Efficacy of Surgery for the Treatment of Gastric Cancer Liver Metastases: A Systematic Review of the Literature and Meta-Analysis of Prognostic Factors

Surgical treatment for liver metastasis from gastric cancer: A systematic review and meta-analysis of long-term outcomes and prognostic factors

Chemotherapy is the mainstay treatment for liver metastasis from gastric cancer. However, some retrospective studies and meta-analyses have indicated the efficacy of hepatectomy, which is an aggressive treatment option. However, the optimal selection criteria for hepatectomy and the role of perioperative chemotherapy remain unclear. Therefore, a meta-analysis of studies on hepatectomy was performed to assess the impact of various factors on overall survival (OS). A systematic review was conducted in accordance with the PRISMA criteria using studies published until 2022. The primary outcome was the hazard ratio (HR) for OS. Comparisons were made between hepatectomy and nonhepatectomy, solitary and multiple metastases, synchronous and metachronous metastases, treatment with and without neoadjuvant chemotherapy, and treatment with and without adjuvant chemotherapy. A total of 50 studies involving 1966 patients who underwent hepatectomy were included in the analysis. The meta-analysis showed a 5-year OS rate of 25 %. A meta-analysis comparing hepatectomy with nonhepatectomy showed an HR of 0.2 for hepatectomy. A meta-analysis comparing solitary and multiple metastases showed a trend toward better OS in patients with solitary metastases (odds ratio [OR]: 0.35). A meta-analysis comparing synchronous and metachronous metastases showed favorable OS for patients with metachronous metastases (OR: 0.66). A meta-analysis comparing neoadjuvant chemotherapy with no neoadjuvant chemotherapy showed no difference in OS. In contrast, a meta-analysis comparing adjuvant chemotherapy with no adjuvant chemotherapy showed better OS for adjuvant chemotherapy (OR: 0.39). This retrospective study indicates that hepatectomy may benefit patients with liver metastases from gastric cancer, particularly those with solitary and metachronous metastases.

Identification of a novel gene signature related to prognosis and metastasis in gastric cancer

BACKGROUND

Gastric Cancer (GC) presents poor outcome, which is consequence of the high incidence of recurrence and metastasis at early stages. GC patients presenting recurrent or metastatic disease display a median life expectancy of only 8 months. The mechanisms underlying GC progression remain poorly understood.

METHODS

We took advantage of public available GC datasets from TCGA using GEPIA, and identified the matched genes among the 100 genes most significantly associated with overall survival (OS) and disease free survival (DFS). Results were confirmed in ACRG cohort and in over 2000 GC cases obtained from several cohorts integrated using our own analysis pipeline. The Kaplan-Meier method and multivariate Cox regression analyses were used for prognostic significance and linear modelling and correlation analyses for association with clinic-pathological parameters and biological hallmarks. In vitro and in vivo functional studies were performed in GC cells with candidate genes and the related molecular pathways were studied by RNA sequencing.

RESULTS

High expression of ANKRD6, ITIH3, SORCS3, NPY1R and CCDC178 individually and as a signature was associated with poor prognosis and recurrent disease in GC. Moreover, the expression of ANKRD6 and ITIH3 was significantly higher in metastasis and their levels associated to Epithelial to Mesenchymal Transition (EMT) and stemness markers. In line with this, RNAseq analysis revealed genes involved in EMT differentially expressed in ANKRD6 silencing cells. Finally, ANKRD6 silencing in GC metastatic cells showed impairment in GC tumorigenic and metastatic traits in vitro and in vivo.

CONCLUSIONS

Our study identified a novel signature involved in GC malignancy and prognosis, and revealed a novel pro-metastatic role of ANKRD6 in GC.

Benefit of a multimodal approach combining chemotherapy and surgery in oligometastatic gastric cancer: experience from a tertiary referral center

Introduction

Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide with limited therapeutic options. The aim of this study was to analyze the value of adding surgery to the first-line treatment in patients with oligometastatic GC (OGC).

Methods

This retrospective study included patients with OGC who underwent induction chemotherapy followed by surgery of both primary tumor and synchronous metastasis between April 2012 and April 2022. Endpoints were overall survival (OS) and relapse-free survival (RFS) analyzed by the Kaplan-Meier method. Prognostic factors were assessed with the Cox model.

Results

Data from 39 patients were collected. All cases were referred to our multidisciplinary tumor board (MTB) to evaluate the feasibility of radical surgery. After a median follow-up of 33.6 months (mo.), median OS was 26.6 mo. (95% CI 23.8-29.4) and median RFS was 10.6 mo. (95% CI 6.3-14.8). Pathologic response according to the Mandard criteria (TRG 1-3, not reached versus 20.5 mo. for TRG 4-5; HR 0.23, p=0.019), PS ECOG ≤ 1 (26.7 mo. for PS ≤ 1 versus 11.2 mo. for PS >1; HR 0.3, p=0.022) and a low metastatic burden (26.7 mo. for single site versus 12.9 mo. for ≥2 sites; HR 0.34, p=0.039) were related to good prognosis. No major intraoperative complications nor surgery-related deaths occurred in our series.

