Feasibility of Gastrectomy with Standard Lymphadenectomy for Patients Over 85 Years Old with Gastric Cancer

Prognostic factors for gastric cancer patients aged ≥ 85 years

BACKGROUND

As gastric cancer patients aged ≥ 85 years have a short life expectancy and often die from other diseases such as pneumonia, indications for surgery are controversial. In this study, we retrospectively analyzed the prognostic factors of elderly patients with gastric cancer who are candidates for curative gastrectomy.

METHODS

Among 114 patients aged ≥ 85 years with gastric cancer at our hospital between 2010 and 2019, prognostic factors were examined using the Cox proportional hazards model in 76 patients excluding those with cStage IVB or endoscopic submucosal dissection. We also analyzed the factors of pneumonia death.

RESULTS

cStage was I/IIA/IIB/III/IVA in 37/6/14/14/5 patients, respectively. Treatment included distal gastrectomy in 28 patients, total gastrectomy in 6, local resection in 9, others in 3, and no surgery in 30. In univariate analyses of overall survival, Eastern Cooperative Oncology Group Performance Status, physiological score of Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Onodera's prognostic nutritional index, cStage, and treatment were prognostic factors. In a multivariate analysis, POSSUM physiological score, cStage, treatment method {no surgery vs. distal gastrectomy: hazard ratio (HR) 5.78, 95% confidence interval (CI) 2.33-14.3}, (total gastrectomy vs. distal gastrectomy: HR 4.26, 95% CI 1.22-14.9) were independent prognostic factors. In univariate analyses of pneumonia-specific survival, treatment (total gastrectomy vs. distal gastrectomy: HR 6.98, 95% CI 1.18-41.3) was the only prognostic factor.

CONCLUSIONS

The prognosis of distal gastrectomy was better than that of non-surgery even in patients aged ≥ 85 years. However, total gastrectomy was considered to be avoidable due to the high rate of postoperative pneumonia death.

Preoperative High C-Reactive Protein to Albumin Ratio Predicts Short- and Long-Term Postoperative Outcomes in Elderly Gastric Cancer Patients

Individualized preoperative assessment of the general condition of elderly patients with gastric cancer is necessary for appropriate surgical treatment planning. This study investigated the efficacy of preoperative markers that could be easily calculated from preoperative peripheral blood to predict the short- and long-term postoperative outcomes of gastrectomy. In total, 571 patients who underwent R0 surgical resection for gastric cancer were enrolled. In the elderly patient group (≥65 years old), univariate analyses revealed that the incidence of postoperative complications was associated with poor performance status (p = 0.012), more comorbidities (p = 0.020), high C-reactive protein to albumin ratio (CAR, p = 0.003), total gastrectomy (p = 0.003), open approach (p = 0.034), blood transfusion (p = 0.002), and advanced cancer (p = 0.003). Multivariate analysis showed that a high CAR was associated with a high incidence of postoperative complications (p = 0.046). High CAR was also associated with poor OS (p = 0.015) and RFS (p = 0.035). However, these trends were not observed among younger patients (<65 years old). Preoperative CAR may play a significant role in predicting short- and long-term surgical outcomes, particularly in elderly patients with gastric cancer.

Differences of clinical features and outcomes between male and female elderly patients in gastric cancer

Although the average life span differs between males and females, little is known about differences in clinical features and short and long-term outcomes between elderly male and female gastric cancer patients. This study was designed to clarify these issues to identify the possibility for sex-based treatment strategies in elderly gastric cancer patients. This study included 295 consecutive elderly gastric cancer patients (75 years or older) who underwent curative gastrectomy between 1997 and 2016. We defined postoperative complications as Clavien-Dindo classification grade II or higher. Comorbidities were present in 67% of all patients. Males tended to have more comorbidities than females (P = 0.077). Male patients had significantly more upper gastric cancers (P = 0.001), a higher incidence of postoperative complications (P = 0.045), and poorer prognoses than females (P = 0.003). Multivariate analysis revealed that being male was an independent risk factor for postoperative complications (Odds ratio 2.5, P = 0.045) and a poor prognostic factor (Hazard ratio 1.81, P = 0.008). Patients who underwent limited surgery without postoperative complications tended to have a better prognosis than patients receiving standard surgery with postoperative complications (3-year overall survival: 78% vs. 55%, P = 0.156). Male was an independent risk factor for postoperative complications and an independent poor prognostic factor in elderly gastric cancer patients. To avoid postoperative complications, the limited surgery might be justified for high-risk elderly male patients.

