1
|
Cho M, Kim HS, Jung M, Hyung WJ. Perioperative intraperitoneal plus systemic chemotherapy and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for gastric cancer: phase Ib/II single-arm prospective study. J Gastrointest Surg 2024; 28:1095-1103. [PMID: 38705369 DOI: 10.1016/j.gassur.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/13/2024] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND In gastric cancer, peritoneal metastasis is the most common form of metastasis and leads to dismal prognosis. We aimed to evaluate the safety and efficacy of combining perioperative intraperitoneal (IP) plus systemic chemotherapy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with gastric cancer with limited peritoneal metastasis or even after reducing peritoneal tumor burden by upfront IP chemotherapy. METHOD Patients were enrolled in phase Ib in a 3 + 3 dose escalation of IP paclitaxel plus a fixed dose of IP cisplatin and oral S-1. In phase II, patients were managed according to the peritoneal cancer index (PCI) by diagnostic laparoscopy. For patients with a PCI of >12, upfront IP and systemic chemotherapy were given. Patients with a PCI of ≤12 or reduced to ≤12 after upfront chemotherapy underwent CRS with HIPEC. The primary endpoints were safety and the recommended phase II dose (RP2D) confirmation for phase Ib and the 1-year overall survival rate for phase II. RESULTS The RP2D was defined as IP 175 mg/m2 paclitaxel and 60 mg/m2 cisplatin and oral 70 mg/m2/day S-1 for 14 days. A total of 22 patients were included. After CRS with HIPEC, there were no grade 3 or higher complications. The median hospital stay was 7 days (range, 6-11). The median overall and progression-free survival were 27.3 months (95% CI, 14.4 to not estimable) and 12.6 months (95% CI, 7.7-14.5), respectively. One-year overall and progression-free survival rates were 81.0% (95% CI, 65.8-99.6) and 54.5% (95% CI, 37.2-79.9), respectively. CONCLUSION A combination of IP plus systemic chemotherapy, CRS, and HIPEC was safe and resulted in good survival outcomes.
Collapse
Affiliation(s)
- Minah Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea; Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyo Song Kim
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea; Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Minkyu Jung
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea; Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea; Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Daniel SK, Sun BJ, Lee B. PIPAC for Gastrointestinal Malignancies. J Clin Med 2023; 12:6799. [PMID: 37959264 PMCID: PMC10650315 DOI: 10.3390/jcm12216799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The peritoneum is a common site of metastases for gastrointestinal tumors that predicts a poor outcome. In addition to decreased survival, peritoneal metastases (PMs) can significantly impact quality of life from the resulting ascites and bowel obstructions. The peritoneum has been a target for regional therapies due to the unique properties of the blood-peritoneum barrier. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) have become accepted treatments for limited-volume peritoneal disease in appendiceal, ovarian, and colorectal malignancies, but there are limitations. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) improves drug distribution and tissue penetration, allowing for a minimally invasive application for patients who are not CRS/HIPEC candidates based on high disease burden. PIPAC is an emerging treatment that may convert the patient to resectable disease, and may increase survival without major morbidity, as indicated by many small studies. In this review, we discuss the rationale and benefits of PIPAC, as well as sentinel papers describing its application for gastric, colorectal, appendiceal, and pancreatobiliary PMs. While no PIPAC device has yet met FDA approval, we discuss next steps needed to incorporate PIPAC into neoadjuvant/adjuvant treatment paradigms, as well as palliative settings. Data on active clinical trials using PIPAC are provided.
Collapse
Affiliation(s)
- Sara K. Daniel
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
| | | | | |
Collapse
|
3
|
Ayoub F, Chapman CG, Chen H, Setia N, Roggin K, Siddiqui UD. Endoscopic Ultrasound Predicts Risk of Occult Intra-Abdominal Metastases in Localized Gastric Cancer: A Validation Study. Gastroenterology Res 2023; 16:9-16. [PMID: 36895700 PMCID: PMC9990533 DOI: 10.14740/gr1589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/09/2023] [Indexed: 03/11/2023] Open
Abstract
Background In gastric cancer (GC) patients without imaging evidence of distant metastasis, diagnostic staging laparoscopy (DSL) is recommended to detect radiographically occult peritoneal metastasis (M1). DSL carries a risk for morbidity and its cost-effectiveness is unclear. Use of endoscopic ultrasound (EUS) to improve patient selection for DSL has been proposed but not validated. We aimed to validate an EUS-based risk classification system predicting risk for M1 disease. Methods We retrospectively identified all GC patients without positron emission tomography (PET)/computed tomography (CT) evidence of distant metastasis who underwent staging EUS followed by DSL between 2010 and 2020. T1-2, N0 disease was EUS "low-risk"; T3-4 and/or N+ disease was "high-risk". Results A total of 68 patients met inclusion criteria. DSL identified radiographically occult M1 disease in 17 patients (25%). Most patients had EUS T3 tumors (n = 59, 87%) and 48 (71%) patients were node-positive (N+). Five (7%) patients were classified EUS "low-risk" and 63 (93%) were classified "high-risk". Of 63 "high-risk" patients, 17 (27%) had M1 disease. The ability of "low-risk" EUS to predict M0 disease at laparoscopy was 100% and DSL would have been avoided in five patients (7%). This stratification algorithm showed a sensitivity of 100% (95% confidence interval (CI): 80.5-100%) and a specificity of 9.8% (95% CI: 3.3-21.4%). Conclusions Use of an EUS-based risk classification system in GC patients without imaging evidence of metastasis helps identify a subset of patients at low-risk for laparoscopic M1 disease who may avoid DSL and proceed directly to neoadjuvant chemotherapy or resection with curative intent. Larger, prospective studies are needed to validate these findings.
Collapse
Affiliation(s)
- Fares Ayoub
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Heather Chen
- Department of Pathology, University of Chicago Medicine, IL 60637, USA
| | - Namrata Setia
- Department of Pathology, University of Chicago Medicine, IL 60637, USA
| | - Kevin Roggin
- Department of Surgery, University of Chicago Medicine, IL 60637, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, IL 60637, USA
| |
Collapse
|
4
|
Allievi N, Bianco F, Pisano M, Montori G, Fugazzola P, Coccolini F, Lotti M, Mosconi S, Merelli B, Campanati L, Lucianetti A, Ansaloni L, Magnone S. Hyperthermic intraperitoneal chemotherapy (HIPEC) as adjuvant and therapeutic options for patients with advanced gastric cancer at high risk of recurrence or established peritoneal metastases: a single-centre experience. Updates Surg 2023; 75:159-167. [PMID: 36371549 DOI: 10.1007/s13304-022-01399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
Peritoneal metastases from gastric cancer (PM-GC) have a detrimental prognostic impact on survival and there is a lack of consensus regarding treatment. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may offer a chance for prolonged survival as compared to standard chemotherapy. This study aims to present our experience in the management of GC with CRS and HIPEC. This is a single-centre retrospective study. Patients were divided into two groups: patients with GC at high risk for developing PM-GC (adjuvant HIPEC group) and patients with PM-GC or positive peritoneal cytology (therapeutic CRS and HIPEC group). Overall survival (OS) and disease-free survival (DFS) were considered as outcome measures. A total of 41 patients with a GC primary received surgery and HIPEC: 14 patients (34.1%) were in the adjuvant HIPEC group, while 27 patients (65.9%) were in the therapeutic CRS and HIPEC group. In the adjuvant HIPEC group, the 1- and 3-year OS were 85.7% and 71.4%, while 1- and 3-year DFS were 71.4% and 64.3%, respectively. In the therapeutic CRS and HIPEC group, OS was 60.3% and 35.1% at 1 and 3 years, whereas 1- and 3-year DFS were 38% and 32.6%, respectively. Univariate survival analysis of patients in the therapeutic CRS and HIPEC group showed that the presence of lymph node metastasis and signet ring cell histology predicted worse OS, while PCI > 12 and lymph node metastasis were associated with decreased DFS. Treatment of highly selected patients with GC at high risk of peritoneal recurrence or established PM with CRS and HIPEC showed satisfactory results in terms of OS and DFS.
Collapse
Affiliation(s)
- Niccolò Allievi
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Federica Bianco
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Michele Pisano
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | | | - Paola Fugazzola
- Unit of General Surgery, IRCCS San Matteo Foundation Hospital, Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Marco Lotti
- Division of General Surgery, Fatebenefratelli Oftalmico Hospital, Milan, Italy
| | | | - Barbara Merelli
- Medical Oncology Unit, Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Campanati
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Luca Ansaloni
- Unit of General Surgery, IRCCS San Matteo Foundation Hospital, Pavia, Italy
| | - Stefano Magnone
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy.
| |
Collapse
|
5
|
Guerrero-Macías S, Pinilla-Morales R, Facundo-Navia H, Manrique-Acevedo ME, Rendón-Hernández J, Rey-Ferro M, Abadía-Díaz M, Guevara-Cruz ´Ó, Vélez-Bernal J, Oliveros-Wilches R. Situación actual de la laparoscopía de estadificación en pacientes con cáncer gástrico en Colombia: ¿Cómo lo estamos haciendo? REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introducción. La laparoscopía de estadificación permite identificar con gran precisión el compromiso locorregional avanzado y metastásico a peritoneo en los pacientes con cáncer gástrico. Las guías internacionales aún difieren en las indicaciones para incluir este procedimiento como parte del proceso de estadificación.
Métodos. Se diseñó una encuesta dirigida a cirujanos residentes en Colombia, sobre el uso de la laparoscopía de estadificación en los pacientes con cáncer gástrico. Se analizaron los resultados y con base en la evidencia disponible se proponen algunas pautas en las indicaciones y técnica del procedimiento.
Resultados. Respondieron la encuesta 74 cirujanos; el 43,8 % considera que el objetivo de la laparoscopía de estadificación es descartar la carcinomatosis peritoneal. El 54,1 % realiza el procedimiento en estadios tempranos, sin embargo, el 48,6 % considera realizarla solo en pacientes con sospecha de carcinomatosis por imágenes. Las áreas evaluadas con mayor frecuencia por los cirujanos (más del 85 %) son la superficie hepática, las cúpulas diafragmáticas, los recesos parietocólicos y la pelvis. Las zonas evaluadas en menor frecuencia son la válvula ileocecal (40,5 %) y el ligamento de Treitz (39 %). El 33 % de los cirujanos no toma rutinariamente citología peritoneal.
Conclusión. Este trabajo muestra la tendencia de los cirujanos en el uso de la laparoscopía de estadificación en pacientes con cáncer gástrico. A pesar de encontrar resultados muy positivos en relación con las indicaciones y técnica del procedimiento, es necesario analizar la evidencia disponible para su uso según cada escenario y mejorar la sistematización del procedimiento.
