Changing patterns of prognosticators during 15-year follow-up of advanced gastric cancer after radical gastrectomy and adjuvant chemotherapy: a 15-year follow-up study at a single korean institute

Feasibility of Extended Postoperative Follow-Up in Patients With Gastric Cancer

Importance

Conventional research and guidelines on postgastrectomy follow-up for gastric cancer often restrict their focus to the first 5 years after surgery.

Objective

To evaluate the association of extended regular follow-up after 5 years postgastrectomy in patients with gastric cancer with overall and postrecurrence survival rates.

Design, Setting, and Participants

This population-based, retrospective cohort study used Korean National Health Insurance claims data extracted between January 1, 2005, and December 31, 2014, with follow-up data examined until December 31, 2021. Patients without recurrence or other cancers at 5 years postgastrectomy were divided into 2 groups: those who had extended regular follow-up visits and those who did not. The data were analyzed between August 15 and November 15, 2023.

Exposures

Regular follow-up vs irregular follow-up after 5 years postgastrectomy.

Main Outcomes and Measures

The main outcome was whether extended regular follow-up after 5 years postgastrectomy was independently associated with overall and postrecurrence survival rates using Cox proportional hazards regression. Postrecurrence survival rates were also compared across different follow-up methods and intervals.

Results

A total of 40 468 patients with gastric cancer were included, with 14 294 in the regular follow-up group (mean [SD] age, 61.3 [11.7] years; 9669 male [67.8%]) and 26 174 in the irregular follow-up group (mean [SD] age, 58.1 [11.1] years; 18 007 male [68.8%]). Late recurrence or gastric remnant cancer (GRC) was identified in 3138 patients (7.8%), including 1610 of 40 468 patients (4.0%) between 5 and 10 years postgastrectomy and 1528 of 16 287 (9.4%) patients after 10 years postgastrectomy. Regular follow-up was associated with a significantly decreased overall mortality rate after 5 years postgastrectomy (from 49.4% to 36.9% in 15-year mortality rate; P < .001), as well as significant improvement of postrecurrence survival rate after occurrence of late recurrence or GRC (from 32.7% to 71.1% in 5-year postrecurrence survival rate; P < .001). Comparison of follow-up methods revealed that the combination of endoscopy and abdominopelvic computed tomography (CT) (only abdominopelvic CT in total gastrectomy subgroup) yielded the highest 5-year postrecurrence survival rate (endoscopy alone vs abdominopelvic CT alone vs a combination of both, 54.5% vs 47.1% vs 74.5%, respectively). A time interval of more than 2 years between previous endoscopy or abdominopelvic CT and late recurrence and GRC diagnosis was associated with a significantly reduced postrecurrence survival rate (hazard ratio, 1.72 [95% CI, 1.45-2.04] and 1.48 [95% CI, 1.25-1.75], respectively).

Conclusions and Relevance

These findings suggest that extended regular follow-up after 5 years postgastrectomy should be implemented clinically and that current practice and value of follow-up protocols in postoperative care of patients with gastric cancer be reconsidered.

A case of laparoscopic lymphadenectomy for adenocarcinoma of unknown primary incidentally detected as a solitary enlarged lymph node along the common hepatic artery

BACKGROUND

Even in cancer of unknown primary (CUP), which is rare clinical condition, solitary anterosuperior lymph node (LN) along the common hepatic artery (No.8a LN) enlargement diagnosed as metastatic adenocarcinoma has never been reported.

CASE PRESENTATION

A 68-year-old Japanese male, with a history of early gastric cancer that had been completely treated by endoscopic submucosal dissection 26 years ago, was detected a single enlarged nodule along the common hepatic artery, No.8a LN, incidentally by computed tomography performed for monitoring of interstitial pneumonia. Endoscopic ultra-sound-guided fine needle aspiration revealed that this nodule was adenocarcinoma suggestive of metastasis, but other imaging studies, including upper and lower gastrointestinal endoscopy, positron emission tomography, and ultrasonography did not detect any primary cancer. We have finally diagnosed as the LN metastasis of CUP and performed laparoscopic lymphadenectomy for this tumor. The tumor was approximately 5 cm in size, was in close proximity to the pancreas, and involved part of the right gastric artery and vein. LNs in the No.5 and No.8a areas, including this tumor, were dissected laparoscopically, and radical resection was achieved. The patient had no postoperative complication and was discharged on postoperative day 10. Immunohistopathological findings revealed that the tumor was poorly differentiated adenocarcinoma, and different from the histology of gastric cancer resected 26 years ago, although the tumor was suggestive of gastrointestinal origin. Imaging studies performed 2 and 6 months after discharge also did not reveal a primary site.

CONCLUSION

We reported a case of solitary No.8a LN adenocarcinoma of CUP. For diagnostic and therapeutic purposes, radical resection is recommended for single enlarged intra-abdominal LN of CUP.

Rectal metastasis of gastric cancer: a case report

The most common metastatic sites of gastric cancer include the liver, peritoneum, lung, and bone. However, there is a lack of relevant clinical reports regarding rectal metastasis. Herein, we report the rare case of a patient with gastric cancer who developed rectal metastasis. A 57-year-old male patient was diagnosed with gastric cancer and underwent a radical gastrectomy in January 2016, followed by eight cycles of adjuvant chemotherapy. The patient subsequently developed a rectal mass in March 2021. He was diagnosed with rectal adenocarcinoma and underwent surgical resection of the rectal tumor. A mass was then found in the abdominal wall in September 2021 and was resected. Specimens obtained from the three surgeries were reviewed, and the rectal tumor and the mass in the abdominal wall were both found to be metastatic tumors from the gastric cancer. Metastasis of gastric cancer to the rectum is rare, but it is important to differentiate between rectal metastasis and primary rectal cancer to help avoid unnecessary treatment.

Reminiscence therapy-based care program alleviates anxiety and depression, as well as improves the quality of life in recurrent gastric cancer patients

Objective

Reminiscence therapy is a non-drug method that eases psychological burden and enhances quality of life by memories and communications in cancer patients. This study aimed to evaluate influence of reminiscence therapy-based care program on anxiety, depression, and quality of life in recurrent gastric cancer patients.

Methods

Totally, 96 recurrent gastric cancer patients were randomly assigned as 1:1 ratio into reminiscence therapy-based care group (N = 48) and usual care group (N = 48) to receive 12-week corresponding interventions. Besides, all patients were follow-up for 6 months.

Results

Hospital Anxiety and Depression Scales-anxiety score at 4th month (p = 0.031) and 6th month (p = 0.004), Hospital Anxiety and Depression Scales-depression score at 6th month (p = 0.018), and anxiety severity at 4th month (p = 0.041) and 6th month (p = 0.037) were lower in reminiscence therapy-based care group than in usual care group. Quality of Life Questionnaire-Core 30 global health status score at 2nd month (p = 0.048), 4th month (p = 0.036), and 6th month (p = 0.014), Quality of Life Questionnaire-Core 30 function score at 4th month (p = 0.014) and 6th month (p = 0.021) were higher, while Quality of Life Questionnaire-Core 30 symptoms score at 2nd month (p = 0.041) and 4th month (p = 0.035) were lower in reminiscence therapy-based care group than in usual care group. Furthermore, reminiscence therapy-based care was more effective on improving mental health and quality of life in recurrent gastric cancer patients with anxiety or depression at baseline than those without.

Conclusion

Reminiscence therapy-based care serves as an effective intervention, which relieves anxiety and depression, and improves quality of life in recurrent gastric cancer patients.

Late recurrent gastric carcinoma 12 years after surgery with attenuation of CD44 variant 9 expression

BACKGROUND

Late recurrence of gastric cancer at 10 years post-gastrectomy is extremely rare, and the underlying mechanism remains unclear. We report a para-aortic lymph node metastasis case that recurred 12 years postoperatively.

