The prognostic scoring model and its simplified surrogate can be used as tools for mortality risk stratification in patients with advanced gastric carcinoma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09079-7.

Prognostic models for stage I-III esophageal cancer: a comparison between existing calculators

Background

Determining the best approach for esophageal cancer and predicting accurate prognosis are critical. Multiple studies evaluated characteristics associated with overall survival, and several prediction models have been developed. This study aimed to evaluate existing models and perform external validation of selected models.

Methods

A retrospective investigation of a multi-site institutional enterprise for patients with a diagnosis of esophageal cancer between 2013-2014 was performed. Selected survival prediction models included the Roswell Park Comprehensive Cancer Center (RPCCC) calculator, Oregon Health & Science University (OHSU) calculator, and two nomograms published by Shapiro et al. and Sun et al. One-year overall survival, level of agreement, and performance for each model were evaluated.

Results

A total of 104 patients were included and used to assess the prediction models. One-year overall survival was 0.76. Different calculators tended to rank patients similarly; however, they did not agree on predicted overall survival. The least disparity in correlation was observed between OHSU and Shapiro calculators. Shapiro's model achieved the highest performance [area under the curve (AUC) =0.63].

Conclusions

Selected models showed fair results in estimating individual overall survival, although none achieved a high performance. While these tools may support the decision-making process for esophageal cancer patients, their implementation in clinical practice requires improved refinement to optimize their clinical utility.

Development and application of a dynamic prediction model for esophageal cancer

Background

Current prediction models of esophageal cancer (EC) are limited to predicting at a specific time point, and ignore changes in hazard ratios of predictive variables, known as time-varying effects. Our study aimed to investigate variables with time-varying effects in EC and to develop a prediction model that can update the 5-year predicted dynamic overall survival (DOS) probability during the follow-up period.

Methods

Firstly, the clinicopathological information and survival data of 4,541 patients with EC was obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2007 and 2011 for modeling. Secondly, the time-varying effect of variables was assessed and the dynamic prediction model was developed based on the proportional baselines landmark supermodel.

Results

Here, we found that age at diagnosis, sex, location of primary tumor, histological type, chemotherapy, surgery, and T stage showed significant time-varying effects on overall survival. Thirdly, the prediction model was validated by an internal SEER validation cohort and a Chinese patient cohort, respectively, and achieved promising results as follows: area under the curve (AUC) =0.733 (internal validation) and 0.864 (external validation). The heuristic shrinkage factor was 0.995. Finally, several clear cases were selected as examples for model application to map the patient’s 5-year DOS curves and to respectively demonstrate the impact of different variables’ time-varying effect on survival.

Conclusions

Overall, our results suggest that the existence of time-varying effect highlights the importance of updating the predicted survival probability during the follow-up period. Moreover, this prediction model can be used to assist doctors in making more-individualized treatment decisions based on a dynamic assessment of patient prognosis.

Causal Considerations Can Inform the Interpretation of Surprising Associations in Medical Registries

An exploratory analysis of registry data from 2437 patients with advanced gastric cancer revealed a surprising association between astrological birth signs and overall survival (OS) with p = 0.01. After dichotomizing or changing the reference sign, p-values <0.05 were observed for several birth signs following adjustments for multiple comparisons. Bayesian models with moderately skeptical priors still pointed to these associations. A more plausible causal model, justified by contextual knowledge, revealed that these associations arose from the astrological sign association with seasonality. This case study illustrates how causal considerations can guide analyses through what would otherwise be a hopeless maze of statistical possibilities.

Prediction of quality of life in early breast cancer upon completion of adjuvant chemotherapy

Quality of life (QoL) is a complex, ordinal endpoint with multiple conditioning factors. A predictive model of QoL after adjuvant chemotherapy can support decision making or the communication of information about the range of treatment options available. Patients with localized breast cancer (n = 219) were prospectively recruited at 17 centers. Participants completed the EORTC QLQ-C30 questionnaire. The primary aim was to predict health status upon completion of adjuvant chemotherapy adjusted for multiple covariates. We developed a Bayesian model with six covariates (chemotherapy regimen, TNM stage, axillary lymph node dissection, perceived risk of recurrence, age, type of surgery, and baseline EORTC scores). This model allows both prediction and causal inference. The patients with mastectomy reported a discrete decline on all QoL scores. The effect of surgery depended on the interaction with age. Women with ages on either end of the range displayed worse scores, especially with mastectomy. The perceived risk of recurrence had a striking effect on health status. In conclusion, we have developed a predictive model of health status in patients with early breast cancer based on the individual's profile.

Prediction of survival in patients with advanced, refractory colorectal cancer in treatment with trifluridine/tipiracil: real-world vs clinical trial data

Trifluridine/tipiracil increases overall survival (OS) in patients with refractory, metastatic colorectal cancer (mCRC). A post hoc exploratory analysis of the RECOURSE randomized clinical trial (RCT) established two categories, a good prognosis corresponding to subjects having a low tumor burden and indolent disease. Other models in refractory mCRC are the FAS-CORRECT and Colon Life nomogram. The main objective was to externally validate the prognostic factors of the RECOURSE and FAS-CORRECT trials, and the Colon Life nomogram in a multicenter, real-world series of mCRC treated in 3rd and successive lines with trifluridine/tipiracil. The secondary aim was to develop an OS predictive model, TAS-RECOSMO. Between 2016 and 2019, 244 patients were recruited. Median OS was 8.15 vs 8.12 months for the poor (85% of the subjects) and good (15%) prognosis groups from the RESOURCE trial, respectively, log-rank p = 0.9. The most common grade 3-4 toxicities were neutropenia (17%), asthenia (6%), and anemia (5%). The AFT lognormal model TAS-RECOSMO included six variables: ECOG-PS, KRAS/NRAS/BRAF mutation status, time between diagnosis of metastasis and beginning of trifluridine/tipiracil, NLR, CEA, and alkaline phosphatase. The model's bootstrapped bias-corrected c-index was 0.682 (95% CI, 0.636-0.722). The factors from the Colon Life model, FAS-CORRECT, and RECOURSE displayed a c-index of 0.690, 0.630, and 0.507, respectively. TAS-RECOSMO, FAS-CORRECT, and the Colon Life nomogram appear to predict OS in patients with refractory mCCR who begin trifluridine/tipiracil treatment in the real world. The prognostic groups of the RECOURCE RCT were unable to capture the situation of real-world subjects treated with trifluridine/tipiracil in this series.

