Update on the Treatment of Gastric Cancer

Prognostic Value of Postoperative Complication for Gastric Cancer

Background: The incidence of complications in gastric cancer (GC) patients after surgery was increasing, and it was not clear whether postoperative complications would have an impact on prognosis. The current study attempted to investigate the role of postoperative complication for prognosis on GC patients undergoing radical resection. Materials and Methods: Eligible studies were searched in three databases, including PubMed, Embase, and the Cochrane Library, in accordance with the searching strategy on September 4th, 2022. The survival values were most concerned; then, hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled up. All prognostic values, including overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), and recurrence-free survival (RFS), were allowed. Subgroup analysis based on complication types was used for further in-depth research. Results: A total of 29 studies involving 33,858 patients were included in this study. Intra-abdominal abscess (19.4%) was the most common complications in the included studies, followed by anastomotic leakage (17.0%) and pneumonia (16.4%). There were 23, 4, 6, and 10 studies that reported OS, DFS, DSS, and RFS, respectively. After analysis, postoperative complication was found to be an independent prognostic factor for OS (HR = 1.52, I2 = 1.14%, 95% CI = 1.42-1.61, P = .00), DFS (HR = 1.71, I2 = 0.00%,95% CI = 1.44-1.98, P < .05), DSS (HR = 1.60, I2 = 54.58%, 95% CI = 1.26-1.93, P < .1), and RFS (HR = 1.26, I2 = 0.00%, 95% CI = 1.11-1.41, P < .05). Subgroup analysis found that noninfectious complication was not significantly associated with OS (HR = 1.39, I2 = 0.00%, 95% CI = 0.96-1.82, P > .05). Conclusion: Surgeons needed to pay more attention to GC patients who developed postoperative complications, especially infectious complications, and take proactive management to improve the prognosis.

Short-term outcomes of preoperative chemotherapy with docetaxel, oxaliplatin, and S-1 for gastric cancer with extensive lymph node metastasis (JCOG1704)

BACKGROUND

The prognosis for marginally resectable gastric cancer with extensive lymph node metastasis (ELM) remains unfavorable, even after R0 resection. To assess the safety and efficacy of preoperative docetaxel, oxaliplatin, and S-1 (DOS), we conducted a multicenter phase II trial.

METHODS

Eligibility criteria included histologically proven HER2-negative gastric adenocarcinoma with bulky nodal (bulky N) involvement around major branched arteries or para-aortic node (PAN) metastases. Patients received three cycles of docetaxel (40 mg/m2, day 1), oxaliplatin (100 mg/m2, day 1), and S-1 (80-120 mg/body, days 1-14), followed by gastrectomy with D2 plus PAN dissection. Subsequently, patients underwent postoperative chemotherapy with S-1 for 1 year. The primary endpoint was major (grade ≥ 2a) pathological response rate (pRR) according to the Japanese Classification of Gastric Carcinoma criteria.

RESULTS

Between October 2018 and March 2022, 47 patients (bulky N, 20; PAN, 17; both, 10) were enrolled in the trial. One patient was ineligible. Another declined any protocol treatments before initiation. Among the 45 eligible patients who initiated DOS chemotherapy, 44 (98%) completed 3 cycles and 42 (93%) underwent R0 resection. Major pRR and pathological complete response rates among the 46 eligible patients, including the patient who declined treatment, were 57% (26/46) and 24% (11/46), respectively. Common grade 3 or 4 toxicities were neutropenia (24%), anorexia (16%), febrile neutropenia (9%), and diarrhea (9%). No treatment-related deaths occurred.

CONCLUSIONS

Preoperative chemotherapy with DOS yielded favorable pathological responses with an acceptable toxicity profile. This multimodal approach is highly promising for treating gastric cancer with ELM.

Essential updates 2021/2022: Perioperative and surgical treatments for gastric and esophagogastric junction cancer

In recent years, important clinical trials for gastric cancer (GC) and esophagogastric junction cancer (EGJC) have been reported, changing the strategies of surgical and perioperative treatment. Although laparoscopic gastrectomy has already been shown to be effective for early-stage cancer, recent evidence from both Asia (JLSSG0901, CLASS-01 and KLASS-02) and Europe (LOGICA and STOMACH trials) has demonstrated that it is useful for advanced GC. Robotic surgery has been rapidly gaining popularity in recent years, and randomized controlled trials are ongoing to evaluate its efficacy. A prospective nationwide multicenter study mapped sites with frequent metastasis and revealed lymphatic flow specific to EGJC, thus establishing the optimal lymph node dissection area and surgical approach based on esophageal involvement. Perioperative chemotherapy, the mainstay of treatment in Europe, also has been established in Asia by the PRODIGY and RESOLVE studies. New clinical trials have been conducted to evaluate the efficacy of combining immunotherapy or molecular-targeted therapy with perioperative chemotherapy or chemoradiotherapy. In this review, we present important recent clinical trials regarding the treatment of GC and EGJC published in 2021 or 2022.