Collapse
|
6
|
Kim H, Park S, Kang SY, Ahn S, Kim KM. Peritoneal Seeding Is More Common in Gastric Cancer Patients with FGFR2 Amplification or High Tumor Mutation Burden. Diagnostics (Basel) 2022; 12:diagnostics12102355. [PMID: 36292044 PMCID: PMC9601213 DOI: 10.3390/diagnostics12102355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022] Open
Abstract
Fibroblast growth factor receptor-2 (FGFR2) gene alterations have been identified in solid tumors. FGFR2 amplification is found in 2−9% of gastric carcinomas. We hypothesized that FGFR2 could be associated with peritoneal seeding and studied 360 advanced gastric carcinoma patients; 222 (61.7%) were male, 246 (73.7%) had poorly differentiated histology, and 175 (48.6%) presented with peritoneal seeding. High tumor mutation burden (TMB) was observed in 44 (12.2%) patients, high microsatellite instability (MSI) was observed in 12 (3.33%) patients, ERBB2 amplification was observed in 44 (12.2%) patients, EBV positivity was observed in 10 (10/278; 3.6%) patients, and PD-L1 positivity was observed in 186 (186/264; 70.5%) cases. We found FGFR2 amplification in 26 (7.2%) patients, of which 12 (46.2%) were female and 22 (84.6%) had poorly differentiated histology. In these 26 cases, the copy number of FGFR2 amplification ranged from 3.7 to 274. Eighteen of them showed seeding, and this association was statistically significant (18/26, 69.2%; 157/334, 47%; p = 0.023). In addition, high TMB was significantly associated with seeding (p = 0.028; OR = 1.83). Poorly differentiated histology was significantly associated with seeding (p = 0.04) but not with FGFR2 amplification (p > 0.1). Seeding was frequent in gastric carcinoma patients with FGFR2 amplification, in patients with high TMB, or in those who were female. The subgroup of patients with FGFR2 amplification could be potential candidates for targeted therapeutic agents.
Collapse
Affiliation(s)
- Hyunjin Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Pathology Center, Seegene Medical Foundation, Seoul 06351, Korea
| | - Sujin Park
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - So Young Kang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Soomin Ahn
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Center of Companion Diagnostics, Samsung Medical Center, Seoul 06351, Korea
| | - Kyoung-Mee Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Center of Companion Diagnostics, Samsung Medical Center, Seoul 06351, Korea
- Correspondence: ; Tel.: +82-2-3410-2807; Fax: +82-2-3410-6396
| |
Collapse
|
7
|
Tham E, Sestito M, Markovich B, Garland-Kledzik M. Current and future imaging modalities in gastric cancer. J Surg Oncol 2022; 125:1123-1134. [PMID: 35481912 DOI: 10.1002/jso.26875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 12/24/2022]
Abstract
Gastric adenocarcinoma treatment can include endoscopic mucosal resection, surgery, chemotherapy, radiation, and palliative measures depending on staging. Both invasive and noninvasive staging techniques have been used to dictate the best treatment pathway. Here, we review the current imaging modalities used in gastric cancer as well as novel techniques to accurately stage and screen these patients.
Collapse
Affiliation(s)
- Elwin Tham
- Department of Surgical Oncology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Michael Sestito
- Department of Surgical Oncology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Brian Markovich
- Department of Diagnostic Radiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Mary Garland-Kledzik
- Department of Surgical Oncology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| |
Collapse
|
8
|
Guel-Klein S, Alberto Vilchez ME, Ceelen W, Rau B, Brandl A. Is PIPAC a Treatment Option in Upper and Lower Gastrointestinal Cancer with Peritoneal Metastasis? Visc Med 2022; 38:90-98. [PMID: 35614892 PMCID: PMC9082136 DOI: 10.1159/000523901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/01/2022] [Indexed: 01/09/2023] Open
Abstract
Background The survival prognosis of patients with peritoneal metastasis (PM) of gastrointestinal (GI) cancer is generally poor and treatment consists of, according to international guidelines, systemic chemotherapy. A multimodal treatment approach, including cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy, not only proved to be beneficial mainly in colorectal cancer, but also in selected patients with gastric cancer. The authors performed systematic research of articles and ongoing clinical trials using the keywords "PIPAC" and "gastric cancer" or "colorectal cancer" in PubMed in October 2021. Key findings, such as complications rates, treatment protocols, and overall survival were summarized and illustrated in Tables and critically discussed. Summary Twenty years ago, the technique of Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) was developed by Reymond et al. and delivered evidence to be recognized as a basic therapeutic tool in this multimodal therapy. Currently, there are several ongoing Phase II and III trials exploring the usage and efficacy of PIPAC as a neoadjuvant, adjuvant, or palliative component of treatment in patients with PM of GI cancer. Key Messages The aim of this narrative review was to help navigate the reader throughout the most current evidence for the use PIPAC and to highlight its indication in patients with upper and lower GI cancer with PM. It also provides an outline of ongoing studies and future perspectives.
Collapse
Affiliation(s)
- Safak Guel-Klein
- Department of Surgery, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Miguel Enrique Alberto Vilchez
- Department of Surgery, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wim Ceelen
- Department of GI Surgery, Ghent University Hospital, Ghent, Belgium
| | - Beate Rau
- Department of Surgery, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Brandl
- Department of Surgery, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Digestive Unit, Champalimaud Foundation, Lisbon, Portugal,*Andreas Brandl,
| |
Collapse
|
9
|
Chen ZX, Li J, Liu WB, Zhang SR, Sun H. Elemene-containing hyperthermic intraperitoneal chemotherapy combined with chemotherapy for elderly patients with peritoneal metastatic advanced gastric cancer. World J Clin Cases 2022; 10:1498-1507. [PMID: 35211587 PMCID: PMC8855251 DOI: 10.12998/wjcc.v10.i5.1498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Almost all elderly patients with peritoneal metastatic gastric cancer (PGC) are unlikely to tolerate cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) and adjuvant chemotherapy. However, determining how to optimize the treatment strategy for such patients has always been a clinical problem. Both HIPEC and palliative adjuvant chemotherapy can benefit patients with PGC. Therefore, optimizing HIPEC and chemotherapy regimens has potential clinical value in reducing side effects, and improving treatment tolerance and clinical effectiveness.
AIM To explore the effect of HIPEC containing elemene, which is an anti-cancer component extracted in traditional Chinese herbal medicine, combined with reduced capecitabine and oxaliplatin (CapeOx) chemotherapy regimens, in elderly patients with PGC.
METHODS In the present study, 39 of 52 elderly PGC patients were included and assigned to different HIPEC treatment groups [lobaplatin group (group L) and mixed group (group M)] for analysis. Lobaplatin was used for all three HIPECs in group L. In group M, lobaplatin was used in the middle of the three HIPECs, and elemene was used for the first and third HIPEC. After HIPEC, patients received CapeOx chemotherapy. The incidence of complications (abdominal infection, lung infection, and urinary tract infection), myelosuppression, immune function (CD4/CD8 ratio), average length of hospital stay, and prognosis were compared between these two groups.
RESULTS There was no significant difference in the incidence of complications between the two groups during hospitalization (P > 0.05). Compared to patients in group M, patients in group L exhibited severe myelosuppression (P = 0.027) and increased length of hospital stay (P = 0.045). However, no overall survival benefit was observed in group M. Furthermore, the immune function of patients in group M was less affected (P < 0.001), when compared to that of patients in group L. The multivariate analysis suggested that the cycles of chemotherapy after perfusion significantly affected the prognosis of patients in both groups.
CONCLUSION Compared to the lobaplatin-based HIPEC regimen, the administration of elemene reduced the myelosuppression incidence in elderly PGC patients. The present study sheds light on the implementation of this therapeutic strategy for this set of patients.
Collapse
Affiliation(s)
- Zhi-Xiong Chen
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Jin Li
- Department of Ultrasound, The Fifth People's Hospital of Chongqing, Chongqing 400062, China
| | - Wen-Bin Liu
- Department of Hepatobiliary and Pancreatic Oncology, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Shou-Ru Zhang
- Department of Teaching and Research Section, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Hao Sun
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing 400030, China
| |
Collapse
|
10
|
Xu Y, Zhang P, Zhang K, Huang C. The application of CA72-4 in the diagnosis, prognosis, and treatment of gastric cancer. Biochim Biophys Acta Rev Cancer 2021; 1876:188634. [PMID: 34656687 DOI: 10.1016/j.bbcan.2021.188634] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/09/2021] [Accepted: 10/10/2021] [Indexed: 02/07/2023]
Abstract
The role of conventional serum tumor marker, carbohydrate antigen 72-4 (CA72-4), in assisting diagnosis, monitoring dynamic progression, and evaluating the prognosis of gastric cancer (GC) should not be ignored, especially in the Chinese population. Even though CA72-4 has been used in clinical practice for decades, its modest positivity rate, sensitivity, and specificity did not meet the high demand of the clinical application. However, over the years, some progress in the functions of CA72-4 has been achieved, suggesting that CA72-4 can still be considered a promising marker in oncology. As a biomarker, CA72-4 can achieve improved sensitivity (SEN) and specificity (SPE) when combined with other biomarkers, selecting suitable reference values, improving detection techniques, and identifying the risk threshold. As a predictor, elevated serum CA72-4 levels were found to be significantly associated with prognostic risk factors, further assessing therapeutic validity and resectability. Recently, an effective method to reduce the toxicity of CA72-4 targeted therapy has been developed. Moreover, CA72-4 could induce novel aptamers to react with tumor cells and enhance the efficacy of trastuzumab in HER2-positive GC. Therefore, in this review, we discuss the most recent application of CA72-4 in the diagnosis, prognosis, and treatment of GC.
Collapse
Affiliation(s)
- Yitian Xu
- Department of Gastrointestinal Surgery, Shanghai General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, PR China
| | - Pengshan Zhang
- Department of Gastrointestinal Surgery, Shanghai General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, PR China
| | - Kundong Zhang
- Department of Gastrointestinal Surgery, Shanghai General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, PR China
| | - Chen Huang
- Department of Gastrointestinal Surgery, Shanghai General Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, PR China.
| |
Collapse
|
11
|
Bacalbasa N, Diaconu C, Socea B, Gherghiceanu F, Savu C, Dimitriu M, Balescu I, Cordos I. Neoadjuvant intraperitoneal chemotherapy for advanced stage gastric cancer (Review). Exp Ther Med 2021; 22:1314. [PMID: 34630668 DOI: 10.3892/etm.2021.10749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/08/2021] [Indexed: 11/05/2022] Open
Abstract
Gastric cancer remains one of the most lethal malignancies especially when diagnosed in advanced stages of the disease; most often patients diagnosed later during the progression of their disease will present a certain degree of peritoneal contamination such as positive peritoneal cytology or peritoneal metastatic nodules. In such cases most often they then progress to peritoneal carcinomatosis and succumb to the disease within one year. In order to increase the lifespan in such cases multiple therapeutic strategies have been proposed such as radical surgery and intraperitoneal heated chemotherapy or direct intraperitoneal chemotherapy followed by radical surgery. To date, the benefits of intraperitoneal heated chemotherapy at the time of resection have been widely investigated; however the method is still associated with increased rates of perioperative complications. Therefore, attention was focused on investigating the benefits of such procedures as neoadjuvant therapies followed by radical surgery. The aim of the present review was to examine the most efficient therapeutic strategies in advanced-stage gastric cancer such as neoadjuvant laparoscopic heated intraperitoneal chemotherapy, perioperative heated intraperitoneal chemotherapy and neoadjuvant systemic and peritoneal chemotherapy.
