Impact of extended lymphadenectomy on morbidity, mortality, recurrence and 5-year survival after gastrectomy for cancer. Meta-analysis of randomized clinical trials

A robust qualitative transcriptional signature for the correct pathological diagnosis of gastric cancer

BACKGROUND

Currently, pathological examination of gastroscopy biopsy specimens is the gold standard for gastric cancer (GC) diagnosis. However, it has a false-negative rate of 10-20% due to inaccurate sampling locations and/or insufficient sampling amount. A signature should be developed to aid the early diagnosis of GC using biopsy specimens even when they are sampled from inaccurate locations.

METHODS

We extracted a robust qualitative transcriptional signature, based on the within-sample relative expression orderings (REOs) of gene pairs, to discriminate both GC tissues and adjacent-normal tissues from non-GC gastritis, intestinal metaplasia and normal gastric tissues.

RESULTS

A signature consisting of two gene pairs for GC diagnosis was identified and validated in data of both biopsy specimens and surgical resection specimens pooled from publicly available datasets measured by different laboratories with different platforms. For gastroscopy biopsy specimens, 96.20% of 79 non-GC tissues were correctly identified as non-GC, and 96.84% of 158 GC tissues and six of seven adjacent-normal tissues were correctly identified as GC. For surgical resection specimens, 98.37% of 2560 GC tissues and 97.28% of 221 adjacent-normal tissues were correctly identified as GC. Especially, 97.67% of the 257 GC patients at stage I were exactly diagnosed as GC. We additionally measured 21 GC tissues from seven different GC patients, each with three specimens sampled from three tumor locations with different proportions of the tumor epithelial cell. All these GC tissues were correctly identified as GC, even when the proportion of the tumor epithelial cell was as low as 14%.

CONCLUSIONS

The qualitative transcriptional signature can distinguish both GC and adjacent-normal tissues from normal, gastritis and intestinal metaplasia tissues of non-GC patients even using inaccurately sampled biopsy specimens, which can be applied robustly at the individual level to aid the early GC diagnosis.

Is There Any Role for D3 Lymphadenectomy in Gastric Cancer?

Although D2 constitutes the level of lymph node dissection which most surgical associations endorse in their treatment guidelines for gastric cancer more extended D3 dissection has also been attempted to improve oncologic outcomes. Existing literature pertinent with the provisional therapeutic impact of D3 lymphadenectomy in advanced gastric cancer is studied in this mini review. Seven non-randomized comparisons, three randomized trials and five meta-analyses, almost exclusively of Asian origin, were identified and examined. D3 compared to D2 lymphadenectomy consistently and significantly proved to be associated with a “heavier” iatrogenic surgical trauma translated to more blood loss, prolonged operative time, higher relaparotomy rates and post-procedural surgical and non-surgical morbidity. Oddly mortality in most of these series did not reach statistical significance a fact probably attributed to Asian surgical expertise and/or methodologic drawbacks. All existing evidence and their meta-analyses, including a well-designed RCT from Japan (JCOG), failed to support a clear overall survival benefit linked to D3 dissection thus excluding the procedure from current treatment algorithms. The Italian GC research group, analyzing their database, proposed tumor histology, macroscopic type, size and location as selection criteria for D3 dissection provided surgical expertise is available. Recently, a phase II clinical trial from Japan reported a 3 -year survival rate of 59% in patients with clinically involved para-aortic nodes treated with neoadjuvant chemotherapy followed by D3 lymphadenectomy, rekindled the issue. Future multicenter randomized trials should test the extend and after effect of lymphadenectomy in gastric cancer combined with modern chemotherapeutic agents in multimodal treatments.

Evaluation the Survival of Patients with Gastric Cancer Treated with Adjuvant or Palliative Chemotherapy

AIM

Our aim was to evaluate impact of chemotherapy (5-fluorouracil plus docetaxel and cisplatin) on the survival of gastric cancer cases.

