The significance of a nineteenth century definition in the era of genomics: linitis plastica

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes

BACKGROUND

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population.

PATIENTS AND METHODS

Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated.

RESULTS

Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months.

CONCLUSIONS

Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

Borrmann Type IV Gastric Cancer: Computed Tomography Features and Corresponding Pathological Findings

OBJECTIVE

We aimed to analyze the association between computed tomography (CT) features and the corresponding pathological findings in Borrmann type IV (BT-4) gastric cancers and explore the pathological basis of the characteristic CT features.

METHODS

This retrospective study included 84 patients with BT-4 gastric cancers who underwent contrast-enhanced CT and surgical resection. Preoperative CT features were evaluated, including the major location, range, circumferential invasion, perigastric fat infiltration, enlarged lymph nodes, layered enhancement, degree of enhancement, and peak enhanced phase. Postoperative pathological findings were also recorded. Differences in CT features according to different World Health Organization types, surgical margin, adjacent organ invasion, and peritoneal status were assessed using the χ 2 or Fisher exact test (n < 5).

RESULTS

The most common World Health Organization type of BT-4 gastric cancer was poorly cohesive carcinoma (65.5%), which tended to show circumferential invasion, fewer enlarged lymph nodes, and layered enhancement. Although 82 patients with BT-4 gastric cancer (97.6%) had positive lymph nodes, only 26 (31.0%) had enlarged lymph nodes. Lesions originating from the gastroesophageal junction had a higher rate of positive margins ( P < 0.05). Adjacent organ invasion was more likely to occur in lesions with perigastric fat infiltration ( P < 0.05). Patients with circumferential invasion tended to show peritoneal metastasis ( P < 0.05).

CONCLUSIONS

The characteristic CT features of BT-4 gastric cancer may be attributed to the corresponding pathological findings. Recognizing the association between CT features and pathological findings may help evaluate the aggressiveness of BT-4 gastric cancers.

Molecular Classifications in Gastric Cancer: A Call for Interdisciplinary Collaboration

Gastric cancer (GC) is a heterogeneous disease, often diagnosed at advanced stages, with a 5-year survival rate of approximately 20%. Despite notable technological advancements in cancer research over the past decades, their impact on GC management and outcomes has been limited. Numerous molecular alterations have been identified in GC, leading to various molecular classifications, such as those developed by The Cancer Genome Atlas (TCGA) and the Asian Cancer Research Group (ACRG). Other authors have proposed alternative perspectives, including immune, proteomic, or epigenetic-based classifications. However, molecular stratification has not yet transitioned into clinical practice for GC, and little attention has been paid to alternative molecular classifications. In this review, we explore diverse molecular classifications in GC from a practical point of view, emphasizing their relationships with clinicopathological factors, prognosis, and therapeutic approaches. We have focused on classifications beyond those of TCGA and the ACRG, which have been less extensively reviewed previously. Additionally, we discuss the challenges that must be overcome to ensure their impact on patient treatment and prognosis. This review aims to serve as a practical framework to understand the molecular landscape of GC, facilitate the development of consensus molecular categories, and guide the design of innovative molecular studies in the field.

The Genomic Signatures of Linitis Plastica Signal the Entrance into a New Era: Novel Approaches for Diagnosis and Treatment

Linitis Plastica (LP) is a rare and aggressive tumor with a distinctive development pattern, leading to the infiltration of the gastric wall, the thickening of the gastric folds and a "leather bottle appearance". LP is an extremely heterogeneous tumor caused by mutations in oncogenic and tumor suppressive genes, as well as molecular pathways, along with mutations in stromal cells and proteins related to tight junctions. Elucidating the molecular background of tumorigenesis and clarifying the correlation between cancerous cells and stromal cells are crucial steps toward discovering novel diagnostic methods, biomarkers and therapeutic targets/agents. Surgery plays a pivotal role in LP management, serving both as a palliative and curative procedure. In this comprehensive review, we aim to present all recent data on the molecular background of LP and the novel approaches to its management.

Thrombotic microangiopathy and disseminated intravascular coagulation in a patient with carcinomatosis of the bone marrow due to gastric adenocarcinoma: Case report

Carcinomatosis of the bone marrow is a rare clinical condition characterized by diffuse tumor infiltration of the bone marrow accompanied by hematological abnormalities, including thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC). In patients with gastric carcinoma, this association is infrequent. Below we present a case of a 19-year-old female patient with no known pathological history who presented with upper digestive tract bleeding. Upon examination, anemia and thrombocytopenia were documented, with schistocytes in the peripheral blood smear and prolonged coagulation times. Endoscopic studies indicated a lesion in the Borrmann IV gastric body, and the bone marrow biopsy showed the presence of signet ring cells. Because there was no possibility of systemic therapy, the patient died during hospitalization. This case contributes to the medical literature by describing an unusual presentation of a very frequent pathology.