Collapse
Affiliation(s)
- Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Visceral Surgery, Center of Excellence in Translational Medicine 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Surgery, 'Sf. Pantelimon' Emergency Hospital, 33094 Bucharest, Romania
| | - Florentina Gherghiceanu
- Department of Marketing and Medical Technology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Cornel Savu
- Department of Thoracic Surgery, 'Marius Nasta' National Institute of Pneumology, 050159 Bucharest, Romania.,Department of Thoracic Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihai Dimitriu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Sf. Pantelimon' Emergency Hospital, 33094 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, 'Ponderas' Academic Hospital, 021188 Bucharest, Romania
| | - Ioan Cordos
- Department of Thoracic Surgery, 'Marius Nasta' National Institute of Pneumology, 050159 Bucharest, Romania.,Department of Thoracic Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| |
Collapse
|
12
|
Yüksel C, Erşen O, Basceken SI, Mercan Ü, Yalkın Ö, Culcu S, Bakırarar B, Bayar S, Ünal AE, Demirci S. The role of laparoscopic staging for the management of gastric cancer. POLISH JOURNAL OF SURGERY 2021; 93:1-8. [PMID: 33949319 DOI: 10.5604/01.3001.0014.7360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AİM Staging laparoscopy enables us to perform palliative treatment, neo-adjuvant therapy for curative resection or direct curative resection and making a decision with minimal morbidity by avoiding from unnecessary laparotomies. In the present study, the importance of staging lapafoscopy was retrospectively investigated by using clinical and pathologic data. METHODS Data of 70 out of 350 patients who underwent diagnostic laparoscopy due to gastric cancer at Surgical Oncology department between August 2013 and January 2020 were retrospectively analyzed. RESULTS Peritoneal biopsy was positive for malignity in 41 (58.5%) and negative in 29 (41.5%) of the patients who underwent SL. Peritoneal cytology (PC) results were negative in 32 (45.7%) patients and positive in 38 (54.3%) patients. Peritoneal biopsy and cytology results were concurrently positive in 35 patients and concurrently negative in 26 patients. CONCLUSİONS In conclusion, even the most developed imaging methods cannot provide 100% staging, therefore SL plays an important role in treatment of gastric cancer and laparoscopic staging is essential as a simple, inexpensive, safe and well tolerated method in patients who have the suspicion of peritoneal disease and who cannot be clearly evaluated with pre-operative methods.
Collapse
Affiliation(s)
- Cemil Yüksel
- University of Health Science, Ankara Abdurrahman Yurtaslan Oncology Training and Research Hospital
| | - Ogün Erşen
- Ankara University School of Medicine Department of Surgical Oncology
| | | | - Ümit Mercan
- Ankara University School of Medicine, Department of Surgical Oncology
| | - Ömer Yalkın
- Bursa State Hospital Surgical Oncology Clinic
| | - Serdar Culcu
- University of Health Science, Ankara Abdurrahman Yurtaslan Oncology Training and Research Hospital
| | | | - Sancar Bayar
- Ankara University School of Medicine, Department of Surgical Oncology
| | - Ali Ekrem Ünal
- Ankara University School of Medicine Department of Surgical Oncology
| | - Salim Demirci
- Ankara University School of Medicine, Department of Surgical Oncology
| |
Collapse
|
13
|
De Vuysere S, Vandecaveye V, De Bruecker Y, Carton S, Vermeiren K, Tollens T, De Keyzer F, Dresen RC. Accuracy of whole-body diffusion-weighted MRI (WB-DWI/MRI) in diagnosis, staging and follow-up of gastric cancer, in comparison to CT: a pilot study. BMC Med Imaging 2021; 21:18. [PMID: 33546626 PMCID: PMC7866710 DOI: 10.1186/s12880-021-00550-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/19/2021] [Indexed: 02/06/2023] Open
Abstract
Background Accurate staging of patients with gastric cancer is necessary for selection of the most appropriate and personalized therapy. Computed tomography (CT) is currently used as primary staging tool, being widely available with a relatively high accuracy for the detection of parenchymal metastases, but with low sensitivity for the detection of peritoneal metastases. Magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) has a very high contrast resolution, suggesting a higher diagnostic performance in the detection of small peritoneal lesions. The aim of this study was to retrospectively evaluate the added value of whole-body diffusion-weighted MRI (WB-DWI/MRI) to CT for detection of peritoneal carcinomatosis (PC) and distant metastases in the preoperative staging of gastric cancer. Methods This retrospective study included thirty-two patients with a suspicion of gastric cancer/recurrence, who underwent WB-DWI/MRI at 1.5 T, in addition to CT of thorax and abdomen. Images were evaluated by two experienced abdominal radiologists in consensus. Histopathology, laparoscopy and/or 1-year follow-up were used as reference standard. Results For overall tumour detection (n = 32), CT sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was 83.3%, 100%, 100% and 82.4% respectively. For WB-DWI/MRI these values were 100%, 92.9%, 94.7% and 100%, respectively. For staging (n = 18) malignant lymph nodes and metastases, CT had a sensitivity, specificity/PPV/NPV of 50%/100%/100%/71.4%, and 15.4%/100%/100%/31.3% respectively. For WB-DWI/MRI, all values were 100%, for both malignant lymph nodes and metastases. WB-DWI/MRI was significantly better than CT in detecting tumour infiltration of the mesenteric root, serosal involvement of the small bowel and peritoneal metastases for which WB-DWI/MRI was correct in 100% of these cases, CT 0%. Conclusions WB-DWI/MRI is highly accurate for diagnosis, staging and follow-up of patients with suspected gastric cancer.
Collapse
Affiliation(s)
- Sofie De Vuysere
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Radiology, Imelda Hospital Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium.
| | - Vincent Vandecaveye
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Yves De Bruecker
- Department of Radiology, Imelda Hospital Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium
| | - Saskia Carton
- Department of Gastroenterology, Imelda Hospital Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium
| | - Koen Vermeiren
- Department of Surgery, Imelda Hospital Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium
| | - Tim Tollens
- Department of Surgery, Imelda Hospital Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium
| | - Frederik De Keyzer
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Raphaëla Carmen Dresen
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| |
Collapse
|
14
|
Allen CJ, Blumenthaler AN, Das P, Minsky BD, Blum M, Roy-Chowdhuri S, Ajani JA, Ikoma N, Mansfield PF, Badgwell BD. Staging laparoscopy and peritoneal cytology in patients with early stage gastric adenocarcinoma. World J Surg Oncol 2020; 18:39. [PMID: 32066454 PMCID: PMC7026970 DOI: 10.1186/s12957-020-01813-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background Staging laparoscopy and peritoneal cytology can detect occult metastatic disease prior to treatment of gastric cancer. The yield of peritoneal staging in patients with early stage disease is lacking. We assess the yield of peritoneal staging in early stage gastric cancer and its impact on survival. Methods Data were obtained from a prospective database of patients who underwent staging laparoscopy and peritoneal cytology for gastric cancer at our institution between July 1995 and July 2018. Clinical stage was determined by endoscopic ultrasound, and early stage was defined as cT1-2 and cN0. Rates of positive cytology and carcinomatosis at time of laparoscopy were obtained. Univariate analyses were used to compare groups, and Kaplan-Meier survival analyses were used to assess survival outcomes. Results Eight hundred sixty-seven patients underwent staging laparoscopy and peritoneal cytology; 56 were defined as early stage. Age was 61 ± 12 years, 66.4% were male, and 62.3% were white. Of the patients with early stage disease, 17.9% had either gross carcinomatosis (10.7%) and/or positive peritoneal cytology (10.9%). All cases of peritoneal disease were in patients with cT2 disease. There were no differences in age, gender, or race based on peritoneal disease (all p > 0.05). The presence of carcinomatosis or positive cytology significantly affected overall survival (p < 0.001), regardless of clinical T or N stage. Conclusions Peritoneal staging identifies metastatic disease in a significant number of patients with early stage disease. Given its poor prognosis and alternate therapy options, independent staging laparoscopy and peritoneal cytology should be considered in patients with early stage gastric adenocarcinoma.
Collapse
Affiliation(s)
- Casey J Allen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sinchita Roy-Chowdhuri
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA.
| |
Collapse
|
15
|
Ellebæk SB, Graversen M, Detlefsen S, Lundell L, Fristrup CW, Pfeiffer P, Mortensen MB. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) of peritoneal metastasis from gastric cancer: a descriptive cohort study. Clin Exp Metastasis 2020; 37:325-332. [PMID: 32002724 DOI: 10.1007/s10585-020-10023-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/23/2020] [Indexed: 12/23/2022]
Abstract
Pressurized intraperitoneal aerosol chemotherapy (PIPAC) represents a novel approach to deliver intraperitoneal chemotherapy. We report our experience with PIPAC in patients with peritoneal metastasis (PM) from gastric cancer (GC). Data from GC patients (n = 20) included in the prospective PIPAC-OPC1 and PIPAC-OPC2 studies are reported. All patients had received prior systemic chemotherapy. The mean peritoneal cancer index (PCI) was 10.5 (range 0-39) and nine patients had diffuse GC. PIPAC with cisplatin 7.5 mg/m2 and doxorubicin 1.5 mg/m2 were administered at 4-6-week intervals. Outcome criteria were objective tumour response, survival and adverse events. Twenty patients had 52 PIPAC procedures with a median follow-up of 10.4 months (3.3-26.5). Median survival from the time of PM diagnosis and after the first PIPAC procedure was 11.5 months and 4.7 months, respectively. Fourteen patients had repeated PIPAC (> 2), and the objective tumour response according to the histological peritoneal regression grading score (PRGS) was observed in 36%, whereas 36% had stable disease. Ten patients completed the three prescheduled sessions (per protocol group) and 40% of those displayed an objective tumour response, while 20% had stable disease. Only minor postoperative complications were noted, and none were considered causally related to the PIPAC treatment. PIPAC with low-dose cisplatin and doxorubicin can induce a quantifiable objective tumour response in selected patients with PM from GC. Survival data are encouraging and warrant further clinical studies.
