Adjuvant intraperitoneal chemotherapy for advanced primary gastric cancer

Efficacy of Adjuvant Systemic Chemotherapy Combined with Radical Surgery and Hyperthermic Intraperitoneal Chemotherapy in Gastric Cancer Treatment

Evaluation of the efficacy of the combination of radical surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), and adjuvant systemic chemotherapy (ACT) in reducing gastric cancer progression in patients with resectable serosa-invasive gastric cancer in a single institution. In 2015-2016, 19 patients with gastric cancer (stage IIB-IIIC) were included in the trial. The trial protocol comprised radical surgery, HIPEC (cisplatin 50 mg/m² + doxorubicin 50 mg/m², 42 °C, 1 hour), and 1-8 cycles of ACT (oxaliplatin 100 mg/m² administered on day 1 of each cycle and oral capecitabine 1000 mg/m² (or tegafur 10-15 mg/kg) administered twice daily on days 1-14 of each cycle with an interval of 7 days between cycles). Following the ACT treatment, the patients were divided into 2 subgroups-those who underwent up to 6 ACT cycles (1-6 cycles, subgroup ≤ 6-8 patients) and those who underwent 7-8 ACT cycles (subgroup > 6-11 patients). Three-year metastasis-free survival (MFS) for the > 6 subgroup was 91 ± 9%. With a follow-up median of 17 months, 3-year MFS for the ≤ 6 subgroup was not reached - p _log-rank = 0.003. The trial showed that in managing advanced gastric cancer patients (pT4a-4bN0-3 M0) by supplementing radical surgery with ACT-enhanced hyperthermic intraperitoneal chemotherapy, ACT proved to be highly effective when administered in its full mode of 7-8 cycles compared with its truncated variant of 1-6 cycles.

Effect of early body cavity continuous circulation hyperthermia perfusion chemotherapy combined with systemic chemotherapy (and nursing) on survival rate and serum tumor markers in patients with advanced gastric cancer

This study was designed to investigate the effects of early coelom continued circulatory hyperthermic perfusion chemotherapy combined with systemic chemotherapy on the survival and serum tumor markers. A total of 128 patients with advanced gastric carcinoma who have received surgical treatments were selected and were randomly divided into study group (receiving early circulatory intraperitoneal hyperthermic perfusion chemotherapy combined with systemic chemotherapy postoperatively) and control group (receiving chemotherapy alone postoperatively), with 64 cases in each. Comparison of serum tumor markers (CA724, CA242), vascular endothelial growth factor (VEGF), matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9), immune function indexes (CD3+, CD4+, CD8+), and 5-year survival rate was assessed. Before treatment, there was no significant difference in the serum tumor markers (CA724 and CA242) as well as the serum VEGF, MMP-2, and MMP-9 levels among the two groups ( P > 0.05). However, the above parameters in the study group were significantly lower than control group 8 weeks after the treatment ( P < 0.05). Before treatment, there was no significant difference in CD3+, CD4+, CD8+ and CD4+/CD8+ between the two groups ( P > 0.05). Eight weeks after the treatment, the CD3+, CD4+ and CD4+/CD8+ in the study group were significantly higher than those in the control group ( P < 0.05), while the CD8+ levels was significantly lower than the latter group ( P < 0.05). The 2-year recurrence rate in the study group was lower than the control group ( P < 0.05). Furthermore, survival rates (1-year, 3-year and 5-year) of the study group were all higher than control group ( P < 0.05). Early circulatory hyperthermia perfusion chemotherapy combined with systemic chemotherapy contributed to the decrease in the serum tumor markers (CA724, CA242) as well as the serum VEGF, MMP-2, and MMP-9 levels, improved the immune functions. This therapeutic regimen prolonged the long-term survival conditions of the patients as well as proved the safety and effectiveness.

Low density neutrophils (LDN) in postoperative abdominal cavity assist the peritoneal recurrence through the production of neutrophil extracellular traps (NETs)

Many types of immune cells appear in peritoneal cavity after abdominal surgery. In patients who underwent laparotomy due to gastric cancer, peritoneal lavages were obtained before and after surgical procedure. Cells were recovered from intermediate layer after Ficoll-Hypaque centrifugation and analyzed for phenotypes and functions, especially focused on low density neutrophils (LDN). The number of CD66b (+) LDN with mature phenotype was markedly elevated in postoperative as compared with preoperative lavages. Short term culture of the purified LDN produced many threadlike structures positive for SYTOX, nucleic acid staining, as well as histone and myeloperoxidase, suggesting the NETs formation. Human gastric cancer cells, MKN45, OCUM-1 and NUGC-4, were selectively attached on the NETs, which was totally abolished by the pretreatment of DNAse I. Intraperitoneal (IP) co-transfer of the LDN with MKN45 in nude mice strongly augments the metastasis formation on peritoneum, which was strongly suppressed by the following IP administration of DNAse I. Many NETs-like structures were detected on the surface of human omental tissue resected by gastrectomy. NETs on peritoneal surface can assist the clustering and growth of free tumor cells disseminated in abdomen. Disruption of the NETs by DNAse might be useful to prevent the peritoneal recurrence after abdominal surgery.

