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Gao B, Zhao Z, Gao X, Zhang T, Zhang N, Zhang Y, Zhu Y. Role of pathological tumor regression grade of lymph node metastasis following neoadjuvant chemotherapy in locally advanced gastric cancer. Dig Liver Dis 2024:S1590-8658(24)00768-0. [PMID: 38811246 DOI: 10.1016/j.dld.2024.05.011] [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] [Received: 12/01/2023] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/31/2024]
Abstract
AIMS To confirm whether the pathological response of lymph node metastasis (LNM) to neoadjuvant chemotherapy (NCT) can predict the prognosis of patients with gastric cancer (GC). METHODS A total of 979 patients with locally advanced GC were included. χ2 test was used to analyze the relationship between LNM TRG and clinicopathological factors. Cox proportional hazards model was used to analyze the relationship between LNM TRG, clinicopathological factors, and overall survival (OS). RESULTS A total of 21,162 lymph nodes were evaluated, with 237 patients (35.4%) in the response group and 433 patients (64.6%) in the non-response group. The non-responsive group was strongly associated with higher ypT, ypN, ypTNM, primary tumor (PT) TRG (all p < 0.001), positive cancer nodules (p = 0.001), and more distant LNM location (p < 0.001). Patients with the same PT TRG but different LNM TRG had different prognosis. There was no difference in OS between the responding and non-responding groups of LNM at location 2, 3, and M. YpN, tumor location, and LNM location were independent prognostic factors. CONCLUSIONS The combination of LNM TRG and PT TRG could better predict patient prognosis. Lymph node dissection should be routinely performed after NCT to provide the reference of radical resection.
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Affiliation(s)
- Bo Gao
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China
| | - Zehua Zhao
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China
| | - Xiaozhuo Gao
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China
| | - Tao Zhang
- Department of Gastric Surgery,Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China
| | - Ning Zhang
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China
| | - Yong Zhang
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China.
| | - Yanmei Zhu
- Department of Pathology, Cancer Hospital of China Medical University, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital &Institute, Shenyang, China.
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2
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Caspers IA, Biesma HD, Wiklund K, Pontén F, Lind P, Nordsmark M, Sikorska K, Meershoek-KleinKranenbarg E, Hartgrink HH, van de Velde CJH, van Sandick JW, Verheij M, Cats A, van Grieken NCT. Effect of preoperative chemotherapy on the histopathological classification of gastric cancer. Gastric Cancer 2024; 27:102-109. [PMID: 37947918 PMCID: PMC10761400 DOI: 10.1007/s10120-023-01442-w] [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: 07/10/2023] [Accepted: 10/12/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In the era of individualized gastric cancer (GC) treatment, accurate determination of histological subtype becomes increasingly relevant. As yet, it is unclear whether preoperative chemotherapy may affect the histological subtype. The aim of this study was to assess concordance in histological subtype between pretreatment biopsies and surgical resection specimens before and after the introduction of perioperative treatment. METHODS Histological subtype was centrally determined in paired GC biopsies and surgical resection specimens of patients treated with either surgery alone (SA) in the Dutch D1/D2 study or with preoperative chemotherapy (CT) in the CRITICS trial. The histological subtype as determined in the resection specimen was considered the gold standard. Concordance rates and sensitivity and specificity of intestinal, diffuse, mixed, and "other" subtypes of GC were analyzed. RESULTS In total, 105 and 515 pairs of GC biopsies and resection specimens of patients treated in the SA and CT cohorts, respectively, were included. Overall concordance in the histological subtype was 72% in the SA and 74% in the CT cohort and substantially higher in the diffuse subtype (83% and 86%) compared to the intestinal (70% and 74%), mixed (21% and 33%) and "other" subtypes (54% and 54%). In the SA cohort, sensitivities and specificities were 0.88 and 0.71 in the intestinal, 0.67 and 0.93 in the diffuse, 0.20 and 0.98 in the mixed, and 0.50 and 0.93 in the "other" subtypes, respectively. CONCLUSION Our results suggest that accurate determination of histological subtype on gastric cancer biopsies is suboptimal but that the impact of preoperative chemotherapy on histological subtype is negligible.
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Affiliation(s)
- I A Caspers
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Pathology, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081HV, Amsterdam, the Netherlands
| | - H D Biesma
- Department of Pathology, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081HV, Amsterdam, the Netherlands
| | - K Wiklund
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - F Pontén
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - P Lind
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - M Nordsmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - K Sikorska
- Department of Biometrics, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - H H Hartgrink
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - M Verheij
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - A Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - N C T van Grieken
- Department of Pathology, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081HV, Amsterdam, the Netherlands.
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3
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Yu JI. Role of Adjuvant Radiotherapy in Gastric Cancer. J Gastric Cancer 2023; 23:194-206. [PMID: 36750999 PMCID: PMC9911621 DOI: 10.5230/jgc.2023.23.e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/07/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022] Open
Abstract
Although continuous improvement in the treatment outcome of localized gastric cancer has been achieved through early screening, diagnosis, and treatment and the active application of surgery and adjuvant chemotherapy, the necessity of adjuvant radiotherapy (RT) remains controversial. In this review, based on the results of two recently published randomized phase III studies (Adjuvant Chemoradiation Therapy In Stomach Cancer 2 and ChemoRadiotherapy after Induction chemoTherapy of Cancer in the Stomach) and a meta-analysis of six randomized trials including these two studies, the role of adjuvant RT in gastric cancer was evaluated and discussed, especially in patients who underwent curative gastrectomy with D2 lymphadenectomy. This article also reported the possible indications for adjuvant RT in the current clinical situation and in future research to enable patient-specific treatments according to the risk of recurrence.
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Affiliation(s)
- Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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4
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Zuo Z, Peng Y, Zeng Y, Lin S, Zeng W, Zhou X, Zhou Y, Li B, Ma J, Long M, Cao S, Liu Y. Survival benefit after neoadjuvant or adjuvant radiotherapy for stage II–III gastroesophageal junction adenocarcinoma: A large population-based cohort study. Front Oncol 2022; 12:998101. [PMID: 36338703 PMCID: PMC9630344 DOI: 10.3389/fonc.2022.998101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/30/2022] [Indexed: 11/24/2022] Open
Abstract
Objective The standard treatment for stage II–III gastroesophageal junction adenocarcinoma (GEJA) remains controversial, and the role of radiotherapy (RT) in stage II–III GEJA is unclear. Herein, we aimed to evaluate the prognosis of different RT sequences and identify potential candidates to undergo neoadjuvant RT (NART) or adjuvant RT (ART). Materials and methods In total, we enrolled 3,492 patients with resectable stage II–III GEJA from the Surveillance, Epidemiology, and End Results (SEER) database, subsequently assigned to three categories: T1–2N+, T3–4N−, and T3–4N+. Survival curves were evaluated using the Kaplan–Meier method along with the log-rank test. We compared survival curves for NART, ART, and non-RT in the three categories. To further determine histological types impacting RT-associated survival, we proposed new categories by combining the tumor, node, and metastasis (TNM) stage with Lauren’s classification. Results ART afforded a significant survival benefit in patients with T1–2N+ and T3–4N+ tumors. In addition, NART conferred a survival advantage in patients with T3–4N+ and T3–4 exhibiting the intestinal type. Notably, ART and NART were both valuable in patients with T3–4N+, although no significant differences between treatment regimens were noted. Conclusions Both NART and ART can prolong the survival of patients with stage II–III GEJA. Nevertheless, the selection of NART or ART requires a concrete analysis based on the patient’s condition.
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Affiliation(s)
- Zhichao Zuo
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Yafeng Peng
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Ying Zeng
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Shanyue Lin
- Department of Radiology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Weihua Zeng
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Xiao Zhou
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Yinjun Zhou
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Bo Li
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, China
| | - Jie Ma
- Department of Radiology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Mingju Long
- Department of General Surgery, Xiangtan Central Hospital, Xiangtan, China
| | - Shenghui Cao
- Department of General Surgery, Xiangtan Central Hospital, Xiangtan, China
- *Correspondence: Shenghui Cao, ; Yang Liu,
| | - Yang Liu
- Department of Radiotherapy, Guangxi Medical University Cancer Hospital, Nanning, China
- *Correspondence: Shenghui Cao, ; Yang Liu,
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5
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Drubay V, Nuytens F, Renaud F, Adenis A, Eveno C, Piessen G. Poorly cohesive cells gastric carcinoma including signet-ring cell cancer: Updated review of definition, classification and therapeutic management. World J Gastrointest Oncol 2022; 14:1406-1428. [PMID: 36160745 PMCID: PMC9412924 DOI: 10.4251/wjgo.v14.i8.1406] [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: 01/26/2022] [Revised: 05/08/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
While the incidence of gastric cancer (GC) in general has decreased worldwide in recent decades, the incidence of diffuse cancer historically comprising poorly cohesive cells-GC (PCC-GC) and including signet ring cell cancer is rising. Literature concerning PCC-GC is scarce and unclear, mostly due to a large variety of historically used definitions and classifications. Compared to other histological subtypes of GC, PCC-GC is nevertheless characterized by a distinct set of epidemiological, histological and clinical features which require a specific diagnostic and therapeutic approach. The aim of this review was to provide an update on the definition, classification and therapeutic strategies of PCC-GC. We focus on the updated histological definition of PCC-GC, along with its implications on future treatment strategies and study design. Also, specific considerations in the diagnostic management are discussed. Finally, the impact of some recent developments in the therapeutic management of GC in general such as the recently validated taxane-based regimens (5-Fluorouracil, leucovorin, oxaliplatin and docetaxel), the use of hyperthermic intraperitoneal chemotherapy as well as pressurized intraperitoneal aerosol chemotherapy and targeted therapy have been reviewed in depth for their relative importance for PCC-GC in particular.
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Affiliation(s)
- Vincent Drubay
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive Surgery, Cambrai Hospital Center and Sainte Marie, Group of Hospitals of The Catholic Institute of Lille, Cambrai 59400, France
| | - Frederiek Nuytens
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk 8500, Belgium
| | - Florence Renaud
- Department of Pathology, University Lille Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Antoine Adenis
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
- Department of Medical Oncology, Montpellier Cancer Institute, Monpellier 34000, France
- IRCM, Inserm, University of Monpellier, Monpellier 34000, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
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6
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Slagter AE, Caspers IA, van Grieken NCT, Walraven I, Lind P, Meershoek-Klein Kranenbarg E, Grootscholten C, Nordsmark M, van Sandick JW, Sikorska K, van de Velde CJH, Jansen EPM, Verheij M, van Laarhoven HWM, Cats A. Triplet Chemotherapy with Cisplatin versus Oxaliplatin in the CRITICS Trial: Treatment Compliance, Toxicity, Outcomes and Quality of Life in Patients with Resectable Gastric Cancer. Cancers (Basel) 2022; 14:cancers14122963. [PMID: 35740628 PMCID: PMC9221508 DOI: 10.3390/cancers14122963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Perioperative chemotherapy is the current standard treatment for patients with resectable gastric cancer. Based on studies in patients with metastatic gastric cancer, oxaliplatin has replaced cisplatin in the curative setting as well. However, evidence to prefer oxaliplatin over cisplatin in the curative setting is limited. (2) Methods: We compared patient-related and tumor-related outcomes for cisplatin versus oxaliplatin in patients with resectable gastric cancer treated with perioperative chemotherapy in the CRITICS trial. (3) Results: Preoperatively, 632 patients received cisplatin and 149 patients received oxaliplatin. Preoperative severe toxicity was encountered in 422 (67%) patients who received cisplatin versus 89 (60%) patients who received oxaliplatin (p = 0.105). Severe neuropathy was observed in 5 (1%) versus 6 (4%; p = 0.009) patients, respectively. Postoperative severe toxicity occurred in 109 (60%) versus 26 (51%) (p = 0.266) patients; severe neuropathy in 2 (1%) versus 2 (4%; p = 0.209) for patients who received cisplatin or oxaliplatin, respectively. Diarrhea impacted the quality of life more frequently in patients who received oxaliplatin compared to cisplatin. Complete or near-complete pathological response was achieved in 94 (21%) versus 16 (15%; p = 0.126) patients who received cisplatin or oxaliplatin, respectively. Overall survival was not significantly different in both groups (p = 0.300). (4) Conclusions: Both cisplatin and oxaliplatin are legitimate options as part of systemic treatment in patients with resectable gastric cancer.
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Affiliation(s)
- Astrid E. Slagter
- Department of Radiation Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (I.W.); (E.P.M.J.); (M.V.)
| | - Irene A. Caspers
- Department of Gastrointestinal Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (C.G.)
- Department of Pathology, Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands;
| | - Nicole C. T. van Grieken
- Department of Pathology, Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands;
| | - Iris Walraven
- Department of Radiation Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (I.W.); (E.P.M.J.); (M.V.)
- Department of Epidemiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Pehr Lind
- Department of Oncology, Stockholm Söder Hospital, 118 83 Stockholm, Sweden;
- Karolinska Institutet, Research Oncology, 171 77 Stockholm, Sweden
| | | | - Cecile Grootscholten
- Department of Gastrointestinal Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (C.G.)
| | | | - Johanna W. van Sandick
- Department of Surgery, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Karolina Sikorska
- Department of Biometrics, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Cornelis J. H. van de Velde
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.M.-K.K.); (C.J.H.v.d.V.)
| | - Edwin P. M. Jansen
- Department of Radiation Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (I.W.); (E.P.M.J.); (M.V.)
| | - Marcel Verheij
- Department of Radiation Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (I.W.); (E.P.M.J.); (M.V.)
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (C.G.)