Analysis of genomic and immune intratumor heterogeneity in linitis plastica via multiregional exome and T-cell receptor sequencing

The molecular landscape and the intratumor heterogeneity (ITH) architecture of gastric linitis plastica (LP) are poorly understood. We performed whole-exome sequencing (WES) and T-cell receptor (TCR) sequencing on 40 tumor regions from four LP patients. The landscape and ITH at the genomic and immunological levels in LP tumors were compared with multiple cancers that have previously been reported. The lymphocyte infiltration was further assessed by immunohistochemistry (IHC) in LP tumors. In total, we identified 6339 non-silent mutations from multi-samples, with a median tumor mutation burden (TMB) of 3.30 mutations per Mb, comparable to gastric adenocarcinoma from the Cancer Genome Atlas (TCGA) cohort (P = 0.53). An extremely high level of genomic ITH was observed, with only 12.42%, 5.37%, 5.35%, and 30.67% of mutations detectable across 10 regions within the same tumors of each patient, respectively. TCR sequencing revealed that TCR clonality was substantially lower in LP than in multi-cancers. IHC using antibodies against CD4, CD8, and PD-L1 demonstrated scant T-cell infiltration in the four LP tumors. Furthermore, profound TCR ITH was observed in all LP tumors, with no T-cell clones shared across tumor regions in any of the patients, while over 94% of T-cell clones were restricted to individual tumor regions. The Morisita overlap index (MOI) ranged from 0.21 to 0.66 among multi-regions within the same tumors, significantly lower than that of lung cancer (P = 0.002). Our results show that LP harbored extremely high genomic and TCR ITH and suppressed T-cell infiltration, suggesting a potential contribution to the frequent recurrence and poor therapeutic response of this adenocarcinoma.

Primary gastric amyloidosis associated with linitis plastica and delayed progression to systemic amyloidosis and multiple myeloma

We report the case of a woman in her 50s who underwent, 5 years prior, a total gastrectomy after neoadjuvant chemotherapy for diffuse-type gastric cancer diagnosed during a workup for isolated gastric primary light chain (AL) amyloidosis. At the time of diagnosis, immunoglobulins light chain measurements and bone marrow biopsy were performed to rule out multiple myeloma and came back normal. Three years later, the patient developed systemic amyloidosis involving the heart and the lungs, after which she developed multiple myeloma. Isolated amyloid deposits in the stomach are a rare finding. While AL amyloidosis is frequently found in concomitance with multiple myeloma, late progression of primary AL amyloidosis to systemic amyloidosis and multiple myeloma is uncommon.

A Unique Presentation of Jaundice

Obstructive jaundice has many common etiologies, which might cause us to overlook diagnoses that are far worse. This is a case of a Hispanic male who presented with jaundice and worsening liver function. During his hospitalization, he was erroneously diagnosed before being diagnosed with gastric cancer. Even though biliary obstruction has many common etiologies, there are cases that can't be explained, which warrants further investigation such as malignant etiologies.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Linitis plastica of the rectum secondary to prostate carcinoma

Linitis plastica is an intramural carcinoma that may occur in any hollow organ. Rectal linitis plastica (RLP) is a morphological variant cancer that may occur as a primary form of cancer or secondary as a metastasis of a primary malignancy. We report the case of a man in his 70s with RLP secondary to prostate carcinoma who was initially suspected to have an obstructing rectal adenocarcinoma. During colonoscopy a segment of cobblestone mucosa was seen in the distal rectum. Subsequent imaging showed enhancement of all wall-layers of the rectum and diffuse retroperitoneal fat infiltration with traction on both ureters. A prostate-specific membrane antigen scan confirmed RLP secondary to a prostate carcinoma mimicking the clinical and radiological signs of an obstructing rectal carcinoma with retroperitoneal fibrosis.This case emphasises the possible pitfalls in the diagnosis of RLP and the importance of advanced imaging techniques, such as MRI, as well as appropriate histological samples. The patient underwent androgen deprivation therapy to which RLP responded well and neither systemic chemotherapy or surgery was necessary.

Gastric linitis plastica with autoimmune pancreatitis diagnosed by an endoscopic ultrasonography-guided fine-needle biopsy: A case report

BACKGROUND

Gastric linitis plastica (GLP) is a subset of gastric cancer with a poor prognosis. It is difficult to obtain a definitive diagnosis by endoscopic mucosal biopsies, and the usefulness of an endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) for GLP has been recently reported. Meanwhile, autoimmune diseases are occasionally known to coexist with malignant tumors as paraneoplastic syndrome. We herein report the usefulness of an EUS-FNB for detecting GLP and the possibility of paraneoplastic syndrome coexisting with GLP.

CASE SUMMARY

An 81-year-old man was admitted to our hospital for a 1-mo history of epigastric pain that increased after eating. His laboratory data revealed high levels of serum carbohydrate antigen 19-9 and immunoglobulin-G4. Endoscopic examinations showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation, suggesting GLP. Computed tomography showed the thickened gastric wall, the diffuse enlargement of the pancreas, and the peripancreatic rim, which suggested autoimmune pancreatitis (AIP) coexisting with GLP. Because the pathological findings of the endoscopic biopsy showed no malignancy, he underwent an EUS-FNB and was diagnosed with GLP. He received chemotherapy for unresectable gastric cancer due to peritoneal metastasis, after which both the gastric wall thickening and diffuse enlargement of the pancreas were improved.