Collapse
Affiliation(s)
- S Bremholm Ellebæk
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark. .,Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Odense, Denmark.
| | - M Graversen
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPEN, Open Patient Data Explorative Network, Odense, Denmark
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - L Lundell
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Odense, Denmark
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, J.B. Winsloews Vej 4, 5000, Odense, Denmark.,Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPEN, Open Patient Data Explorative Network, Odense, Denmark
| |
Collapse
|
16
|
Bonnot PE, Piessen G, Kepenekian V, Decullier E, Pocard M, Meunier B, Bereder JM, Abboud K, Marchal F, Quenet F, Goere D, Msika S, Arvieux C, Pirro N, Wernert R, Rat P, Gagnière J, Lefevre JH, Courvoisier T, Kianmanesh R, Vaudoyer D, Rivoire M, Meeus P, Passot G, Glehen O. Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer With Peritoneal Metastases (CYTO-CHIP study): A Propensity Score Analysis. J Clin Oncol 2019; 37:2028-2040. [DOI: 10.1200/jco.18.01688] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Gastric cancer (GC) with peritoneal metastases (PMs) is a poor prognostic evolution. Cytoreductive surgery (CRS) yields promising results, but the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. Here we aimed to compare outcomes between CRS-HIPEC versus CRS alone (CRSa) among patients with PMs from GC. PATIENTS AND METHODS From prospective databases, we identified 277 patients with PMs from GC who were treated with complete CRS with curative intent (no residual nodules > 2.5 mm) at 19 French centers from 1989 to 2014. Of these patients, 180 underwent CRS-HIPEC and 97 CRSa. Tumor burden was assessed using the peritoneal cancer index. A Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used to assess the effect of HIPEC and account for confounding factors. RESULTS After IPTW adjustment, the groups were similar, except that median peritoneal cancer index remained higher in the CRS-HIPEC group (6 v 2; P = .003). CRS-HIPEC improved overall survival (OS) in both crude and IPTW models. Upon IPTW analysis, in CRS-HIPEC and CRSa groups, median OS was 18.8 versus 12.1 months, 3- and 5-year OS rates were 26.21% and 19.87% versus 10.82% and 6.43% (adjusted hazard ratio, 0.60; 95% CI, 0.42 to 0.86; P = .005), and 3- and 5-year recurrence-free survival rates were 20.40% and 17.05% versus 5.87% and 3.76% ( P = .001), respectively; the groups did not differ regarding 90-day mortality (7.4% v 10.1%, respectively; P = .820) or major complication rate (53.7% v 55.3%, respectively; P = .496). CONCLUSION Compared with CRSa, CRS-HIPEC improved OS and recurrence-free survival, without additional morbidity or mortality. When complete CRS is possible, CRS-HIPEC may be considered a valuable therapy for strictly selected patients with limited PMs from GC.
Collapse
Affiliation(s)
- Pierre-Emmanuel Bonnot
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | - Vahan Kepenekian
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Delphine Vaudoyer
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | | | - Guillaume Passot
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | - Olivier Glehen
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | |
Collapse
|
17
|
Borggreve AS, Goense L, Brenkman HJF, Mook S, Meijer GJ, Wessels FJ, Verheij M, Jansen EPM, van Hillegersberg R, van Rossum PSN, Ruurda JP. Imaging strategies in the management of gastric cancer: current role and future potential of MRI. Br J Radiol 2019; 92:20181044. [PMID: 30789792 DOI: 10.1259/bjr.20181044] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Accurate preoperative staging of gastric cancer and the assessment of tumor response to neoadjuvant treatment is of importance for treatment and prognosis. Current imaging techniques, mainly endoscopic ultrasonography (EUS), computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), have their limitations. Historically, the role of magnetic resonance imaging (MRI) in gastric cancer has been limited, but with the continuous technical improvements, MRI has become a more potent imaging technique for gastrointestinal malignancies. The accuracy of MRI for T- and N-staging of gastric cancer is similar to EUS and CT, making MRI a suitable alternative to other imaging strategies. There is limited evidence on the performance of MRI for M-staging of gastric cancer specifically, but MRI is widely used for diagnosing liver metastases and shows potential for diagnosing peritoneal seeding. Recent pilot studies showed that treatment response assessment as well as detection of lymph node metastases and systemic disease might benefit from functional MRI (e.g. diffusion weighted imaging and dynamic contrast enhancement). Regarding treatment guidance, additional value of MRI might be expected from its role in better defining clinical target volumes and setup verification with MR-guided radiation treatment.
Collapse
Affiliation(s)
- Alicia S Borggreve
- 1 Department of Surgery, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands.,2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Lucas Goense
- 1 Department of Surgery, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands.,2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Hylke J F Brenkman
- 1 Department of Surgery, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Stella Mook
- 2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Gert J Meijer
- 2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Frank J Wessels
- 3 Department of Radiology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Marcel Verheij
- 4 Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek (NKI-AVL) , Amsterdam , Netherlands
| | - Edwin P M Jansen
- 4 Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek (NKI-AVL) , Amsterdam , Netherlands
| | - Richard van Hillegersberg
- 1 Department of Surgery, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Peter S N van Rossum
- 2 Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| | - Jelle P Ruurda
- 1 Department of Surgery, University Medical Center Utrecht, Utrecht University , Utrecht , Netherlands
| |
Collapse
|
18
|
Dahdaleh FS, Turaga KK. Evolving Treatment Strategies and Outcomes in Advanced Gastric Cancer with Peritoneal Metastasis. Surg Oncol Clin N Am 2018; 27:519-537. [PMID: 29935687 DOI: 10.1016/j.soc.2018.02.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Gastric cancer (GC) has a predilection to metastasize to the peritoneum, denoting a poor prognosis. Treatment strategies available for advanced GC have significantly evolved over time and can be categorized into systemic, regional, and surgical. Although systemic therapies have been the mainstay for the treatment of advanced GC, their ability in achieving long-term survival in patients with peritoneal involvement is modest at best. This article describes advances in combined modality treatment of peritoneal metastases, specifically with an emphasis on peritoneal-directed therapies.
Collapse
Affiliation(s)
- Fadi S Dahdaleh
- Complex General Surgical Oncology, Section of General Surgery/Surgical Oncology, The University of Chicago Medicine, 5841 South Maryland Avenue, Room S214, MC 5094, Chicago, IL 60637, USA
| | - Kiran K Turaga
- The University of Chicago Medicine, Section of General Surgery/Surgical Oncology, 5841 South Maryland Avenue, Room G207, MC 5094, Chicago, IL 60637, USA.
| |
Collapse
|
19
|
Saklani A, Sugoor P, Chaturvedi A, Bhamre R, Jatal S, Ostwal V, Engineer R. Clinical Utility of Staging Laparoscopy for Advanced Obstructing Rectal Adenocarcinoma: Emerging Tool. Indian J Surg Oncol 2018; 9:488-494. [PMID: 30538377 DOI: 10.1007/s13193-018-0803-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 07/17/2018] [Indexed: 02/07/2023] Open
Abstract
The multimodal treatment for advanced rectal adenocarcinoma mandates accurate preoperative staging with contrast-enhanced computed tomography (CECT) of the thorax, abdomen, and pelvis, and magnetic resonance imaging (MRI) of the pelvis. Unlike gastric cancer, the role of staging laparoscopy (SL) in advanced colorectal cancer has not been evaluated. This study aims to evaluate the clinical value of SL in treatment decision-making for advanced rectal cancer (RC) with near or complete obstructing tumors. Observational review of colorectal database at Tata Memorial Hospital from January 2013 to December 2016 identified 562 patients diagnosed and treated for advanced RC. Of the 562 cases, 48.7% (274) were clinically and radiologically diagnosed of near or complete obstructing advanced RC. Medical records of 34% (94/274) who underwent SL with diversion stoma (DS) were analyzed. In the absence of ascites, extensive peritoneal deposits, and unresectable liver metastases on SL, a curative treatment was offered, which entailed neoadjuvant chemoradiation (NACTRT), whereas the cohort of patients with extensive peritoneal disease received palliative therapy. Of the 94 patients with advanced RC, conventional imaging studies staged 73.5% (69/94) cohort as non-metastatic locally advanced and 26.5% (25/94) had potentially resectable metastatic RC. Pre-therapeutic SL upstaged the disease by 26% (18/69) and 8% (2/25) in locally advanced and potentially resectable metastatic RC cohorts, respectively. Treatment decision changed in 21.2% (20/94) of the patients, and midline laparotomy was thus avoided. In our observational study, SL was found to be a safe and effective staging modality in RC; it detected occult peritoneal disease and prevented midline laparotomy in 21.2% of the cohort, which was of value to determine treatment strategy in patients with advanced RC before initiating NACTRT. SL and laparoscopic-assisted de-functioning stoma were associated with minimal morbidity and led to early initiation of NACTRT.
Collapse
Affiliation(s)
- Avanish Saklani
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| | - P Sugoor
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| | - A Chaturvedi
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| | - R Bhamre
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| | - S Jatal
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| | - V Ostwal
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India.,2Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - R Engineer
- 1Department of Gastrointestinal Surgery and Colorectal Surgical Oncology, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai, Maharashtra 400012 India
| |
Collapse
|
20
|
Li TT, Liu H, Yu J, Shi GY, Zhao LY, Li GX. Prognostic and predictive blood biomarkers in gastric cancer and the potential application of circulating tumor cells. World J Gastroenterol 2018; 24:2236-2246. [PMID: 29881233 PMCID: PMC5989238 DOI: 10.3748/wjg.v24.i21.2236] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/27/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer (GC), with its high incidence and mortality rates, is a highly fatal cancer that is common in East Asia particularly in China. Its recurrence and metastasis are the main causes of its poor prognosis. Circulating tumor cells (CTCs) or other blood biomarkers that are released into the circulating blood stream by tumors are thought to play a crucial role in the recurrence and metastasis of gastric cancer. Therefore, the detection of CTCs and other blood biomarkers has an important clinical significance; in fact, they can help predict the prognosis, assess the staging, monitor the therapeutic effects and determine the drug susceptibility. Recent research has identified many blood biomarkers in GC, such as various serum proteins, autoantibodies against tumor associated antigens, and cell-free DNAs. The analysis of CTCs and circulating cell-free tumor DNA (ctDNA) in the peripheral blood of patients with gastric cancer is called as liquid biopsy. These blood biomarkers provide the disease status for individuals and have clinical meaning. In this review, we focus on the recent scientific advances regarding CTCs and other blood biomarkers, and discuss their origins and clinical meaning.