Significance of Preoperative Pulmonary Function on Short- and Long-Term Outcomes Following Gastrectomy for Gastric Cancer

BACKGROUND

Preoperative pulmonary function assessment is useful for selecting surgical candidates and operative methods and assessing the risk of postoperative pulmonary complications. However, few studies have investigated the relationship between preoperative pulmonary function and short- and long-term outcomes in patients who underwent gastrectomy for gastric cancer.

METHODS

Of the 1040 patients with gastric cancer (stages I-III) who had undergone R0 gastrectomy between 2009 and 2020, 750 who underwent preoperative spirometry were included. Restrictive ventilatory impairment was defined as a vital capacity of the predicted value (%VC) < 80%, while obstructive ventilatory impairment was defined as forced expiratory volume in one second (FEV1%) < 70%. Postoperative complications were assessed using the Clavien-Dindo (CD) classification. The relationship between clinical factors, including %VC, FEV1%, severe postoperative complications (CD ≥ 3b), overall survival (OS), and relapse-free survival, were assessed.

RESULTS

The mean age of the 750 patients was 68 ± 10.5 years. Severe postoperative complications were observed in 25 (3.3%) patients and were significantly associated with FEV1% < 70% in the univariate analysis. The 5-year OS was 72.5%. Multivariate analysis showed that the cancer stage, age > 75 years, preoperative comorbidities, %VC < 80%, total gastrectomy, severe postoperative complications, and postoperative adjuvant chemotherapy were the significant independent factors affecting OS. Pneumonia was significantly associated with %VC < 80%.

CONCLUSIONS

FEV1% < 70%was associated with the development of severe postoperative complications, while %VC < 80% was associated with poor OS independent of the cancer stage because of death from pneumonia. Spirometry helps surgeons and patients discuss the risks and benefits of surgery.

Risk factors for non‐gastric‐cancer‐related death after gastrectomy in elderly patients

Aim

To identify preoperative factors, especially other diseases that cause death, that are associated with the prognosis of gastrectomy in elderly patients with gastric cancer.

Methods

This retrospective study included a total of 211 consecutive patients aged ≥75 years who underwent radical gastrectomy due to gastric cancer. Time‐dependent receiver operating characteristic curve analysis was performed to determine the optimal cutoff values for various perioperative factors. Risk factors for the overall survival and death from other diseases were analyzed using the Cox proportional hazards model.

Results

Among the all perioperative factors, sex, neutrophil‐to‐lymphocyte ratio, skeletal muscle mass index, and lymph node dissection in accordance with guidelines or not extracted as independent risk factors for death from other diseases. In an analysis restricted to the preoperative factors, sex, neutrophil‐to‐lymphocyte ratio, and skeletal muscle mass index of the patients were extracted as independent risk factors for death from other diseases and overall survival. We divided the patients into four groups according to the number of preoperative risk factors for death from other diseases and found that the 5‐year non‐gastric‐cancer‐related survival was different among the four groups (risk factor 0, 91.7%; risk factor 1, 83.3%; risk factor 2, 56.3%; risk factor 3, 27.2%; P < 0.001).

Conclusion

Male sex, low skeletal muscle mass index, and high neutrophil‐to‐lymphocyte ratio are risk factors for non‐gastric‐cancer‐related death and the overall survival of elderly patients undergoing gastrectomy. Cautious treatment strategies are needed for elderly gastric cancer patients with many risk factors.

Comparison of Standard D2 and Limited Lymph Node Dissection in Elderly Patients with Advanced Gastric Cancer

BACKGROUND

Knowledge on the optimal extent of lymphadenectomy among elderly patients with advanced gastric cancer is limited. This study was designed to compare standard D2 and limited lymphadenectomy for evaluating the appropriate extent of lymphadenectomy.

PATIENTS AND METHODS

We retrospectively reviewed patient's data based on a prospectively collected gastric cancer registry. The inclusion criteria were age above 75 years and histologically confirmed stage II or more advanced gastric cancer. In this study, 103 patients who underwent limited lymph node dissection and 134 patients who underwent standard D2 lymph node dissection were included to evaluate surgical and oncological outcomes using propensity score matching (PSM) analysis.

RESULTS

The mean age after PSM was approximately 78 years in both groups. The Charlson Comorbidity Index was 5.81 ± 0.87 and 5.75 ± 0.76, respectively, and 12.5% of the patients in both groups had American Society of Anesthesiologists scores of more than 3. The limited lymphadenectomy group showed a shorter operation time and fewer retrieved lymph. However, other surgical outcomes and pathological data were not significantly different between the groups. No postoperative mortality within 30 days was observed. There were no significant differences in overall complications between the groups. The 3-year overall survival rates of the limited and standard lymphadenectomy groups were 58.3% and 73.6%, respectively. The 3-year recurrence-free survival rate of the limited lymphadenectomy group was lower than that of the standard lymphadenectomy group; however, the difference was not statistically significant.