Peritoneal lavage examination as a prognostic tool in cases of gastric cancer

INTRODUCTION

Peritoneal tumor seeding is a common form of recurrence after gastric cancer surgery. The finding of free tumor cells and/or elevation of tumor markers in the peritoneal fluid could predict intraperitoneal tumor recurrence. The results of these examination can be used for indication of aggressive treatment modalities such as hyperthermic intraperitoneal chemotherapy (HIPEC).

MATERIAL AND METHODS

We have operated on 105 patients suffering from gastric cancer. The control group consisted of 12 patients without malignant disease. Peritoneal lavage fluid or ascites was collected immediately after laparotomy and examined by cytology and biochemistry (levels of carcinoembryonic antigen (CEA) and Ca 19-9). Sensitivity, specificity, stage correlation and overall survival were observed.

RESULTS

Elevation of tumor markers or the finding of free intraperitoneal tumor cells predicts recurrence. The prognosis of these patients is same as in stage IV TNM classification with median survival time less than 1 year (p = 0.713). Patients with negative cytology have median survival time 5 years contrary to them with positive cytology (p < 0.001). Sensitivity of the cytology was 34% and specificity was 85%. Sensitivity of biochemistry was 53% (combination of both markers) and specificity was 100%.

CONCLUSIONS

This study confirms the importance of peritoneal fluid examination for the prognosis. We cannot recommend routine use as an indicator for HIPEC due to low sensitivity, but the result of cytological examination is an independent factor for patient survival.

Adjuvant combined systemic chemotherapy and intraperitoneal chemotherapy for locally advanced gastric cancer

The optimal adjuvant treatment modality for gastric cancer has not been well defined. The aim of this study was to evaluate the efficacy and feasibility of adjuvant combined systemic and intraperitoneal chemotherapy (ACSIP) in high-risk patients with locally advanced gastric cancer. Between June 2003 and December 2008, 62 eligible patients with serosa-infiltrating and/or node-positive gastric cancer following curative gastrectomy with D2 lymphadenectomy received ACSIP, consisting of intravenous oxaliplatin 85 mg/m(2) on day 1 followed by leucovorin (LV) 200 mg/m(2) and 5-fluorouracil (5-FU) 450 mg/m(2) on days 1-3, intraperitoneal 5-FU 600 mg/m(2) on days 4-5 and cisplatin (CDDP) 40 mg/m(2) on day 5. Survival rates, the sites of first treatment failure and safety were analyzed. At a median follow-up of 45 months (range 7-101), the 3-year disease-free survival (DFS) and overall survival (OS) rates were 66.1 and 74.2%, respectively. Initial peritoneal and hepatic failures were found in 6 (24.0%) and 3 (12.0%) of the 25 patients with recurrence, respectively. Neutropenia, gastrointestinal side effects and peripheral neuropathy were the most common grade 3-4 toxicities; however, they were all infrequent and manageable. No serious surgical complications or treatment-related mortality was observed. The results of this study indicate that ACSIP is effective and feasible for locally advanced gastric cancer with encouraging survival rates and possibly decreased peritoneal and hepatic recurrences. The benefits of this promising combined adjuvant treatment modality warrant further studies.

In vivo biocompatibility of three potential intraperitoneal implants

The intraperitoneal biocompatibility of PDMS, polyHEMA and pEVA was investigated in rats, rabbits and rhesus monkeys. No inflammation was evidenced by hematological analyses and measurement of inflammatory markers throughout the experiment and by post-mortem examination of the pelvic cavity. After 3 or 6 months, histological analysis revealed fibrous tissue encapsulating PDMS and PEVA implants in all species and polyHEMA implants in rabbits and monkeys. Calcium deposits were observed inside polyHEMA implants. The intraperitoneal biocompatibility of all 3 polymers makes them suitable for the design of drug delivery systems, which may be of great interest for pathologies confined to the pelvic cavity.

