Clinicopathological factors affecting the effect of neoadjuvant chemotherapy in patients with gastric cancer

Deep learning nomogram for predicting neoadjuvant chemotherapy response in locally advanced gastric cancer patients

PURPOSE

Developed and validated a deep learning radiomics nomogram using multi-phase contrast-enhanced computed tomography (CECT) images to predict neoadjuvant chemotherapy (NAC) response in locally advanced gastric cancer (LAGC) patients.

METHODS

This multi-center study retrospectively included 322 patients diagnosed with gastric cancer from January 2013 to June 2023 at two hospitals. Handcrafted radiomics technique and the EfficientNet V2 neural network were applied to arterial, portal venous, and delayed phase CT images to extract two-dimensional handcrafted and deep learning features. A nomogram model was built by integrating the handcrafted signature, the deep learning signature, with clinical features. Discriminative ability was assessed using the receiver operating characteristics (ROC) curve and the precision-recall (P-R) curve. Model fitting was evaluated using calibration curves, and clinical utility was assessed through decision curve analysis (DCA).

RESULTS

The nomogram exhibited excellent performance. The area under the ROC curve (AUC) was 0.848 [95% confidence interval (CI), 0.793-0.893)], 0.802 (95% CI 0.688-0.889), and 0.751 (95% CI 0.652-0.833) for the training, internal validation, and external validation sets, respectively. The AUCs of the P-R curves were 0.838 (95% CI 0.756-0.895), 0.541 (95% CI 0.329-0.740), and 0.556 (95% CI 0.376-0.722) for the corresponding sets. The nomogram outperformed the clinical model and handcrafted signature across all sets (all P < 0.05). The nomogram model demonstrated good calibration and provided greater net benefit within the relevant threshold range compared to other models.

CONCLUSION

This study created a deep learning nomogram using CECT images and clinical data to predict NAC response in LAGC patients undergoing surgical resection, offering personalized treatment insights.

Is neoadjuvant chemotherapy followed by surgery the appropriate treatment for esophagogastric signet ring cell carcinomas? A systematic review and meta-analysis

Background

The impact of neoadjuvant chemotherapy (nCTX) on survival and tumor response in patients with esophagogastric signet ring cell carcinoma (SRCC) is still controversial.

Methods

Two independent reviewers performed a systematic literature search in Medline, CENTRAL, and Web of Science including prospective and retrospective two-arm non-randomized and randomized controlled studies (RCTs). Data was extracted on overall survival (OS) and tumor regression in resected esophagogastric SRCC patients with or without nCTX. Survival data was analyzed using published hazard ratios (HR) if available or determined it from other survival data or survival curves. OS and histopathological response rates by type of tumor (SRCC vs. non-SRCC) were also investigated.

Results

Out of 559 studies, ten (1 RCT, 9 non-RCTs) were included in this meta-analysis (PROSPERO CRD42022298743) investigating 3,653 patients in total. The four studies investigating survival in SRCC patients treated with nCTX + surgery vs. surgery alone showed no survival benefit for neither intervention, but heterogeneity was considerable (HR, 1.01; 95% CI, 0.61-1.67; p = 0.98; I2 = 89%). In patients treated by nCTX + surgery SRCC patients showed worse survival (HR, 1.45; 95% CI, 1.21-1.74; p < 0.01) and lower rate of major histopathological response than non-SRCC patients (OR, 2.47; 95% CI, 1.78-3.44; p < 0.01).

Conclusion

The current meta-analysis could not demonstrate beneficial effects of nCTX for SRCC patients. Histopathological response to and survival benefits of non-taxane-based nCTX seem to be lower in comparison to non-SRC esophagogastric cancer. However, certainty of evidence is low due to the scarcity of high-quality trials. Further research is necessary to determine optimal treatment for SRCC patients.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42022298743).