CONCLUSION

An EUS-FNB for GLP with a negative endoscopic biopsy is useful, and AIP may develop as a paraneoplastic syndrome.

pCLE detects mucosal neoplastic vascular pattern in gastric linitis plastica

Linitis plastica (LP) is a very aggressive and rare carcinoma with a scirrhous stroma that affects the submucosal and muscular layers of the stomach even without mucosal alterations. Lack of timely diagnosis is a crucial problem related to its prognosis and treatment. In this study, we investigated the LP-associated vascular pattern as a possible means to improve the diagnosis of these patients. During standard endoscopy, mucosal architecture, tortuosity and enlargement of vessels, as well as the presence of vascular leakage and efficiency of the blood flow were assessed in six LP patients using probe-based Confocal Laser Endomicroscopy (pCLE). In all LP patients, we detected abnormal changes in vasculature. The aberrant features of the vascular network were common to all LP patients examined and consisted of vessel enlargement, tortuosity, and leakage associated with the affected submucosal layer. This is the first study to highlight the presence of marked vascularization associated with LP, characterized by the presence of abnormal and non-functional vessels, similar to what is observed in neoplastic tissues. Therefore, the analysis of LP by pCLE may provide a new endoscopic approach and strategy to better define these patients.

Endoscopic ultrasound guided fine needle biopsy in patients with suspected gastric linitis plastica

BACKGROUND

Gastric linitis plastica (GLP) is a diffuse infiltrating type of gastric adenocarcinoma. It is associated with a poor prognosis and a five-year survival of 3-10%. The infiltrating profile of this tumor explains the low yield of the superficial mucosal biospies. The objective of this study was to investigate the role of endoscopic ultrasound-fine needle biopsy (EUS-FNB) in the diagnosis of GLP.

METHODS

We performed a retrospective analysis including all patients who had an EUS-FNB, at a tertiary referral center, over the last 3 years. The primary outcome was the sensitivity of EUS-FNB in patients with suspected GLP.

RESULTS

Between January 2017 and December 2020, 34 patients had an EUS-FNB for suspected GLP. Ten patients had a diagnostic of GLP. This diagnosis was obtained by EUS-FNB in 90% (9/10) of the cases. Eight patients had at least one previous esophagogastroduodenoscopy (EGD) with negative mucosal biopsies. Gastric EUS-FNB helped diagnose other serious conditions in 47% (16/34) of cases with inconclusive mucosal biopsies.

CONCLUSION

Gastric EUS-FNB in patients with suspected GLP and normal endoscopic mucosal biopsies may lead to a positive diagnosis of GLP in 90% of cases without notable adverse events. This technique should be considered as a second step in the setting of suspicion of GLP after inconclusive mucosal biopsies.

Prognosis of poorly cohesive gastric cancer after complete cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CYTO-CHIP study)

BACKGROUND

The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC.

METHODS

All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed.

RESULTS

In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P < 0.001). In multivariable analyses, PCC (hazard ratio (HR) 1.51, 95 per cent c.i. 1.01 to 2.25; P = 0.044) was associated with poorer OS, as were pN3, Peritoneal Cancer Index (PCI), and resection with a completeness of cytoreduction score of 1, whereas HIPEC was associated with improved OS (HR 0.52; P < 0.001). The benefit of CRS-HIPEC over CRS alone was consistent, irrespective of histology, with a median OS of 16.7 versus 11.3 months (HR 0.60, 0.39 to 0.92; P = 0.018) in the PCC group, and 34.5 versus 14.3 months (HR 0.43, 0.25 to 0.75; P = 0.003) in the non-PCC group. Non-PCC and HIPEC were independently associated with improved recurrence-free survival and fewer peritoneal recurrences. In patients who underwent HIPEC, PCI values of below 7 and less than 13 were predictive of OS in PCC and non-PCC populations respectively.

CONCLUSION

In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

Development of a Quantitative Diagnostic Criterion for Gastric Linitis Plastica: Findings From a Large Single-Institutional Study

Gastric linitis plastica (GLP) is a descriptive term but lacks a quantitative definition. Several relatively quantitative criteria had been proposed, such as tumor involving a limit of one-third or two-thirds of the gastric surface. However, these criteria needed doctors to subjectively judge tumor infiltration area, which made diagnosis difficult to be objective and reproducible. This study aimed to propose a quantitative diagnostic criterion for distinguishing GLP. We performed a retrospective cohort study of 2,907 patients with Borrmann III and IV gastric cancer (GC) who underwent gastrectomy between 2011 and 2018 in our center. The Kaplan–Meier curves showed that patients with an observed tumor size more than 8 cm had obviously lower overall survival (OS) and disease-free survival (DFS) rates than those with a size less than 8 cm(p < 0.001; p < 0.001). However, there was no significantly different prognosis of patients with tumor sizes between more than 8 cm and more than 10 cm (p = 0.248; p = 0.534). Moreover, patients with tumor sizes greater than 8 cm more presented with advanced stage and had extremely poor 3-year OS and DFS (31.4%; 29.3%), with a stronger propensity toward peritoneal metastasis. Therefore, we considered patients’ observed tumor size more than 8 cm as a critical value for distinguishing the prognosis of Borrmann III and IV GC. Furthermore, we proposed an observed tumor size more than 8 cm as a quantitative diagnostic criterion for GLP on the premise of satisfying the originally descriptive and pathological definition regardless of Borrmann type.