- Correspondence: ; Tel.: +31-(0)20-5129111
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7
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van Amelsfoort RM, Walraven I, Kieffer J, Jansen EPM, Cats A, van Grieken NCT, Meershoek-Klein Kranenbarg E, Putter H, van Sandick JW, Sikorska K, van de Velde CJH, Aaronson NK, Verheij M. Quality of Life Is Associated With Survival in Patients With Gastric Cancer: Results From the Randomized CRITICS Trial. J Natl Compr Canc Netw 2022; 20:261-267. [PMID: 35276669 DOI: 10.6004/jnccn.2021.7057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The evaluation of health-related quality of life (HRQoL) in clinical trials has become increasingly important because it addresses the impact of treatment from the patient's perspective. The primary aim of this study was to investigate the effect of postoperative chemotherapy and chemoradiotherapy (CRT) after neoadjuvant chemotherapy and surgery with extended (D2) lymphadenectomy on HRQoL in the CRITICS trial. Second, we investigated the potential prognostic value of pretreatment HRQoL on event-free survival (EFS) and overall survival (OS). PATIENTS AND METHODS Patients in the CRITICS trial were asked to complete HRQoL questionnaires (EORTC Quality-of-Life Questionnaire-Core 30 and Quality-of-Life Questionnaire gastric cancer-specific module) at baseline, after preoperative chemotherapy, after surgery, after postoperative chemotherapy or CRT, and at 12 months follow-up. Patients with at least 1 evaluable questionnaire (645 of 788 randomized patients) were included in the HRQoL analyses. The predefined endpoints included dysphagia, pain, physical functioning, fatigue, and Quality-of-Life Questionnaire-Core 30 summary score. Linear mixed modeling was used to assess differences over time and at each time point. Associations of baseline HRQoL with EFS and OS were investigated using multivariate Cox proportional hazards analyses. RESULTS At completion of postoperative chemo(radio)therapy, the chemotherapy group had significantly better physical functioning (P=.02; Cohen's effect size = 0.42) and less dysphagia (P=.01; Cohen's effect size = 0.38) compared with the CRT group. At baseline, worse social functioning (hazard ratio [HR], 2.20; 95% CI, 1.36-3.55; P=.001), nausea (HR, 1.89; 95% CI, 1.39-2.56; P<.001), worse WHO performance status (HR, 1.55; 95% CI, 1.13-2.13; P=.007), and histologic subtype (diffuse vs intestinal: HR, 1.94; 95% CI, 1.42-2.67; P<.001; mixed vs intestinal: HR, 2.35; 95% CI, 1.35-4.12; P=.003) were significantly associated with worse EFS and OS. CONCLUSIONS In the CRITICS trial, the chemotherapy group had significantly better physical functioning and less dysphagia after postoperative treatment. HRQoL scales at baseline were significantly associated with EFS and OS.
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Affiliation(s)
| | - Iris Walraven
- 1Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam.,2Department for Health Evidence, Radboud University Medical Center, Nijmegen
| | | | - Edwin P M Jansen
- 1Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam
| | - Annemieke Cats
- 4Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam
| | | | | | - Hein Putter
- 6Department of Surgical Oncology, Leiden University Medical Center, Leiden
| | | | - Karolina Sikorska
- 8Department of Biostatistics, Netherlands Cancer Institute, Amsterdam; and
| | | | - Neil K Aaronson
- 2Department for Health Evidence, Radboud University Medical Center, Nijmegen
| | - Marcel Verheij
- 1Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam.,9Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
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8
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Baxter MA, Marinho J, Soto-Perez-de-Celis E, Rodriquenz MG, Arora SP, Lok WCW, Shih YY, Liposits G, O'Hanlon S, Petty RD. Gastroesophageal adenocarcinoma in older adults: A comprehensive narrative review of management by the Young International Society of Geriatric Oncology. J Geriatr Oncol 2022; 13:7-19. [PMID: 34548259 DOI: 10.1016/j.jgo.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
Gastroesophageal adenocarcinoma is a disease of older adults with very poor survival rates. Its incidence has risen dramatically across the world in recent decades. Current treatment approaches for older adults are based largely on extrapolated evidence from clinical trials conducted in younger and fitter participants than those more commonly encountered in clinical practice. Understanding how to apply available evidence to our patients in the clinic setting is essential given the high morbidity of both curative and palliative treatment. This review aims to use available data to inform the management of an older adult with gastroesophageal adenocarcinoma.
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Affiliation(s)
- Mark A Baxter
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK; Tayside Cancer Centre, Ninewells Hospital, Dundee, UK.
| | - Joana Marinho
- Department of Medical Oncology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Espinho, Portugal
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Maria Grazia Rodriquenz
- Oncology Unit, Foundation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Sukeshi Patel Arora
- Mays Cancer Center, University of Texas Health San Antonio, Leader in Gastrointestinal Malignancies, 7979 Wurzbach Rd, 78229 San Antonio, TX, USA
| | - Wendy Chan Wing Lok
- Department of Clinical Oncology, LKS Faculty of Medicine, University of Hong Kong, China
| | - Yung-Yu Shih
- Department of Hematology and Oncology, Kaiser Franz Josef Hospital-Clinic Favoriten, Vienna, Austria
| | - Gabor Liposits
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense, Denmark
| | - Shane O'Hanlon
- Department of Geriatric Medicine, St Vincent's University Hospital, Dublin, Ireland; University College, Dublin, Ireland
| | - Russell D Petty
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK; Tayside Cancer Centre, Ninewells Hospital, Dundee, UK
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9
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Slagter AE, Vollebergh MA, Caspers IA, van Sandick JW, Sikorska K, Lind P, Nordsmark M, Putter H, Braak JPBM, Meershoek-Klein Kranenbarg E, van de Velde CJH, Jansen EPM, Cats A, van Laarhoven HWM, van Grieken NCT, Verheij M. Prognostic value of tumor markers and ctDNA in patients with resectable gastric cancer receiving perioperative treatment: results from the CRITICS trial. Gastric Cancer 2022; 25:401-410. [PMID: 34714423 PMCID: PMC8882113 DOI: 10.1007/s10120-021-01258-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
AIM To evaluate the prognostic value of tumor markers in a European cohort of patients with resectable gastric cancer. METHODS We performed a post hoc analysis of the CRITICS trial, in which 788 patients received perioperative therapy. Association between survival and pretreatment CEA, CA 19-9, alkaline phosphatase, neutrophils, hemoglobin and lactate dehydrogenase were explored in uni- and multivariable Cox regression analyses. Likelihoods to receive potentially curative surgery were investigated for patients without elevated tumor markers versus one of the tumor markers elevated versus both tumor markers elevated. The association between tumor markers and the presence of circulating tumor DNA (ctDNA) was explored in 50 patients with available ctDNA data. RESULTS In multivariable analysis, in which we corrected for allocated treatment and other baseline characteristics, elevated pretreatment CEA (HR 1.43; 95% CI 1.11-1.85, p < 0.001) and CA 19-9 (HR 1.79; 95% CI 1.42-2.25, p < 0.001) were associated with worse OS. Likelihoods to receive potentially curative surgery were 86%, 77% and 60% for patients without elevated tumor marker versus either elevated CEA or CA 19-9 versus both elevated, respectively (p < 0.001). Although both preoperative presence of ctDNA and tumor markers were prognostic for survival, no association was found between these two parameters. CONCLUSION CEA and CA 19-9 were independent prognostic factors for survival in a large cohort of European patients with resectable gastric cancer. No relationship was found between tumor markers and ctDNA. These factors could potentially guide treatment choices and should be included in future trials to determine their definitive position. TRIAL REGISTRATION ClinicalTrial.gov identifier: NCT00407186. EudraCT number: 2006-00413032.
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Affiliation(s)
- Astrid E. Slagter
- grid.430814.a0000 0001 0674 1393Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marieke A. Vollebergh
- grid.430814.a0000 0001 0674 1393Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Irene A. Caspers
- grid.430814.a0000 0001 0674 1393Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Pathology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johanna W. van Sandick
- grid.430814.a0000 0001 0674 1393Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karolina Sikorska
- grid.430814.a0000 0001 0674 1393Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Pehr Lind
- grid.416648.90000 0000 8986 2221Department of Oncology, Stockholm Söder Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Karolinska Institutet, Stockholm, Sweden
| | - Marianne Nordsmark
- grid.7048.b0000 0001 1956 2722Department of Medical Oncology, Aarhus University, Aarhus, Denmark
| | - Hein Putter
- grid.10419.3d0000000089452978Department of Biometrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeffrey P. B. M. Braak
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cornelis J. H. van de Velde
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Edwin P. M. Jansen
- grid.430814.a0000 0001 0674 1393Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annemieke Cats
- grid.430814.a0000 0001 0674 1393Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hanneke W. M. van Laarhoven
- grid.7177.60000000084992262Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole C. T. van Grieken
- grid.16872.3a0000 0004 0435 165XDepartment of Pathology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marcel Verheij
- grid.430814.a0000 0001 0674 1393Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein 32, 6500 HB Nijmegen, The Netherlands
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10
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Rodriguez MJ, Ore AS, Schawkat K, Kennedy K, Bullock A, Pleskow DK, Critchlow J, Moser AJ. Treatment burden of robotic gastrectomy for locally advanced gastric cancer (LAGC): a single western experience. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1408. [PMID: 34733960 PMCID: PMC8506707 DOI: 10.21037/atm-21-1054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/23/2021] [Indexed: 12/12/2022]
Abstract
Background This study compares standard of care (SOC) open and robotic D2-gastrectomy for locally advanced gastric cancer (LAGC) in the Western context of low disease prevalence, reduced surgical volume, and neoadjuvant chemotherapy (NAC). We hypothesized that robotic gastrectomy (RG) after NAC reduces treatment burden for LAGC across multiple outcome domains vs. SOC. Methods Single institution, interrupted time series comparing SOC (2008–2013) for LAGC (T2–4Nany/TanyN+) vs. NAC + RG (2013–2018). Treatment burden was a composite metric of narcotic consumption, oncologic efficacy, cumulative morbidity, and 90-day resource utilization. Predictors were evaluated via multivariate modeling. Learning curve analysis was done using CUSUM. Results After exclusions, 87 subjects with equivalent baseline characteristics, aside from male sex, were treated via SOC (n=55) or NAC + RG (n=32). All four domains of treatment burden were significantly reduced in the NAC + RG cohort compared to SOC (P=0.003). The odds ratio for excess treatment burden in the NAC/RG was 0.23 (95% CI: 0.07–0.72, P=0.0117) vs. SOC upon multivariable modeling, whereas the extent of resection (total/subtotal), tumor size, T-stage, sex, and early learning curve had no effect. Differences in treatment burden persisted in subgroup analysis for NAC (n=51). Conclusions NAC + RG was associated with decreased treatment burden relative to SOC for LAGC. Frequencies of unfavorable hospitalization, adverse oncological outcomes, major morbidity, and narcotic consumption all decreased in this interrupted time series.
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Affiliation(s)
- M Juanita Rodriguez
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ana Sofia Ore
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Khoschy Schawkat
- Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Institute of Diagnostic and Interventional Radiology, University Hospital Zürich, Zürich, Switzerland
| | - Kevin Kennedy
- Biostatistics, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Andrea Bullock
- Medical Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Douglas K Pleskow
- Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jonathan Critchlow
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - A James Moser
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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11
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Lieto E, Auricchio A, Tirino G, Pompella L, Panarese I, Del Sorbo G, Ferraraccio F, De Vita F, Galizia G, Cardella F. Naples Prognostic Score Predicts Tumor Regression Grade in Resectable Gastric Cancer Treated with Preoperative Chemotherapy. Cancers (Basel) 2021; 13:cancers13184676. [PMID: 34572903 PMCID: PMC8471422 DOI: 10.3390/cancers13184676] [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: 07/30/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 02/03/2023] Open
Abstract
Simple Summary Multimodal treatment of locally advanced gastric cancer is still debated today due to controversial results in different trials. Nevertheless, perioperative chemotherapy with radical surgery certainly shows a better long-term outcome than surgery alone, so much so it is the main multimodal treatment offered in Europe, at the present. Tumor regression grade is the objective response to preoperative chemotherapy and its extent, in terms of reduction of neoplastic cells in the resected specimen, is strongly affected by Lauren’s classification, TNM stage, and tumor grading. Therefore, since this information can be achieved only after surgical resection, the return of chemotherapy is quite unpredictable in advance and, in about half cases, it is definitely ineffective. Naples Prognostic Score, that mirrors the immune–nutritional conditions, tested on 59 consecutive advanced gastric cancer patients undergoing multimodal treatment, showed a strong power in predicting tumor regression grade and therefore is strictly correlated with long-term outcome and survival. Abstract Despite recent progresses, locally advanced gastric cancer remains a daunting challenge to embrace. Perioperative chemotherapy and D2-gastrectomy depict multimodal treatment of gastric cancer in Europe, shows better results than curative surgery alone in terms of downstaging, micrometastases elimination, and improved long-term survival. Unfortunately, preoperative chemotherapy is useless in about 50% of cases of non-responder patients, in which no effect is registered. Tumor regression grade (TRG) is directly related to chemotherapy effectiveness, but its understanding is achieved only after surgical operation; accordingly, preoperative chemotherapy is given indiscriminately. Conversely, Naples Prognostic Score (NPS), related to patient immune-nutritional status and easily obtained before taking any therapeutic decision, appeared an independent prognostic variable of TRG. NPS was calculated in 59 consecutive surgically treated gastric cancer patients after neoadjuvant FLOT4-based chemotherapy. 42.2% of positive responses were observed: all normal NPS and half mild/moderate NPS showed significant responses to chemotherapy with TRG 1–3; while only 20% of the worst NPS showed some related benefits. Evaluation of NPS in gastric cancer patients undergoing multimodal treatment may be useful both in selecting patients who will benefit from preoperative chemotherapy and for changing immune-nutritional conditions in order to improve patient’s reaction against the tumor.
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Affiliation(s)
- Eva Lieto
- Division of GI Tract Surgical Oncology, Department of Translational Medical Sciences, Vanvitelli University, 80132 Napoli, Italy; (A.A.); (G.D.S.); (G.G.); (F.C.)
- Correspondence:
| | - Annamaria Auricchio
- Division of GI Tract Surgical Oncology, Department of Translational Medical Sciences, Vanvitelli University, 80132 Napoli, Italy; (A.A.); (G.D.S.); (G.G.); (F.C.)
| | - Giuseppe Tirino
- Division of Medical Oncology, Department of Precision Medicine, Vanvitelli University, 80132 Napoli, Italy; (G.T.); (L.P.); (F.D.V.)
| | - Luca Pompella
- Division of Medical Oncology, Department of Precision Medicine, Vanvitelli University, 80132 Napoli, Italy; (G.T.); (L.P.); (F.D.V.)
| | - Iacopo Panarese
- Division of Pathology, Department of Mental and Physical Health and Rehabilitation Medicine, Vanvitelli University, 80132 Napoli, Italy; (I.P.); (F.F.)
| | - Giovanni Del Sorbo
- Division of GI Tract Surgical Oncology, Department of Translational Medical Sciences, Vanvitelli University, 80132 Napoli, Italy; (A.A.); (G.D.S.); (G.G.); (F.C.)
| | - Francesca Ferraraccio
- Division of Pathology, Department of Mental and Physical Health and Rehabilitation Medicine, Vanvitelli University, 80132 Napoli, Italy; (I.P.); (F.F.)