Clinical scoring system for the prediction of survival of patients with advanced gastric cancer

OBJECTIVE

In this study, we established a risk scoring system using easily obtained clinical characteristics at the time of initiating palliative chemotherapy to predict accurate overall survival of patients with advanced gastric cancer after first-line treatment with fluoropyrimidine-platinum combination chemotherapy.

METHODS

A total of 1733 patients treated at the Samsung Medical Center, Korea were included in the study, and clinicopathological and laboratory data were retrospectively analysed. The dataset was split into a training set (n=1156, 67%) and a validation set (n=577, 33%). Top-ranked variables were identified using the random forest survival algorithm and integrated into a Cox regression model, thereby constructing the scoring system for predicting the overall survival of patients with advanced gastric cancer.

RESULTS

The following five variables were finally included in the scoring system: serum neutrophil-lymphocyte ratio, alkaline phosphatase level, albumin level, performance status and histologic differentiation. The scoring system determined four distinct risk groups in the validation dataset with median overall survival of 17.1 months (95% CI=14.9 to 20.5 months), 12.9 months (95% CI=11.4 to 14.6 months), 8.1 months (95% CI=5.3 to 12.3 months) and 3.9 months (95% CI=1.5 to 8.2 months), respectively. The area under the curve to estimate the discrimination performance of the scoring system was 66.1 considering 1 year overall survival.

CONCLUSIONS

We developed a simple and clinically useful predictive scoring model in a homogeneous population with advanced gastric cancer treated with fluoropyrimidine-containing and platinum-containing chemotherapy. However, additional independent validation will be required before the scoring model can be used commonly.

Is advanced esophageal adenocarcinoma a distinct entity from intestinal subtype gastric cancer? Data from the AGAMENON-SEOM Registry

BACKGROUND

Advanced esophageal adenocarcinoma (EAC) is generally treated similarly to advanced gastroesophageal junction (GEJ-AC) and gastric (GAC) adenocarcinomas, although GAC clinical trials rarely include EAC. This work sought to compare clinical characteristics and treatment outcomes of advanced EAC with those of GEJ-AC and GAC and examine prognostic factors.

PATIENTS AND METHODS

Participants comprised patients with advanced EAC, intestinal GEJ-AC, and GAC treated with platin and fluoropyrimidine (plus trastuzumab when HER2 status was positive). Overall and progression-free survival were estimated using the Kaplan-Meier method. Cox proportional hazards regression gauged the prognostic value of the AGAMENON model.

RESULTS

Between 2008 and 2019, 971 participants from the AGAMENON-SEOM registry were recruited at 35 centers. The sample included 67.3% GAC, 13.3% GEJ-AC, and 19.4% EAC. Pulmonary metastases were most common in EAC and peritoneal metastases in GAC. Median PFS and OS were 7.7 (95% CI 7.3-8.0) and 13.9 months (12.9-14.7). There was no difference in PFS or OS between HER2- and HER2+ tumors from the three locations (p > 0.05). Five covariates were found to be prognostic for the entire sample: ECOG-PS, histological grade, number of metastatic sites, NLR, and HER2+ tumors treated with trastuzumab. In EAC, the same variables were prognostic except for grade. The favorable prognosis for HER2+ cancers treated with trastuzumab was homogenous for all three subgroups (p = 0.351) and, after adjusting for the remaining covariates, no evidence supported primary tumor localization as a prognostic factor (p = 0.331).

CONCLUSION

Our study supports the hypothesis that EAC exhibits clinicopathological characteristics, prognostic factors, and treatment outcomes comparable to intestinal GEJ-AC and GAC.

A Prognostic Model for Patients With Gastric Signet Ring Cell Carcinoma

Background:

The aim of our study was to develop a nomogram model to predict overall survival (OS) and cancer-specific survival (CSS) in patients with gastric signet ring cell carcinoma (GSRC).

Methods:

GSRC patients from 2004 to 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database and randomly assigned to the training and validation sets. Multivariate Cox regression analyses screened for OS and CSS independent risk factors and nomograms were constructed.

Results:

A total of 7,149 eligible GSRC patients were identified, including 4,766 in the training set and 2,383 in the validation set. Multivariate Cox regression analysis showed that gender, marital status, race, AJCC stage, TNM stage, surgery and chemotherapy were independent risk factors for both OS and CSS. Based on the results of the multivariate Cox regression analysis, prognostic nomograms were constructed for OS and CSS. In the training set, the C-index was 0.754 (95% CI = 0.746-0.762) for the OS nomogram and 0.762 (95% CI: 0.753-0.771) for the CSS nomogram. In the internal validation, the C-index for the OS nomogram was 0.758 (95% CI: 0.746-0.770), while the C-index for the CSS nomogram was 0.762 (95% CI: 0.749-0.775). Compared with TNM stage and SEER stage, the nomogram had better predictive ability. In addition, the calibration curves also showed good consistency between the predicted and actual 3-year and 5-year OS and CSS.

Conclusion:

The nomogram can effectively predict OS and CSS in patients with GSRC, which may help clinicians to personalize prognostic assessments and clinical decisions.

Predictive Roles of HER2 Gene Amplification and Neutrophil-to-Lymphocyte Ratio on Survival in HER2-Positive Advanced Gastric Cancer Treated With Trastuzumab-Based Chemotherapy

OBJECTIVES

Trastuzumab is used as an agent against human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (AGC). The aim of this study was to determine how HER2 gene amplification and neutrophil-to-lymphocyte ratio (NLR) could predict long-term survival in AGC patients that underwent trastuzumab-based chemotherapy.

METHODS

We retrospectively reviewed medical records of 112 patients between 28 and 91 years old (median of 66 y) with AGC treated with first-line trastuzumab-based chemotherapy. The level of HER2 gene amplification was determined by the HER2/centromere enumerator probe 17 (CEP17) ratio and HER2 gene copy number (GCN). NLR was calculated as the neutrophil count divided by the lymphocyte counts.

RESULTS

Median HER2/CEP17 ratio, HER2 GCN, and NLR values were 2.85, 7.1, and 2.81, respectively. Objective response rate in both high HER2/CEP17 ratio (59.4% vs. 28.1%, P=0.012) and HER2 GCN groups (62.1% vs. 33.3%, P=0.032) was higher than that of each group. High NLR correlated with significantly worse median overall survival (OS) (median OS, 8.2 vs. 18.9 mo, P=0.002) and progression free survival (PFS) (median PFS: 5.1 vs. 8.0 mo, P=0.005). However, median OS and PFS were not significantly different according to HER2/CEP17 ratio or HER2 GCN. In the multivariate analysis, high NLR, Eastern Cooperative Group performance status, and poorly differentiated/signet ring cell type were independent factors for OS.