METHOD

Seventy-nine patients were eligible to take part in this study between November 2006 and April 2013, who received 5-fluorouracil (700 mg/m², 21-h infusion within 5 days), cisplatin (60 mg/m² on day 3), and Docetaxel (60 mg/m² on day 2). Radiotherapy was added to the treatment only in the cases with entire stomach body cancer (positive margin) and with giant ulcer (above 50 mm) in proximal gastric cancer.

RESULTS

Twenty-four patients were female and 55 were male. The median age was 54. In this study, 54 % of the tumors were located in the proximal and 46 % in the distal of stomach. Seventy five percent of patients were at stage I-III (adjuvant chemotherapy), and 25 % at stage IV (palliative chemotherapy). Ninety-one percent of the patients at stages I-II, 68.3 % of the patients at stage III, and one out of 20 patients at stage IV were alive at the end of follow-up. Median disease-free survival for the patients at stages I-III was 63 months, and the overall survival for all patients was 50 months.

CONCLUSION

The results of our study indicate that the survival of the patients with stomach cancer increases with chemotherapy. Radiotherapy was used for our patients with gastric cancer in specific cases.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Insights into the distinct roles of MMP-11 in tumor biology and future therapeutics (Review)

The biological processes of cancer cells such as tumorigenesis, proliferation, angiogenesis, apoptosis and invasion are greatly influenced by the surrounding microenvironment. The ability of solid malignant tumors to alter the microenvironment represents an important characteristic through which tumor cells are able to acquire specific functions necessary for their malignant biological behaviors. Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases with the capacity of remodeling extracellular matrix (ECM) by degrading almost all ECM proteins, which plays essential roles during the invasion and metastasis process of solid malignant tumors, including allowing tumor cells to modify the ECM components and release cytokines, ultimately facilitating protease-dependent tumor progression. MMP-11, also named stromelysin-3, is a member of the stromelysin subgroup belonging to MMPs superfamily, which has been detected in cancer cells, stromal cells and adjacent microenvironment. Differently, MMP-11 exerts a dual effect on tumors. On the one hand MMP-11 promotes cancer development by inhibiting apoptosis as well as enhancing migration and invasion of cancer cells, on the other hand MMP-11 plays a negative role against cancer development via suppressing metastasis in animal models. Overexpression of MMP-11 was discovered in sera of cancer patients compared with normal control group as well as in multiple tumor tissue specimens, such as gastric cancer, breast cancer, and pancreatic cancer. At present, some evidence supports that MMP-11 may work as a significant tumor biomarker for early detection of cancer, tumor staging, prognostic analysis, monitoring recurrence during follow-up and also a potential target for immunotherapy against cancer. In view of the importance of MMP-11 in modifying tumor microenvironment and potent antitumoral effects on solid tumors, there is an urgent need for a deeper understanding of how MMP-11 modulates tumor progression, and exploring its potential clinical application.

HNRNPC as a candidate biomarker for chemoresistance in gastric cancer

Chemoresistance is a major cause of treatment failure and high mortality in advanced gastric cancer (AGC). Currently, the mechanism of chemoresistance remains unclear, and there is no biomarker to accurately predict the efficacy of chemotherapy. In the present study, we established human gastric cancer (GC) cell lines resistant to 5-fluorouracil (5FU), paclitaxel (TA), or cisplatin (DDP) by gradient drug treatment and generated a novel monoclonal antibody 5B2 targeting heterogeneous nuclear ribonucleoproteins C1/C2 (HNRNPC) overexpressed in chemoresistant GC cells. Overexpressing HNRNPC in GC cells promoted chemoresistance, and knockdown of HNRNPC by small interfering RNA (siRNA) reversed chemoresistance. By utilizing available datasets, we demonstrated that high level of HNRNPC transcript indicated poor overall survival (OS) and free of progression (FP). HNRNPC expression was negatively correlated with OS of GC patients treated with 5FU-based drugs and with time to progression (TTP) of GC patients treated with CF regimen. These data suggest the potential usefulness of HNRNPC as a prognostic and therapeutic marker of GC.

