Oncologic effectiveness of regular follow-up to detect recurrence after curative resection of gastric cancer

Effect of Vitamin B12 Replacement Intervals on Clinical Symptoms and Laboratory Findings in Gastric Cancer Patients after Total Gastrectomy

The management of patients with vitamin B12 deficiency after total gastrectomy (TG) remains controversial. We aimed to evaluate the effect of vitamin B12 replacement intervals on the clinical characteristics in these patients. The data from patients who received vitamin B12 supplementation after TG between 2007 and 2018 at the National Cancer Center, Korea, were retrospectively evaluated. Vitamin B12 deficiency was defined as a serum vitamin B12 level of <200 pg/mL or urine methylmalonic acid level > 3.8 mg/gCr. The patients were divided into a regular replacement group (patients received an intramuscular injection or oral medication regularly), and a lab-based replacement group (patients received vitamin B12 intermittently after checking the level). The symptoms and biochemical parameters were compared between these groups. The regular and lab-based replacement groups included 190 and 216 patients, respectively. The median vitamin B12 replacement intervals were 1 and 9 months, respectively (p < 0.001). After replacement, the regular replacement group had higher vitamin B12 levels than the lab-based replacement group (p < 0.001). However, the serum hemoglobin level showed no significant changes. After replacement, there was no significant difference in the proportion of the symptomatic patients between the groups. Replacing vitamin B12 with a lab-based protocol may be sufficient for TG patients.

Whether preferences of gastric cancer patients after surgery for follow-up change over time? Analysis based on discrete choice experiment

PURPOSES

The purposes of this discrete choice experiment are as follows: (1) quantify the relevant characteristics that may affect the follow-up selection of gastric cancer patients after surgery and (2) explore the differences in follow-up preferences of gastric cancer patients at different stages and reveal the change trend of preferences over time, thereby providing references for the formulation and optimization of follow-up strategies.

METHODS

A survey instrument that was developed using the design principle of a discrete choice experiment investigated gastric cancer patients on the day of discharge, and at 3 months, 6 months, and 12 months after discharge. In Stata 15.0, a mixed logit model was used to explore the preferences of gastric cancer patients after surgery at different stages, the willingness to pay was calculated, and the NLCOM command was used to simulate the follow-up uptake rates of different attribute levels at different stages.

RESULTS

On the day of discharge, and 3 months, 6 months, and 12 months after discharge, the most important attribute levels of gastric cancer patients after surgery were "thoroughness-very thorough," "method-face-to-face," "thoroughness-very thorough," and "provider-specialist nurse," respectively, and patients were willing to pay more for these services. Patients' preference for the attribute level "very thorough" decreased over time, while their preferences for "specialist doctors" as follow-up providers remained relatively stable. Furthermore, the attribute levels with the greatest effect on receiving the baseline follow-up program varied across stages.

CONCLUSION

The gastric cancer patients' preferences for follow-up change over time, and the time factor should be considered when developing follow-up strategies.

Evaluation of post-operative surveillance strategies for esophageal and gastric cancers: a systematic review and meta-analysis

BACKGROUND

There is no consensus or guidelines internationally to inform clinicians of how patients should be monitored for recurrence after esophagogastric resections.

AIM

This systematic review and meta-analysis summarizes the latest evidence investigating the usefulness of surveillance protocols in patients who underwent esophagectomy or gastrectomy.

METHODS

A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Articles were evaluated for the use of surveillance strategies including history-taking, physical examination, imaging modalities and endoscopy for monitoring patients post-gastrectomy or esophagectomy. Studies that compared surveillance strategies and reported detection of recurrence and post-recurrence survival were also included in the meta-analysis.

RESULTS

Fifteen studies that described a surveillance protocol for post-operative patients were included in the review. Seven studies were used in the meta-analysis. Random-effects analysis demonstrated a statistically significant higher post-recurrence survival (standardized mean difference [SMD] 14.15, 95% CI 1.40-27.26, p = 0.03) with imaging-based planned surveillance post-esophagectomy. However, the detection of recurrence (OR 1.76, 95% CI 0.78-3.97, p = 0.17) for esophageal cancers as well as detection of recurrence (OR 0.73, 95% CI 0.11-5.12, p = 0.76) and post-recurrence survival (SMD 6.42, 95% CI -2.16-18.42, p = 0.14) for gastric cancers were not significantly different with planned surveillance.