Diagnostic Value of EUS-Guided Fine-Needle Aspiration Biopsy for Gastric Linitis Plastica with Negative Endoscopic Biopsy

Due to the tendency of gastric linitis plastica (GLP) to cause extensive submucosal infiltration, a superficial endoscopic biopsy sometimes yields no evidence of malignancy, hindering definite diagnosis. The present study was a single-center retrospective analysis of 54 consecutive patients diagnosed with GLP between 2016 and 2020 to evaluate EUS-guided fine-needle aspiration (EUS-FNA) biopsy outcomes in patients with negative endoscopic biopsy findings. A pathological GLP diagnosis was achieved by endoscopic biopsy in 40 patients (74.1%). EUS-FNA biopsy with a 22-gauge needle was performed in 13 of the remaining 14 patients, and GLP diagnosis was confirmed in 10 patients, with a median of three needle passes. The remaining four patients were laparoscopically diagnosed with GLP. The diagnostic ability of EUS-FNA biopsy for GLP was 76.9%, and EUS-FNA biopsy contributed to GLP diagnosis in 18.5% (10/54) of all cases. None of the 13 patients exhibited EUS-FNA biopsy-related adverse events. Univariable and multivariable analyses revealed an absence of superficial ulcerations as a predictor of false-negative endoscopic biopsy findings in patients with GLP. These results suggest EUS-FNA biopsy as a minimally invasive and safe alternative diagnostic modality for GLP in cases where conventional endoscopic biopsy fails to verify malignancy, although prospective studies with larger cohorts are warranted to confirm these findings.

Comparative Outcomes of Laparoscopic Gastrectomy and Open Gastrectomy for Scirrhous Gastric Cancer: A Multicenter Retrospective Cohort Study

Objective

A multicenter retrospective cohort study was performed to compare the outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for scirrhous gastric cancer (GC) as a unique subtype also known as type 4 gastric cancer or linitis plastica.

Background

Although data on the efficacy and safety of LG as an alternative to OG are emerging, the applicability of LG to scirrhous GC remains unclear.

Methods

Patients with clinical type 4 GC undergoing gastrectomy at 13 hospitals from 2005 to 2015 were retrospectively reviewed. As the primary endpoint, we compared overall survival (OS) between the LG and OG groups. To adjust for confounding factors, we used multivariate Cox regression analysis for the main analyses and propensity-score matching for sensitivity analysis. Short-term outcomes and recurrence-free survival were also compared.

Results

A total of 288 patients (LG, 62; OG, 226) were included in the main analysis. Postoperative complications occurred in 25.8% and 30.1%, respectively (P = 0.44). No significant difference in recurrence-free survival was observed (P = 0.72). The 5-year OS rates were 32.4% and 31.6% in the LG and OG groups, respectively (P = 0.60). The hazard ratio (LG/OG) for OS was 0.98 (95% confidence interval [CI], 0.65-1.43) in the multivariate regression analysis. In the sensitivity analyses after propensity-score matching, the hazard ratio for OS was 0.92 (95% CI, 0.58-1.45).

Conclusions

Considering the hazard ratios and 95% CIs for OS, LG for scirrhous GC was not associated with worse survival than that for OG.

Primary gastric Ewing sarcoma/primitive neuroectodermal tumor

A rare and highly malignant small round cell tumor, Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) usually occurs in the pelvis, long-axis bones, and femur. In contrast, extraosseous ES is more often found in the paraspinal region, limbs, and retroperitoneum, but is extremely rare in the stomach. We report a case of a 55-year-old woman who presented with fatigue, fever, and black stool. Preoperative computed tomography (CT) imaging showed a large ulcerative lesion of approximately 5.5 × 5.0 cm in the stomach and irregular thickening of the ulcer wall. Upper endoscopy revealed a large, irregular ulcer in the posterior wall of the stomach. Histopathological examination suggested that the mass with the largest diameter (7.5 cm) was ES. Immunohistochemistry indicated positivity for CD99. Enhanced CT of the whole body was performed but no definite masses were found in other organs, and the patient was diagnosed with primary gastric ES. The patient underwent radical distal gastrectomy with Roux-en-Y gastrojejunostomy, but refused chemoradiotherapy.

Scirrhous carcinoma: A previously undescribed tumor of the oral cavity

This patient was found to have a scirrhous carcinoma with extensive perineural invasion and without any evidence of minor salivary gland carcinoma. To our knowledge, this is the first report of isolated scirrhous carcinoma of the oral cavity. Treatment was surgery and adjuvant chemoradiation, and there was complete disease response.

Prognosis prediction model for a special entity of gastric cancer, linitis plastica

Background

Gastric linitis plastica (GLP) is characteristic by its poor prognosis and highly aggressive characteristics compared with other types of gastric cancer (GC). However, the guidelines have not yet been distinguished between GLP and non-GLP.

Methods

A total of 342 eligible patients with GLP identified in the Surveillance, Epidemiology, and End Results (SEER) dataset were randomly divided into training set (n=298) and validation set (n=153). A nomogram would be developed with the constructed predicting model based on the training cohort's data, and the validation cohort would be used to validate the model. Principal component analysis (PCA) was used to evaluate the differences between groups. Cox regression and LASSO (least absolute shrinkage and selection operator) were used to construct the models. Calibration curve, time-dependent receiver operating characteristic (ROC) curve, concordance index (C-index) and decision curve analysis (DCA) were used to evaluate the predicting performance. Restricted mean survival time (RMST) was used to analyze the curative effect of adjuvant therapy.

