Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Immunotherapy or Targeted Therapy Versus Best Supportive Care for Advanced Gastric Cancer: A Systematic Review and Meta-analysis of Randomized Trials

PURPOSE

To assess the efficacy and safety of non-chemotherapy anticancer drugs (immunotherapy or targeted therapy) compared to best supportive care (BSC) or placebo for the treatment of advanced gastric cancer (GC).

METHODS

Systematic review of randomized controlled trials (RCTs) searching (May 2022) MEDLINE, EMBASE, CENTRAL, Epistemonikos, ClinicalTrials.gov, and PROSPERO. Certainty of evidence was evaluated following GRADE.

RESULTS

Six RCTs included. Targeted therapies likely result in a slight increase in overall survival (OS) (HR 0.84, 95% CI 0.75, 0.93; moderate certainty) and progression-free survival (PFS) (HR 0.52, 95% CI 0.43, 0.62; moderate certainty). Toxicity had a slightly increased risk (RR 1.19, 95% CI 0.95, 1.48; low certainty). Immunotherapy also showed a likely improvement in PFS (HR 0.60, 95% CI 0.49, 0.73; moderate certainty), while toxicity showed a likely higher risk (RR 2.72, 95% CI 1.24, 5.94; moderate certainty). However, benefits in survival translated to time gains of slightly over a month for OS and less than a month for PFS. No data were reported on performance status (PS), hospital admissions, or quality of life (QoL).

CONCLUSIONS

Our study suggests some survival benefits with low toxicity from these treatments, but gains are marginal. Uncertainties persist regarding their impact on QoL and outcomes for patients with poor PS. Caution is advised in treatment selection for advanced GC patients, who should actively participate in decision-making. Future research should include diverse patient populations and assess patient-centered outcomes with consistent comparator groups for BSC.

TRIAL REGISTRATION

The study protocol was registered in OSF ( https://doi.org/10.17605/OSF.IO/7CHX6 ) on 2022-04-01.

Selecting Targets for Molecular Imaging of Gastric Cancer: An Immunohistochemical Evaluation

PURPOSE

Tumor-targeted positron emission tomography (PET) and fluorescence-guided surgery (FGS) could address current challenges in pre- and intraoperative imaging of gastric cancer. Adequate selection of molecular imaging targets remains crucial for successful tumor visualization. This study evaluated the potential of integrin αvβ6, carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5), epidermal growth factor receptor (EGFR), epithelial cell adhesion molecule (EpCAM) and human epidermal growth factor receptor-2 (HER2) for molecular imaging of primary gastric cancer, as well as lymph node and distant metastases.

METHODS

Expression of αvβ6, CEACAM5, EGFR, EpCAM and HER2 was determined using immunohistochemistry in human tissue specimens of primary gastric adenocarcinoma, healthy surrounding stomach, esophageal and duodenal tissue, tumor-positive and tumor-negative lymph nodes, and distant metastases, followed by quantification using the total immunostaining score (TIS).

RESULTS

Positive biomarker expression in primary gastric tumors was observed in 86% for αvβ6, 72% for CEACAM5, 77% for EGFR, 93% for EpCAM and 71% for HER2. Tumor expression of CEACAM5, EGFR and EpCAM was higher compared to healthy stomach tissue expression, while this was not the case for αvβ6 and HER2. Tumor-positive lymph nodes could be distinguished from tumor-negative lymph nodes, with accuracy ranging from 82 to 93% between biomarkers. CEACAM5, EGFR and EpCAM were abundantly expressed on distant metastases, with expression in 88-95% of tissue specimens.

CONCLUSION

Our findings show that CEACAM5, EGFR and EpCAM are promising targets for molecular imaging of primary gastric cancer, as well as visualization of both lymph node and distant metastases. Further clinical evaluation of PET and FGS tracers targeting these antigens is warranted.

Postoperative changes in body composition after laparoscopic and open resection of colorectal liver metastases: data from the randomized OSLO-COMET trial

BACKGROUND

Low muscle mass is negatively associated with survival in patients undergoing surgery for colorectal cancer. Current evidence is limited regarding whether the surgical approach for liver resection of colorectal metastasis impacts postoperative changes in body composition and whether preoperative body composition can impact complication rate and survival.

METHOD

This study included patients previously included in the randomized OSLO-COMET trail where patients was allocated to laparoscopic or open liver resection for colorectal liver metastasis. CT scans 0-3 months before and 2-6 months after liver resection were segmented with the artificial intelligence-based tool BodySegAI to measure skeletal muscle mass (SM), visceral adipose tissue (VAT), and inter- and intramuscular adipose tissue (IMAT). SM, VAT and IMAT was compared between the open and laparoscopic group and as predictors for 5-year survival and postoperative complications.

RESULTS

This study included 216 patients, median age was 67, 127 (59%) were male, 91 (42%) had primary tumor in rectum and 86 (40%) had multiple liver metastasis. There was no significant difference in postoperative change in SM, VAT or IMAT between those undergoing laparoscopy or open surgery. In multivariate analysis, high preoperative IMAT was a predictor for increased risk of postoperative complications (HR (95% CI): 1.045 (CI 95%: 1.003-1.089), p = 0.034). Moreover, postoperative increase in IMAT was a negative predictor for 5-year survival (HR (95%CI):1.009 (1.003-1.016), p = 0.003).

CONCLUSION

Postoperative change in body composition did not differ between patients randomly assigned to open or laparoscopic liver resection for colorectal metastasis. High preoperative IMAT was associated with an increased risk of postoperative complications.

Baseline (derived) neutrophil-lymphocyte ratio associated with survival in gastroesophageal junction or gastric cancer treated with ICIs

Objective

We carried out the meta-analysis to determine the predictive value of baseline neutrophil to lymphocyte ratio (NLR) and derived neutrophil to lymphocyte ratio (dNLR) levels in patients with gastroesophageal junction or gastric cancer (GJGC) who underwent immune checkpoint inhibitor (ICI) treatment.

Methods

Eligible articles were obtained through PubMed, the Cochrane Library, EMBASE, and Google Scholar, until April 15, 2023. The clinical outcomes evaluated in this study encompassed overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR).

Results

A total of 24 articles with 2221 patients were included in this meta-analysis. The pooled results demonstrated that patients with high NLR levels had significantly poorer OS (HR: 1.860, 95% CI: 1.564-2.213, p < 0.001) and PFS (HR: 1.678, 95% CI: 1.354-2.079, p < 0.001), and lower ORR (OR: 0.754, 95% CI: 0.621-0.915, p = 0.004) and DCR (OR: 0.391, 95% CI: 0.262-0.582, p < 0.001). Besides, we also found that high dNLR levels were significantly associated with shorter OS (HR: 2.117, 95% CI: 1.590-2.820, p < 0.001) and PFS (HR: 1.803, 95% CI: 1.415-2.297, p < 0.001).

Conclusion

Low baseline (Derived) NLR has the potential to predict the good efficacy of ICIs and survival outcomes in patients with GJGC. (Derived) NLR could be useful in determining the optimal treatment strategies for these patients.

Patients' experiences in early satiety after total gastrectomy for gastric cancer: a phenomenological study

Introduction

This study examines how gastric cancer patients adjust their eating habits and quality of life after total gastrectomy, particularly concerning early satiety. While total gastrectomy may provide a potential cure, it also leads to significant physical, psychological, and social changes. Understanding these adaptations is essential for enhancing survivorship care.

Methods

We conducted a qualitative study utilizing a phenomenological approach to gain insights into the lived experiences of gastric cancer patients following total gastrectomy. Semi-structured interviews were analyzed to identify key themes related to eating habits and quality of life.

Results

Four core themes emerged: (1) Ineluctability of bodily transformations-patients experienced significant disruptions to their bodily identity; (2) Feelings of weaning and loss of habits-a sense of mourning for lost routines and pleasures; (3) Redefining habits-the process of adapting to new eating patterns; and (4) Experiencing tentative conviviality-struggles to restore social interactions around meals. Social anxiety, particularly regarding dining outside the home, was a notable challenge. Family caregivers played complex roles, providing both support and unintentional obstacles.

Discussion

The findings highlight the multifaceted impact of total gastrectomy on patients' lives, influencing their physical health, psychological well-being, and social dynamics. Survivorship care plans should consider these aspects to facilitate adaptation. Targeted interventions, such as nutritional counseling, telemonitoring, and digital tools, are suggested to assist patients in adjusting to post-gastrectomy life. These strategies could enhance quality of life and promote improved physical, psychological, and social well-being integration.

The Role of Metastasectomy in Patients with Liver-Only Metastases from Gastric Adenocarcinoma

BACKGROUND

The role of metastasectomy in patients with liver-only metastases from gastric adenocarcinoma remains under investigation. Therefore, we performed a national registry analysis comparing surgical treatment options for patients with gastric adenocarcinoma and liver-only metastases.

PATIENTS AND METHODS

In this retrospective National Cancer Database (2010-2019) study, adults (≥ 18 years) with gastric adenocarcinoma and liver-only metastases (no brain, bone, or lung metastases) were included. Patients were stratified into four groups: no surgical treatment, primary tumor resection (PTR), liver metastasectomy, and PTR with liver metastasectomy. Survival was evaluated using the Kaplan-Meier method, log-rank test, and Cox regression.