CONCLUSION

There is no consensus on whether surveillance carries prognostic survival benefit or how surveillance should be carried out. Surveillance may carry prognostic benefit for patients who underwent surgery for esophageal cancer. Randomized controlled trials are required to evaluate the survival benefits of intensive surveillance strategies, determine the ideal surveillance protocol and tailor it to the appropriate population.

Prospective multicentre randomised clinical trial comparing survival rates, quality of life and nutritional status between advanced gastric cancer patients with different follow-up intensities: study protocol for the STOFOLUP trial

INTRODUCTION

Patients who underwent curative gastrectomy for gastric cancer are regularly followed-up for the early detection of recurrence and postoperative symptom management. However, there is a lack of evidence with regard to proper surveillance intervals and diagnostic tools. This study aims to evaluate whether frequent surveillance tests have a survival benefit or improve the quality of life in patients who underwent curative resection for advanced gastric cancer.

METHODS AND ANALYSIS

The STOFOLUP trial is an investigator-initiated, parallel-assigned, multicentre randomised controlled trial involving 16 hospitals in the Republic of Korea. Patients (n=886) diagnosed with pathological stage II or III gastric adenocarcinoma will be randomised to either the 3-month or the 6-month group at a 1:1 ratio, stratified by trial site and tumour stage. Patients allocated to the 3-month group will undergo an abdominal CT scan every 3 months postoperatively and those allocated to the 6-month group will undergo CT every 6 months. The primary endpoint is 3-year overall survival and the secondary endpoints are quality of life, as assessed using KOrean QUality of life in Stomach cancer patients Study group-40, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the stomach cancer-specific module (STO22), and nutritional outcomes. Other survival data including data concerning 3-year disease-free survival, recurrence-free survival, gastric cancer-specific survival and postrecurrence survival will also be estimated. The first patient was enrolled on July 2021 and active patient enrolment is currently underway.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of eight of the participating hospitals (NCC 2021-0085, KBSMC2021-01-059, SMC 2021-01-140, KC21OEDE0082, 4-2021-0281, AJIRB-MED-INT-20-608, 2021-0515 and H-2102-093-1198). This study will be disseminated through peer-reviewed publications, national or international conferences.

TRIAL REGISTRATION NUMBER

NCT04740346.

Eliciting gastric cancer survivors' preferences for follow-up services: a discrete choice experiment protocol

INTRODUCTION

Follow-up care is important for gastric cancer survivors, but follow-up strategies for gastric cancer survivors remain inconsistent, and compliance of gastric cancer survivors with follow-up care is very low. Understanding the needs and preferences of gastric cancer survivors is conducive to developing appropriate and acceptable follow-up strategies, thereby improving patient compliance. Discrete choice experiments can quantify individual needs and preferences. However, to date, there is no discrete choice experiment on the preferences of gastric cancer survivors, and no studies have examined how gastric cancer survivors make choices based on different characteristics of follow-up. This paper outlines an ongoing discrete choice experiment that aims to (1) explore follow-up service-related characteristics that may affect gastric cancer survivors' choices about their follow-up, (2) elicit how gastric cancer survivors consider the trade-offs among different follow-up service options using discrete choice experiment, (3) determine whether gastric cancer survivors' needs and preferences for follow-up vary due to the economy, politics, technology and culture in different regions.

METHODS AND ANALYSIS

Six attributes were developed through a literature review, semistructured interviews and experts and focus group discussions. A fractional factorial design was used to evaluate the interaction between attributes. A multiple logit model will be used to understand the trade-off between the follow-up characteristics of gastric cancer survivors. A mixed logit model will be used to explore the willingness to pay and uptake rate of gastric cancer survivors for follow-up attributes and further explore the preferences of different groups.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of the School of Nursing, Jilin University. The results of this study will be shared through online blogs, policy briefs, seminars and peer-reviewed journal articles and will be used to modify the current strategy of gastric cancer survivors' follow-up services according to economic development and regional culture.

Preferences of gastric cancer survivors for follow-up care-a multicenter discrete choice experiment study

PURPOSES

The purposes of this discrete choice experiment are as follows: (1) to investigate the preferences of gastric cancer survivors for follow-up care, and (2) to quantify the importance of follow-up care-related characteristics that may affect the gastric cancer survivors' choices of their follow-up, so as to provide references for the development of the follow-up strategy of gastric cancer survivors.