Collapse
Affiliation(s)
- Ting-Ting Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Hao Liu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Jiang Yu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Guang-Yao Shi
- Division of Cardiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Li-Ying Zhao
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Guo-Xin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| |
Collapse
|
21
|
Thiels CA, Ikoma N, Fournier K, Das P, Blum M, Estrella JS, Minsky BD, Ajani J, Mansfield P, Badgwell BD. Repeat staging laparoscopy for gastric cancer after preoperative therapy. J Surg Oncol 2018; 118:61-67. [PMID: 29878364 DOI: 10.1002/jso.25094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/16/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Staging laparoscopy is recommended before preoperative therapy in patients with locoregional gastric cancer, but yield of repeated diagnostic laparoscopy at the time of resection is unknown. METHODS Retrospective review of a prospective database of patients with gastric adenocarcinoma (1994-2016) who had negative staging laparoscopy followed by preoperative therapy and subsequent attempted resection. Primary outcome was positive exploration (peritoneal or unresectable disease) at the time of resection. Multivariable logistic regression identified factors associated with positive exploration. RESULTS Of the 451 patients with attempted resection, 54 (12.0%) had positive explorations, including 48 with peritoneal disease. Patients with positive explorations were more likely to be female and have poorly differentiated tumors, linitis features, and signet-ring morphology. There was no significant difference by exploration results in age, race, clinical stage, or delayed definitive surgery. Positive explorations were independently associated with poor differentiation (OR 4.6, 95%CI 1.4-15.3; P = 0.01) and linitis (OR 4.2, 95%CI 1.9-9.2; P < 0.001). Positive explorations were seen in 14.0% of patients with poor differentiation, 36.6% of patients with linitis, and 5.8% of patients with neither linitis nor poor differentiation. CONCLUSION Despite negative pretreatment laparoscopy, post-treatment repeat laparoscopy may prevent non-therapeutic laparotomies. At a minimum, we recommend selective repeat laparoscopy for patients with linitis features.
Collapse
Affiliation(s)
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
22
|
Brown ZJ, Hernandez JM, Ripley RT, Davis JL. Heated intraperitoneal chemotherapy and gastrectomy for gastric cancer in the U.S.: the time is now. J Gastrointest Oncol 2018; 8:1109-1113. [PMID: 29299372 DOI: 10.21037/jgo.2017.09.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Peritoneal metastasis is a common final pathway in patients with gastric adenocarcinoma. Microscopic evidence of early peritoneal dissemination of gastric cancer is present in a substantial proportion of patients presumed to have localized disease. Prognosis is poor even for patients with microscopic and low-volume peritoneal carcinomatosis highlighting the need for a more effective treatment strategy. Treatment of peritoneal carcinomatosis with intraperitoneal chemotherapy has been evaluated in gastric cancer and is associated with improved survival in selected patients. We hypothesize that removal of the primary tumor combined with treatment of low-volume peritoneal metastasis may improve survival in patients with gastric cancer. Our group is investigating the role of heated intraperitoneal chemotherapy administered at time of gastrectomy in patients with gastric adenocarcinoma and metastasis limited to the peritoneum. To date, trials dedicated to the study of regional therapy for peritoneal metastasis due to gastric cancer have originated primarily in Asian centers. Although the incidence of gastric cancer is relatively low in the United States, mortality rates are high and the need is real for prospective study of intraperitoneal chemotherapy in patients with this deadly disease.
Collapse
Affiliation(s)
- Zachary J Brown
- Thoracic & Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan M Hernandez
- Thoracic & Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - R Taylor Ripley
- Thoracic & Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jeremy L Davis
- Thoracic & Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
23
|
Pasqual EM, Bertozzi S, Londero AP, Brandolin D, Mariuzzi L, De Pellegrin A, Bacchetti S, Zoratti L, Petri R, Della Bianca C, Snidero D, Terrosu G, Uzzau A, Risaliti A, Di Loreto C, Pizzolitto S, Zilli M, de Manzoni G. Microscopic peritoneal carcinomatosis in gastric cancer: Prevalence, prognosis and predictive factors. Oncol Lett 2017; 15:710-716. [PMID: 29399143 PMCID: PMC5772791 DOI: 10.3892/ol.2017.7442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/23/2017] [Indexed: 12/29/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is typically identified in advanced stage gastric cancer and is frequently considered to be an incurable disease. Along with macroscopic PC, microscopic PC may be diagnosed through pathological examination of tissue specimens and is not detectable during surgical intervention. The present study aimed to analyse the prevalence, prognostic value and predictive factors for microscopic PC. In the present retrospective study, data from patients with epithelial gastric cancer that were treated with curative intent surgery were examined. Patients with macroscopic PC were excluded. Additionally, the study population was divided into two groups based on the presence or absence of microscopic PC. The prevalence of microscopic PC was 5.5%. Microscopic PC exhibited a significant negative effect on overall survival. In addition, multivariate analyses revealed that the significant predictive factors for the presence of microscopic PC were adenocarcinoma of a diffuse type, lymphatic and vascular invasion, cancer location at the site of previous gastric surgery and a tumour extent >T2. In particular, the presence of lymphatic and vascular invasion was the most significant predictive factor. These results indicate that ≥5.5% of patients with gastric cancer who undergo surgery with a curative intent may benefit from more aggressive loco-regional treatment against microscopic PC at the time of surgery.
Collapse
Affiliation(s)
- Enrico Maria Pasqual
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Serena Bertozzi
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Ambrogio P Londero
- Department of Obstetrics and Gynaecology, Monfalcone Hospital, I-34074 Monfalcone, Italy
| | - Denise Brandolin
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Laura Mariuzzi
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Alessandro De Pellegrin
- Department of Pathology, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Stefano Bacchetti
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Loris Zoratti
- Department of Gastroenterology, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Roberto Petri
- Department of Surgery, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | | | - Daniele Snidero
- Department of Surgery, San Daniele Hospital, I-33038 San Daniele, Italy
| | - Giovanni Terrosu
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Alessandro Uzzau
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Andrea Risaliti
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Carla Di Loreto
- Department of Medical Area, University of Udine, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Stefano Pizzolitto
- Department of Pathology, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Maurizio Zilli
- Department of Gastroenterology, Santa Maria della Misericordia University Hospital Udine, I-33100 Udine, Italy
| | - Giovanni de Manzoni
- Department of Upper Gastrointestinal Surgery, The Civil Hospital of Verona University, I-37126 Verona, Italy
| |
Collapse
|
24
|
Impact of clinical tumor-node-metastasis staging on survival in gastric carcinoma patients receiving surgery. Gastric Cancer 2017; 20:448-456. [PMID: 27586236 DOI: 10.1007/s10120-016-0637-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/23/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative clinical staging of gastric cancer is used to determine therapeutic strategies. However, the impact of the clinical stage on survival has not been completely investigated, although the relationship between pathologic staging and survival outcome has been reported. The aim of the present study was to clarify the predictability of patient survival based on clinical staging and to evaluate the usefulness of staging as an indicator for selecting the treatment modality. METHODS A total of 3033 patients who underwent surgery for gastric cancer were included. A survival analysis was conducted based on the seventh edition of the tumor-node-metastasis (TNM) clinical staging system of the American Joint Committee on Cancer. The predictive ability of the TNM clinical stage for survival was evaluated by Harrell's C-index, a measure of the separation of survival distributions. RESULTS The cumulative 5-year survival rates according to the clinical stage were 94.3 % (IA), 84.7 % (IB), 71.7 % (IIA), 56.1 % (IIB), 55.7 % (IIIA), 42.3 % (IIIB), 22.8 % (IIIC), and 9.1 % (IV). Although no significant difference was observed between clinical stages IIB and IIIA (p = 0.865), significant differences existed between all other clinical stages (p < 0.001). Harrell's C-index applied to these results was 0.825 (95 % confidence interval 0.819-0.831). CONCLUSIONS The seventh edition of the TNM clinical staging system has a strong prognostic ability with a satisfactory C-index and should be considered valuable for selecting therapeutic strategies for the treatment of gastric cancer.
Collapse
|
25
|
Predictive Role of the Number of 18F-FDG-Positive Lymph Nodes Detected by PET/CT for Pre-Treatment Evaluation of Locally Advanced Gastric Cancer. PLoS One 2016; 11:e0166836. [PMID: 27936109 PMCID: PMC5147842 DOI: 10.1371/journal.pone.0166836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 11/06/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate the predictive value of the numbers of metabolically positive lymph nodes (MPLN) detected by 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) in patients with locally advanced gastric cancer (LAGC). METHODS We retrospectively analyzed the records of 50 patients with LAGC (stage T2-T4) who had undergone pre-operative PET/CT examination and laparotomy (total gastrectomy, n = 11; subtotal gastrectomy, n = 13; distal gastrectomy, n = 22; and bypass with gastrojejunstomy, n = 4). The numbers of MPLN were determined by combining visual observations with semi-quantitative measurements of the maximized standardized uptake value (SUVmax). Performance was investigated in terms of predicting post-surgical overall survival (OS). RESULTS The median post-surgical OS was 32.57 months (range 3.0-94 months). The numbers of MPLN were moderately correlated with the numbers of histological positive LN (r = 0.694, p = 0.001). In univariate analyses, the numbers of MPLN (≤ 2 vs. ≥3), PET/CT LN (positivity vs. negativity), SUVmax of LN (< 2.8 vs. ≥ 2.8), TNM stage (I, II vs. III, IV), and surgery type (R0 vs. non-R0) were significantly associated with OS. In multivariate analysis, surgery type (R0 vs. non-R0) and numbers of MPLN (≤ 2 vs. ≥ 3) were both independent factors for poor OS. CONCLUSIONS This explored study indicates that the number of MPLN could provide additional information for LAGC prognosis. Patients with MPLNs ≥ 3 may be at the risk of the more bad outcomes, and the further clinical trials are needed.
Collapse
|
26
|
Dong Y, Ma S, Yang S, Luo F, Wang Z, Guo F. Non-curative surgery for patients with gastric cancer with local peritoneal metastasis: A retrospective cohort study. Medicine (Baltimore) 2016; 95:e5607. [PMID: 27930586 PMCID: PMC5266058 DOI: 10.1097/md.0000000000005607] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The role of non-curative surgery for patients with M1 gastric cancer (GC) is controversial. This study aimed to evaluate the efficacy of non-curative resectional surgery for patients with GC with local peritoneal metastasis.We reviewed the medical records of 47 patients with GC with local peritoneal metastasis, which was found by laparotomy or laparoscopy. The patients were divided into 2 groups: those who underwent gastric resection (n = 29), and a non-resection group who did not (n = 18). The clinical characteristics, postoperative complications, mortality, palliative intervention, and long-term outcomes of the 2 groups were compared.Complications occurred more frequently in the resection group than in non-resection group (P = 0.017). There was no postoperative mortality or reoperation in either group. Palliative intervention was performed in 9 (31%) patients in resection group and 16 (88.9%) patients in non-resection group (P < 0.001). The intervention interval and hospital-free time were significant longer in resection group than in non-resection group (P < 0.001, P < 0.001). The Kaplan-Meier survival curves revealed that resection group had longer survival than non-resection group (P < 0.001).Non-curative resectional surgery helps prolong survival time and improve the quality of life for patients with GC with local peritoneal metastasis.
