1
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Stelmach R, Apostolidis L, Kahle S, Sisic L, Nienhüser H, Weber TF, Jäger D, Haag GM. Pattern and time point of relapse in locally advanced esophagogastric adenocarcinoma after multimodal treatment: implications for a useful structured follow-up. J Cancer Res Clin Oncol 2023; 149:14785-14796. [PMID: 37589924 PMCID: PMC10602954 DOI: 10.1007/s00432-023-05254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/04/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Despite improvements in multimodal treatment of locally advanced esophagogastric adenocarcinoma, the majority of patients still relapses. The impact of structured follow-up for early detection of recurrence is unclear and controversially discussed. METHODS Patients with locally advanced esophagogastric adenocarcinoma having received neoadjuvant/perioperative chemotherapy followed by tumor resection between 2009 and 2021, underwent a structured follow-up including three-monthly imaging during the first 2 years, followed by semiannual and annual examinations in year 3-4 and 5, respectively. Clinical outcome including pattern and time point of relapse was analyzed. RESULTS Two hundred fifty-seven patients were included in this analysis. In 50.2% (n = 129) of patients, recurrent disease was diagnosed, with the majority (94.6%) relapsing within the first 2 years. The most common site of relapse were lymph node metastases followed by peritoneal carcinomatosis and hepatic and pulmonary metastases. 52.7% of patients presented with symptoms at the time of relapse. Cumulative risk and time point of relapse differed significantly between patient with a node-positive tumor (ypN+) after neoadjuvant treatment (high-risk group) and patients with node-negative primary tumor (ypN0) (low-risk group). High-risk patients had a significantly inferior disease-free survival (DFS) and overall survival (OS) with 11.1 and 29.0 months, respectively, whereas median DFS and OS were not reached for the low-risk group. CONCLUSIONS The risk of relapse differs significantly between high- and low-risk patients. Only a part of relapses is associated with clinical symptoms. An individualized follow-up strategy is recommended for high- and low-risk patients considering the individual risk of relapse.
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Affiliation(s)
- Ramona Stelmach
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| | - Leonidas Apostolidis
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Steffen Kahle
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Leila Sisic
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Henrik Nienhüser
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tim Frederik Weber
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dirk Jäger
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Applied Tumor-Immunity, German Cancer Research Center, Heidelberg, Germany
| | - Georg Martin Haag
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
- Clinical Cooperation Unit Applied Tumor-Immunity, German Cancer Research Center, Heidelberg, Germany
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Koerner AS, Moy RH, Ryeom SW, Yoon SS. The Present and Future of Neoadjuvant and Adjuvant Therapy for Locally Advanced Gastric Cancer. Cancers (Basel) 2023; 15:4114. [PMID: 37627142 PMCID: PMC10452310 DOI: 10.3390/cancers15164114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Gastric cancer is a highly prevalent and lethal disease worldwide. Given the insidious nature of the presenting symptoms, patients are frequently diagnosed with advanced, unresectable disease. However, many patients will present with locally advanced gastric cancer (LAGC), which is often defined as the primary tumor extending beyond the muscularis propria (cT3-T4) or having nodal metastases (cN+) disease and without distant metastases (cM0). LAGC is typically treated with surgical resection and perioperative chemotherapy. The treatment of LAGC remains a challenge, given the heterogeneity of this disease, and the optimal multimodal treatment regimen may be different for different LAGC subtypes. However, many promising treatments are on the horizon based on knowledge of molecular subtypes and key biomarkers of LAGC, such as microsatellite instability, HER2, Claudin 18.2, FGFR2, and PD-L1. This review will expand upon the discussion of current standard neoadjuvant and adjuvant therapies for LAGC and explore the ongoing and future clinical trials for novel therapies, with information obtained from searches in PubMed and ClinicalTrials.gov.