METHODS

Discrete choice experimental design principle was applied to develop the survey instrument. All questionnaires were filled out by the respondents and collected on site. A mixed logit model was used to estimate gastric cancer survivors' preferences. Willingness to pay estimates and simulations of follow-up uptake rates were calculated.

RESULTS

All six attributes are significantly important for the follow-up care of gastric cancer survivors (p < 0.05). Achieving very thorough follow-up contents was the most valued attribute level (coefficient = 1.995). Specialist doctors are the most preferred providers followed by specialist nurses, and gastric cancer survivors were willing to pay more for these attribute levels. Changes in attribute levels affected uptake rate of follow-up. When the multiple attribute levels were changed at the same time, a very thorough follow-up content was provided by the same specialist doctor (specialist nurse), and the probability of receiving follow-up increases by 95.82% (94.90%).

CONCLUSIONS

The characteristics of follow-up care in our study reflect the health management services' expectations of gastric cancer survivors. A dedicated specialist nurse involved in follow-up care should be developed to contribute to solve the complex and multifaceted personal needs of gastric cancer survivors.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

ADJUVANT CHEMORADIOTHERAPY AFTER SUBTOTAL OR TOTAL GASTRECTOMY AND D2 LIMPHADENECTOMY INCREASES SURVIVAL IN ADVANCED GASTRIC CANCER?

BACKGROUND

The treatment of advanced gastric cancer with curative intent is essentially surgical and chemoradiotherapy is indicated as neo or adjuvant to control the disease and prolong survival.

AIM

To assess the survival of patients undergoing subtotal or total gastrectomy with D2 lymphadenectomy followed by adjuvant chemoradiotherapy.

METHODS

Were retrospectively analyzed 87 gastrectomized patients with advanced gastric adenocarcinoma, considered stages IB to IIIC and submitted to adjuvant chemoradiotherapy (protocol INT 0116). Tumors of the esophagogastric junction, with peritoneal implants, distant metastases, and those that had a compromised surgical margin or early death after surgery were excluded. They were separated according to the extention of the gastrectomy and analyzed for tumor site and histopathology, lymph node invasion, staging, morbidity and survival.

RESULTS

The total number of patients who successfully completed the adjuvant treatment was 45 (51.7%). Those who started treatment and discontinued due to toxicity, tumor-related worsening, or loss of follow-up were 10 (11.5%) and reported as incomplete adjuvant. The number of patients who refused or did not start adjuvant treatment was 33 (48.3%). Subtotal gastrectomy was indicated in 60 (68.9%) and total in 27 (31.1%) and this had a shorter survival. The mean resected lymph nodes was 30.8. Staging and number of lymph nodes affected were predictors of worse survival and the more advanced the tumor. Patients undergoing adjuvant therapy with complete chemoradiotherapy showed a longer survival when compared to those who did it incompletely or underwent exclusive surgery. On the other hand, comparing the T4b (IIIB + IIIC) staging patients who had complete adjuvance with those who underwent the exclusive operation or who did not complete the adjuvant, there was a significant difference in survival.

CONCLUSION

Adjuvant chemoradiotherapy presents survival gain for T4b patients undergoing surgical treatment with curative intent.

Gastric Cancer Peritoneal Carcinomatosis Risk Score

BACKGROUND

Gastric cancer (GC) peritoneal carcinomatosis (PC) is associated with a poor prognosis. Although grade, histology, and stage are associated with PC, the cumulative risk of PC when multiple risk factors are present is unknown. This study aimed to develop a cumulative GCPC risk score based on individual demographic/tumor characteristics.

METHODS

Patient-level data (2004-2014) from the California Cancer Registry were reviewed by creating a keyword search algorithm to identify patients with gastric PC. Multivariable logistic regression was used to assess demographic/tumor characteristics associated with PC in a randomly selected testing cohort. Scores were assigned to risk factors based on beta coefficients from the logistic regression result, and these scores were applied to the remainder of the subjects (validation cohort). The summed scores of each risk factor formed the total risk score. These were grouped, showing the percentages of patients with PC.