Results

For patients in training cohort, univariable and multivariable Cox analyses showed that age, examined lymph nodes (LN.E), positive lymph nodes (LN.P), lesion size, combined resection, and radiotherapy are independent prognostic factors for overall survival (OS), while chemotherapy can not meet the proportional hazards (PHs) assumption; age, race, lesion size, LN.E, LN.P, combined resection and marital status are independent prognostic factors for cancer-specific survival (CSS). The C-index of the nomogram was 0.678 [95% confidence interval (CI), 0.660-0.696] and 0.673 (95% CI, 0.630-0.716) in the training and validation cohort, respectively. Meanwhile, the C-index of the CSS nomogram was 0.671 (95% CI, 0.653-0.699) and 0.650 (95% CI, 0.601-0.691) in the training and validation cohort for CSS, respectively. Furthermore, the nomogram was well calibrated with satisfactory consistency. RMST analysis further determined that chemotherapy and radiotherapy might be beneficial for improving 1- and 3-year OS and CSS, but not the 5-year CSS.

Conclusions

We developed nomograms to help predict individualized prognosis for GLP patients. The new model might help guide treatment strategies for patients with GLP.

Preoperative T2-weighted MR imaging texture analysis of gastric cancer: prediction of TNM stages

PURPOSE

To explore the capability of algorithms to build multivariate models integrating morphological and texture features derived from preoperative T₂-weighted magnetic resonance (MR) images of gastric cancer (GC) to evaluate tumor- (T), node- (N), and metastasis- (M) stages.

METHODS

A total of 80 patients at our hospital who underwent abdominal MR imaging and were diagnosed with GC from December 2011 to November 2016 were retrospectively included. Texture features were calculated using T₂-weighted images with a manual region of interest. Morphological characteristics were also evaluated. Classifiers and regression analyses were used to build multivariate models. Receiver operating characteristic (ROC) curve analysis was performed to assess diagnostic efficacy.

RESULTS

There were 8, 10, and 3 texture parameters that showed significant differences in GCs at different overall (I-II vs. III-IV), T (1-2 vs. 3-4), and N (- vs. +) stages (all p < 0.05), respectively. Mild thickening was more common in stages I-II, T1-2, and N- GCs (all p < 0.05). An irregular outer contour was more commonly observed in stages III-IV (p = 0.001) and T3-4 (p = 0.001) GCs. T3-4 and N+ GCs tended to be thickening type lesions (p = 0.005 and 0.032, respectively). The multivariate models using the naive bayes algorithm showed the highest diagnostic efficacy in predicting T and N stages (area under the ROC curves [AUC] = 0.900 and 0.863, respectively), and the model based on regression analysis had the best predictive performance in overall staging (AUC = 0.839).

CONCLUSION

Multivariate models combining morphological characteristics with texture parameters based on machine learning algorithms were able to improve diagnostic efficacy in predicting the overall, T, and N stages of GCs.

Is there still a place for conventional histopathology in the age of molecular medicine? Laurén classification, inflammatory infiltration and other current topics in gastric cancer diagnosis and prognosis

Gastric cancer (GC) is the fifth most common cancer and the third cause of cancer-related deaths worldwide. In western countries, more than half of GC patients are diagnosed at advanced stages and 5-year survival rates range between 20-30%. The only curative treatment is surgery, and despite recent advances in oncological therapies, GC prognosis is still poor. The main prognostic tool for patient categorization and treatment selection is the TNM classification, but its limitations are being increasingly recognized. Early recurrences may occur in early-stage disease, and patients at the same stage show heterogeneous outcomes. Thus, there is a need to improve GC stratification and to identify new prognostic factors, which may allow us to select drug-susceptible populations, refine patient grouping for clinical trials and discover new therapeutic targets. Molecular classifications have been developed, but they have not been translated to the clinical practice. On the other hand, histological assessment is cheap and widely available, and it is still a mainstay in the era of molecular medicine. Furthermore, histological features are acquiring new roles as reflectors of the genotype-phenotype correlation, and their potential impact on patient management is currently being analyzed. The aim of this literature review is to provide a modern overview of the histological assessment of GC. In this study, we discuss recent topics on the histological diagnosis of GC, focusing on the current role of Laurén classification and the potential value of new histological features in GC, such as inflammatory infiltration and tumor budding.

Limited Clinical Significance of Splenectomy and Splenic Hilar Lymph Node Dissection for Type 4 Gastric Cancer

Purpose

Type 4 gastric cancer (GC) has a very poor prognosis even after curative resection, and the survival benefit of splenectomy for splenic hilar lymph node (LN; #10) dissection in type 4 GC remains equivocal. This study aimed to clarify the clinical significance of splenectomy for #10 dissection in patients with type 4 GC.

Materials and Methods

The data of a total of 56 patients with type 4 GC who underwent total gastrectomy with splenectomy were retrospectively analyzed. Postoperative morbidity, state of LN metastasis, survival outcomes, and therapeutic value index (TVI) of each LN station were evaluated. TVI was calculated by multiplying the incidence of LN metastasis at each nodal station and the 5-year overall survival (OS) of patients who had metastasis to each node.

Results

Overall, the postoperative morbidity rate was 28.6%, and the incidence of #10 metastasis in the patients was 28.6%. The 5-year OS rate for all patients was 29.9%, and most patients developed peritoneal recurrence. Moreover, the 5-year OS rates with and without #10 metastasis were 6.7% and 39.1% (median survival time, 20.4 vs. 46.0 months; P=0.006). The TVI of #10 was as low as 1.92.

Conclusions

The clinical significance of splenectomy in the dissection of #10 for type 4 GC is limited and splenectomy for splenic hilar dissection alone should be omitted.