Fucoxanthin inhibits gastric cancer lymphangiogenesis and metastasis by regulating Ran expression

BACKGROUND

Lymph node metastasis is a key mechanism in gastric cancer (GC) metastasis and lymphangiogenesis is a vital step in the process of lymph node metastasis. Currently, there are no drugs which can treat lymph node metastasis in GC. Previous studies using the drug fucoxanthin have mainly focused on cell cycle arrest, induction of apoptosis, or inhibition of angiogenesis in GC. However, the effects of fucoxanthin on lymphangiogenesis and metastasis in GC have not been studied.

METHODS

Cell counting kit 8 and transwell experiments were used to evaluate the inhibitory effect of fucoxanthin on cell proliferation, migration and invasion. HGC-27 and HLEC cells were co-cultured in a transwell chamber and the footpad metastasis model was established to evaluate lymphangiogenesis and lymph node metastasis. The possible regulatory targets of fucoxanthin in GC were analyzed using human tissue microarrays, bioinformatics analysis, and molecular docking. The regulatory pathway of fucoxanthin was verified using confocal laser microscopy, adenovirus transfection and western blotting.

RESULTS

Tissue microarray and bioinformatics analyses showed that Ran was highly expressed in metastatic lymph nodes and has some predictive value for metastasis in GC. Molecular docking results revealed that fucoxanthin interacted with Met189 and Lys167 of Ran via hydrogen bonds. Mechanistically, fucoxanthin inhibits the nuclear transport of NF-κB by downregulating protein expression of Ran and importinβ, thereby inhibiting VEGF-C secretion, and ultimately inhibiting tumor lymphangiogenesis and lymph node metastasis in vivo and in vitro.

CONCLUSIONS

Fucoxanthin suppressed GC-induced lymphangiogenesis and metastasis in vitro and in vivo by regulating Ran expression via the importinβ/NF-κB/VEGF-C nuclear transport signaling pathway. These novel findings provide the basis for the research and development of novel treatments using traditional Chinese medicine in treatment of lymph node metastasis, which has important theoretical significance and clinical value.

N6-methyadenosine modified SUV39H2 regulates homologous recombination through epigenetic repression of DUSP6 in gastric cancer

Despite many advances in treatment over the past few years, the poor 5-year survival rate and high recurrence rate of gastric cancer (GC) remain unsatisfactory. As the most abundant epigenetic modification in the eukaryotic mRNA, N6-methyladenosine (m⁶A) methylation participates in tumor progression and tissue development. During tumor progression, DNA damage repair mechanisms can be reprogrammed to give new growth advantages on tumor clones whose genomic integrity is disturbed. Here we detected the elevated SUV39H2 expression in GC tissues and cell lines. Functionally, SUV39H2 promoted GC proliferation and inhibited apoptosis in vitro and in vivo. Mechanistically, METTL3-mediated m⁶A modification promotes mRNA stability of SUV39H2 in an IGF2BP2 dependent manner, resulting in upregulated mRNA expression of SUV39H2. As a histone methyltransferase, SUV39H2 was verified to increase the phosphorylation level of ATM through transcriptional repression of DUSP6, thereby promoting HRR and ultimately inhibiting GC chemosensitivity to cisplatin. Collectively, these results indicate the specific mechanism of m⁶A-modified SUV39H2 as a histone methyltransferase promoting HRR to inhibit the chemosensitivity of GC. SUV39H2 is expected to become a key target in the precision targeted therapy of GC.

Chordin-Like 2: A Possible Therapeutic Target for Gastric Cancer by Affecting Cell Cycle and Proliferation

PURPOSE

This study aimed to examine the role of chordin-like 2 (CHRDL2) in gastric cancer.

METHODS

The Gene Expression Omnibus (GEO) and the Cancer Genome Atlas (TCGA) datasets were screened and the differentially expressed gene CHRDL2 was identified. The CHRDL2 expression was examined in the Human Protein Atlas and TCGA. Clinical data on gastric cancer were evaluated for their association with CHRDL2 by using TCGA and KM-plotter databases. The possible relationship amongst CHRDL2, immune cells, and related genes was investigated via the TIMER database. Enrichment analysis was performed using GO and KEGG pathways to explore the mechanisms.

RESULTS

Screening of databases revealed that CHRDL2 was a differentially expressed gene. An increase in cytoplasmic CHRDL2 expression was found in cancer tissues compared with the surrounding normal tissues. The data, together with those from TCGA and the KM-plotter databases, showed that patients with gastric cancer with high level of CHRDL2 have worse prognosis than those with low expression. A strong correlation was found between CHRDL2 expression and T stage, race, pathological grade, and pathological type according to clinical data analysis. CHRDL2 expression is linked to immune infiltration, as shown by the TIMER database. The data suggested that CHRDL2 plays a pivotal role in the tumor microenvironment of gastric cancer and might help tumor cells evade the immune system. Gene set enrichment analysis showed that CHRDL2 is involved in the chemokine signaling route, the intestinal immune network, the MAPK pathway, cell cycle, and the PI3K-Akt signaling system that are associated with the pathological processes of gastric cancer.