RESULTS

The study identified 4285 patients with gastric adenocarcinoma (2757 males, 64.3%). The median age of the patients was 67 years (interquartile range [IQR], 20 years). Most of the patients were non-Hispanic white (n = 1748, 40.8%), with proximal (n = 1675, 39.1%) and poorly differentiated (n = 2908, 67.9%) tumors. The characteristics most highly associated with PC were T4 (odds ratio [OR], 3.12; 95% confidence interval [CI], 2.19-4.44), overlapping location (OR 2.27; 95% CI 1.52-3.39), age of 20-40 years (OR 3.42; 95% CI 2.24-5.21), and Hispanic ethnicity (OR 1.86; 95% CI 1.36-2.54). The demographic/tumor characteristics used in the risk score included age, race/ethnicity, T stage, histology, tumor grade, and location. Increasing GCPC score was associated with increasing percentage of patients with PC.

CONCLUSION

Based on demographic/tumor characteristics in GC, it is possible to distinguish groups with varying odds for PC. Understanding the risk for PC based on the cumulative effect of high-risk features can help clinicians to customize surveillance strategies and can aid in early identification of PC.

Current challenges in gastric cancer surgery: European perspective

Gastric cancer (GC) remains one of the most common causes of cancer death worldwide with expected 5-year survival rates around 25% in Western countries. In order to improve treatment strategy, a most effective staging process should be completed. A novel TNM staging for GC has been proposed recently, along with a separate staging system for GC patients who underwent preoperative therapy (ypStage). Availability of high-quality imaging and access to diagnostic laparoscopy with lavage cytology should be applied while planning the multimodal therapy. In the European setting, GC treatment is based on a combination of surgery and perioperative chemotherapy. However, in selected groups of patients with high risk of locoregional recurrence, adjuvant chemoradiotherapy should be considered. New epidemiological trends of GC in the Western countries include an upward shift in the location of the primary tumour and a relative increase of advanced and diffuse type tumours. These trends dictate modification of surgical techniques towards a more individualized GC treatment approach.

Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy

BACKGROUND

We sought to determine the sites of recurrence and identify predicting factors for recurrence and survival in patients who underwent gastrectomy for adenocarcinoma at an institution where preoperative therapy is commonly used for advanced gastric cancer.

METHODS

We collected clinicopathologic data and sites of recurrence from a prospectively maintained database of patients who underwent potentially curative resection of gastric or gastroesophageal adenocarcinoma at our institution in 1995-2014, and we assessed associations between these characteristics and recurrence patterns and survival.

RESULTS

We identified 488 patients who underwent R0 resection of localized gastric cancer. The median age was 63 years (interquartile range 53-71 years), and 60% were male. The most common T and N categories, per endoscopic ultrasonography, were T3 (58%) and N0 (61%). Preoperative treatment was used in 61% of patients. A total of 125 (26%) patients experienced recurrence during follow-up. Recurrences were locoregional in 19 patients (15%), peritoneal in 61 (49%), and nonperitoneal distant in 67 (54%). The peritoneum also was the most common organ of recurrence (49%), followed by the liver (21%). The median time from primary resection to recurrence was 2.7 years for locoregional, 1.3 years for peritoneal, and 0.6 years for nonperitoneal distant recurrence (p = 0.01). Median overall survival was markedly shorter after peritoneal and nonperitoneal distant recurrences than after locoregional recurrences.

CONCLUSIONS

The peritoneum was a common site of recurrence after curative resection of gastric cancer and was associated with poor survival. Prophylactic treatment targeting the peritoneal cavity might improve survival of advanced gastric cancer.

Early detection of nonperitoneal recurrence may contribute to survival benefit after curative gastrectomy for gastric cancer

BACKGROUND

There is no evidence that strict follow-up using cross-sectional imaging after curative gastrectomy benefits survival; however, nonperitoneal recurrence detected early might be treated with additional surgery. The present study examined whether early detection of recurrence by imaging modalities could increase survival, particularly in patients with nonperitoneal recurrence.

METHODS

We retrospectively analyzed 218 patients with recurrent gastric cancer after curative gastrectomy performed from 2002 to 2014. The patients were divided into an asymptomatic group (n = 117) and a symptomatic group (n = 101), according to the presence of symptoms at the time of recurrence, to compare clinicopathological characteristics and long-term survival.