RESULTS

Of 10,977 included patients, 93.6% underwent no surgical treatment, 4.6% PTR alone, 0.8% liver metastasectomy alone, and 1.0% both PTR and liver metastasectomy. The median OS after no surgical treatment was 6.5 months, after PTR alone 10.9 months, after liver metastasectomy alone 9.9 months, and after PTR and liver metastasectomy 18.6 months. In multivariable analysis, when adjusting for age, sex, race/ethnicity, insurance status, Charlson-Deyo score, chemotherapy, and radiation, PTR and liver metastasectomy was associated with superior OS compared with no surgical treatment (HR 2.17, 95% CI 1.76-2.69, p < 0.001), PTR alone (HR 1.42, 95% CI 1.12-1.79, p = 0.003), and liver metastasectomy alone (HR 1.96, 95% CI 1.45-2.64, p < 0.001).

CONCLUSIONS

These data suggest that, in highly selected patients with gastric adenocarcinoma and synchronous liver-only metastases and favorable biology, surgical resection might grant a survival advantage.

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

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

Extensive methylation analysis of circulating tumor DNA in plasma of patients with gastric cancer

DNA methylation is known to be involved in tumor progression. This is the first study to perform an extensive methylation analysis of plasma circulating tumor DNA (ctDNA) using targeted bisulfite sequencing in gastric cancer (GC) patients to evaluate the usefulness of ctDNA methylation as a new biomarker. Sixteen patients who received chemotherapy for recurrent GC were included. After confirmation of the methylation status of 63 genes using the Cancer Genome Atlas (TCGA) dataset, the methylation status in paired tumor and non-tumor tissues and plasma were investigated using targeted bisulfite sequencing in these genes. Forty-four of the 63 genes were significantly hypermethylated in GC patients in the TCGA cohort. Of these 44 genes, hierarchical clustering showed that five (SPG20, FBN1, SDC2, TFPI2, SEPT9) were particularly hypermethylated in tumor compared to non-tumor tissues in our GC cohort. In plasma methylation analysis, patients with high methylation of these genes had significantly worse overall survival than those with low methylation (log-rank P = 0.009). In a patient who underwent blood sampling at multiple points, the methylation levels of these five genes varied closely with clinical tumor status. The plasma ctDNA methylation levels of these five genes could be useful as a noninvasive prognostic biomarker for GC.

Association Between Reconstruction Technique and Clinical Outcomes in Advanced Gastric Cancer Patients Undergoing Proximal Gastrectomy

BACKGROUND

There is an upward shift in the incidence and localization of gastric cancer (GC). Proximal gastrectomy (PG) has been advocated as an alternative operation for upper-third GC. An uneventful postoperative course is currently measured using a well-defined textbook outcome (TO), which represents a composite of surgical quality metrics. The aim of this study was to compare TO after two reconstruction methods following PG: double-tract reconstruction (DTR) and posterior esophagogastrostomy with partial neo-fundoplication (EGF).

MATERIALS AND METHODS

Primary proximal gastric adenocarcinoma patients who had undergone PG with DTR or EGF were included in this study. In a prospectively collected database, DTR and EGF were identified in 30 and 30 patients, respectively.

RESULTS

Patients with DTR had a 5.5-fold higher chance of achieving TO compared to those with EGF (OR = 5.67; p = 0.0266). No statistically significant differences in overall survival were noted when both reconstruction methods were compared.

CONCLUSION

In patients with proximal GC undergoing PG, TO is more likely to be achieved using DTR compared to EGF, with similar overall survival. Randomized controlled trials are warranted to indicate the preferred reconstruction technique after PG.

Effectiveness of neoadjuvant chemotherapy with a docetaxel, cisplatin, and S-1 (DCS) regimen for T4b gastric cancer

BACKGROUND

No studies on neoadjuvant chemotherapy for gastric cancer (GC) with T4b stage were reported. This study aimed to assess the effectiveness of neoadjuvant chemotherapy using DCS regimen (docetaxel, cisplatin, and S-1) for GC with T4b stage.

METHODS

Forty-three patients diagnosed GC with surgical or clinical T4b stage received three or four preoperative cycles of DCS therapy followed by gastrectomy and lymphadenectomy between Jan-2018 and Dec-2022. Short-tern outcomes including tumor response, completion of neoadjuvant chemotherapy, toxicity and adverse events, rate of treatment-related death, R0 resection, rate of complete adjuvant chemotherapy and short-term surgical results were investigated. The oncologic outcomes comprised 3-year OS and 3-year disease-free survival (DFS).

RESULTS

A total of 43 patients with T4b gastric cancer were included in the analysis. Among them, twenty-five patients underwent gastrectomy and lymphadenectomy. The completion rate of neoadjuvant chemotherapy was 88.4%, including 4 cycles of 51.2% and 3 cycles of 37.2%. The disease-control and clinical response rate were 88.4% and 58.1%, respectively. During preoperative chemotherapy, grade 3/4 neutropenia occurred in 20.9%, anemia in 13.9%, hyponatremia in 4.8%, and vomiting in 2.3%. Pathologic complete response was achieved in 8.0%. After surgery, no patient experienced severe complications (Clavien Dindo > = 3). The R0 resection rate was 72.0% and the rate of complete adjuvant chemotherapy was 83.3%. The 3-year OS and DFS rates were 49% and 38%, respectively.

CONCLUSIONS

Neoadjuvant chemotherapy with DCS regimen demonstrated a high tolerance, high tumor response rate, high complete adjuvant chemotherapy rate and satisfactory 3-year survival outcomes. Three- or four-course of preoperative DCS regimen is a promising approach for GC with T4b stage.

Research Progress of Liquid Biopsy Based on DNA Methylation in Tumor Diagnosis and Treatment

Liquid biopsy has been gradually applied to the clinical diagnosis and treatment of tumors because of its non-invasive and real-time reflection of the tumor status, as well as the convenience of sample collection, which allows the detection of primary or metastatic malignant tumors and reflects the heterogeneity of the tumors. DNA methylation, which is a type of epigenetic modification, is essential in the progression of tumors. This review introduces the common DNA methylation analysis methods and discusses their advantages and disadvantages, focusing on the new progress of DNA methylation-based liquid biopsy in tumor diagnosis and treatment.

Highly Sensitive Multiplexed Sensing of miRNAs in a Gastric Cancer Patient's Liquid Biopsy

Gastric cancer (GC) is one of the leading causes of cancer mortality in the world. Most patients are in the advanced stage of the disease at the time of diagnosis because the symptoms of early gastric cancer patients are not obvious. Early diagnosis of gastric cancer is still challenging due to the high cost, invasiveness, and low accuracy of traditional diagnostic methods such as endoscopy and biopsy. Herein, we develop clinically accurate and highly sensitive detection of multiple GC miRNA biomarkers in human serum using an isothermal nucleic acid primer exchange reaction (PER). The isothermal nucleic acid primer exchange reaction demonstrates high sensitivity and robustness, exemplified by a one-pot reaction achieving a detection limit of 28.71 fM. By quantifying the levels of three miRNA biomarkers selected through bioinformatics analysis in gastric cancer serum samples, the diagnostic approach effectively distinguished between clinical gastric cancer patients (n = 25) and noncancer controls (n = 10). The performance of our three-miRNA signature in discriminating between GC and controls was as follows: area under the curve (AUC): 0.808, sensitivity: 89%, specificity: 88%, positive predictive value (PPV): 96%, and negative predictive value (NPV): 70%.

Prime suspect or collective responsibility: Impact of specific lymph node station dissection on short- and long-term outcomes among locally advanced gastric cancer patients after neoadjuvant chemotherapy

BACKGROUND

Lymphatic route is the main pathway for gastric cancer (GC) spread, and lymph node (LN) involvement is a major prognostic factor after curative resection. The aim of this study was to assess the outcomes of specific LN station dissection.

METHODS

Patients with locally advanced (cT2-4N0-3M0) GC who underwent multimodal treatment between 2013 and 2023 were included in the study. Patients who had not undergone gastrectomy, had early (cT1) or metastatic GC, who had undergone multiorgan resections, palliative care, had died before the end of curative-intent planned treatment, or had incomplete clinical or pathological information were excluded. The primary endpoint was the development of serious complications, and the secondary outcome was OS.

RESULTS

Mulivariable analysis revealed, that among patients who received neoadjuvant chemotherapy (NAC), it was observed that station 10 lymphadenectomy was associated with a higher risk of serious postoperative complications. (27.6 % vs 8.7 %; OR = 3.28) Among the no-NAC group, it was observed that station 13 lymphadenectomy was associated with a higher risk of serious postoperative complications. (57.1 % vs 13.2 %; OR = 6.96). Among the NAC group, a lower risk of death was observed in patients with station 8 (HR = 0.53) or 11 lymphadenectomy (HR = 0.53).

CONCLUSION

While D2 lymphadenectomy remains crucial, particularly in in high-volume, experienced GC centers, the necessity of a more extensive D2+ lymphadenectomy is not supported by our findings. Moreover, we aimed to highlight the importance of tailored surgical approaches and emphasize the significance of LN station dissection in influencing both short-term complications and long-term survival outcomes.