CONCLUSIONS

NLR was a significant predictor of long-term survival in AGC patients treated with first-line trastuzumab-based chemotherapy. Future validation of prospective trials with larger patient populations will be needed.

External validity of clinical trials with diverse trastuzumab-based chemotherapy regimens in advanced gastroesophageal adenocarcinoma: data from the AGAMENON-SEOM registry

BACKGROUND

Trastuzumab combined with cisplatin and fluoropyrimidines, either capecitabine or 5-fluorouracile (XP/FP), is the standard first-line treatment for advanced, HER2-positive, gastric cancer patients based on the ToGA trial. Despite the lack of phase III trials, many clinicians administer trastuzumab with alternative regimens. One meta-analysis suggests that substituting cisplatin for oxaliplatin might lead to greater efficacy and less toxicity.

METHODS

594 patients with HER2-positive gastroesophageal adenocarcinoma were recruited from the AGAMENON-SEOM registry. The objective was to evaluate the external validity of clinical trials with chemotherapy and trastuzumab.

RESULTS

The regimens used in at least 5% of the patients were XP (27%), oxaliplatin and capecitabine (CAPOX) (26%), oxaliplatin and 5-fluorouracil (FOLFOX) (14%), FP (14%), triplet with anthracycline/docetaxel (7%), and carboplatin-FU (5%). Median exposure to trastuzumab was longer with FOLFOX (11.4 months, 95% CI, 9.1-21.0) versus ToGA regimens (7.5, 6.4-8.5), p < 0.001. Patients with HER2-IHC 3+ cancers had higher response rates than those with IHC 2+/FISH+, odds-ratio 1.97 (95% CI, 1.25-3.09). The results achieved with CAPOX-trastuzumab were comparable to those attained with ToGA regimens. FOLFOX-trastuzumab was superior to ToGA schemes in terms of overall survival (OS), with a greater magnitude of effect in IHC 2+/FISH+ tumors (HR 0.47, 0.24-0.92) compared with IHC 3+ (HR 0.69, 0.49-0.96), and in diffuse (HR 0.37, 0.20-0.69) versus intestinal-type tumors (HR 0.76, 0.54-1.06).

CONCLUSION

We have updated the external validity of clinical trials with trastuzumab in first-line treatment of gastric cancer. Our data confirm the comparable outcomes of ToGA regimens and CAPOX-trastuzumab in clinical practice and point toward a possible benefit of FOLFOX-trastuzumab, contingent on the subtypes typically less sensitive to trastuzumab, to be confirmed in clinical trials.

[Factors affecting survival prognosis of advanced gastric cancer and establishment of a nomogram predictive model]

OBJECTIVE

To explore the factors affecting the survival of patients with advanced gastric cancer and establish a reliable predictive model of the patients' survival outcomes.

OBJECTIVE

We retrospectively collected the clinical data from patients with advanced gastric cancer treated in our department between January, 2015 and December, 2019. Univariate survival analysis was carried out using Kaplan-Meier method followed by multivariate Cox regression analysis to identify the factors associated with the survival outcomes of the patients. The R package was used to generate the survival rates, and a nomogram was established based on the results of multivariate analysis. The calibration curves and C-index were calculated to determine the predictive and discriminatory power of the model. The performance of the nomogram model for predicting the survival outcomes of the patients was evaluated using receiver- operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

OBJECTIVE

Univariate analysis showed that the number of metastatic sites, the number of treatment lines received, disease control rate (DCR) and progression-free survival (PFS) time following first-line treatment, and surgical treatment in first-line treatment were significantly correlated with the survival time of the patients (P < 0.05). Multivariate Cox regression analysis showed that surgical treatment, number of treatment lines, PFS time following first-line treatment and peritoneal metastasis, as independent prognostic factors, were significantly correlated with the patients' survival (P < 0.05). The C-index of the nomogram was 0.785 (95%CI: 0.744-0.826) for overall survival of the patients. The calibration curves showed that the actual survival rate of the patients was consistent with the predicted survival rate. The time-dependent AUC and DCA demonstrated that the nomogram had a good performance for predicting the survival outcomes of patients with advanced gastric cancer.

OBJECTIVE

Peritoneal metastasis is associated with s shorter overall survival time of patients with advanced gastric cancer, while a PFS time following first-line treatment of more than 7.0 months and third-line and posterior-line treatments are related with a longer survival time. Systematic treatment including elective surgery can improve the survival outcomes of the patients. The nomogram we established provides a reliable prognostic model for evaluating the prognosis of patients with advanced gastric cancer.

External validity of docetaxel triplet trials in advanced gastric cancer: are there patients who still benefit?

BACKGROUND

The purpose of our study was to develop an online calculator to estimate the effect of docetaxel triplets (DPF) in first line of advanced gastric cancer (AGC), and to assess the external validity of docetaxel trials in individual patients.

METHODS

The study includes patients with HER2(-) AGC treated with platin and fluoropyrimidine (PF) or with DPF in first line. Treatment effect and interactions were assessed using Bayesian accelerated failure time models.

RESULT

The series comprises 1376 patients; 238 treated with DPF and 1138 with PF between 2008 and 2019. DPF was associated with increased progression-free survival (PFS) and overall survival (OS) with time ratio (TR) 1.27 (95% credible interval [CrI], 1.15-1.40), and TR 1.19 (95% CrI, 1.09-1.27), respectively. Serious adverse events were more common with DPF, particularly hematological effects (32% vs 22%). Younger participants received greater DPF dose density without achieving greater disease control, while severe toxicity was likewise higher. DPF yielded superior OS in Lauren intestinal (TR 1.27, 95% CrI, 1.08-1.11) vs diffuse subtype (TR 1.17, 95% CrI, 1.09-1.24) and the probability of increasing OS > 15% was 90% vs 67% in each subtype, respectively. The effect dwindles over time, which can be attributed to pathological changes and clinical practice changes.

CONCLUSION

Our study confirms the effect of DPF is highly dependent on several clinical-pathological variables, with discreet and gradually declining benefit over platinum doublets in later years, at the expense of increased toxicity. These results may help to underpin the idea that external validity of AGC trials should be revised regularly.