CONCLUSION

Patients with gastric cancer with decreased CHRDL2 levels have dramatically improved OS, PFS, and PPS. CHRDL2 plays a pivotal role in enabling tumor cell immune evasion in tumor microenvironment, suggesting a function of this gene in the development of gastric cancer and its immune infiltration. Interfering with CHRDL2 may slow down the development of this malignancy by affecting cell cycle and apoptosis pathways.

Phase 2 trial of neoadjuvant docetaxel, oxaliplatin, and S‐1 for clinical stage III gastric or esophagogastric junction adenocarcinoma

Background

Although perioperative treatment has been the standard of care for resectable gastric cancer in the West, postoperative adjuvant chemotherapy is still the standard in Japan. We conducted the first phase 2 trial to investigate the efficacy and safety of neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) chemotherapy for cStage III gastric or esophagogastric junction (EGJ) adenocarcinoma in Japan.

Methods

Eligibility criteria included cStage III adenocarcinoma of the stomach or EGJ. Patients received docetaxel (40 mg/m², day 1), oxaliplatin (100 mg/m², day 1), or S-1 (80 mg/m², days 1-14) during a 3-week cycle. After two or three cycles of DOS, patients underwent surgical resection. The primary endpoint was progression-free survival (PFS).

Results

Between June 2015 and March 2019, 50 patients were enrolled from four institutions. Of 48 eligible patients (37 gastric and 11 EGJ adenocarcinoma), 42 (88%) completed two or three DOS cycles. Grade 3-4 neutropenia and diarrhea occurred in 69% and 19% of patients, respectively, but there were no treatment-related deaths. R0 resection was achieved in 44 (92%) patients, and the pathological response rate (≥ grade 1b) was 63% (30/48). The 3-year PFS, overall survival, and disease-specific survival rates were 54.2%, 68.7%, and 75.8%, respectively.

Conclusion

Neoadjuvant DOS chemotherapy had a sufficient antitumor effect and tolerable safety profile in patients with gastric or EGJ adenocarcinoma. The survival benefit of a neoadjuvant strategy using our DOS regimen should be validated in phase 3 trials.

The Significance of Fibrinogen in Combination with the Neutrophil to Lymphocyte Ratio in Predicting the Prognosis of Patients with Gastric Cancer

Objective

To investigate the significance of fibrinogen (Fib) in combination with the neutrophil to lymphocyte ratio (NLR) in predicting the prognosis of patients with gastric cancer.

Methods

The preoperative peripheral blood-related indicators of 281 gastric cancer patients were reviewed retrospectively, and the differences in relationship indicators between the survival and death groups were compared and analyzed. The COX regression analysis and Kaplan–Meier Curve (K-M) were used to assess the prognostic significance of Fib combined with NLR in patients with gastric cancer.

Results

① The difference between the survival and death groups of patients with gastric cancer was statistically significant in the high and low Fib and NLR levels (X²=6.868 and 17.051, respectively, all P <0.01).② The correlation between Fib and NLR was remarkable (r=0.266, P=0.000).③ The F-NLR classifications showed statistically significant difference between the survival and death groups for gastric cancer patients (X²=20.200, P=0.000).④ Except for Fib and the middle/low classification of F-NLR, which was P<0.05, and the rest were all P<0.01. There was a substantial statistical difference between F-NLR classifications, Fib and NLR.⑤ F-NLR was found to be a predictive factor of death in patients with gastric cancer in COX regression analysis (P=0.000).⑥Patients with F-NLR scores of “0”, “1” and “2” had 5-year survival rates of 92.6%, 64.0% and 47.2%, respectively, and 3-year survival rates of 92.6%, 74.3% and 51.9%, respectively (all P=0.000).

Conclusion

The combination of Fib and NLR (F-NLR) improves the accuracy of prognosis in patients with gastric cancer.

Vitamin D—The Nutritional Status of Post-Gastrectomy Gastric Cancer Patients—Systematic Review

Gastric cancer is a malignant neoplasm of the gastrointestinal tract, with one of the standard treatment methods remaining gastrectomy. The authors conducted a systemic review of the Medline and Embase databases concerning the serum vitamin D level in post-gastrectomy gastric cancer patients, regarding all articles published until 22 May 2022 according to the PRISMA guidelines. 18 studies with a total number of 908 gastric cancer survivors were included in the analysis. The initial rate of vitamin D deficiency in gastric cancer patients undergoing gastrectomy appears to be similar to the global population deficiency. In post-gastrectomy survivors, the level of 25(OH)D may remain stable or decrease, while the level of 1, 25(OH)₂D remains normal. Supplementation with vitamin D results in an improvement in its serum concentration and positively affects bone mineral density, which is gradually reduced in post-gastrectomy survivors. Combining vitamin D supplementation with calcium and bisphosphonates enables us to obtain better results than vitamin D and calcium only. The type of surgery influences the level of serum vitamin D and its metabolites, with total or partial gastrectomy and maintenance of the duodenal food passage remaining the most important factors. There is a strong need for randomized, controlled trials that would investigate this matter in the future.