RESULTS

Peritoneal recurrence was less frequent in the asymptomatic group (22.2%) than in the symptomatic group (62.4%), the median time to recurrence was shorter (12.7 months vs 18.9 months; P < 0.001), and the median survival time after recurrence was longer (18.7 months vs 7.5 months; P < 0.001). In the asymptomatic group, 10 of 117 patients (8.5%) received additional curative surgery after recurrence. Median overall survival after gastrectomy was not significantly different between the groups (30.1 months for the asymptomatic group vs 30.0 months for the symptomatic group; P = 0.132); however, it was significantly longer among asymptomatic patients with nonperitoneal recurrence compared with symptomatic patients (35.9 months vs 24.0 months; P = 0.039).

CONCLUSIONS

The presence of symptoms at recurrence did not affect survival in patients with recurrent gastric cancer. However, detection of nonperitoneal recurrence before the appearance of symptoms may provide survival benefit. Therefore, regular follow-up, including use of imaging modalities, is recommended.

Surveillance for Gastric Cancer

This article discusses the current National Comprehensive Cancer Network guidelines and other available Western and Eastern guidelines for the surveillance of gastric cancer following surgical resection. It reviews the literature assessing the utility of intensive surveillance strategies for gastric cancer, which fails to show an improvement in survival. The unique issues relating to follow-up of early gastric cancer and after endoscopic resection of early gastric cancer are discussed. This article also reviews the available modalities for follow-up. In addition, it briefly discusses the advancements in treatment of recurrent and metastatic disease and the implications for gastric cancer survival and surveillance strategies.

Postgastrectomy follow-up in the West: evidence base, guidelines, and daily practice

Follow-up after gastrectomy for gastric cancer has several purposes, including management of side effects of surgery, oncological recurrence surveillance, psychological support, and data collection for research. How follow-up after gastrectomy, and especially recurrence surveillance, is performed differs immensely between different Western countries, despite guidelines from Western oncological organizations quite unanimously advocating symptom-driven surveillance, without scheduled cross-sectional imaging, endoscopies, or analysis of tumor markers. Given a complete lack of randomized data, the available body of observational data does not support intensive routine surveillance for recurrent disease. Moreover, studies of other cancers have shown a negative emotional impact of routine surveillance. There is an apparent need for randomized controlled trials to address the issue of optimized strategies for postgastrectomy recurrence surveillance.

Does finding early recurrence improve outcomes, and at what cost?

The putative goal of surveillance is the early detection of recurrence while both the cancer and patient are still treatable. To be cost and clinically effective, surveillance requires a tailored approach based on stage, tumor biology, conditional survival, and available treatment options. Although surveillance is the major component of care for cancer patients after potentially curative treatment, current guidelines for surveillance lack the high-level data seen on the treatment side of the patient care continuum. J. Surg. Oncol. 2016;114:329-335. © 2016 Wiley Periodicals, Inc.

Characterising timing and pattern of relapse following surgery for localised oesophagogastric adenocarcinoma: a retrospective study

Background

Oesophagogastric adenocarcinoma (OGA) has a poor prognosis, even for patients with operable disease. However, the optimal surveillance strategy following surgery is unknown.

Methods

We performed a retrospective review of all patients with OGA who had undergone surgery with radical intent at the Royal Marsden between January 2001 and December 2010.

Results

Of the 360 patients with OGA who underwent potentially curative surgery, 100/214 patients (47 %) with oesophageal/gastro-oesophageal junction (GOJ) adenocarcinoma and 47/146 patients (32 %) with gastric adenocarcinoma developed recurrent disease. 51, 79 and 92 % of relapses occurred within 1, 2 and 3 years respectively and the majority of patients relapsed at distant sites. Of the patients who relapsed, 67 % (67/100) with oesophageal/GOJ adenocarcinoma and 72 % of patients with gastric cancer (34/47) were symptomatic at the time of relapse. The majority of asymptomatic relapses were first detected by a rise in tumour markers. There was no difference in disease-free survival between asymptomatic and symptomatic patients, but asymptomatic patients were more likely to receive further treatment and had a longer survival beyond relapse.

Conclusion

The majority of relapses occur within the first 3 years and at distant sites. Monitoring of tumour markers should be considered as part of a surveillance program.