Outcomes of Advanced Gastroesophageal Cancer Patients with Equivocal HER2 Expression with or without ERBB2 Gene Amplification

BACKGROUND

Prior studies have shown that patients whose tumor overexpresses Her2 at 3+ level by immunohistochemistry (IHC) fare better than those whose tumor overexpresses Her2 at 2+ level (with ERBB2 amplified). Therefore, it would be important to compare the outcome of patients whose tumor expresses Her2 at 2+ level but further classify by gene amplification studies as positive or negative.

METHODS

We retrospectively identified patients with advanced gastroesophageal adenocarcinoma with low Her2 protein expression (2+ by IHC) whose tumors were evaluated for gene amplification of ERBB2 by fluorescence in situ hybridization (FISH). All patients received first-line therapy, and trastuzu-mab was added according to Her2 status. We compared overall survival (OS), progression-free survival (PFS), and overall response rate (ORR) of the entire cohort and compared Her2-positive tumor patients' outcomes with Her2-negative tumor patients' outcomes. All patients had treatment response assessments and follow-ups at our institution.

RESULTS

We identified 87 patients whose tumors expressed Her2 at 2+ level. 51 (58.6%) were Her2-negative and 36 (41.4%) were Her2-positive by FISH. For the entire cohort, the median OS was 26 months (95% confidence interval 16.6-37.6), and the median PFS was 12.2 months (95% confidence interval 9.7-19.3). Median OS, median PFS, and ORR did not differ between Her2-positive and Her2-negative patients (p = 0.70, p = 0.60, p = 0.91, respectively).

CONCLUSIONS

Our data suggest that patients with Her2 positivity or negativity when tumors have lower Her2 protein expression (2 + by IHC) have similar clinical outcomes. Further research is warranted in this cohort.

Second-line treatment in advanced gastric cancer: Data from the Spanish AGAMENON registry

Background

Second-line treatments boost overall survival in advanced gastric cancer (AGC). However, there is a paucity of information as to patterns of use and the results achieved in actual clinical practice.

Materials and methods

The study population comprised patients with AGC in the AGAMENON registry who had received second-line. The objective was to describe the pattern of second-line therapies administered, progression-free survival following second-line (PFS-2), and post-progression survival since first-line (PPS).

Results

2311 cases with 2066 progression events since first-line (89.3%) were recorded; 245 (10.6%) patients died during first-line treatment and 1326/2066 (64.1%) received a second-line. Median PFS-2 and PPS were 3.1 (95% CI, 2.9–3.3) and 5.8 months (5.5–6.3), respectively. The most widely used strategies were monoCT (56.9%), polyCT (15.0%), ramucirumab+CT (12.6%), platinum-reintroduction (8.3%), trastuzumab+CT (6.1%), and ramucirumab (1.1%). PFS-2/PPS medians gradually increased in monoCT, 2.6/5.1 months; polyCT 3.4/6.3 months; ramucirumab+CT, 4.1/6.5 months; platinum-reintroduction, 4.2/6.7 months, and for the HER2+ subgroup in particular, trastuzumab+CT, 5.2/11.7 months. Correlation between PFS since first-line and OS was moderate in the series as a whole (Kendall’s τ = 0.613), lower in those subjects who received second-line (Kendall’s τ = 0.539), especially with ramucirumab+CT (Kendall’s τ = 0.413).

Conclusion

This analysis reveals the diversity in second-line treatment for AGC, highlighting the effectiveness of paclitaxel-ramucirumab and, for a selected subgroup of patients, platinum reintroduction; both strategies endorsed by recent clinical guidelines.

Practical guidance for the evaluation of disease progression and the decision to change treatment in patients with advanced gastric cancer receiving chemotherapy

After failure of first-line chemotherapy with fluoropyrimidines and platinum compounds for advanced gastric cancer, second-line chemotherapy with ramucirumab plus paclitaxel, which elicits a durable response, and third-line or later chemotherapy with nivolumab have been shown to lead to a more favorable prognosis in advanced gastric cancer patients. As new and more effective drugs are now available, sequential chemotherapy would contribute to prolonged survival. From this point of view, the patient's disease course should be frequently monitored in order to adapt treatment regimens. This review summarizes the points to note in regard to radiological assessment, and discusses the integration of prognostic factors, tumor markers, and clinical symptoms that need to be taken into account to change treatment at an appropriate timing.

Nomogram-based prediction of survival in unresectable or metastatic gastric cancer patients with good performance status who received first-line chemotherapy

Background

Good performance status (PS) is widely acknowledged to have a high prognostic ability, although the prognostic parameters of cancer patients with good PS are still uncertain. This study was conducted to establish and validate a point-based nomogram to assist with predicting prognosis in unresectable or metastatic gastric cancer (GC) patients who had good PS and underwent first-line chemotherapy.

Methods

At random, a total of 309 patients with GC were split into 2 cohorts: a training cohort (n=259) and an internal validation cohort (n=50). An independent external validation cohort comprising 147 patients was also recruited. Both univariate and multivariate Cox regression analyses were used to evaluate patients based on the overall survival (OS) to develop the nomogram, which was subsequently validated using the concordance index (c-index), calibration curve, and decision curve analysis (DCA).

Results

The nomogram contained 3 independent prognostic variables in the training cohort: the number of distant metastatic sites (P<0.001), carbohydrate antigen 199 (CA199) level (P=0.002), and fibrinogen (P=0.020). The nomogram predicted an OS with a c-index of 0.623 (95% CI, 0.58–0.67) in the training cohort. The internal validation showed that the nomogram had a c-index of 0.614 (95% CI, 0.51–0.72). For external validation, the c-index was 0.638 (95% CI, 0.58–0.70).

Conclusions

A reliable point-based nomogram for predicting the prognosis of patients who had unresectable or metastatic GC and good PS who underwent first-line chemotherapy was developed and validated.

Keywords

Nomogram-based prediction; overall survival; unresectable gastric cancer; metastatic gastric cancer; good performance status; first-line chemotherapy

Population-based analysis of esophageal large cell neuroendocrine carcinoma between 2004 and 2015

Background

Esophageal large cell neuroendocrine carcinoma (ELCNC) seems a rarely gastrointestinal malignancy. By far, its clinicopathological characteristics and prognosis have not been deeply studied.

Methods

The data of patients having ELCNC was extracted from the Surveillance, Epidemiology, and End Results (SEER) database, then assessed and compared with information from patients with esophageal small cell neuroendocrine carcinoma (ESCNC) or esophageal squamous cell carcinoma (ESCC). We used univariate and multivariate analyses to accurately detect independent prognostic factors.