Long-term nutrition in patients candidate to neoadjuvant and adjuvant treatments

To improve outcomes, to decrease the rate of local recurrence and development of distant metastases neoadjuvant and adjuvant therapies are employed in cancer patients in forms of radiation, chemo-, endocrine-, targeted-, and immunotherapy or their combination. Nutrition therapy plays important role in all phases of the cancer journey. From neoadjuvant therapy to prehabilitation, early postoperative nutrition, and long-term nutrition care during the adjuvant phase and survivorship determines the survival and quality of life of cancer patients. During the neoadjuvant phase patients may be in poor nutritional condition which can be aggravated by the applied oncological treatment. Beside this apparent threat this period also gives an excellent opportunity to maintain or even improve the nutritional status of the patients by nutrition therapy. After surgery the burdening effects of the operation may jeopardize the execution of adjuvant therapy. After early postoperative feeding a long-term nutrition strategy should be developed for cancer patients in order to avoid nutritional deterioration during the usually lengthy postoperative therapy. In this narrative review we discuss how preoperative nutritional status and medical nutrition therapy influence the results of surgery and after the operation what is the available evidence about nutritional status and outcome and the potentials to influence them by nutrition therapy.

Nomogram for predicting pathological response to neoadjuvant treatment in patients with locally advanced gastric cancer: Data from a phase III clinical trial

PURPOSE

This study aimed to establish a nomogram using routinely available clinicopathological parameters to predict the pathological response in patients with locally advanced gastric cancer (LAGC) undergoing neoadjuvant treatment.

MATERIALS AND METHODS

We conducted this study based on the ongoing Neo-CRAG trial, a prospective study focused on preoperative treatment in patients with LAGC. A total of 221 patients who underwent surgery following neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT) at Sun Yat-sen University Cancer Center between June 2013 and July 2022 were included in the analysis. We defined complete or near-complete pathological regression and ypN0 as good response (GR), and determined the prognostic value of GR by Kaplan-Meier survival analysis. Eventually, a nomogram for predicting GR was developed based on statistically identified predictors through multivariate logistic regression analysis and internally validated by the bootstrap method.

RESULTS

GR was confirmed in 54 patients (54/221, 24.4%). Patients who achieved GR had a longer progression-free survival and overall survival. Then, five independent factors, including pretreatment tumor differentiation, clinical T stage, monocyte count, CA724 level, and the use of nCRT, were identified. Based on these predictors, the nomogram was established with an area under the curve (AUC) of 0.777 (95% CI, 0.705-0.850) and a bias-corrected AUC of 0.752.

CONCLUSION

A good pathological response after neoadjuvant treatment was associated with an improved prognosis in LAGC patients. The nomogram we established exhibits a high predictive capability for GR, offering potential value in devising personalized and precise treatment strategies for LAGC patients.

Gastrıc cancer surgery in elderly patients: promising results from a mid-western population

BACKGROUNDS

Extended resection for gastric cancer in elderly patients is still challenging for surgeons. This study aimed to evaluate the prognosis and the postoperative outcomes of elderly patients underwent gastric cancer surgery in a high-volume center.

METHODS

The medical records of patients with gastric cancer surgery at Marmara University Hospital's General Surgery Department were examined retrospectively. Patients were divided into two groups: Age ≤ 70 and Age > 70. The clinicopathological data of the patients were compared. The prognostic factors regarding gastric cancer surgery were analyzed with Cox proportional regression models. Kaplan Meier analysis and log-rank test were used to compare Overall Survival (OS) and Cancer-Specific Survival (CSS) among the groups. Competing risk regression analysis was used to examine cause-specific hazards among elderly patients.

RESULTS

The number of eligible patients was 250. Age > 70 group was 68 patients, and Age ≤ 70 group was 182 patients. There is no significant difference between the patient's demographics or pathological outcomes. Neoadjuvant therapies performed less in elderly patients [40 (22%) vs. 7 (10%), p: 0.03, respectively]. There was no significant difference in severe complication (≥ Grade III) rates in both groups. Multivariate analysis showed that advanced T stage and adjacent organ invasion were the independent risk factors for OS. No significant difference was observed between the groups regarding OS (Log Rank (Mantel-Cox): 0.102). Younger patients have worse CSS than those who are older. Cause-specific hazard model demonstrated a not increased hazard ratio [HR: 1.04(0.78-1.38)] for elderly patients for OS and CSS.

CONCLUSION

Gastric resections can be safely performed for elderly patients diagnosed with gastric cancer. This study showed that growing age is no longer a factor that will affect the clinician's decision in performing surgery in gastric cancer patients.