Minimally Invasive Versus Open Distal Gastrectomy for Locally Advanced Gastric Cancer: Trial Sequential Analysis of Randomized Trials

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) has been shown to be associated with improved short-term outcomes compared to open distal gastrectomy (ODG) in patients with locally advanced gastric cancer (LAGC). The impact of MIDG on long-term patient survival remains debated. Aim was to compare the MIDG vs. ODG effect on long-term survival.

METHODS

Systematic review and trial sequential analysis (TSA) of randomized controlled trials (RCTs). Web of Science, Scopus, MEDLINE, the Cochrane Central Library, and ClinicalTrials.gov were queried. Hazard ratio (HR) and 95% confidence intervals (CI) were used as pooled effect size measures. Five-year overall (OS) and disease-free survival (DFS) were primary outcomes.

RESULTS

Five RCTs were included (2835 patients). Overall, 1421 (50.1%) patients underwent MIDG and 1414 (49.9%) ODG. The ages ranged from 48 to 70 years and 63.4% were males. The pooled 5-year OS (HR = 0.86; 95% CI 0.70-1.04; I2 = 0.0%) and 5-year DFS (HR = 1.03; 95% CI 0.87-1.23; I2 = 0.0%) were similar for MIDG vs. ODG. The TSA shows a cumulative z-curve without crossing the monitoring boundaries line (Z = 1.96), thus suggesting not conclusive 5-year OS and DFS results because the total information size was not sufficient.

CONCLUSIONS

MIDG and ODG seem to have equivalent 5-year OS and DFS in patients with LAGC. However, the cumulative evidence derived from the TSA showed that the actual information size is not sufficient to provide conclusive data.

The risk and distribution of second primary cancers according to subsite of primary stomach cancer: a retrospective cohort population-based study

Background

The development of second primary cancers (SPCs) following a diagnosis of stomach cancer presents a significant clinical challenge, with varying risks depending on the anatomic subsite of the primary tumor, patient demographics, and treatment modalities. This study aims to assess the risk of SPCs in stomach cancer survivors, focusing on differences across anatomic subsites, sex, age, and treatment periods.

Methods

The authors conducted a retrospective cohort study using data from stomach cancer patients, analyzing the incidence of SPCs based on the anatomic location of the primary tumor, with stratifications by sex, age, latency period, and year of diagnosis. Standardized incidence ratios (SIRs) were calculated to compare the observed SPC rates with those expected in the general population.

Results

Elevated stomach SPC risk was observed across most anatomic subsites, particularly in the body (SIR 8.84) and fundus (SIR 7.34). Females exhibited higher SIRs compared to males, especially in the fundus (SIR 13.33 for females vs. 4.55 for males). Younger patients (<50 years) had significantly higher SPC risks, particularly for cancers originating in the fundus (SIR 49.56). Notably, patients diagnosed after 2010 showed the highest SIRs, indicating a potential impact of advances in diagnostic and therapeutic modalities. Nonstomach SPCs, including colorectal, lung, and thyroid cancers, were significantly elevated, with distinct patterns based on the primary tumor site.

Conclusions

The study highlights the critical role of primary tumor location, sex, age, and treatment era in determining SPC risk in stomach cancer survivors. These findings underscore the need for tailored surveillance strategies to manage long-term cancer risks in this population.

Clinicopathological features and survival outcomes for gastric adenocarcinoma: Real-world single-center data

INTRODUCTION

Gastric cancer is the fifth most-common cancer and fourth common cause for cancer-related deaths globally. Surgery preceded or followed by chemotherapy or chemoradiotherapy is considered an optimal treatment for locally advanced gastric cancer. This study is a real-world data from a tertiary referral institute in southern India, in its experience with treating gastric adenocarcinoma over a period of four years with a minimum of two-year follow-up.

METHODS

This was a retrospective analysis of data of patients with histologically proven gastric adenocarcinoma enrolled in the Department of Medical Oncology from 2015 to 2018. The demographic details, presentation, staging, treatment received and outcomes of patients with gastric adenocarcinoma were collected and analyzed in this study.

RESULTS

Total 488 patients with gastric adenocarcinoma were included for the study. The stage-wise distribution of patients revealed early and locally advanced (45%) and metastatic (55%). The peritoneum and liver were the common sites of metastasis. The treatment distribution of these patients included perioperative chemotherapy followed by surgery (25 [5%]), surgery followed by adjuvant chemotherapy (65 [13%]), surgery alone (16 [3%]), perioperative chemotherapy alone (23 [4%]), palliative chemotherapy (274 [56%]) and supportive care (85 [17%]). The median overall survival for curative, palliative and supportive treatment was 23 (18-28), nine (7.6-10.4) and four (2.7-5.3) months, respectively. The two-year overall survival in the intention to treat population in the primary surgery (n = 81) and perioperative chemotherapy groups (n = 66) was 67.4% vs. 29.9% (p < 0.0001), respectively.

CONCLUSION

This study highlights the advanced nature of the presentation of gastric cancer patients and the poor rate of treatment completion. The median survival rates in curative patients remain to be dismally poor. The treatment sequence in curable gastric cancer of surgery followed by adjuvant chemotherapy vs. perioperative chemotherapy followed by surgery needs to be explored in our country.

Durable Complete Remission of Metastatic Gastric Cancer Following Platinum-Based Chemotherapy: A Case Report

Gastric cancer is a common type of gastrointestinal tract malignancy. It is characterized by a poor prognosis - median survival for metastatic disease is about 12 months. A small percentage of gastric cancer is characterized by high sensitivity to systemic treatment, resulting in deep and durable responses. Predictors for such hyper-responses are still under investigation, and a wide variety of possible mechanisms exist, including the DNA damage response, intracellular signaling, immune engagement, genetic alterations, and the tumor microenvironment. Here we present a case of a 59-year-old patient with human epidermal growth factor receptor-2 (HER-2)-negative, programmed death ligand-1 (PD-L1) negative, mismatch repair proficient (pMMR) metastatic gastric cancer who reached a particularly long progression-free survival (PFS) exceeding 93 months.

Impact of splenectomy on long-term outcomes after gastrectomy for gastric cancer: a population-based study

BACKGROUND

No national studies comparing long-term survival after total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation exist. This study aimed to examine the 5-year overall survival (OS) of patients with gastric adenocarcinoma who underwent total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation in a population-based nationwide setting.

METHODS

This study included all patients undergoing total or partial gastrectomy with splenectomy or spleen preservation for gastric adenocarcinoma in Finland from 2005 to 2016, with follow-up until December 31, 2019. A total of 2196 patients with gastric cancer diagnosis and total or partial gastrectomy were identified in the registries. Of these patients, 2118 were applicable for this study. Cox proportional hazard models provided hazard ratios (HRs) with 95% CIs of 5-year OS. The results were adjusted for age, sex, year of operation, comorbidities, tumor location, pathologic stage, and neoadjuvant therapy.

RESULTS

The observed 5-year OS rates were 38.7% in patients with no or minor spleen injury, 39.7% in patients with splenectomy due to injury, and 30.8% in patients with splenectomy due to oncologic reasons (P = .032). Patients who underwent R0 gastrectomy with splenectomy due to oncologic reasons had higher 5-year mortality (the adjusted model HR, 1.26; 95% CI, 1.01-1.56) than patients who underwent spleen preservation.

CONCLUSION

The OS was worst in patients who underwent gastrectomy with splenectomy due to oncologic reasons, highlighting the poor prognosis in patients with advanced gastric cancer. Splenectomy due to injury does not compromise the prognosis.

Cross-sectional imaging of gastric cancer: pearls, pitfalls and lessons learned from multidisciplinary conference

Gastric cancer is rising in prevalence associated with high mortality, primarily due to late-stage detection, underscoring the imperative for early and precise diagnosis. Etiology involves an interplay of genetic susceptibilities and environmental factors with a prominent role of Helicobacter pylori infection. Due to its often-delayed symptom presentation, prompt and accurate diagnosis is necessary. A multimodal imaging approach, including endoscopic ultrasound (EUS), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) is critical for accurate staging. Each modality contributes unique advantages and limitations, highlighting the importance of integrating diagnostic strategy. Moreover, multidisciplinary conferences offer a vital collaborative platform, bringing together specialists from diverse fields for treatment planning. This synergistic approach not only enhances diagnostic precision but also improves patient outcome. This review highlights the critical role of imaging in diagnosis, staging, and management and advocates for interdisciplinary collaboration in early detection and comprehensive management of gastric cancer, aiming to reduce mortality.

Surgical Resection Enhances Survival in Patients With Liver Metastases From Gastric Cancer: A Population-Based, Case-Control Study

Background and Aims

Gastric cancer with liver metastases (GCLM) is a challenging condition that significantly reduces long-term survival rates, but recent advancements in surgical techniques have shown promise. This study aims to comprehensively evaluate the impact of surgical resection on survival rates in GCLM patients.

Methods

We conducted a population-based analysis utilizing the SEER database for patients diagnosed with GCLM between 2010 and 2015. Overall survival (OS) was compared between patients who underwent cancer-directed surgery (CDS) and those who did not. The overlap weighting method based on lasso regression with penalty factors was employed to minimize selection bias. Survival outcomes were compared using Kaplan-Meier curves and Cox proportional hazards models, with subgroup analyses to further explore the effects of surgery among patients.