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Affiliation(s)
- Anna S. Koerner
- Division of Surgical Oncology, Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032, USA
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Ryan H. Moy
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Sandra W. Ryeom
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
- Division of Surgical Sciences, Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Sam S. Yoon
- Division of Surgical Oncology, Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032, USA
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Kumar S, Kumar N, Deo S, Bhoriwal S, Mandal A, Sharma A, Pathy S, Das P, Thulkar S, Bhatnagar S. Patterns of Multimodality Management of Gastric Cancer—Single Institutional Experience of 372 Cases From a Tertiary Care Center in North India. Front Oncol 2022; 12:877493. [PMID: 35586487 PMCID: PMC9108362 DOI: 10.3389/fonc.2022.877493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/25/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction Worldwide gastric cancer is the 5th most commonly diagnosed cancer and the leading cause of gastrointestinal cancer-related deaths. Alone surgery provides long-term survival improvements in 20% of the patients with local advanced gastric cancer. The results can be improved considering multimodal management including chemotherapy and radiotherapy. However, in low middle-income countries like India, multimodal management is challenging. Herein, we evaluated the experience of multimodal management of gastric cancer and the long-term outcome. Methods Retrospective analysis of the data of 372 patients was done from a prospectively maintained computerized database from 1994 to 2021. Records were analyzed for demographic details, treatment patterns, recurrences, and long-term outcomes (DFS and OS). Statistical analysis was done with the package SPSS version 26 (IBM Corp, Chicago, Illinois, USA). Results This study included 372 patients. The mean age of the patients was 54.07. A total of 307 patients (82.5%) were operated upfront, 45 (12%) received NACT, and 20 (5.5%) underwent the palliative procedure. A total of 53.2% underwent curative resection. R0 resection rate was achieved in 95% of patients. A total of 72.58% of patients required adjuvant treatment, and the majority of the patients underwent chemoradiotherapy. The most common site of metastasis was the liver. Median follow-up was 50.16 months. The 3-year disease-free survival and overall survival were 36.28% and 67.8%, and the 5-year disease-free survival and overall survival were 30.15% and 37.7%, respectively. Conclusion Our study suggested that multimodal management is required in locally advanced gastric cancer to achieve good long-term outcomes. The treatment sequence can be tailored based on the available resources.
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Affiliation(s)
- Sunil Kumar
- Department of Surgical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Kumar
- Department of Surgical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Suryanarayana Deo
- Department of Surgical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
- *Correspondence: Suryanarayana Deo,
| | - Sandeep Bhoriwal
- Department of Surgical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Amitabha Mandal
- Department of Surgical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Sushmita Pathy
- Department of Radiation Oncology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Oncoradiology, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Oncoanasthesia, DR. Bhim Rao Ambedkar Institute Rotary Cancer Hospital (DRBRAIRCH), All India Institute of Medical Sciences, New Delhi, India
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4
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Allen CJ, Pointer DT, Blumenthaler AN, Mehta RJ, Hoffe SE, Minsky BD, Smith GL, Blum M, Mansfield PF, Ikoma N, Das P, Ajani J, Dineen SP, Fleming JB, Badgwell BD, Pimiento JM. Chemotherapy Versus Chemotherapy Plus Chemoradiation as Neoadjuvant Therapy for Resectable Gastric Adenocarcinoma: A Multi-institutional Analysis. Ann Surg 2021; 274:544-548. [PMID: 34132693 PMCID: PMC8988446 DOI: 10.1097/sla.0000000000005007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We compare neoadjuvant chemotherapy (CT) to neoadjuvant chemotherapy plus chemoradiation (CRT) for patients with gastric adenocarcinoma (GA). SUMMARY OF BACKGROUND DATA The optimal neoadjuvant therapy regimen for resectable GA is not defined. METHODS Utilizing data from 2 high-volume cancer centers, we analyzed patients who underwent surgery for localized GA from 1/1/2000-12/31/2017. Standard CT regimens were used according to treatment period. We compared propensity matched cohorts based on age, sex, race, histology, and clinical stage. RESULTS Four-hundred five patients (age 62 ± 12 year, 58% male, 56% White) were analyzed. 231 (57%) received CRT and 174 (43%) received CT. Groups differed based on histopathologic characteristics including preoperative stage (p = 0.013). To control for these differences, propensity matched cohorts of 113 CT and 113 CRT patients were compared. CRT had similar frequencies of microscopically negative resections to CT (93% vs 91%, p = 0.81), but higher rates of complete pathologic response (15% vs 4%, p = 0.003) and lower pathologic stage (p = 0.002). Completion of intended perioperative therapy occurred in 63% of CT and 91% of CRT patients (p < 0.001). Median DFS was 45mo (95%CI: 20-70) in the CT group and 113mo (95%CI: 75-151) in the CRT group (p = 0.018). Median OS was 53mo (95%CI: 30-77) versus 120mo (95%CI: 101-138); p = 0.015. CONCLUSIONS In this multi-institutional comparison of neoadjuvant CT and CRT for resectable GA, CRT is associated with higher rates of completed perioperative therapy, higher rates of complete pathologic response, lower pathologic stage, and improved survival.Level of Evidence: Level III.