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Precision Medicine, Vanvitelli University, 80132 Napoli, Italy; (G.T.); (L.P.); (F.D.V.)
| | - Gennaro Galizia
- Division of GI Tract Surgical Oncology, Department of Translational Medical Sciences, Vanvitelli University, 80132 Napoli, Italy; (A.A.); (G.D.S.); (G.G.); (F.C.)
| | - Francesca Cardella
- Division of GI Tract Surgical Oncology, Department of Translational Medical Sciences, Vanvitelli University, 80132 Napoli, Italy; (A.A.); (G.D.S.); (G.G.); (F.C.)
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12
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Caspers IA, Sikorska K, Slagter AE, van Amelsfoort RM, Meershoek-Klein Kranenbarg E, van de Velde CJH, Lind P, Nordsmark M, Jansen EPM, Verheij M, van Sandick JW, Cats A, van Grieken NCT. Risk Factors for Metachronous Isolated Peritoneal Metastasis after Preoperative Chemotherapy and Potentially Curative Gastric Cancer Resection: Results from the CRITICS Trial. Cancers (Basel) 2021; 13:cancers13184626. [PMID: 34572852 PMCID: PMC8469213 DOI: 10.3390/cancers13184626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/09/2022] Open
Abstract
Simple Summary Around 20% of gastric cancer patients develop peritoneal metastasis after preoperative chemotherapy and curative surgery. Patients with peritoneal metastasis as a single site of metastasis may potentially benefit from prophylactic strategies. In this post-hoc analysis of the international phase III CRITICS trial, we aim to identify factors that can distinguish patients at high risk for developing peritoneal metastasis as a single site. Diffuse or mixed histological subtype, tumors with serosal involvement (ypT4) and advanced lymph node stage (ypN3 or a tumor positive lymph node ratio >20%) were independent risk factors for isolated peritoneal metastasis after preoperative chemotherapy and curative surgery. The combination of these risk factors identifies a subgroup that may benefit from treatment strategies that aim to prevent peritoneal metastasis. Abstract Gastric cancer (GC) patients at high risk of developing peritoneal metastasis (PM) as a single site of metastasis after curative treatment may be candidates for adjuvant prophylactic strategies. Here we investigated risk factors for metachronous isolated PM in patients who were treated in the CRITICS trial (NCT00407186). Univariable and multivariable analyses on both metachronous isolated PM and ‘other events’, i.e., (concurrent) distant metastasis, locoregional recurrence or death, were performed using a competing risk model and summarized by cumulative incidences. Isolated PM occurred in 64 of the 606 (11%) included patients. Diffuse or mixed histological subtype, ypT4 tumor stage and LNhigh (ypN3 lymph node stage or a lymph node ratio >20%) were independent risk factors for isolated PM in both univariable and multivariable analyses. Likewise, LNhigh was an independent risk factor for ‘other events’. Patients with tumors who were positive for all three independent risk factors had the highest two-year cumulative incidence of 43% for isolated PM development. In conclusion, diffuse or mixed histological subtype, ypT4 and LNhigh were identified as independent risk factors for isolated PM in patients treated with preoperative chemotherapy followed by surgical resection. The combination of these factors may identify a subgroup that may benefit from PM-preventing treatment strategies.
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Affiliation(s)
- Irene A. Caspers
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (A.C.)
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Astrid E. Slagter
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | - Romy M. van Amelsfoort
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | | | | | - Pehr Lind
- Department of Oncology, Stockholm Söder Hospital, 118 83 Stockholm, Sweden;
- Department of Oncology and Pathology, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Marianne Nordsmark
- Department of Medical Oncology, Aarhus University, 8200 Aarhus, Denmark;
| | - Edwin P. M. Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Johanna W. van Sandick
- Department of Surgery, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (A.C.)
| | - Nicole C. T. van Grieken
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Correspondence:
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13
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Staging laparoscopy in patients with advanced gastric cancer: A single center cohort study. Eur J Surg Oncol 2021; 48:362-369. [PMID: 34384656 DOI: 10.1016/j.ejso.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/29/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Most studies exploring the role of staging laparoscopy in gastric cancer are limited by low sample size and are predominantly conducted in Asian countries. This study sets out to determine the value of staging laparoscopy in patients with advanced gastric cancer in a Western population. METHODS All patients with gastric cancer from a tertiary referral center without definite evidence of non-curable disease after initial staging, and who underwent staging laparoscopy between 2013 and 2020, were identified from a prospectively maintained database. The proportion of patients in whom metastases or locoregional non-resectability was detected during staging laparoscopy was established. Secondary outcomes included the avoidable surgery rate (detection of non-curable disease during gastrectomy with curative intent) and diagnostic accuracy (sensitivity, specificity, accuracy, negative and positive predictive value). RESULTS A total of 216 patients were included. Staging laparoscopy revealed metastatic disease in 46 (21.3 %) patients and a non-resectable tumor in three (1.4 %) patients. During intended gastrectomy, non-curable disease was revealed in 13 (8.6 %) patients. Overall sensitivity, specificity and diagnostic accuracy were 76.6 %, 100 % and 92.6 %, respectively. The positive predictive value was 100 % and the negative predictive value was 90.3 %. CONCLUSION Staging laparoscopy is valuable in the staging process of gastric cancer with a high accuracy in detecting non-curable disease, thereby preventing futile treatment and its associated burden.
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14
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Mansouri H, Zemni I, Achouri L, Mahjoub N, Ayedi MA, Ben Safta I, Ben Dhiab T, Chargui R, Rahal K. Chemoradiotherapy or chemotherapy as adjuvant treatment for resected gastric cancer: should we use selection criteria? ACTA ACUST UNITED AC 2021; 26:266-280. [PMID: 34211778 DOI: 10.5603/rpor.a2021.0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 02/08/2021] [Indexed: 12/24/2022]
Abstract
Background The management of gastric adenocarcinoma is essentially based on surgery followed by adjuvant treatment. Adjuvant chemotherapy (CT) as well as chemoradiotherapy (CTRT) have proven their effectiveness in survival outcomes compared to surgery alone. However, there is little data comparing the two adjuvant approaches. This study aimed to compare the prognosis and survival outcomes of patients with gastric adenocarcinoma operated and treated by adjuvant radio-chemotherapy or chemotherapy. Materials and methods We retrospectively evaluated 80 patients with locally advanced gastric cancer (LGC) who received adjuvant treatment. We compared survival outcomes and patterns of recurrence of 53 patients treated by CTRT and those of 27 patients treated by CT. Results After a median follow-up of 38.48 months, CTRT resulted in a significant improvement of the 5-year PFS (60.9% vs. 36%, p = 0.03) and the 5-year OS (55.9% vs. 33%, p = 0.015) compared to adjuvant CT. The 5-year OS was significantly increased by adjuvant CTRT (p = 0.046) in patients with lymph node metastasis, and particularly those with advanced pN stage (p = 0.0078) and high lymph node ratio (LNR) exceeding 25% (p = 0.012). Also, there was a significant improvement of the PFS of patients classified pN2-N3 (p = 0.022) with a high LNR (p = 0.018). CTRT was also associated with improved OS and PFS in patients with lymphovascular and perineural invasion (LVI and PNI) compared to chemotherapy. Conclusion There is a particular survival benefit of adding radiotherapy to chemotherapy in patients with selected criteria such as lymph node involvement, high LNR LVI, and PNI.
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Affiliation(s)
- Houyem Mansouri
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Ines Zemni
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia.,Laboratory of Microorganisms and Active Biomolecules, Faculty of sciences, University of Tunis El Manar, Tunisia
| | - Leila Achouri
- Department of surgical oncology, Regional Hospital of Jendouba, Tunisia
| | - Najet Mahjoub
- Department of medical oncology, Regional Hospital of Jendouba, Tunisia
| | - Mohamed Ali Ayedi
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia.,Laboratory of Microorganisms and Active Biomolecules, Faculty of sciences, University of Tunis El Manar, Tunisia
| | - Ines Ben Safta
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia.,Laboratory of Microorganisms and Active Biomolecules, Faculty of sciences, University of Tunis El Manar, Tunisia
| | - Tarek Ben Dhiab
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Riadh Chargui
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Khaled Rahal
- Department of Surgical Oncology, Salah Azaiez institute of oncology, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
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15
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Wang SB, Qi WX, Chen JY, Xu C, Cao WG, Cai R, Cao L, Cai G. Identification of Patients With Locally Advanced Gastric Cancer Who May Benefit From Adjuvant Chemoradiotherapy After D2 dissection: A Propensity Score Matching Analysis. Front Oncol 2021; 11:648978. [PMID: 33869049 PMCID: PMC8047641 DOI: 10.3389/fonc.2021.648978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/15/2021] [Indexed: 01/21/2023] Open
Abstract
Background One of the most controversial areas in gastrointestinal oncology is the benefit of postoperative chemoradiotherapy (CRT) over chemotherapy (CT) alone after D2 dissection of locally advanced gastric cancer (LAGC). We aimed to identify the LAGC patients who may benefit from adjuvant CRT. Methods We analyzed retrospectively 188 patients receiving radical gastrectomy with D2 dissection for LAGC in our hospital. Patients were divided into two balanced groups by using propensity score matching: CRT group (n = 94) received adjuvant CRT, and CT group received adjuvant CT alone. Results At a median follow-up of 27.10 months, 188 patients developed 79 first recurrence events (36 in CRT group and 43 in CT group). Our results showed that adjuvant CRT significantly decreased the risk of developing local regional recurrence (LRR) when compared to CT alone (14.9% vs. 25.5%, p = 0.044), while the estimated 3-year disease-free survival (DFS) was comparable between the CRT and CT groups (59.3% vs. 50.9%, p = 0.239). In the subgroup analysis, a significantly decreased LRR rate was also observed in LAGC patients with N1-3a stage after adjuvant CRT (p = 0.046), but not for N3b. Para-aortic lymph nodes (station No. 16) were the most frequent sites of LRR. After receiving radiotherapy, recurrence of 16 a2 region and 16 b1 region were significantly deceased (p = 0.026 and p = 0.044, respectively). Patients who received irradiation more than 4 months after surgery showed an increased risk of LRR (p = 0.022). Conclusions This study showed that adjuvant CRT significantly reduced LRR after D2 dissection of LAGC. Early initiation of adjuvant RT with clinical target volume encompassing a2 and b1 regions of para-aortic lymph nodes is recommended for pN1-3a patients after D2 dissection.
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Affiliation(s)
- Shu-Bei Wang
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei-Xiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei-Guo Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Gang Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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16
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Bausys A, Ümarik T, Luksta M, Reinsoo A, Rackauskas R, Anglickiene G, Kryzauskas M, Tõnismäe K, Senina V, Seinin D, Bausys R, Strupas K. Impact of the Interval Between Neoadjuvant Chemotherapy and Gastrectomy on Short- and Long-Term Outcomes for Patients with Advanced Gastric Cancer. Ann Surg Oncol 2021; 28:4444-4455. [PMID: 33417120 DOI: 10.1245/s10434-020-09507-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The optimal time between neoadjuvant chemotherapy (NAC) and gastrectomy for gastric cancer (GC) remains unknown. This study aimed to investigate the association between the time-to-surgery (TTS) interval and the major pathologic response (mPR). METHODS In this study, 280 consecutive GC patients who underwent NAC followed by gastrectomy between 2014 and 2018 were retrospectively analyzed by the use of prospectively collected databases from three major GC treatment centers in Lithuania and Estonia. Based on TTS, they were grouped into three interval categories: the early-surgery group (ESG: ≤ 30 days; n = 70), the standard-surgery group (SSG: 31-43 days; n = 138), and the delayed-surgery group (DSG: ≥ 44 days, n = 72). The primary outcome of the study was the mPR rate. The secondary end points were postoperative morbidity, mortality, oncologic safety (measured as the number of resected lymph nodes and radicality), and long-term outcomes. RESULTS The mPR rate for the ESG group (32.9%) was significantly higher than for the SSG group (20.3%) or the DSG group (16.7%) (p = 0.047). Furthermore, after adjustment for patient, tumor, and treatment characteristics, the odds for achievement of mPR were twofold higher for the patients undergoing early surgery (odds ratio [OR] 2.09; 95% conflidence interval [CI] 1.01-4.34; p = 0.047). Overall morbidity, severe complications, 30-day mortality, R0 resection, and retrieval of at least 15 lymph nodes rates were similar across the study groups. In addition, the long-term outcomes did not differ between the study groups. CONCLUSIONS This study suggests that an interval of more than 30 days between the end of NAC and gastrectomy is associated with a higher mPR rate, the same oncologic safety of surgery, and similar morbidity and mortality.
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Affiliation(s)
- Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania. .,Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.
| | - Toomas Ümarik
- Upper Gastrointestinal Tract Surgery Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arvo Reinsoo
- Upper Gastrointestinal Tract Surgery Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Rokas Rackauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Giedre Anglickiene
- Department of Medical Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kristina Tõnismäe
- Pathology Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Veslava Senina
- National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Dmitrij Seinin
- National Centre of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Rimantas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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17
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Kung CH, Jestin Hannan C, Linder G, Johansson J, Nilsson M, Hedberg J, Lindblad M. Impact of surgical resection rate on survival in gastric cancer: nationwide study. BJS Open 2020; 5:6043682. [PMID: 33688944 PMCID: PMC7944854 DOI: 10.1093/bjsopen/zraa017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/07/2020] [Indexed: 12/24/2022] Open
Abstract
Background There are marked geographical variations in the proportion of patients undergoing resection for gastric cancer. This study investigated the impact of resection rate on survival. Methods All patients with potentially curable gastric cancer between 2006 and 2017 were identified from the Swedish National Register of Oesophageal and Gastric Cancer. The annual resection rate was calculated for each county per year. Resection rates in all counties for all years were grouped into tertiles and classified as low, intermediate or high. Survival was analysed using the Cox proportional hazards model. Results A total of 3465 patients were diagnosed with potentially curable gastric cancer, and 1934 (55.8 per cent) were resected. Resection rates in the low (1261 patients), intermediate (1141) and high (1063) tertiles were 0–50.0, 50.1–62.5 and 62.6–100 per cent respectively. The multivariable Cox analysis revealed better survival for patients diagnosed in counties during years with an intermediate versus low resection rate (hazard ratio (HR) 0.81, 95 per cent c.i. 0.74 to 0.90; P < 0.001) and high versus low resection rate (HR 0.80, 0.73 to 0.88; P < 0.001). Conclusion This national register study showed large regional variation in resection rates for gastric cancer. A higher resection rate appeared to be beneficial with regard to overall survival for the entire population.