Results

A total of 3694 patients with GCLM were identified. Of those, 354 (9.58%) patients underwent CDS. After propensity score adjustment, The median OS was significantly higher in the surgical resection group (12 months, 95% confidence interval (CI) 11-16) compared to the nonresection group (6 months, 95% CI: 5-6). Cox regression analysis revealed a substantial improvement in OS for the surgical resection group, with a hazard ratio (HR) of 0.562 (95% CI: 0.482-0.656), including patients with adverse conditions.

Conclusions

The analysis demonstrated a clear association between surgical resection and enhanced OS in GCLM patients. Nevertheless, further research endeavors should be undertaken to identify specific prognostic factors that aid in the selection of optimal candidates for surgical resection.

Dioscin Impedes Proliferation, Metastasis and Enhances Autophagy of Gastric Cancer Cells via Regulating the USP8/TGM2 Pathway

Gastric cancer (GC) is one of the most common cancers worldwide. Dioscin has been shown to have anti-cancer effects in GC. The aim of this study is to explore a novel mechanism of dioscin in repressing GC progression. Cell viability, proliferation, apoptosis and invasion were measured by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT), 5-ethynyl-2'-deoxyuridine (EdU), flow cytometry and transwell assays, respectively. Monodansylcadaverine (MDC) staining was used to assess cell autophagy. The expression of transglutaminase-2 (TGM2), ubiquitin-specific peptidase 8 (USP8) and autophagy-related proteins was detected by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot. A xenograft tumor model was established to investigate the function of dioscin in vivo. Dioscin inhibited GC cell proliferation and invasion, but induced apoptosis and autophagy. TGM2 was highly expressed in GC, and dioscin suppressed GC progression by decreasing the protein level of TGM2. Furthermore, USP8 positively regulated TGM2 expression, and TGM2 overexpression reversed the inhibitory effect of USP8 knockdown on GC cell progression. USP8 abated the effect of dioscin in GC cells. Dioscin decreased the protein level of TGM2 via regulating USP8. In addition, dioscin restrained GC tumor growth in vivo. Dioscin played an anti-cancer effect in GC by enhancing cancer cell autophagy via regulating the USP8/TGM2 pathway.

Microsatellite Instability in Urine: Breakthrough Method for Bladder Cancer Identification

Bladder cancer (BC) is the most common neoplasm of the urinary system and ranks tenth in global cancer incidence. Due to its high recurrence rate and the need for continuous monitoring, it is the cancer with the highest cost per patient. Cystoscopy is the traditional method for its detection and surveillance; however, this is an invasive technique, while non-invasive methods, such as cytology, have a limited sensitivity. For this reason, new non-invasive strategies have emerged, analyzing useful markers for BC detection from urine samples. The identification of tumor markers is essential for early cancer detection and treatment. Urine analysis offers a non-invasive method to identify these markers. Microsatellite instability (MSI) has been proposed as a promising marker for tumor cell detection and guided targeted therapies. Therefore, this review aims to explore the evidence supporting the identification of MSI in exfoliated bladder tumor cells (EBTCs) in the urine, emphasizing its potential as a non-invasive and clinically effective alternative for tumor identification. Furthermore, establishing clinical guidelines is crucial for standardizing its application in oncological screening and validating its clinical utility.

NIT2 dampens BRD1 phase separation and restrains oxidative phosphorylation to enhance chemosensitivity in gastric cancer

5-Fluorouracil (5-FU) chemoresistance contributes to poor therapeutic response and prognosis of gastric cancer (GC), for which effective strategies to overcome chemoresistance are limited. Here, using a CRISPR-Cas9 system, we identified that nitrilase family member 2 (NIT2) reverses chemoresistance independent of its metabolic function. Depletion or low expression of NIT2 led to 5-FU resistance in GC cell lines, patient-derived organoids, and xenografted tumors. Mechanistically, NIT2 interacted with bromodomain-containing protein 1 (BRD1) to inhibit HBO1-mediated acetylation of histone H3 at lysine-14 (H3K14ac) and RELA-targeted oxidative phosphorylation (OXPHOS) gene expression. Upon 5-FU stimulation, NIT2 phosphorylation by Src at Y49 promoted the dissociation of NIT2 from BRD1, followed by binding to E3 ligase CCNB1IP1, causing autophagic degradation of NIT2. Consequently, reduced NIT2 protein resulted in BRD1 forming phase separation and binding to histone H3, as well as increased RELA stability due to suppression of inhibitor of growth family member 4-mediated RELA ubiquitination. In addition, NIT2 expression negatively correlated with H3K14ac and OXPHOS and positively correlated with the chemotherapeutic responses and prognosis of patients with GC. Our findings reveal the moonlighting function of NIT2 in chemoresistance and underscore that OXPHOS blockade by metformin enhances 5-FU chemosensitivity upon NIT2 loss.

Is Adjuvant Therapy Necessary for Stage IB Gastric Cancer: A Retrospective Cohort Study

BACKGROUND

The benefit of adjuvant therapy for patients with IB gastric cancer (GC) is a topic of debate. This study aimed to evaluate the benefit of adjuvant therapy for patients with IB GC.

METHODS

Overall, the study selected 510 IB GC patients after gastrectomy at the First Medical Center of the Chinese PLA General Hospital, Beijing, China between 2005 and 2018. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method and the log-rank test. Cox regression analyses were used to confirm the independent prognostic factors.

RESULTS

Patients who received postoperative adjuvant therapy had a longer 5-year OS (92.9 %) than those who received surgery alone (86.7 %; P < 0.05), but the 5-year DFS did not differ significantly between the two groups (92.6 vs. 95.0 %; P > 0.05). Moreover, DFS did not differ between monotherapy, and combination therapy. Uni- and multivariate analyses showed that older age was a significant risk factor for tumor recurrence. Subgroup analyses also failed to identify suitable candidates for chemotherapy.

CONCLUSIONS

Because adjuvant therapy did not demonstrate any benefits in terms of tumor recurrence or DFS, these treatment strategies may be unnecessary for IB GC patients after gastrectomy. Further studies are required to identify subgroups of IB GC patients who may benefit from adjuvant treatments.

Micronutrient deficiencies and anemia in the follow-up after gastroesophageal cancer surgery

Due to insufficient dietary intake and altered digestion and absorption of nutrients, patients after gastroesophageal cancer surgery are at risk of becoming malnourished and consequently develop micronutrient deficiencies. The aim of this study was to determine the prevalence of micronutrient deficiencies and anemia during follow-up after gastroesophageal cancer surgery. This single-center cross-sectional study included patients after resection for esophageal or gastric cancer visiting the outpatient clinic in 2016 and 2017. Only patients without signs of recurrent disease were included. All patients were guided by a dietician in the pre- and postoperative phase. Dietary supplements or enteral tube feeding was prescribed in case of inadequate dietary intake. Blood samples were examined for possible deficiencies or abnormalities in hemoglobin, prothrombin time, iron, ferritin, folic acid, calcium, zinc, vitamin A, vitamin B1, vitamin B6, vitamin B12, vitamin D and vitamin E. The percentage of patients with micronutrient deficiencies were scored. Of the 335 patients visiting the outpatient clinic, measurements were performed in 263 patients (221 after esophagectomy and 42 after gastrectomy), resulting in an inclusion rate of 79%. In the esophagectomy group, deficiencies in iron (36%), vitamin D (33%) and zinc (20%) were most prevalent. After gastric resection, deficiencies were most frequently observed in vitamin D (52%), iron (33%), zinc (28%) and ferritin (17%). Low levels of hemoglobin were found in 21% of patients after esophagectomy and 24% after gastrectomy. Despite active nutritional guidance, deficiencies in vitamin D, iron, zinc and ferritin, as well as low levels of hemoglobin, are frequently observed following gastroesophageal resection for cancer. These micronutrients should be periodically checked during follow-up and supplemented if needed.

Node Reporting and Data System Combined With Computed Tomography Radiomics Can Improve the Prediction of Nonenlarged Lymph Node Metastasis in Gastric Cancer

OBJECTIVES

To investigate the diagnostic performance of Node Reporting and Data System (Node-RADS) combined with computed tomography (CT) radiomics for assessing nonenlargement regional lymph nodes in gastric cancer (GC).

METHODS

Preoperative CT images were retrospectively collected from 376 pathologically confirmed of gastric adenocarcinoma from January 2019 to December 2023, with 605 lymph nodes included for analysis. They were divided into training (n = 362) and validation (n = 243) sets. Radiomics features were extracted from venous-phase, and the radiomics score was obtained. Clinical information, CT parameters, and Node-RADS classification were collected. A combined model was built using machine-learning approach and tested in validation set using receiver operating characteristic curve analysis. Further validation was conducted in different subgroups of lymph node short-axis diameter (SD) range.

RESULTS

Node-RADS score, SD, maximum diameter of thickness of tumor, and radiomics were identified as the most predictive factors. The results demonstrated that the integrated model combining SD, maximum diameter of thickness of tumor, Node-RADS, and radiomics outperformed the model excluding radiomics, yielding an area under the receiver operating characteristic curve of 0.82 compared with 0.79, with a statistically significant difference (P < 0.001). Subgroup analysis based on different SDs of lymph nodes also revealed enhanced diagnostic accuracy when incorporating the radiomics score for the 4- to 7.9-mm subgroups, all P < 0.05. However, for the 8- to 9.9-mm subgroup, the combination of the radiomics did not significantly improve the prediction, with an area under the receiver operating characteristic curve of 0.85 versus 0.85, P = 0.877.