Emerging Role of Epigenetic Modifiers in Breast Cancer Pathogenesis and Therapeutic Response

Breast cancer pathogenesis, treatment, and patient outcomes are shaped by tumor-intrinsic genomic alterations that divide breast tumors into molecular subtypes. These molecular subtypes often dictate viable therapeutic interventions and, ultimately, patient outcomes. However, heterogeneity in therapeutic response may be a result of underlying epigenetic features that may further stratify breast cancer patient outcomes. In this review, we examine non-genetic mechanisms that drive functional changes to chromatin in breast cancer to contribute to cell and tumor fitness and highlight how epigenetic activity may inform the therapeutic response. We conclude by providing perspectives on the future of therapeutic targeting of epigenetic enzymes, an approach that holds untapped potential to improve breast cancer patient outcomes.

Efficacy of continuous gastric artery infusion chemotherapy in relieving digestive obstruction in advanced gastric cancer

BACKGROUND

Obstruction or fullness after feeding is common in gastric cancer (GC) patients, affecting their nutritional status and quality of life. Patients with digestive obstruction are generally in a more advanced stage. Existing methods, including palliative gastrectomy, gastrojejunostomy, endoluminal stent, jejunal nutrition tube and intravenous chemotherapy, have limitations in treating these symptoms.

AIM

To analyze the efficacy of continuous gastric artery infusion chemotherapy (cGAIC) in relieving digestive obstruction in patients with advanced GC.

METHODS

This study was a retrospective study. Twenty-nine patients with digestive obstruction of advanced GC who underwent at least one cycle of treatment were reviewed at The Second Affiliated Hospital of Zhejiang University School of Medicine. The oxaliplatin-based intra-arterial infusion regimen was applied in all patients. Mild systemic chemotherapy was used in combination with local treatment. The clinical response was evaluated by contrast-enhanced computed tomography using Response Evaluation Criteria In Solid Tumors (RECIST) criteria. Digestive tract symptoms and toxic effects were analyzed regularly. A comparison of the Karnofsky Performance Status (KPS) score and Stooler’s Dysphagia Score before and after therapy was made. Univariate survival analysis and multivariate survival analysis were also performed to explore the key factors affecting patient survival.

RESULTS

All patients finished cGAIC successfully without microcatheter displacement, as confirmed by arteriography. The median follow-up time was 24 mo (95%CI: 20.24-27.76 mo). The overall response rate was 89.7% after cGAIC according to the RECIST criteria. The postoperative Stooler’s Dysphagia Score was significantly improved. Twenty-two (75.9%) of the 29 patients experienced relief of digestive obstruction after the first two cycles, and 13 (44.8%) initially unresectable patients were then considered radically resectable. The median overall survival time (mOS) was 16 mo (95%CI: 9.32-22.68 mo). Patients who received radical surgery had a significantly longer mOS than other patients (P value < 0.001). Multivariate Cox regression analysis indicated that radical resection after cGAIC, intravenous chemotherapy after cGAIC, and immunotherapy after cGAIC were independent predictors of mOS. None of the patients stopped treatment because of adverse events.

CONCLUSION

cGAIC was effective and safe in relieving digestive obstruction in advanced GC, and it could improve surgical conversion possibility and survival time.

Characterization of LIMA1 and its emerging roles and potential therapeutic prospects in cancers

Actin is the most abundant and highly conserved cytoskeletal protein present in all eukaryotic cells. Remodeling of the actin cytoskeleton is controlled by a variety of actin-binding proteins that are extensively involved in biological processes such as cell motility and maintenance of cell shape. LIM domain and actin-binding protein 1 (LIMA1), as an important actin cytoskeletal regulator, was initially thought to be a tumor suppressor frequently downregulated in epithelial tumors. Importantly, the deficiency of LIMA1 may be responsible for dysregulated cytoskeletal dynamics, altered cell motility and disrupted cell-cell adhesion, which promote tumor proliferation, invasion and migration. As research progresses, the roles of LIMA1 extend from cytoskeletal dynamics and cell motility to cell division, gene regulation, apical extrusion, angiogenesis, cellular metabolism and lipid metabolism. However, the expression of LIMA1 in malignant tumors and its mechanism of action have not yet been elucidated, and many problems and challenges remain to be addressed. Therefore, this review systematically describes the structure and biological functions of LIMA1 and explores its expression and regulatory mechanism in malignant tumors, and further discusses its clinical value and therapeutic prospects.

