Palliative Gastrectomy Prolongs Survival of Metastatic Gastric Cancer Patients with Normal Preoperative CEA or CA19-9 Values: A Retrospective Cohort Study

Are Palliative Interventions Worth the Risk in Advanced Gastric Cancer? A Systematic Review

Background: Less than 25% of gastric cancers (GC) are discovered early, leading to limited treatment options and poor outcomes (27.8% mortality, 3.7% 5-year survival). Screening programs have improved cure rates, yet post-diagnosis treatment guidelines remain unclear (systemic chemotherapy versus surgery). The optimal type of palliative surgery (palliative gastrectomy (PG), surgical bypass (SB), endoscopic stenting (ES)) for long-term outcomes is also debated. Methods: A literature review was conducted using PubMed, MEDLINE, and EMBASE databases along with Google Scholar with the search terms "gastric cancer" and "palliative surgery" for studies post-1985. From the initial 1018 articles, multiple screenings narrowed it to 92 articles meeting criteria such as "metastatic, stage IV GC", and intervention (surgery or chemotherapy). Data regarding survival and other long-term outcomes were recorded. Results: Overall, there was significant variation between studies but there were similarities of the conclusions reached. ES provided quick symptom relief, while PG showed improved overall survival (OS) only with adjuvant chemotherapy in a selective population. PG had higher mortality rates compared to SB, with ES having a reported 0% mortality, but OS improved with chemotherapy across both SB and PG. Conclusions: Less frail patients may experience an improvement in OS with palliative resection under limited circumstances. However, operative intervention without systemic chemotherapy is unlikely to demonstrate a survival benefit. Further research is needed to explore any correlations.

The prognostic role of palliative gastrectomy in advanced gastric cancer: a systematic review and meta-analysis

BACKGROUND

The effectiveness of palliative gastrectomy for advanced GC remains a topic of debate. This study sought to establish whether palliative gastrectomy has an impact on prolonging survival.

METHODS

We carried out systematic searches in PubMed, Cochrane Library, Web of Science, and the EMBASE databases from database inception to July 2023 to gather studies that examined the connection between palliative gastrectomy and the prognosis of advanced GC. The study employed overall survival as the primary outcome, with the hazard ratio serving as the selected parameter to gauge the association. Subgroup analyses were performed to delve into potential differences within the included studies, categorizing them by study region and sample size in order to examine possible sources of heterogeneity. The stability of individual studies was assessed through sensitivity analysis. The analysis included 20 articles, encompassing a total of 23,061 patients.

RESULTS

According to the meta-analysis results, patients who underwent palliative gastrectomy exhibited a noteworthy enhancement in overall survival (HR: 1.49; 95% CI: 1.12-1.99; P = 0.006) in comparison to those who did not receive this procedure. There was no association between the type of surgery and the length of hospital stay, as revealed by the analysis (HR = -0.02; 95% CI: -0.84-0.81; P = 0.970).

CONCLUSIONS

Based on this meta-analysis, patients with advanced gastric cancer who underwent palliative gastrectomy may experience an extended survival duration without a significant prolongation of their hospitalization.

Multiple bioinformatics analysis identifies IGFBP1 as associated with the prognosis of stomach adenocarcinoma

This study aimed to screen the hub gene for predicting the prognosis of patients with stomach adenocarcinoma (STAD). The RNA-sequencing expression data and clinical data of STAD were collected from the cancer genome atlas. The R package "limma" was performed to ascertain the differentially expressed genes (DEGs) between the relapse group and non-relapse group, and the DEGs between the survival dead status group and survival alive status group were screened. The overlapping genes between 2 DEGs sets were identified by the Venn diagram. Many different bioinformatics analysis methods were performed to analyze the importance of hub genes. One gene signature, IGFBP1, was extracted. The KM plot indicated that STAD patients with low IGFBP1 mRNA expression have a shorter overall survival time. The top 100 co-expression genes of IGFBP1 were mainly enriched in complement and coagulation cascades, epithelial cell signaling in Helicobacter pylori infection, and Wnt signaling pathway. Immune infiltration analysis indicated IGFBP1 may inhibit immune cell infiltration in tumors by infiltration and immune escape, leading to tumor metastasis and progression. The bioinformatics analysis results indicate that IGFBP1 can be used as a tool to evaluate the mortality risk of patients with STAD.