MicroRNA-30c-2-3p represses malignant progression of gastric adenocarcinoma cells via targeting ARHGAP11A

MicroRNAs are crucial tumor regulators to tumor development and progression. MiR-30c-2-3p can suppress malignant progression of tumor cells, but no study has reported the modulatory process of miR-30c-2-3p in gastric adenocarcinoma (GA). We herein investigated role of miR-30c-2-3p in GA cells. Here, we evaluated gene level in cancer cells by qRT-PCR. CCK-8, colony formation, flow cytometry, and transwell assays revealed biological functions of miR-30c-2-3p and ARHGAP11A. Genes downstream of miR-30c-2-3p were acquired through bioinformatics analysis. Our results suggested a low level of miR-30c-2-3p in GA tissue and cells, while its high expression could repress the malignant progression and promote cell cycle arrest and apoptosis of GA cells. Besides, ARHGAP11A was downstream of miR-30c-2-3p, with up-regulated ARHGAP11A facilitating malignant progression and repressing cell cycle arrest and apoptosis of GA cells. In addition, changes in GA cell functions caused by high ARHGAP11A expression could be partially offset by enhancing miR-30c-2-3p. Thus, our observations indicated that miR-30c-2-3p was a tumor repressor that could inhibit GA progression via modulating ARHGAP11A.

Neoadjuvant Bevacizumab Plus Docetaxel/Cisplatin/Capecitabine Chemotherapy in Locally Advanced Gastric Cancer Patients: A Pilot Study

Background

Bevacizumab (BEV) plus chemotherapy as a neoadjuvant regimen presents good efficacy in patients with locally advanced cancer. However, its role in patients with locally advanced gastric cancer (LAGC) is not clear. Thus, the study aimed to assess the efficacy and safety of neoadjuvant BEV plus chemotherapy in patients with LAGC.

Methods

Twenty resectable patients with LAGC who received BEV plus docetaxel/cisplatin/capecitabine (DCC) chemotherapy for 3 cycles with 21 days as one cycle as neoadjuvant regimen were involved. Besides, their treatment response, survival profiles, and adverse events were assessed.

Results

In total, two (10.0%), 9 (45.0%), 8 (40.0%), and 1 (5.0%) patients achieved complete remission, partial remission, stable disease, and progressive disease (PD) according to imaging evaluation, which resulted in 55.0% of objective response rate and 95.0% of disease control rate, respectively. Moreover, the number of patients with pathological response grades 1, 2, and 3 was 8 (40.0%), 8 (40.0%), and 3 (15.0%); while 1 (5.0%) patient did not receive surgery due to PD, thus the data of this patient was not assessable. Meanwhile, 18 (90.0%) patients achieved R0 resection. Regarding survival profile, the median disease-free survival or overall survival were both not reached. The 1-year, 2-, and 3-year disease-free survival rates were 88.8, 80.7, and 67.3%. Meanwhile, the 1-, 2-, and 3-year overall survival rates were 100.0%, 75.8%, and 75.8%, respectively. Additionally, the main adverse events were anemia (90.0%), alopecia (90.0%), leukopenia (70.0%), and anorexia (65.0%). Indeed, most adverse events were of grade 1 or 2 and were manageable.

Conclusion

Neoadjuvant BEV plus DCC chemotherapy presents a favorable pathological response and survival profile with acceptable safety in patients with LAGC.

Three-Year Outcomes of a Phase II Study of Perioperative Capecitabine Plus Oxaliplatin Therapy for Clinical SS/SE N1-3 M0 Gastric Cancer (OGSG 1601)

Background

We previously reported the good feasibility and favorable efficacy of perioperative capecitabine plus oxaliplatin (CapeOx) in patients (pts) with clinical T3(SS)/T4a(SE) N1-3 M0 gastric cancer (GC) in a phase II study in which the pathological response rate, the primary endpoint, of 54.1% was demonstrated. Here, we report 3-year follow-up data.

Methods

The eligibility criteria included clinical T3(SS)/T4a(SE) N1-3 M0 GC according to the Japanese Classification of Gastric Carcinoma-3rd English Edition (JCGC). Three cycles of neoadjuvant CapeOx (capecitabine, 2000mg/m² for 14 days; oxaliplatin, 130mg/m² on day 1, every 3 weeks) were administered, followed by 5 cycles of adjuvant CapeOx after D2 gastrectomy. Three-year overall survival and relapse-free survival are presented here, and analyzed by cohorts based on pathologic response rate (pRR).