Neoadjuvant Gastric Cancer Treatment and Associated Nutritional Critical Domains for the Optimization of Care Pathways: A Systematic Review

(1) Background: Gastric cancer patients are known to be at a high risk of malnutrition, sarcopenia, and cachexia, and the latter impairs the patient's nutritional status during their clinical course and also treatment response. A clearer identification of nutrition-related critical points during neoadjuvant treatment for gastric cancer is relevant to managing patient care and predicting clinical outcomes. The aim of this systematic review was to identify and describe nutrition-related critical domains associated with clinical outcomes. (2) Methods: We performed a systematic review (PROSPERO ID:CRD42021266760); (3) Results: This review included 14 studies compiled into three critical domains: patient-related, clinical-related (disease and treatment), and healthcare-related. Body composition changes during neoadjuvant chemotherapy (NAC) accounted for the early termination of chemotherapy and reduced overall survival. Sarcopenia was confirmed to have an independent prognostic value. The role of nutritional interventions during NAC has not been fully explored. (4) Conclusions: Understanding critical domain exposures affecting nutritional status will enable better clinical approaches to optimize care plans. It may also provide an opportunity for the mitigation of poor nutritional status and sarcopenia and their deleterious clinical consequences.

Is Systemic Inflammatory Response Index (SIRI) a Reliable Tool for Prognosis of Gastric Cancer Patients Without Neoadjuvant Therapy?

BACKGROUND

The systemic inflammatory response index (SIRI), which depends on peripheral neutrophil, monocyte, and lymphocyte count, was found as an effective prognostic indicator for various malignancies. This study aims to investigate the predictive value of preoperative SIRI in the prognosis of gastric cancer patients without neoadjuvant therapy.

METHODS

 The patients who underwent gastric cancer surgery in Marmara University Hospital's General Surgery Department between 2019 and 2021 were analyzed retrospectively. SIRI was calculated from preoperative peripheral blood samples' neutrophil, lymphocyte, and monocyte count. The optimal cut-off value for SIRI was calculated by the receiver operating characteristics (ROC) curve and was found to be 1.35. The clinicopathological outcomes and overall survival (OS) were analyzed under two groups according to the SIRI values lower or higher than 1.35.

RESULTS

 The number of eligible patients was 199. The median follow-up time was 25 (1-56) months. The higher SIRI was associated with male gender (p = 0.044), lower serum albumin (0.002) level, and Clavien-Dindo (CD) Grade III and higher complications (p = 0.018). However, there was no significant difference between the groups regarded pathological tumor, nodes, and metastases (TNM) stages, histological grade, and Lauren Type. In addition, OS and stage-specific OS were similar between the groups.

CONCLUSIONS

 SIRI may be a valuable and effective predictive indicator for postoperative morbidity. The prognostic performance of SIRI on long-term OS is still controversial. Further investigations are needed into this topic.

Increased CD4/CD8 Lymphocyte ratio predicts favourable neoadjuvant treatment response in gastric cancer: A prospective pilot study

BACKGROUND

Despite optimal neoadjuvant chemotherapy only 40% of gastric cancer tumours achieve complete or partial treatment response. In the absence of treatment response, neoadjuvant chemotherapy in gastric cancer contributes to adverse events without additional survival benefit compared to adjuvant treatment or surgery alone. Additional strategies and methods are required to optimize the allocation of existing treatment regimens such as FLOT chemotherapy (5-Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel). Predictive biomarkers detected using immunohistochemistry (IHC) methods may provide useful data regarding treatment response.

AIM

To investigate the utility of CD4, CD8, Galectin-3 and E-cadherin in predicting neoadjuvant FLOT chemotherapy tumour response in gastric adenocarcinoma.

METHODS

Forty-three adult patients with gastric adenocarcinoma, of which 18 underwent neoadjuvant chemotherapy, were included in a prospective clinical cohort. Endoscopic biopsies were obtained from gastric cancer and normal adjacent gastric mucosa. Differences in expression of Galectin-3, E-cadherin, CD4⁺ and CD8⁺ molecules between tumours with and without treatment response to neoadjuvant chemotherapy were assessed with IHC. Treatment response was graded by clinical pathologists using the Tumour Regression Score according to the College of American Pathologists criteria. Treatment response was defined as complete or near complete tumour response, whereas partial or poor/no response was defined as incomplete. Digital IHC images were annotated and quantitatively assessed using QuPath 0.3.1. Biomarker expression between responsive and incomplete response tumours was assessed using a two-sided Wilcoxon test. Biomarker expression was also compared between normal and cancer tissue and between 15 paired tumour samples before and after chemotherapy. We performed a preliminary multivariate analysis and power analysis to guide future study. Statistical analyses were completed using R 4.1.2.