HER2-mediated upregulation of MMP-1 is involved in gastric cancer cell invasion

HER2 overexpression is associated with metastasis-the main cause of death in individuals with gastric cancer. In this study, we demonstrated that vector-based shRNA significantly knocked down the expression of HER2 and considerably inhibited both the migration and invasion of gastric cancer cells. HER2 knockdown resulted in the downregulation of the expression of MMP-1, while HER2 overexpression improved the transcription of MMP-1 through the activation of an MMP-1 promoter. The promoter region of MMP-1 between -2500 and -2000 bp was found to be crucial for the upregulation of HER2-mediated transcription. Furthermore, a truncated promoter (-70 to+63) did not display any transcriptional activity. Cell invasion activity was almost completely inhibited when MMP-1 was knocked down. Conversely, the overexpression of MMP-1 partly rescued the invasion ability of cell strains with knocked-down HER2. These findings help further understanding of the molecular mechanisms through which HER2 promotes malignancy, and suggest that targeting both HER2 and MMP-1 may be required to effectively block HER2 signaling in gastric cancer therapy.

Signet ring cell histology is an independent predictor of poor prognosis in gastric adenocarcinoma regardless of tumoral clinical presentation

OBJECTIVE

To test the hypothesis that signet ring cell (SRC) histology has a negative prognostic value in patients with gastric adenocarcinoma (ADC).

SUMMARY BACKGROUND DATA

In western countries, gastric ADC with SRC often occurs after the disease has advanced. Consequently, the prognosis of SRC is generally regarded as poor, although survival studies comparing SRC and non-SRC have yielded inconsistent results.

METHODS

: An intent to treat analysis was performed among 215 patients with gastric ADC scheduled for surgical resection from 1996 to 2007. Of these, 180 patients underwent the resection and 35 were not resected due to diffuse metastatic illness. From 59 resected patients with SRC (SRC group), control non-SRC resected patients matched by age, gender, American Society of Anaesthesiologists (ASA) classification, tumoral location, and pTNM stage were randomly selected by computer (non-SRC group: n = 100) during the same study period.

RESULTS

The overall median survival was 21 months, which was significantly higher in resected compared to non-resected patients (31 vs. 5 months, P < 0.001). In non-resected patients, SRC histological subtype was associated with higher rates of diffuse peritoneal carcinomatosis (90.1% vs. 62.5%, P = 0.053) and neoplastic ascitis (63.6% vs. 34.7%, P = 0.059) and poorer median survival (5 vs. 7 months, P = 0.062). For resected patients, the 2 groups (SRC and non-SRC) were comparable regarding matching variables, demographic variables, and postoperative course. The median survival was significantly lower for SRC patients (21 vs. 44 months, P = 0.004). SRC resected patients exhibited higher rates of localized peritoneal carcinomatosis (P = 0.013) and lymph node involvement (P < 0.001) at diagnosis, lower R0 resection rate (P = 0.019) and earlier tumor relapse (P = 0.009), which was generally in a peritoneal carcinomatosis form (P = 0.011). By multivariate analysis, we concluded that SRC histology was independently associated with a dismal prognosis after adjustment on confounding variables (hazard ratio = 1.5, 95% confidence interval 1.1-2.0, P = 0.004). The prognostic role of SRC was maintained after exclusion of patients with advanced stage at initial diagnosis such as localized peritoneal carcinomatosis or lymph node invasion.

CONCLUSIONS

This study is currently the best evidence showing that SRC is a major and independent predictor of poor prognosis due to specific characteristics such as more infiltrating tumors showing affinity for lymphatic tissue accompanied by a higher rate of peritoneal carcinomatosis. Our results suggest the need for a specific therapeutic strategy for such tumors.

Locally advanced and metastatic gastric cancer: current management and new treatment developments

The management of gastric cancer remains a challenge. In recent years, the most important advances have been achieved in the adjuvant setting for patients with locally advanced disease, where significant survival benefits have been demonstrated for both perioperative chemotherapy and adjuvant chemoradiotherapy. These findings have changed the standard of care for patients with resectable disease. In the setting of metastatic gastric cancer, the development of new cytotoxic regimens must consider the balance between efficacy and toxicity in patients whose overall prognosis is poor. Major advances in recent years include the development of orally administered fluoropyrimidine analogues, which can be used in place of intravenous fluorouracil, and the addition of newer agents such as oxaliplatin and docetaxel, which have demonstrated efficacy in patients with advanced disease. Targeted therapies have had a major impact on the management of certain malignancies, and while their evaluation in the treatment of advanced gastric cancer remains early, it is likely that these agents will continue to be developed and studied in combination with chemotherapy. This article reviews recent advances in the use of chemotherapy for advanced gastric cancer. Targeted therapies, their mechanisms of action and emerging data supporting their use in gastric cancer are also discussed. The two randomized phase III trials supporting adjuvant therapy for locally advanced, resectable gastric cancer are discussed in detail, together with strategies for future trials in this area. Overall, there remains optimism that further incremental gains will be achieved with future studies combining chemotherapy, radiotherapy and targeted therapies, both in the adjuvant and metastatic disease settings.