CASE PRESENTATION

A 44-year-old woman pathologically diagnosed with moderately to poorly differentiated adenocarcinoma with pT2(SS)pN2cM0pStageIIIA according to the Japanese Classification of Gastric Carcinoma (the 13th Edition) underwent laparoscopic distal gastrectomy with D1 + lymph node dissection. She received adjuvant chemotherapy with tegafur-uracil (400 mg/day) for 2 years. At postoperative year (POY) 5, a swollen lymph node was detected in the No.16b1lat lymph node station. However, positron emission tomography (PET) revealed normal uptake, and the levels of tumor markers were within normal limits; hence, the possibility of metastasis was considered low, and the patient was placed under observation. At POY 12, computed tomography revealed an enlargement of the No.16b1lat lymph node station, and PET showed abnormal uptake. Endoscopic ultrasound-guided fine-needle aspiration revealed a moderately differentiated adenocarcinoma. Hence, a diagnosis of recurrence of gastric cancer was made. The patient underwent para-aortic nodal dissection (PAND) of No.16b1lat & int stations. Immunochemical staining results also suggested the recurrence of gastric cancer. However, the expression of CD44 variant 9 (CD44v9), a cancer stem cell marker for gastric adenocarcinoma, was attenuated in the recurrent lesions compared with that in the primary lesions. Postoperatively, she received chemotherapy with tegafur-gimeracil-oteracil (80 mg/day) for 1 year. Bone metastasis was observed at POY 4 after PAND, and the IHC analysis showed a HER2 score of 3 + in a needle biopsy specimen of bone metastasis. The expression of CD44v9 was slightly positive. The patient is being treated with chemotherapy with FOLFOX + trastuzumab.

CONCLUSIONS

A defense mechanism against reactive oxygen species has been reported as a mechanism causing recurrence of CD44v9-positive gastric cancer. Consequently, CD44v9-positive gastric cancer grows in metastatic organs, repeatedly self-renews, and proliferates to form recurrent lesions. In the present case, the degree of CD44v9 staining in recurrent lesions was suggested to be related to the recurrence time.

Lymph Node Metastasis-Related Gene ITGA4 Promotes the Proliferation, Migration, and Invasion of Gastric Cancer Cells by Regulating Tumor Immune Microenvironment

The Integrin Subunit Alpha 4 (ITGA4) plays important roles in cancers pathogenesis. However, the expression and association with clinicopathological and survival probability have not been previously assessed in gastric cancer (GC). Protein expression of ITGA4 was assessed in TMA using immunohistochemistry and correlated with clinicopathological factors and survival. The mRNA expression of ITGA4 was also assessed in the HMU-GC cohort. Bioinformatics function analysis was conducted through GSEA. The “CIBERSORT” package was used for immune infiltration analysis. “SvyNom” package is used to construct prognosis model. ITGA4 knock down using shRNA. The evaluation of cell function was performed by CCK-8 and Transwell invasion and migration experiments. ITGA4 was significantly associated with N classification ( $P=0.031$ ), tumor location ( $P=0.033$ ), WHO classification ( $P=0.007$ ), and poor prognosis in mRNA level. GSEA analysis of the validation cohort suggested that ITGA4 was associated with macrophage infiltration. Immunohistochemistry showed that ITGA4 was associated with poor prognosis. Multivariate Cox regression analysis found that ITGA4 ( $P=0.045$ ) and lymph node metastasis rate ( $P=0.026$ ) were independent prognostic factors and could construct a prognosis model. ITGA4 knockdown cell line significantly reduced the ability of proliferation, invasion, and metastasis. ITGA4 is associated with patient survival in GC and may be an important prognostic biomarker.

Extragastric recurrence in patients who underwent surgical resection of stage I gastric cancer: Incidence, risk factors, and value of abdominal computed tomography as a postoperative surveillance method

Extragastric recurrence after radical resection of stage I gastric cancer is very rare. We investigated the incidence of extragastric recurrence and risk factors in patients who underwent surgical resection of stage I gastric cancer and evaluated the value of abdominal CT as a surveillance tool. This retrospective study enrolled 914 patients with stage I gastric cancer who underwent surgical resection at a single tertiary hospital. We investigated extragastric recurrence during the follow-up period, and disease-free survival (DFS) was assessed. Over a median follow-up period of 39 months, the overall incidence of extragastric recurrence was 2.2% (20/914). Risk factors for extragastric recurrence included deep submucosal invasion (SM2-3), muscularis propria invasion, and lymph node metastasis (hazard ratio [HR]=10.37, 28.101, and 6.843; P = .028, .002, and .001, respectively). Based on the number of risk factors, patients were stratified into 3 subgroups: low-risk (pT1aN0, pT1b(SM1)N0, 496/914), moderate-risk (pT1aN1, pT1b(SM1)N1, pT1b(SM2-3)N0, pT2N0, 369/914), and high-risk (pT1b(SM2-3)N1, 49/914). DFS was significantly longer in the low-risk group, followed by the moderate-risk and high-risk groups. We propose that postoperative CT surveillance should be omitted for stage 1A cases involving the mucosa and SM1 because of the extreme rarity of extragastric recurrence.

Ziyin Huatan Recipe, a Chinese herbal compound, inhibits migration and invasion of gastric cancer by upregulating RUNX3 expression

OBJECTIVES

Ziyin Huatan Recipe (ZYHT), a traditional Chinese medicine comprised of Lilii Bulbus, Pinelliae Rhizoma, and Hedyotis Diffusa, has shown promise in treating gastric cancer (GC). However, its potential mechanism has not yet been clearly addressed. This study aimed to predict targets and molecular mechanisms of ZYHT in treating GC by network pharmacology analysis and to explore the role of ZYHT in GC both in vitro and in vivo.

METHODS

Targets and molecular mechanisms of ZYHT were predicted via network pharmacology analysis. The effects of ZYHT on the expression of metastasis-associated targets were further validated by Western blot and quantitative real-time polymerase chain reaction. To explore the specific molecular mechanisms of the effects of ZYHT on migration and invasion, the runt-related transcription factor 3 (RUNX3) gene was knocked out by clustered regularly interspaced short palindromic repeats/Cas9, and lentiviral vectors were transfected into SGC-7901 cells. Then lung metastasis model of GC in nude mice was established to explore the anti-metastasis effect of ZYHT. Western blot and immunohistochemistry were used to explore the impact of ZYHT on the expression of metastasis-related proteins with or without RUNX3 gene.

RESULTS

The network pharmacology analysis showed that ZYHT might inhibit focal adhesion, migration, invasion and metastasis of GC. ZYHT inhibited the proliferation, migration and invasion of GC cells in vitro via regulating the expression of metastasis-associated targets. Knocking out RUNX3 almost completely reversed the cell phenotypes (migration and invasion) and protein expression levels elicited by ZYHT. In vivo studies showed that ZYHT inhibited the metastasis of GC cells to the lung and prolonged the survival time of the nude mice. Knocking out RUNX3 partly reversed the metastasis of GC cells to the lung and the protein expression levels elicited by ZYHT.

CONCLUSION

ZYHT can effectively inhibit the invasion and migration of GC in vitro and in vivo, and its molecular mechanism may relate to the upregulation of RUNX3 expression.

Pulmonary Tumor Thrombotic Microangiopathy Caused by Recurrent Gastric Cancer 26 Years After Total Gastrectomy

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare cancer-related complication that induces pulmonary hypertension (PH). PTTM can be caused by recurrent cancer, with 12 years being the longest reported interval from primary cancer to the development of PTTM. We herein report a 74-year-old woman who presented with dyspnea due to PH. The postmortem diagnosis was PTTM caused by recurrent gastric cancer 26 years after total gastrectomy. An autopsy revealed PTTM-specific histological characteristics. Our findings indicate that PTTM should be considered as a diagnosis for patients with a history of cancer who develop PH, even several decades after treatment.

Proposed Models for Prediction of Mortality in Stage-I and Stage-II Gastric Cancer and 5 Years after Radical Gastrectomy

The current American Joint Committee on Cancer (AJCC) staging system provides limited information for patients with early death from stage-I and stage-II gastric cancer (GC) and death at >5 years after radical gastrectomy. The aim of this study was to construct nomogram models to predict the mortality risk of these patients. In this study, clinical and pathological data on patients who underwent curative gastrectomy at Harbin Medical University Cancer Hospital between 2000 and 2014 were retrospectively collected. Receiver operating characteristic analysis was used to screen for sensitive serum immune biomarkers to predict the risk of mortality death >5 years after radical gastrectomy (Group A) and risk of early death in stage-I and stage-II GC (Group B). The prediction model was constructed by combining serum immune markers with clinicopathological features by R Studio. We found that serum fibrinogen (F), systemic immune inflammation (SII), and pTNM stage were independent risk factors for prognosis in Group A (P < 0.05). F, SII, age, Borrmann type, and scope of gastrectomy were independent risk factors for prognosis in Group B (P < 0.05). The area under the curve of the predictive model in Groups A and B was 0.726 and 0.848, respectively. In conclusion, the predictive models of F and SII combined with clinicopathological features can predict high mortality risk in patients with stage-I and stage-II GC and >5 years after radical gastrectomy, which will contribute to the supplement of the traditional AJCC system and to individual survival prediction.