Results

Thirty-seven pts were enrolled from July 2016 to May 2017, and fully evaluated for efficacy and toxicity. Thirty-three pts (89.2%) completed the planned three cycles of neoadjuvant CapeOx and underwent gastrectomy, with an R0 resection rate of 78.4% (n = 29). The overall survival (OS) rate and relapse-free survival (RFS) rate at 3 years was 83.8% (95% CI, 72.7-96.5%) and 73.0% (95% CI, 60.0-88.8%), respectively. Further, the 3-year OS rate in pts with pathological response of grade 1a (n = 13) and grade 1b or higher (n = 20) was 69.2% (95% CI: 48.2-99.5%) and 100.0%, respectively, based on JCGC. Pathological response rate was classified according to JCGC as follows: grade 0, the tumor was not affected; grade 1a, less than one-third of the tumor was affected; grade 1b, one to two thirds of the tumor was affected; grade 2, greater than or equal to two thirds was affected; and grade 3, no residual tumor. A pathological response was defined as grade 1b or greater.

Conclusion

Perioperative CapeOx showed good feasibility and favorable prognosis, especially in pts with pathological response of grade 1b or higher and was found to be useful in predicting prognosis. The data obtained using this novel approach warrant further investigation (Trial ID: UMIN000021641, jRCTs051180109).

METTL14-mediated m6A modification of circORC5 suppresses gastric cancer progression by regulating miR-30c-2-3p/AKT1S1 axis

Background

N6-methyladenosine (m6A) RNA methylation and circular RNAs (circRNAs) have been shown to act vital roles in multiple malignancies including gastric cancer (GC). However, there is little knowledge about how m6A modification of circRNAs contributes to GC progression.

Methods

The association of METTL14 expression with the clinicopathological characteristics and prognosis in patients with GC was assessed by Western blot, Immunohistochemistry and public datasets. In vitro and vivo function experiments were conducted to investigate the role of METTL14 in GC. Furthermore, m6A-circRNA epitranscriptomic microarray was utilized to identify METTL14-mediated m6A modification of circRNAs, which were validated by methylated RNA immunoprecipitation (Me-RIP), RT-qPCR and rescue experiments in GC cells. The sponge of circORC5 with miR-30c-2-3p was confirmed by luciferase gene report and RNA immunoprecipitation assays. The expression, localization and prognosis of circORC5 in GC were evaluated by fluorescence in situ hybridization. The effects of METTL14 and (or) circORC5 on miR-30c-2-3p-mediated AKT1S1 and EIF4B were estimated by RT-qPCR and Western blot analyses.

Results

We found that METTL14 was downregulated in GC tissue samples and its low expression acted as a prognostic factor of poor survival in patients with GC. Ectopic expression of METTL14 markedly repressed growth and invasion of GC cells in vitro and in vivo, whereas knockdown of METTL14 harbored the opposite effects. Mechanically, m6A-circRNA epitranscriptomic microarray and Me-RIP identified circORC5 as the downstream target of METTL14. Silencing of METTL14 reduced the m6A level of circORC5, but increased circORC5 expression. Moreover, circORC5 could sponge miR-30c-2-3p, and reverse METTL14-caused upregulation of miR-30c-2-3p and downregulation of AKT1S1 and EIF4B. In addition, circORC5 possessed a negative correlation with miR-30c-2-3p and indicated a poor survival in GC.

Conclusion

Our findings demonstrate that METTL14-mediated m6A modification of circORC5 suppresses gastric cancer progression by regulating miR-30c-2-3p/AKT1S1 axis.

Prediction of genetic alterations from gastric cancer histopathology images using a fully automated deep learning approach

BACKGROUND

Studies correlating specific genetic mutations and treatment response are ongoing to establish an effective treatment strategy for gastric cancer (GC). To facilitate this research, a cost- and time-effective method to analyze the mutational status is necessary. Deep learning (DL) has been successfully applied to analyze hematoxylin and eosin (H and E)-stained tissue slide images.

AIM

To test the feasibility of DL-based classifiers for the frequently occurring mutations from the H and E-stained GC tissue whole slide images (WSIs).

METHODS

From the GC dataset of The Cancer Genome Atlas (TCGA-STAD), wild-type/mutation classifiers for CDH1, ERBB2, KRAS, PIK3CA, and TP53 genes were trained on 360 × 360-pixel patches of tissue images.

RESULTS

The area under the curve (AUC) for the receiver operating characteristic (ROC) curves ranged from 0.727 to 0.862 for the TCGA frozen WSIs and 0.661 to 0.858 for the TCGA formalin-fixed paraffin-embedded (FFPE) WSIs. The performance of the classifier can be improved by adding new FFPE WSI training dataset from our institute. The classifiers trained for mutation prediction in colorectal cancer completely failed to predict the mutational status in GC, indicating that DL-based mutation classifiers are incompatible between different cancers.

CONCLUSION

This study concluded that DL could predict genetic mutations in H and E-stained tissue slides when they are trained with appropriate tissue data.