RESULTS

The ratio between CD4⁺ and CD8⁺ lymphocytes was significantly greater in treatment responsive tumours (Wilcoxon, P = 0.03). In univariate models, CD4⁺/CD8⁺ ratio was the only biomarker that significantly predicted favourable treatment response (Accuracy 86%, P < 0.001). Using a glmnet multivariate model, high CD4⁺/CD8⁺ ratio and low Galectin-3 expression were the most influential variables in predicting a favourable treatment response. Analyses of paired samples found that FLOT chemotherapy also results in increased expression of CD4⁺ and CD8⁺ tumour infiltrating lymphocytes (Paired Wilcoxon, P = 0.002 and P = 0.008, respectively). Our power analysis suggests future study requires at least 35 patients in each treatment response group for CD8 and Galectin-3 molecules, whereas 80 patients in each treatment response group are required to assess CD4 and E-cadherin biomarkers.

CONCLUSION

We demonstrate that an elevated CD4⁺/CD8⁺ Ratio is a promising IHC-based biomarker to predict favourable treatment response to FLOT neoadjuvant chemotherapy in locally advanced gastric cancer.

Comparison between signet-ring cell carcinoma and non-signet-ring cell carcinoma of the stomach: clinicopathological parameters, epidemiological data, outcome, and prognosis-a cohort study of 123 patients from a non-endemic country

Background

Signet-ring cell carcinoma of the stomach (SRCC) is a particular gastric cancer entity. Its incidence is increasing. Its diagnosis is pathological; it corresponds to adenocarcinoma with a majority of signet-ring cells component (> 50%).

These histological features give it its aggressiveness characteristics. This has repercussions on the prognostic level and implications for the alternatives of therapy, especially since some authors suggest a potential chemoresistance.

This survey aimed to identify the epidemiological, pathological, therapeutic, and prognostic characteristics of SRCC as a separate disease entity.

Methods

This was a retrospective study of 123 patients admitted for gastric adenocarcinoma to Habib Thameur Hospital in Tunis over 11 years from January 2006 to December 2016. A comparative study was performed between 2 groups: the SRCC group with 62 patients and the non-SRCC (non-signet-ring cell carcinoma of the stomach) with 61 patients.

Results

The prevalence of SRCC in our series was 50%. SRCC affected significantly younger patients (55 vs 62 years; p = 0.004). The infiltrative character was more common in SRCC tumors (30.6 vs 14.8%; p = 0.060), whereas the budding character was more often noted in non-SRCC tumors (78.7 vs 58.1%; p = 0.039). There was no significant difference in tumor localization between both groups. Linitis plastica was noted in 14 patients with SRCC against a single patient with non-SRCC (p = 0.001). The tumor size was more important in the non-SRCC group (6.84 vs 6.39 cm; p = 0.551). Peritoneal carcinomatosis was noted in 4.3% of cases in the SRCC group versus 2.2% of cases in the NSRCC group (p = 0.570). Total gastrectomy was more often performed in the SRCC group (87 vs 56%; p = 0.001). Resection was more often curative in the non-SRCC group (84.4 vs 78.3%; p = 0.063). Postoperative chemotherapy was more commonly indicated in the SRCC group (67.4 vs 53.3%; p = 0.339). Tumor recurrence was more common in the non-SRCC group (35.7 vs 32%; p = 0.776). The most common type of recurrence was peritoneal carcinomatosis in the SRCC group (62.5%) and hepatic metastasis in the non-SRCC group (60%; p = 0.096). The overall 5-year survival in the SRCC group was lower than in the non-SRCC group, with no statistically significant difference (47.1 vs 51.5%; p = 0.715). The overall survival was more important for SRCC in early cancer (100 vs 80%; p = 0.408), whereas it was higher for non-SRCC in advanced cancer (48.1 vs 41.9%; p = 0.635).

Conclusion

Apart from its epidemiological and pathological features, SRCC seems to have a worse prognosis. Indeed, it is diagnosed at a more advanced stage and has a worse prognosis in advanced cancer than non-SRCC. It is therefore to be considered as a particular entity of gastric adenocarcinoma requiring a specific therapeutic protocol where the place of chemotherapy remains to be more investigated.