Results

The data of 36 patients for ELCNC were obtained between 2004 and 2015. Compared with patients with ESCNC and ESCC, the mean survival time of ECLNC patients was worse than those with ESCC, while similar to ESCNC. Thus, ELCNC had significantly different clinicopathological characteristics compared to ESCNC and ESCC. Univariate and multivariate analyses revealed that age (P=0.001) and M stage (P=0.004) were independent prognostic factors.

Conclusions

ELCNC is a rare subtype of esophageal neuroendocrine carcinoma. The clinicopathological features differ from those of other esophageal carcinomas. Prognosis may be closely related to age and M stage.

SEOM clinical guideline for the diagnosis and treatment of gastric cancer (GC) and gastroesophageal junction adenocarcinoma (GEJA) (2019)

Gastric cancer (GC) is the fifth most common cancer worldwide with a varied geographic distribution and an aggressive behavior. In Spain, it represents the sixth cause of cancer death. In Western countries, the incidence is decreasing slightly, with an increase in gastroesophageal junction adenocarcinoma (GEJA), a different entity that we separate specifically in the guideline. Molecular biology advances have been done recently, but do not yet lead to the choice in treatment approach except in advanced disease with overexpression of HER2. Endoscopic resection in very early stage, perioperative chemotherapy in locally advanced tumors and preliminary immune therapy resulting in advanced disease are the main treatment innovations in the GC/GEJA treatment. We describe the different evidences and recommendations following the statements of the American College of Physicians.

Blood-based Markers in the Prognostic Prediction of Esophagogastric Junction Cancer

Esophagogastric junction cancer poses a great threat to human beings both in western countries and East Asia, especially in China and Japan, and its incidence has increased during recent decades. The 5-year survival rate of esophagogastric junction cancer is quite poor compared with that of other gastric cancer sites. Until now, the traditional TNM staging system has been widely used in clinical practice for prognosis. However, the TNM system is based on pathology after surgical resection or radiology using CT and MRI, not on blood markers. Evidently, some research has been reported concentrated on the prognostic value of blood-based markers with the character of non-invasive and non-radioactive in EJA. Hematologic, biochemical and coagulation parameters could be obtained from clinical data and utilized to analyze their prognostic values. Tumor-associated antigens, microRNAs and circulating tumor cells have also been reported in EJC prognosis. In this article, we review research focused on blood-based markers to evaluate their prognostic value in esophagogastric junction cancer, especially its main subtype adenocarcinoma.

The Use of (Network) Meta-Analysis in Clinical Oncology

Meta-analysis is important in oncological research to provide a more reliable answer to a clinical research question that was assessed in multiple studies but with inconsistent results. Pair-wise meta-analysis can be applied when comparing two treatments at once, whereas it is possible to compare multiple treatments at once with network meta-analysis (NMA). After careful systematic review of the literature and quality assessment of the identified studies, there are several assumptions in the use of meta-analysis. First, the added value of meta-analysis should be evaluated by examining the comparability of study populations. Second, the appropriate comparator in meta-analysis should be chosen according to the types of comparisons made in individual studies: (1) Experimental and comparator arms are different treatments (A vs. B); (2) Substitution of a conventional treatment by an experimental treatment (A+B vs. A+C); or (3) Addition of an experimental treatment (A+B vs. B). Ideally there is one common comparator treatment, but when there are multiple common comparators, the most efficacious comparator is preferable. Third, treatments can only be adequately pooled in meta-analysis or merged into one treatment node in NMA when considering likewise mechanism of action and similar setting in which treatment is indicated. Fourth, for both pair-wise meta-analysis and NMA, adequate assessment of heterogeneity should be performed and sub-analysis and sensitivity analysis can be applied to objectify a possible confounding factor. Network inconsistency, as statistical manifestation of violating the transitivity assumption, can best be evaluated by node-split modeling. NMA has advantages over pair-wise meta-analysis, such as clarification of inconsistent outcomes from multiple studies including multiple common comparators and indirect effect calculation of missing direct comparisons between important treatments. Also, NMA can provide increased statistical power and cross-validation of the observed treatment effect of weak connections with reasonable network connectivity and sufficient sample-sizes. However, inappropriate use of NMA can cause misleading results, and may emerge when there is low network connectivity, and therefore low statistical power. Furthermore, indirect evidence is still observational and should be interpreted with caution. NMA should therefore preferably be conducted and interpreted by both expert clinicians in the field and an experienced statistician. Finally, the use of meta-analysis can be extended to other areas, for example the identification of prognostic and predictive factors. Also, the integration of evidence from both meta-analysis and expert opinion can improve the construction of prognostic models in real-world databases.

Prediction of Progression-Free Survival in Patients With Advanced, Well-Differentiated, Neuroendocrine Tumors Being Treated With a Somatostatin Analog: The GETNE-TRASGU Study

PURPOSE

Somatostatin analogs (SSAs) are recommended for the first-line treatment of most patients with well-differentiated, gastroenteropancreatic (GEP) neuroendocrine tumors; however, benefit from treatment is heterogeneous. The aim of the current study was to develop and validate a progression-free survival (PFS) prediction model in SSA-treated patients.

PATIENTS AND METHODS

We extracted data from the Spanish Group of Neuroendocrine and Endocrine Tumors Registry (R-GETNE). Patient eligibility criteria included GEP primary, Ki-67 of 20% or less, and first-line SSA monotherapy for advanced disease. An accelerated failure time model was developed to predict PFS, which was represented as a nomogram and an online calculator. The nomogram was externally validated in an independent series of consecutive eligible patients (The Christie NHS Foundation Trust, Manchester, United Kingdom).

RESULTS

We recruited 535 patients (R-GETNE, n = 438; Manchester, n = 97). Median PFS and overall survival in the derivation cohort were 28.7 (95% CI, 23.8 to 31.1) and 85.9 months (95% CI, 71.5 to 96.7 months), respectively. Nine covariates significantly associated with PFS were primary tumor location, Ki-67 percentage, neutrophil-to-lymphocyte ratio, alkaline phosphatase, extent of liver involvement, presence of bone and peritoneal metastases, documented progression status, and the presence of symptoms when initiating SSA. The GETNE-TRASGU (Treated With Analog of Somatostatin in Gastroenteropancreatic and Unknown Primary NETs) model demonstrated suitable calibration, as well as fair discrimination ability with a C-index value of 0.714 (95% CI, 0.680 to 0.747) and 0.732 (95% CI, 0.658 to 0.806) in the derivation and validation series, respectively.

CONCLUSION

The GETNE-TRASGU evidence-based prognostic tool stratifies patients with GEP neuroendocrine tumors receiving SSA treatment according to their estimated PFS. This nomogram may be useful when stratifying patients with neuroendocrine tumors in future trials. Furthermore, it could be a valuable tool for making treatment decisions in daily clinical practice.

