Current status of perioperative chemotherapy for locally advanced gastric cancer and JCOG perspectives

Minimally invasive versus open gastrectomy for gastric cancer. A pooled analysis of two European randomized controlled trials

INTRODUCTION

Minimally invasive techniques have shown better short term and similar oncological outcomes compared to open techniques in the treatment of gastric cancer in Asian countries. It remains unknown whether these outcomes can be extrapolated to Western countries, where patients often present with advanced gastric cancer.

MATERIALS AND METHODS

A pooled analysis of two Western randomized controlled trials (STOMACH and LOGICA trial) comparing minimally invasive gastrectomy (MIG) and open gastrectomy (OG) in advanced gastric cancer was performed. Postoperative recovery (complications, mortality, hospital stay), oncological outcomes (lymph node yield, radical resection rate, 1-year survival), and quality of life was assessed.

RESULTS

Three hundred and twenty-one patients were included from both trials. Of these, 162 patients (50.5%) were allocated to MIG and 159 patients (49.5%) to OG. A significant difference was seen in blood loss in favor of MIG (150 vs. 260 mL, p < 0.001), whereas duration of surgery was in favor of OG (180 vs. 228.5 min, p = 0.005). Postoperative recovery, oncological outcomes and quality of life were similar between both groups.

CONCLUSION

MIG showed no difference to OG regarding postoperative recovery, oncological outcomes or quality of life, and is therefore a safe alternative to OG in patients with advanced gastric cancer.

Neoadjuvant chemotherapy for locally advanced gastric cancer in Japan: Consensus meeting at the 77th general meeting of the Japanese Society of Gastroenterological Surgery

Treatment strategy for locally advanced gastric cancer differs worldwide. Neoadjuvant chemotherapy (NAC) is considered one of the promising treatment options for locally advanced gastric cancer, even in Japan, and clinical trials have been conducted or are ongoing. A consensus meeting was organized at the 77th general meeting of the Japanese Society of Gastroenterological Surgery in 2022, in which the current status and future prospects of NAC for locally advanced gastric cancer were discussed. Participants at the meeting looked forward to the results of the JCOG1509 trial, providing solid evidence regarding NAC. The optimal indications and regimens for NAC were also debated. Patients with cStage III gastric cancer are the main targets of NAC in Japan, and a doublet regimen of S-1 and oxaliplatin was preferred by the participants. However, the feasibility of a triplet regimen with S-1, oxaliplatin, and docetaxel, and that with 5-FU, leucovorin, oxaliplatin, and docetaxel has been demonstrated, and these could become treatment options in Japan. Other points of discussion include perioperative chemotherapy to avoid peritoneal recurrence and for patients with dMMR/MSI-high tumors. The panel regarded NAC as a promising treatment option, and NAC will become the standard treatment for cStage III gastric cancer in Japan if an ongoing clinical trial successfully demonstrates its efficacy.

Protocol digest of a phase III trial to evaluate the efficacy of preoperative chemotherapy with S-1 plus oxaliplatin followed by D2 gastrectomy with postoperative S-1 in locally advanced gastric cancer: Japan Clinical Oncology Group study JCOG1509 (NAGISA Trial)

In Japan, postoperative chemotherapy is a standard care for stage II/III gastric cancer after curative resection with D2 lymph node dissection, and the clinical outcomes of patients with stage III gastric cancer are unsatisfactory. A combination of oral S-1 and oxaliplatin, that is the standard chemotherapy regimen for unresectable advanced/recurrent gastric cancer associated with a high response rate, was considered the most promising preoperative chemotherapy regimen. This randomized phase III trial was started in September 2016 to confirm the superiority of preoperative chemotherapy with S-1 plus oxaliplatin followed by D2 gastrectomy with postoperative chemotherapy compared with D2 gastrectomy with postoperative chemotherapy for patients with clinical T3–4N1–3 M0 locally advanced gastric cancer in terms of overall survival. A total of 470 patients will be enrolled from 63 hospitals in Japan for 8.5 years. This trial has been registered in the Japan Registry of Clinical Trials as jRCTs031180350 [https://jrct.niph.go.jp/latest-detail/jRCTs031180350].

Transcriptomic profiling on localized gastric cancer identified CPLX1 as a gene promoting malignant phenotype of gastric cancer and a predictor of recurrence after surgery and subsequent chemotherapy

BACKGROUND

Localized gastric cancer (GC) becomes fatal once recurring. We still have room for improving their prognoses.

METHODS

Transcriptomic analysis was done on surgically resected specimens of 16 patients with UICC stage III GC who underwent curative gastrectomy and adjuvant oral fluoropyrimidine monotherapy. Four of them were free from disease for longer than 5 years, and the others experienced metachronous metastasis within 2 years after surgery. Quantitative RT-PCR determined mRNA expression levels of primary gastric cancer tissues, which were collected from 180 patients who underwent gastric resection for stage II-III GC without preoperative treatment between 2001 and 2014. We tested alteration of malignant phenotypes including drug resistance of GC cell lines by siRNA and shRNA-mediated knockdown and forced expression experiments.