Recurrent Gastric Cancer Metastasizing to the Bone Marrow Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography/Contrast-Enhanced Computed Tomography Scan

Gastric cancer is one of the important causes of cancer-related mortality worldwide, with significantly low median survival in metastatic gastric cancer. Thus, when planning treatment for gastric cancer, it becomes important to determine whether or not there is metastasis. Bone marrow is a rare region for metastasis in cases of gastric carcinoma, as suggested by the literature. We are herewith presenting the case of a 56-year-old patient of recurrent gastric carcinoma who showed a rare site of metastasis involving marrow on fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan.

Gastric cancer with positive peritoneal cytology: survival benefit after induction chemotherapy and conversion to negative peritoneal cytology

Background

The optimal treatment in patients with gastric cancer and peritoneal disease remains controversial. Some guidelines indicate palliative treatment only, while others consider surgical treatment in case of positive lavage cytology (CY+) or limited peritoneal disease. Here, we analyzed the role of peritoneal disease in patients with gastric cancer, and the prognostic relevance of response to neoadjuvant therapy.

Methods

In this retrospective cohort analysis, we analyzed patients with adenocarcinoma of the stomach or esophago-gastric junction from a single center operated between 2011 and 2019. According to histology and lavage cytology, patients were classified into four risk groups: (A) no peritoneal disease, (B) CY+ who converted to negative lavage cytology (CY−) after neoadjuvant chemotherapy, (C) CY+ without conversion after chemotherapy, and (D) patients with visible peritoneal metastasis.

Results

Overall, n = 172 patients were included. At initial presentation, n = 125 (73%) had no peritoneal disease, and about a third of patients (n = 47, 27%) had microscopic or macroscopic peritoneal disease. Among them, n = 14 (8%) were CY+ without visible peritoneal metastasis, n = 9 converted to CY− after chemotherapy, and in n = 5 no conversion was observed. Median overall survival was not reached in patients who had initially no peritoneal disease and in patients who converted after chemotherapy, resulting in 3-year survival rates of 65% and 53%. In contrast, median overall survival was reduced to 13 months (95% CI 8.7–16.7) in patients without conversion and was 16 months (95% CI 12–20.5) in patients with peritoneal metastasis without difference between the two groups (p = .364). The conversion rate from CY+ to CY− was significantly higher after neoadjuvant treatment with FLOT (5-fluorouracil plus leucovorin, oxaliplatin, and docetaxel) compared to ECF (epirubicin, cisplatin, and 5-fluorouracil) (p = 0.027).

Conclusion

Conversion of CY+ to CY− after neoadjuvant chemotherapy with FLOT is a significant prognostic factor for a better overall survival. Surgical treatment in well-selected patients should therefore be considered. However, peritoneal recurrence remains frequent despite conversion, urging for a better local control.

A Case Study on Modeling the Time to Recurrence of Gastric Cancer Patients

BACKGROUND

Gastric cancer is a malignant tumor of the stomach and it is one of the leading causes of death worldwide. The study aimed to model the time to first recurrence of gastric cancer patients at the Tikur Anbesa specialized hospital.

METHODS

The data for this study were gastric cancer patients followed up from January 1, 2013 to February 29, 2020 at Tikur Anbesa Specialized Hospital, Oncology Center, Addis Ababa. We used Weibull, log-logistic and lognormal as baseline hazard functions with the gamma and the inverse Gaussian frailty distributions. Data analyzed with the statistical software R.

RESULTS

The median recurrence time of the patients was about 23.96 months with a maximum recurrence time of 60.81 months, of which about 61.2% had first recurrences of gastric cancer. The clustering effect is significant in modeling the time to recurrence of gastric cancer. According to the result of the log-logistic inverse Gaussian frailty model, the sex of the patient, the tumor size, smoking habit, the treatment carried out, the vascular invasion, the stage of the disease, the helicobacter pylori infection and the histological type were the significant prognostic factors  at 5% level of significance.

CONCLUSION

Inverse Gaussian frailty model is the model that best describes the time to recurrence of the gastric cancer data set. Gender of the patients, tumor size, treatment taken, vascular invasion, disease stage, helicobacter pylori infection and histological type were the determining prognostic factors. This requires measures to improve patient health and prevent relapse based on significant risk factors, and particular attention should be paid to patients with such factors.

Impact of skeletal muscle mass in patients with recurrent gastric cancer

BACKGROUND

We retrospectively examined the relationship among skeletal muscle mass index (SMI), prognosis, and chemotherapy side effects in patients with recurrent gastric cancer (RGC).

METHODS

Sixty-seven patients who developed recurrence after undergoing curative gastrectomy for gastric cancer at Tottori University Hospital and received palliative chemotherapy were included in this study. Pretreatment computed tomography was performed to measure the skeletal muscle mass (SMM) and cross-sectional SMM at the third lumbar vertebra. We focused on haematologic toxicity (neutropenia, thrombocytopenia, and anaemia), febrile neutropenia, and gastrointestinal toxicity (diarrhoea, vomiting, and stomatitis) as the side effects of chemotherapy.

RESULTS

Median SMIs for males and females (43.9 and 34.7 cm²/m², respectively) were used as cutoff values. The patients were classified into high (SMI^High; n = 34) and low SMI groups (SMI^Low; n = 33). The SMI^Low group included more patients treated with monotherapy (P = 0.016) compared with the SMI^High group, had a significantly lower number of chemotherapy lines (P = 0.049), and had a significantly higher incidence of grade 3 or 4 side effects (P = 0.010). The median survival rate was significantly higher in the SMI^High group (17.8 vs 15.8 months; P = 0.034). In the univariate analysis, body mass index, SMI, histological type, and prognostic nutritional index were identified as prognostic indicators. The multivariate analysis identified SMI (P = 0.037) and histological type (P = 0.028) as independent prognostic factors.

CONCLUSION

The incidence of grade 3 or 4 side effects was significantly higher in patients with SMI^Low RGC. SMI was a useful prognostic marker of RGC.

Adequate period of surveillance in each stage for curatively resected gastric cancer: analyzing the time and rates of recurrence

BACKGROUND

Surveillance after curative surgery for gastric cancer is conventionally performed for 5 years. However, the appropriate follow-up period remains controversial.

METHODS

This study retrospectively compiled a clinicopathological database of patients who underwent curative gastrectomy between 1975 and 2010 at Toranomon Hospital and were reviewed until March 2020. Analyzing the follow-up rate and recurrence rate for each stage in each postoperative year, we set each follow-up endpoint when the subsequent recurrence rate fell below 1%.

RESULTS

A total of 5235 patients were eligible for inclusion in the study. The rate of patients followed up for 5 years was 90.3%. The rates of follow-up were 52.7% at 10 years, 38.3% at 15 years, and 10.3% at 20 years. Recurrence was confirmed in 850 patients in total (16.2%) and in 50 patients beyond 5 years. The adequate follow-up endpoints according to stage (with < 1% recurrence risk) were 2 years for stage IA, 4 years for IB, 6 years for IIA, 9 years for IIB, 7 years for IIIA, and 8 years for IV (curative). For stage IIIB and IIIC, the recurrence risk remained.

CONCLUSIONS

The adequate surveillance duration of resected gastric cancer might be different in each stage. Although the follow-up duration for stage I disease could be reduced to less than 5 years, advanced gastric cancer such as stage III or IV disease has risk of recurrence beyond 5 years and therefore additional follow-up is required. These results could help decide the strategy for surveillance.

Detection of asymptomatic recurrence improves survival of gastric cancer patients

BACKGROUND

The effect of long-term surveillance for asymptomatic patients after curative resection of gastric cancer is being debated. We compared the prognosis of Korean patients with recurrent gastric cancer according to the presence or absence of cancer-related symptoms at the time of recurrence detection.

METHODS

We retrospectively reviewed the medical records of 305 Korean patients who experienced recurrence after curative resection of primary gastric cancer between March 2002 and February 2017 at Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.