Discussion

A sequential strategy of preoperative chemotherapy and radical surgical excision of both primary tumor and metastases was demonstrated to significantly improve OS and RFS. Multidisciplinary evaluation is mandatory to identify patients who could benefit from this strategy.

High serum alpha-fetoprotein and positive immunohistochemistry of alpha-fetoprotein are related to poor prognosis of gastric cancer with liver metastasis

Liver metastasis in gastric cancer is incurable. Alpha-fetoprotein-producing gastric cancer has a poor prognosis and is prone to liver metastasis. We investigated the association between preoperative serum alpha-fetoprotein levels, liver metastasis, and expression of primitive enterocyte phenotype markers. We reviewed the medical records of 401 patients with gastric cancer who underwent curative surgical resection and immunohistochemically evaluated the primitive phenotype markers. The preoperative serum alpha-fetoprotein levels were elevated and normal in 8 and 393 patients, respectively. Liver metastasis was more frequent in patients with higher preoperative alpha-fetoprotein levels. The 5-year postoperative recurrence-free survival and overall survival rates were significantly worse in patients with higher preoperative serum alpha-fetoprotein levels. Although alpha-fetoprotein and Glypican3 and Spalt-like transcription factor 4 tended to be stained with high preoperative serum alpha-fetoprotein levels, these markers were also positive in some patients with normal alpha-fetoprotein levels. In summary, patients with gastric cancer and high preoperative serum alpha-fetoprotein levels have a poor prognosis and high incidence of liver metastasis. Alpha-fetoprotein can help detect liver metastasis relating to the primitive enterocyte phenotype.

Comprehensive profiling of cell subsets of gastric cancer and liver metastasis based on single cell RNA-sequencing analysis

Background

Liver metastasis (Li) is one of the most common distant metastatic sites for gastric cancer. A deeper understanding of its mechanism of action from a bioinformatics perspective may provide new insights. Therefore, the aim of this study was to use single cell RNA sequencing (scRNA-seq) to evaluate cell subtypes and understand the molecular mechanism of gastric cancer Li.

Methods

The scRNA-seq data GSE163558 of gastric cancer and Li were downloaded from Gene Expression Omnibus (GEO). Single cell data were analyzed by various R packages such as Seurat, CellChat, gene set variation analysis (GSVA), monocle, gene set enrichment analysis (GSEA), and survival analysis and the results were plotted by ggplot2, R4.1.1. Protein expression was confirmed by immunohistochemistry in an additional patient cohort.

Results

The genes APOD, CXCL5, and JUN are involved in epithelial cell metastasis. The infiltration of cytotoxic CD8 T cells was more frequent in gastric primary tumors (PTs) than in Lis. IL7R high natural killer (NK) cells that had high TXNIP and RIPOR2 expression were located at the site of Li and corresponded to a favorable prognosis. NK cells with high TNFAIP3 expression were located at the PT site and corresponded to a poor prognosis. Furthermore, the gene expression of myeloid cells was different depending on their localization in the PT site or Li. MHC-I signaling pathway was found to be activated in the PT compared to MHC-II at the site of Li, as revealed by cell-cell interaction, and HLA-E-CD94/NKG2A of NK cells was only activated in the PT and not in the Li.

Conclusions

The present study revealed the difference between Li and gastric PT by scRNA-seq, demonstrating the impact of partial gene expression on patient prognosis. Our study provides new insights into gastric cancer and Li.

A bibliometric analysis of gastric cancer liver metastases: advances in mechanisms of occurrence and treatment options

BACKGROUND

Gastric cancer (GC) is the fifth most commonly diagnosed cancer worldwide, and its poor prognosis is predominantly attributed to distant metastasis. Liver is the primary site of GC metastasis. However, there is no universally approved treatment regimen for liver metastasis in GC. The aim of this article is to review the current research status and trends of liver metastasis of gastric cancer worldwide.

METHODS

We utilized the Web of Science Core Collection database to identify articles on liver metastasis from GC published between 2000 and 2022. We used bibliometric methods to analyze authors, institutions, countries, journals, and references through CiteSpace and VOSviewer. A total of 1,003 articles were included in this study.

RESULTS

Japan published the most articles in the field, followed by China. Nagoya University is the leading institution in the field of liver metastases in GC. Yasuhiro Kodera from Japan has made significant achievements in this area. We identified Gastric Cancer to be the most influential journal in this field. Using cluster analysis, the keywords were divided into four major clusters:(1) the molecular mechanism of gastric cancer liver metastasis (2) prognosis (3) liver resection (4) chemotherapy.