Collapse
Affiliation(s)
| | - Shulan Ma
- Department of Gynecology, Huashan North Hospital
- Central Laboratory, Huashan North Hospital
| | - Shuo Yang
- Department of General Surgery, Huashan Hospital
| | - Fen Luo
- Department of General Surgery, Huashan Hospital
- Surgical Laboratory, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhiming Wang
- Department of General Surgery, Huashan Hospital
- Central Laboratory, Huashan North Hospital
- Surgical Laboratory, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Fenghua Guo
- Department of General Surgery, Huashan Hospital
- Surgical Laboratory, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
27
|
Ikoma N, Blum M, Chiang YJ, Estrella JS, Roy-Chowdhuri S, Fournier K, Mansfield P, Ajani JA, Badgwell BD. Yield of Staging Laparoscopy and Lavage Cytology for Radiologically Occult Peritoneal Carcinomatosis of Gastric Cancer. Ann Surg Oncol 2016; 23:4332-4337. [DOI: 10.1245/s10434-016-5409-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
28
|
Feingold PL, Kwong MLM, Davis JL, Rudloff U. Adjuvant intraperitoneal chemotherapy for the treatment of gastric cancer at risk for peritoneal carcinomatosis: A systematic review. J Surg Oncol 2016; 115:192-201. [PMID: 27878811 DOI: 10.1002/jso.24476] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/02/2016] [Indexed: 12/29/2022]
Abstract
The peritoneal surface is a frequent site of recurrence following surgery for gastric cancer. A systematic review and random effect analysis was undertaken to analyze current literature regarding the role of adjuvant intraperitoneal chemotherapy in gastric cancer. While pooled analysis supports the use of adjuvant IP chemotherapy in resectable gastric cancer, maximal benefit occured with intra-operative delivery, and possibly the use of MMC. J. Surg. Oncol. 2017;115:192-201. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Paul L Feingold
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mei Li M Kwong
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeremy L Davis
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Udo Rudloff
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
29
|
Beeharry MK, Liu WT, Yao XX, Yan M, Zhu ZG. A critical analysis of the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy combo in the clinical management of advanced gastric cancer: an effective multimodality approach with scope for improvement. Transl Gastroenterol Hepatol 2016; 1:77. [PMID: 28138643 DOI: 10.21037/tgh.2016.08.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/22/2016] [Indexed: 12/16/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is manifested in up to 40% of gastric cancer (GC) patients, after which their 5-year survival drops to less than 5%. The currently most acceptable treatment option for advanced GC (AGC) is systemic chemo and radio therapies with however generally very unsatisfying results and this led to a resurgence of interest in regional therapies like cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Small trials have indicated an association with prolonged survival when applying this technique to AGC manifesting with PC. High procedure-related morbidity and mortality associated with the CRS-HIPEC approach have however brought by a polemic on the merits of the latter: with the advent of regulatory approval of more effective as well as novel, more personalized treatment options in AGC, along with advances in tailoring investigational agents specifically for peritoneal delivery, there clearly is a need to outline the appropriate role of CRS-HIPEC in this disease. In a clear objective to improve the therapeutic efficiency of HIPEC, there have been immense developments in the technical aspects of this technology including the use of nanotechnology in more precise drug delivery systems (DDS) or choice of more efficient drugs such as gene-target technology, laparoscopy and so on. Henceforth, in this review, we will be highlighting the past and current status of the CRS + HIPEC procedure, shedding light on the pros and cons in order to boost up the efficiency of this multimodality approach.
Collapse
Affiliation(s)
- Maneesh K Beeharry
- Department of Surgery, Rui Jin Hospital, Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Institute of Digestive Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wen-Tao Liu
- Department of Surgery, Rui Jin Hospital, Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Institute of Digestive Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xue-Xin Yao
- Department of Surgery, Rui Jin Hospital, Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Institute of Digestive Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Min Yan
- Department of Surgery, Rui Jin Hospital, Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Institute of Digestive Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zheng-Gang Zhu
- Department of Surgery, Rui Jin Hospital, Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Institute of Digestive Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| |
Collapse
|
30
|
Yamada N, Akai A, Nomura Y, Tanaka N. The impact and optimal indication of non-curative gastric resection for stage IV advanced gastric cancer diagnosed during surgery: 10 years of experience at a single institute. World J Surg Oncol 2016; 14:79. [PMID: 26965446 PMCID: PMC4785630 DOI: 10.1186/s12957-016-0790-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/03/2016] [Indexed: 12/12/2022] Open
Abstract
Background The survival benefit of non-curative gastric resection for patients with stage IV gastric cancer is still unclear. Methods Of the patients who underwent open abdominal surgery that was preoperatively intended to be a radical excision procedure for gastric cancer, 72 were diagnosed with stage IV during the operation. At this institution, non-curative gastric resection is performed whenever possible. Results Non-curative gastric resection was performed in 44 of the 72 patients. According to the survival analysis, the median survival times in the gastric resection and no-resection groups were 1.9 and 0.9 years, respectively (log-rank test, p = 0.014). Based on the multivariate analysis, we selected gastric resection (hazard ratio [HR] = 0.309; 95 % confidence interval [CI] = 0.152–0.615) and postoperative chemotherapy (HR = 0.136; 95 % CI = 0.056–0.353) as independent factors associated with overall survival (OS). In the subgroup analyses of OS, the factors that were associated with gastric resection having no survival benefit were the existence of distant lymph node or liver metastasis (p = 0.527) and the lack of postoperative chemotherapy (p = 0.589). Conclusions For patients who have distant lymph node or liver metastasis and those who will not undergo postoperative chemotherapy, non-curative gastric resection has no survival benefit.
Collapse
Affiliation(s)
- Naoya Yamada
- Department of Surgery, Asahi General Hospital, 1326 I, Asahi-shi, Chiba, 289-2511, Japan.
| | - Atsushi Akai
- Department of Surgery, Asahi General Hospital, 1326 I, Asahi-shi, Chiba, 289-2511, Japan
| | - Yukihiro Nomura
- Department of Surgery, Asahi General Hospital, 1326 I, Asahi-shi, Chiba, 289-2511, Japan
| | - Nobutaka Tanaka
- Department of Surgery, Asahi General Hospital, 1326 I, Asahi-shi, Chiba, 289-2511, Japan
| |
Collapse
|
31
|
Feingold PL, Kwong MLM, Sabesan A, Sorber R, Rudloff U. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer and other less common disease histologies: is it time? J Gastrointest Oncol 2016; 7:87-98. [PMID: 26941987 DOI: 10.3978/j.issn.2078-6891.2015.098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer is the fourth most commonly diagnosed cancer worldwide, and once spread to the peritoneum, has a 5-year survival of less than 5%. Recent years have demonstrated advances in the use of cytoreductive surgery (CRS) in combination with heated intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal carcinomatosis due to various malignancies. The frequent desmoplastic stroma and poor vascularization impeding drug delivery particularly in the diffuse form of gastric cancer is thought to provide a sound rationale for a regionalized treatment approach in this disease. Here, we seek to review the available data to define the role of CRS and HIPEC in gastric cancer metastatic to the peritoneal surface, and furthermore, analyze the use of CRS and HIPEC in malignancies less commonly treated with the regionalized perfusion approach.
Collapse
Affiliation(s)
- Paul L Feingold
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mei Li M Kwong
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Arvind Sabesan
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Sorber
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Udo Rudloff
- Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
32
|
Added value of pretreatment (18)F-FDG PET/CT for staging of advanced gastric cancer: Comparison with contrast-enhanced MDCT. Eur J Radiol 2016; 85:989-95. [PMID: 27130061 DOI: 10.1016/j.ejrad.2016.03.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the added clinical value of pretreatment (18)F-FDG PET/CT compared with conventional contrast-enhanced multidetector-row CT (CECT) alone for staging of advanced gastric cancer MATERIALS AND METHODS We studied 106 patients with locally advanced gastric cancer who underwent pretreatment CECT and (18)F-FDG PET/CT. Two experienced reviewers assessed the diagnostic performance of both CECT alone and the combination of CECT and (18)F-FDG PET/CT for the primary tumor, regional lymph node metastasis (N) and distant metastasis (M), rating their diagnostic confidence with a 5-point scoring system for each location. The two methods were compared using receiver operating characteristic (ROC) curve analysis for histopathologic findings, imaging, and clinical follow-up as the reference standards. RESULTS Among the 106 patients, 96 primary tumors (90.6%) were detected by CECT, while 101 (95.3%) were clearly identified by (18)F-FDG PET/CT (p=0.074). Patient-based areas under the ROC curves for CECT alone versus the combination of CECT and (18)F-FDG PET/CT for diagnosis of N stage, peritoneal dissemination, liver metastasis, distant lymph node metastasis, bone metastasis, metastasis at other sites and overall M stage were 0.787 vs. 0.858 (p=0.13), 0.866 vs. 0.878 (p=0.31), 0.998 vs. 1.0 (p=0.36), 0.744 vs. 0.865 (p=0.049), 0.786 vs. 0.998 (p=0.034), 0.944 vs. 0.984 (p=0.34), and 0.889 vs. 0.912 (p=0.21), respectively. The diagnostic performance of primary tumor detection and NM staging was not influenced by the histologic subtype. CONCLUSION Adding (18)F-FDG PET/CT to CECT provides better diagnostic accuracy for detection of distant lymph node metastasis and bone metastasis in patients with untreated advanced gastric cancer.