Optimal duration of first-line chemotherapy for advanced gastric cancer: data from the AGAMENON registry

BACKGROUND

The optimal duration of first-line chemotherapy for patients with advanced gastric cancer is unknown. Diverse clinical trials have proposed different strategies including limited treatment, maintenance of some drugs, or treatment until progression.

METHOD

The sample comprises patients from the AGAMENON multicenter registry without progression after second evaluation of response. The objective was to explore the optimal duration of first-line chemotherapy. A frailty multi-state model was conducted.

RESULTS

415 patients were divided into three strata: discontinuation of platinum and maintenance with fluoropyrimidine until progression (30%, n = 123), complete treatment withdrawal prior to progression (52%, n = 216), and full treatment until progression (18%, n = 76). The hazard of tumor progression decreased by 19% per month with the full treatment regimen. However, we found no evidence that fluoropyrimidine maintenance (hazard ratio [HR] 1.07, confidence interval [CI] 95%, 0.69-1.65) worsened progression-free survival (PFS) with respect to treatment until progression. Predictive factors for PFS were ECOG performance status, ≥ 3 metastatic sites, prior tumor response, and bone metastases. Toxicity grade 3/4 was more common in those who continued the full treatment until progression vs fluoropyrimidine maintenance (16% vs 6%).

CONCLUSION

The longer duration of the full initial regimen exerted a protective effect on the patients of this registry. Platinum discontinuation followed by fluoropyrimidine maintenance yields comparable efficacy to treatment up to PD, with a lower rate of serious adverse events.

Efficacy and Toxicity of Weekly Carboplatin and Paclitaxel as Induction or Palliative Treatment in Advanced Esophageal Cancer Patients

Many patients have advanced esophageal cancer at diagnosis. However, the most optimal treatment has not been identified. Therefore, we evaluated a weekly regimen of carboplatin (area under the curve (AUC)) of 4 and paclitaxel at 100 mg/m² as an induction or palliative treatment. All patients with advanced (gastro)esophageal cancer treated with this regimen between 2002-2018 were included. Exclusion criteria were previous radiotherapy or treatment elsewhere. Data on toxicity, response, and survival were collected. Analyses were performed in two groups: induction (iCT) or palliative chemotherapy (pCT). Median progression free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method. A total of 291 patients was included (iCT: 122; pCT: 169). Most patients had T3 carcinoma (iCT: 54%; pCT: 66%) and stage IV disease (iCT: 42%; pCT: 91%). A toxicity grade ≥3 occurred mainly as hematological toxicity (iCT: 71%; pCT: 73%) and gastrointestinal toxicity (iCT: 3%; pCT: 5%). Response rates were 48% (iCT) and 44% (pCT). Esophagectomy or definitive chemoradiotherapy followed in 42% of iCT, resulting in a PFS of 22.1 months (interquartile range (IQR): 12.4-114.2) and OS of 26.8 months (IQR: 15.4-91.7). For pCT, PFS was 8.2 months (IQR: 5.1-14.5) and OS 10.9 months (IQR: 6.5-18.3). This retrospective cohort study demonstrated that weekly carboplatin (AUC4) and paclitaxel (100 mg/m²) is a well-tolerated and effective induction or palliative treatment regimen for patients with locally advanced or metastatic disease. Future research should directly compare this treatment regimen with other first-line treatment options to determine its true value for clinical practice.

Feasibility of CT radiomics to predict treatment response of individual liver metastases in esophagogastric cancer patients

In this study we investigate a CT radiomics approach to predict response to chemotherapy of individual liver metastases in patients with esophagogastric cancer (EGC). In eighteen patients with metastatic EGC treated with chemotherapy, all liver metastases were manually delineated in 3D on the pre-treatment and evaluation CT. From the pre-treatment CT scans 370 radiomics features were extracted per lesion. Random forest (RF) models were generated to discriminate partial responding (PR, >65% volume decrease, including 100% volume decrease), and complete remission (CR, only 100% volume decrease) lesions from other lesions. RF-models were build using a leave one out strategy where all lesions of a single patient were removed from the dataset and used as validation set for a model trained on the lesions of the remaining patients. This process was repeated for all patients, resulting in 18 trained models and one validation set for both the PR and CR datasets. Model performance was evaluated by receiver operating characteristics with corresponding area under the curve (AUC). In total 196 liver metastases were delineated on the pre-treatment CT, of which 99 (51%) lesions showed a decrease in size of more than 65% (PR). From the PR set a total of 47 (47% of RL, 24% of initial) lesions were no longer detected in CT scan 2 (CR). The RF-model for PR lesions showed an average training AUC of 0.79 (range: 0.74-0.83) and 0.65 (95% ci: 0.57-0.73) for the combined validation set. The RF-model for CR lesions had an average training AUC of 0.87 (range: 0.83-0.90) and 0.79 (95% ci 0.72-0.87) for the validation set. Our findings show that individual response of liver metastases varies greatly within and between patients. A CT radiomics approach shows potential in discriminating responding from non-responding liver metastases based on the pre-treatment CT scan, although further validation in an independent patient cohort is needed to validate these findings.

Prognostic impact of lactic dehydrogenase to albumin ratio in hepatocellular carcinoma patients with Child-Pugh I who underwent curative resection: a prognostic nomogram study

Background

Radical resection is the treatment of choice for hepatocellular carcinoma (HCC). However, even with this treatment, HCC prognosis and the efficacy of current predictive models for such patients remain unsatisfactory. Here, we describe an accurate and easy-to-use prognostic index for patients with HCC who have undergone curative resection.

Methods

The study population comprised of 1,041 patients with HCC who underwent curative resection at Zhongshan Hospital. This population was reduced to 768 patients who were treated in 2012 analyzed as the training cohort and 273 patients treated in 2007 who were used as a validation cohort.

Results

The lactic dehydrogenase to albumin ratio (LAR) was identified as a significant prognostic index for both overall survival and recurrence-free survival in two independent cohorts. The optimal cutoff value for LAR was determined to be 5.5. The C-index of LAR was superior to other inflammatory scores and serum parameters. This biomarker was also shown to be a stable predictive index in the validation cohort. The new nomogram combining LAR with the Barcelona Clinic Liver Cancer staging system had an improved ability to discriminate overall survival and recurrence-free survival. Nomogram predictions were consistent with observations based on calibration and decisive curve analysis in both independent cohorts.