RESULTS

CPLX1 was identified as a candidate biomarker for GC recurrence among 57,749 genes. Inhibiting and forced expression experiments indicated that CPLX1 promotes proliferation, motility, and invasiveness of GC cells, and decreases apoptosis and sensitivity to fluorouracil. Subcutaneous xenograft mouse models revealed that shRNA-mediated knockdown of CPLX1 also attenuated tumor growth of MKN1 cells in vivo. Overexpression of CPLX1 in gastric cancer tissue correlated with worse prognosis and was an independent risk factor for peritoneal recurrence in subgroups receiving adjuvant chemotherapy.

CONCLUSIONS

CPLX1 may represent a biomarker for recurrence of gastric cancer and a target for therapy.

Short and long-term outcomes between laparoscopic and open total gastrectomy for advanced gastric cancer after neoadjuvant chemotherapy

BACKGROUND

Neoadjuvant chemotherapy (NACT) combined with surgery is regarded as an effective treatment for advanced gastric cancer (AGC). Laparoscopic surgery represents the mainstream of minimally invasive surgery. Currently, surgeons focus more on surgical safety and oncological outcomes of laparoscopic gastrectomy after NACT. Thus, we sought to evaluate short- and long-term outcomes between laparoscopic total gastrectomy (LTG) and open total gastrectomy (OTG) after NACT.

AIM

To compare the short and long-term outcomes between LTG and OTG for AGC after NACT.

METHODS

We retrospectively collected the clinicopathological data of 136 patients who accepted gastrectomy after NACT from June 2012 to June 2019, including 61 patients who underwent LTG and 75 who underwent OTG. Clinicopathological characteristics between the LTG and OTG groups showed no significant difference. SPSS 26.0, R software, and GraphPad PRISM 8.0 were used to perform statistical analyses.

RESULTS

Of the 136 patients included, eight acquired pathological complete response, and the objective response rate was 47.8% (65/136). The LTG group had longer operation time (P = 0.015), less blood loss (P = 0.003), shorter days to first flatus (P < 0.001), and shorter postoperative hospitalization days (P < 0.001). LTG spent more surgical cost than OTG (P < 0.001), while total hospitalized cost of LTG was less than OTG (P < 0.001). 21 (28.0%) patients in the OTG group and 14 (23.0%) in the LTG group had 30-d postoperative complications, but there was no significant difference between the two groups (P = 0.503). The 3-year overall survival (OS) rate was 60.6% and 64.6% in the LTG and OTG groups, respectively [hazard ratio (HR) = 0.859, 95% confidence interval (CI): 0.522-1.412, P = 0.546], while the 3-year disease-free survival (DFS) rate was 54.5% and 51.8% in the LTG and OTG group, respectively (HR = 0.947, 95%CI: 0.582-1.539, P = 0.823). Multivariate cox analysis showed that body mass index and pTNM stage were independent risk factors for OS while vascular invasion and pTNM stage were independent risk factors for DFS (P < 0.05).

CONCLUSION

After NACT, LTG shows comparable 30-d postoperative morbidity as well as 3-year OS and DFS rate to OTG. We recommend that experienced surgeons select LTG other than OTG for proper AGC patients after NACT.

Clinicopathological characteristics and prognosis of poorly cohesive cell subtype of gastric cancer

BACKGROUND

The new World Health Organization (WHO) classification of gastric cancer includes a histological subtype of poorly cohesive carcinoma (PCC), which includes signet-ring cell (SRC) phenotype. We aimed to examine the concordance between preoperative clinical and postoperative histological diagnoses according to the 2010 WHO histological subtypes and to compare the prognoses of these subtypes.

METHODS

The study cohort comprised 665 patients who underwent gastrectomy from 2005 to 2019. Histological subtypes were classified into PCC-NOS (non-signet ring cell subtype), SRC, and non-PCC, which were defined by the predominant component in accordance with the 2010 WHO classification of gastric cancer. The concordance of clinical and pathological diagnosis was examined and clinicopathological characteristics and survival outcome of the three subtypes compared.

RESULTS

The cancers of 443 patients (66.7%) were classified as non-PCC, of 112 patients (16.8%) as PCC-NOS, and of 110 patients (16.5%) as SRC predominant subtypes. Significant differences in sex, age, tumor location, size, macroscopic type, and pathological TNM category (all P<0.05) were found. The concordance rate of preoperative and postoperative histological subtypes was significantly lower for poorly cohesive than other subtypes (P<0.0001). Preoperative stage tended to be underestimated for PCC-NOS subtype and these patients had poorer overall survival than those with the other two subtypes (P=0.005). Multivariate logistic regression analysis of overall survival showed that WHO histological subtype (PCC-NOS vs. non-PCC/SRC, HR: 1.64, 95% CI: 1.18-2.29, P=0.0034) was a significant independent prognostic factor.