Collapse
|
33
|
Nadiradze G, Giger-Pabst U, Zieren J, Strumberg D, Solass W, Reymond MA. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with Low-Dose Cisplatin and Doxorubicin in Gastric Peritoneal Metastasis. J Gastrointest Surg 2016; 20:367-73. [PMID: 26511950 PMCID: PMC4722080 DOI: 10.1007/s11605-015-2995-9] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/13/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique of intraperitoneal chemotherapy. First results obtained with PIPAC in patients with advanced peritoneal metastasis (PM) from gastric cancer (GC) are presented. METHODS Retrospective analysis: Sixty PIPAC were applied in 24 consecutive patients with PM from GC. 67 % patients had previous surgery, and 79 % previous platinum-based systemic chemotherapy. Mean Peritoneal Carcinomatosis Index (PCI) of 16 ± 10 and 18/24 patients had signet-ring GC. Cisplatin 7.5 mg/m(2) and doxorubicin 1.5 mg/m(2) were given for 30 min at 37 °C and 12 mmHg at 6 week intervals. Outcome criteria were survival, adverse events, and histological tumor response. RESULTS Median follow-up was 248 days (range 105-748), and median survival time was 15.4 months. Seventeen patients had repeated PIPAC, and objective tumor response was observed in 12 (12/24 = 50 %): no vital tumor cells = 6, major pathological response = 6, minor response = 3. Postoperative adverse events > CTCAE 2 were observed in 9 patients (9/24, 37.5 %). In 3/17 patients, a later PIPAC could not be performed due to non-access. Two patients (ECOG 3 and 4) died in the hospital due to disease progression. CONCLUSION PIPAC with low-dose cisplatin and doxorubicin was safe and induced objective tumor regression in selected patients with PM from recurrent, platinum-resistant GC. First survival data are encouraging and justify further clinical studies in this indication.
Collapse
Affiliation(s)
- Giorgi Nadiradze
- />Department of Surgery, University of Magdeburg, Magdeburg, Germany
| | - Urs Giger-Pabst
- />Department of Surgery, Ruhr University Bochum, Bochum, Germany
| | - Juergen Zieren
- />Department of Surgery, Ruhr University Bochum, Bochum, Germany
| | - Dirk Strumberg
- />Department of Internal Medicine, Oncology and Haematology, Ruhr University Bochum, Bochum, Germany
| | - Wiebke Solass
- />Institute of Pathology, Medical School Hanover, Hanover, Germany
| | - Marc-André Reymond
- />Department of Surgery, University of Magdeburg, Magdeburg, Germany , />Department of Surgery, Ruhr University Bochum, Bochum, Germany , />Marienhospital Herne, Ruhr University Bochum, Hölkeskampring 40, 44625 Herne, Germany
| |
Collapse
|
34
|
Shiozaki H, Elimova E, Slack RS, Chen HC, Staerkel GA, Sneige N, Shimodaira Y, Sagebiel T, Lee JH, Bhutani MS, Das P, Mansfield PF, Estrella JS, Badgwell BD, Ajani JA. Prognosis of gastric adenocarcinoma patients with various burdens of peritoneal metastases. J Surg Oncol 2015; 113:29-35. [PMID: 26603684 DOI: 10.1002/jso.24087] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/21/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peritoneal metastases (PM) in patients with gastric adenocarcinoma (GAC) may be identified by diagnostic laparoscopy (DL) or imaging (I). Although prognosis is poor, some patients have excellent outcome. We compared the overall survival (OS) of patients in 3 groups: those with positive cytology (CY+) by DL (DL-CY+), those with gross PM (GPM) by DL (DL-GPM+) and with GPM obvious on I (I-GPM+). METHODS 146 GAC patients were identified. The Kaplan-Meier analysis, univariate, and multivariate Cox proportional hazards regression models were employed. RESULTS Patients were primarily men (67%), with good ECOG scores (0-1; 89%), had DL (84%), had poorly differentiated GAC (92%), and had received chemotherapy (89%). The median OS for all patients was 15 months (5% CI, 12.9-18.2 months). The DL-CY+ group had median OS of 22.5 months (95% CI, 15-29.3 months). Patients with I-GPM+ had four times the risk of death than those with DL-CY+ (P < 0.001) and patients with DL-GPM+ had two times the risk of death than those with DL-CY+ (P = 0.001). At 36 months, all DL-GPM+ and I-GPM+ had died but 8 patients with DL-CY+ remained alive. CONCLUSIONS Some GAC patients with DL-CY+ have long OS; therefore, novel strategies to further prolong their OS are needed.
Collapse
Affiliation(s)
- Hironori Shiozaki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elena Elimova
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca S Slack
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gregg A Staerkel
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nour Sneige
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yusuke Shimodaira
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tara Sagebiel
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
35
|
Rudloff U, Langan RC, Mullinax JE, Beane JD, Steinberg SM, Beresnev T, Webb CC, Walker M, Toomey MA, Schrump D, Pandalai P, Stojadinovic A, Avital I. Impact of maximal cytoreductive surgery plus regional heated intraperitoneal chemotherapy (HIPEC) on outcome of patients with peritoneal carcinomatosis of gastric origin: results of the GYMSSA trial. J Surg Oncol 2014; 110:275-84. [PMID: 25042700 DOI: 10.1002/jso.23633] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 04/05/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND A prospective randomized trial was conducted to compare the impact of systemic chemotherapy versus multi-modality therapy (complete cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), and systemic chemotherapy) on overall survival (OS) in patients with gastric carcinomatosis. METHODS Patients with measurable metastatic gastric adenocarcinoma involving the peritoneum, and resectable to "no evidence of disease" were randomized to gastrectomy, metastasectomy, HIPEC, and systemic FOLFOXIRI (GYMS arm) or FOLFOXIRI alone (SA arm). RESULTS Seventeen patients were enrolled (16 evaluable); 7 of 9 patients in the multi-modality GYMS arm achieved complete cytoreduction (CCR0). Median OS was 11.3 months in the GYMS arm and 4.3 months in the SA arm. Four patients in the GYMS arm survived >12 months, 2 patients close to 2 years at last follow-up, and 1 patient more than 4 years, with 2 of these patients still alive. No patient in the SA arm lived beyond 11 months. All patients surviving beyond 12 months in the surgery arm achieved complete cytoreduction and had an initial Peritoneal Cancer Index (PCI) of ≤ 15. CONCLUSION Maximal cytoreductive surgery combined with regional (HIPEC) and systemic chemotherapy in selected patients with gastric carcinomatosis and limited disease burden can achieve prolonged survival.
Collapse
Affiliation(s)
- Udo Rudloff
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
OBJECTIVE Defining processes of care, which are appropriate and necessary for management of gastric cancer (GC), is an important step toward improving outcomes. METHODS Using a RAND/UCLA Appropriateness Method, an international multidisciplinary expert panel created 22 statements reflecting optimal management. All statements were scored for appropriateness and necessity. RESULTS The following tenets were scored appropriate and necessary: (1) preoperative staging by computed tomography of abdomen/pelvis; (2) positron-emission tomographic scans not routinely indicated; (3) consideration for adjuvant therapy; (4) further clinical trials; (5) multidisciplinary decision making; (6) sufficient support at hospitals; (7) assessment of 16 or more lymph nodes (LNs); (8) in metastatic disease, surgery only for palliation of major symptoms; (9) surgeons experienced in GC management; (10) and surgeons experienced in both GC management and advanced laparoscopic surgery for laparoscopic resection. The following were scored appropriate, but of indeterminate necessity: (1) diagnostic laparoscopy before treatment; (2) a multidisciplinary approach to linitis plastica; (3) genetic assessment for diffuse GC and family history, or age less than 45 years; (4) endoscopic removal of select T1aN0 lesions; (5) D2 LN dissection in curative intent cases; (6) D1 LN dissection for early GC or patients with comorbidities; (7) frozen section analysis of margins; (8) nonemergent cases performed in a hospital with a volume of more than 15 resections per year; and (9) by a surgeon with more than 6 resection per year. CONCLUSIONS The expert panel has created 22 statements for the perioperative management of GC patients, to provide guidance to clinicians and improve the care received by patients.
Collapse
|
37
|
Abstract
Adenocarcinoma of the stomach is often diagnosed in the late stages of the disease. Surgical resection of all gross and microscopic disease is essential for curative treatment. Complete resection is often not achievable when patients present with advanced stage IV cancer. In the absence of symptoms, chemotherapy without resection has been the standard of care in most major centers. With improvements in response to chemotherapy and less invasive surgical approaches, patients with metastatic gastric cancer have had better survival outcomes than in the past. The challenge today when treating these patients is in defining who will benefit from more aggressive interventions. Reviewing the literature for guidance is difficult because the goals of treatment are often not clearly defined. Finding the proper balance of aggressiveness needed to extend survival while preserving and maximizing quality of life is a decision that clinicians have to make with increasing frequency. This review will attempt to provide a framework to aid in determining what role, if any, gastrectomy has in the management of patients with stage IV gastric cancer.
Collapse
Affiliation(s)
- Martin S Karpeh
- Department of Surgery, Beth Israel Medical Center, Continuum Cancer Centers of New York, New York, N.Y., USA.
| |
Collapse
|
38
|
Sarela AI. Laparoscopic gastrectomy: Quo vadis? J Minim Access Surg 2013; 9:53-4. [PMID: 23741108 PMCID: PMC3673573 DOI: 10.4103/0972-9941.110960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Abeezar I Sarela
- Department of Minimally Invasive Upper GI Surgery, St James's University Hospital, Leeds, UK and P. D. Hinduja Hospital, Mumbai, India
| |
Collapse
|
39
|
Blakely AM, Miner TJ. Surgical considerations in the treatment of gastric cancer. Gastroenterol Clin North Am 2013; 42:337-57. [PMID: 23639644 PMCID: PMC4467541 DOI: 10.1016/j.gtc.2013.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.
Collapse
Affiliation(s)
- Andrew M. Blakely
- Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 4, Providence, RI 02903, USA
| | - Thomas J. Miner
- Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA,Corresponding author.
| |
Collapse
|
40
|
Blakely AM, Miner TJ. Surgical considerations in the treatment of gastric cancer. Gastroenterol Clin North Am 2013. [PMID: 23639644 DOI: 10.1016/j.gtc.2013.01.010.surgical] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.
Collapse
Affiliation(s)
- Andrew M Blakely
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | | |
Collapse
|
41
|
Tourani SS, Cabalag C, Link E, Chan STF, Duong CP. Laparoscopy and peritoneal cytology: important prognostic tools to guide treatment selection in gastric adenocarcinoma. ANZ J Surg 2013; 85:69-73. [PMID: 23647832 DOI: 10.1111/ans.12197] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies have suggested that patients with occult peritoneal metastases not seen on preoperative imaging have poor prognosis. In this study, we aim to evaluate the utility and impact of staging laparoscopy and peritoneal cytology in patients with gastric adenocarcinoma. METHODS A retrospective analysis of patients with gastric adenocarcinoma managed at two major metropolitan hospitals in Melbourne, Australia, between January 1999 and July 2010 was undertaken. The main outcome measures were the number of patients in whom laparoscopy and/or peritoneal cytology changed treatment intent, and the overall survival of patients with occult metastases detected by laparoscopy/cytology. RESULTS Staging laparoscopy as an independent procedure was performed in 74.3% (148/199) of patients who had neither unequivocal metastases (M1) on preoperative imaging nor early T1 disease on endoscopic ultrasound. Laparoscopy/cytology detected occult metastases in 38 (25.6%) patients (27 macroscopic M1 and 11 microscopic M1 with positive peritoneal cytology only), leading to change in the treatment intent in 37 cases. The median overall survivals of patients with metastatic disease detected at staging laparoscopy (8.3 months, 95% confidence interval (CI) 5.4-16.5) or on peritoneal cytology (4.9 months, 95% CI 4.2-48) were as poor as those with M1 disease seen on preoperative imaging (6.7 months, 95% CI 4.2-8.9), P = 0.97. CONCLUSIONS Laparoscopy and peritoneal cytology add incremental value to modern imaging in the staging of gastric adenocarcinomas by detecting occult metastatic disease. Their utility needs to be optimized to allow better treatment selection for gastric cancer patients.