Prognostic Relevance of Weight and Weight Loss during Multimodal Therapy for Oesophagogastric Tumours

The prognostic meaning of weight loss (WL) during standard treatment for operable oesophagogastric cancer is still unclear. The aim of this study is to analyse the prognostic effect of WL during perioperative chemotherapy (PC) for gastric cancer (GC) and oesophageal adenocarcinomas (OAC). We retrospectively analysed data from 128 patients (pts) with GC and OAC who underwent surgery in the context of multimodal treatment with PC. We collected data on WL during different steps of therapy together with other histopathologic and demographic information. We analysed the effects on overall survival (OS) and disease-free survival (DFS). Results: Pts with WL ≥ 5% during neoadjuvant chemotherapy exhibited significantly worse OS compared with pts with WL < 5% (median OS: 23.6 months [95% CI: 4.4−42.9] vs. 63.5 months [95% CI: 50.7−76.2], p = 0.007) and DFS (median DFS: 12.5 months [95% CI: 2.9−22.1] vs. 63.5 months [95% CI: 31.6−95.4], p = 0.016). Pts with WL ≥ 14% during the whole treatment exhibited significantly worse OS compared with pts with WL < 14% (median OS: 43.7 months [95% CI: 13.2−74.2] vs. not reached, p = 0.028) and DFS (median DFS: 34.3 months [95% CI: 14.0−54.5] vs. not reached, p = 0.038). Conclusion: WL patterns during neoadjuvant chemotherapy and during the whole treatment correlate with a significantly worse prognosis in operated pts with curative GC or OAC in the context of a multimodal treatment with PC. A validation of this prognostic effect in prospective studies is warranted.

A CT-based deep learning radiomics nomogram for predicting the response to neoadjuvant chemotherapy in patients with locally advanced gastric cancer: A multicenter cohort study

BACKGROUND

Accurate prediction of treatment response to neoadjuvant chemotherapy (NACT) in individual patients with locally advanced gastric cancer (LAGC) is essential for personalized medicine. We aimed to develop and validate a deep learning radiomics nomogram (DLRN) based on pretreatment contrast-enhanced computed tomography (CT) images and clinical features to predict the response to NACT in patients with LAGC.

METHODS

719 patients with LAGC were retrospectively recruited from four Chinese hospitals between Dec 1st, 2014 and Nov 30th, 2020. The training cohort and internal validation cohort (IVC), comprising 243 and 103 patients, respectively, were randomly selected from center I; the external validation cohort1 (EVC1) comprised 207 patients from center II; and EVC2 comprised 166 patients from another two hospitals. Two imaging signatures, reflecting the phenotypes of the deep learning and handcrafted radiomics features, were constructed from the pretreatment portal venous-phase CT images. A four-step procedure, including reproducibility evaluation, the univariable analysis, the LASSO method, and the multivariable logistic regression analysis, was applied for feature selection and signature building. The integrated DLRN was then developed for the added value of the imaging signatures to independent clinicopathological factors for predicting the response to NACT. The prediction performance was assessed with respect to discrimination, calibration, and clinical usefulness. Kaplan-Meier survival curves based on the DLRN were used to estimate the disease-free survival (DFS) in the follow-up cohort (n = 300).

FINDINGS

The DLRN showed satisfactory discrimination of good response to NACT and yielded the areas under the receiver operating curve (AUCs) of 0.829 (95% CI, 0.739-0.920), 0.804 (95% CI, 0.732-0.877), and 0.827 (95% CI, 0.755-0.900) in the internal and two external validation cohorts, respectively, with good calibration in all cohorts (p > 0.05). Furthermore, the DLRN performed significantly better than the clinical model (p < 0.001). Decision curve analysis confirmed that the DLRN was clinically useful. Besides, DLRN was significantly associated with the DFS of patients with LAGC (p < 0.05).

INTERPRETATION

A deep learning-based radiomics nomogram exhibited a promising performance for predicting therapeutic response and clinical outcomes in patients with LAGC, which could provide valuable information for individualized treatment.

A population-based predictive model to identify patients with signet ring cell carcinoma of the stomach who are most suitable for primary tumor resection

Background

Though the survival benefit of primary tumor operation for patients with signet ring cell carcinoma of the stomach is known, the specific characteristics of those patients who would profit from the operation are yet to be determined. To this end, a predictive model was developed to identify the conjecture that the survival profit from primary tumor operation would only be obtained by patients.