Serum angiopoietin-like protein 2 as a potential biomarker for diagnosis, early recurrence and prognosis in gastric cancer patients

Chronic inflammation of gastric mucosa by Helicobacter pylori infection can initiate gastric carcinogenesis. As angiopoietin-like protein 2 (ANGPTL2) mediates inflammation and inflammation-associated carcinogenesis, we investigated the functional and clinical significance of ANGPTL2 in human gastric cancer (GC). SiRNA knockdown studies were performed for the functional assessment of ANGPTL2 in GC cell lines. ANGPTL2 expression was evaluated immunohistochemically in 192 tissue specimens from GC patients. In addition, we screened serum ANGPTL2 levels from 32 GC patients and 23 healthy controls; and validated these results in 194 serum samples from GC patients and 45 healthy controls by ELISA. ANGPTL2 knockdown caused anoikis and inhibited proliferation, invasion and migration in GC cells. ANGPTL2 expression was upregulated in GC tissues compared to normal gastric mucosa; and high ANGPTL2 expression was significantly associated with tumor progression, early recurrence (P = 0.003) and poor prognosis (P = 0.007). Serum ANGPTL2 in GC patients was significantly higher than for healthy controls (P < 0.05), and accurately distinguished GC patients from healthy control (AUC = 0.865). The validation step confirmed significantly higher serum ANGPTL2 levels in GC patients than healthy controls (P < 0.0001). Receiver operating characteristic curves yielded robust AUC value (0.831) accompanied by high sensitivity (73.0%) and specificity (82.2%) in distinguishing GC patients from healthy controls. High serum ANGPTL2, rather than its expression in matched tissues, was significantly associated with tumor progression, and emerged as an independent marker for recurrence (HR: 5.05, P = 0.0004) and prognosis (HR: 3.6, P = 0.01). Serum ANGPTL2 expression is a potential noninvasive biomarker for diagnosis, early recurrence and prognosis of GC patients.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1⁺ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Role of (chemo)-radiotherapy in resectable gastric cancer

The prognosis of patients with locally advanced gastric cancer remains poor, despite radical surgical resection. Adjuvant therapy has been shown to improve survival and, in Western countries, is delivered either postoperatively (chemoradiotherapy) or perioperatively (chemotherapy). Debate continues as to which of these represents the optimal strategy. High-dose gastric irradiation comes at the expense of significant toxicity, and increasing efforts have focused on attempts to reduce toxicity and normal tissue doses. The development of advancing radiotherapy technologies now allows improved target delineation and coverage. However, gastric irradiation remains technically challenging and requires an understanding of postoperative surgical anatomy, patterns of failure and lymph node drainage, as well as an appreciation of the uncertainties around organ motion and filling. Ongoing trials are examining the optimal strategy in which to incorporate (chemo)-radiotherapy, as well as the addition of targeted therapies, in gastric cancer. This overview discusses the current role and evidence for (chemo)-radiotherapy, as well as the technical challenges encountered in the radiotherapeutic management of resectable gastric cancer.

[Lymph node dissection: what for? From esophagus to rectum: surgical and lymph node related prognostic factors]

Surgery has still a key role in curative treatment of digestive carcinomas, and for almost all localisations, lymph node status is a major prognostic factor. As far as oesophageal and gastric cancer are concerned, there is not yet any internationally standardized approach. Occidental guidelines recommend more limited lymph node dissections than Asiatic ones. Lymph node numbers requested during surgery of such cancers remain high, at least 23 lymph nodes for oesophageal cancer, and 25 for a D2 or D1.5 lymphadenectomy for gastric cancer. Generalisation of neo-adjuvant and adjuvant treatments has not yet modified these standards. On the other hand, rectal cancer surgery is well standardized since the global adoption of Total Mesorectal Excision (TME) for the late eighties. Development of mini-invasive techniques (laparoscopy and robot-assisted surgery) enabled an important decrease of surgery related morbidity as well as an enhanced post-operative recovery. However, rectal cancer surgery still has an important morbidity. Development of neo-adjuvant chemo-radiotherapy as well as in-depth knowledge of risk factor of lymph node invasion opened up the path for transanal full thickness resection without lymphadenectomy. The goal of such an approach is to avoid TME's morbidity without risking local recurrence rate increase. As a consequence, this technique might need to be completed with a TME case histological factors are not favorable.