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Affiliation(s)
- C-H Kung
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Skellefteå County Hospital, Skellefteå, Sweden
| | - C Jestin Hannan
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - G Linder
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J Johansson
- Department of Surgery, Lund University, Lund, Sweden
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Digestive Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Digestive Surgery, Karolinska University Hospital, Stockholm, Sweden
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18
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de Steur WO, van Amelsfoort RM, Hartgrink HH, Putter H, Meershoek-Klein Kranenbarg E, van Grieken NCT, van Sandick JW, Claassen YHM, Braak JPBM, Jansen EPM, Sikorska K, van Tinteren H, Walraven I, Lind P, Nordsmark M, van Berge Henegouwen MI, van Laarhoven HWM, Cats A, Verheij M, van de Velde CJH. Adjuvant chemotherapy is superior to chemoradiation after D2 surgery for gastric cancer in the per-protocol analysis of the randomized CRITICS trial. Ann Oncol 2020; 32:360-367. [PMID: 33227408 DOI: 10.1016/j.annonc.2020.11.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Intergroup 0116 and the MAGIC trials changed clinical practice for resectable gastric cancer in the Western world. In these trials, overall survival improved with post-operative chemoradiotherapy (CRT) and perioperative chemotherapy (CT). Intention-to-treat analysis in the CRITICS trial of post-operative CT or post-operative CRT did not show a survival difference. The current study reports on the per-protocol (PP) analysis of the CRITICS trial. PATIENTS AND METHODS The CRITICS trial was a randomized, controlled trial in which 788 patients with stage Ib-Iva resectable gastric or esophagogastric adenocarcinoma were included. Before start of preoperative CT, patients from the Netherlands, Sweden and Denmark were randomly assigned to receive post-operative CT or CRT. For the current analysis, only patients who started their allocated post-operative treatment were included. Since it is uncertain that the two treatment arms are balanced in such PP analysis, adjusted proportional hazards regression analysis and inverse probability weighted analysis were used to minimize the risk of selection bias and to estimate and compare overall and event-free survival. RESULTS Of the 788 patients, 478 started post-operative treatment according to protocol, 233 (59%) patients in the CT group and 245 (62%) patients in the CRT group. Patient and tumor characteristics between the groups before start of the post-operative treatment were not different. After a median follow-up of 6.7 years since the start of post-operative treatment, the 5-year overall survival was 57.9% (95% confidence interval: 51.4% to 64.3%) in the CT group versus 45.5% (95% confidence interval: 39.2% to 51.8%) in the CRT group (adjusted hazard ratio CRT versus CT: 1.62 (1.24-2.12), P = 0.0004). Inverse probability weighted analysis resulted in similar hazard ratios. CONCLUSION After adjustment for all known confounding factors, the PP analysis of patients who started the allocated post-operative treatment in the CRITICS trial showed that the CT group had a significantly better 5-year overall survival than the CRT group (NCT00407186).
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Affiliation(s)
- W O de Steur
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - R M van Amelsfoort
- Department of Radiation Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - H H Hartgrink
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - H Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - N C T van Grieken
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Y H M Claassen
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - J P B M Braak
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - E P M Jansen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - K Sikorska
- Department of Biometrics, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - H van Tinteren
- Department of Biometrics, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - I Walraven
- Department of Radiation Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - P Lind
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - M Nordsmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - A Cats
- Department of Gastrointestinal Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M Verheij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C J H van de Velde
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
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19
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Observational Study Comparing Efficacy and Safety between Neoadjuvant Concurrent Chemoradiotherapy and Chemotherapy for Patients with Unresectable Locally Advanced or Metastatic Gastric Cancer. JOURNAL OF ONCOLOGY 2020; 2020:6931317. [PMID: 32963531 PMCID: PMC7492932 DOI: 10.1155/2020/6931317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 02/08/2023]
Abstract
Objective Dismal outcomes in patients with locally advanced or metastatic gastric cancer (GC) highlight the need for effective systemic neoadjuvant treatment strategies to improve clinical results. Neoadjuvant multimodality strategies vary widely. This study compared the efficacy, safety, and clinical outcomes of neoadjuvant CCRT and chemotherapy for such patients. Materials and Methods Sixty-five patients with histologically confirmed locally advanced or metastatic GC following neoadjuvant CCRT or computed tomography (CT) were retrospectively enrolled between January 2010 and April 2019. Clinical outcomes included response, progression-free survival (PFS), and overall survival (OS), and toxicity was compared between the two groups. Results Of the 65 patients, 18 (27.7%) were in the response group (2 patients with a complete response and 16 with a partial response) and 47 (72.3%) in the nonresponse group (29 patients with a stable disease and 18 with a progressive disease). Multivariate analysis revealed no independent response predictor between CCRT and chemotherapy groups (all P > 0.05). Furthermore, results revealed no statistical differences in toxicity between the two groups (all P > 0.05). With a follow-up median of 12 months (ranging 6–48 months), 12-month OS and PFS were 39.7% and 20.4% in the CCRT group and 30.3% and 13.2% in the chemotherapy group, respectively. The median OS and PFS were 14.0 months (95% CI 9.661–18.339) and 9.0 months (95% CI 6.805–11.195) in the CCRT group and 10.0 months (95% CI 6.523–13.477) and 8.0 months (95% CI 6.927–9.073) in the chemotherapy group, respectively. Both OS (P=0.011) and PFS (P=0.008) in patients with CCRT were significantly better than those in patients with chemotherapy alone. Conclusion Neoadjuvant CCRT achieved more favorable OS and PFS than did neoadjuvant chemotherapy alone, without significant increases of toxicity in patients. However, prospective randomized trials comparing treatment modalities are necessary to confirm the potential advantages of neoadjuvant CCRT.
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20
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Davarzani N, Hewitt LC, Hale MD, Melotte V, Nankivell M, Hutchins GGA, Cunningham D, Allum WH, Langley RE, Jolani S, Grabsch HI. Histological intratumoral heterogeneity in pretreatment esophageal cancer biopsies predicts survival benefit from neoadjuvant chemotherapy: results from the UK MRC OE02 trial. Dis Esophagus 2020; 33:5863449. [PMID: 32591823 PMCID: PMC7397482 DOI: 10.1093/dote/doaa058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/16/2020] [Accepted: 05/28/2020] [Indexed: 12/24/2022]
Abstract
Despite the use of multimodal treatment, survival of esophageal cancer (EC) patients remains poor. One proposed explanation for the relatively poor response to cytotoxic chemotherapy is intratumor heterogeneity. The aim was to establish a statistical model to objectively measure intratumor heterogeneity of the proportion of tumor (IHPoT) and to use this newly developed method to measure IHPoT in the pretreatment biopsies from from EC patients recruited to the OE02 trial. A statistical mixed effect model (MEM) was established for estimating IHPoT based on variation in hematoxylin/eosin (HE) stained pretreatment biopsy pieces from the same individual in 218 OE02 trial patients (103 treated by chemotherapy and surgery (chemo+surgery); 115 patients treated by surgery alone). The relationship between IHPoT, prognosis, chemotherapy survival benefit, and clinicopathological variables was assessed. About 97 (44.5%) and 121 (55.5%) ECs showed high and low IHPoT, respectively. There was no significant difference in IHPoT between surgery (median [range], 0.1637 [0-3.17]) and chemo+surgery (median [range], 0.1692 [0-2.69]) patients (P = 0.43). Chemo+surgery patients with low IHPoT had a significantly longer survival than surgery patients (HR = 1.81, 95% CI: 1.20-2.75, P = 0.005). There was no survival difference between chemo+surgery and surgery patients with high IHPoT (HR = 1.15, 95% CI: 0.72-1.81, P = 0.566). This is the first study suggesting that IHPoT measured in the pretreatment biopsy can predict chemotherapy survival benefit in EC patients. IHPoT may represent a clinically useful biomarker for patient treatment stratification. Future studies should determine if pathologists can reliably estimate IHPoT.
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Affiliation(s)
- Naser Davarzani
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center + Maastricht, The Netherlands,Biosystems Data Analysis, Swammerdam Institute for Life Sciences, Amsterdam University, Amsterdam, The Netherlands
| | - Lindsay C Hewitt
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center + Maastricht, The Netherlands,Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Matthew D Hale
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Veerle Melotte
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center + Maastricht, The Netherlands,Department of Clinical Genetics, University of Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit at University College, London, UK
| | - Gordon G A Hutchins
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - David Cunningham
- Gastrointestinal and Lymphoma Unit, Royal Marsden Hospital, London, UK
| | | | - Ruth E Langley
- Medical Research Council Clinical Trials Unit at University College, London, UK
| | - Shahab Jolani
- Department of Methodology and Statistics, CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Heike I Grabsch
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center + Maastricht, The Netherlands,Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK,Address correspondence to: Professor Heike I. Grabsch, Department of Pathology, Maastricht University Medical Center+, P. Debyelaan, 256229 HX Maastricht, The Netherlands.
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21
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Clinical Outcomes and Prognostic Factors in Gastric Carcinoma Patients with Curative Surgery Followed by Adjuvant Treatment: Real-World Scenario. J Gastrointest Cancer 2020; 52:616-624. [PMID: 32535755 DOI: 10.1007/s12029-020-00440-w] [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: 11/12/2022]
Abstract
BACKGROUND A wide range of adjuvant treatment regimens exist in gastric carcinoma patients which include chemotherapy, radiotherapy, and/or both either sequential or concurrent. The study aimed to assess the benefit of adjuvant sequential chemotherapy followed by radiotherapy for operable gastric cancers and evaluate the prognostic factors associated with clinical outcomes. METHODS Patients of stage IB-III gastric carcinoma who underwent radical surgery followed by adjuvant treatment from January 2013 to December 2016 were analyzed retrospectively. Survival was computed using Kaplan-Meier method and prognostic factors were analyzed in multivariate analysis using Cox progression hazard model. A P value < 0.05 was taken as statistically significant. RESULTS A total of 108 patients were identified with a median follow-up of 31.7 months (range: 6-96). Seventy-two percent of the patients received adjuvant sequential chemoradiation (N = 77) and 28% of patients received chemotherapy alone. The median survival was 26 months (95% CI: 23.09-28.90). Overall survival (OS) rates for 1, 2, 3, 4, and 5 years were 88.9%, 57.4%, 40.7%, 28.8%, and 20.4%, respectively. Five-year OS for stage-IB, II, and III was 75%, 45%, and 8.3%, respectively (p = 0.023). Surgical margin positivity (9.5% vs. 26.9%, p = 0.042), signet-ring cell histology (6.5% vs. 25.8%, p = 0.00), and adjuvant sequential chemoradiation (p = 0.002) showed a significant impact on survival outcomes and proved as independent prognostic factors. CONCLUSION The present study demonstrated that survival in gastric carcinoma is influenced by the stage of disease and surgical margins. In locally advanced patients, radical surgery followed by sequential chemoradiation based on a doublet/triplet regimen was an independent prognostic factor for survival. Majority of patients in our set-up presented in locally advanced stage, curative resection followed by adjuvant sequential chemoradiation was an independent prognostic factor for survival.
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22
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Pereira MA, Ramos MFKP, Dias AR, Cardili L, Ribeiro RRE, Charruf AZ, de Castria TB, Zilberstein B, Ceconello I, Avancini Ferreira Alves V, Ribeiro U, de Mello ES. Lymph node regression after neoadjuvant chemotherapy: A predictor of survival in gastric cancer. J Surg Oncol 2020; 121:795-803. [PMID: 31773740 DOI: 10.1002/jso.25785] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Neoadjuvant chemotherapy (nCMT) has been increasingly used in advanced gastric cancer (GC). However, the prognostic impact of tumor response remains unclear. This study aimed to evaluate if tumor response at the primary site and lymph nodes (LN) correlate with survival in GC patients after nCMT. METHODS Patients with gastric adenocarcinoma treated with nCMT followed by gastrectomy were evaluated. Residual tumor was graded from 0% to 100%, defining two groups: poor (PR) and major response (MR). LN regression rate (LNRR) was determined based on tumor/fibrosis examination at each LN and a cutoff value established by receiver operating characteristic curve. RESULTS Among 62 cases, 20 (32.2%) had MR and 42 (67.7%) PR. Smaller size, diffuse histology, lower ypT status and less advanced stage were associated with the MR group. Based on cutoff value of 57, 45.6% and 54.4% patients were classified as low-LNRR and high-LNRR. High-LNRR correlated with absence of venous, lymphatic and perineural invasion, and less advanced stage. Survival was equivalent between MR and PR (P = .956). High-LNRR had better disease-free survival (DFS) than low-LNRR (P < .001). In multivariate analysis, only LNRR associated with DFS. CONCLUSION High-LNRR associates with DFS in GC treated with nCMT. Response at the primary site does not correlate with survival.