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Affiliation(s)
- Casey J. Allen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David T. Pointer
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alisa N. Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rutika J. Mehta
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah E. Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F. Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean P. Dineen
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose M. Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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5
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Ludmir EB, Das P. Shifting sands: the role of radiotherapy for patients with gastric and gastroesophageal adenocarcinoma. Transl Gastroenterol Hepatol 2021; 6:50. [PMID: 34423171 PMCID: PMC8343419 DOI: 10.21037/tgh.2020.03.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/11/2020] [Indexed: 12/26/2022] Open
Abstract
Gastric adenocarcinoma, a leading cause of cancer-related mortality worldwide, is treated primarily with surgical resection in the non-metastatic setting. However, the optimal role and sequencing of adjunctive therapies, including radiotherapy (RT) as well as systemic therapy, remains unclear. A complex milieu of trials spanning several decades has evaluated different treatment strategies for gastric cancer, including the role of RT. In this review, we summarize the trial-level evidence for the diverse gastric cancer treatment paradigms. Despite initial success, postoperative RT has not shown a clear benefit in modern prospective studies in the setting of more aggressive surgical nodal dissection. On the other hand, the role of preoperative RT in optimizing oncologic outcomes for gastric cancer patients remains relatively under-explored; ongoing trials assessing preoperative RT aim to illuminate the optimal treatment strategy for non-metastatic gastric cancer patients.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Harada K, Hwang H, Wang X, Abdelhakeem A, Iwatsuki M, Blum Murphy MA, Maru DM, Weston B, Lee JH, Rogers JE, Thomas I, Shanbhag N, Zhao M, Bhutani MS, Nguyen QN, Swisher SG, Ikoma N, Badgwell BD, Hofstetter WL, Ajani JA. Frequency and Implications of Paratracheal Lymph Node Metastases in Resectable Esophageal or Gastroesophageal Junction Adenocarcinoma. Ann Surg 2021; 273:751-757. [PMID: 31188215 DOI: 10.1097/sla.0000000000003383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We aimed to evaluate the frequency of paratracheal lymph nodes (LN) metastases and their prognostic influence. SUMMARY BACKGROUND DATA Paratracheal LNs are considered regional nodes in the esophageal cancer classification, but their metastatic rate and influence on survival remain unclear. METHODS One thousand one hundred ninety-nine patients with resectable esophageal or gastroesophageal junction adenocarcinoma (EAC) (January 2002 and December 2016) in our Gastrointestinal Medical Oncology Database were analyzed. Paratracheal LNs were defined as1R, 1L, 2R, 2L, 4R, and 4L, according to the 8th American Joint Committee on Cancer classification. RESULTS Of 1199 patients, 73 (6.1%) had positive paratracheal LNs at diagnosis. The median overall survival (OS) of 73 patients with initial paratracheal LN involvement was 2.10 years (range 0.01-10.1, 5-yrs OS 24.2%). Of 1071 patients who were eligible for recurrence evaluation, 70 patients (6.5%) developed paratracheal LN metastases as the first recurrence. The median time to recurrence was 1.28 years (range 0.28-5.96 yrs) and the median OS following recurrence was only 0.95 year (range 0.03-7.88). OS in 35 patients who had only paratracheal LN recurrence was significantly longer than in patients who had other recurrences (median OS 2.26 vs 0.51 yrs, 5-yrs OS; 26.8% vs 0%, P < 0.0001). Higher T stage (T3/T4) was an independently risk factor for paratracheal LN recurrence (odds ratio 5.10, 95% confidence interval 1.46-17.89). We segregated patients in 3 groups based on the distance of tumor's proximal edge to esophagogastric junction (low; ≤2 cm, medium; 2.0-7.0 cm, and high; >7.0 cm). Paratracheal LN metastases were more frequent with the proximal tumors (low, 4.2%; medium, 12.0%; high, 30.3%; Cochran-Armitage Trend test, P < 0.001). CONCLUSION Paratracheal LN metastases were associated with a shorter survival in resectable EAC patients. Alternate approaches to prolong survival of this group of patients are warranted.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hyunsoo Hwang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed Abdelhakeem
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Masaaki Iwatsuki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Mariela A Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dipen M Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian Weston
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane E Rogers
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Irene Thomas
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Blumenthaler AN, Newhook TE, Ikoma N, Estrella JS, Blum Murphy M, Das P, Minsky BD, Ajani JA, Mansfield PF, Badgwell BD. Concurrent lymphovascular and perineural invasion after preoperative therapy for gastric adenocarcinoma is associated with decreased survival. J Surg Oncol 2021; 123:911-922. [PMID: 33400838 DOI: 10.1002/jso.26367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES We sought to evaluate the impact of lymphovascular invasion (LVI) and perineural invasion (PNI) on survival outcomes in gastric cancer patients treated with preoperative therapy. METHODS Patients with gastric cancer treated with preoperative therapy and potentially curative resection were stratified according to the presence of LVI, PNI, or both. Kaplan-Meier and Cox regression analyses were used to evaluate the impact on overall survival (OS) and disease-free survival (DFS). RESULTS The study included 281 patients, of whom 93 (33%) had LVI, 69 (25%) had PNI, 51 (18%) had both LVI and PNI, and 170 (61%) had neither. LVI and PNI were each associated with higher ypT and ypN categories and more positive lymph nodes (all p < .001), associations that were emphasized with both factors present. On multivariable analyses, ypN (p < .001) and concurrent LVI/PNI (hazard ratio [HR]: 2.62; 95% confidence interval [CI]: 1.55-4.45; p = .001) were predictive of OS and DFS (ypN: p < .001; both LVI/PNI: HR: 2.27; 95% CI: 1.34-3.82; p = .002). CONCLUSIONS Gastric cancer patients with concurrent LVI and PNI after preoperative therapy have more advanced disease and worse survival outcomes than patients with neither or only one of these factors.