RESULTS

The median follow-up duration was 169.8 months (1-267.2), and the median age at first recurrence was 58.1 years (23.4-81.9). Among 305 patients with recurrence, 97 of 231 (42.0%) patients with early recurrence (≤5 years after curative surgical resection) and 47 of 74 (63.5%) patients with late recurrence (>5 years after curative surgical resection) had cancer-related symptoms at recurrence (p = 0.001). For survival after recurrence, detection of asymptomatic recurrence was an independent favorable factor (hazard ratio, 0.527; 95% confidence interval, 0.409-0.681; p < 0.001) accompanied with the possibility of subsequent treatment, targeted-, or immunotherapy for recurrent disease, and locoregional recurrence only. In the late-recurrence group, the patients with asymptomatic detection of recurrence showed favorable post-recurrence survival (median, 33.3 months vs. 14.7 months; p = 0.002), overall survival (median, 136.3 months vs. 106.1 months; p = 0.010), and cancer-specific survival (median, 177.5 months vs. 106.1 months; p = 0.005) than the patients with symptomatic detection.

CONCLUSION

The detection of gastric cancer recurrence in patients without cancer-related symptoms may be related to improved survival, suggesting the potential benefit of long-term surveillance.

Pulmonary lymphangitic carcinomatosis from recurrent gastric cancer 19 years after primary resection: a case report

Pulmonary lymphangitic carcinomatosis is one rare pattern of pulmonary metastases in advanced cancers. Gastric cancer is one of the most common forms of cancer that causes pulmonary lymphangitic carcinomatosis. However, recurrent gastric cancer presenting as pulmonary lymphangitic carcinomatosis after surgery is extremely rare. Furthermore, recurrence is usually observed within 5 years. We present the first case of pulmonary lymphangitic carcinomatosis in a patient with recurrent gastric cancer, 19 years after resection. In patients with a history of gastric cancer and the presence of interstitial shadow, pulmonary lymphangitic carcinomatosis should be considered in the differential diagnosis even if several years have passed since surgery.

Prognostic Value of Restaging F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography to Predict 3-Year Post-Recurrence Survival in Patients with Recurrent Gastric Cancer after Curative Resection

OBJECTIVE

The aim of this study was to investigate the prognostic value of the maximum standardized uptake value (SUV_max) measured while restaging with F-18 fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) to predict the 3-year post-recurrence survival (PRS) in patients with recurrent gastric cancer after curative surgical resection.

MATERIALS AND METHODS

In total, 47 patients with recurrent gastric cancer after curative resection who underwent restaging with ¹⁸F-FDG PET/CT were included. For the semiquantitative analysis, SUV_max was measured over the visually discernable ¹⁸F-FDG-avid recurrent lesions. Cox proportional-hazards regression models were used to predict the 3-year PRS. Differences in 3-year PRS were assessed with the Kaplan-Meier analysis.

RESULTS

Thirty-nine of the 47 patients (83%) expired within 3 years after recurrence in the median follow-up period of 30.3 months. In the multivariate analysis, SUV_max (p = 0.012), weight loss (p = 0.025), and neutrophil count (p = 0.006) were significant prognostic factors for 3-year PRS. The Kaplan-Meier curves demonstrated significantly poor 3-year PRS in patients with SUV_max > 5.1 than in those with SUV_max ≤ 5.1 (3-year PRS rate, 3.5% vs. 38.9%, p < 0.001).

CONCLUSION

High SUV_max on restaging with ¹⁸F-FDG PET/CT is a poor prognostic factor for 3-year PRS. It may strengthen the role of ¹⁸F-FDG PET/CT in further stratifying the prognosis of recurrent gastric cancer.

Pulmonary resection for metachronous metastatic gastric cancer diagnosed using multi-detector computed tomography: Report of five cases

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The standard treatment for metastatic gastric cancer is systemic chemotherapy.

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Pulmonary resection for metastatic gastric cancer has been rarely reported on.

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Five patients with metastatic gastric cancer diagnosed using MDCT underwent surgery.

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We demonstrated remarkably better survival values compared to previous reports.

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Pulmonary resection may be treatment option for select patients.

Introduction

As pulmonary resection for metastatic gastric cancer has been rarely reported on, the role of metastasectomy remains unclear in such settings. We reviewed the clinicopathological characteristics and surgical outcomes of patients with metachronous pulmonary metastasis from gastric cancer (MPMGC) diagnosed using multi-detector computed tomography (MDCT) who underwent pulmonary resection.

Presentation of case

From September 2002 to May 2018, five patients underwent pulmonary resection for MPMGC at Shizuoka Cancer Center. All patients received curative resection for initial gastric cancer. Three patients received adjuvant chemotherapy. The median age at pulmonary resection was 70 years. The median disease-free interval between initial gastrectomy and MPMGC diagnosis was 41 months. The first site of recurrence was the lung in all patients. All patients were diagnosed as having primary lung cancer using MDCT before pulmonary resection and fit the surgical indication for primary lung cancer. Lobectomy was performed in three patients, while wedge resection was performed in two. The median overall survival following pulmonary resection was 79 (range, 18–89) months. Two patients experienced recurrence. While one showed recurrence in the mediastinal lymph node, in the other it was observed in the remnant lung; the latter underwent repeated pulmonary resection followed by systemic chemotherapy. Four patients survived for longer than 4 years after pulmonary resection.

Conclusions

Of the five patients with MPMGC diagnosed using MDCT who underwent pulmonary resection, long-term survival was achieved after pulmonary resection in four. Thus, pulmonary resection may be considered for those diagnosed with lung nodules after surgery for gastric cancer, and who fit the surgical indication for primary lung cancer.

Late recurrence of gastric carcinoma 15 years after surgery

A 70-year-old man who had undergone total gastrectomy 15 years ago for mucinous gastric carcinoma on the lesser curvature of the cardia, visited our hospital complaining of cough. Chest X-ray showed a right hilar shadow and an infiltrative shadow in the left middle lung field, which was not seen in the previous year. Whole-body positron emission tomography-computed tomography (CT) revealed abnormal uptake in the irregular consolidation of the left lung, enlarged right hilar lymph nodes, and a mass lesion on the right adrenal gland. Advanced primary lung adenocarcinoma with multi-organ metastasis was suspected and a CT-guided percutaneous lung biopsy was performed. Histopathological examination showed immunostaining patterns in complete accordance with those of the resected specimen of stomach, and the diagnosis of late recurrence of gastric carcinoma was confirmed. Pulmonary metastasis might have occurred as a direct hematogenous metastasis rather than through the liver. He achieved 31 months survival after the diagnosis receiving some sequences of chemotherapy. Late recurrence over 10 years after gastrectomy is extremely rare and significant predictive factors of late recurrence are not known. We hope that this case will help in detecting significant factors predictive of late recurrence after gastrectomy for gastric carcinoma.

Recurrence of Cutaneous and Lymph Node Metastases 12 Years after Radical Total Gastrectomy for Stage IIA Gastric Cancer

We herein report a rare case of cutaneous and lymph node metastases that recurred 12 years after radical total gastrectomy for stage IIA gastric cancer. A 62-year-old man had undergone total gastrectomy for stage IIA gastric cancer 12 years earlier without postoperative adjuvant chemotherapy. At 12 years after the surgery, he was admitted for left jugular swelling. Computed tomography revealed supraclavicular lymph node swelling and precordial subcutaneous edema. The lymph node specimens and cutaneous biopsies indicated late recurrence of the gastric cancer. Concurrent chemoradiotherapy was administered effectively, but after eight months, the patient died due to deterioration in his general condition.

Long Noncoding RNA DLGAP1-AS1 Promotes the Aggressive Behavior of Gastric Cancer by Acting as a ceRNA for microRNA-628-5p and Raising Astrocyte Elevated Gene 1 Expression

Purpose

The long noncoding RNA DLGAP1 antisense RNA 1 (DLGAP1-AS1) plays well-defined roles in the malignant progression of hepatocellular carcinoma. The purpose of this study was to determine whether DLGAP1-AS1 affects the aggressive behavior of gastric cancer (GC).

Methods

DLGAP1-AS1 expression in GC tissue samples and cell lines was determined by reverse-transcription quantitative PCR. GC cell proliferation, apoptosis, migration, invasion, and tumor growth in vitro as well as in vivo were examined by the Cell Counting Kit-8 assay, flow-cytometric analysis, transwell migration and invasion assays, and xenograft model experiments, respectively.