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Affiliation(s)
- Marina Alessandra Pereira
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Andre Roncon Dias
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Leonardo Cardili
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Renan Ribeiro E Ribeiro
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Amir Zeide Charruf
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Tiago Biachi de Castria
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruno Zilberstein
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ivan Ceconello
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Ulysses Ribeiro
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Evandro Sobroza de Mello
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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23
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Slagter AE, Tudela B, van Amelsfoort RM, Sikorska K, van Sandick JW, van de Velde CJH, van Grieken NCT, Lind P, Nordsmark M, Putter H, Hulshof MCCM, van Laarhoven HWM, Grootscholten C, Braak JPBM, Meershoek-Klein Kranenbarg E, Jansen EPM, Cats A, Verheij M. Older versus younger adults with gastric cancer receiving perioperative treatment: Results from the CRITICS trial. Eur J Cancer 2020; 130:146-154. [PMID: 32208351 DOI: 10.1016/j.ejca.2020.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 01/25/2023]
Abstract
AIM To evaluate treatment-related toxicity, treatment compliance, surgical complications and event-free survival (EFS) in older (≥70 years) versus younger (<70 years) adults who underwent perioperative treatment for gastric cancer. METHODS In the CRITICS trial, 788 patients with resectable gastric cancer were randomised before start of any treatment and received preoperative chemotherapy (3 cycles of epirubicin, cisplatin or oxaliplatin and capecitabine), followed by surgery, followed by either postoperative chemotherapy or chemoradiotherapy (45Gy + cisplatin + capecitabine). RESULTS 172 (22%) patients were older adults. During preoperative chemotherapy, 131 (77%) older adults versus 380 (62%) younger adults experienced severe toxicity (p < 0.001); older adults received significantly lower relative dose intensities (RDIs) for all chemotherapeutic drugs. Equal proportions of older versus younger adults underwent curative surgery: 137 (80%) versus 499 (81%), with comparable postoperative complications and postoperative mortality. Postoperative therapy after curative surgery started in 87 (64%) older adults versus 391 (78%) younger adults (p < 0.001). Incidence of severe toxicity during postoperative chemotherapy was 22 (54%) in older adults versus 113 (59%) in younger adults (p = 0.541); older adults received significantly lower RDIs for all chemotherapeutic drugs. Severe toxicity rates for postoperative chemoradiotherapy were 22 (48%) older adults versus 89 (45%) for younger adults (p = 0.703), with comparable chemotherapy RDIs and radiotherapy dose. Two-year EFS was 53% for older adults versus 51% for younger adults. CONCLUSION Perioperative treatment compliance, especially in the postoperative phase, was poorer in older adults compared with younger adults. As comparable proportions of patients underwent curative surgery, future studies should focus on neo-adjuvant treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00407186. EudraCT number: 2006-00413032.
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Affiliation(s)
- Astrid E Slagter
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Benjamin Tudela
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Universidad de Valparaíso, Valparaíso, Chile
| | - Romy M van Amelsfoort
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Karolina Sikorska
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Nicole C T van Grieken
- Department of Pathology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Pehr Lind
- Department of Oncology, Stockholm Söder Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden
| | | | - Hein Putter
- Department of Biometrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Cecile Grootscholten
- Department of Gastrointestinal Oncology/Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jeffrey P B M Braak
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Edwin P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology/Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands.
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24
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Effect of Hospital Volume With Respect to Performing Gastric Cancer Resection on Recurrence and Survival: Results From the CRITICS Trial. Ann Surg 2020; 270:1096-1102. [PMID: 29995679 DOI: 10.1097/sla.0000000000002940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We examined the association between surgical hospital volume and both overall survival (OS) and disease-free survival (DFS) using data obtained from the international CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. SUMMARY BACKGROUND DATA In the CRITICS trial, patients with resectable gastric cancer were randomized to receive preoperative chemotherapy followed by adequate gastrectomy and either chemotherapy or chemoradiotherapy. METHODS Patients in the CRITICS trial who underwent a gastrectomy with curative intent in a Dutch hospital were included in the analysis. The annual number of gastric cancer surgeries performed at the participating hospitals was obtained from the Netherlands Cancer Registry; the hospitals were then classified as low-volume (1-20 surgeries/year) or high-volume (≥21 surgeries/year) and matched with the CRITICS trial data. Univariate and multivariate analyses were then performed to evaluate the hazard ratio (HR) between hospital volume and both OS and DFS. RESULTS From 2007 through 2015, 788 patients were included in the CRITICS trial. Among these 788 patients, 494 were eligible for our study; the median follow-up was 5.0 years. Five-year OS was 59.2% and 46.1% in the high-volume and low-volume hospitals, respectively. Multivariate analysis revealed that undergoing surgery in a high-volume hospital was associated with higher OS [HR = 0.69, 95% confidence interval (CI) = 0.50-0.94, P = 0.020] and DFS (HR = 0.73, 95% CI: 0.54-0.99, P = 0.040). CONCLUSIONS In the CRITICS trial, hospitals with a high annual volume of gastric cancer surgery were associated with higher overall and DFS. These findings emphasize the value of centralizing gastric cancer surgeries in the Western world.
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25
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Gene regulatory network analysis with drug sensitivity reveals synergistic effects of combinatory chemotherapy in gastric cancer. Sci Rep 2020; 10:3932. [PMID: 32127608 PMCID: PMC7054272 DOI: 10.1038/s41598-020-61016-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
The combination of docetaxel, cisplatin, and fluorouracil (DCF) is highly synergistic in advanced gastric cancer. We aimed to explain these synergistic effects at the molecular level. Thus, we constructed a weighted correlation network using the differentially expressed genes between Stage I and IV gastric cancer based on The Cancer Genome Atlas (TCGA), and three modules were derived. Next, we investigated the correlation between the eigengene of the expression of the gene network modules and the chemotherapeutic drug response to DCF from the Genomics of Drug Sensitivity in Cancer (GDSC) database. The three modules were associated with functions related to cell migration, angiogenesis, and the immune response. The eigengenes of the three modules had a high correlation with DCF (−0.41, −0.40, and −0.15). The eigengenes of the three modules tended to increase as the stage increased. Advanced gastric cancer was affected by the interaction the among modules with three functions, namely cell migration, angiogenesis, and the immune response, all of which are related to metastasis. The weighted correlation network analysis model proved the complementary effects of DCF at the molecular level and thus, could be used as a unique methodology to determine the optimal combination of chemotherapy drugs for patients with gastric cancer.
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Ramos MFKP, de Castria TB, Pereira MA, Dias AR, Antonacio FF, Zilberstein B, Hoff PMG, Ribeiro U, Cecconello I. Return to Intended Oncologic Treatment (RIOT) in Resected Gastric Cancer Patients. J Gastrointest Surg 2020; 24:19-27. [PMID: 31745892 DOI: 10.1007/s11605-019-04462-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative chemotherapy (CMT) or chemoradiotherapy (CRT) is commonly recommended for gastric cancer (GC) patients in order to improve survival. However, some factors that prevent patients from return to intended oncologic treatment (RIOT) may increase the risk of recurrence and decrease the survival benefits achieved with curative resection. The aim of this study was to determine the frequency and factors associated with inability to RIOT and their impact on survival. METHODS This retrospective study included stage II/III GC patients treated with potentially curative gastrectomy. Patients who could return to intended oncologic treatment (RIOT group) and those who could not (inability to RIOT group) were analyzed. RESULTS Of the 313 eligible GC patients, 89 (28.4%) and 85 (27.2%) patients receive CRT and CMT, respectively, representing a RIOT rate of 55.6%. The main reason was attributed to general poor performance status (30.2%), followed by surgical postoperative complications (POC) (20.1%). Older age, higher ASA, D1 lymphadenectomy, and major POC were related to inability to RIOT. Older age, neutrophil-lymphocyte ratio (NLR), and major POC were independent risk factors for inability to RIOT. Five-year DFS and OS were worse for the inability to RIOT group than for the RIOT group (p = 0.008 and p = 0.004, respectively). In multivariate analyses, absence of neoadjuvant therapy, total gastrectomy, pT3/T4, pN+, and inability to RIOT were associated with worse DFS. Type of gastrectomy, lymphadenectomy, pN status, Rx resection, and RIOT group were associated with OS. CONCLUSION Older age, high NLR, and major POC were risk factors for inability to RIOT. RIOT was an independent predictor of survival.
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Affiliation(s)
- Marcus Fernando Kodama Pertille Ramos
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil.
| | - Tiago Biachi de Castria
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Marina Alessandra Pereira
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Andre Roncon Dias
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Fernanda Fronzoni Antonacio
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Bruno Zilberstein
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Paulo Marcelo Gehm Hoff
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ulysses Ribeiro
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ivan Cecconello
- Instituto do Cancer, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
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Gamboa AC, Winer JH. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer. Cancers (Basel) 2019; 11:E1662. [PMID: 31717799 PMCID: PMC6896138 DOI: 10.3390/cancers11111662] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 12/24/2022] Open
Abstract
The management of peritoneal metastases from gastric cancer origin has evolved considerably over the last three decades with the establishment of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as efficacious therapies in carefully selected patients. Other approaches such as the use of prophylactic/adjuvant HIPEC in patients who are considered high-risk and those with positive peritoneal cytology will benefit from additional data before being adopted into routine clinical practice. Lastly, there are new and emerging intraperitoneal chemotherapy techniques such as early post-operative intraperitoneal chemotherapy (EPIC) for residual microscopic disease, and pressurized intraperitoneal aerosolized chemotherapy (PIPAC) for patients with advanced unresectable peritoneal carcinomatosis, which are currently under evaluation in clinical trials. The following review outlines the natural history of gastric cancer, currently available neoadjuvant and adjuvant therapies for resectable disease, and existing evidence supporting various approaches to CRS and intraperitoneal chemotherapy.
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Affiliation(s)
- Adriana C. Gamboa
- Division of Surgical Oncology, 1365B Clifton Road NE, Suite B4000, Atlanta, GA 30322, USA;
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Surgicopathological Quality Control and Protocol Adherence to Lymphadenectomy in the CRITICS Gastric Cancer Trial. Ann Surg 2019; 268:1008-1013. [PMID: 28817437 DOI: 10.1097/sla.0000000000002444] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate surgicopathological quality and protocol adherence for lymphadenectomy in the CRITICS trial. SUMMARY OF BACKGROUND DATA Surgical quality assurance is a key element in multimodal studies for gastric cancer. In the multicenter CRITICS trial (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach), patients with resectable gastric cancer were randomized for preoperative chemotherapy, followed by gastrectomy with a D1+ lymphadenectomy (removal of stations 1 to 9 and 11), followed by either chemotherapy or chemoradiotherapy. METHODS Surgicopathological compliance was defined as removal of ≥15 lymph nodes. Surgical compliance was defined as removal of the indicated lymph node stations. Surgical contamination was defined as removal of lymph node stations that should be left in situ. The Maruyama Index (MI, lower is better), which has proven to be an indicator of surgical quality and is strongly associated with survival, was analyzed. RESULTS Between 2007 and 2015, 788 patients were randomized, of whom 636 patients underwent a gastrectomy with curative intent. Surgicopathological compliance occurred in 72.8% (n = 460) of the patients and improved from 55.0% (2007) to 90.0% (2015). Surgical compliance occurred in 41.1% (n = 256). Surgical contamination occurred in 59.6% (n = 371). Median MI was 1 (range 0 to 136). CONCLUSION Surgical quality in the CRITICS trial was excellent, with a MI of 1. Surgicopathological compliance improved over the years. This might be explained by the quality assurance program within the study and centralization of gastric cancer surgery in the Netherlands.
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Goetze TO, Al-Batran SE, Berlth F, Hoelscher AH. Multimodal Treatment Strategies in Esophagogastric Junction Cancer: a Western Perspective. J Gastric Cancer 2019; 19:148-156. [PMID: 31245159 PMCID: PMC6589422 DOI: 10.5230/jgc.2019.19.e19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagogastric junction (EGJ) cancer is a solid tumor entity with rapidly increasing incidence in the Western countries. Given the high proportion of advanced cancers in the West, treatment strategies routinely employed include surgery and chemotherapy perioperatively, and chemoradiation in neoadjuvant settings. Neoadjuvant chemoradiation and perioperative chemotherapy are mostly performed in esophageal cancer that extends to the EGJ and gastric as well as EGJ cancers, respectively. Recent trials have tried to combine both strategies in a perioperative context, which might have beneficial outcomes, especially in patients with EGJ cancer. However, it is difficult to recruit patients for trials, exclusively for EGJ cancers; therefore, the results have to be carefully reviewed before establishing a standard protocol. Trastuzumab was the first drug for targeted therapy that was positively evaluated for this tumor entity, and there are several ongoing trials investigating more targeted drugs in order to customize effective therapies based on tissue characteristics. The current study reviews the multimodal treatment concept for EGJ cancers in the West and summarizes the latest reports.
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Affiliation(s)
- Thorsten Oliver Goetze
- Institute of Clinical Cancer Research, Krankenhaus Nordwest, UCT University Cancer Center, Frankfurt am Main, Germany
| | - Salah-Eddin Al-Batran
- Institute of Clinical Cancer Research, Krankenhaus Nordwest, UCT University Cancer Center, Frankfurt am Main, Germany
| | - Felix Berlth
- Department of Surgery, Division of Gastrointestinal Surgery, Seoul National University Hospital, Seoul, Korea
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Claassen YHM, van Sandick JW, Hartgrink HH, Dikken JL, De Steur WO, van Grieken NCT, Boot H, Cats A, Trip AK, Jansen EPM, Meershoek-Klein Kranenbarg WM, Braak JPBM, Putter H, van Berge Henegouwen MI, Verheij M, van de Velde CJH. Association between hospital volume and quality of gastric cancer surgery in the CRITICS trial. Br J Surg 2019; 105:728-735. [PMID: 29652082 DOI: 10.1002/bjs.10773] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Studies investigating the association between hospital volume and quality of gastric cancer surgery are lacking. In the present study, the effect of hospital volume on quality of gastric cancer surgery was evaluated by analysing data from the CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. METHODS Patients who underwent gastrectomy with curative intent in the Netherlands were selected from the CRITICS trial database. Annual hospital volume of participating centres was derived from the Netherlands Cancer Registry. Hospital volume was categorized into very low (1-10 gastrectomies per year per institution), low (11-20), medium (21-30) and high (31 or more), and linked to the CRITICS database. Quality of surgery was analysed by surgicopathological compliance (removal of at least 15 lymph nodes), surgical compliance (removal of indicated lymph node stations) and the Maruyama Index. Postoperative morbidity and mortality were also compared between hospital categories. RESULTS Between 2007 and 2015, 788 patients were included in the CRITICS study, of whom 494 were analysed. Surgicopathological compliance was higher (86·7 versus 50·4 per cent; P < 0·001), surgical compliance was greater (52·9 versus 19·8 per cent; P < 0·001) and median Maruyama Index was lower (0 versus 6; P = 0·006) in high-volume hospitals compared with very low-volume hospitals. There was no statistically significant difference in postoperative complications or mortality between the hospital volume categories. CONCLUSION Surgery performed in high-volume hospitals was associated with better surgical quality than surgery carried out in lower-volume hospitals.