Docetaxel plus S-1 versus cisplatin plus S-1 in unresectable gastric cancer without measurable lesions: a randomized phase II trial (HERBIS-3)

BACKGROUND

Cisplatin plus S-1 (CS) is the standard first-line chemotherapy for advanced gastric cancer (AGC) in Japan. A previous phase III trial showed that docetaxel plus S-1 (DS) was effective for AGC without measurable lesions, but no studies have compared these two regimens.

METHODS

Eligible patients had unresectable or recurrent HER2-negative AGC without measurable lesions. Patients were randomized to DS (docetaxel 40 mg/m² on day 1, S-1 80-120 mg on days 1-14, every 3 weeks) or CS (cisplatin 60 mg/m² on day 8, S-1 80-120 mg on days 1-21, every 5 weeks). The primary endpoint was overall survival (OS).

RESULTS

All patients had unresectable primary disease. Sixty-one patients were randomly assigned to DS (n = 30) or CS (n = 31). One CS patient was ineligible due to HER2 positivity. The median number of cycles was 9.5 (range 2-49) with DS and 5.5 (range 1-10) with CS. There were no treatment-related deaths. The most common grade 3-4 non-hematological toxicity was fatigue (7% with DS, 13% with CS), followed by anorexia (3% with DS, 10% with CS) and diarrhea (3% with DS, 10% with CS). The 2-year OS rates were 43.3% with DS and 30.0% with CS (log-rank P = 0.113), with a hazard ratio of 0.617 (95% confidence interval 0.337-1.128), indicating non-inferiority of DS to CS with respect to OS (P < 0.001).

CONCLUSIONS

DS showed slightly but nonsignificantly less toxicity and higher efficacy than CS for AGC without measurable lesions. DS should be further investigated in phase III trials.

Impacts of Preoperative Psoas Muscle Mass and Visceral Fat Area on Postoperative Short- and Long-Term Outcomes in Patients with Gastric Cancer

BACKGROUND

Sarcopenia and obesity are associated with outcomes after surgery. However, few studies have investigated which more accurately predicts postoperative complications or prognosis in patients with gastric cancer.

METHODS

A total of 567 consecutive patients with gastric cancer who underwent gastrectomy between 2010 and 2015 were retrospectively reviewed. Psoas muscle mass index (PMI) and visceral fat area (VFA) were measured by CT scan. Patients were divided into two groups based on PMI (PMI-H group: male ≥ 6.36 cm²/m², female ≥ 3.92 cm²/m²; and PMI-L group: male < 6.36 cm²/m², female < 3.92 cm²/m²) and two groups based on VFA (VFA-H group: ≥ 100 cm²; VFA-L group: < 100 cm²). The incidence of postoperative complications and the recurrence-free survival (RFS) were compared between the two groups.

RESULTS

The incidence of postoperative complications was significantly higher in the VFA-H group than in the VFA-L group (35.1% vs. 20.3%; P < 0.001), whereas there was no significant difference between the PMI-H and PMI-L groups. Multivariate analysis showed that PMI-L and VFA-H were independent risk factors for pneumonia (odds ratio, 4.49; P = 0.018) and intra-abdominal abscess (odds ratio, 5.19; P = 0.004), respectively. While there was no significant difference in RFS between the VFA-H and VFA-L groups, the PMI-L group showed significantly worse RFS than the PMI-H group (P < 0.001).

CONCLUSIONS

PMI and VFA were useful predictive factors for postoperative pneumonia and intra-abdominal abscess, respectively. PMI might be a useful prognostic factor in patients with gastric cancer, but VFA is not.

Prognostic Value of the Combined Index of Plasma Fibrinogen and the Neutrophil-Lymphocyte Ratio in Gastric Cancer

BACKGROUND

It has been reported that both fibrinogen and the neutrophil-lymphocyte ratio (NLR) are related to the degree of malignancy in various types of cancer. This study compared the combined index of fibrinogen and NLR (F-NLR) with NLR alone for predicting the prognosis of patients with resectable gastric cancer.

METHODS

We collected data on 666 patients with resectable gastric cancer. Patients were divided into three F-NLR score groups based on the following criteria: score 2, both hyperfibrinogenemia (≥350 mg/dl) and high NLR (≥2.5); score 1, either hyperfibrinogenemia or high NLR; and score 0, neither abnormality. The association between prognosis and NLR alone or F-NLR was evaluated using the Kaplan-Meier method and Cox multivariate analysis.

RESULTS

The high-NLR group had significantly worse overall survival (OS) than the low-NLR group (hazard ratio 1.62; 95% confidence interval [CI] 1.07-2.45; log-rank P = 0.022), but there was no significant difference between the high- and low-NLR groups after adjusting for the fibrinogen level. F-NLR groups showed significantly different OS (log-rank P < 0.001) and recurrence-free survival (log-rank P < 0.001). The 5-year OS rate for the groups with F-NLR scores of 2, 1, and 0 was 72.6%, 81.4%, and 90.4%, respectively. A Cox multivariate analysis of OS revealed that a high F-NLR score (1 or 2) was an independent prognostic factor (P = 0.007).