CONCLUSIONS

Standard D2 lymphadenectomy has better oncological outcomes in elderly patients with advanced gastric cancer.

Gastroesophageal adenocarcinoma in older adults: A comprehensive narrative review of management by the Young International Society of Geriatric Oncology

Gastroesophageal adenocarcinoma is a disease of older adults with very poor survival rates. Its incidence has risen dramatically across the world in recent decades. Current treatment approaches for older adults are based largely on extrapolated evidence from clinical trials conducted in younger and fitter participants than those more commonly encountered in clinical practice. Understanding how to apply available evidence to our patients in the clinic setting is essential given the high morbidity of both curative and palliative treatment. This review aims to use available data to inform the management of an older adult with gastroesophageal adenocarcinoma.

Laparoscopic and endoscopic cooperative surgery for advanced gastric cancer as palliative surgery in elderly patients: a case report

Background

The number of elderly patients with gastric cancer is increasing, with the very elderly often refusing radical gastrectomy with lymph node dissection. Such a patient presented to us and we proposed a palliative surgery involving gastric local resection using laparoscopy endoscopy cooperative surgery (LECS).

Case presentation

An 89-year-old woman presented to our hospital with progressing anemia. She had an aortic arch replacement for aortic dissection 6 months previously and was taking antithrombotic drugs for atrial fibrillation. She was diagnosed with advanced gastric cancer, and we presented a radical resection treatment plan involving distal gastrectomy with lymph node dissection. However, she strongly refused undergoing radical gastric cancer resection. We believed that at least local control of the tumor could be effective in preventing future bleeding or stenosis due to tumor progression. Therefore, we proposed a local gastrectomy with LECS as an optional treatment, and she agreed to this treatment. The surgery was performed with minimal blood loss, and no postoperative complications were observed. Histopathological examination revealed a 45 × 31-mm, Type 2, poorly differentiated adenocarcinoma (pT4a, ly0, v1a), and the resected margin was negative. The patient was alive 2 years after surgery without apparent recurrence or other illness. In addition, her weight was maintained, together with her daily activity.

Conclusion

Local resection of gastric cancer with LECS might be an option for the palliative treatment of patients who refuse radical resection of gastric cancer.

Ninety-day mortality after total gastrectomy for gastric cancer

BACKGROUND

Total gastrectomy for gastric cancer is associated with significant 30-day mortality, but this endpoint may underestimate the short-term mortality of the procedure.

METHODS

Retrospective analysis was performed using the National Cancer Database (2004-2015). Patients who underwent total gastrectomy for stage I to III gastric adenocarcinoma were identified and divided into cohorts based on 90-day mortality. Predictors of mortality were analyzed using multivariable logistic regression, and annual trends in mortality rates were calculated by Joinpoint Regression.

RESULTS

Of the 5,484 patients who underwent total gastrectomy, 90-day and 30-day mortality rates were 9.1% and 4.7%, respectively. Factors associated with 90-day mortality included increasing age (odds ratio 1.0, P < .001), income below the median (odds ratio 1.2, P = .039), Charlson-Deyo score ≥2 (odds ratio 1.4, P = .039), treatment at low-volume facilities (odds ratio 1.5, P < .001), N1 (odds ratio 2.0, P < .001), N2 (odds ratio 2.0, P < .001), or N3 (odds ratio 2.7, P < .001) stage disease, having <16 lymph nodes harvested (odds ratio 1.5, P < .001), and lack of treatment with chemotherapy (3.7, P < .001). Lack of health insurance (odds ratio 4.1, P = .080), and positive microscopic margins (odds ratio 1.3, P = .080) were correlated, but not significantly associated, with 90-day mortality. The 90-day mortality rate significantly declined from 14.3% in 2004 to 7.9% in 2015 (P = .006), and the 30-day mortality rate significantly declined from 7.7% in 2004 to 4.8% in 2015 (P = .009).

CONCLUSION

Nearly half of the deaths within 90 days after total gastrectomy for cancer occur beyond 30 days postoperative. Ninety-day mortality has improved over time, but rates remain high, suggesting the need for improved out-of-hospital postoperative care beyond 30 days.

