Impact of Treatment Sequencing on Survival for Patients with Locally Advanced Gastric Cancer

Evaluation of pathologic response and surgical safety of total neoadjuvant therapy for patients with clinical stage III gastric cancer in a real-world setting

BACKGROUND

Perioperative chemotherapy is the standard treatment for locally advanced gastric cancer. However, the potential benefit of extending therapy before surgery remains largely unknown. In this study, we aimed to evaluate the efficacy and safety of total neoadjuvant chemotherapy, with or without immune checkpoint blockade.

METHODS

A cohort of 174 patients with clinical stage III gastric cancer who underwent D2 gastrectomy from October 2021 to March 2024 in the real-world setting were included in this study. Among these patients, 101 were treated with total neoadjuvant therapy (TNT) and 73 were treated with perioperative neoadjuvant therapy (PNT). We compared the pathologic complete response (pCR) rate, ypN0 rate, recurrence-free survival (RFS), overall survival (OS), and postoperative complications between the 2 groups. Multivariate logistic regression analysis was conducted to identify factors associated with pCR or ypN0.

RESULTS

Compared with the PNT group, the patients in the TNT group were more frequently treated with intensive chemotherapy with triplets + immunotherapy. Apart from this, there were no significant differences in baseline characteristics. There were no statistically significant differences in pCR (16.8% vs 12.3%), ypN0 (49.5% vs 38.4%), RFS, OS, and postoperative complications (27.7% vs 26.0%) between the TNT and PNT groups. Older age, diffuse type, and stable disease/progressive disease based on clinical efficacy evaluation were independently associated with non-pCR. Stable disease/progressive disease, linitis plastica, and poor differentiation were independently associated with ypN+. Neither the number of neoadjuvant therapy cycles nor the specific regimens were associated with pCR or ypN0. In the subgroup analysis of patients receiving total gastrectomy, there were still no statistically significant differences in pCR (16.7% vs 2.6%), ypN0 (43.8% vs 39.5%), and postoperative complications (45.8% vs 36.8%) between the 2 groups.

CONCLUSION

Although TNT did not increase the postoperative complication rate, it also did not provide any additional short-term benefits compared with PNT for clinical stage III gastric cancer.

Survival Outcomes in Patients with Resectable Gastric Cancer Treated with Total Neoadjuvant Therapy

BACKGROUND

Perioperative chemotherapy has become the standard of care for locally advanced gastric cancer. Total neoadjuvant therapy (TNT), including both chemotherapy and chemoradiation, is utilized in other gastrointestinal malignancies. We determined survival in a contemporary cohort of gastric cancer patients treated with TNT.

METHODS

Using a prospective institutional database, patients diagnosed with cT2-4 or cN+ gastric adenocarcinoma (January 2012 to June 2022) who underwent staging laparoscopy, received TNT, and underwent gastrectomy were identified. Overall survival (OS) and disease-specific survival (DSS) were determined using standard statistical methods.

RESULTS

The study included 203 patients. The most common TNT sequence was induction chemotherapy followed by chemoradiation (n = 186 [91.6%]). A total of 195 (96.1%) patients completed planned neoadjuvant treatments. Surgery included total gastrectomy in 108 (53.2%), extended (D1+/D2) lymphadenectomy in 193 (95.1%), and adjacent organ resection in 19 (9.4%) patients. Pathologic complete response (pCR) was achieved in 32 (15.8%) patients. The 5-year OS rate was 65.2% (95% confidence interval [CI] 57.8-73.5%), and the 5-year DSS rate was 70.8% (95% CI 63.6-78.9%) in the study cohort. Among patients with pCR, the 5-year OS rate was 89.1% (95% CI 78.1-100.0%), and the 5-year DSS rate was 96.9% (95% CI 91-100%). Posttreatment pathologic N and M stages were the strongest prognostic indicators associated with both OS and DSS.

CONCLUSIONS

Total neoadjuvant therapy for resectable gastric cancer is associated with a high rate of treatment completion and promising survival outcomes. Prospective comparisons with perioperative treatment are needed to identify patients most likely to benefit from TNT.

Dynamic Nomogram for Predicting Long-Term Survival in Terms of Preoperative and Postoperative Radiotherapy Benefits for Advanced Gastric Cancer

Studies on the prognostic significance of preoperative radiotherapy (PERT) and postoperative radiotherapy (PORT) in patients with advanced gastric cancer (GC) remain elusive. The aim of the study was to evaluate the survival advantage of preoperative and postoperative radiotherapy and construct a dynamic nomogram model to provide customized prediction of the probability of prognostic events for advanced GC patients. We collected clinical records from 2010 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database with a specific target for stage II-IV GC patients treated with PERT or PORT. We used the least absolute shrinkage and selection operator (LASSO) regression model to identify factors that contribute to the overall survival (OS) of GC patients. The dynamic nomogram infographic was constructed based on the prognostic factors of tumor-specific survival. Out of the 3215 total patients (2271 [70.6%] male; median age, 61 [SD = 12] years), 1204 were in the PERT group and 2011 in the PORT group. Receiving PORT was associated with a survival advantage over PERT for stage II GC patients (HR = 0.791, 95% CI= 0.712-0.879, p < 0.001). The 1-, 3-, and 5-year OS rates were 89.9%, 63.8%, and 53.8% in the PORT group, whereas the corresponding rates were significantly lower in the PERT group (86.4%, 57.1%, and 44.3%, respectively, all p < 0.05). The survival prediction model demonstrated that patients aged > 65 years, with an advanced cancer development stage and tumor size >3 were independent risk factors for poor prognosis (all HR > 1, p < 0.05). In this study, a dynamic nomogram was established based on the LASSO model to provide a statistical basis for the clinical characteristics and predictive factors of advanced GC in a large population. PORT demonstrated significantly better treatment advantages than PERT for stage II GC patients.

Superiority of Laparoscopic Gastrojejunostomy Combined With Multimodality Therapy for Gastric Outlet Obstruction Caused by Advanced Gastric Cancer

BACKGROUND

Data are limited concerning the survival outcomes of patients with gastric outlet obstruction (GOO) caused by advanced gastric cancers according to laparoscopic gastrojejunostomy (LGJ) combined with multimodality therapy (MMT). Therefore, the purpose of this study was to examine the feasibility and efficacy of these therapies.

METHODS

This single-centered, retrospective analysis included data of 184 patients with GOO due to advanced gastric cancer (AGC). Treatment models were: laparoscopic gastrojejunostomy combined with multimodality therapy (LGJ+MMT), endoscopic metal stent placement combined with multimodality therapy (EMSP+MMT), and multimodality therapy (MMT).

RESULTS

Improved oral intake, better nutritional indices, and better response to chemotherapy were observed in the LGJ+MMT group. Subsequent gastrectomy was performed in 43 (61.4%) patients in the LGJ+MMT group, 23 (37.7%) in the EMSP+MMT group, and 11 (20.8%) in the MMT group (P<0.001). LGJ+MMT was associated with better long-term prognosis. As confirmed by propensity scores and multivariate analyses, the 3-year survival rates in the three treatment models were 31.4% with LGJ+MMT, 0% with EMSP+MMT, and 0% with MMT in conversion therapy, and 50.0% with LGJ+MMT, 33.3% with EMSP+MMT, and 23.5% with MMT in NAC. A forest plot revealed that LGJ+MMT was related to a decreased risk of death.

CONCLUSIONS

LGJ combined with MMT was associated with better nutritional status, higher rates of subsequent gastrectomy, and good prognosis. LGJ combined with MMT may improve the long-term survival of patients with GOO caused by AGC.