High level of serum AMBP is associated with poor response to paclitaxel-capecitabine chemotherapy in advanced gastric cancer patients

Gastric cancer is one of the most common human cancers and ranks the second in the global cancer-related mortality. The clinical outcome of patients with advanced gastric cancer (AGC) is markedly dependent on their response to the chemotherapy. Paclitaxel plus capecitabine, as a first-line regimen, is widely administrated in AGC patients, but more than a half of the patients have a poor response, possibly due to their resistance to the treatment. Therefore, it is important to identify potential responders to improve the efficacy of the chemotherapy. In the present study, we used an isobaric tag approach for relative and absolute quantification combined with ESI-QUAD-TOF/MS to identify potential predictive biomarkers for the chemotherapy. We found 211 serum proteins, and confirmed 17 candidates that were differentially present in the progression of disease (PD) group and the partial response (PR) group to the treatment of paclitaxel plus capecitabine. In further validation of the 17 candidates in the set of 12 PD and 12 PR AGC patients, we identified a higher level of AMBP (Alpha-1-Microglobulin/Bikunin Precursor) in the sera of PD patients than of the PR patients assayed by ELISA (9.13 ± 0.45 vs. 8.11 ± 0.26 μg/mL, p = 0.06) and by the Western blotting (relative gray value 396.4 ± 39.1 vs. 275.0 ± 34.76, p = 0.03), respectively. The receiver operating characteristics curve showed 75% sensitivity and 75% specificity of AMBP in AGC patients treated with the chemotherapy. Our data indicated that the high level of serum AMBP could predict the poor response of the AGC patients treated with the paclitaxel-capecitabine chemotherapy, which could be used as a potential biomarker to identify patients who would benefit from this chemotherapeutic regimen.

Survival and recurrence free benefits with different lymphadenectomy for resectable gastric cancer: a meta-analysis

BACKGROUND

The objective of the present meta-analysis was to estimate the magnitude of survival and recurrence free benefits from different lymphadenectomy in patients with resectable gastric cancer.

METHODS

A comprehensive search was performed for original studies published from their inception to 2012. Two reviewers independently assessed search results, methodological quality, and data extraction of included studies. Results regarding the overall survival (OS) and recurrence free survival (RFS) in the meta-analysis were expressed as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Twelve randomized control trials (RCTs) were eligible for final meta-analysis. There was not significant difference in OS between D1 and D2 lymphadenectomy (HR = 0.92, 95% CI: 0.77-1.10, P = 0.36), but subgroup analysis of patients without splenectomy and/or pancreatectomy has a trend for OS much more benefiting D2 compared to D1 patients. A significant RFS improvement was found in favor of D2 lymphadenectomy, sensitivity analysis also gives similar fixed effect estimates (HR = 0.68, 95% CI: 0.58-0.81, P = 0.84). There were no significant differences in OS and RFS between D2 group and D3 group (1 trial).

CONCLUSIONS

The present meta-analysis indicates that D2 lymphadenectomy with spleen and pancreas preservation offers the most survival benefit for patients with gastric cancer when done safety.

Quality of care indicators for the surgical treatment of gastric cancer: a systematic review

BACKGROUND

Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer.

METHODS

A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators.

RESULTS

A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection.

CONCLUSIONS

Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.

A meta-analysis of D1 versus D2 lymph node dissection

BACKGROUND

Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. Therefore, with the publication of newer trial results, we conducted an updated meta-analysis of D1 versus D2 randomized controlled trials comparing outcomes.