CONCLUSION

Our study systematically summarizes the results of gastric cancer liver metastasis research from 2000 to 2022 and describes and predicts research hotspots and trends on a global scale. Research on the molecular mechanisms of gastric cancer liver metastasis will become a hot topic in the future, and the expansion of the surgical treatment scope and the advancement of translational therapy will benefit more patients.

Precision-based tertiary care improves nutritional status and quality of life in patients undergoing adjuvant chemotherapy after radical gastrectomy for gastric cancer

OBJECTIVE

To assess the impact of a precision-based tertiary care protocol, including participatory dietary care, on the nutritional status, immune function, and quality of life in gastric cancer patients after radical gastrectomy.

METHODS

The clinical and laboratory data of 124 patients diagnosed with gastric cancer at the Second People's Hospital of Lanzhou City from June 2020 to May 2022 were collected and retrospectively analyzed. The patients were grouped into a control group of 54 patients who received standard care and a study group of 70 patients who additionally received detailed tertiary care and bundled nutritional interventions. The clinical data (age, gender, surgical method, clinical staging, chemotherapy regimen, histories of diabetes, hypertension, smoking, alcohol consumption, time to first flatus and bowel movement, time to first liquid intake, length of hospital stay, complications at discharge, PG-SGA score, and QLQ-C30 score) and lab indices (serum albumin (ALB), prealbumin (PA), transferrin (TRF), hemoglobin (Hb), immunoglobulin A (IgA), M (IgM), and G (IgG)) were compared between the two groups.

RESULTS

Study group had significantly higher levels of ALB, PA, TRF, Hb, IgA, IgM, and IgG compared to the control group after intervention (all P<0.001). QLQ-C30 score was higher while PG-SGA score was lower in the study group (both P<0.01). Postoperative digestive system recovery was faster in the study group, as evidenced by a shorter time to first anal defecation, bowel movement, liquid food intake, and hospital stay (P<0.001). Complication rate was significantly lower in the study group (P<0.05). Cox regression analysis showed age (P=0.021) and clinical stage (P=0.039) as independent prognostic factors, while treatment regimen was not (P>0.05).

CONCLUSION

Precision-based tertiary care protocol can improve nutritional status, enhance immune function, and facilitate faster postoperative recovery for gastric cancer patients following gastrectomy, thus greatly improving the quality of life of the patient. However, age and clinical staging, rather than the care protocol, are independent prognostic factors for patients' 1-year survival.

Simultaneous colonic metastasis of advanced gastric cancer: a case report

BACKGROUND

Although distant metastasis in gastric cancer can be present at the time of the initial diagnosis, colonic metastasis is extremely rare. This report describes a case of simultaneous colonic metastasis of advanced gastric cancer.

CASE PRESENTATION

The patient was a 78-year-old woman with nausea and epigastric pain. Upper gastrointestinal endoscopy revealed an advanced invasive ulcerative tumor in the lesser curvature of the stomach extending from the anterior to the middle portion. Colonoscopy revealed a 4-mm polyp-like lesion in the mid-transverse colon; therefore, a polypectomy was performed. Both gastric and colonic tumors showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. After providing informed consent, the patient underwent a total gastrectomy. Histologic examination showed similar morphologic features of both gastric and colonic tumors. Immunohistochemistry staining showed that these tumor cells were positive for cytokeratin (CK) 7 and negative for CK20.

CONCLUSIONS

This was an extremely rare case of simultaneous colonic metastasis of advanced gastric cancer. Because missed metastasis can result in a poorer prognosis, we propose a systemic search including colonoscopy for patients with advanced gastric cancer, especially cases involving poorly differentiated adenocarcinoma or signet ring cell carcinoma.

Successful second conversion surgery after trastuzumab deruxtecan for recurrent HER2-positive gastric cancer

A 65-year-old woman with HER2-positive gastric cancer with multiple liver metastases underwent first conversion surgery of gastrectomy with D2 lymph nodes dissection and three liver metastases after combination therapy with capecitabine, cisplatin, and trastuzumab. Two years later, she experienced multiple liver metastases that were refractory to combination therapy with paclitaxel albumin-bound nanoparticles and ramucirumab. She participated in the DESTINY-Gastric01 trial and received tri-weekly trastuzumab deruxtecan as third-line treatment for 26 cycles. The recurrent lesions markedly shrank, and this effect continued for 19 months. We then performed partial hepatectomy for the one remaining lesion. No adjuvant chemotherapy was given, and she remains alive without recurrence 18 months after the second conversion surgery. Trastuzumab deruxtecan may generate a notable tumor response and subsequent conversion surgery could be a treatment option for HER2-positive stage IV gastric cancer.