CONCLUSION

The integration of radiomics scores with Node-RADS assessments significantly enhances the accuracy of lymph node metastasis evaluation for GC. This combined model is particularly effective for lymph nodes with smaller standard deviations, yielding a marked improvement in diagnostic precision.

CLINICAL RELEVANCE STATEMENT

The findings of this study indicate that a composite model, which incorporates Node-RADS, radiomics features, and conventional parameters, may serve as an effective method for the assessment of nonenlarged lymph nodes in GC.

Metformin in combination with chemotherapy increases apoptosis in gastric cancer cells and counteracts senescence induced by chemotherapy

Gastric cancer (GC) is the fourth leading cause of cancer death in the world, and there is a demand for new therapeutic agents to treat GC. Metformin has been demonstrated to be an antineoplastic agent in some types of cancer; however, it has not been sufficiently valued in treating GC because the effect of metformin in combination with chemotherapy regimens has not yet been evaluated. The present study aimed to evaluate the mechanisms underlying cell death induced by metformin alone or when combined with chemotherapy. The cytogenetic characteristics of the NCI-N87 cell line were determined by fluorescence in situ hybridization (FISH). To determine viability, the cells were treated with metformin, epirubicin, cisplatin, docetaxel and 5-fluorouracil (individually and at different concentrations). Subsequently, the cells were treated with metformin alone, and in combination with the chemotherapeutic drugs and the epirubicin + cisplatin + 5-fluorouracil, docetaxel + cisplatin + 5-fluorouracil, and cisplatin + 5-fluorouracil regimens. Cell viability, proliferation and mitochondrial membrane potential (ΔΨm) were analyzed by spectrophotometry. Apoptosis, caspase activity and cell cycle progression were assessed by flow cytometry. Finally, light microscopy was used to evaluate senescence and clonogenicity. The results revealed that metformin, alone and when combined with chemotherapy, increased the proportion of apoptotic cells, promoted the loss of ΔΨm, and induced apoptosis through caspase activity in GC cells. Moreover, metformin decreased cell proliferation. In addition, metformin alone did not induce senescence and it counteracted the effects of chemotherapy-induced senescence in GC cells. Additionally, metformin, alone and when combined with chemotherapy, decreased the clonogenic capacity of NCI-N87 GC cells. In conclusion, metformin may increase the effects of chemotherapy on NCI-N87 cell death and could represent an option to improve the treatment of GC.

Dual-energy CT quantitative parameters to evaluate occult peritoneal metastasis in advanced gastric cancer preoperatively

PURPOSE

To explore whether dual-energy CT (DECT) quantitative parameters could provide analytic value for the diagnosis of patients with occult peritoneal metastasis (OPM) in advanced gastric cancer preoperatively.

MATERIALS AND METHODS

This retrospective study included 219 patients with advanced gastric cancer and DECT scans. The patient's clinical data and DECT related iodine concentration (IC) parameters and effective atomic number (Zeff) were collated and analyzed among noun-peritoneal metastasis (NPM), OPM and radiologically peritoneal metastasis (RPM) groups. The predictive performance of the DECT parameters was compared with that of the conventional CT features and clinical characteristics through evaluating area under curve of the precision-recall (AUC-PR), F1 score, balanced accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Borrmann IV type diagnosed on CT and serum tumor indicator CA125 index were statistically different between the NPM and OPM groups. DECT parameters included IC, normalized IC (NIC), and Zeff of PM group were lower than the NPM group. The DECT predictive nomogram combined three independent DECT parameters produced a better diagnostic performance than the conventional CT feature Borrmann IV type and serum CA125 index in AUC-PR with 0.884 vs 0.368 vs 0.189, but similar to the combined indicator which was based on the DECT parameters, the conventional CT feature, and serum CA125 index in AUC-PR with 0.884 vs 0.918.

CONCLUSION

The lower quantitative NIC, IC ratio, and Zeff on DECT was associated with peritoneal metastasis in advanced gastric cancer and was promising to identify patients with OPM noninvasively.

1657 Resected Gastric Adenocarcinomas at a Single Institution: Outcomes and Trends over 17 Years

BACKGROUND

Outside of clinical trials, real-world data of advanced gastric cancers (AGCs) managed with perioperative or adjuvant chemotherapy with a backbone of D2 lymphadenectomy is limited.

PATIENTS AND METHODS

Curative resections for gastric adenocarcinoma between January 2003 and January 2020 at the Tata Memorial Centre were analyzed, comparing three time periods marking major increments in annual gastric resections (GRs).

RESULTS

1657 radical gastric resections were performed with a morbidity and mortality rate of 34.9% and 1.4%, respectively. Over three consecutive periods, the number of annual GRs increased from 56/year to 97/year to 156/year (P < 0.001) with a significant escalation in surgical magnitude and complexity. Improvement in surgical quality indicators (median lymph node yield from 15 to 25, P < 0.001 and margin negativity from 8.2 to 5.5%, P = 0.002) was observed with no corresponding increase in severe complications (6.9%) or mortality (1.4%). The proportion of distal and signet ring cancers was found to decrease over time, with an increase in proximal cancers and younger age at presentation. Overall, 90% of GRs were for AGCs with a median overall survival (OS) of 4.4 years (± 6 months), and 5-year OS rate of 47.6% (± 1.9%).

CONCLUSIONS

Change in pattern of tumor characteristics was observed. Aggressive treatment options for AGC were employed progressively with excellent survival. With increase in volumes, improvements in surgical quality indicators, and a relative improvement in postoperative mortality was observed. These results provide a roadmap for developing dedicated gastric cancer centers.

Prognostic Relevance of the Proximal Resection Margin Distance in Distal Gastrectomy for Gastric Adenocarcinoma

BACKGROUND

The risk for recurrence in patients with distal gastric cancer can be reduced by surgical radicality. However, dispute exists about the value of the proposed minimum proximal margin distance (PMD). Here, we assess the prognostic value of the safety distance between the proximal resection margin and the tumor.

PATIENTS AND METHODS

This is a single-center cohort study of patients undergoing distal gastrectomy for gastric adenocarcinoma (2001-2021). Cohorts were defined by adequacy of the PMD according to the European Society for Medical Oncology (ESMO) guidelines (≥ 5 cm for intestinal and ≥ 8 cm for diffuse Laurén's subtypes). Overall survival (OS) and time to progression (TTP) were assessed by log-rank and multivariable Cox-regression analyses.

RESULTS

Of 176 patients, 70 (39.8%) had a sufficient PMD. An adequate PMD was associated with cancer of the intestinal subtype (67% vs. 45%, p = 0.010). Estimated 5-year survival was 63% [95% confidence interval (CI) 51-78] and 62% (95% CI 53-73) for adequate and inadequate PMD, respectively. Overall, an adequate PMD was not prognostic for OS (HR 0.81, 95% CI 0.48-1.38) in the multivariable analysis. However, in patients with diffuse subtype, an adequate PMD was associated with improved oncological outcomes (median OS not reached versus 131 months, p = 0.038, median TTP not reached versus 88.0 months, p = 0.003).

CONCLUSION

Patients with diffuse gastric cancer are at greater risk to undergo resection with an inadequate PMD, which in those patients is associated with worse oncological outcomes. For the intestinal subtype, there was no prognostic association with PMD, indicating that a distal gastrectomy with partial preservation of the gastric function may also be feasible in the setting where an extensive PMD is not achievable.

Risk of Esophageal and Gastric Cancer in Patients with Type 2 Diabetes Receiving Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs): A National Analysis

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are becoming more popular in managing type 2 diabetes mellitus (T2DM). Concerns linger over potential links to malignancies like pancreatic and thyroid cancers, requiring more research to clarify their safety profiles. Additionally, evidence suggests GLP-1 RAs may lower colorectal and pancreatic cancer risk, especially in obese and overweight individuals, indicating a protective effect beyond weight loss. Current studies leave a gap in comprehensively understanding cancer risks associated with GLP-1 RAs, which prompts further research to enhance our understanding of their overall safety.

METHODS

We queried the US Collaborative Network (63 health care organizations) of the TriNetX research database. Patients with T2DM were identified and divided into two cohorts: patients on GLP-1 RAs and patients not on GLP-1 RAs. We excluded tobacco use and alcohol use disorders, obese patients with a body mass index (BMI) of >25 kg/m2, and those with a family history of gastrointestinal malignancy, infectious mononucleosis, chronic gastritis, pernicious anemia, helicobacter pylori infection, or gastroesophageal reflux disease (GERD). We used a 1:1 propensity score matching (PSM) model using patients' baseline characteristics, medications, labs, and genetics. We compared the rate of gastric cancer and esophageal cancer at the seven-year mark.

RESULTS

A total of 2,748,431 patients with T2DM were identified. Of those, 6% (n = 167,077) were on a GLP-1 RA and 94% (n = 2,581,354) were not on a GLP-1 RA. After PSM, both cohorts included 146,277 patients. Patients with T2DM who were on a GLP-1 RA, compared to those who were not, had a statistically significant lower risk of both gastric cancer (0.05% vs. 0.13%, p < 0.0001) and esophageal cancer (0.04% vs. 0.13%, p < 0.0001) at the seven-year mark.