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Affiliation(s)
- Y H M Claassen
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H H Hartgrink
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J L Dikken
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - W O De Steur
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - N C T van Grieken
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H Boot
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A K Trip
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - J P B M Braak
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - M Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C J H van de Velde
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
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Mokadem I, Dijksterhuis WPM, van Putten M, Heuthorst L, de Vos-Geelen JM, Haj Mohammad N, Nieuwenhuijzen GAP, van Laarhoven HWM, Verhoeven RHA. Recurrence after preoperative chemotherapy and surgery for gastric adenocarcinoma: a multicenter study. Gastric Cancer 2019; 22:1263-1273. [PMID: 30949777 PMCID: PMC6811385 DOI: 10.1007/s10120-019-00956-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In most western European countries perioperative chemotherapy is a part of standard curative treatment for gastric cancer. Nevertheless, recurrence rates remain high after multimodality treatment. This study examines patterns of recurrence in patients receiving perioperative chemotherapy with surgery for gastric cancer in a real-world setting. METHODS All patients diagnosed with gastric adenocarcinoma between 2010 and 2015 who underwent at least preoperative chemotherapy and a gastrectomy with curative intent (cT1N+/cT2-4a,X; any cN; cM0) in 18 Dutch hospitals were selected from the Netherlands Cancer Registry. Additional data on chemotherapy and recurrence were collected from medical records. Rates, patterns, and timing of recurrence were examined. Multivariable Cox proportional hazard analyses were used to determine prognostic factors for recurrence. RESULTS 408 patients were identified. After a median follow-up of 27.8 months, 36.8% of the gastric cancer patients had a recurrence of which the majority (88.8%) had distant metastasis. The 1-year recurrence-free survival was 71.8%. The risk of recurrence was higher in patients with an ypN+ stage (HR 4.92, 95% CI 3.35-7.24), partial or no tumor regression (HR 2.63, 95% CI 1.22-5.64), 3 instead of ≥ 6 chemotherapy cycles (HR 3.04, 95% CI 1.99-4.63), R1 resection (HR 1.52, 95% CI 1.02-2.26), and < 15 resected lymph nodes (HR 1.64, 95% CI 1.14-2.37). CONCLUSION A considerable amount of gastric cancer patients who were treated with curative intent developed a recurrence despite surgery and perioperative treatment. The majority developed distant metastases, therefore, multimodality treatment approaches should be focused on the prevention of distant rather than locoregional recurrences to improve survival.
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Affiliation(s)
- I. Mokadem
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), PO Box 19079, 3501 DB Utrecht, The Netherlands
| | - W. P. M. Dijksterhuis
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), PO Box 19079, 3501 DB Utrecht, The Netherlands ,Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M. van Putten
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), PO Box 19079, 3501 DB Utrecht, The Netherlands
| | - L. Heuthorst
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. M. de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, GROW-School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - N. Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - H. W. M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R. H. A. Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), PO Box 19079, 3501 DB Utrecht, The Netherlands ,Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Claassen YHM, Hartgrink HH, de Steur WO, Dikken JL, van Sandick JW, van Grieken NCT, Cats A, Trip AK, Jansen EPM, Kranenbarg WMMK, Braak JPBM, Putter H, van Berge Henegouwen MI, Verheij M, van de Velde CJH. Impact of upfront randomization for postoperative treatment on quality of surgery in the CRITICS gastric cancer trial. Gastric Cancer 2019; 22:369-376. [PMID: 30238171 PMCID: PMC6394698 DOI: 10.1007/s10120-018-0875-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative randomization for postoperative treatment might affect quality of surgery. In the CRITICS trial (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach), patients were randomized before treatment to receive chemotherapy prior to a D1 + gastrectomy (removal of lymph node station (LNS) 1-9 + 11), followed by either chemotherapy (CT) or chemoradiotherapy (CRT). In this analysis, the influence of upfront randomization on the quality of surgery was evaluated. METHODS Quality of surgery was analyzed in both study arms using surgicopathological compliance (removal of ≥ 15 lymph nodes), surgical compliance (removal of the indicated LNS), and surgical contamination (removal of LNS that should be left in situ). Furthermore, the 'Maruyama Index of Unresected disease' (MI) was evaluated in both study arms, and validated with overall survival. RESULTS Between 2007 and 2015, 788 patients with gastric cancer were included in the CRITICS study of which 636 patients were operated with curative intent. No difference was observed between the CT and CRT group regarding surgicopathological compliance (74.8% vs 70.9%, P = 0.324), surgical compliance (43.2% vs 39.2%, P = 0.381), and surgical contamination (59.4% vs 59.9%, P = 0.567). Median MI was 1 in both groups (range CT 0-88 and CRT 0-136, P = 0.700). A MI below 5 was associated with better overall survival (CT: P = 0.009 and CRT: P = 0.013). CONCLUSION Surgical quality parameters were similar in both study arms in the CRITICS gastric cancer trial, indicating that upfront randomization for postoperative treatment had no impact on the quality of surgery. A Maruyama Index below five was associated with better overall survival.
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Affiliation(s)
- Y. H. M. Claassen
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - H. H. Hartgrink
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - W. O. de Steur
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - J. L. Dikken
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - J. W. van Sandick
- grid.430814.aDepartment of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - N. C. T. van Grieken
- 0000 0004 0435 165Xgrid.16872.3aDepartment of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - A. Cats
- grid.430814.aDepartment of Gastrointestinal Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A. K. Trip
- grid.430814.aDepartment of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E. P. M. Jansen
- grid.430814.aDepartment of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - J. P. B. M. Braak
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - H. Putter
- 0000000089452978grid.10419.3dDepartment of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - M. Verheij
- grid.430814.aDepartment of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C. J. H. van de Velde
- 0000000089452978grid.10419.3dDepartment of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Xu J, Zhu J, Wei Q. Adjuvant Radiochemotherapy versus Chemotherapy Alone for Gastric Cancer: Implications for Target Definition. J Cancer 2019; 10:458-466. [PMID: 30719140 PMCID: PMC6360300 DOI: 10.7150/jca.27335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/28/2018] [Indexed: 12/19/2022] Open
Abstract
The INT0116 trial was a milestone study and laid the foundation for the adjuvant radiotherapy (RT) associated to concurrent chemotherapy (CT) for the treatment of gastric cancer (GC) after gastrectomy. However, it is still controversial whether adding RT to CT could further benefit D2-dissected GC patients. The ARTIST trial indicated that the addition of RT to CT did not have a positive impact on disease-free survival (DFS). Nevertheless, in a subgroup of 396 patients with positive pathological lymph nodes, combined treatment with RT was superior to CT alone. A similar randomized Chinese trial confirmed the superiority of adding RT to CT in terms of DFS for patients with D2 lymphadenectomy. However, several previous randomized studies provided inconsistent results with the benefits of combined treatment of RT and CT. The inconsistent results of several studies may be due to the differences between tumor epidemiology, treatment policies, and treatment outcomes. During the past decade, major progress in accurate target delineation utilizing RT technology has been observed. However, even though the use of adjuvant RT doubled after the INT-0116 trial results became public, the fraction of patients receiving adjuvant RT was still low according to the SEER database. The low rate of adjuvant RT can partially be explained by concern over toxicity while undergoing RT. Several studies have also defined the specific location of locoregional recurrence for postoperative RT in GC, but these studies are still limited. A number of retrospective studies demonstrated that the most prevalent nodal recurrence was outside the D2 dissection field. In order to overcome the restricted nature of a retrospective study and provide more individual radiation field determination, additional large-scale prospective multicenter studies are required to evaluate the optimal RT target.
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Affiliation(s)
- Jing Xu
- Department of Radiation Oncology, the Second Affiliated Hospital and Cancer Institute (National Ministry of Education Key Laboratory of Cancer Prevention and Intervention), Zhejiang University School of Medicine, Hangzhou 310009, P.R. China
| | - Jonathan Zhu
- Ben May Department for Cancer Research, University of Chicago, Chicago, IL, 60637, USA
| | - Qichun Wei
- Department of Radiation Oncology, the Second Affiliated Hospital and Cancer Institute (National Ministry of Education Key Laboratory of Cancer Prevention and Intervention), Zhejiang University School of Medicine, Hangzhou 310009, P.R. China
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Luo H, Wu L, Huang M, Jin Q, Qin Y, Chen J. Postoperative morbidity and mortality in patients receiving neoadjuvant chemotherapy for locally advanced gastric cancers: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12932. [PMID: 30412102 PMCID: PMC6221738 DOI: 10.1097/md.0000000000012932] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM To investigate the postoperative morbidity and mortality for neoadjuvant chemotherapy (NAC) plus surgery compared with surgery alone. METHODS PubMed and Embase were searched to capture the incidence of any postoperative complications, pulmonary complications, anastomotic leakage, surgical site infections, and postoperative mortality in randomized clinical trials comparing NAC plus surgery with surgery alone. The meta-analyses were performed with a random effects model. RESULTS Nine relevant studies were included. Comparing NAC with surgery alone, there were no increases in any postoperative complications, pulmonary complications, anastomotic leakage, surgical site infections, or postoperative mortality attributable to NAC. Sensitivity analysis suggested a possible increased risk of any postoperative complications compared with surgery alone: the risk difference 0.056 (95% confidence interval -0.032 to 0.145). Severe complications such as anastomotic leakage and pulmonary complications were similar in the 2 groups. CONCLUSIONS NAC for gastric cancer does not increase the risk of postoperative morbidity and mortality compared with surgery alone.
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Affiliation(s)
- Huiyu Luo
- Affiliated Tumor Hospital of Guangxi Medical University
| | - Liucheng Wu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi Autonomous Region, China
| | - Mingwei Huang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi Autonomous Region, China
| | - Qinwen Jin
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi Autonomous Region, China
| | - Yuzhou Qin
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi Autonomous Region, China
| | - Jiansi Chen
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi Autonomous Region, China
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Benevento I, Bulzonetti N, De Felice F, Musio D, Vergine M, Tombolini V. The role of different adjuvant therapies in locally advanced gastric adenocarcinoma. Oncotarget 2018; 9:34022-34029. [PMID: 30338043 PMCID: PMC6188065 DOI: 10.18632/oncotarget.26106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/27/2018] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Complete surgical resection remains the only curative treatment option in locally advanced gastric cancer (GC). Several studies were conducted to prevent local recurrence and to increase the chance of cure. The aim of this study was to summarize our experience in locally advanced GC patients treated with adjuvant chemoradiotherapy (CRT) and to evaluate overall survival (OS), disease-free survival (DFS), toxicity rate and compliance to treatment. Materials and Methods Locally advanced GC stage IB-III were included. Adjuvant CRT consisted of 45–50.4 Gy (1.8 Gy/day, 5 days/week) with concomitant Macdonald regimen (Mcd) or Epirubicin, Cisplatin and 5-Fluorouracil (ECF) scheme. Univariate and multivariate analysis of several prognostic factors for OS was conducted. Results Fourty-nine GC patients were treated: 24 received Mcd and 25 received ECF. Median follow up was 48 months. Acute grade 3–4 toxicity was observed in 6 patients. The 2-year and 5-year OS rates were 65.3% and 41.5%, respectively. The 2-year and 5-year DFS were 59.2% and 41.2%, respectively. No prognostic factors were significantly associated with OS. Conclusions Adjuvant CRT is a feasible strategy in locally advanced GC. It has an acceptable toxicity rate and it is able to increase both DFS and OS.
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Affiliation(s)
- Ilaria Benevento
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
| | - Nadia Bulzonetti
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
| | - Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
| | - Daniela Musio
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
| | - Massimo Vergine
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
| | - Vincenzo Tombolini
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome 155, Italy
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Agolli L, Nicosia L. Between evidence and new perspectives on the current state of the multimodal approach to gastric cancer: Is there still a role for radiation therapy? World J Gastrointest Oncol 2018; 10:271-281. [PMID: 30254722 PMCID: PMC6147768 DOI: 10.4251/wjgo.v10.i9.271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/08/2018] [Accepted: 06/27/2018] [Indexed: 02/05/2023] Open
Abstract
In patients affected by gastric cancer (GC), especially those in advanced stage, the multidisciplinary approach of treatment is fundamental to obtain a good disease control and quality of life. Although many chemotherapeutics in combination to radiotherapy are adopted in the peri- or postoperative setting, the most optimal timing, regimens and doses remains controversial. In the era of radical surgery performed with D2-lymphadenectomy, the role of radiation therapy remains to be better defined. Categories of patients, who could benefit more from an intensified local treatment rather than more toxic systemic therapy, are still under investigation. Evidence and recent updates of the randomized trials, meta-analysis and prospective trials show that the postoperative radiotherapy plays a fundamental role in reducing the loco-regional recurrence and in turn the disease-free survival in operable advanced GC patients, also after a well performed D2 surgery. Therapeutic decisions should be taken considering the individual patients, but the multimodal approach is necessary to guarantee a longer survival and a good quality of life. Ongoing randomized trials could better define the timing and the combination of radiotherapy and systemic therapy.
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Affiliation(s)
- Linda Agolli
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01037, Germany
| | - Luca Nicosia
- Department of Radiation Oncology, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
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Slagter AE, Jansen EPM, van Laarhoven HWM, van Sandick JW, van Grieken NCT, Sikorska K, Cats A, Muller-Timmermans P, Hulshof MCCM, Boot H, Los M, Beerepoot LV, Peters FPJ, Hospers GAP, van Etten B, Hartgrink HH, van Berge Henegouwen MI, Nieuwenhuijzen GAP, van Hillegersberg R, van der Peet DL, Grabsch HI, Verheij M. CRITICS-II: a multicentre randomised phase II trial of neo-adjuvant chemotherapy followed by surgery versus neo-adjuvant chemotherapy and subsequent chemoradiotherapy followed by surgery versus neo-adjuvant chemoradiotherapy followed by surgery in resectable gastric cancer. BMC Cancer 2018; 18:877. [PMID: 30200910 PMCID: PMC6131797 DOI: 10.1186/s12885-018-4770-2] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/22/2018] [Indexed: 12/21/2022] Open
Abstract
Background Although radical surgery remains the cornerstone of cure in resectable gastric cancer, survival remains poor. Current evidence-based (neo)adjuvant strategies have shown to improve outcome, including perioperative chemotherapy, postoperative chemoradiotherapy and postoperative chemotherapy. However, these regimens suffer from poor patient compliance, particularly in the postoperative phase of treatment. The CRITICS-II trial aims to optimize preoperative treatment by comparing three treatment regimens: (1) chemotherapy, (2) chemotherapy followed by chemoradiotherapy and (3) chemoradiotherapy. Methods In this multicentre phase II non-comparative study, patients with clinical stage IB-IIIC (TNM 8th edition) resectable gastric adenocarcinoma are randomised between: (1) 4 cycles of docetaxel+oxaliplatin+capecitabine (DOC), (2) 2 cycles of DOC followed by chemoradiotherapy (45Gy in combination with weekly paclitaxel and carboplatin) or (3) chemoradiotherapy. Primary endpoint is event-free survival, 1 year after randomisation (events are local and/or regional recurrence or progression, distant recurrence, or death from any cause). Secondary endpoints include: toxicity, surgical outcomes, percentage radical (R0) resections, pathological tumour response, disease recurrence, overall survival, and health related quality of life. Exploratory endpoints include translational studies on predictive and prognostic biomarkers. Discussion The aim of this study is to select the most promising among three preoperative treatment arms in patients with resectable gastric adenocarcinoma. This treatment regimen will subsequently be compared with the standard therapy in a phase III trial. Trial registration clinicaltrials.gov NCT02931890; registered 13 October 2016. Date of first enrolment: 21 December 2017.