Survival outcomes of management in metastatic gastric adenocarcinoma patients

Chemotherapy is generally considered as the main treatment for metastatic gastric adenocarcinoma. The role of gastrectomy for metastatic gastric cancer without obvious symptoms is controversial. The objective of this study is to investigate survival outcomes of treatment modalities using a real-world data setting. A retrospective cohort study was designed using the Taiwan Cancer Registry database. We identified the treatment modalities and used Kaplan–Meier estimates and Cox regressions to compare patient survival outcomes. From 2008 to 2015, 5599 gastric adenocarcinoma patients were diagnosed with metastatic disease (M1). The median overall survival (OS) of patients with surgery plus chemotherapy had the longest survival of 14.2 months. The median OS of the patients who received chemotherapy alone or surgery alone was 7.0 and 3.9, respectively. Age at diagnosis, year of diagnosis, tumor grade, and treatment modalities are prognostic factors for survival. The hazard ratios for patients who received surgery plus chemotherapy, surgery alone, and supportive care were 0.47 (95% CI 0.44–0.51), 1.22 (95% CI 1.1–1.36), and 3.23 (95% CI 3.01–3.46), respectively, by multivariable Cox regression analysis when using chemotherapy alone as a referent. Chemotherapy plus surgery may have a survival benefit for some selected gastric adenocarcinoma patients with metastatic disease.

Prognostic value of preoperative body mass index for diabetic patients with non-metastasis gastric cancer: a single center experience

Aim

This study was designed to investigate the prognostic effect of preoperative body mass index (BMI) for Type 2 diabetes mellitus (T2DM) patients with non-metastasis gastric cancer (GC) who underwent D₂ gastrectomy.

Methods

T2DM patients with pT_1–4bN_0–3bM₀ GC were retrospectively collected in Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital from January, 2000 to December, 2010. These patients underwent D₂ radical resection of the stomach combined with regional lymphadenectomy. Chi-square test was used to analyze unordered categorical variables and ranked data, followed by Kaplan–Meier analysis as well as Cox regression models to detect risk factors for survival outcomes. In addition, the cut-off point was determined by the X-tile program. All analyses were carried out using survival package of R and SPSS Software.

Results

A total of 302 T2DM patients with pT_1–4bN_0–3bM₀ GC were collected and analyzed. The cut-off points of BMI, identified by the X-tile program, was 19 kg/m². Patients with low BMI (< 19 kg/m²) had a higher percentage of advanced T stage (T_4a and T_4b), more advanced TNM stage (stage IIIA, IIIB and IIIC), and more elevated level of serum carcinoembryonic antigen (CEA), compared to those with high BMI (> 19 kg/m²) (all P < 0.05). In the low BMI subgroup, the 5-year overall survival rate was 39.02%, which was as high as 58.11% in the high BMI subgroup (P < 0.05). In the multivariate Cox regression model revealed that III_C stage (OR = 3.101), N_3b stage (OR = 3.113) were the most important prognostic indicators, followed by pretreatment BMI (OR = 2.136).

Conclusion

Low preoperative BMI (< 19 kg/m²) was a poor prognostic marker for T2DM patients with pT_1–4bN_0–3bM₀ GC.

Gastrectomy for stage IV gastric cancer: a comparison of different treatment strategies from the SEER database

In the West, more than one third of newly diagnosed subjects show metastatic disease in gastric cancer (mGC) with few care options available. Gastrectomy has recently become a subject of debate, with some evidence showing advantages in survival beyond the sole purpose of treatment tumor-related complications. We investigated the survival benefit of different strategies in mGC patients, focusing on the role and timing of gastrectomy. Data were extracted from the SEER database. Groups were determined according to whether patients received gastrectomy, chemotherapy, supportive care. Patients receiving a multimodality treatment were further divided according to timing of surgery, whether performed before (primary gastrectomy, PG) or after chemotherapy (secondary gastrectomy, SG). 16,596 patients were included. Median OS was significantly higher (p < 0.001) in the SG (15 months) than in the PG (13 months), gastrectomy alone (6 months), and chemotherapy (7 months) groups. In the multivariate analysis, SG showed better OS (HR = 0.22, 95%CI = 0.18-0.26, p < 0.001) than PG (HR = 0.25, 95%CI = 0.23-0.28, p < 0.001), gastrectomy (HR = 0.40, 95%CI = 0.36-0.44, p < 0.001), and chemotherapy (HR = 0.42, 95%CI = 0.4-0.44, p < 0.001). The survival benefits persisted even after the PSM analysis. This study shows survival advantages of gastrectomy as multimodality strategy after chemotherapy. In selected patients, SG can be proposed to improve the management of stage IV disease.