Results

DLGAP1-AS1 was overexpressed in GC tissue samples and cell lines. Among patients with GC, the increased level of DLGAP1-AS1 correlated with tumor size, TNM stage, lymph node metastasis, distant metastasis, and shorter overall survival. The knockdown of DLGAP1-AS1 suppressed GC cell proliferation, migration, and invasion in vitro, as well as promoted cell apoptosis and hindered tumor growth in vivo. Mechanistically, DLGAP1-AS1 functioned as a competing endogenous RNA for microRNA-628-5p (miR-628-5p) in GC cells, thereby increasing the expression of the miR-628-5p target astrocyte elevated gene 1 (AEG-1). Functionally, the recovery of the miR-628-5p/AEG-1 axis output attenuated the effects of DLGAP1-AS1 knockdown in GC cells.

Conclusion

DLGAP1-AS1 is a pleiotropic oncogenic lncRNA in GC. DLGAP1-AS1 plays a pivotal part in the oncogenicity of GC in vitro and in vivo by regulating the miR-628-5p/AEG-1 axis. DLGAP1-AS1, miR-628-5p, and AEG-1 form a regulatory pathway to facilitate GC progression, suggesting this pathway as an effective target for the treatment of GC.

Mechanism of metastasis to the spermatic cord and testis from advanced gastric cancer: a case report

BACKGROUND

The spermatic cord and testis are very rare sites for metastasis from gastric cancer. Although several mechanisms have been suggested to explain this unusual metastasis, the actual mechanism remains unclear. We report a case of right spermatic cord and testicular metastasis, review its imaging findings, and suggest a mechanism of tumor spread.

CASE PRESENTATION

A 61-year-old man complained of a palpable mass in the right inguinal area. He had been treated with distal gastrectomy with chemotherapy for advanced gastric cancer 5 years ago. Computed tomography, ultrasound, and magnetic resonance imaging showed a mass surrounding the right spermatic cord, involving the right testis. Another mass was observed in the aortocaval space, presumed to be a metastatic lymph node. The imaging features of the right testicular lesion were different than those of the primary testicular cancer. The lesions at both sites showed similar radiologic features of abundant internal necrosis, which is consistent with metastatic lesions. Pathology confirmed metastatic adenocarcinoma. He underwent a series of chemotherapy sessions, and all metastatic masses had partially decreased in size at the 5-month outpatient follow-up.

CONCLUSIONS

The imaging features of testicular mass and spermatic cord involvement are important clues for accurate differential diagnosis of metastasis from other primary tumors in patients with a history of stomach cancer. This unusual metastasis can be explained via retrograde tumor spread along the lymphatic channels in terms of concurrent aortocaval lymph node metastasis. A suspicion of metastasis should not be overlooked, even if a patient has undergone curative treatment, including surgery and adjuvant chemotherapy, many years ago.

Long noncoding RNA LINC00339 promotes the oncogenicity of gastric cancer by regulating SRY-box 9 expression via sponging of microRNA-539

Differential expression of LINC00339 is involved in the malignancy of multiple human cancer types. Nonetheless, the expression profile, functions, and potential mechanisms of action of LINC00339 in gastric cancer are yet to be fully elucidated. This study aimed at measuring LINC00339 expression in gastric cancer and examining the prognostic significance of LINC00339 in patients with gastric cancer. The detailed functions of LINC00339 with regard to the aggressive characteristics of gastric cancer cells and the underlying molecular mechanisms were investigated. Here, we found that LINC00339 expression was aberrantly high in gastric cancer and significantly associated with lymph node metastasis, invasive depth, and TNM stage. Patients with gastric cancer in a LINC00339 high-expression group showed shorter overall survival than patients in a LINC00339 low-expression group. A knockdown of LINC00339 suppressed gastric cancer cell proliferation, migration, and invasion and induced apoptosis in vitro and slowed tumor growth in vivo. In terms of the mechanism, LINC00339 was found to act as a molecular sponge on microRNA-539 (miR-539). SRY-box 9 (SOX9) was confirmed as a direct target gene of miR-539 in gastric cancer cells. An miR-539 knockdown attenuated the effects of the LINC00339 knockdown on the malignant characteristics of gastric cancer cells. Overall, LINC00339 plays a critical role in the malignancy of gastric cancer by regulating SOX9 via sponging of miR‑539. Our findings highlight the importance of the LINC00339-miR-539-SOX9 pathway in gastric cancer pathogenesis and may point to novel targets for the diagnosis, prognosis, and/or treatment of gastric cancer.

INTRODUCTION OF THE NEW LYMPHOPARIETAL INDEX FOR GASTRIC CANCER PATIENTS

Background:

The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients.

Aim:

Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent.

Method:

Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries.

Results:

A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96).

Conclusion:

The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.

A case of a long-term survival achieved by surgical treatment and chemotherapy for late recurrence of AFP-producing gastric cancer

Background

Alpha-fetoprotein-producing gastric cancer (AFP-GC) is a relatively rare disease, with a dismal prognosis.

Case presentation

We report the case of a patient with long-term survival after surgery for the recurrence of AFP-GC. A 71-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy with D2 lymphadenectomy (pT3N2M0). Pathological examination of the resected specimen revealed AFP-GC. Fifteen years after the gastrectomy, the patient experienced anorexia and was admitted with a mass located at the mesentery of the small intestine. Following a diagnosis of gastrointestinal stromal tumor of the mesentery, a tumor resection with partial small intestine was performed. The final histopathological diagnosis was AFP-GC’s recurrence in the small-bowel mesentery. Two months later, multiple liver metastases were identified, and serum AFP level was found to be extremely high (17,447 ng/mL). Chemotherapy with S-1+CDDP (SP) was initiated for liver metastasis. However, owing to anorexia and fatigue, SP therapy was discontinued following the patient’s request at the end of two courses. A CT scan at 1 month after the discontinuation of chemotherapy did not reveal liver metastasis, and serum AFP level decreased to the normal range. He is alive at present with no re-recurrence and no elevation of serum AFP level at 7 years after the second surgery without any chemotherapy.

Conclusion

Even if recurrence of AFP-GC is diagnosed, radical resection and chemotherapy are effective, as noted in the present case.

OGDH mediates the inhibition of SIRT5 on cell proliferation and migration of gastric cancer

SIRT5 has a wide range of functions in different cellular processes such as glycolysis, TCA cycle and antioxidant defense, which mediates lysine desuccinylation, deglutarylation and demalonylation. Recent evidences have implicated that SIRT5 is a potential suppressor of gastric cancer (GC). However, the underlying mechanism of SIRT5 in gastric cancer is still unclear. Here, we show that SIRT5 expression is significantly decreased in human GC tissues. Functional analysis demonstrates that SIRT5 inhibits cell growth in vitro and in vivo, arrests the cell cycle in G1/S transition, and suppresses migration and invasion of GC cells via regulating epithelial-to-mesenchymal transition. Mechanistically, we demonstrate that there is the direct interaction between SIRT5 and 2-oxoglutarate dehydrogenase (OGDH), and desuccinylation of OGDH by SIRT5 inhibits the activity of OGDH complex. Further studies of the relationship between SIRT5 and OGDH show OGDH inhibition by succinyl phosphonate (SP) or siRNA suppresses the increase in cell growth and migration induced by SIRT5 deletion. Moreover, SIRT5 decreases mitochondrial membrane potential (ΔΨm), ATP products and increases the ROS levels and NADP/NADPH ratio in GC cells through the inhibition of OGDH complex activity. Therefore, SIRT5 suppresses GC cell growth and migration through desuccinylating OGDH and inhibiting OGDH complex activity to disturb mitochondrial functions and redox status.