Pre- and post-operative low prognostic nutritional index influences survival in older patients with gastric carcinoma

OBJECTIVES

The survival impact of the preoperative prognostic nutritional index (PNI) has been investigated in older patients with gastric carcinoma (GC), while that of the postoperative PNI has yet to be addressed. We evaluated the significance of PNI before and after surgery in older GC patients (≥75 years).

MATERIALS AND METHODS

In total, 309 older GC patients undergoing radical gastrectomy between 2006 and 2016 were retrospectively reviewed. The PNI was evaluated before and at six months after gastrectomy. Patients were divided into low (<45) and high (≥45) PNI groups. The impact of low PNI on overall survival (OS), cancer-specific survival (CSS), and non-GC-related death were investigated.

RESULTS

Low PNI was present in 134 patients (43.4%) preoperatively and 121 (39.2%) postoperatively. Low pre-PNI was independently associated with poor overall survival (P < .001). Similarly, OS was significantly stratified by post-PNI (P < .001). The significant survival difference according to post-PNI was present only in pStage I disease (P < .001). Low post-PNI independently increased the risk of non-GC-related death in a multivariable analysis (P = .002). In contrast, CSS was not stratified by post-PNI (P = .45). In the high pre-PNI group, total gastrectomy and super-older age (≥80 years) independently increased the risk of low post-PNI, which was significantly associated with poor survival outcomes.

CONCLUSIONS

Pre- and post-operative PNI are useful for predicting long-term outcomes in older patients with GC. Low postoperative PNI is a powerful determinant of mortality due to other diseases. Optimal perioperative management is required for those at high risk of malnutrition postoperatively.

Surgical outcomes of elderly patients with Stage I gastric cancer from the nationwide registry of the Japanese Gastric Cancer Association

BACKGROUND

The proportion of elderly patients undergoing surgery for gastric cancer is increasing. However, limited number of therapeutic outcomes in the elderly has been reported. Here we examined the surgical results based on a nationwide survey of elderly patients who underwent surgery for Stage I gastric cancer.

METHODS

Data from 68,353 Stage I patients who underwent gastrectomy between 2001 and 2007 were retrospectively collected. The accumulated data were reviewed and analyzed by the Japanese Gastric Cancer Association registration committee. We first classified the patients as those aged ≤ 74 years and ≥ 75 years. We further classified those patients aged ≥ 75 years into groups by 5-year increments to examine their short- and long-term postoperative outcomes.

RESULTS

Patients aged ≥ 75 years accounted for 46.5%. The 30-day mortality rate was < 0.7% for any age group, but for those aged ≥ 75 years, the 60-day and 90-day mortality rates were 0.9-2.3% and 1.2-5.1%, respectively. An examination of long-term survival indicated that, as the class of age increased, the 5-year overall survival (OS) was 47.0-93.1% and disease-specific survival (DSS) was 91.4-98.2%, respectively. Although high DSS rates of ≥ 90% were found for all age groups, OS only accounted for ≤ 82% of patients aged ≥ 75 years.

CONCLUSION

Among elderly patients with Stage I gastric cancer, deaths due to other diseases were frequently observed in the long term. Thus, for elderly patients, it may be appropriate to reconsider the treatment strategy with respect to the balance between the invasiveness of the treatment and the prognosis.

Feasibility and Effectiveness of Gastrectomy for Elderly Gastric Cancer Patients

BACKGROUND/AIM

The benefits of gastrectomy for elderly gastric cancer (GC) patients remain unknown. The aim of this study was to evaluate the validity of gastrectomy.

PATIENTS AND METHODS

Patients who had R0 or R1 resection and diagnosed as pathological Stage I-III GC were enrolled in this study. Patients were classified according to age: Elderly group (≥80 years old), non-Elderly group (70-79 years old), Standard group (≤69 years old).

RESULTS

As the age raised, the number of comorbidities increased and patients had a worse physical status. Operative procedure and postoperative complications of the Elderly group were similar to that of the non-Elderly group. The overall survival was similar in pathological Stages I and III between the Elderly and non-Elderly groups, while the Stage II Elderly group had shorter overall survival. Also, the Elderly group did not undergo adjuvant chemotherapy compared to other groups.

CONCLUSION

Gastrectomy can be performed safely in elderly patients following gastrectomy, survival of elderly patients was similar to non-elderly patients. Therefore, gastrectomy is an acceptable treatment for elderly patients in good condition.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Surgical outcomes after gastrectomy in very elderly patients with gastric cancer

PURPOSE

Whether or not gastrectomy is feasible for very elderly gastric cancer patients is unclear. This study aimed to clarify the feasibility and safety of surgical treatment for patients in this age group.