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

Survival benefits of palliative gastrectomy in stage IV gastric cancer: a propensity score matched analysis

Background

This study aimed to investigate the effect of palliative gastrectomy on survival in stage IV gastric cancer.

Methods

Patients diagnosed with stage IV gastric cancer between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Survival curves were estimated by the Kaplan-Meier method before and after propensity score matching (PSM). Univariate and multivariate Cox analyses were performed to evaluate risk factors for survival in patients who underwent palliative gastrectomy.

Results

We examined 6,529 patients with stage IV gastric cancer, of which 625 underwent palliative gastrectomy. Using a 1:2 PSM, the 625 patients were matched with 1,250 patients from the no gastrectomy group. The overall survival was higher in the gastrectomy group before [hazard ratio (HR) =0.57, 95% confidence interval (CI): 0.53-0.62, P<0.0001] and after PSM (HR =0.51, 95% CI: 0.46-0.57, P<0.0001). Multivariate Cox analysis confirmed the survival benefits of palliative gastrectomy and chemotherapy. Older age, over-lapping lesions, non-adenocarcinomas, higher tumor grade, and lung metastasis significantly increased the risk of mortality. In the gastrectomy group, patients aged ≥80 years, diagnosed with grades 3/4 non-adenocarcinomas, or with lung metastasis showed poorer prognosis. However, chemotherapy could improve the survival of these patients.

Conclusions

Palliative gastrectomy provides survival benefits to stage IV gastric cancer patients. However, age, tumor grade, tumor histology, and lung metastasis status should be considered while making a decision regarding gastrectomy. Chemotherapy should also be recommended for these patients.

Nomograms for predicting survival in patients with metastatic gastric adenocarcinoma who undergo palliative gastrectomy

BACKGROUND

Recently, evidence has emerged that palliative gastrectomy in patients with stage IV gastric cancer may offer some survival benefits. However, the decision whether to perform primary tumor surgery remains challenging for surgeons, and investigations into models that are predictive of prognosis are scarce. Current study aimed to develop and validate prognostic nomograms for patients with metastatic gastric adenocarcinoma treated with palliative gastrectomy.

METHODS

The development dataset comprised 1186 patients from the Surveillance, Epidemiology, and End Results Program who were diagnosed with metastatic gastric adenocarcinoma in 2004-2011, while the validation dataset included 407 patients diagnosed in 2012-2015. Variables were incorporated into a Cox proportional hazards model to identify independent risk factors for survival. Both pre- and postoperative nomograms for predicting 1- or 2-year survival probabilities were constructed using the development dataset. The concordance index (c-index) and calibration curves were plotted to determine the accuracy of the nomogram models. Finally, the cut-off value of the calculated total scores based on preoperative nomograms was set and validated by comparing survival with contemporary cases without primary tumor surgery.

RESULTS

Age, tumor size, location, grade, T stage, N stage, metastatic site, scope of gastrectomy, number of examined lymph node(s), chemotherapy and radiotherapy were risk factors of survival and were included as variables in the postoperative nomogram; the c-indices of the development and validation datasets were 0.701 (95% confidence interval [CI]: 0.693-0.710) and 0.699 (95% CI: 0.682-0.716), respectively. The preoperative nomogram incorporated age, tumor size, location, grade, depth of invasion, regional lymph node(s) status, and metastatic site. The c-indices for the internal (bootstrap) and external validation sets were 0.629 (95% CI: 0.620-0.639) and 0.607 (95% CI: 0.588-0.626), respectively. Based on the preoperative nomogram, patients with preoperative total score > 28 showed no survival benefit with gastrectomy compared to no primary tumor surgery.

CONCLUSIONS

Our survival nomograms for patients with metastatic gastric adenocarcinoma undergoing palliative gastrectomy can assist surgeons in treatment decision-making and prognostication.

A real-world evidence of efficacy of palliative gastrectomy plus chemotherapy in metastatic gastric cancer patients

Background: The benefit of palliative gastrectomy for patients with metastatic gastric cancer (mGC) is controversial, and suitable candidates for surgery and treatment strategies remain unclear. The present study aimed to investigate the efficacy of palliative gastrectomy plus chemotherapy among patients with mGC and to identify the potential patients for such treatment using real-world data.

