Prognostic factors in T4b gastric cancer after surgery: A more balanced and sequential therapy for patients?

INTRODUCTION

This study aimed to evaluate the prognostic factors in T4b gastric cancer (GC) in order to improve future therapeutic strategies.

METHODS

We retrospectively analyzed the medical records of 43 patients with advanced GC who underwent surgery and were surgically or pathologically diagnosed with T4b GC. The overall survival (OS) rate of patients with T4b GC was analyzed, and univariate and multivariate analyses were performed to identify clinicopathological factors that were independently associated with OS. In addition, we assessed the relationship between postoperative chemotherapy and laboratory parameters 4 weeks post-surgery.

RESULTS

The proportion of patients with invasion of cancer in organs, including the pancreas, transverse colon, and liver, were 58.1%, 18.6%, and 14.0%, respectively. The proportion of patients who exhibited distant metastases was 44.2%, and R0 resection was achieved in 30.2% of patients. A total of 69.8% of patients underwent postoperative chemotherapy. The median survival rate was 12.3 months. Upon multivariate analysis, the presence of distant metastases (P = 0.01, HR; 3.48), the use of postoperative chemotherapy (P = 0.0004, HR; 0.12), and R0 resection (P < 0.0001, HR; 0.14) were significantly correlated with OS. Patients who did not undergo postoperative chemotherapy showed significantly higher levels of inflammatory parameters and lower levels of nutritional parameters 4 weeks after surgery than those who did.

CONCLUSIONS

We evaluated that the presence of distant metastases was significantly associated with a poor prognosis, and the use of postoperative chemotherapy and R0 resection was significantly associated with a better prognosis in patients with T4b GC. It would be more important for a T4b GC treatment to balance between therapeutic tolerance for postoperative chemotherapy and surgical therapeutic effect.

What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer?

BACKGROUND

Locally advanced gastric cancer (GC) extending to the surrounding tissues may require a multivisceral resection (MVR) to provide the best chance of cure. However, little is known about how the extent of organ resection affects the risks and benefits of surgery.

METHODS

An electronic database of patients treated between 1996 and 2020 in an academic surgical centre was reviewed. MVRs were defined as partial or total gastrectomy combined with splenectomy, distal pancreatectomy, or partial colectomy.

RESULTS

Suspected intraoperative tumour invasion of perigastric organs (cT4b) was found in 298 of 1476 patients with non-metastatic GC, and 218 were subject to MVRs, including the spleen (n = 126), pancreas (n = 51), and colon (n = 41). MVRs were associated with higher proportions of surgical and general complications, but not mortality. A nomogram was developed to predict the risk of major postoperative morbidity (Clavien-Dindo's grade ≥ 3a), and the highest odds ratio for major morbidity identified by logistic regression modelling was found for distal pancreatectomy (2.53, 95% CI 1.23-5.19, P = 0.012) and colectomy (2.29, 95% CI 1.04-5.09, P = 0.035). Margin-positive resections were identified by the Cox proportional hazards model as the most important risk factor for patients' survival (hazard ratio 1.47, 95% CI 1.10-1.97). The extent of organ resection did not affect prognosis, but a MVR was the only factor reducing the risk of margin positivity (OR 0.44, 95% CI 0.21-0.87).

CONCLUSIONS

The risk of multivisceral resections is associated with the organ being removed, but only MVRs increase the odds of complete tumour clearance for locally advanced gastric cancer.

Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review?

Introduction  Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods  A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results  MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n  = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p  < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion  Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.

Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center

Background: Multivisceral resection is occasionally necessary for pT4b gastric cancer patients to achieve negative margin. The purpose of this study is to assess the short-term safety and long-term efficacy of this approach. Methods: A single-center, retrospective analysis was conducted for pT4b gastric cancer patients after curative-intent multivisceral resection from the China National Cancer Center Gastric Cancer Database (NCCGCDB) from 1998 to 2018. The postoperative complications, recurrence patterns, long-term survival, and prognostic factors were analyzed. Results: A total of 210 patients were included in the study. The most common combined resection organs were multiple organs (30.5%), pancreas (20.5%), colon (16.7%), and liver (9.0%). Seventeen patients (8.1%) developed postoperative complications and hospital death was observed in one patient (0.5%). The most common postoperative complications were anastomotic leak (4.3%) and intra-abdominal infection (5.7%). The 3-year and 5-year disease-free survival (DFS) rates for the patients investigated were 38.0% and 33.8%, respectively, and the 3-year and 5-year overall survival (OS) rates were 48.2% and 39.1%, respectively. Multivariate Cox regression analysis proved that negative nerve invasion was independent risk factors for DFS (HR: 2.202, 95%CI: 1.144-4.236, P=0.018) and OS (HR: 2.219, 95%CI: 1.164-4.231, P=0.015). Conclusions: Multivisceral resection in pT4b gastric cancer patients without distant metastasis was effective and had an acceptable safety profile.