CONCLUSION

Our results suggest that poorly cohesive carcinoma subtypes have different biological characteristics and prognoses.

Impact of preoperative endoscopy for predicting treatment response and prognosis in patients with gastric cancer after neoadjuvant chemotherapy

Background and study aims  Response evaluation criteria in solid tumors (RECIST) have been the gold standard to preoperatively predict treatment response and prognosis in patients with gastric cancer (GC) after neoadjuvant chemotherapy (NAC); however, methods for patients without evaluable lesions by RECIST are not yet confirmed. The aim of this study was to assess the utility of preoperative endoscopy for predicting treatment response and prognosis in patients with GC after NAC. Patients and methods  This retrospective study included 105 patients with initially resectable GC who underwent NAC followed by surgical treatment. Preoperative factors for predicting treatment response and survival outcomes were analyzed. Results  The number of patients classified as responders using preoperative endoscopic assessment, RECIST, and postoperative pathological evaluation were 25 (23.8 %), 28 (26.7 %), and 18 (17.1 %), respectively. Forty-three patients (41 %) were classified as non-targeted disease only, and their treatment responses were not evaluable by RECIST. Multivariate analysis identified endoscopic response as an independent preoperative factor to predict postoperative histological treatment response (odds ratio = 4.556, 95 % CI = 1.169-17.746, P  = 0.029). Endoscopic treatment response was the only independent preoperative predictive factor for overall survival (OS) (hazard ratio = 0.419, 95 % confidence interval (CI) = 0.206-0.849, P  = 0.016). Further, endoscopic treatment response was available for 33 patients (76.7 %) with non-targeted disease only, which showed significantly different OS between endoscopic responders (80.0 %) and non-responders (43.5 %) ( P  = 0.025). Conclusions  Endoscopic evaluation was an independent preoperative factor to predict treatment response and prognosis in patients with GC after NAC. Endoscopic assessment may be especially valuable for patients who could not be assessed by RECIST.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study

Background and Objectives

In the setting of a minimally invasive approach, we aimed to compare short and long‐term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.

Methods

All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score‐matching, postoperative morbidity and oncologic outcomes were investigated.

Results

After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease‐free‐survival (p = 0.34) was found between groups.

Conclusions

NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short‐term outcomes are more evident in patients over 60 years old receiving NAT.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

Could neoadjuvant chemotherapy increase postoperative complication risk of laparoscopic total gastrectomy? A mono-institutional propensity score-matched study in China

BACKGROUND

The potential survival benefit of neoadjuvant chemotherapy (NC) in patients with advanced gastric cancer has been widely recognized. With the development of minimally invasive surgery, which is represented by laparoscopy, the effect of NC on the safety of laparoscopic gastrectomy remains to be further explored.

AIM

To compare the short-term outcomes of laparoscopic total gastrectomy (LTG) after NC (NC-LTG) with LTG alone.

METHODS

A total of 92 patients who underwent NC-LTG and 381 patients who received LTG alone at the Chinese PLA General Hospital between September 2015 and September 2020 were retrospectively included in our study. We used propensity-score matching (PSM) to balance baseline bias. After 1:1 PSM, 73 patients were included in each group with no statistically significant difference in baseline characteristics.

RESULTS

The NC-LTG group exhibited a longer operation time (244.10 ± 48.13 min vs 225.74 ± 45.33 min, P = 0.019) and increased intraoperative blood loss [150 (100-300) mL vs 100 (100-200) mL, P = 0.011] compared to the LTG group. The 30-d postoperative morbidity of the NC-LTG group was 20.5% (15/73), and that of the LTG group was 13.7% (10/73). There were no significant differences in 30-d severe complication rates or anastomotic leakage rates. Subgroup analysis showed that the patients with pTNM (pathological tumor-node-metastasis classification) T0N0-II in the NC-LTG group underwent a longer operation than the LTG group, while no significant difference was found in any perioperative index for the pTNM III patients. A multivariate analysis showed that an operation time longer than 240 min was an independent risk factor (odds ratio = 3.021, 95% confidence interval: 1.160-7.868, P = 0.024), while NC was not an independent risk factor for postoperative complications in LTG.

CONCLUSION

Despite a longer operation time and more blood loss after NC-LTG, which indicate surgical difficulty, NC-LTG exhibits acceptable short-term outcomes compared to LTG, suggesting the safety and feasibility of NC-LTG.