Fluorine-18-fluorodeoxyglucose positron emission tomography to evaluate recurrent gastric cancer after surgical resection: a systematic review and meta-analysis

We aimed to explore the diagnostic accuracy of (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) for detection of gastric cancer recurrence after surgical resection through a systematic review and meta-analysis. "PubMed", EMBASE, Web of Knowledge and Springer, from the beginning of 2002 to Feb 2015, were searched for studies evaluating the diagnostic performance of 18F-FDG PET in detecting recurrent gastric cancer. We calculated sensitivities, specificities, diagnostic odds ratios and likelihood ratios, and constructed summary receiver operating characteristic curves. Fourteen studies (828 patients) were included. On a per-patient basis, the forest plots showed that the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of (18)F-FDG PET or PET/CT were 0.85 [95 % confidence interval (CI) 0.75-0.92], 0.78 (95 % CI 0.72-0.84), 3.9 (95 % CI 2.9-5.4), 0.19 (95 % CI 0.11-0.34), and 21 (95 % CI 9-47), respectively. On a per-lesion basis, the pooled sensitivity was 0.75 (95 % CI 0.61-0.86). The area under the SROC curve of PET/CT on the basis of per-patient was 0.86. (18)F-FDG PET had great value in the detection of gastric cancer recurrence after surgical resection. The sensitivities of (18)F-FDG PET were 85 and 75 %, respectively, on per-patient basis and on per-lesion basis.

Patterns of surveillance following curative intent therapy for gastroesophageal cancer

PURPOSE

Our aims were to examine surveillance strategies after curative treatment of early gastroesophageal (GE) cancer and to evaluate the impact of different approaches on outcomes.

METHODS

A total of 292 patients with non-metastatic GE cancer who were referred to the BC Cancer Agency from 2001 to 2010 for curative intent treatment were analyzed. Surveillance practices were classified into the following: cohort 1 (discharge to general practitioner), cohort 2 (follow-up by oncologist with clinical assessments), cohort 3 (specialist follow-up with laboratory investigations), and cohort 4 (specialist follow-up with imaging or endoscopy). Outcomes were compared across cohorts using Kaplan-Meier methods and Cox regression.

RESULTS

In total, median age was 63 years and 76 % were men. Eighty-nine (30%), 18 (6%), 32 (11%), and 152 (53%) patients were classified into cohorts 1 to 4, respectively. Patients with primary lesions involving the distal esophagus were more likely to undergo intensive surveillance which involved imaging studies and endoscopic procedures (p = 0.001). Individuals affected by specific histological subtypes, such as squamous cell carcinoma and the signet cell variant, and those whose disease were managed with definitive chemoradiotherapy without surgery were also more inclined to receive intensive follow-up (p = 0.008 and p = 0.001, respectively) There were no significant differences in overall (p = 0.34) or relapse-free survival (p = 0.59) among the different surveillance strategies, even after adjusting for measured prognostic factors.

CONCLUSION

In this population-based analysis, outcomes of GE cancer were comparable irrespective of surveillance strategy. Intensive follow-up with routine imaging and endoscopy may not be justified given the financial implications of these costly investigations.

Incidence, time course and independent risk factors for metachronous peritoneal carcinomatosis of gastric origin--a longitudinal experience from a prospectively collected database of 1108 patients

Background

Comprehensive evidence on the incidence, time course and independent risk factors of metachronous peritoneal carcinomatosis (metaPC) in gastric cancer patients treated with curative intent in the context of available systemic combination chemotherapies is lacking.

Methods

Data from a prospectively collected single-institutional Center Cancer Registry with 1108 consecutive patients with gastric adenocarcinoma (GC), clinical, histological and survival data were analyzed for independent risk factors and prognosis with focus on the development of metaPC. Findings were then stratified to the time periods of treatment with surgery alone, 5-Fluorouracil-only and contemporary combined systemic perioperative chemotherapy strategies, respectively.

Results

Despite R0 D2 gastrectomy (n = 560), 49.6% (±5.4%) of the patients were diagnosed with tumour recurrence and 15.5% (±1.8%) developed metaPC after a median time of 17.7 (15.1-20.3) months after surgery resulting in a tumour related mortality of 100% with a median survival of 3.0 months (2.1 – 4.0). Independent risk factors for the development of metaPC were serosa positive T-category, nodal positive-status, signet cell and undifferentiated gradings (G3/G4). Contemporary systemic combination chemotherapy did not improve the incidence and prognosis of metaPC (p = 0.54).