Conclusion

LAR is a novel, convenient, reliable, and accurate prognostic predictor in patients with HCC undergoing curative resection. Our results suggest the recommendation of LAR to be used in routine clinical practice.

Prognostic and predictive factors for overall survival in metastatic oesophagogastric cancer: A systematic review and meta-analysis

BACKGROUND

Consistent evidence on prognostic and predictive factors for advanced oesophagogastric cancer is lacking. Therefore, we performed a systematic review and meta-analysis.

METHODS

We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for phase II/III randomised controlled trials (RCTs) until February 2017 on palliative systemic therapy for advanced oesophagogastric cancer that reported prognostic or predictive factors for overall survival (PROSPERO-CRD42014015177). Prognostic factors were identified from multivariate regression analyses in study reports. Factors were considered potentially clinically relevant if statistically significant (P ≤ 0.05) in multivariate analysis in ≥50% of the total number of patients in the pooled sample of the RCTs and were reported with a pooled sample size of ≥600 patients in the first-line or ≥300 patients in the beyond first-line setting. Predictive factors were identified from time-to-event stratified treatment comparisons and deemed potentially clinically relevant if the P-value for interaction between subgroups was ≤0.20 and the hazard ratio in one of the subgroups was significant (P ≤ 0.05).

RESULTS

Forty-six original RCTs were included (n = 15,392 patients) reporting on first-line (n = 33) and beyond first-line therapy (n = 13). Seventeen prognostic factors for overall survival in the first-line and four in the beyond first-line treatment setting were potentially clinically relevant. Twenty-one predictive factors in first-line and nine in beyond first-line treatment setting were potentially relevant regarding treatment efficacy.

CONCLUSIONS

The prognostic and predictive factors identified in this systematic review can be used to characterise patients in clinical practice, be included in future trial designs, enrich prognostic tools and generate hypotheses to be tested in future research to promote patient-centred treatment.

Biomarkers defining probability of receiving second-line targeted therapy in metastatic renal cell carcinoma

In order to facilitate long-term treatment decisions, we aimed to define biomarkers defining the probability of receiving second-line (SL) targeted therapy (TT) in patients with metastatic renal cell carcinoma (mRCC) based on their characteristics present at first-line TT initiation. We analysed 152 consecutive mRCC patients treated and used multivariable binominal logistic regression to identify factors contributing to the probability of receiving SL TT. Final model was assessed with bias-corrected indices (Nagelkerke’s R² and area under receiver operating characteristic curve [AUC]) and two bootstrap procedures were used for internal validation. Factors associated with the probability of SL TT eligibility were the presence of brain metastases (odds ratio [OR] 0.084, 95% confidence interval [CI] 0.010–0.707), number of metastatic sites (OR 0.740, 95% CI 0.575–0.953 per each site), platelet count (OR 0.971, 95% CI 0.947–0.997, per 10⁴/ml), lactate dehydrogenase level (OR 0.952, 95% CI 0.910–0.997 per 10 units/l), and albumin concentration (OR 1.924, 95% CI 1.057–3.503 per 1 g/dl). We developed on-line calculator that enables practicing clinicians to estimate SL treatment probability (http://www.r-calc.com).

Survival prediction tools for esophageal and gastroesophageal junction cancer: A systematic review

BACKGROUND

Clinical, pathological, and molecular information combined with cancer stage in prognostication algorithms can offer more personalized estimates of survival, which might guide treatment choices. Our aim was to evaluate the quality of prognostication tools in esophageal cancer.

METHODS

We systematically searched MedLine and Embase from 2005 to 2017 for studies reporting development or validation of models predicting long-term survival in esophageal cancer. We evaluated tools using the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies guidelines and the American Joint Committee on Cancer acceptance criteria for risk models.

RESULTS

We identified 16 prognostication tools for patients treated with curative intent and 1 for patients with metastatic disease. These tools frequently excluded adenocarcinoma, contained outdated data, and were developed with a limited sample size. Nine tools were developed in China for squamous cell cancer, and 11 used data on patients diagnosed before 2010. Most tools excluded key prognostic factors such as age and sex. Tumor stage and grade were the most commonly, but not universally, included factors. Twelve tools were designed to predict overall survival; 5 predicted cancer-specific survival. Bootstrap internal validation was performed for most tools; c-statistics ranged from 0.63 to 0.77 and graphically evaluated calibration was "good." Five tools were externally validated; c-statistics ranged from 0.70 to 0.77.

CONCLUSIONS

Existing tools cannot be confidently used for esophageal cancer prognostication in current clinical practice. Better-quality tools might help to more individually and accurately estimate disease course, select further treatments, and risk-stratify for future clinical trials.

New nomogram predicts the recurrence of hepatocellular carcinoma in patients with negative preoperative serum AFP subjected to curative resection

BACKGROUND

There is currently no established model for predicting the recurrence of hepatocellular carcinoma (HCC) in patients with negative alpha-fetoprotein (AFP) after curative resection. Therefore, the objective of this study was to establish a nomogram to identify the risk of recurrence in AFP-negative (<or = 20 ng/mL) patients with HCC.

METHODS

A retrospective study was conducted to establish the recurrence-free survival (RFS) nomogram in a training cohort of 326 AFP-negative HCC patients. The results were validated on a well-matched validation cohort in the literature.

RESULTS

Macrovascular tumour invasion (P = 0.018, HR = 1.642), macronodular cirrhosis (P < 0.001, HR = 2.128), tumor size (P = 0.004, HR = 1.691), and γ-glutamyl transferase (P = 0.039, HR = 1.496) were found to be independent risk factors for RFS in the training cohort, and all these factors were included in the nomogram. The C-index for RFS in the nomogram was 0.661, which was higher than that of the BCLC system (0.551), the CLIP score (0.537), and the prediction model of Ju (0.618). The high consistency between the nomogram prediction and actual observation was further demonstrated by the calibration curve. In the subsequent study, the better net benefit and higher threshold probability of the nomogram were determined by decision curve analysis, and these advantages were confirmed in the validation cohort.

CONCLUSIONS

The present RFS nomogram for AFP-negative HCC patients after curative resection provides an accurate and reliable prognostic model to facilitate recurrence surveillance. Once AFP-negative patients are predicted to have a high recurrence score, additional high-end imaging examinations, such as MRI or CT exams, should be considered, and the interval time of regular folow-up should be reduced.