The 140 years' journey of gastric cancer surgery: From the two hands of Billroth to the multiple hands of the robot

After the initial achievement by Billroth in 1881, surgery for gastric cancer has become increasingly extended. However, it turned out to be limited in Western countries after the publication that denied the role of extended surgery in the 1960s. While surgeons in Japan were still enthusiastic about extended surgery, the Japan Clinical Oncology Group (JCOG) conducted clinical trials to validate the role of extended surgery. Contrary to expectations, the efficacy of extended surgery was not demonstrated. In gastric cancer surgery, postoperative complications were reported to be associated with poor survival. A survival benefit could not be obtained by extended surgery, with high morbidity. Therefore, the paradigm had been changed from extended surgery to minimally invasive surgery (MIS). As an MIS for gastric cancer, laparoscopic surgery has been considered a practical method. Initial laparoscopic gastrectomy (LG) was first performed by Kitano in 1991. Thereafter, LG became increasingly common. Several clinical trials demonstrated the noninferiority of LG to open gastrectomy. LG is now regarded as the standard for cStage I gastric cancer, and the indication is expanding to advanced cancer. However, LG has some drawbacks owing to the restriction of movement caused by straight-shaped forceps. Robotic gastrectomy (RG) is considered a major breakthrough to circumvent the drawbacks in LG using articulated devices. However, the solid evidence demonstrating the advantage of RG has not been proved yet. The JCOG is now conducting a randomized controlled trial to evaluate the superiority of RG to LG in terms of reducing morbidity.

Pancreaticoduodenectomy after neoadjuvant chemotherapy for gastric cancer invading the pancreatic head: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high morbidity and mortality rates and low survival rate. However, neoadjuvant chemotherapy for advanced gastric cancer has improved, and chemotherapy combined with trastuzumab may have a preoperative tumor-reducing effect, especially for human epidermal growth factor receptor 2 (HER2)-positive cases.

CASE SUMMARY

We report a case of successful radical resection with PD after neoadjuvant S-1 plus oxaliplatin (SOX) and trastuzumab in a patient (66-year-old male) with advanced gastric cancer invading the pancreatic head. Initial esophagogastroduodenoscopy detected a type 3 advanced lesion located on the lower part of the stomach obstructing the pyloric ring. Computed tomography detected lymph node metastasis and tumor invasion to the pancreatic head without distant metastasis. Pathological findings revealed adenocarcinoma and HER2 positivity (immunohistochemical score of 3 +). We performed staging laparoscopy and confirmed no liver metastasis, no dissemination, negative lavage cytological findings, and immobility of the distal side of the stomach due to invasion to the pancreas. Laparoscopic gastrojejunostomy was performed at that time. One course of SOX and three courses of SOX plus trastuzumab were administered. Preoperative computed tomography showed partial response; therefore, PD was performed after neoadjuvant chemotherapy, and pathological radical resection was achieved.

CONCLUSION

We suggest that radical resection with PD after neoadjuvant chemotherapy plus trastuzumab is an option for locally advanced HER2-positive gastric cancer invading the pancreatic head in the absence of non-curative factors.

Association Among Blood Transfusion, Postoperative Infectious Complications, and Cancer-Specific Survival in Patients with Stage II/III Gastric Cancer After Radical Gastrectomy: Emphasizing Benefit from Adjuvant Chemotherapy

OBJECTIVES

This study was designed to investigate the potential additive influence of perioperative blood transfusion (BTF) and postoperative infections on cancer-specific survival (CSS) in patients with stage II/III gastric cancer (GC) after radical gastrectomy.

METHODS

The medical records of 2114 consecutive stage II/III GC patients who underwent curative resection and planned to receive adjuvant chemotherapy (AC) were retrospectively reviewed. The independent predictive factors for infections were identified using univariate and multivariate analyses. Cox regression analysis was used to assess any associations between BTF, infection and CSS.

RESULTS

A total of 507 (24.0%) received perioperative BTF and 148 (7.0%) developed infections with BTF being identified as an independent predictor for infections. Both BTF and infections independently predicted poor CSS (hazard ratio [HR]: 1.193, 95% confidence interval [CI] 1.007-1.414; HR 1.323, 95% CI 1.013-1.727) and an additive effect was confirmed as patients who had both BTF and infection had even worse CSS. Further stratified analyses showed that complete AC (≥ 6 cycles) could significantly improve CSS in patients who had BTF and/or infection, which was comparable to those without BTF and/or infection (P = 0.496).

CONCLUSIONS

Infection was the most common complication after gastrectomy and BTF was identified as an independent risk factor. BTF was associated with shorter CSS in stages II/III GC, independent of infections, and receiving BTF and developing infections had an additive effect that was associated with even worse CSS. However, complete AC could significantly improve CSS in these patients. Thus, strategies designed to ensure the completion of AC, such as neoadjuvant chemotherapy, should be further investigated.