METHODS

Systematic searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1985, to December 31, 2010. Meta-analyses were performed using RevMan v5 software. Both short- and long-term outcomes were analyzed. Subgroup analyses of T stage and spleen/pancreas resection versus preservation were performed.

RESULTS

Outcomes of 5 randomized trials involving 1642 patients (845 D1, 797 D2) enrolled from 1982 to 2005 were included. Despite the addition of the more recent trials, overall hospital mortality and reoperation rates were still higher in D2 cases. Subgroup analysis of recent trials and spleen/pancreas preservation revealed no significant difference in hospital mortality between groups. Five-year overall survival was similar between D1 versus D2 trials. Sub-analysis by tumor depth and spleen/pancreas preservation detected trends for improved survival with D2 lymphadenectomy in T3/T4 patients and those with spleen/pancreas preservation.

CONCLUSION

Earlier trials show that D2 dissections have higher operative mortality, while recent trials have similar rates. A trend of improved survival exists among D2 patients who did not undergo resection of the spleen or pancreas, as well as for patients with T3/T4 cancers.

Serum levels of TUBB3 correlate with clinical outcome in Chinese patients with advanced gastric cancer receiving first-line paclitaxel plus capecitabine

The overexpression of β-tubulin III (TUBB3) in tumor tissues was reversely related with the efficacy of paclitaxel and clinical outcome in different cancers. In this study, we aimed to investigate the association between serum levels of TUBB3 and clinical outcome in advanced gastric cancer patients receiving first-line paclitaxel plus capecitabine. One hundred and twenty-eight advanced gastric cancer patients receiving first-line paclitaxel plus capecitabine in Peking University Cancer Hospital from December 2006 to October 2010 were enrolled in the study. Serum samples from 32 healthy individuals were used as controls. TUBB3 expression level in advanced gastric cancer was significantly higher than that in healthy control group (31.6 ± 17.8 ng/mL vs. 16.9 ± 3.8 ng/mL, p < 0.001). For all patients, the clinical benefit rate (CBR), median progression-free survival (PFS), and overall survival (OS) were 55.6 %, 179 and 306 days, respectively. The CBR, median PFS, and OS in patients with low (n = 27) and high levels (n = 101) of TUBB3 were 95.8 %/45.1 % (low vs. high, p < 0.001), 190 days/166 days (p = 0.064), and 360 days/297 days (p = 0.023), respectively. Cox multivariate regression analysis demonstrated that the serum levels of TUBB3 were an independent prognostic factor for advanced gastric cancer patients (HR = 1.950; 95 % CI, 1.242-3.062; p = 0.004). This study indicated that low levels of TUBB3 in serum could predict better response and survival for advanced gastric cancer patients receiving paclitaxel plus capecitabine, which could be used to select patients who would benefit from this regimen.

Lymph node dissection for gastric cancer: a critical review

Gastric cancer is one of the most common neoplasms and an important cause of cancer-related death worldwide. Efforts to reduce its high mortality rates are currently focused on multidisciplinary management. However, surgery remains a cornerstone in the management of patients with resectable disease. There is still some controversy as to the extent of lymph node dissection for potentially curable stomach cancer. Surgeons in eastern countries favor more extensive lymph node dissection, whereas those in the West favor less extensive dissection. Thus, extent of lymph node dissection remains one of the most hotly discussed aspects of gastric surgery, particularly because most stomach cancers are now often comprehensively treated by adding some perioperative chemotherapy or chemo-radiation. We provide a critical review of lymph nodes dissection for gastric cancer with a particular focus on its benefits in a multimodal approach.

Serum levels of MMP-11 correlate with clinical outcome in Chinese patients with advanced gastric adenocarcinoma

Background

The aim of the present study was to investigate the association between serum levels of matrix metalloproteinase 11 (MMP-11) and responses to front-line chemotherapy and prognosis in advanced unresectable gastric adenocarcinoma.