CONCLUSIONS

F-NLR was an independent prognostic factor in patients with gastric cancer and a more useful prognostic indicator than NLR alone.

Prognostic value of postoperative C-reactive protein elevation versus complication occurrence: a multicenter validation study

BACKGROUND

Several studies have shown that postoperative complications worsen the prognosis of patients with malignancies. However, our previous study showed that C-reactive protein (CRP) elevation over 12 mg/dL was a more reliable prognostic indicator than complication occurrence. This large-scale, multicenter validation study aimed to confirm the prognostic value of postoperative CRP elevation in resectable gastric cancer.

METHODS

Data of 1456 patients with pT2-T4 gastric cancer who underwent R0 resection were collected from 21 institutions. The prognostic value of the highest postoperative serum level of CRP (CRP_max) during hospitalization was evaluated using the Kaplan-Meier method. The prognostic independence of CRP_max with assessed with a Cox multivariate analysis of recurrence-free survival (RFS).

RESULTS

RFS in the high CRP_max (≥ 12 mg/dL) group was significantly worse than that in the low CRP_max (< 12 mg/dL) group (log-rank P = 0.002). The recurrence pattern showed that liver metastasis occurred more frequently in the high CRP_max group (9.2%) than in the low CRP_max group (4.7%) (P = 0.001). In patients without intra-abdominal infectious complications, the high CRP_max group showed significantly worse RFS than the low CRP_max group (log-rank P = 0.026). In patients with intra-abdominal infectious complications, the high CRP_max group had worse RFS than the low CRP_max group, but this difference was not significant (log-rank P = 0.075). Cox multivariate analysis with 13 covariables showed that CRP_max (P = 0.043) was an independent prognostic factor, but postoperative complications were not (P = 0.387).

CONCLUSION

Postoperative CRP elevation was a better predictor of prognosis in patients with gastric cancer than the occurrence of intra-abdominal infectious complications.

Postoperative Long-Term Outcomes in Elderly Patients with Gastric Cancer and Risk Factors for Death from Other Diseases

BACKGROUND

Elderly patients with gastric cancer are frequently treated surgically in current clinical practice. Although several studies have investigated short-term outcomes after gastrectomy in elderly patients, most did not evaluate long-term outcomes.

METHODS

We analyzed 1154 consecutive patients who underwent curative gastrectomy for gastric cancer between 2001 and 2013. We classified them into two groups: the elderly group (n = 241), consisting of patients aged ≥75 years, and the non-elderly group (n = 913), consisting of patients aged <75 years, and compared the short- and long-term outcomes between the two groups. The risk factors for death from other diseases in elderly patients were also examined.

RESULTS

Although the incidence of postoperative pneumonia was significantly higher in the elderly group (P < 0.001), the proportion of overall postoperative complications did not differ significantly between the two groups (P = 0.097). The disease-specific survival was similar between the two groups (P = 0.743), whereas the overall survival in the elderly group was significantly shorter than that in the non-elderly group (P < 0.001) because of a higher incidence of death from other diseases throughout all gastric cancer stages. Multivariate analysis revealed that a low preoperative prognostic nutrition index (PNI) and multiple comorbidities were significant risk factors for death from other diseases within 5 years in the elderly group.

CONCLUSIONS

Despite acceptable short-term outcomes, long-term outcomes in elderly patients with gastric cancer were poor due to the high incidence of death from other diseases. Indications for surgery in elderly patients with a low PNI or multiple comorbidities should be considered carefully.

Global updates in the treatment of gastric cancer: a systematic review. Part 2: perioperative management, multimodal therapies, new technologies, standardization of the surgical treatment and educational aspects

Gastric cancer is the fifth malignancy and the third cause of cancer death worldwide, according to the global cancer statistics presented in 2018. Its definition and staging have been revised in the eight edition of the AJCC/TNM classification, which took effect in 2018. Novel molecular classifications for GC have been recently established and the process of translating these classifications into clinical practice is ongoing. The cornerstone of GC treatment is surgical, in a context of multimodal therapy. Surgical treatment is being standardized, and is evolving according to new anatomical concepts and to the recent technological developments. This is leading to a massive improvement in the use of mini-invasive techniques. Mini-invasive techniques aim to be equivalent to open surgery from an oncologic point of view, with better short-term outcomes. The persecution of better short-term outcomes also includes the optimization of the perioperative management, which is being implemented on large scale according to the enhanced recovery after surgery principles. In the era of precision medicine, multimodal treatment is also evolving. The long-time-awaited results of many trials investigating the role for preoperative and postoperative management have been published, changing the clinical practice. Novel investigations focused both on traditional chemotherapeutic regimens and targeted therapies are currently ongoing. Modern platforms increase the possibility for further standardization of the different treatments, promote the use of big data and open new possibilities for surgical learning. This systematic review in two parts assesses all the current updates in GC treatment.