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Affiliation(s)
- Alisa N Blumenthaler
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Timothy E Newhook
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeannelyn S Estrella
- Departments of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum Murphy
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prajnan Das
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruce D Minsky
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer A Ajani
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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8
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Allen CJ, Blumenthaler AN, Smith GL, Das P, Minsky BD, Blum M, Ajani J, Mansfield PF, Ikoma N, Badgwell BD. Chemotherapy Versus Chemotherapy Plus Chemoradiation as Preoperative Therapy for Resectable Gastric Adenocarcinoma: A Propensity Score-Matched Analysis of a Large, Single-Institution Experience. Ann Surg Oncol 2020; 28:758-765. [PMID: 32696305 DOI: 10.1245/s10434-020-08864-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We compared oncologic outcomes of patients who received neoadjuvant chemotherapy (CT) with those of patients who received neoadjuvant chemotherapy plus chemoradiation (CRT) for resectable gastric adenocarcinoma. METHODS We compared oncologic and survival outcomes of patients who received CT or CRT for gastric adenocarcinoma at our institution between July 1995 and July 2018. We analyzed propensity score-matched cohorts based on age, sex, race, tumor histologic characteristics, and clinical stage. RESULTS We identified 440 patients (mean age 61 ± 12 years, 62% male, 55% white); 345 (78%) received CRT, and 95 (22%) received CT. The propensity score-matched cohorts included 65 patients who received CT and 65 who received CRT. The CRT group had similar frequencies of R1 resection margins to the CT group (7.7% vs. 6.2%, p = 0.75) but significantly higher frequency of pathologic complete response (27.7% vs. 1.5%, p < 0.001). The CRT group had lower pathologic stages (p = 0.002). Median disease-free survival was 50.9 months (95% confidence interval [CI]: 4.7-97.2) in the CT group and 122.1 months (95% CI: 69.0-175.1) in the CRT group (p = 0.07). Median overall survival was 70.7 months (95% CI: 23.9-117.5) in the CT group and 122.1 months (95% CI: 68.7-175.4) in the CRT group (p = 0.21). CONCLUSIONS Compared with CT, CRT for resectable gastric adenocarcinoma is associated with higher rates of pathologic complete response and subsequent lower final pathologic stage, but survival differences are not significant. Ongoing investigation is necessary to better determine the optimal neoadjuvant therapy and identify patients who receive optimal benefit from CRT. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Casey J Allen
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alisa N Blumenthaler
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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9
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Harada K, Patnana M, Wang X, Iwatsuki M, Murphy MAB, Zhao M, Das P, Minsky BD, Weston B, Lee JH, Bhutani MS, Estrella JS, Shanbhag N, Ikoma N, Badgwell BD, Ajani JA. Low metabolic activity in primary gastric adenocarcinoma is associated with resistance to chemoradiation and the presence of signet ring cells. Surg Today 2020; 50:1223-1231. [PMID: 32409870 DOI: 10.1007/s00595-020-02018-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/17/2020] [Indexed: 12/14/2022]
Abstract
PURPOSES Preoperative chemoradiation is a potential treatment option for localized gastric adenocarcinoma (GAC). Currently, the response to chemoradiation cannot be predicted. We analyzed the pretreatment maximum standardized uptake value (SUVmax) and total lesion glycolysis (TLG) on positron emission tomography/computed tomography as potential predictors of the response to chemoradiation. METHODS We analyzed the SUVmax and TLG data from 59 GAC patients who received preoperative chemoradiation. We used logistic regression models to predict a pathologic complete response (pCR) and Kaplan-Meier curves to determine overall survival among patients with high and low SUVmax or TLG. RESULTS Twenty-nine patients (49%) had Siewert type III adenocarcinoma and 30 (51%) had tumors located in the lower stomach. Forty-one patients had poorly differentiated GAC, and 26 had signet ring cells. The median SUVmax was 7.3 (0-28.2) and the median TLG was 56.6 (0-1881.5). Patients with signet ring cells had a low pCR rate, as well as a low SUVmax and TLG. In the multivariable logistic regression model, high SUVmax was a predictor of pCR (odds ratio = 11.1, 95% confidence interval = 2.12-50.0, p = 0.004). Overall survival was not associated with the SUVmax (log-rank p = 0.69) or TLG (log-rank p = 0.85) CONCLUSION: A high SUVmax was associated with sensitivity to chemoradiation and pCR in GAC, and signet ring cells seemed to confer resistance.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Madhavi Patnana
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Masaaki Iwatsuki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Mariela A Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Weston
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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10