Methods

Clinical data concerning 86 patients with advanced gastric adenocarcinoma (stages III c to IV), treated in Beijing Chao-Yang Hospital from 2005 to 2009, were reviewed retrospectively. Adenocarcinoma was confirmed by pathology and patients received 5-fluorouracil-based front-line combination chemotherapy with third generation chemotherapeutic agents including paclitaxel, docetaxel and oxaliplatin. The regimen was repeated every two to three weeks, and the first evaluation was carried out after three cycles. The median cycle of chemotherapy was 6 (ranging from three to twelve cycles). Serum MMP-11 protein from the 86 patients was examined using enzyme-linked-immunosorbent-assay (ELISA) prior to chemotherapy and after three cycles of chemotherapy. Serum samples from healthy individuals were used as controls.

Results

The response rate (RR, complete response plus partial response) to chemotherapy in the 86 patients was 44.2% (38/86). The median TTP (time to progression) and overall survival (OS) in patients who responded to chemotherapy were 6.0 and 10.0 months, respectively. The response rate to chemotherapy in patients with high levels of serum MMP-11 (42.9%; 9/21) was similar to that in patients with low levels (44.6%; 29/65) (P = 0.935). Patients with low serum levels of MMP-11 had a higher median survival time and 1-year survival rate than those with high levels (11 months vs. 8 months, 50.2% vs. 21.7%, P = 0.017), although the TTP was comparable in all patients, irrespective of serum MMP-11 level (P = 0.178). Serum MMP-11 levels were correlated with lymph node metastasis (P = 0.006). Cox multivariate regression analysis demonstrated that the serum level of MMP-11 was an independent prognostic factor for patients presenting with advanced gastric carcinoma.

Conclusions

Serum levels of MMP-11 in Chinese patients with advanced gastric carcinoma were not associated with the response to front-line chemotherapy, but could play an important role in lymph node metastasis and prognosis.

Serum levels of MMP-11 correlate with clinical outcome in Chinese patients with advanced gastric adenocarcinoma

BACKGROUND

The aim of the present study was to investigate the association between serum levels of matrix metalloproteinase 11 (MMP-11) and responses to front-line chemotherapy and prognosis in advanced unresectable gastric adenocarcinoma.

METHODS

Clinical data concerning 86 patients with advanced gastric adenocarcinoma (stages III c to IV), treated in Beijing Chao-Yang Hospital from 2005 to 2009, were reviewed retrospectively. Adenocarcinoma was confirmed by pathology and patients received 5-fluorouracil-based front-line combination chemotherapy with third generation chemotherapeutic agents including paclitaxel, docetaxel and oxaliplatin. The regimen was repeated every two to three weeks, and the first evaluation was carried out after three cycles. The median cycle of chemotherapy was 6 (ranging from three to twelve cycles). Serum MMP-11 protein from the 86 patients was examined using enzyme-linked-immunosorbent-assay (ELISA) prior to chemotherapy and after three cycles of chemotherapy. Serum samples from healthy individuals were used as controls.

RESULTS

The response rate (RR, complete response plus partial response) to chemotherapy in the 86 patients was 44.2% (38/86). The median TTP (time to progression) and overall survival (OS) in patients who responded to chemotherapy were 6.0 and 10.0 months, respectively. The response rate to chemotherapy in patients with high levels of serum MMP-11 (42.9%; 9/21) was similar to that in patients with low levels (44.6%; 29/65) (P = 0.935). Patients with low serum levels of MMP-11 had a higher median survival time and 1-year survival rate than those with high levels (11 months vs. 8 months, 50.2% vs. 21.7%, P = 0.017), although the TTP was comparable in all patients, irrespective of serum MMP-11 level (P = 0.178). Serum MMP-11 levels were correlated with lymph node metastasis (P = 0.006). Cox multivariate regression analysis demonstrated that the serum level of MMP-11 was an independent prognostic factor for patients presenting with advanced gastric carcinoma.

CONCLUSIONS

Serum levels of MMP-11 in Chinese patients with advanced gastric carcinoma were not associated with the response to front-line chemotherapy, but could play an important role in lymph node metastasis and prognosis.