CONCLUSION

The use of GLP-1 RAs in patients with T2DM does not significantly increase the risk of gastric or esophageal cancer. This finding supports the continued use of GLP-1 analogues as a therapeutic option in managing T2DM, considering their well-established benefits and low risk of complications. Based on the study results, these medications may even have a protective effect against these malignancies.

Modified Banxiaxiexin decoction benefitted chemotherapy in treating gastric cancer by regulating multiple targets and pathways

ETHNOPHARMACOLOGICAL RELEVANCE

Chemotherapy tolerance weakened efficacy of chemotherapy drugs in the treating gastric cancer (GC). Banxiaxiexin decoction (BXXXD) was widely used in digestive diseases for thousands of years in Traditional Chinese medicine (TCM). In order to better treat GC, three other herbs were added to BXXXD to create a new prescription named Modified Banxiaxiexin decoction (MBXXXD). Although MBXXXD potentially treated GC by improving chemotherapy tolerance, the possible mechanisms were still unknown.

AIM OF THE STUDY

To explore the therapeutic effect of MBXXXD on GC patients and explore the possible anti-cancer mechanism.

MATERIALS AND METHODS

A randomized controlled trial (n = 146) was conducted to evaluate the clinical efficacy between MBXXXD + chemotherapy (n = 73) and placebo + chemotherapy (n = 73) in GC patients by testing overall survival, progression free survival, clinical symptoms, quality of life score, tumor markers, T cell subpopulation, and adverse reactions. Network pharmacology was conducted to discover the potential mechanism of MBXXXD in treating GC. Metabolic activity assay, cell clone colony formation and mitochondrial apoptosis were detected in human GC cell lines including AGS cell, KNM-45 cell and SGC7901 cell treated by MBXXXD. Multiple pathways including P53, AKT, IκB, P65, P38, ERK, JNK p-AKT, p-P65, p-P38, p-ERK and p-JNK in AGS cell, KNM-45 cell and SGC7901 cell treated by MBXXXD and GC patients treated by MBXXXD + chemotherapy were also detected.

RESULTS

MBXXXD + chemotherapy promoted overall survival and progression free survival, improved clinical symptoms and quality of life score, increased T4 lymphocyte ratio and T8 lymphocyte ratio as well as T4/T8 lymphocyte ratio, and alleviated adverse reactions in GC patients. Network pharmacology predicted multiple targets and pathways of MBXXXD in treating GC including apoptosis, P53 pathway, AKT pathway, MAPK pathway. MBXXXD inhibited cell viability, decreased cell clone colony formation, and promoted mitochondrial apoptosis by producing reactive oxygen species (ROS), promoting mitochondrial permeability transition pore (MPTP) and the cleavage of pro-caspase-3 and pro-caspase-9, and decreasing mito-tracker red Chloromethyl-X-rosamine (CMXRos) in AGS cell, KNM-45 cell and SGC7901 cell. MBXXXD up-regulated the expression of P53 and IκB, and down-regulated the expression of p-AKT, p-P65, p-P38, p-ERK, p-JNK, AKT, P65, P38, ERK and JNK AGS cell, KNM-45 cell and SGC7901 cell treated by MBXXXD and GC patients treated by MBXXXD + chemotherapy.

CONCLUSION

MBXXXD benefitted chemotherapy for GC by regulating multiple targets and pathways.

Omentum preservation versus complete omentectomy in gastrectomy for gastric cancer (OMEGA trial): study protocol for a randomized controlled trial

BACKGROUND

Potentially curative therapy for locally advanced gastric cancer consists of gastrectomy, usually in combination with perioperative chemotherapy. An oncological resection includes a radical (R0) gastrectomy and modified D2 lymphadenectomy; generally, a total omentectomy is also performed, to ensure the removal of possible microscopic disease. However, the omentum functions as a regulator of regional immune responses to prevent infections and prevents adhesions which could lead to bowel obstructions. Evidence supporting a survival benefit of routine complete omentectomy during gastrectomy is lacking.

METHODS

OMEGA is a randomized controlled, open, parallel, non-inferiority, multicenter trial. Eligible patients are operable (ASA < 4) and have resectable (≦ cT4aN3bM0) primary gastric cancer. Patients will be 1:1 randomized between (sub)total gastrectomy with omentum preservation distal of the gastroepiploic vessels versus complete omentectomy. For a power of 80%, the target sample size is 654 patients. The primary objective is to investigate whether omentum preservation in gastrectomy for cancer is non-inferior to complete omentectomy in terms of 3-year overall survival. Secondary endpoints include intra- and postoperative outcomes, such as blood loss, operative time, hospital stay, readmission rate, quality of life, disease-free survival, and cost-effectiveness.

DISCUSSION

The OMEGA trial investigates if omentum preservation during gastrectomy for gastric cancer is non-inferior to complete omentectomy in terms of 3-year overall survival, with non-inferiority being determined based on results from both the intention-to-treat and the per-protocol analyses. The OMEGA trial will elucidate whether routine complete omentectomy could be omitted, potentially reducing overtreatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05180864. Registered on 6th January 2022.

MEST promotes immune escape in gastric cancer by downregulating MHCI expression via SHP2

BACKGROUND

Immune escape is a major obstacle to T-cell-based immunotherapy for cancers such as gastric cancer (GC). Mesoderm-specific transcript (MEST) is a tumor-promoting factor that regulates multiple oncogenic signaling pathways. However, the role of MEST-mediated immune escape is unclear.

METHODS

Bioinformatics analysis of MEST expression and enrichment pathways were performed Quantitative reverse transcription PCR (qPCR) or western blot was used to detect the expression of MEST, Src homology region 2-containing protein tyrosine phosphatase 2 (SHP2), Major histocompatibility class I (MHCI)-related genes. Cell function was assessed by Cell Counting Kit (CCK)-8, Transwell, Lactate dehydrogenase (LDH) kit, flow cytometry, enzyme-linked immunosorbent assay (ELISA), and immunohistochemistry (IHC). Xenograft nude mice and immune-reconstructed mice were used to test the effects of different treatments on tumor growth and immune escape in vivo.

RESULTS

MEST was upregulated in GC and promoted tumor proliferation, migration, and invasion. Rescue experiments revealed that TNO155 treatment or knockdown of SHP2 promoted the killing ability of CD8+ T cells and the expression of granzyme B (GZMB) and interferon-gamma (IFN-γ), and MEST overexpression reversed the effect. In vivo experiments confirmed that MEST promoted tumor growth, knockdown of MEST inhibited immune escape in GC, and that combination treatment with anti-PD-1 improved anti-tumor activity.

CONCLUSION

In this study, we demonstrated that MEST inhibited IFN-γ secretion from CD8+ T cells by up-regulating SHP2, thereby downregulating MHCI expression in GC cells to promote immune escape and providing a new T cell-based therapeutic potential for GC.

Association of pre-existing cardiovascular disease with administration of fluoropyrimidine chemotherapy in patients with gastrointestinal malignancies

Objective

Fluoropyrimidine chemotherapy is a first-line treatment for many gastrointestinal (GI) cancers, however, cardiotoxicity concerns may limit administration in patients with pre-existing cardiovascular disease (CVD). This study investigated the association of pre-existing CVD with use of fluoropyrimidine chemotherapy in tumour-eligible GI cancer patients.

Methods and analysis

National cancer registry data from the Virtual Cardio-Oncology Research Initiative from England between 2014 and 2018 was used to identify GI cancer patients eligible to receive fluoropyrimidine chemotherapy. Linkage to Hospital Episode Statistics and CVD registry data were used to ascertain prior CVD and outcomes. Primary outcome was first administration of fluoropyrimidine chemotherapy following cancer diagnosis. Cox proportional hazard models determined HR and 95% CIs for the association between initiation of fluoropyrimidine treatment and prior CVD.

Results

112 726 eligible patients were identified (median age 71 years (IQR 62-80), 39.7% female). 33 026 (29.3%) had pre-existing CVD. 73 392 (65.1%) patients had a diagnosis of colorectal, 23 208 (20.6%) oesophageal, 14 788 (13.1%) gastric and 1338 (1.2%) small bowel cancer. Individuals with pre-existing CVD had a 27% reduced rate of receiving fluoropyrimidine chemotherapy (HR, 0.73; 95% CI 0.70 to 0.75) on multivariable analysis. Significantly reduced rates of fluoropyrimidine administration were found across all subtypes of pre-existing CVD.

Conclusions

GI cancer patients with all types of pre-existing CVD are less likely to receive fluoropyrimidine chemotherapy despite eligibility. This suggests widespread caution regarding administration of fluoropyrimidines across this population; further research is needed to assess whether such conservatism is justified.

Deep learning-accelerated T2WI: image quality, efficiency, and staging performance against BLADE T2WI for gastric cancer

PURPOSE

The purpose of our study is to investigate image quality, efficiency, and diagnostic performance of a deep learning-accelerated single-shot breath-hold (DLSB) against BLADE for T2-weighted MR imaging (T2WI) for gastric cancer (GC).