Method

The clinical data of the patients with signet ring cell carcinoma of the stomach were obtained from the Surveillance, Epidemiology, and End Results database, and then divided into operation and no-operation groups based on whether the patients underwent the primary tumor operation. To remove the confounding factors, propensity score matching was employed, and it was hypothesized that the patients who had been operated on and lived a longer life than the median cancer-specific survival time of those who hadn’t must have profited from the surgery. To discuss the independent factors of cancer-specific survival time in the beneficial group and the non-beneficial group, the Cox model was used, and based on the various vital predictive factors, a nomogram was drawn using logistic regression.

Result

The number of eligible patients was 12,484, with 43.9% (5483) of them having received surgery. After employing propensity score matching, the cancer-specific survival time of the operation group was found to be apparently longer (median: 21 vs. 5 months; p < 0.001) than the no-operation group. In the operation group, 4757 (86.7%) of the patients lived longer than five months (beneficial group). The six indexes (beneficial and non-beneficial group) included gender, age, Tumor Node Metastasis stage, histologic type, differentiation grade, and tumor position, and were used as predictors to draw the nomogram. The nomogram was used to divide the patients who had taken operations into two groups: the beneficial operation group and the non-beneficial operation group. The beneficial operation group, it was found, survived longer than the non-beneficial operation group (median cancer-specific survival time: 28 vs. 3 months, p < 0.001). Moreover, there was we could tell little difference in survival between the two groups (median cancer-specific survival time: 3 vs. 5 months).

Conclusions

The predictive model created to select suitable candidates for surgical treatment from patients with signet ring carcinoma of the stomach could be adopted to identify certain patients benefiting from the primary tumor operation.

A novel nomogram based on cardia invasion and chemotherapy to predict postoperative overall survival of gastric cancer patients

Background

We aimed to establish and externally validate a nomogram to predict the 3- and 5-year overall survival (OS) of gastric cancer (GC) patients after surgical resection.

Methods

A total of 6543 patients diagnosed with primary GC during 2004–2016 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. We grouped patients diagnosed during 2004–2012 into a training set (n = 4528) and those diagnosed during 2013–2016 into an external validation set (n = 2015). A nomogram was constructed after univariate and multivariate analysis. Performance was evaluated by Harrell’s C-index, area under the receiver operating characteristic curve (AUC), decision curve analysis (DCA), and calibration plot.

Results

The multivariate analysis identified age, race, location, tumor size, T stage, N stage, M stage, and chemotherapy as independent prognostic factors. In multivariate analysis, the hazard ratio (HR) of non-cardia invasion was 0.762 (P < 0.001) and that of chemotherapy was 0.556 (P < 0.001). Our nomogram was found to exhibit excellent discrimination: in the training set, Harrell’s C-index was superior to that of the 8th American Joint Committee on Cancer (AJCC) TNM classification (0.736 vs 0.699, P < 0.001); the C-index was also better in the validation set (0.748 vs 0.707, P < 0.001). The AUCs for 3- and 5-year OS were 0.806 and 0.815 in the training set and 0.775 and 0.783 in the validation set, respectively. The DCA and calibration plot of the model also shows good performance.

Conclusions

We established a well-designed nomogram to accurately predict the OS of primary GC patients after surgical resection. We also further confirmed the prognostic value of cardia invasion and chemotherapy in predicting the survival rate of GC patients.

Development and Validation of a Computed Tomography-Based Radiomics Signature to Predict Response to Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer

IMPORTANCE

Neoadjuvant therapies have been shown to decrease tumor burden, increase resection rate, and improve the outcomes among patients with locally advanced gastric cancer (GC). However, not all patients are equally responsive; therefore, differentiating potential respondents from nonrespondents is clinically important.

OBJECTIVE

To use pretreatment computed tomography (CT)-pixelated feature-difference extraction techniques to identify diagnostically relevant features that could predict patients' response to neoadjuvant chemotherapy at diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study included patients with locally advanced GC who were treated from January 2010 to July 2017 at 2 hospitals in southern China (training cohort) and 1 hospital in northern China (external validation cohort). Their clinicopathological data, pretreatment CT images, and pathological reports were retrieved and analyzed. Data analysis was conducted from December 2017 to May 2021.

EXPOSURES

All patients underwent 2 to 4 cycles of fluorouracil in combination with a platinum-based neoadjuvant chemotherapy regimen. All gastrectomies were performed according to the Japanese Classification of Gastric Carcinoma (14th edition) guidelines.

MAIN OUTCOMES AND MEASURES

Reliability of clinicopathological and radiomics-based features were assessed with area under receiver operating characteristic curve (AUC) and Mann-Whitney U test.