Endoscopic ultrasound efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study

BACKGROUND

Endoscopic ultrasound (EUS) is a key imaging technique in gastric cancer (GC). The aim of this study was to evaluate the performance of EUS in the staging of parietal and lymph node involvement in linitis plastica (LP) compared to "classical" GC.

METHODS

A retrospective multicentric French study was conducted on patients with no metastatic LP and operated by gastrectomy. A 2/1 matching based on pTNM stage and center was performed with GC.

RESULTS

Forty-three patients were included, sixteen patients in the LP group and 27 in the control group. Sensitivity and specificity of EUS for diagnosis of T3-T4 parietal invasion were 77% and 100% respectively in the LP group and 89% and 56% respectively in the control group. Sensitivity and specificity of EUS for diagnosis of lymph node involvement were 73% and 80%, respectively in the LP group and 88% and 50%, respectively in the control group. Patients from LP group had significantly more advanced histological lesion, and frequent undiagnosed peritoneal carcinomatosis.

CONCLUSIONS

This study evaluated for the first time in a European population, the preoperative EUS performance in LP. Our study identified a similar sensitivity and specificity of the EUS in LP compared to "classical" GC paving for a broader use of EUS in preoperative settings.

Targeted therapy for upper gastrointestinal tract cancer: current and future prospects

Gastric and oesophageal carcinoma remain major causes of worldwide mortality and morbidity. Despite incredible progress in understanding tumour biology, few targeted treatment options have proved effective in prolonging survival, and adjuvant therapy is largely interchangeable in these carcinomas. Through large-scale sequencing by the Cancer Genome Atlas and the Asian Cancer Research Group, numerous potential molecular targets have been discovered. Of the approved targeted therapies for gastric and oesophageal cancer, pathologists play a role in patient selection for the majority of them. Trastuzumab has been approved as a first-line therapy in conjunction with standard treatment in adenocarcinomas with either 3+ HER2/neu expression by immunohistochemistry or ERBB2 amplification by FISH. PD-L1 immunohistochemistry showing a combined positive score of 1 or greater qualifies patients for third-line pembrolizumab therapy, and identification of microsatellite instability-high carcinomas may qualify patients for second-line pembrolizumab. Ramucirumab, targeting VEGFR2, has also been approved for second-line therapy in gastric carcinoma. Non-surgical therapy for gastrointestinal stromal tumours relies mainly upon tyrosine kinase inhibitors, while new targeted therapy options for neuroendocrine neoplasms have recently emerged. Potential future options for targeted therapy in all these malignancies are being investigated in clinical trials, as this review will discuss.

The efficacy of treating patients with non-metastatic gastric linitis plastica using surgery with chemotherapy and/or radiotherapy

Background

To explore the efficacy of treatment strategies for non-metastatic gastric linitis plastica (GLP).

Methods

Patients with non-metastatic GLP from 2004 to 2014 were identified from the National Cancer Database (NCDB). We compared overall survival (OS) of those patients who received different treatments, including surgery alone, a combination of surgery with chemotherapy and/or radiotherapy (S + C/R), chemotherapy and/or radiotherapy (C/R), and no treatment.

Results

The cohort included 474 patients with non-metastatic GLP. Overall, the median survival was significantly different among four groups (13.90 months in S + C/R, 8.38 months in surgery alone, 8.94 months in C/R and 2.50 months in no treatment). Then, we compared the efficacy of surgery alone and surgery with postoperative chemotherapy and/or radiotherapy (S + post C/R). When the tumor size was greater than 8 cm in stage III patients, S + post C/R was associated with a better survival benefit than surgery alone. S + post C/R also conferred an obvious survival advantage compared to surgery alone for R0 patients with positive lymph nodes and patients with positive margins.

Conclusions

Surgery plays the fundamental role in improving the OS of patients with non-metastatic GLP. S + post C/R would benefit patients in stage III with large-sized tumors (>8 cm), patients with negative margins and positive lymph nodes, and/or patients with positive margins.

Development and internal validation of a diagnostic score for gastric linitis plastica

BACKGROUND

There is no consensual definition for gastric linitis plastica (GLP). We aim to construct a diagnostic score to distinguish this rare tumor from usual gastric adenocarcinomas.

METHODS

In this retrospective study, all patients who had gastrectomy for cancer between 2007 and 2017 in French tertiary centers were included. The outcome was a diagnosis of GLP based on pathological review of the surgical specimen. The diagnostic score was created by using variables that were most frequently associated with GLP using penalized logistic regression on multiply imputed datasets. We used discrimination measures to assess the performances of the score. Internal validation was performed using bootstrapping methods to correct for over-optimism.

RESULTS

220 patients including 71 linitis plastica (female 49%, median age 57 years) were analyzed. The six parameters retained in the diagnosis score were the presence of large folds and/or parietal thickening on at least one segment, pangastric infiltration and presence of gastric stenosis on the upper endoscopy, circumferential thickening on at least one segment and thickening of the third hyperechogenic layer on endoscopic ultrasound and the presence of signet ring cells on endoscopic biopsies. The area under the ROC curve (AUC) was 0.967 with a sensitivity of 94% [89.9-97.3] and a specificity of 88.7% [81.7-95.8] for a threshold of 2.75. After internal validation, the corrected AUC was 0.959.