Methods: A dataset of 236 patients with mGC diagnosed at the Sun Yat-Sen University Cancer Center from January 1, 2006 to December 31, 2012 were analyzed retrospectively. The cohort comprised 80 patients who had palliative gastrectomy plus chemotherapy (SC) and 156 patients who had chemotherapy only (CO). Propensity score matching (PSM) was employed to minimize the influence of confounders.

Results: The median overall survival of the SC group was significantly better than that of the CO group (Before PSM: 17.0 months vs 12.0 months, P=0.038; after PSM: 17.0 months vs 13.0 months, P=0.017). In the multivariate analysis, SC (Before PSM: hazard ratio (HR) =0.68, P=0.023; after PSM: HR =0.64, P=0.021) was favored for better survival after adjustment for sex, age, year of diagnosis, primary tumor location, and tumor grade. Total gastrectomy (P=0.026) was associated with worse survival for the SC group. The significant survival advantage of SC over CO was retained in patients with single organ metastasis (P=0.016), peritoneal seedings (P=0.039), and those receiving taxane-based chemotherapy (P=0.011).

Conclusion: SC could improve the overall survival of patients with mGC as compared with CO. The chemotherapy regimen and type of resection were proven to influence efficacy. Patients who received taxane-based regimens might be suitable for palliative gastrectomy.

Outcomes of gastrectomy following upfront chemotherapy in advanced gastric cancer patients with a single noncurable factor: a cohort study

Purpose

Chemotherapy is the standard care for patients with incurable advanced gastric cancer. Whether or when the addition of gastrectomy to chemotherapy improves survival of advanced gastric cancer patients with a single noncurable factor remains controversial. We aimed to evaluate the superiority of gastrectomy following chemotherapy vs chemotherapy alone regarding overall survival (OS) in these patients.

Patients and methods

Patients with advanced gastric cancer from January 2008 to December 2014 were retrieved from our prospectively acquired database and retrospectively analyzed. The patients with a single noncurable factor were grouped in terms of cancer treatment: chemotherapy alone or gastrectomy following chemotherapy.

Results

Four hundred and fourteen patients (333 chemotherapy alone and 81 gastrectomy following chemotherapy) were included in this study. Kaplan–Meier survival curve showed a significant difference on median OS between chemotherapy-alone group and the gastrectomy plus chemotherapy group (10.9 vs 15.9 months, P<0.01). After propensity score analysis (n=126), chemotherapy plus surgery (81 patients) also showed survival benefit over chemotherapy alone (35 patients) (15.9 vs 10.0 months, P<0.01). Furthermore, stratified analyses indicated that patients with liver metastasis, <65 years of age, male, having normal level of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA199) upon diagnosis, or having nongastro-esophageal junction tumor benefited from surgery.

Conclusion

This study suggests that gastrectomy after chemotherapy could lead to survival benefit over chemotherapy alone in advanced gastric cancer patients with a single nonresectable factor if the disease was controllable by chemotherapy.

Associations between CA19-9 and CA125 levels and human epidermal growth factor receptor 2 overexpression in patients with gastric cancer

The aim of the present study was to investigate the association between serum carbohydrate antigen (CA)19-9 and CA125 levels, and human epidermal growth factor receptor 2 (HER2) expression in patients with gastric cancer, as well as to identify any correlation between them and the risk of recurrence and metastasis. A total of 256 patients were enrolled in the present study, and 219 patients were followed-up to investigate recurrence and metastasis of gastric cancer. Immunohistochemistry was used to detect HER-2 in gastric adenocarcinoma and paracancerous tissues. The positive rate of CA19-9 and CA125 in stages III/IV was higher compared with that in stages I/II. The positive rate of HER2 in distinct stages of gastric cancer was not statistically different. Serum CA19-9 and CA125 were not associated with the positive expression of HER2. The recurrence and metastasis of CA19-9, CA125 and HER2-positive gastric cancer were increased compared with those experienced by CA19-9, CA125 and HER2-negative patients. Age, stage and preoperative tumor markers were associated with 3-year prognosis of gastric cancer. HER2 [odds ratio (OR)=2.55] and CA19-9 (OR=1.22) were independent prognostic factors in patients with gastric cancer. CA19-9, CA125 and HER2 may be used to predict the recurrence or metastasis of gastric cancer. The combined detection may be able to improve the sensitivity and efficiency of predicting the recurrence or metastasis of gastric cancer. Preoperative positive serum for CA19-9 and CA125 were associated with poor prognosis in patients with gastric cancer. CA19-9 and HER2 were independent prognostic factors of gastric cancer.