RESULTS

A total of 323 patients (242 [74.9%] men; median [range] age, 58 [24-82] years) were included in the study, with 250 patients (77.4%) in the training cohort and 73 (22.6%) in the validation cohort. The baseline pretreatment characteristics of the training and validation cohorts were well-balanced. The number of respondents in the training and validation cohort was 122 (48.8%) and 40 (54.8%), respectively, and the number of nonrespondents was 128 (51.2%) and 33 (45.2%), respectively. No clinicopathological variables were significantly associated with treatment response. Using radiomics, 20 low-intercorrelated features from a total of 7477 features were used to construct a radiomics signature that demonstrated significant association with treatment response. Good discrimination performance of the radiomics signature for predicting treatment response in the training (AUC, 0.736; 95% CI, 0.675-0.798) and external validation (AUC, 0.679; 95% CI, 0.554-0.803) cohorts was observed. Decision curve analysis confirmed the clinical utility of the radiomics signature.

CONCLUSIONS AND RELEVANCE

In this study, the proposed radiomics signature showed potential as a clinical aid for predicting the response of patients with locally advanced GC before treatment, thereby allowing timely planning for effective treatments for potential nonrespondents.

The value of restaging CT following neoadjuvant chemotherapy for resectable gastric cancer. A population-based study

Background

Response evaluation following neoadjuvant chemotherapy (NAC) in gastric cancer is debated. The aim of this study was to investigate the value of UICC-downstaging as mode of response evaluation following a MAGIC-style regimen of NAC.

Methods

Retrospective, population-based study on consecutive patients with resectable gastric adenocarcinoma receiving NAC from 2007 to 2016. CT-scan was obtained at diagnosis (rTNM) and repeated following NAC (yrTNM) to evaluate response in terms of downstaging. Further, yrTNM stage was crosstabulated to pathologic stage (ypTNM) to depict correlation between radiologic and pathologic assessment.

Results

Of 171 patients receiving NAC, 169 were available for response evaluation. For TNM-stages, 43% responded, 50% had stable disease and 7% progressed at CT. Crosstabulating yrTNM stage to ypTNM stage, 24% had concordant stages, with CT overstaging 38% and understaging 38% of the tumours, Cohen kappa ƙ = 0,06 (95%CI 0.004–0.12). Similar patterns of discordance were found for T-stages and N-stages separately. For M-category, restaging CT detected 12 patients with carcinomatosis, with an additional 14 diagnosed with carcinomatosis only at operation. No patient developed parenchymal or extra abdominal metastases, and none developed locally non-resectable tumour during delivery of NAC. Restaging CT with response evaluation was not able to stratify patients into groups of different long-term survival rates based on response mode.

Conclusions

Routine CT-scan following NAC is of limited value. Accuracy of CT staging compared to final pathologic stage is poor, and radiologic downstaging as measure of response evaluation is unreliable and unable to discriminate long-term survival rates based on response mode.

Prognosis and Biological Behavior of Gastric Signet-Ring Cell Carcinoma Better or Worse: A Meta-Analysis

BACKGROUND

The clinical pathology of gastric signet-ring cell carcinoma (SRC) is still unclear. This meta-analysis was performed to evaluate the difference in biological behavior and prognosis between SRC and non-signet ring cell carcinoma (NSRC).

METHODS

A total of 58 eligible studies were analyzed using RevMan and other auxiliary software. Biological behaviors were compared based on odds ratio (OR) and mean difference (MD). Hazards ratio (HR) was calculated for prognosis based on Kaplan-Meier curves.

RESULTS

Totally, 28,946 SRC patients were compared with 81,917 NSRC patients. Compared with NSRC patients, lower male: female ratio (OR = 0.53, P < 0.01), younger age (MD = -4.89, P < 0.01), more middle location (OR = 1.64, P < 0.01), more depressed type at early stage (OR = 1.31, P < 0.05), higher incidence of Borrmann type IV (OR = 1.96, P < 0.01), less lymph node metastasis at early stage (OR = 0.78, P < 0.05), better prognosis at early stage (HR = 0.59, P < 0.01), and worse prognosis at advanced stage (HR = 1.19, P < 0.01) were associated with SRC patients.

CONCLUSION

The prognosis of SRC at early stage is better than other types of gastric cancer, while that of SRC at advanced stage is relatively poorer.