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Affiliation(s)
- Astrid E Slagter
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Edwin P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Academic Medical Center Amsterdam, Meibergdreef 9, 1106 AZ, Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Nicole C T van Grieken
- Department of Pathology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Karolina Sikorska
- Statistical Department, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Pietje Muller-Timmermans
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center Amsterdam, Meibergdreef 9, 1106 AZ, Amsterdam, The Netherlands
| | - Henk Boot
- Department of Gastroenterology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Laurens V Beerepoot
- Department of Medical Oncology, St. Elisabeth Hospital, Hilvarenbeekse Weg 60, 5022 GC, Tilburg, The Netherlands
| | - Frank P J Peters
- Department of Medical Oncology, Zuyderland Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Academic Medical Center Amsterdam, Meibergdreef 9, 1106 AZ, Amsterdam, The Netherlands
| | - Grard A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3484 CX, Utrecht, The Netherlands
| | - Donald L van der Peet
- Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Heike I Grabsch
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, P Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,Department of Pathology & Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Jabo B, Selleck MJ, Morgan JW, Lum SS, Bahjri K, Aljehani M, Garberoglio CA, Reeves ME, Namm JP, Solomon NL, Luca F, Yang G, Senthil M. Role of lymph node ratio in selection of adjuvant treatment (chemotherapy vs. chemoradiation) in patients with resected gastric cancer. J Gastrointest Oncol 2018; 9:708-717. [PMID: 30151267 DOI: 10.21037/jgo.2018.05.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Recent randomized controlled trials have failed to show a survival difference between adjuvant chemotherapy (CT) and adjuvant chemoradiotherapy (CRT) in patients with resected gastric cancer (GC). However, a subset of patients with lymph node (LN) positive disease may still benefit from CRT. Additional evidence is needed to help guide physicians in identifying patients in whom CRT should be considered. Our objective was then to compare survival outcomes based on lymph node ratio (LNR) (ratio of metastatic to harvested LNs) for patients with gastric and gastroesophageal junction (GEJ) adenocarcinoma treated with surgery and either CT or CRT. Methods This retrospective population-based study used California Cancer Registry (CCR) data from 2004 to 2013. It included 1,493 patients diagnosed with stage IB-III gastric/GEJ adenocarcinoma and treated with CT or CRT following total or partial gastrectomy. Overall survival (OS) was the primary outcome and GC-specific survival was secondary. Mortality hazards ratios (HR) for these outcomes were computed using propensity score weighted Cox regression models, stratified by LNR strata categories as 0%, 1-9%, 10-25% and >25%. Results Out of 1,493 patients that met inclusion criteria, 462 were treated with CT while 1,031 received CRT. Median follow-up for all subjects was 76 months and median survival was 54 months for CRT and 35 for the CT cohort, P<0.001. Compared to CT, CRT was associated with improved survival among patients with LNR of 10-25% [HR =0.62 (95% CI, 0.46-0.83)] and >25% [HR =0.67 (95% CI, 0.56-0.80)]. Similar findings were observed for GC-specific survival and for analyses limited to patients that had at least 15 LNs evaluated. Conclusions LNR appears to be a simple and readily available measure that could be used in treatment planning for resected GC. CRT offers significant survival advantage over CT among patients with high LN disease burden (LNR of ≥10%).
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Affiliation(s)
- Brice Jabo
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Matthew J Selleck
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
| | - John W Morgan
- School of Public Health, Loma Linda University, Loma Linda, CA, USA.,Surveillance Epidemiology and End Results (SEER) Cancer Registry, Cancer Registry of Greater California and California Cancer Registry, Sacramento, Loma Linda, CA, USA
| | - Sharon S Lum
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
| | - Khaled Bahjri
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Mayada Aljehani
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | | | - Mark E Reeves
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
| | - Jukes P Namm
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
| | | | - Fabrizio Luca
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
| | - Gary Yang
- Department of Radiation Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Maheswari Senthil
- Division of Surgical Oncology, Loma Linda University, Loma Linda, CA, USA
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Brenkman HJF, Tegels JJW, Ruurda JP, Luyer MDP, Kouwenhoven EA, Draaisma WA, van der Peet DL, Wijnhoven BPL, Stoot JHMB, van Hillegersberg R. Factors influencing health-related quality of life after gastrectomy for cancer. Gastric Cancer 2018; 21:524-532. [PMID: 29067597 PMCID: PMC5906484 DOI: 10.1007/s10120-017-0771-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 09/28/2017] [Indexed: 02/07/2023]
Abstract
AIM Insight in health-related quality of life (HRQoL) may improve clinical decision making and inform patients about the long-term effects of gastrectomy. This study aimed to evaluate and identify factors associated with HRQoL after gastrectomy. METHODS This cross-sectional study used prospective databases from seven Dutch centers (2001-2015) including patients who underwent gastrectomy for cancer. Between July 2015 and November 2016, European Organization for Research and Treatment of Cancer HRQoL questionnaires QLQ-C30 and QLQ-STO22 were sent to all surviving patients without recurrence. The QLQ-C30 scores were compared to a Dutch reference population using a one-sample t test. Spearman's rank test was used to correlate time after surgery to HRQoL, and multivariable linear regression was performed to identify factors associated with HRQoL. RESULTS A total of 222 of 274 (81.0%) patients completed the questionnaires. Median follow-up was 29 months (range, 3-171) and 86.9% of patients had a follow-up >1 year. The majority of patients had undergone neoadjuvant treatment (64.4%) and total gastrectomy (52.7%). Minimally invasive gastrectomy (MIG) was performed in 50% of the patients. Compared to the general population, gastrectomy patients scored significantly worse on most functional and symptom scales (p < 0.001) and slightly worse on global HRQoL (78 vs. 74, p = 0.012). Time elapsed since surgery did not correlate with global HRQoL (Spearman's ρ = 0.06, p = 0.384). Distal gastrectomy, neoadjuvant treatment, and MIG were associated with better HRQoL (p < 0.050). CONCLUSION After gastrectomy, patients encounter functional impairments and symptoms, but experience only a slightly impaired global HRQoL. Distal gastrectomy, the ability to receive neoadjuvant treatment, and MIG may be associated with HRQoL benefits.
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Affiliation(s)
- Hylke J. F. Brenkman
- Department of Surgery, Division Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Juul J. W. Tegels
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - Jelle P. Ruurda
- Department of Surgery, Division Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Werner A. Draaisma
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | | | | | - Jan H. M. B. Stoot
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, Division Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - on behalf of the LOGICA Study Group
- Department of Surgery, Division Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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40
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Sharfo AWM, Stieler F, Kupfer O, Heijmen BJM, Dirkx MLP, Breedveld S, Wenz F, Lohr F, Boda-Heggemann J, Buergy D. Automated VMAT planning for postoperative adjuvant treatment of advanced gastric cancer. Radiat Oncol 2018; 13:74. [PMID: 29685166 PMCID: PMC5913894 DOI: 10.1186/s13014-018-1032-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/16/2018] [Indexed: 12/13/2022] Open
Abstract
Background Postoperative/adjuvant radiotherapy of advanced gastric cancer involves a large planning target volume (PTV) with multi-concave shapes which presents a challenge for volumetric modulated arc therapy (VMAT) planning. This study investigates the advantages of automated VMAT planning for this site compared to manual VMAT planning by expert planners. Methods For 20 gastric cancer patients in the postoperative/adjuvant setting, dual-arc VMAT plans were generated using fully automated multi-criterial treatment planning (autoVMAT), and compared to manually generated VMAT plans (manVMAT). Both automated and manual plans were created to deliver a median dose of 45 Gy to the PTV using identical planning and segmentation parameters. Plans were evaluated by two expert radiation oncologists for clinical acceptability. AutoVMAT and manVMAT plans were also compared based on dose-volume histogram (DVH) and predicted normal tissue complication probability (NTCP) analysis. Results Both manVMAT and autoVMAT plans were considered clinically acceptable. Target coverage was similar (manVMAT: 96.6 ± 1.6%, autoVMAT: 97.4 ± 1.0%, p = 0.085). With autoVMAT, median kidney dose was reduced on average by > 25%; (for left kidney from 11.3 ± 2.1 Gy to 8.9 ± 3.5 Gy (p = 0.002); for right kidney from 9.2 ± 2.2 Gy to 6.1 ± 1.3 Gy (p < 0.001)). Median dose to the liver was lower as well (18.8 ± 2.3 Gy vs. 17.1 ± 3.6 Gy, p = 0.048). In addition, Dmax of the spinal cord was significantly reduced (38.3 ± 3.7 Gy vs. 31.6 ± 2.6 Gy, p < 0.001). Substantial improvements in dose conformity and integral dose were achieved with autoVMAT plans (4.2% and 9.1%, respectively; p < 0.001). Due to the better OAR sparing in the autoVMAT plans compared to manVMAT plans, the predicted NTCPs for the left and right kidney and the liver-PTV were significantly reduced by 11.3%, 12.8%, 7%, respectively (p ≤ 0.001). Delivery time and total number of monitor units were increased in autoVMAT plans (from 168 ± 19 s to 207 ± 26 s, p = 0.006) and (from 781 ± 168 MU to 1001 ± 134 MU, p = 0.003), respectively. Conclusions For postoperative/adjuvant radiotherapy of advanced gastric cancer, involving a complex target shape, automated VMAT planning is feasible and can substantially reduce the dose to the kidneys and the liver, without compromising the target dose delivery. Electronic supplementary material The online version of this article (10.1186/s13014-018-1032-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abdul Wahab M Sharfo
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075, EA, Rotterdam, The Netherlands.
| | - Florian Stieler
- Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oskar Kupfer
- Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ben J M Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075, EA, Rotterdam, The Netherlands
| | - Maarten L P Dirkx
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075, EA, Rotterdam, The Netherlands
| | - Sebastiaan Breedveld
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075, EA, Rotterdam, The Netherlands
| | - Frederik Wenz
- Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Lohr
- Unita Operativa di Radioterapia, Dipartimento di Oncologia, Az. Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Judit Boda-Heggemann
- Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Buergy
- Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial. Lancet Oncol 2018; 19:616-628. [PMID: 29650363 DOI: 10.1016/s1470-2045(18)30132-3] [Citation(s) in RCA: 325] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Both perioperative chemotherapy and postoperative chemoradiotherapy improve survival in patients with resectable gastric cancer from Europe and North America. To our knowledge, these treatment strategies have not been investigated in a head to head comparison. We aimed to compare perioperative chemotherapy with preoperative chemotherapy and postoperative chemoradiotherapy in patients with resectable gastric adenocarcinoma. METHODS In this investigator-initiated, open-label, randomised phase 3 trial, we enrolled patients aged 18 years or older who had stage IB- IVA resectable gastric or gastro-oesophageal adenocarcinoma (as defined by the American Joint Committee on Cancer, sixth edition), with a WHO performance status of 0 or 1, and adequate cardiac, bone marrow, liver, and kidney function. Patients were enrolled from 56 hospitals in the Netherlands, Sweden, and Denmark, and were randomly assigned (1:1) with a computerised minimisation programme with a random element to either perioperative chemotherapy (chemotherapy group) or preoperative chemotherapy with postoperative chemoradiotherapy (chemoradiotherapy group). Randomisation was done before patients were given any preoperative chemotherapy treatment and was stratified by histological subtype, tumour localisation, and hospital. Patients and investigators were not masked to treatment allocation. Surgery consisted of a radical resection of the primary tumour and at least a D1+ lymph node dissection. Postoperative treatment started within 4-12 weeks after surgery. Chemotherapy consisted of three preoperative 21-day cycles and three postoperative cycles of intravenous epirubicin (50 mg/m2 on day 1), cisplatin (60 mg/m2 on day 1) or oxaliplatin (130 mg/m2 on day 1), and capecitabine (1000 mg/m2 orally as tablets twice daily for 14 days in combination with epirubicin and cisplatin, or 625 mg/m2 orally as tablets twice daily for 21 days in combination with epirubicin and oxaliplatin), received once every three weeks. Chemoradiotherapy consisted of 45 Gy in 25 fractions of 1·8 Gy, for 5 weeks, five daily fractions per week, combined with capecitabine (575 mg/m2 orally twice daily on radiotherapy days) and cisplatin (20 mg/m2 intravenously on day 1 of each 5 weeks of radiation treatment). The primary endpoint was overall survival, analysed by intention-to-treat. The CRITICS trial is registered at ClinicalTrials.gov, number NCT00407186; EudraCT, number 2006-004130-32; and CKTO, 2006-02. FINDINGS Between Jan 11, 2007, and April 17, 2015, 788 patients were enrolled and randomly assigned to chemotherapy (n=393) or chemoradiotherapy (n=395). After preoperative chemotherapy, 372 (95%) of 393 patients in the chemotherapy group and 369 (93%) of 395 patients in the chemoradiotherapy group proceeded to surgery, with a potentially curative resection done in 310 (79%) of 393 patients in the chemotherapy group and 326 (83%) of 395 in the chemoradiotherapy group. Postoperatively, 233 (59%) of 393 patients started chemotherapy and 245 (62%) of 395 started chemoradiotherapy. At a median follow-up of 61·4 months (IQR 43·3-82·8), median overall survival was 43 months (95% CI 31-57) in the chemotherapy group and 37 months (30-48) in the chemoradiotherapy group (hazard ratio from stratified analysis 1·01 (95% CI 0·84-1·22; p=0·90). After preoperative chemotherapy, in the total safety population of 781 patients (assessed together), there were 368 (47%) grade 3 adverse events; 130 (17%) grade 4 adverse events, and 13 (2%) deaths. Causes of death during preoperative treatment were diarrhoea (n=2), dihydropyrimidine deficiency (n=1), sudden death (n=1), cardiovascular events (n=8), and functional bowel obstruction (n=1). During postoperative treatment, grade 3 and 4 adverse events occurred in 113 (48%) and 22 (9%) of 233 patients in the chemotherapy group, respectively, and in 101 (41%) and ten (4%) of 245 patients in the chemoradiotherapy group, respectively. Non-febrile neutropenia occurred more frequently during postoperative chemotherapy (79 [34%] of 233) than during postoperative chemoradiotherapy (11 [4%] of 245). No deaths were observed during postoperative treatment. INTERPRETATION Postoperative chemoradiotherapy did not improve overall survival compared with postoperative chemotherapy in patients with resectable gastric cancer treated with adequate preoperative chemotherapy and surgery. In view of the poor postoperative patient compliance in both treatment groups, future studies should focus on optimising preoperative treatment strategies. FUNDING Dutch Cancer Society, Dutch Colorectal Cancer Group, and Hoffmann-La Roche.