METHODS

112 patients with GCs undergoing gastric MRI were prospectively enrolled between Aug 2022 and Dec 2022. Axial DLSB-T2WI and BLADE-T2WI of stomach were scanned with same spatial resolution. Three radiologists independently evaluated the image qualities using a 5-scale Likert scales (IQS) in terms of lesion delineation, gastric wall boundary conspicuity, and overall image quality. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated in measurable lesions. T staging was conducted based on the results of both sequences for GC patients with gastrectomy. Pairwise comparisons between DLSB-T2WI and BLADE-T2WI were performed using the Wilcoxon signed-rank test, paired t-test, and chi-squared test. Kendall's W, Fleiss' Kappa, and intraclass correlation coefficient values were used to determine inter-reader reliability.

RESULTS

Against BLADE, DLSB reduced total acquisition time of T2WI from 495 min (mean 4:42 per patient) to 33.6 min (18 s per patient), with better overall image quality that produced 9.43-fold, 8.00-fold, and 18.31-fold IQS upgrading against BALDE, respectively, in three readers. In 69 measurable lesions, DLSB-T2WI had higher mean SNR and higher CNR than BLADE-T2WI. Among 71 patients with gastrectomy, DLSB-T2WI resulted in comparable accuracy to BLADE-T2WI in staging GCs (P > 0.05).

CONCLUSIONS

DLSB-T2WI demonstrated shorter acquisition time, better image quality, and comparable staging accuracy, which could be an alternative to BLADE-T2WI for gastric cancer imaging.

Neoadjuvant Chemotherapy Does Not Improve Survival in cT2N0M0 Gastric Adenocarcinoma Patients: A Multicenter Propensity Score Analysis

BACKGROUND

According to current international guidelines, stage cT2N0M0 gastric adenocarcinoma warrants preoperative chemotherapy followed by surgery. However, upfront surgery is often preferred in clinical practice, depending on patient clinical status and local treatment preferences.

OBJECTIVE

The aim of the present study was to assess the impact of neoadjuvant chemotherapy in overall survival (OS) and disease-free survival (DFS) of cT2N0M0 patients.

METHODS

A retrospective analysis was performed among 32 centers, including gastric adenocarcinoma patients operated between January 2007 and December 2017. Patients with cT2N0M0 stage were divided into upfront surgery (S) and neoadjuvant chemotherapy followed by surgery (CS) groups. Inverse probability of treatment weighting (IPTW) was used to compensate for baseline differences between the groups.

RESULTS

Among the 202 patients diagnosed with cT2N0M0 stage, 68 (33.7%) were in the CS group and 134 (66.3%) were in the S group. CS patients were younger (mean age 62.7 ± 12.8 vs. 69.8 ± 12.1 years for S patients; p < 0.001) and had a better health status (World Health Organization performance status = 0 in 60.3% of CS patients vs. 34.5% of S patients; p = 0.006). During follow-up, recurrence occurred in 27.2% and 19.6% of CS and S patients, respectively, after IPTW (p = 0.32). Five-year OS was similar between CS and S patients (78.9% vs. 68.3%; p = 0.42), as was 5-year DFS (70.4% vs. 68.5%; p = 0.96). Neoadjuvant chemotherapy was associated with neither OS nor DFS in multivariable analysis after IPTW.

CONCLUSIONS

Patients with cT2N0M0 gastric adenocarcinoma did not present a survival or recurrence benefit if treated with perioperative chemotherapy followed by surgery as opposed to surgery alone.

Oligometastatic esophageal cancer cured by systemic therapy combined with radiotherapy to primary tumor and metastasis (metastasis-directed therapy)-small case series

The prognosis of metastatic esophageal cancer (EC) remains poor with an average life expectancy of around 9-12 months with standard systemic chemotherapy. The concept of oligometastatic disease (OMD) in EC cancer is controversial with no universally accepted definition. From the original cohort of metastatic oesophago-gastric (OG) cancer patients, 4 cases were identified that developed unusually favourable outcome with long-term survival and probable cure. In retrospect, all patients had OMD at presentation with striking similarities in terms of their clinical presentation, staging, treatment response and outcomes. All patients presented with locally advanced EC and 1-2 areas of metastatic disease (bone, lung, non-regional lymph node (LN) involvement). All were treated with combined therapeutic strategy using initial systemic chemotherapy followed by local radiotherapy to primary tumor and adjacent areas of visible/residual metastatic disease (metastasis-directed therapy). All patients experienced long-term survival (range = 7-13 years) with no evidence of recurrence and probable cure. The present case series adds to the growing pool of evidence indicating OM EC cancer represents a distinct and prognostically favorable subgroup.

Meta-Analysis of the Efficacy and Safety of Pembrolizumab in the Treatment of Advanced Gastric Cancer and Gastroesophageal Junction Cancer

INTRODUCTION

Pembrolizumab has been approved for the first-line treatment of patients with advanced gastric cancer (GC) and gastroesophageal junction (GEJ) cancer. However, the results of several clinical trials are not entirely consistent, and the dominant population of first-line immunotherapy for advanced GC/GEJ still needs to be precisely determined.

PURPOSE

The aim of this meta-analysis was to assess the efficacy and safety of pembrolizumab in the treatment of advanced GC/GEJ.

METHODS

We conducted computerized searches across multiple databases, including PubMed, Cochrane Library, Web of Science, and Embase. We established the inclusion criteria to comprise randomized clinical trials examining the efficacy of pembrolizumab in late-stage GC/GCJ cancer. We conducted a meta-analysis of outcome measures using STATA 14.0 software.

RESULTS

A total of six studies involving 1,448 cases were included in this analysis. The results of the meta-analysis indicate that, when compared to chemotherapy, patients in the pembrolizumab group experienced a significant reduction in the risk of mortality in terms of overall survival (OS) (hazard ratio [HR] = 0.72, 95% confidence interval [CI]: 0.65-0.79, p < 0.01). In terms of progression-free survival (PFS), pembrolizumab was associated with a similar PFS as compared to chemotherapy (HR = 0.88, 95% CI: 0.73-1.07, p = 0.206). Subgroup analyses based on PD-L1 expression levels indicated a significantly longer PFS with pembrolizumab in subgroups of patients with PD-L1 CPS ≥10 but not in those with PD-L1 CPS ≥1 and PD-L1 CPS ≥5. Subgroup analyses based on distinct geographical regions revealed a comparable effect of PFS in patients residing in Asia or the USA Subgroup analysis based on tumor sites consistently demonstrated a similar effect of PFS in patients with EC/GEJ tumors and GC patients.

CONCLUSION

Our findings demonstrated that pembrolizumab led to a significant extension in OS and objective response rate, along with a favorable tolerability profile compared to chemotherapy. Furthermore, the observed survival benefits were particularly pronounced in subgroup patients with a CPS of ≥10. Given the potential limitations inherent in our study, it is imperative to underscore the necessity for further large-scale RCTs to corroborate our results.

Histopathologic response in patients with curative resection with D2 dissection following neoadjuvant treatment for locally advanced gastric and esophagogastric junction adenocarcinoma

AIM

This study evaluated pathologic response rate, overall survival (OS), and postoperative complications in locally advanced gastric cancer (GC) and esophagogastric junction (EGJ) adenocarcinoma patients who underwent curative gastric resection D2 lymph node dissection with neoadjuvant treatment.

METHODS

We reviewed the medical records of 122 patients with locally advanced GC and EGJ adenocarcinoma who had neoadjuvant treatment and curative resection with D2 dissection between January 2014 and December 2022. Patients were divided into responders and nonresponders. Grades 1a-1b were responders, while 2-3 were non-responders. Patients' clinicopathological features, pathologic response rate, survival, and postoperative complications were evaluated. We assessed complications using the Clavien-Dindo (CD) classification. Total survival was assessed using the Kaplan-Meier model. Overall survival was assessed using univariate and multivariate Cox regression analysis.

RESULTS

The mean age of the study participants was 61 (N = 89 males; N = 33 females). There were 79 GC and 43 EGJ adenocarcinomas. Overall postoperative complications (CD ≥ II) were 27 %. Postoperative complications were similar in responders and non-responders (p = 0.316). YpT0N0 had a 2.5 % pathological complete response rate. Responders had better overall survival, but there was no statistical difference.

CONCLUSIONS

Both responder and non-responder groups have similar postoperative complications. A complete pathologic response is discouraging for assessing neoadjuvant chemotherapy for locally advanced gastric cancer, but a positive treatment response is acceptable. Pathologic response rate helps stage and predict gastric cancer prognosis. Responder groups survive slightly better.

Identification of prognostic factors for survival in patients with metastatic gastric adenocarcinoma in a Mexican population

INTRODUCTION AND AIMS

Gastric adenocarcinoma is among the high-ranking tumors, with respect to frequency and mortality, worldwide. The inflammatory process and immune system activity are associated with oncologic control. Our aim was to identify whether the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and other variables are prognostic factors for survival in patients with metastatic gastric cancer in a Mexican population.

MATERIAL AND METHODS

Patients diagnosed with metastatic gastric adenocarcinoma, hospitalized within the time frame of December 2011 to 2021, were analyzed. The NLR, PLR, and albumin and hemoglobin levels obtained from blood samples were calculated. Functional status (ECOG and Karnofsky), sex, histology, and the presence of signet ring cells were also considered possible prognostic factors. Each factor's prognostic value for overall survival was determined through univariate and multivariate analyses.