Clinical significance of chromatin remodeling factor CHD5 expression in gastric cancer

Chromodomain helicase DNA-binding 5 (CHD5), which is a member of the CHD family, has been identified as a tumor suppressor gene in a variety of malignancies. The aim of the current study was to clarify the clinical significance of CHD5 expression in gastric cancer. CHD5 expression was evaluated using immunohistochemistry (IHC) in 154 specimens resected from patients with gastric cancer from January 2011 to December 2013, and assessed its relationships with clinicopathological characteristics and survival. In vitro cell proliferation, invasion, and migration assays and western blotting analysis were performed to clarify the role of CHD5 in human gastric cancer cell lines. Of a total of 154 patients, 57 (37.0%) exhibited low CHD5 expression, which was significantly associated with positive lymphatic invasion (P=0.032), advanced pT status (P=0.011), and advanced pStage (P=0.014). Overall survival (OS) in patients with low CHD5 expression was significantly worse compared with patients with high CHD5 expression (hazard ratio, 1.96; 95% confidence interval, 1.09-3.45; log-rank P=0.023). Cox multivariate analysis for OS revealed that CHD5 expression was an independent prognostic factor with age and pN status. In vitro, the upregulation of CHD5 in gastric cancer cells with low CHD5 expression significantly decreased cell proliferation, migration and invasion. CHD5 was associated with the regulation of multiple cancer-related targets, including p53 and enhancer of zeste homolog 2 (EZH2) in western blotting analysis. In conclusion, since CHD5 regulated multiple cancer-related targets, its expression may be a useful prognostic biomarker in patients with gastric cancer.

What is the most useful body composition parameter for predicting toxicities of preoperative chemotherapy for gastric cancer?

PURPOSE

Preoperative chemotherapy is an effective treatment option for resectable gastric cancer, but it is associated with various adverse events (AEs). This study aimed to identify the body composition parameters that most accurately predicted the incidence of AEs in preoperative chemotherapy for gastric cancer.

METHODS

The present study included a total of 114 patients who received preoperative chemotherapy for resectable gastric cancer. We estimated various body composition parameters using computed tomography images obtained before preoperative chemotherapy. Their associations with the incidence of hematological (grade ≥ 3) and non-hematological (grade ≥ 2) AEs were analyzed by multivariate logistic regression analyses.

RESULTS

Seventy-two of the 114 (63.2%) patients experienced hematological AEs (grade ≥ 3), specifically neutropenia in 68 (59.6%), anemia in 5 (4.9%), and thrombocytopenia in 3 (2.6%). Meanwhile, 59 patients (51.8%) experienced non-hematological AEs (grade ≥ 2), namely hypoalbuminemia in 31 (27.2%), anorexia in 24 (21.1%), and febrile neutropenia in 17 (14.9%). Multivariate analyses revealed that a low psoas muscle index (PMI) was an independent risk factor for the incidence of both hematological and non-hematological AEs.

CONCLUSIONS

Patients with a low PMI experienced an increased incidence of hematological and non-hematological toxicities during preoperative chemotherapy for gastric cancer. Clinicians should be aware of these risks in this population.

Predictive value of MLH1 and PD-L1 expression for prognosis and response to preoperative chemotherapy in gastric cancer

BACKGROUND

Microsatellite instability (MSI) and programmed death-ligand 1 (PD-L1) are candidate predictors for the response to immune checkpoint inhibitors, and may predict chemotherapy sensitivity. We investigated the simultaneous expression of mutL homolog 1 (MLH1), a mismatch repair gene, and PD-L1 in gastric cancers.

METHODS

We examined MLH1 and PD-L1 expression in surgical specimens from 285 gastric cancer patients treated with or without preoperative chemotherapy, and assessed the relation between expression results and both histological response and recurrence-free survival (RFS).

RESULTS

Of 285 patients, 28 (9.8%) and 70 (24.6%) exhibited negative MLH1 and high PD-L1 expression, respectively. Most MLH1-negative tumors (85.7%) showed high MSI, and these tumors exhibited high PD-L1 expression more frequently than MLH1-positive tumors (57.1% vs. 21.0%, P < 0.001). MLH1-negative patients were significantly less likely to respond to preoperative chemotherapy than MLH1-positive patients (16.7% vs. 61.2%, P = 0.005), whereas there was no significant difference between high- and low-PD-L1 expression patients (55.9% vs. 56.6%, P = 0.95). RFS in patients without preoperative chemotherapy was significantly longer in the MLH1-negative group than in the MLH1-positive group (HR 0.30; 95% CI 0.09-0.95; P = 0.030), whereas in patients with preoperative chemotherapy there was no significant difference in RFS between the two groups (HR 0.70; 95% CI 0.30-1.63; P = 0.41). PD-L1 expression was not associated with RFS in patients with or without chemotherapy.

CONCLUSIONS

Loss of MLH1 was associated with chemoresistance and did not prolong survival following neoadjuvant chemotherapy. The strong association between MLH1 and MSI status suggests that immune checkpoint inhibitors may be preferable to conventional chemotherapy for MLH1-negative gastric cancer.