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Jiang DM, Suzuki C, Espin-Garcia O, Lim CH, Ma LX, Sun P, Sim HW, Natori A, Chan BA, Moignard S, Chen EX, Liu G, Swallow CJ, Darling GE, Wong R, Jang RW, Elimova E. Surveillance and outcomes after curative resection for gastroesophageal adenocarcinoma. Cancer Med 2020; 9:3023-3032. [PMID: 32130793 PMCID: PMC7196047 DOI: 10.1002/cam4.2948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background The goal of surveillance testing is to enable curative salvage therapy through early disease detection, however supporting evidence in gastroesophageal adenocarcinoma is limited. We evaluated frequency of successful salvage therapy and outcomes in patients who underwent surveillance. Methods A single‐site, retrospective cohort study was conducted to identify all patients who received curative resection for gastroesophageal adenocarcinoma. Surveillance testing were those investigations not triggered by abnormal symptoms, physical examination, or blood tests. Successful salvage therapy was any potentially curative therapy for disease recurrence which resulted in postrecurrence disease‐free survival ≥2 years. Time‐to‐event data were analyzed using the Kaplan‐Meier method and log rank tests. Results Between 2011 and 2016, 210 consecutive patients were reviewed. Esophageal (14%), gastroesophageal junction (40%), and gastric adenocarcinomas (45%) were treated with surgery alone (29%) or multimodality therapy (71%). Adjuvant therapy was administered in 35%. At median follow‐up of 38.3 months, 5‐year overall survival (OS) rate was 56%. Among 97 recurrences, 53% were surveillance‐detected, and 46% were symptomatic. None was detected by surveillance endoscopy. Median time‐to‐recurrence (TTR) was 14.8 months. Recurrences included locoregional only (4%), distant (86%), and both (10%). Salvage therapy was attempted in 15 patients, 4 were successful. Compared to symptomatic recurrences, patients with surveillance‐detected recurrences had longer median OS (36.2 vs 23.7 months, P = .004) and postrecurrence survival (PRS, 16.5 vs 4.6 months, P < .001), but similar TTR (16.2 vs 13.3 months, P = .40) and duration of palliative chemotherapy (3.9 vs 3.3 months, P = .64). Conclusions Among patients surveyed, 96% of recurrences were distant, and salvage therapy was successful in only 1.9% of patients. Longer OS in patients with surveillance‐detected compared to symptomatic recurrences was not associated with significant earlier disease detection, and may be contributed by differences in disease biology. Further prospective data are warranted to establish the benefit of surveillance testing in gastroesophageal adenocarcinoma.
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Affiliation(s)
- Di M Jiang
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Chihiro Suzuki
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles H Lim
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lucy X Ma
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Peiran Sun
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hao-Wen Sim
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akina Natori
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bryan A Chan
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Moignard
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eric X Chen
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Geoffrey Liu
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carol J Swallow
- Department of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Ontario Cancer Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Raymond W Jang
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Elena Elimova
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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11
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Lopez A, Harada K, Chen HC, Bhutani MS, Weston B, Lee JH, Maru DM, Chin FW, Rogers JE, Thomas I, Amlashi FG, Blum-Murphy MA, Rice DC, Zhao M, Hofstetter WL, Nguyen Q, Ajani JA. Taxane-based or platinum-based combination chemotherapy given concurrently with radiation followed by surgery resulting in high cure rates in esophageal cancer patients. Medicine (Baltimore) 2020; 99:e19295. [PMID: 32118743 PMCID: PMC7478597 DOI: 10.1097/md.0000000000019295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy (CRT) is one standard option for localized esophageal or gastroesophageal junction (GEJ) cancer patients but an optimal concurrent chemotherapy combination is not established. METHODS 412 patients with resectable (cT1N1M0 or cT2-4N0-3M0) esophageal or GEJ cancer treated at the MDACC between October 2002 and June 2016 were analyzed. Exposures: CRT with DF or FOX followed by surgery (trimodality; TMT). Main outcomes and measures: Primary endpoints were overall survival (OS) and disease-free survival (DFS). Univariate and multivariate Cox analyses were performed. RESULTS Of the 412 patients analyzed, 264 (64%) received DF and 148 (36%) FOX. The median age was 60 years, and 95% had adenocarcinoma. The clinical complete response, positron-emission tomography response, and pathologic complete response rates were 73%, 73%, and 30%, respectively. Median follow-up was 60.4 months. Median OS for the entire cohort was 81.6 months (95% confidence interval [CI], 56.3-122.0); 81.6 months (95% CI, 55.9-not estimable) for the DF group and 67.7 months (95% CI, 41.6-not estimable) for the FOX group (P = .24). The median DFS was 45.6 months (95% CI, 33.1-61.7) for the entire cohort; 49.5 months (95% CI, 38.6-70.3) for DF and 33.0 months (95% CI, 18.1-70.4; P = .38) for FOX. Higher tumor location (unfavorable) and clinical complete response (favorable) were prognostic for both OS and DFS in the multivariate analysis. CONCLUSION At our high-volume center, the outcome of 412 TMT esophageal cancer patients was excellent. Taxane-based chemotherapy produces nonsignificant favorable trend.