Conclusions

Despite significant improvements in the overall survival for the complete cohort with gastric cancer over time, those patients with metaPC did not experience the same benefits. The lack of change in the incidence, and persistent poor prognosis of metaPC after curative surgery expose the need for further prevention and/or improved treatment options for this devastating condition.

Follow-up after gastrectomy for cancer: Results of an international web round table

Oncological follow-up after radical gastrectomy for cancer still represents a discrepancy in the field, with many retrospective series demonstrating that early diagnosis of recurrence does not result in an improvement in patient survival; yet, many centers with high quality of care still provide routine patient follow-up after surgery by clinical and instrumental controls. This was the topic for a web round table entitled “Rationale and limits of oncological follow-up after gastrectomy for cancer” that was launched one year before the 10^th International Gastric Cancer Congress. Authors having specific expertise were invited to comment on their previous publications to provide the subject for an open debate. During a three-month-long discussion, 32 authors from 12 countries participated, and 2299 people visited the dedicated web page. Substantial differences emerged between the participants: authors from Japan, South Korea, Italy, Brazil, Germany and France currently engage in instrumental follow-up, whereas authors from Eastern Europe, Peru and India do not, and British and American surgeons practice it in a rather limited manner or in the context of experimental studies. Although endoscopy is still considered useful by most authors, all the authors recognized that computed tomography scanning is the method of choice to detect recurrence; however, many limit follow-up to clinical and biochemical examinations, and acknowledge the lack of improved survival with early detection.

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.

Association of smoking history with cancer recurrence and survival in stage III-IV male gastric cancer patients

BACKGROUND

Smoking and drinking alcohol are major risk factors for cancer development, and we investigated their effects on gastric cancer prognosis following initial resection.

METHODS

Data from male patients with stage III-IV gastric adenocarcinoma who underwent surgery between 2001 and 2006 were retrospectively reviewed. Patients were followed up until 2011. Kaplan-Meier plots and Cox proportional hazards regressions were applied for survival rates.

RESULTS

Among 238 patients, 151 (63.4%) smoked and 146 (61.3%) drank alcohol. Current smokers had an increased risk of cancer recurrence or death from any cause [adjusted HR (aHR), 1.94; 95% confidence interval (CI), 1.18-3.21], cancer recurrence (aHR, 1.89; 95% CI, 1.12-3.21), and overall mortality (aHR, 2.14; 95% CI, 1.23-3.73) compared with never-smokers. Patients with a lifetime cigarette smoking of <40 and ≥ 40 pack-years had increased cancer recurrence or death from any cause (aHR, 1.72 and 2.43, respectively; 95% CI, 1.03-2.86 and 1.38-4.30, respectively), cancer recurrence (aHR, 1.63 and 2.61, respectively; 95% CI, 0.95-2.79 and 1.43-4.77, respectively), and overall mortality (aHR, 1.92 and 2.75, respectively; 95% CI, 1.09-3.38 and 1.47-5.12, respectively) compared with never-smokers. However, drinking alcohol was not associated with postsurgery survival.

CONCLUSIONS

Cigarette-smoking history at the time of diagnosis, but not drinking history, is associated with cancer recurrence and poor survival after surgery in male patients with stage III-IV gastric cancer.

IMPACT

These findings encourage physicians to advise patients with gastric cancer to stop smoking to obtain a general health benefit and likely improvement in the gastric cancer course.

Association of family history with cancer recurrence and survival in patients with gastric cancer

PURPOSE

Family history of gastric cancer is a major risk factor for the disease. In this study, we investigated the prognoses of patients with gastric cancer with a family history.

PATIENTS AND METHODS

We retrospectively reviewed data from 1,273 patients with gastric adenocarcinoma who had undergone gastrectomy between 2001 and 2005 at a tertiary cancer center hospital. A positive family history was defined as a self-reported history of cancer in first- or second-degree relatives. Patients were followed up until December 2009 for death or recurrence. Clinicopathologic characteristics were compared by family history. Kaplan-Meier plots and Cox proportional hazards regressions were applied for disease-free survival (DFS), recurrence-free survival (RFS), and overall survival (OS).