Collapse
Affiliation(s)
- Saam S Tourani
- Department of Surgery, Western Health, Footscray, Victoria, Australia
| | | | | | | | | |
Collapse
|
42
|
Survival benefit of palliative gastrectomy in gastric cancer patients with peritoneal metastasis. World J Surg 2013; 36:2637-43. [PMID: 22820871 DOI: 10.1007/s00268-012-1721-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The survival benefit of palliative gastrectomy in patients with peritoneal metastasis as a single incurable factor remains unclear. METHODS A total of 148 gastric cancer patients with peritoneal metastasis underwent gastrectomy or chemotherapy at the Shizuoka Cancer Center between September 2002 and December 2008 and were included in this study. The effects of gastrectomy and chemotherapy on their long-term outcome were investigated. Multivariate analysis was also performed to identify independent prognostic factors. RESULTS Gastrectomy was performed in 82 patients and subsequent chemotherapy was administered to 55. Chemotherapy was selected as an initial treatment for 66 patients. Median survival time (MST) was identical between patients with and without gastrectomy (13.1 vs. 12.0 months; P = 0.410). Conversely, MST was significantly longer in patients who received chemotherapy (13.7 months) than those who did not (7.1 months; P = 0.048). According to the results of multivariate analysis, chemotherapy (hazards ratio [HR] = 0.476; 95 % CI = 0.288-0.787) was selected as an independent prognostic factor, while gastrectomy was not. CONCLUSIONS The results of the present study did not show a survival benefit of palliative gastrectomy in selected patients with peritoneal metastasis. Instead, chemotherapy has to be considered as an initial treatment for these patients.
Collapse
|
43
|
Lee SJ, Lee WW, Yoon HJ, Lee HY, Lee KH, Kim YH, Park DJ, Kim HH, So Y, Kim SE. Regional PET/CT after water gastric inflation for evaluating loco-regional disease of gastric cancer. Eur J Radiol 2013; 82:935-42. [PMID: 23410909 DOI: 10.1016/j.ejrad.2013.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/10/2013] [Accepted: 01/11/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We aimed to improve diagnostic accuracy of (18)F-fluoro-2-deoxyglucose (FDG) PET/CT for gastric cancer with water gastric inflation. MATERIALS AND METHODS 44 gastric cancer patients (M:F=30:14, age ± std=62.1 ± 14.5 y) were enrolled before surgery. Fifty minutes after injection of FDG (0.14 mCi/kg body weight), whole body PET/CT was performed first and then regional PET/CT over gastric area was obtained 80 min post FDG injection after water gastric inflation. Diagnostic accuracies for loco-regional lesions were compared between whole body and regional PET/CT. RESULTS 48 primary tumors (23 EGC and 25 AGC) and 348 LN stations (61 metastatic and 287 benign) in 44 patients were investigated. Primary tumor sensitivity of whole body PET/CT (50%=24/48) was significantly improved by regional PET/CT (75%=36/48, p<0.005). Sensitivity of whole body PET/CT (24.6%=15/61) for LN metastasis was also significantly improved by regional PET/CT (36.1%=22/61, p<0.01), whereas specificity of whole body PET/CT (99.3%=285/287) was not compromised by regional PET/CT (98.3%=282/287, p>0.05). Higher primary tumor FDG uptake in regional PET/CT indicated shorter progress-free survival (p=0.0003). CONCLUSION Diagnostic accuracy of whole body PET/CT for loco-regional disease of gastric cancer could be significantly improved by regional PET/CT after water gastric inflation and prognosis could be effectively predicted by primary tumor FDG uptake in regional PET/CT.
Collapse
Affiliation(s)
- Soo Jin Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Youn SH, Seo KW, Lee SH, Shin YM, Yoon KY. 18F-2-Deoxy-2-Fluoro-D-Glucose Positron Emission Tomography: Computed Tomography for Preoperative Staging in Gastric Cancer Patients. J Gastric Cancer 2012; 12:179-86. [PMID: 23094230 PMCID: PMC3473225 DOI: 10.5230/jgc.2012.12.3.179] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 07/18/2012] [Accepted: 07/30/2012] [Indexed: 12/20/2022] Open
Abstract
Purpose The use of 18F-2-deoxy-2-fluoro-D-glucose positron emission tomography-computed tomography as a routine preoperative modality is increasing for gastric cancer despite controversy with its usefulness in preoperative staging. In this study we aimed to determine the usefulness of preoperative positron emission tomography-computed tomography scans for staging of gastric cancer. Materials and Methods We retrospectively analyzed 396 patients' positron emission tomography-computed tomography scans acquired for preoperative staging from January to December 2009. Results The sensitivity of positron emission tomography-computed tomography for detecting early gastric cancer was 20.7% and it was 74.2% for advanced gastric cancer. The size of the primary tumor was correlated with sensitivity, and there was a positive correlation between T stage and sensitivity. For regional lymph node metastasis, the sensitivity and specificity of the positron emission tomography-computed tomography were 30.7% and 94.7%, respectively. There was no correlation between T stage and maximum standardized uptake value or between tumor markers and maximum standardized uptake value. Fluorodeoxyglucose uptake was detected by positron emission tomography-computed tomography in 24 lesions other than the primary tumors. Among them, nine cases were found to be malignant, including double primary cancers and metastatic cancers. Only two cases were detected purely by positron emission tomography-computed tomography. Conclusions Positron emission tomography-computed tomography could be useful in detecting metastasis or another primary cancer for preoperative staging in gastric cancer patients, but not for T or N staging. More prospective studies are needed to determine whether positron emission tomography-computed tomography scans should be considered a routine preoperative imaging modality.
Collapse
Affiliation(s)
- Seok Hwa Youn
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | | | | | | | | |
Collapse
|
45
|
Detection of gastric cancer peritoneal metastases by peritoneal lavage: Current limitations and future perspectives. Surgery 2012; 152:1-4. [PMID: 22703894 DOI: 10.1016/j.surg.2012.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/22/2012] [Indexed: 12/16/2022]
|
46
|
Sonbare D. Image-enhanced laparosocopy: would it change staging and management protocols in surgical oncology? Surgery 2012; 152:939-40. [PMID: 22902200 DOI: 10.1016/j.surg.2012.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/14/2012] [Indexed: 10/28/2022]
|
47
|
Ruiz-Casado A, Miliani C, López C, López M, Martin T, Pereira F. Round ligament metastatic gastric cancer as a finding in an inguinal surgery. GASTROINTESTINAL CANCER RESEARCH : GCR 2012; 5:137-138. [PMID: 23077689 PMCID: PMC3433264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
| | | | | | | | - Teresa Martin
- Department of Radiology Hospital Universitario de Fuenlabrada Madrid, Spain
| | | |
Collapse
|
48
|
Liu X, Cai H, Sheng W, Wang Y. Long-term results and prognostic factors of gastric cancer patients with microscopic peritoneal carcinomatosis. PLoS One 2012; 7:e37284. [PMID: 22615966 PMCID: PMC3353918 DOI: 10.1371/journal.pone.0037284] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 04/17/2012] [Indexed: 02/07/2023] Open
Abstract
Background Clinical significance of microscopic peritoneal carcinomatosis remained unclear. The aim of this study was to evaluate the prognostic value of microscopic peritoneal carcinomatosis in gastric cancer. Methods From 1996 to 2007, 4426 patients underwent gastrectomy for gastric cancer at Fudan University Shanghai Cancer Center. The clinical and pathological data were reviewed to identify patients with microscopic peritoneal carcinomatosis (group 1). The clinicopathological features and prognosis were examined. Additionally, 242 stage-matched gastric cancer patients without microscopic peritoneal carcinomatosis (group 2) and 118 with macroscopic peritoneal carcinomatosis (group 3) were selected as control groups. Results Microscopic peritoneal carcinomatosis was found in 121 patients. There were 85 males and 36 females (2.36:1). There was a higher incidence rate of large size tumor (≥5 cm) (P = 0.045), Borrmann IV (P = 0.000), and serosal invasion (P = 0.000) in gastric cancer with microscopic peritoneal carcinomatosis compared with the control group. The 5-year survival rate of gastric cancer with microscopic peritoneal carcinomatosis was 24%, significantly poorer than that of the stage-matched control group but better than that of patients with macroscopic peritoneal carcinomatosis. The independent prognostic factors identified included pathological stage and operative curability. Conclusions The presence of microscopic peritoneal carcinomatosis was associated with worse prognosis for gastric cancer, but curative surgery showed potential to improve prognosis.
Collapse
Affiliation(s)
- Xiaowen Liu
- Department of Gastric Cancer and Soft Tissue Sarcoma, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hong Cai
- Department of Gastric Cancer and Soft Tissue Sarcoma, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weiqi Sheng
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yanong Wang
- Department of Gastric Cancer and Soft Tissue Sarcoma, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- * E-mail:
| |
Collapse
|
49
|
Pavlidis TE, Pavlidis ET, Sakantamis AK. The role of laparoscopic surgery in gastric cancer. J Minim Access Surg 2012; 8:35-8. [PMID: 22623823 PMCID: PMC3353610 DOI: 10.4103/0972-9941.95524] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 04/19/2011] [Indexed: 02/05/2023] Open
Abstract
The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.
Collapse
Affiliation(s)
- Theodoros E Pavlidis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Konstantinoupoleos 49, 546 42 Thessaloniki, Greece
- Address for correspondence: Prof. Theodoros E Pavlidis A Samothraki 23 542 48 Thessaloniki, Greece. E-mail:
| | - Efstathios T Pavlidis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Konstantinoupoleos 49, 546 42 Thessaloniki, Greece
| | - Athanasios K Sakantamis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Konstantinoupoleos 49, 546 42 Thessaloniki, Greece
| |
Collapse
|
50
|
Atay-Rosenthal S, Wahl RL, Fishman EK. PET/CT findings in gastric cancer: potential advantages and current limitations. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/iim.12.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|