Retrospective analysis of surgically treated pT4b gastric cancer with pancreatic head invasion

BACKGROUND

For advanced gastric cancer patients with pancreatic head invasion, some studies have suggested that extended multiorgan resections (EMR) improves survival. However, other reports have shown high rates of morbidity and mortality after EMR. EMR for T4b gastric cancer remains controversial.

AIM

To evaluate the surgical approach for pT4b gastric cancer with pancreatic head invasion.

METHODS

A total of 144 consecutive patients with gastric cancer with pancreatic head invasion were surgically treated between 2006 and 2016 at the China National Cancer Center. Gastric cancer was confirmed in 76 patients by postoperative pathology and retrospectively analyzed. The patients were divided into the gastrectomy plus en bloc pancreaticoduodenectomy group (GP group) and gastrectomy alone group (GA group) by comparing the clinicopathological features, surgical outcomes, and prognostic factors of these patients.

RESULTS

There were 24 patients (16.8%) in the GP group who had significantly larger lesions (P < 0.001), a higher incidence of advanced N stage (P = 0.030), and less neoadjuvant chemotherapy (P < 0.001) than the GA group had. Postoperative morbidity (33.3% vs 15.3%, P = 0.128) and mortality (4.2% vs 4.8%, P = 1.000) were not significantly different in the GP and GA groups. The overall 3-year survival rate of the patients in the GP group was significantly longer than that in the GA group (47.6%, median 30.3 mo vs 20.4%, median 22.8 mo, P = 0.010). Multivariate analysis identified neoadjuvant chemotherapy [hazard ratio (HR) 0.290, 95% confidence interval (CI): 0.103–0.821, P = 0.020], linitis plastic (HR 2.614, 95% CI: 1.024–6.675, P = 0.033), surgical margin (HR 0.274, 95% CI: 0.102–0.738, P = 0.010), N stage (HR 3.489, 95% CI: 1.334–9.120, P = 0.011), and postoperative chemoradiotherapy (HR 0.369, 95% CI: 0.163–0.836, P = 0.017) as independent predictors of survival in patients with pT4b gastric cancer and pancreatic head invasion.

CONCLUSION

Curative resection of the invaded pancreas should be performed to improve survival in selected patients. Invasion of the pancreatic head is not a contraindication for surgery.

Advanced gastric cancer with abdominal wall invasion treated with curative resection after chemotherapy: a case report

INTRODUCTION

In patients with gastric cancer, 6-27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients.

CASE PRESENTATION

A 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer (L-Circ type 3 T4b N2 M0 H0 stage IVA, based on the 15th edition of the Japanese Classification of Gastric Carcinoma) with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/m2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively.

CONCLUSIONS

We report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer.

Laparoscopic Whipple's Operation for Locally Advanced Gastric Cancer Invading the Pancreas and Duodenum: a Case Report

Few surgeons have adopted pancreaticoduodenectomy (PD) for the treatment of advanced gastric cancer (AGC) invading the pancreas or duodenum because it remains controversial whether its prognostic benefits outweigh the high morbidity rates in such advanced cases. However, recent technical advances have revived diverse surgical procedures in minimally invasive approaches. Inspired by this trend, laparoscopic PD procedures have been performed for AGC in our institute since 2014. We recently performed a laparoscopic Whipple's operation in a case of cT4b gastric cancer with invasion of the pancreatic head and duodenum.

Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience

PURPOSE

This study reports single-surgeon experience with extended gastrectomy including en-bloc resection of adjacent organs/structures for T4b stage gastric adenocarcinoma. Time-related changes in patient selection criteria and outcomes were also analyzed.

METHODS

All consecutive gastrectomies for adenocarcinoma performed between May 2004 and December 2017 were extracted from prospectively collected database to study surgical and oncologic results. Time-related changes in outcomes were examined according to three time periods.

RESULTS

Five hundred eighty-seven gastrectomies were performed throughout the study period including 87 (14.8%) extended resections. The latter most often included pancreatosplenectomy, colon, and liver resections (21, 16, and 11 patients, respectively) resulting in similar postoperative outcomes and survival. Extended gastrectomy was associated with larger tumor size (8.4 vs 5.6 cm), performing total gastrectomy (55.2 vs 35.2%, p < 0.01) and increased blood loss (375 vs 150 ml, p < 0.01) compared with standard gastrectomy. Larger experience in extended gastrectomy allowed for expanding patient selection criteria, considering complex resections and extensive lymphadenectomy. Median and 3-year survival following extended gastrectomy for T4b adenocarcinoma were 14 months and 18%, respectively, which was comparable to standard gastrectomy for T4a adenocarcinoma (p = 0.48). Obesity, nodal stage and type of gastrectomy were associated with survival in T4b adenocarcinoma in the univariable analysis. Obesity and N3a and N3b stages were independent predictors in the multivariable model.