RESULTS

Of 1,273 patients, 263 patients (20.6%) had first-degree relatives with a history of gastric cancer. First-degree family history of gastric cancer was associated with better DFS, RFS, and OS (P = .012, .006, and .005, respectively). In patients with stage I or II gastric cancer, first-degree family history was not associated with survival. However, it was associated with a reduced risk of recurrence or mortality in patients with stage III or IV gastric cancer. Compared with patients without a family history, the adjusted hazard ratios for those with a first-degree family history of gastric cancer were 0.49 (95% CI, 0.29 to 0.84) for DFS, 0.51 (95% CI, 0.30 to 0.87) for RFS, and 0.47 (95% CI, 0.26 to 0.84) for OS in patients with stage III or IV gastric cancer.

CONCLUSION

A first-degree family history of gastric cancer is associated with improved survival after curative-intent surgery in patients with stage III or IV gastric cancer.

Gastric malignancy: surgical management

PURPOSE OF REVIEW

To highlight the recent changes and development in the surgical management of gastric adenocarcinoma. There is significant development in the field. However, issues like extent of resection, lymphadenectomy, and minimal access approach are still to be refined for clinical and oncological effectiveness and safety.

RECENT FINDINGS

The outcomes of surgical treatment of gastric adenocarcinoma are improving due to several factors, including specialist unit settings, refinement of the surgical techniques, improved adequacy of lymphadenectomy and some other minor factors such as multidisciplinary team approach and the use of perioperative chemotherapy or radiotherapy. The most hot issue in the past year's literatures is the use of minimal access surgery for resection and lymphadenectomy. The trend of studies is supporting minimal access approach for limited, subtotal and even total gastrectomy.

SUMMARY

The outcomes of surgical treatment of gastric adenocarcinoma are improving. Minimal access approach to treat gastric adenocarcinoma is evolving and continuing to have a substantial role in current surgical practice. The potential role of minimal access surgery, surgical resectional techniques, extent of lymphadenectomy and setting of specialized units and multidisciplinary team approach have stimulated an active research.

Significance of SUV on Follow-up F-18 FDG PET at the Anastomotic Site of Gastroduodenostomy after Distal Subtotal Gastrectomy in Patients with Gastric Cancer

PURPOSE

The aim of this study was to characterize the patterns of fluorodeoxyglucose (FDG) uptake on F-18 FDG positron emission tomography/computed tomography (FDG PET/CT) at the anastomotic site of gastroduodenostomy after distal subtotal gastrectomy in patients with gastric cancer.

METHODS

From May 2007 to May 2010, two or more follow-up measurements using FDG PET/CT scans were done for 19 patients (11 men, 8 women; mean age, 62.0 ± 10.3 years) who underwent distal subtotal gastrectomy with gastroduodenostomy between February 2006 and March 2008 for detecting gastric cancer recurrence at our medical center. The FDG PET/CT images were retrospectively reviewed. Patients with local recurrence, regional nodal metastasis or distant metastasis on follow-up studies were excluded. CT and endoscopy were done within 1 month before or after the FDG PET/CT scan. Eight patients had two follow-ups of FDG PET/CT, and 11 patients had three follow-ups. The mean interval between surgery and the first follow-up FDG PET/CT was 12.9 ± 0.8 months (n = 19); between the first and second it was 12.3 ± 1.0 months (n = 19); between the second and third it was 11.6 ± 0.7 months (n = 11). The F-18 FDG uptakes at the anastomotic site and fundus in the remnant stomach were measured by maximum standardized uptake value (SUVmax) using a region of interest technique.

RESULTS

The SUVmax at the anastomotic site was significantly higher than that of the fundus on all series of first, second and third follow-up studies (3.3 ± 1.1 vs. 2.1 ± 0.7, p < 0.001: 3.1 ± 0.9 vs. 2.2 ± 0.7, p = 0.001: 3.0 ± 0.6 vs. 2.1 ± 0.7, p = 0.006, respectively). The SUVmax for the anastomotic site and fundus, and SUVmax ratio for the anastomotic site over the fundus were not significantly different throughout the series.

CONCLUSION

The SUVmax at the anastomotic site is significantly higher than that of the fundus and does not decrease significantly over time. Therefore, the local recurrence of gastric cancer after surgery could not be definitely differentiated from physiologic uptake or postoperative inflammatory change.