RESULTS

The study included 956 patients diagnosed with metastatic gastric cancer, of whom 494 (51.7%) were men and 462 (48.3%) were women. The main histologic finding was diffuse adenocarcinoma (n = 619, 64.7%), followed by intestinal adenocarcinoma (n = 293, 30.6%), and the presence of signet ring cells was found in 659 (68.9%) patients. Diagnostic laparoscopy was performed on 238 patients (24.9%) to confirm peritoneal carcinomatosis. The multivariate analysis showed that an NLR above 3.2 (HR 1.51, 95% CI 1.27-1.8; p < 0.001), albumin below 3.5 g/dl (HR 1.25, CI 1.06-1.47; p = 0.006), and an ECOG performance status of 2 or higher (HR 1.39, CI 1.10-1.76; p = 0.005) were independent factors that predicted a lower survival rate, whereas a Karnofsky score above 70% (HR 0.69, CI 0.53-0.91; p = 0.008) was associated with a better survival rate. Lastly, the PLR was not statistically significant in the multivariate analysis.

CONCLUSIONS

The NLR, nutritional status assessed through albumin measurement, and functional status can act as independent prognostic survival factors in hospitalized Mexican patients diagnosed with metastatic gastric adenocarcinoma and be taken into account during therapeutic decision-making.

Impact of Neoadjuvant Treatment on Body Composition in Patients with Locally Advanced Gastric Cancer

Neoadjuvant chemotherapy (NT) followed by radical surgery is the standard treatment for locally advanced gastric cancer (GC). The incidence of sarcopenia in upper gastrointestinal tract malignancies is very high, and it may be increased after NT. This study aimed to evaluate the impact of NT on body composition. A retrospective study of patients with locally advanced GC undergoing gastrectomy who had received NT in a tertiary hospital between 2012 and 2019 was conducted. CT measured the skeletal muscle index, total psoas area, and visceral and subcutaneous adipose tissue before and after NT. Of the 180 gastrectomies for GC, 61 patients received NT. During NT, changes in body composition were observed with a decrease in the skeletal muscle mass index (SMMI -2.5%; p < 0.001), and these changes were significantly greater in men (SMMI -10.55%). Before surgery, patients who received NT presented 15% more sarcopenia than those without NT (p = 0.048). In conclusion, patients with locally advanced gastric cancer who receive NT have significant changes in body composition during chemotherapy. These changes, which are at the expense of a loss of muscle mass, lead to an increased incidence of pre-surgical sarcopenia.

Plasma circulating tumor DNA unveils the efficacy of PD-1 inhibitors and chemotherapy in advanced gastric cancer

Programmed Death Receptor 1 (PD-1) inhibitors, when combined with chemotherapy, have exhibited notable effectiveness in enhancing the survival outcomes of patients afflicted with advanced gastric cancer. However, it is important to acknowledge that not all patients derive substantial benefits from this therapeutic approach, highlighting the crucial necessity of identifying efficacious biomarkers to inform immunotherapy interventions. In this study, we sought to investigate the predictive utility of circulating tumor DNA (ctDNA) as a biomarker in a cohort of 30 patients diagnosed with advanced gastric cancer, all of whom underwent first-line treatment involving PD-1 inhibitor administration alongside chemotherapy. We procured peripheral blood samples both at baseline and following the completion of two treatment cycles. Additionally, baseline tissue specimens were collected for the purpose of genomic alteration assessment, employing both 47-gene and 737-gene next-generation sequencing panels for plasma and tumor tissue, respectively. We delineated a ctDNA response as the eradication of maximum variant allele frequencies relative to baseline levels. Notably, the objective response rate among individuals exhibiting a ctDNA response proved significantly superior in comparison to non-responders (P = 0.0073). Furthermore, patients who manifested a ctDNA response experienced markedly prolonged progression-free survival (PFS) and overall survival (OS) when juxtaposed with those devoid of a ctDNA response (median PFS: 15.6 vs. 6.0 months, P = 0.003; median OS: not reached [NR] vs. 9.0 months, P = 0.011). In summation, patients with advanced gastric cancer receiving first-line treatment with PD-1 inhibitors and chemotherapy, dynamic changes in ctDNA can serve as a potential biomarker for predicting treatment efficacy and long-term outcomes.

Real-World Efficacy and Safety of First-Line Nivolumab Plus Chemotherapy in Patients with Advanced Gastric, Gastroesophageal Junction, and Esophageal Adenocarcinoma: A Nationwide Observational Turkish Oncology Group (TOG) Study

Based on the CheckMate 649 trial, nivolumab plus chemotherapy is the recommended first-line treatment for HER2-negative unresectable advanced or metastatic gastric, gastroesophageal junction (GEJ), or esophageal adenocarcinoma. This nationwide, multicenter, retrospective study evaluated the real-world effectiveness of this regimen in Turkish patients and identified subgroups that may experience superior outcomes. Conducted across 16 oncology centers in Turkey, this study retrospectively reviewed the clinical charts of adult patients diagnosed with HER2-negative unresectable advanced or metastatic gastric, GEJ, or esophageal adenocarcinoma from 2016 to 2023. This study included 111 patients (54 women, 57 men) with a median age of 58 years. The median progression-free survival (PFS) and overall survival (OS) were 11.7 months and 18.2 months, respectively, whereas the objective response rate (ORR) was 70.3%. Multivariable analyses revealed that previous curative surgery was a favorable independent prognostic factor for both PFS and OS. Conversely, an Eastern Cooperative Oncology Group performance status of 2 emerged as an adverse independent prognostic factor for OS. The safety profile of nivolumab plus chemotherapy was found to be manageable. Our findings support the use of nivolumab plus chemotherapy for the first-line treatment of Turkish patients with HER2-negative unresectable advanced or metastatic gastric, GEJ, or esophageal adenocarcinoma. Patient selection based on clinical characteristics is crucial for optimizing treatment outcomes.

Comparison of the predictive performance of three lymph node staging systems for late-onset gastric cancer patients after surgery

Introduction

Lymph node (LN) status is a vital prognostic factor for patients. However, there has been limited focus on predicting the prognosis of patients with late-onset gastric cancer (LOGC). This study aimed to investigate the predictive potential of the log odds of positive lymph nodes (LODDS), lymph node ratio (LNR), and pN stage in assessing the prognosis of patients diagnosed with LOGC.

Methods

The LOGC data were obtained from the Surveillance, Epidemiology, and End Results database. This study evaluated and compared the predictive performance of three LN staging systems. Univariate and multivariate Cox regression analyses were carried out to identify prognostic factors for overall survival (OS). Three machine learning methods, namely, LASSO, XGBoost, and RF analyses, were subsequently used to identify the optimal LN staging system. A nomogram was built to predict the prognosis of patients with LOGC. The efficacy of the model was demonstrated through receiver operating characteristic (ROC) curve analysis and decision curve analysis.

Results

A total of 4,743 patients with >16 removed lymph nodes were ultimately included in this investigation. Three LN staging systems demonstrated significant performance in predicting survival outcomes (P < 0.001). The LNR exhibited the most important prognostic ability, as evidenced by the use of three machine learning methods. Utilizing independent factors derived from multivariate Cox regression analysis, a nomogram for OS was constructed.

Discussion

The calibration, C-index, and AUC revealed their excellent predictive performance. The LNR demonstrated a more powerful performance than other LN staging methods in LOGC patients after surgery. Our novel nomogram exhibited superior clinical feasibility and may assist in patient clinical decision-making.

Gastric Cancer Survivorship: Multidisciplinary Management, Best Practices and Opportunities

PURPOSE

Gastric cancer is the 5th most common malignancy worldwide. As early detection increases and treatments for gastric cancer improve, the number of gastric cancer survivors grows.

METHODS

Here, we review the diagnosis and management of gastric cancer and discuss important considerations for gastric cancer survivorship including cancer surveillance, weight loss, malnutrition, fatigue, specific complications related to surgery and radiation, quality of life in gastric cancer survivorship, health behavior, and models of survivorship.

RESULTS

Multimodality therapy with chemotherapy and surgery can result in chronic toxicities in multiple organ systems. This emphasizes the need for a multidisciplinary survivorship care model including cancer surveillance, management of chronic toxicities, and optimization of modifiable risk factors with long-term involvement of appropriate providers.

CONCLUSION

Adequately caring for gastric cancer survivors requires a coordinated, multidisciplinary approach.

Interaction of microbiota, mucosal malignancies, and immunotherapy-Mechanistic insights

The microbiome has emerged as a crucial modulator of host-immune interactions and clearly impacts tumor development and therapy efficacy. The microbiome is a double-edged sword in cancer development and therapy as both pro-tumorigenic and anti-tumorigenic bacterial taxa have been identified. The staggering number of association-based studies in various tumor types has led to an enormous amount of data that makes it difficult to identify bacteria that promote tumor development or modulate therapy efficacy from bystander bacteria. Here we aim to comprehensively summarize the current knowledge of microbiome-host immunity interactions and cancer therapy in various mucosal tissues to find commonalities and thus identify potential functionally relevant bacterial taxa. Moreover, we also review recent studies identifying specific bacteria and mechanisms through which the microbiome modulates cancer development and therapy efficacy.

Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study

BACKGROUND

Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging.

MATERIALS AND METHODS

In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3-4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations).

RESULTS

18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870-1253 in the sensitivity analysis.

CONCLUSIONS

For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs.

TRIAL REGISTRATION

NCT03208621. This trial was registered prospectively on 30-06-2017.