METHOD

The study included 55 very elderly patients with resectable gastric cancer who underwent gastrectomy (≥ 85 years of age; very-E group). The surgical outcomes were compared with those of 611 elderly patients (75-84 years old; E group).

RESULTS

Female sex, a poor physical and performance status, and a low serum albumin level patients were more frequent in the very-E group than in the E group. Lymphadenectomy was less aggressive in the very-E group than in the E group (P < 0.001). The overall postoperative complication rate was not significantly different between the groups (46 vs 33%; P = 0.073). A multivariate analysis to predict the overall survival identified male sex (hazard ratio 1.75, 95% confidence interval 1.30-2.36), low body mass index (2.19, 1.52-3.16), poor performance status (2.14, 1.60-2.86), low serum albumin level (1.84, 1.37-2.48), and advanced tumor stage (1.71, 1.29-2.27) but not age (1.31, 0.84-2.03) as independent prognostic factors.

CONCLUSION

Chronological age alone is not a contraindicative factor for gastrectomy in very elderly patients.

Surgery for gastric cancer patients of age 85 and older: Multicenter survey

AIM

To investigate the surgical therapies for gastric cancer (GC) patients of age 85 or older in a multicenter survey.

METHODS

Therapeutic opportunities for elderly GC patients have expanded in conjunction with extended life expectancy. However, the number of cases encountered in a single institution is usually very small and surgical therapies for elderly GC patients have not yet been standardized completely. In the present study, a total of 134 GC patients of age 85 or older who underwent surgery in 9 related facilities were retrospectively investigated. The relationships between surgical therapies and clinicopathological or prognostic features were analyzed.

RESULTS

Eighty-nine of the patients (66%) presented with a comorbidity, and 26 (19% overall) presented with more than two comorbidities. Radical lymphadenectomy was performed in 59 patients (44%), and no patient received pre- or post-operative chemotherapy. Forty of the patients (30%) experienced perioperative complications, but no surgical or perioperative mortality occurred. Laparoscopic surgery was performed in only 12 of the patients (9.0%). Univariate and multivariate analyses of the 113 patients who underwent R0 or R1 resection identified the factors of pT3/4 and limited lymphadenectomy as predictive of worse prognosis (HR = 4.68, P = 0.02 and HR =2.19, P = 0.05, respectively). Non-cancer-specific death was more common in cStage I patients than in cStage II or III patients. Limited lymphadenectomy correlated with worse cancer-specific survival (P = 0.01), particularly in cStage II patients (P < 0.01). There were no relationships between limited lymphadenectomy and any comorbidities, except for cerebrovascular disease (P = 0.07).

CONCLUSION

Non-cancer-specific death was not negligible, particularly in cStage I, and gastrectomy with radical lymphadenectomy appears to be an effective treatment for cStage II elderly GC patients.

Endoscopic submucosal dissection for early gastric cancer in very elderly patients age 85 or older

Background and study aims The safety and efficacy of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in very elderly patients remains unclear. The aim of this study was to evaluate the safety and efficacy of ESD for EGC in patients age 85 years and older. Patients and methods Patients who underwent ESD for EGC between September 2003 and April 2015 were divided into 3 groups: the very elderly (≥ 85 years; 43 patients), the elderly (65 - 84 years; 511 patients), and the non-elderly ( ≤ 64 years; 161 patients). Adverse events (AEs) were used as the primary endpoint to assess the safety of ESD, and the ESD treatment outcomes (i. e., en bloc resection rate, complete en bloc resection rate, and curative resection rate) and the overall survival rate after ESD were the secondary endpoints. These parameters were retrospectively evaluated in the 3 groups. Results There were no significant differences in AEs (non-elderly, elderly, and very elderly: 7.3, 9.5, and 12.5 %, respectively, P = 0.491) or in the en bloc resection and complete en bloc resection rates among the three groups. However, there was a significant difference in the curative resection rates (non-elderly, elderly, and very elderly: 91.5, 84.1, and 77.1 %, respectively, P = 0.014). Regarding overall survival, there was a significant difference among the three groups (1-, 5-, and 10-year overall survival rates: non-elderly: 98.6, 90.2, and 74.7 %; elderly: 97.2, 86.2, and 61.9 %; and very elderly: 92.7, 66.8, and 34.4 %, respectively, P = 0.001). Moreover, the overall survival rate in the very elderly patients with cardiovascular disease was significantly lower than that in the very elderly patients without cardiovascular disease (P < 0.001). Conclusions ESD is an acceptable treatment for EGC in patients 85 years of age or older in terms of safety. However, the overall survival after ESD in the very elderly patients with cardiovascular disease was short.