CONCLUSION

It is the first study validating a pre-therapeutic diagnostic score (Saint Louis linitis score) with an excellent ability to discriminate GLP from non-GLP adenocarcinomas. An external validation is necessary to confirm our data.

Primary colorectal linitis plastica presenting as rapid acute deterioration: a diagnostic dilemma

We present a rare case of primary colorectal linitis plastica presenting as an acute admission to hospital with a wide range of systemic symptoms, sudden rapid deterioration and subsequent mortality. A postmortem examination revealed a primary linitis plastica of the colon and rectum with diffuse metastatic disease. To our knowledge, this is the first report of primary colorectal linitis plastica presenting as an acute deterioration as a result of extensive metastatic disease.

Linitis Plastica: a Distinct Type of Gastric Cancer

BACKGROUND

The prognosis of patients with linitis plastica (LP) gastric cancer is reported to be poor. The purpose of our retrospective study was to characterize the clinicopathologic features and survival outcomes of patients with LP, using a univocal definition.

METHODS

We defined LP as gastric cancer that involves more than 1/3 of the gastric wall macroscopically. We reviewed a prospectively maintained institutional database of gastric cancer patients and summarized and compared clinicopathologic factors of patients with and without LP who had undergone gastrectomy. Patients were matched 1:1 using propensity score matching, and their overall survival (OS) rates and durations were compared. Multivariable Cox regression analyses were conducted, using gastrectomy as a time-varying covariate.

RESULTS

We identified 740 patients with radiographically non-metastatic gastric cancer, 157 (21.2%) of whom had LP. Most patients with LP had advanced-stage disease (75.8% had stage IV disease, mainly due to peritoneal involvement). Patients with LP had significantly shorter OS durations than did those without LP in the entire cohort (median OS, 14.0 vs. 33.5 months; p value < 0.001) and in the surgical cohort (median OS after gastrectomy, 21.8 vs. 91.0 months; p < 0.001), as well as in the propensity-matched surgical cohort. In the LP cohort, chemotherapy (hazard ratio [HR] = 0.594; p = 0.076), chemoradiation therapy (HR = 0.346; p = 0.001), and gastrectomy (HR = 0.425; p = 0.003) were associated with a longer OS.

CONCLUSIONS

LP is a phenotype of gastric cancer that often presents at an advanced stage, with a high rate of peritoneal involvement. The survival durations of patients with LP were poor in our study, even in the surgical cohort. The use of preoperative chemotherapy, chemoradiation therapy, and gastrectomy appeared to be important in carefully selected patients with localized LP.

A detailed analysis of the recurrence timing and pattern after curative surgery in patients undergoing neoadjuvant therapy or upfront surgery for gastric cancer

BACKGROUND AND OBJECTIVES

The aim of this study was to determine whether the administration of neoadjuvant therapy (NAD) affects the incidence, timing, and pattern of recurrence in patients treated by curative gastrectomy.

METHODS

Sixty-nine patients undergoing NAD and R0 gastrectomy were compared with 198 patients undergoing upfront surgery using the propensity score matching (PSM) method. Disease-free survival (DFS), disease-specific survival (DSS), and progression-free survival (PFS) analyses were conducted with a log-rank test and Cox regression. Risk factors for recurrence were assessed by logistic regression.

RESULTS

Among 69 patients with NAD, 28 (40.6%) experienced recurrence, and signet-ring cell (SRC) carcinoma was the only factor independently associated with recurrence. In the whole sample, NAD did not influence DFS, DSS, rate of recurrence, or PFS. After PSM, the variables associated with DFS were cN1, type of gastrectomy, the presence of SRCs, and the presence of lymphovascular invasion. Variables independently associated with recurrence were cN1, type of gastrectomy, and the presence of SRCs.

CONCLUSIONS

NAD had no impact on DFS, DSS, or the pattern of recurrence in any patients with gastric cancer. To define a better treatment strategy, future studies should focus on subtypes that do not respond to the current neoadjuvant regimens.

Molecular avenues in targeted doxorubicin cancer therapy

In recent, intra- and inter-tumor heterogeneity is seen as one of key factors behind success and failure of chemotherapy. Incessant use of doxorubicin (DOX) drug is associated with numerous post-treatment debacles including cardiomyopathy, health disorders, reversal of tumor and formation of secondary tumors. The module of cancer treatment has undergone evolutionary changes by achieving crucial understanding on molecular, genetic, epigenetic and environmental adaptations by cancer cells. Therefore, there is a paradigm shift in cancer therapeutic by employing amalgam of peptide mimetic, small RNA mimetic, DNA repair protein inhibitors, signaling inhibitors and epigenetic modulators to achieve targeted and personalized DOX therapy. This review summarizes on recent therapeutic avenues that can potentiate DOX effects by removing discernible pitfalls among cancer patients.

Analysis and external validation of a nomogram to predict peritoneal dissemination in gastric cancer

OBJECTIVE

Peritoneal dissemination is difficult to diagnose by conventional imaging technologies. We aimed to construct a nomogram to predict peritoneal dissemination in gastric cancer (GC) patients.

METHODS

We retrospectively analyzed 1,112 GC patients in Sun Yat-sen University Cancer Center between 2001 and 2010 as the development set and 474 patients from The Sixth Affiliated Hospital, Sun Yat-sen University between 2010 and 2016 as the validation set. The clinicopathological variables associated with gastric cancer with peritoneal dissemination (GCPD) were analyzed. We used logistic regression analysis to identify independent risk factors for peritoneal dissemination. Then, we constructed a nomogram for the prediction of GCPD and defined its predictive value with a receiver operating characteristic (ROC) curve. External validation was performed to validate the applicability of the nomogram.