The role of Tenascin-C and Twist1 in gastric cancer: cancer progression and prognosis

The aim of the present study was to identify the relation between Tenascin-C (TNC) and Twist1 and determine their clinical significance in gastric cancer (GC). We analyzed the expression of TNC and Twist1 in 159 GC samples and in 91 non-tumor samples using immunohistochemistry. In this study, TNC expression in stromal fibroblasts of GC was remarkably higher than non-tumor gastric lesions. The expression of TNC in GC stromal fibroblasts was significantly associated with pT stage, lymph node metastasis, distant metastasis. Twist1 expression in stromal fibroblasts of GC was remarkably higher than non-tumor gastric lesions. Twist1 expression in the stromal fibroblasts of GC was associated with tumor size, lymph node metastasis, and clinical stage. Furthermore, TNC expression levels in GC stromal fibroblasts were positively associated with Twist1. The simultaneous expression of TNC and Twist1 was significantly higher in stromal fibroblasts of GC than in noncancerous tissues. The simultaneous expression of TNC and Twist1 in GC stromal fibroblasts was positively associated with tumor location, pT stage, lymph node metastasis and clinical stage. Moreover, patients with co-expression of TNC and Twist1 had a poorer prognosis than either TNC or Twist1 positive in GC. Our study revealed that the simultaneous expression of TNC and Twist1 indicated the poorer prognosis of GC. Co-targeting TNC and Twist1 confer significant clinical advantage, which offers a novel therapeutic target in GC.

Aldolase A as a prognostic factor and mediator of progression via inducing epithelial-mesenchymal transition in gastric cancer

Glycolysis is regarded as the hallmark of cancer development and progression, which involves a multistep enzymatic reaction. This study aimed to explore the clinicopathological significance and potential role of glycolytic enzyme aldolase A (ALDOA) in the carcinogenesis and progression of gastric cancer (GC). ALDOA was screened from three paired liver metastasis tissues and primary GC tissues and further explored with clinical samples and in vitro studies. The ALDOA protein level significantly correlated with a larger tumor diameter (P = .004), advanced T stage (P < .001), N stage (P < .001) and lymphovascular invasion (P = .001). Moreover, the expression of ALDOA was an independent prognostic factor for the 5‐year overall survival and disease‐free survival of patients with GC in both univariate and multivariate survival analyses (P < .05). Silencing the expression of ALDOA in GC cell lines significantly impaired cell growth, proliferation and invasion ability (P < .05). Knockdown of the expression of ALDOA reversed the epithelial–mesenchymal transition process. Mechanically, ALDOA could affect the hypoxia‐inducible factor (HIF)‐1α activity as demonstrated by the HIF‐1α response element–luciferase activity in GC cells. Collectively, this study revealed that ALDOA was a potential biomarker of GC prognosis and was important in the carcinogenesis and progression of human GC.

CDK2 positively regulates aerobic glycolysis by suppressing SIRT5 in gastric cancer

Although significant progress has been made in the diagnosis and treatment of gastric cancer, the overall survival rate of the disease remains unchanged at approximately 20%‐25%. Thus, there is an urgent need for a better understanding of the molecular biology aspects of the disease in the hope of discovering novel diagnosis and treatment strategies. Recent years have witnessed decisive roles of aberrant cancer cell metabolism in the maintenance of malignant hallmarks of cancers, and cancer cell metabolism has been regarded as a novel target for the treatment of cancer. CDK2, a cell cycle‐dependent kinase that usually regulates cell cycle progression and the DNA damage response, is reported to be upregulated in many cancers. However, little is known about its role in cancer cell metabolism. In the present study, we showed that silencing CDK2 inhibited the aerobic glycolytic capacity of gastric cancer cell lines. Mechanism explorations showed that silencing CDK2 increased expression of the SIRT5 tumor suppressor. In addition, the physiological roles of SIRT5 in the regulation of proliferation and glycolysis were studied in gastric cancer cells. Taken together, the present study uncovered novel roles of the CDK2/SIRT5 axis in gastric cancer and suggests future studies concerning gastric cancer cell metabolism.

MicroRNA-28 promotes cell proliferation and invasion in gastric cancer via the PTEN/PI3K/AKT signalling pathway

Gastric cancer is the fourth most common malignant disease and second leading cause of cancer‑associated mortalities worldwide. Previous studies revealed aberrantly expressed microRNAs (miRNAs) in various types of human cancer; these miRNAs play important roles in tumourigenesis and tumour development. miRNAs present a considerable potential for novel therapeutic approaches for treating human cancer. Therefore, the investigation of novel miRNAs involved in gastric cancer progression provides an opportunity to improve the prognosis of patients with gastric cancer. miRNA‑28 (miR‑28) has been investigated with regards to its expression and biological functions in many types of human cancer. However, previous studies have not discussed the expression patterns, roles and associated molecular mechanisms of miR‑28 in gastric cancer. In the present study, miR‑28 expression was identified to be upregulated in gastric cancer tissues and cell lines. miR‑28 inhibition functionally inhibited cell proliferation and invasion in gastric cancer in vitro. Using bioinformatics analysis, luciferase reporter assay, reverse transcription‑quantitative polymerase chain reaction and western blot analysis, phosphatase and tensin homolog (PTEN) was mechanically identified as a direct target of miR‑28 in gastric cancer. PTEN was downregulated in gastric cancer and negatively correlated with miR‑28 levels. Inhibition of PTEN restored the biological effects of miR‑28 downregulation on the proliferation and invasion of gastric cancer cells. Notably, the downregulation of miR‑28 results in the regulation of the phosphatidylinositol 3‑kinase/protein kinase B signaling pathway in gastric cancer. These results suggested that miR‑28 may be targeted for the development of novel treatments for gastric cancer in the future.

IL-6 secreted by cancer-associated fibroblasts promotes epithelial-mesenchymal transition and metastasis of gastric cancer via JAK2/STAT3 signaling pathway

Cancer-associated fibroblasts (CAFs), as the activated fibroblasts in tumor stroma, are important modifiers of tumor progression. However, the molecular mechanisms underlying the tumor-promoting properties of CAFs in gastric cancer remain unclear. Here, we show that CAFs isolated from gastric cancer produce significant amounts of interleukin-6 (IL-6). CAFs enhances the migration and EMT of gastric cancer cells through the secretion of IL-6 that activates Janus kinase 2/signal transducers and activators of transcription (JAK2/STAT3) pathway in gastric cancer cells, while deprivation of IL-6 using a neutralizing antibody or inhibition of JAK/STAT3 pathway with specific inhibitor AG490 markedly attenuates these phenotypes in gastric cancer cells induced by CAFs. Moreover, silencing IL-6 expression in CAFs or inhibiting JAK2/STAT3 pathway in gastric cancer cells impairs tumor peritoneal metastasis induced by CAFs in vivo. Taken together, these results suggest that CAFs in the tumor microenvironment promote the progression of gastric cancer through IL-6/JAK2/STAT3 signaling, and IL-6 targeted therapy could be a complementary approach against gastric cancer by exerting their action on stromal fibroblasts.

Treatment outcomes of hepatectomy for liver metastases of gastric cancer diagnosed using contrast-enhanced magnetic resonance imaging

BACKGROUND

Chemotherapy is the standard treatment for liver metastases of gastric cancer (LMGC). Hepatectomy for LMGC reportedly has a 5-year survival rate of 13-37 %; however, its significance has not been established. At our hospital, hepatectomy is performed for patients with three or fewer metastases diagnosed using contrast-enhanced magnetic resonance imaging (MRI). To identify the ideal patient subpopulation for resection, we retrospectively analyzed treatment outcomes in patients with LMGC who underwent hepatectomy.

METHODS

Clinicopathological factors affecting survival were explored using univariate and multivariate analyses in 28 patients who underwent hepatectomy for LMGC diagnosed using contrast-enhanced MRI between December 2004 and October 2014.

RESULTS

The study included 23 men and 5 women with a median age of 72 years. Metastases were synchronous in 15 patients and metachronous in 13 patients. The median overall survival time was 49 months, with a 5-year survival rate of 32 %. Univariate analysis revealed that overall survival time was shorter in the presence of the following factors: age ≥70 years (p = 0.030), synchronous liver metastases (p = 0.017), and presence of postoperative complications (p = 0.042). In patients with metachronous liver metastases, the post-resection 5-year survival rate was 59 %.

CONCLUSIONS

The 5-year survival rate was 32 % in patients who underwent hepatectomy for LMGC according to our criteria, suggesting that hepatectomy is an important treatment if indications are on the basis of contrast-enhanced MRI. Therefore, active resection should be considered, particularly for patients with metachronous liver metastases.

Up-regulation of CRKL by microRNA-335 methylation is associated with poor prognosis in gastric cancer

BACKGROUND

MicroRNAs have been suggested to play a vital role in regulating carcinogenesis, tumor progression and invasion. MiR-335 is involved in suppressing metastasis and invasion in various human cancers. However, the mechanisms responsible for the aberrant expression of miR-335 in gastric cancer (GC) remain unknown.