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Hospital variation and the impact of postoperative complications on the use of perioperative chemo(radio)therapy in resectable gastric cancer. Results from the Dutch Upper GI Cancer Audit. Eur J Surg Oncol 2018; 44:532-538. [DOI: 10.1016/j.ejso.2018.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 10/07/2017] [Accepted: 01/05/2018] [Indexed: 01/13/2023] Open
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van der Kaaij RT, de Rooij MV, van Coevorden F, Voncken FEM, Snaebjornsson P, Boot H, van Sandick JW. Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery. Br J Surg 2018; 105:561-569. [PMID: 29465746 DOI: 10.1002/bjs.10729] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/18/2017] [Accepted: 09/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality-of-care parameters and has been developed recently using population-based data. Its association with long-term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long-term survival after treatment for oesophagogastric cancer. METHODS All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival. RESULTS A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32). CONCLUSION Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome.
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Affiliation(s)
- R T van der Kaaij
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M V de Rooij
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - F van Coevorden
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - F E M Voncken
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - P Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H Boot
- Department of Gastroenterology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Surgical morbidity and mortality after neoadjuvant chemotherapy in the CRITICS gastric cancer trial. Eur J Surg Oncol 2018; 44:613-619. [PMID: 29503129 DOI: 10.1016/j.ejso.2018.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/11/2018] [Accepted: 02/05/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In order to determine the optimal combination of perioperative chemotherapy and chemoradiotherapy for Western patients with advanced resectable gastric cancer, the international multicentre CRITICS trial (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) was initiated. In this trial, patients with resectable gastric cancer were randomised before start of treatment between adjuvant chemotherapy or adjuvant chemoradiotherapy following neoadjuvant chemotherapy plus gastric cancer resection. The purpose of this study was to report on surgical morbidity and mortality in this trial, and to identify factors associated with surgical morbidity. METHODS Patients who underwent a gastrectomy with curative intent were selected. Logistic regression analyses were used to assess risk factors for developing postoperative complications. RESULTS Between 2007 and 2015, 788 patients were included in the CRITICS trial, of whom 636 patients were eligible for current analyses. Complications occurred in 296 patients (47%). Postoperative mortality was 2.2% (n = 14). Complications due to anastomotic leakage was cause of death in 5 patients. Failure to complete preoperative chemotherapy (OR = 2.09, P = 0.004), splenectomy (OR = 2.82, P = 0.012), and male sex (OR = 1.55, P = 0.020) were associated with a greater risk for postoperative complications. Total gastrectomy and oesophago-cardia resection were associated with greater risk for morbidity compared with subtotal gastrectomy (OR = 1.88, P = 0.001 and OR = 1.89, P = 0.038). CONCLUSION Compared to other Western studies, surgical morbidity in the CRITICS trial was slightly higher whereas mortality was low. Complications following anastomotic leakage was the most important factor for postoperative mortality. Important proxies for developing postoperative complications were failure to complete preoperative chemotherapy, splenectomy, male sex, total gastrectomy, and oesophago-cardia resection.
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Radiation Therapy in Gastric Cancer. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_42-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Ikoma N, Blum M, Estrella JS, Das P, Hofstetter WL, Fournier KF, Mansfield P, Ajani JA, Badgwell BD. Evaluation of the American Joint Committee on Cancer 8th edition staging system for gastric cancer patients after preoperative therapy. Gastric Cancer 2018; 21. [PMID: 28643144 PMCID: PMC7703858 DOI: 10.1007/s10120-017-0743-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Joint Committee on Cancer (AJCC) recently released its 8th edition staging system, which created a separate staging system for gastric cancer patients who have undergone preoperative therapy (ypStage). The objective of this retrospective study was to apply the new ypStage to patients who have undergone preoperative therapy and potentially curative gastrectomy. METHODS We collected data from a prospectively maintained institutional database of gastric cancer patients who underwent potentially curative gastrectomy after preoperative therapy (1995-2015). Kaplan-Meier survival estimations and log-rank tests were performed to compare survival. Univariable and multivariable analyses were performed to determine risk factors for overall survival. RESULTS A total of 354 patients met our criteria. Most patients completed planned preoperative therapy (94%; 332/354) and received chemoradiation therapy (75%; 265/354). Although clinical stage (cStage) provided a poor discrimination of survival, postneoadjuvant pathological stage (ypStage) identified significant variation in survival (p < 0.001). Multivariable analysis showed the following factors were associated with survival after adjustment for ypStage: Asian race (HR 0.52; p = 0.028), linitis plastica (HR 1.66; p = 0.037), and R1 resection (HR 1.91; p = 0.016). Survival was not longer in ypT0N0 patients than in ypStage I patients (HR 1.29; p = 0.377). CONCLUSIONS The AJCC 8th edition staging system for gastric cancer demonstrated reasonable survival prediction by ypStage, but not cStage, in patients who had undergone preoperative therapy. ypT0N0 patients, although not defined in the 8th edition, may be considered for inclusion in the ypStage I group.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S. Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L. Hofstetter
- Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F. Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX 77030, USA
| | - Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 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
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Cheng X, Lu Y. A review of capecitabine-based adjuvant therapy for gastric cancer in the Chinese population. Future Oncol 2017; 14:771-779. [PMID: 29252007 DOI: 10.2217/fon-2017-0558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In China, the treatment of locally advanced gastric cancer (AGC) faces unique challenges. Chinese patients may harbor more unfavorable prognostic factors than western populations and, in comparison with other Asian populations such as Japan and South Korea, a higher proportion of Chinese patients are diagnosed with AGC due to inadequate early diagnosis of the malignancy. This review summarizes the use of combination chemotherapy regimens with capecitabine as adjuvant therapy in the Chinese AGC population. Based on the available domestic data in China, the review concludes that capecitabine-based chemotherapy regimens, especially XELOX, offer good efficacy following radical gastrectomy in patients with AGC, with a low incidence of adverse events, acceptable tolerance, greater patient convenience and a lower overall cost than other regimens.
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Affiliation(s)
- Xiangdong Cheng
- Department of Gastrointestinal Surgery, Zhejiang Provincial Hospital of TCM, Hangzhou, Zhejiang, PR China
| | - Yi Lu
- Medical Department, Shanghai Roche Pharmaceutical Company, Shanghai, PR China
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Predictors and Prognostic Implications of Perioperative Chemotherapy Completion in Gastric Cancer. J Gastrointest Surg 2017; 21:1984-1992. [PMID: 28963709 DOI: 10.1007/s11605-017-3594-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative chemotherapy in gastric cancer is increasingly used since the "MAGIC" trial, while clinical practice data outside of trials remain limited. We sought to evaluate the predictors and prognostic implications of perioperative chemotherapy completion in patients undergoing curative-intent gastrectomy across multiple US institutions. METHODS Patients who underwent curative-intent resection of gastric adenocarcinoma between 2000 and 2012 in eight institutions of the US Gastric Cancer Collaborative were identified. Patients who received preoperative chemotherapy were included, while those who died within 90 days or with unknown adjuvant chemotherapy status were excluded. Predictors of chemotherapy completion and survival were identified using multivariable logistic regression and Cox proportional hazards. RESULTS One hundred sixty three patients were included (median age 63.3, 36.8% female). The postoperative component of perioperative chemotherapy was administered in 112 (68.7%) patients. Factors independently associated with receipt of adjuvant chemotherapy were younger age (odds ratio (OR) 2.73, P = 0.03), T3 tumors (OR 14.3, P = 0.04), lymph node metastasis (OR 5.82, P = 0.03), and D2 lymphadenectomy (OR 4.12, P = 0.007), and, inversely, postoperative complications (OR 0.25, P = 0.008). Median overall survival (OS) was 25.1 months and 5-year OS was 36.5%. Predictors of OS were preexisting cardiac disease (hazard ratio (HR) 2.7, 95% CI 1.13-6.46), concurrent splenectomy (HR 4.11, 95% CI 1.68-10.0), tumor stage (reference stage I; stage II HR 2.62; 95% CI 0.99-6.94; stage III HR 4.86, 95% CI 1.81-13.02), and D2 lymphadenectomy (HR 0.43, 95% CI 0.19-0.95). After accounting for these factors, adjuvant chemotherapy administration was associated with improved OS (HR 0.33, 95% CI 0.14-0.82). CONCLUSION Completion of perioperative chemotherapy was successful in two thirds of patients with gastric cancer and was independently associated with improved survival.
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Bringeland EA, Wasmuth HH, Grønbech JE. Perioperative chemotherapy for resectable gastric cancer - what is the evidence? Scand J Gastroenterol 2017; 52:647-653. [PMID: 28276825 DOI: 10.1080/00365521.2017.1293727] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The UK MAGIC trial published in 2006 was the first RCT to identify improved long-term survival rates using preoperative chemotherapy for resectable gastric or gastroesophageal cancer. Overnight, the treatment regimen impacted European guidelines. However, the majority of patients underwent limited lymph node dissection, and analyses of the rates of curative resection, downsizing and downstaging were not by intention to treat, rightfully raising concerns about their validity. For the subset of true gastric cancers, meta-analyses may even question the claims of improved long-term survival rates by present-day regimens. A rhetorical question can be posed as to whether downstaging and improved survival rates by preoperative (radio)-chemotherapy for cancers of the distal esophagus or gastric cardia, has confounded our conclusions on the (lack of) effect of present-day regimens of perioperative chemotherapy for true gastric cancers, let alone in a situation with proper lymph node dissection. At present, a plea can be made to move one step back and revert to an RCT with a surgery alone arm. Inclusion criteria and analyses of future RCTs must stratify on tumor location and the Lauren type and embrace the newly developed scheme of sub-classification of gastric cancers based on extensive molecular profiling as reported in the seminal Cancer Genome Atlas Study.
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Affiliation(s)
- Erling A Bringeland
- a Department of Gastrointestinal Surgery , St. Olavs Hospital, Trondheim University Hospital , Trondheim , Norway
| | - Hans H Wasmuth
- a Department of Gastrointestinal Surgery , St. Olavs Hospital, Trondheim University Hospital , Trondheim , Norway
| | - Jon E Grønbech
- a Department of Gastrointestinal Surgery , St. Olavs Hospital, Trondheim University Hospital , Trondheim , Norway.,b Department of Cancer Research and Molecular Medicine , Norwegian University of Science and Technology , Trondheim , Norway
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Elimova E, Slack RS, Chen HC, Planjery V, Shiozaki H, Shimodaira Y, Charalampakis N, Lin Q, Harada K, Wadhwa R, Estrella JS, Kaya DM, Sagebiel T, Lee JH, Weston B, Bhutani M, Murphy MB, Matamoros A, Minsky B, Das P, Mansfield PF, Badgwell BD, Ajani JA. Patterns of relapse in patients with localized gastric adenocarcinoma who had surgery with or without adjunctive therapy: costs and effectiveness of surveillance. Oncotarget 2017; 8:81430-81440. [PMID: 29113402 PMCID: PMC5655297 DOI: 10.18632/oncotarget.19226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 06/02/2017] [Indexed: 02/06/2023] Open
Abstract
PURPOSE After therapy of localized gastric adenocarcinoma (GAC) patients, the costs of surveillance, relapse patterns, and possibility of salvage are unknown. MATERIALS AND METHODS We identified 246 patients, who after having a negative peritoneal staging, received therapy (any therapy which included surgery) and were surveyed (every 3-6 months in the first 3 years, then yearly; ∼10 CTs and ∼7 endoscopies per patient). We used the 2016 Medicare dollars reimbursed as the "costs" for surveillance. RESULTS Common features were: Caucasians (57%), men (60%), poorly differentiated histology (76%), preoperative chemotherapy (74%), preoperative chemoradiation (59%), and had surgery (100%). At a median follow-up of 3.7 years (range, 0.1 to 18.3), the median overall survival (OS) was 9.2 years (95% CI, 6.0 to 11.2). Tumor grade (p = 0.02), p/yp stage (p < 0.001), % residual GAC (p = 0.05), the R status (p = 0.01), total gastrectomy (p = 0.001), and relapse type (p = 0.02) were associated with OS. Relapse occurred in 79 (32%) patients (only 8% were local-regional) and 90% occurred within 36 months of surgery. P/yp stage (p < 0.001) and total gastrectomy (p = 0.01) were independent prognosticators for OS in the multivariate analysis. Only 1 relapsed patient had successful salvage therapy. The estimated reimbursement for imaging studies and endoscopies was $1,761,221.91 (marked underestimation of actual costs). CONCLUSIONS The median OS of localized GAC patients was excellent with infrequent local-regional relapses. Rigorous surveillance had a low yield and high "costs". Our data suggest that less frequent surveillance intervals and limiting expensive investigations to symptomatic patients may be warranted.
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Affiliation(s)
- Elena Elimova
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Rebecca S. Slack
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Venkatram Planjery
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Hironori Shiozaki
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Yusuke Shimodaira
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nick Charalampakis
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Quan Lin
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Roopma Wadhwa
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S. Estrella
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Dilsa Mizrak Kaya
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Tara Sagebiel
- Department of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H. Lee
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Brian Weston
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Manoop Bhutani
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Aurelio Matamoros
- Department of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Bruce Minsky
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Paul F. Mansfield
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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