RESULTS

In total, 250 patients were histologically identified as having peritoneal dissemination. Logistic regression analysis demonstrated that age, sex, tumor location, tumor size, signet-ring cell carcinoma (SRCC), T stage, N stage and Borrmann classification IV (Borrmann IV) were independent risk factors for peritoneal dissemination. We constructed a nomogram consisting of these eight factors to predict GCPD and found an optimistic predictive capability, with a C-index of 0.791, an area under the curve (AUC) of 0.791, and a 95% confidence interval (95% CI) of 0.762-0.820. The results found in the external validation set were also promising.

CONCLUSIONS

We constructed a highly sensitive nomogram that can assist clinicians in the early diagnosis of GCPD and serve as a reference for optimizing clinical management strategies.

Extramedullary leukemia behaving as solid cancer: clinical, histologic, and genetic clues to chemoresistance in organ sites

Recent studies of leukemic tumors in individual extramedullary sites showed they adopt the clinical and metastatic behavior of solid cancers originating in those sites. To elucidate features of leukemic tumors that render them resistant to agents effective against marrow leukemia, we analyzed a series of AML breast tumors by histology, immunohistochemistry, and RNA sequencing. Striking histologic similarities to solid cancers were found: a single-filing architectural pattern virtually identical to that of invasive lobular breast carcinoma and dense desmoplastic keloid-like fibrosis similar to colon, gallbladder, and pancreas carcinomas. Sequencing found 2157 genes significantly downregulated in AML breast tumors compared to normal breast. Comparison to triple-negative breast cancer found 859 genes similarly downregulated. At least 30 of these genes have been associated with poor prognosis in breast cancers. Five were reported in AML marrow studies to correlate with poor prognosis. The findings of this pilot study suggest the seed-and-soil interaction recognized in solid cancer growth may help explain how leukemic cells, in some patients, adopt solid tumor behavior in non-marrow sites. Transformed cells that metastasize from tumor to marrow can impart chemoresistance and be an unrecognized cause of treatment failure and death. Further studies comparing leukemic tumor to simultaneous marrow could potentially identify biomarkers that predict extramedullary resistance and lead to new therapeutic targets. Recognizing the potential for leukemia to adopt solid tumor phenotype, and implementation of body scanning and ablative tumor treatment, could decrease the persistently high rates of marrow resistance and treatment failure.

Endoscopic ultrasound-guided fine-needle aspiration biopsy for diagnosis of gastric linitis plastica with negative malignant endoscopy biopsies

The value of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy in the gastric linitis plastica (GLP) with negative malignant endoscopy biopsies was investigated. Forty-six patients with linitis plastica who had undergone EUS-FNA were retrospectively studied, and their clinicopathological data were examined. Among the 46 eligible patients, 38 cases were diagnosed clearly by EUS-FNA. There were 24 cases with lymph node metastasis in the 38 patients. Both the lymph nodes and gastric lesions were punctured by EUS-FNA in the 24 cases. We compared the diagnostic accuracy in different sites, and the results showed that the diagnostic accuracy in lymph nodes was significantly higher than that in gastric lesions (P<0.05). Among them, 16 patients underwent surgical resection, and the accuracy of the pathological diagnosis by EUS-FNA was 87.5% (14/16). The preoperative diagnostic accuracy of T and N staging by endoscopic ultrasound (EUS) were both 75%. Neither severe hemorrhage nor perforation occurred in any patient. In conclusion, EUS-FNA is a safe and effective procedure for the diagnosis of indefinite linitis plastica, and puncturing metastatic lymph nodes can improve the diagnostic accuracy.

Repeat staging laparoscopy for gastric cancer after preoperative therapy

BACKGROUND AND OBJECTIVES

Staging laparoscopy is recommended before preoperative therapy in patients with locoregional gastric cancer, but yield of repeated diagnostic laparoscopy at the time of resection is unknown.

METHODS

Retrospective review of a prospective database of patients with gastric adenocarcinoma (1994-2016) who had negative staging laparoscopy followed by preoperative therapy and subsequent attempted resection. Primary outcome was positive exploration (peritoneal or unresectable disease) at the time of resection. Multivariable logistic regression identified factors associated with positive exploration.

RESULTS

Of the 451 patients with attempted resection, 54 (12.0%) had positive explorations, including 48 with peritoneal disease. Patients with positive explorations were more likely to be female and have poorly differentiated tumors, linitis features, and signet-ring morphology. There was no significant difference by exploration results in age, race, clinical stage, or delayed definitive surgery. Positive explorations were independently associated with poor differentiation (OR 4.6, 95%CI 1.4-15.3; P = 0.01) and linitis (OR 4.2, 95%CI 1.9-9.2; P < 0.001). Positive explorations were seen in 14.0% of patients with poor differentiation, 36.6% of patients with linitis, and 5.8% of patients with neither linitis nor poor differentiation.

CONCLUSION

Despite negative pretreatment laparoscopy, post-treatment repeat laparoscopy may prevent non-therapeutic laparotomies. At a minimum, we recommend selective repeat laparoscopy for patients with linitis features.