METHODS

Expression of miR-335 in four GC cell lines and 231 GC tissues was determined by real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR). DNA methylation status in the CpG islands upstream of miR-335 in GC cell lines and tissues was determined by methylation-specific PCR and bisulfite sequence-PCR. The effects of the demethylating agent 5-aza-2'-deoxycytidine on cell proliferation, apoptosis, cell cycle, migration, and invasion were investigated in GC cell lines.

RESULTS

Cancer-specific methylation was detected in the upstream CpG-rich regions of miR-335, which dramatically silenced its transcriptional activity in GC cell lines and tissues. Low levels of miR-335 expression and high levels of miR-335 methylation in GC tissues were associated with poor clinical features and prognosis. Restoration of miR-335 expression in GC cells promoted cell apoptosis, inhibited tumor cell migration, invasion, and proliferation, and arrested the cell cycle at G0/G1 phase. Overexpression of miR-335 significantly reduced the activity of a luciferase reporter containing the 3' untranslated region of V-crk avian sarcoma virus CT10 oncogene homolog-like (CRKL).

CONCLUSIONS

MiR-335 functions as a tumor suppressor and may be silenced by promoter hypermethylation. It plays a role in inhibiting tumor cell migration, invasion, and proliferation, arresting the cell cycle at G0/G1 phase, and promoting apoptosis in GC cells through targeting CRKL.

Early gastric cancer metastasizing to the rectum, possibly via a hematogenous route: a case report and review of literature

BACKGROUND

The most common pattern of recurrence of gastric cancer (GC) is peritoneal dissemination. However, rectal metastasis via hematogenous or lymphatic spread is exceedingly rare. We present a case of a 65-year-old man with an intramucosal GC who developed a rectal recurrence, possibly via a hematogenous route.

CASE PRESENTATION

A 65-year-old man underwent curative endoscopic submucosal dissections for the intramucosal GCs at the anterior wall of the fornix twice. The third GC at the similar location was treated by radical laparoscopic proximal gastrectomy; microscopic examination revealed well-differentiated tubular adenocarcinoma confined to the lamina propria mucosae (T1aN0M0, stage IA). Follow-up colonoscopy revealed a 30-mm submucosal mass in the rectal wall 2 years later, and a metastasis of gastric origin was suspected histopathologically. After a staging laparoscopy confirmed the absence of findings suggestive of serosal involvement or peritoneal dissemination, including negative peritoneal washing cytology, a laparoscopic low anterior resection with lymph node dissection was performed. Microscopically, the tumor was found to mainly be located in the submucosal layer and showed features of moderately differentiated tubular adenocarcinoma. The serosal surface was free of disseminated tumor. Lymph node metastases were identified. Immunohistochemically, there were foci of carcinoma cells that were positive for cytokeratin 20; however, they were negative for cytokeratin 7. Negative staining for caudal-type homeobox 2, a transcription factor indicating goblet cell differentiation, combined with absence of intramucosal carcinoma in the rectal mucosa, suggested a diagnosis of metastatic adenocarcinoma of gastric origin. The absence of evidence of peritoneal dissemination suggested hematogenous or lymphatic spread.

CONCLUSION

Although rectal metastasis from GC, particularly when attributable to hematologic or lymphatic metastasis, is very rare, metastatic gastric adenocarcinoma should be considered as a differential diagnosis for patients who present with a rectal tumor and a past history of GC, even if it is an early GC.

MicroRNA-106a functions as an oncogene in human gastric cancer and contributes to proliferation and metastasis in vitro and in vivo

Mounting evidences has shown that miRNAs are involved in the development and progression of gastric cancer acts as tumor suppressor genes or oncogenes. In our previous studies, we have found that the up-regulation of miR-106a occurs frequently in human gastric cancer tissues compared with that of normal tissues. Here, we investigate the role of the ectopic expressed miR-106a in the progression and metastasis of gastric cancer in vitro and in vivo. FFPE samples have the priority to be included and qRT-PCR was used to detect the miR-106a expression. Human gastric cancer cells and immortalized gastric epithelial cell were selected and the miR-106a mimic and inhibitor were transfected. Cell growth was determined by MTT method. The flow cytometric analysis for cell apoptosis and transwell assays for evaluating the cell migration and invasion were conducted. Luciferase assay and western blot confirmed the direct binding site of miR-106a and its target. BALB/c nude mice were randomly divided to explore the implantation of gastric cancer cells transfected with miR-106a antagomir. Abnormal over-expression of miR-106a significantly promoted gastric cancer cell proliferation, metastasis, inhibited the cell apoptosis. Functional experiment ascertained that miR-106a interacted with FAS and mediated caspase3 pathway. Knockdown of miR-106a leaded to the attenuation of gastric cancer implantation capacity in vivo. Moreover, expression of TIMP2 was inversely associated with miR-106a in nodule tissues. Apoptotic body was also seen under electron microscope accompanied by silencing of miR-106a. Together, this data indicated that miR-106a may act as an oncogene and contribute to gastric cancer development.

ZHX1 Inhibits Gastric Cancer Cell Growth through Inducing Cell-Cycle Arrest and Apoptosis

Zinc-fingers and homeoboxes 1 (ZHX1) was implicated in the carcinogenesis of human cancers. However, little is known about the role of ZHX1 in gastric cancer (GC). Here, we found that ZHX1 was downregulated in GC tissues compared with paired non-tumor tissues and loss of ZHX1 expression correlated with aggressive clinical characteristics of GC patients. ZHX1 induced G1/S arrest by decreasing cyclin D1 and cyclin E expression, and induced cell apoptosis by Bcl2 downregulation and Bax and cleaved Caspase-3 upregulation. Our findings revealed that ZHX1 could inhibit cell growth through inducing cell-cycle arrest and apoptosis in GC.

Characteristics of gastric cancer recurrence five or more years after curative gastrectomy

OBJECTIVE

To investigate the characteristics of recurrences that occurred 5 or more years after curative resection for gastric cancer.

METHODS

We analyzed recurrences among 1,299 patients with gastric cancer who underwent curative operations at the Department of Surgery, Inje University Seoul Paik Hospital between September 1998 and December 2002. Recurrences were classified as within 2 years (early), 2-5 years (intermediate), and more than 5 years (late) after gastrectomy. The clinicopathologic findings of the patients with late recurrence were compared with those of patients in the other two recurrence groups, with special reference to the patterns of recurrence. Both univariate and multivariate analyses were performed, incorporating factors such as operation type, T-stage, N-stage, stage, lymphatic invasion, neural invasion, histology, tumor size, and recurrence site.

RESULTS

At the time of last follow-up, recurrence occurred in 266 (20.5%) patients. Recurrence times were classified as <2 years (182 patients), 2-5 years (61 patients), or >5 years (23 patients). The late recurrence rate was 8.6%. The occurrence of recurrence >5 years after gastrectomy was significantly correlated with age, operation type, T-stage, N-stage, stage, lymphatic invasion, neural invasion, histology, tumor size, location and recurrence site (P<0.05). The main recurrence patterns in the 23 patients with late recurrence were locoregional metastasis (10 patients, 43.5%), peritoneal seeding (8 patients, 34.8%), hematogenous metastasis (2 patients, 8.7%), and multiple metastasis (3 patients, 13.0%). A multivariate analysis showed that larger tumor size and younger age were independent prognostic factors for late recurrence. Additionally, locoregional and peritoneal recurrences were significantly more common than hematogenous recurrences.

CONCLUSIONS

Although late recurrence was uncommon, younger age and larger tumor size were associated with high risk. Follow-up surveillance is recommended for locoregional and peritoneal metastasis.

Recurrence of gastric cancer in patients who are disease-free for more than 5 years after primary resection

BACKGROUND

Late recurrence of gastric cancer is rare and there are few data on recurrence in patients who are disease free for >5 years after gastrectomy. The aim of this study was to evaluate the predictors and status of tumor recurrence among these patients.

METHODS

Clinicopathologic characteristics, patterns of recurrence, and postrecurrence survival were analyzed in patients who were diagnosed as disease free at 5 years postoperatively and thereafter experienced recurrence. Independent factors associated with the late recurrence were analyzed.