Survival Outcomes of Hepatectomy in Gastric Cancer Liver Metastasis: A Systematic Review and Meta-Analysis

Gastric cancer liver metastasis (GCLM) is a contraindication for surgical treatment in current guidelines. However, the results of recent studies are questioning this paradigm. We assessed survival outcomes and their predictors following hepatectomy for GCLM in a systematic review of studies published from 2000 to 2022 according to PRISMA guidelines. We identified 42,160 references in four databases. Of these, 55 articles providing data from 1990 patients fulfilled our criteria and were included. We performed a meta-analysis using random-effects models to assess overall survival (OS) and disease-free survival (DFS) at one, three, and five years post-surgery. We studied the impact of potential prognostic factors on survival outcomes via meta-regression. One, three, and five years after surgery, OS was 69.79%, 34.79%, and 24.68%, whereas DFS was 41.39%, 23.23%, and 20.18%, respectively. Metachronous presentation, well-to-moderate differentiation, small hepatic tumoral size, early nodal stage, R0 resection, unilobar compromisation, and solitary lesions were associated with higher overall survival. Metachronous presentation, smaller primary tumoral size, and solitary metastasis were linked to longer DFS. The results of our meta-analysis suggest that hepatectomy leads to favorable survival outcomes in patients with GCLM and provides data that might help select patients who will benefit most from surgical treatment.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

Hepatic resection using intraoperative ultrasound and near-infrared imaging with indocyanine green fluorescence detects hepatic metastases from gastric cancer: A case report

Introduction and importance

Near-infrared (NIR) imaging with indocyanine green (ICG) is a sensitive intraoperative tool for detecting liver tumors. NIR imaging has been used to distinguish metastatic liver cancer from colon cancer; however, its utility for identifying metastatic lesions from gastric cancer remains unknown. We present a case of advanced gastric cancer with multiple liver metastases, which was diagnosed and treated using intraoperative NIR imaging with ICG.

Case presentation

A 69-year-old man with advanced gastric cancer and simultaneous multiple liver metastases presented with gastric bleeding. He underwent gastrectomy and chemotherapy, which reduced the tumor burden. No new lesions were noted, and the patient was advised to undergo surgical resection of the residual liver metastases. Prior to surgery, 0.5 mg/kg of intravenous ICG was administered. NIR imaging was performed during hepatectomy, which revealed clear green fluorescence in several liver segments, indicating liver metastases. Two lesions were not identified during preoperative magnetic resonance imaging. All fluorescent areas were resected. The tumors identified by both preoperative and fluoresced intraoperatively demonstrated malignant features on histopathological examination. The two lesions that fluoresced intraoperatively but were not identified on preoperative images demonstrated normal liver parenchyma and no signs of malignancy. The patient remains tumor-free 1 year after surgery.

Clinical discussion

This report demonstrates that hepatic metastases from gastric cancer can be diagnosed with intraoperative NIR imaging with ICG.

Conclusions

NIR imaging with ICG can detect liver metastases but may provide false positive results. As the percentage of false positives is high, additional resections must be decided upon carefully.

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We used intraoperative NIR-ICG imaging to detect gastric cancer liver metastases.

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Two lesions fluoresced intraoperatively that were not identified preoperatively.

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Histopathology showed normal liver parenchyma and no malignancy in these lesions.

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NIR imaging with ICG detects liver metastases but may give false positive results, thus additional resections of liver tumor must be decided on carefully.

Fecal Streptococcus Alteration Is Associated with Gastric Cancer Occurrence and Liver Metastasis

The gut microbiome plays an indispensable role in the occurrence and progression of various diseases. However, its ability to predict gastric cancer (GC) and liver metastasis (GCLM) has not been fully identified. Fecal samples were collected from 49 GC patients (cancer group [group C]) and 49 healthy people (normal group [group N]) between 4 July 2020 and 9 March 2021. Furthermore, 26 patients with metastatic GC were divided into a liver metastatic group (group L) (n = 13) and a non-liver-metastatic group (group M) (n = 13). DNA was extracted, and 16S rRNA gene sequencing was performed. SPSS was used for statistical analyses, and all bioinformatics analyses were based on QIIME2. P values of <0.05 were considered statistically significant. The microbial richness and diversity in group C were higher than those in group N, and there were significant differences in species compositions between the two groups. Streptococcus, enriched in groups C and L by linear discriminant analysis (LDA) effect size (LEfSe) and further identified by a random forest (RF) model, enhances its potential as a biomarker for GC and GCLM. Functional gene and metabolic pathway analyses showed that d-galacturonate degradation pathway II was of great importance in the occurrence and development of GC. Streptococcus has the potential ability to predict GC and GCLM, which is critical for the early diagnosis of GC and GCLM.