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Affiliation(s)
- Anthony Lopez
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterology and Hepatology and Inserm U954, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | | | | | | | | | | | | | - Jane E. Rogers
- Department of Pharmacy Clinical Programs Gastroenterology
| | - Irene Thomas
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fatemeh G. Amlashi
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mariela A. Blum-Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David C. Rice
- Department of Thoracic and Cardiovascular Surgery Surgical Oncology
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Quynh Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Allen CJ, Vreeland TJ, Newhook TE, Das P, Minsky BD, Blum M, Ajani J, Ikoma N, Mansfield PF, Badgwell BD. Prognostic Value of Lymph Node Yield After Neoadjuvant Chemoradiation for Gastric Cancer. Ann Surg Oncol 2020; 27:534-542. [DOI: 10.1245/s10434-019-07840-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 08/30/2023]
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13
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Harada K, Lopez A, Shanbhag N, Badgwell B, Baba H, Ajani J. Recent advances in the management of gastric adenocarcinoma patients. F1000Res 2018; 7:F1000 Faculty Rev-1365. [PMID: 30228868 PMCID: PMC6117861 DOI: 10.12688/f1000research.15133.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 12/16/2022] Open
Abstract
Gastric adenocarcinoma (GAC) is one of the most aggressive malignancies and has a dismal prognosis. Therefore, multimodality therapies to include surgery, chemotherapy, targeted therapy, immunotherapy, and radiation therapy are needed to provide advantage. For locally advanced GAC (>cT1B), the emerging strategies have included preoperative chemotherapy, postoperative adjuvant chemotherapy, and (occasionally) postoperative chemoradiation in various regions. Several novel therapies have been assessed in clinical trials, but only trastuzumab and ramucirumab (alone and in combination with paclitaxel) have shown overall survival advantage. Pembrolizumab has been approved by the US Food and Drug Administration on the basis of response rate only for patients with microsatellite instability (MSI-H) or if PD-L1 expression is positive (≥1% labeling index in tumor/immune cells in the presence of at least 100 tumor cells in the specimen). Nivolumab has been approved in Japan on the basis of a randomized trial showing significant survival advantage for patients who received nivolumab compared with placebo in the third or later lines of therapy. The cure rate of patients with localized GAC in the West is only about 40% and that for metastatic cancer is very poor (only 2-3%). At this stage, much more target discovery is needed through molecular profiling. Personalized therapy of patients with GAC remains a challenge.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
| | - Anthony Lopez
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
- Department of Gastroenterology and Hepatology and Inserm U954, Nancy University Hospital, Lorraine University, 5 allée du Morvan, 54511 Vandoeuvre-lès-Nancy, France
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Brian Badgwell
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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14
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Abstract
Gastric adenocarcinoma (GAC) is estimated as the fifteenth most common cancer in the USA. Incidence rate has been gradually decreasing, but prognosis remains dismal. For patients with locally advanced GAC (stage > T1B and < T4B), multimodality therapies, such as surgery, chemotherapy, and radiation therapy, are needed. Perioperative chemotherapy or postoperative chemoradiation/chemotherapy is recommended. For metastatic GAC patients, combination of two cytotoxics (platinum compound and fluoropyrimidine) has become a common place in the USA, and when HER2 is positive, trastuzumab is added. When GAC progresses after the first line therapy, additional biomarkers (microsatellite instability and programmed death ligand 1) should be tested so that checkpoint inhibitors can be used. Overall, the options for advanced GAC patients are limited and more research is needed.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto 860-8556, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto 860-8556, Japan
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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