RESULTS

Among 1,573 patients who underwent curative surgery from June 1992 to December 2006, 348 patients had recurrence. Of them, 7.6% (n = 25) suffered from late recurrence after 5 years after gastrectomy. Among patients who were diagnosed as disease free at 5 years after surgery, it accounted for 2.8% (25/902). Cases with late recurrence were characterized by more aggressive clinicopathologic features than those without recurrence. The median time to recurrence was 88.8 months (range, 64.8-238.0); of the 25 patients, 18 (72.0%) had recurrence within 8 years after surgery. The most common pattern was peritoneal recurrence (n = 19; 76.0%). The estimated median survival after recurrence was 9.4 months. On multivariate analysis, pT4 classification was the only independent risk factor for late recurrence. There were 185 patients with pT4 tumor who had no recurrence at 5 years after surgery; 19 (10.3%) had late recurrence.

CONCLUSION

pT4 tumor was the only important predictor of late recurrence. Whether extended follow-up for T4 tumors affects survival needs to be demonstrated in more large-scale studies.

Reduced miR-126 expression facilitates angiogenesis of gastric cancer through its regulation on VEGF-A

miR-126 is an endothelial-specific microRNA essential for governing vascular integrity and angiogenesis. Its role in tumor angiogenesis of gastric cancer (GC) is unclear. This study aimed at determining the role of miR-126 in GC angiogenesis. Down-regulation of miR-126 was found to inversely correlate with an increased microvessel density (MVD) and vascular endothelial growth factor A (VEGF-A) expression in gastric cancer tissues. Bioinformatics analysis and luciferase reporter assay revealed that miR-126 directly targeted the 3′-untranslated region (3′-UTR) of VEGF-A mRNA. In addition, the restoration of miR-126 expression by lentivirus-miR-126 (Lenti-miR-126) transfection obviously reduced the expression of VEGF-A and the activition of its downstream genes, Akt, mTOR and Erk1/2 in gastric cancer cell lines SGC-7901, MKN-28 and MKN-45. In contrast, the down-regulation of miR-126 expression by lentivirus-anti-miR-126 (Lenti-anti-miR-126) transfection obviously up-regulated the expression of VEGF-A and its downstream signaling pathways. In vivo xenograft mice model experiments clarified the down-regulation of VEGF-A and MVD as well as inhibition of tumor growth by up-regulation of miR-126. Overall, the results from our study suggested that miR-126 could suppress tumor growth and tumor angiogenesis of GC through VEGF-A signaling, and it is a novel potential therapeutic target for GC.

Vertebral carcinomatosis eleven years after advanced gastric cancer resection: A case report

Bone metastasis is an uncommon event in advanced gastric cancer patients and bone metastases are rarely detected as isolated lesions. However, eleven years after treatment for locally advanced gastric cancer, including total gastrectomy followed by adjuvant chemotherapy, a 49-year-old female was admitted to the IX Division of General Surgery of the Second University of Naples (Naples, Italy) exhibiting severe progressive neurological symptoms. Magnetic resonance imaging indicated vertebral abnormalities, with evidence of marrow infiltration in several vertebral bodies; however, a contrast-enhanced computed tomography scan did not detect disease progression to other sites. Biopsy of the soft tissue at the level of the second lumbar vertebra (L2) revealed a metastatic lesion derived from gastric mucinous adenocarcinoma. The patient was initially treated with radiotherapy directed to the L2–L4 vertebral bodies to control the pain. Subsequently, systemic chemotherapy according to a FOLFOX-4 (leucovorin, fluorouracil and oxaliplatin) regimen commenced. However, after eight cycles, pulmonary progression of the disease occurred. Thus, palliative care was administered and the patient succumbed one month later. The late relapse of gastric cancer in the current patient may be associated with the theory of tumour dormancy.

Transmembrane protein 106A is silenced by promoter region hypermethylation and suppresses gastric cancer growth by inducing apoptosis

Inactivation of tumour suppressor genes by promoter methylation plays an important role in the initiation and progression of gastric cancer (GC). Transmembrane 106A gene (TMEM106A) encodes a novel protein of previously unknown function. This study analysed the biological functions, epigenetic changes and the clinical significance of TMEM106A in GC. Data from experiments indicate that TMEM106A is a type II membrane protein, which is localized to mitochondria and the plasma membrane. TMEM106A was down-regulated or silenced by promoter region hypermethylation in GC cell lines, but expressed in normal gastric tissues. Overexpression of TMEM106A suppressed cell growth and induced apoptosis in GC cell lines, and retarded the growth of xenografts in nude mice. These effects were associated with the activation of caspase-2, caspase-9, and caspase-3, cleavage of BID and inactivation of poly (ADP-ribose) polymerase (PARP). In primary GC samples, loss or reduction of TMEM106A expression was associated with promoter region hypermethylation. TMEM106A was methylated in 88.6% (93/105) of primary GC and 18.1% (2/11) in cancer adjacent normal tissue samples. Further analysis suggested that TMEM106A methylation in primary GCs was significantly correlated with smoking and tumour metastasis. In conclusion, TMEM106A is frequently methylated in human GC. The expression of TMEM106A is regulated by promoter hypermethylation. TMEM106A is a novel functional tumour suppressor in gastric carcinogenesis.

Late-onset metastatic adenocarcinoma of the spermatic cord from primary gastric cancer

BACKGROUND

Metastatic cancers of the paratesticular tissue are very rare; however, the most frequent primary site of spermatic cord metastasis is the gastrointestinal tract.

CASE PRESENTATION

We recently observed two cases of late-onset metastatic adenocarcinoma of the spermatic cord. Both patients complained of groin discomfort with a palpable mass in the scrotum and inguinal area. Radical orchiectomy and adjuvant chemotherapy were performed in both patients. Although the prognosis of patients with metastatic adenocarcinoma of the spermatic cord is typically poor, the prognosis of our patients was favorable after follow-up for 14 to 18 months.

CONCLUSIONS

In patients with groin discomfort or swelling and a history of gastric cancer, metastatic adenocarcinoma should be included in the differential diagnosis for early detection of tumors.

Follow-up after gastrectomy for cancer: an appraisal of the Italian research group for gastric cancer

BACKGROUND

The Italian Research Group for Gastric Cancer supports the practice of follow-up after radical surgery for gastric cancer.

METHODS

This multicenter, retrospective study (1998-2009) included patients with T1-4N0-3M0 gastric cancer who had undergone D2 gastrectomy and lymphadenectomy, with at least 15 lymph nodes examined, and who had developed recurrent disease. Timing and site of recurrence were correlated to the actual scheduled follow-up timing and modalities.

RESULTS

From eight centers, 814 patients with recurrent cancer and over 1,754 (46.4 %) patients undergoing gastrectomy were investigated (median follow-up 31 months). The most frequent sites of recurrence were local/regional lymph nodes (35.4 %), liver (24.3 %), peritoneum (30.3 %), lung (10.4 %) and intraluminal (7.5 %). Ninety-four percent of the recurrences were diagnosed within 2 years and 98 % within 3 years. Thoracoabdominal computed tomography (CT) scan and (18)F-fluoro-2-deoxy-D-glucose positron emission tomography (18-FDG-PET) detected more than 90 % of recurrences, abdominal ultrasound detected 70 % and tumor markers detected 40 %, while <10 % were identified by physical examination, chest X-ray, and upper gastrointestinal endoscopy. Twenty-six percent of patients with recurrence were treated, but only 3.2 % were treated with potentially radical intent.

CONCLUSION

Oncological follow-up after radical surgery for gastric cancer should be focused in the first 3 years, and based mainly on thoracoabdominal CT scan and 18-FDG-PET.

Solitary rib recurrence of hilar cholangiocarcinoma 10 years after resection: report of a case

A 61-year-old female underwent right hemihepatectomy and caudate lobectomy for hilar cholangiocarcinoma in 1999. Ten years later, increasing serum carbohydrate 19-9 was detected by routine follow-up. Subsequent positron emission tomography revealed an asymptomatic lesion in the right 11th rib. As the mass steadily grew in size, the lesion was resected en bloc with the affected rib and muscle. The histopathological findings closely resembled those of the primary cholangiocarcinoma. Thus, the tumor was diagnosed as a metastatic recurrence 10 years after resection of the primary tumor. There have been a few reports of cholangiocarcinoma recurrence in long-term survivors at the surgical margins, peritoneum, or transhepatic drainage route. However, there are no reports of solitary extra-abdominal recurrence. This case highlights the need for careful follow-up of patients with cholangiocarcinoma and nodal metastasis, even in the absence of recurrence for >5 years after curative resection.