Durable and Complete Response to Herceptin Monotherapy in Patients with Metastatic Gastroesophageal Cancer

Gastroesophageal cancer is the sixth leading cause of cancer-related death worldwide. The 2 most common histologies are squamous cell carcinoma and adenocarcinoma, which has seen an increase in incidence correlating with an increase in obesity in developed countries. Gastroesophageal adenocarcinoma has a preponderance to metastasize early, making it a highly lethal cancer with a low 5-year survival rate of ∼15-25%. Therefore, for the majority of patients, treatment focuses on palliation and prolongation of survival. Combination chemotherapy regimens, mostly platinum-based, have only modestly prolonged survival in patients with stage IV disease. Recently, it was discovered that the activation of the HER2 receptor plays an important role in a minority of adenocarcinomas of the distal esophagus and stomach. This introduced the treatment option of trastuzumab (Herceptin), a monoclonal antibody directed at the HER2 receptor, which has demonstrated improvement in overall and progression-free survival as noted in the ToGA trial. Currently, the role of Herceptin therapy beyond first-line therapy and outside of combination regimens is not well established. In this case report we review 2 cases of patients with gastroesophageal cancer, with HER2 overexpression, who achieved a robust response to trastuzumab in combination with chemotherapy and were able to maintain a durable response with maintenance trastuzumab monotherapy.

Establishment and validation of prognostic nomograms in first-line metastatic gastric cancer patients

Background

It remains unclear whether human epidermal growth factor receptor 2 (HER2) status is an outcome-associated biomarker independent of known prognostic factors for metastatic gastric cancer. Moreover, there are few reports about nomograms in inoperable locally advanced or metastatic gastric cancer (AGC), although several studies have been reported regarding other cancer types. This retrospective study aimed to develop nomograms that combine HER2 status and other prognostic factors to predict the survival outcomes of AGC patients starting first-line treatment.

Methods

In this study, 838 consecutive AGC patients starting first-line chemotherapy at the Aichi Cancer Center Hospital (ACC) were included to establish the nomograms that calculated the predicted probability of survival at different time points, 6 months and 1 and 2 years for overall survival (OS) and 3 and 6 months, and 1 year for progression free survival (PFS). Nomograms were independently validated with 269 consecutive AGC patients at the Cancer Center Hospital (SCC) who underwent first-line chemotherapy. The discriminatory ability and accuracy of the models were assessed using Harrell's c-index. IHC3+ or IHC2+/ISH+ tumors were defined as HER2 positive.

Results

At a median follow-up of 12.3 (ACC) and 11.6 (SCC) months, the median OS was 12.5 and 12.4 months (P=1.00), and the median PFS was 4.8 and 5.8 months (P=0.03), respectively. The nomograms showed good C-index values: OS was respectively 0.688 and 0.576 and PFS was respectively for 0.643 and 0.544.

Conclusions

The nomograms including HER2 status as covariate are crucial determinants of clinical care.

Efficacy and safety of chemotherapy in older versus non-older patients with advanced gastric cancer: A real-world data, non-inferiority analysis

OBJECTIVE

Advanced gastric cancer (AGC) is a common neoplasm in older adults. Nevertheless, there are few specific management data in the literature. The aim of this study was to assess non-inferiority of survival and efficacy-related outcomes of chemotherapy used in older vs non-older patients with AGC.

MATERIALS AND METHODS

We recruited 1485 patients from the AGAMENON registry of AGC treated with polychemotherapy between 2008-2017. A statistical analysis was conducted to prove non-inferiority for overall survival (OS) associated with the use of chemotherapy schedules in individuals ≥70 vs.<70years. The fixed-margin method was used (hazard ratio [HR]<1.176) that corresponds to conserving at least 85% efficacy.

RESULTS

33% (n=489) of the cases analyzed were ≥70 years. Two-agent chemotherapies and combinations with oxaliplatin (48% vs. 29%) were used more often in the older patients, as were modified schedules and/or lower doses. Toxicity grade 3-4 was comparable in both groups, although when looking at any grade, there were more episodes of enteritis, renal toxicity, and fatigue in older patients. In addition, toxicity was a frequent cause for discontinuing treatment in older patients. The response rate was similar in both groups. After adjusting for confounding factors, the non-inferiority of OS associated with schedules administered to the older vs. younger subjects was confirmed: HR 1.02 (90% CI, 0.91-1.14), P (non inferiority)=0.018, as well as progression-free survival: HR 0.97 (90% CI, 0.87-1.08), P(non-inferiority)=0.001.

CONCLUSION

In this AGC registry, the use of chemotherapy with schedules adapted to patients ≥70 years provided efficacy that was not inferior to that seen in younger cases, with comparable adverse effects.

Lauren subtypes of advanced gastric cancer influence survival and response to chemotherapy: real-world data from the AGAMENON National Cancer Registry

BACKGROUND

The choice of chemotherapy in HER2-negative gastric cancer is based on centre's preferences and adverse effects profile. No schedule is currently accepted as standard, nor are there any factors to predict response, other than HER2 status. We seek to evaluate whether Lauren type influences the efficacy of various chemotherapies and on patient overall survival (OS).

METHODS

We have conducted a multicenter study in 31 hospitals. The eligibility criteria include diagnosis of stomach or gastroesophageal junction adenocarcinoma, HER2 negativity, and chemotherapy containing 2-3 drugs. Cox proportional hazards regression adjusted for confounding factors, with tests of 'treatment-by-histology' interaction, was used to estimate treatment effect.

RESULTS

Our registry contains 1303 tumours analysable for OS end points and 730 evaluable for overall response rate (ORR). A decrease in ORR was detected in the presence of a diffuse component: odds ratio 0.719 (95% confidence interval (CI), 0.525-0.987), P=0.039. Anthracycline- or docetaxel-containing schedules increased ORR only in the intestinal type. The diffuse type displayed increased mortality with hazard ratio (HR) of 1.201 (95% CI, 1.054-1.368), P=0.0056. Patients receiving chemotherapy with docetaxel exhibited increased OS limited to the intestinal type: HR 0.65 (95% CI, 0.49-0.87), P=0.024, with no increment in OS for the subset having a diffuse component. With respect to progression-free survival (PFS), a significant interaction was seen in the effect of docetaxel-containing schedules, with better PFS limited to the intestinal type subgroup, in the comparison against any other schedule: HR 0.65 (95% CI, 0.50-0.85), P=0.015, and against anthracycline-based regimens: HR 0.64 (95% CI, 0.46-0.88), P=0.046.

CONCLUSIONS

As a conclusion, in this registry, Lauren classification tumour subtypes predicted survival and responded differently to chemotherapy. Future clinical trials should stratify effect estimations based on histology.