CONCLUSIONS

Extended gastrectomy for T4b gastric adenocarcinoma provides satisfactory surgical outcomes even with expanded patient selection criteria and regardless of the organ involved. Given its poor prognosis, neoadjuvant therapy should be considered to improve the long-term oncologic results.

Multivisceral Resection for Locally Advanced Gastric and Gastroesophageal Junction Cancers-11-Year Experience at a High-Volume North American Center

INTRODUCTION

The oncologic benefit of multivisceral en bloc resections for T4 gastroesophageal tumors has been questioned, given the increased morbidity associated. We thus sought to investigate the surgical and oncologic outcomes of curative-intent en bloc multivisceral resections for T4 gastroesophageal carcinomas.

METHODS

Between 2005 and 2016, 35 of the 525 patients who had gastric or EGJ carcinomas underwent curative-intent multivisceral resections for direct invasion or adhesion to adjacent organs.

RESULTS

Postoperative complications occurred in 16(46%), 10 of which were Clavien-Dindo ≥ 3 (29%). Ninety-day mortality was 3%. The R0 resection rate was 94% (33). Direct organ invasion (pT4b) was confirmed on pathological analysis in 14 (40%) and did not affect survival. The majority (28, 80%) had lymph node involvement with a high nodal disease burden and was associated with decreased survival. Overall 5-year survival rate was 34%, and the vast majority of recurrences were distant/peritoneal (81%). On multivariate analysis, positive lymph nodes (H.R. 21.2; 95%CI 2.34-192) and R1 resection (H.R. 5.6; 95%CI 1.02-30.9) were predictors of survival.

CONCLUSION

Multivisceral resections for T4 gastric and GEJ adenocarcinomas, in combination with effective systemic therapy, result in prolonged long-term survival with acceptable morbidity. Complete resection to negative margins should remain a mainstay of curative-intent treatment in carefully selected patients.

Incomplete resection and linitis plastica are factors for poor survival after extended multiorgan resection in gastric cancer patients

The aim of this retrospective study was to analyze the morbidity, mortality, and survival rates of extended multiorgan resection (EMR) for locally advanced gastric cancer patients compared to gastrectomy alone and a palliative operation. 893 locally advanced gastric cancer patients without distant metastasis had surgery including gastrectomy alone (GA group, n = 798), EMR resection (EMR group, n = 75), and palliative operation (palliative gastrectomy or gastrojejunostomy (PO group, n = 20)). Postoperative mortality and complication rates in the EMR group were significantly higher than in the GA group (2.7% vs 0.4%, P = 0.010 and 25.3% vs 8.1%, P < 0.001, respectively), but similar in the PO group. The median survival time of the EMR group was significantly longer than in the PO group (27 months vs 11 months, P = 0.020), but significantly worse (P = 0.020) than in the GA group (44 months). Incompleteness of resection (R1) and linitis plastica were independent prognostic factors for survival in the EMR group. Three different gastric cancer surgeries led to different postoperative mortality and complication rates. EMR had a better survival rate compared with PO while GA had the longest survival time with the lowest mortality and complication rates.

Analysis of postoperative morbidity and mortality following surgery for gastric cancer. Surgeon volume as the most significant prognostic factor

Introduction

Surgical resection is the only potentially curative modality for gastric cancer and it is associated with substantial morbidity and mortality.

Aim

To determine risk factors for postoperative morbidity and mortality following major surgery for gastric cancer.

Material and methods

Between 1.08.2006 and 30.11.2014 in the Department of Oncological Surgery of Gdynia Oncology Centre 162 patients underwent gastric resection for adenocarcinoma. All procedures were performed by 13 surgeons. Five of them performed at least two gastrectomies per year (n = 106). The remaining 56 resections were done by eight surgeons with annual volume lower than two. Perioperative mortality was defined as every in-hospital death and death within 30 days after surgery. Causes of perioperative deaths were the matter of in-depth analysis.

Results

Overall morbidity was 23.5%, including 4.3% rate of proximal anastomosis leak. Mortality rate was 4.3%. Morbidity and mortality were not dependent on: age, gender, body mass index, tumour location, extent of surgery, splenectomy performance, or pTNM stage. The rates of morbidity (50% vs. 21.3%) and mortality (16.7% vs. 3.3%) were significantly higher in cases of tumour infiltration to adjacent organs (pT4b). Perioperative morbidity and mortality were 37.5% and 8.9% for surgeons performing less than two gastrectomies per year and 16% and 0.9% for surgeons performing more than two resections annually. The differences were statistically significant (p = 0.002, p = 0.003).

Conclusions

Annual surgeon case load and adjacent organ infiltration (pT4b) were significant risk factors for morbidity and mortality following major surgery for gastric cancer. The most common complications leading to perioperative death were cardiac failure and proximal anastomosis leak.

Morbidity and mortality associated with gastrectomy for gastric cancer

BACKGROUND

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning.

MATERIAL AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated.

RESULTS

Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028).

CONCLUSIONS

Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.