Follow-up after gastrectomy for cancer: Results of an international web round table

Imaging of Gastric Carcinomatosis

Diagnosing the absence or presence of peritoneal carcinomatosis in patients with gastric cancer, including its extent and distribution, is an essential step in patients' therapeutic management. Such diagnosis still remains a radiological challenge. In this article, we review the strengths and weaknesses of the different imaging techniques for the diagnosis of peritoneal carcinomatosis of gastric origin as well as the techniques' imaging features. We also discuss the assessment of response to treatment and present recommendations for the follow-up of patients with complete surgical resection according to the presence of risk factors of recurrence, as well as discussing future directions for imaging improvement.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Conventional radiotherapy planning of cervical cancer in resource-constrained set-up: Utilizing soldering lead wire to delineate radiotherapy portal

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Cervical cancer is the commonest malignancy among women in developing countries.

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Radiotherapy is mainstay of management and simulator for RT planning may be sparse.

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Our study has demonstrated the utility of locally available resources for simulation.

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Using soldering wire for conventional RT field delineation appears to be feasible.

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Future studies are needed to validate the RT portals delineated by this technique.

Simulator for radiotherapy planning may not be available in resource-constrained set-up. Surface anatomy based planning has its own limitation in terms of adequately covering target due to variation of anatomy and tumor growth and spread pattern. Hence, improvisation of radiotherapy planning of cervical cancer, commonest malignancy among women in this set-up, utilizing locally available resource may improve treatment quality.

Soldering lead wire, plumber’s measuring tape, diagnostic x-ray and transpore adhesive tape were utilized to delineate radiotherapy portals for management of cervical cancer. Delineation of radiotherapy portals for irradiation of different regions in selected patients of carcinoma cervix is feasible in resource-constrained set-up. Radiotherapy delivery by conventional 2-D technique through the portal designed by utilizing soldering lead wire and diagnostic x-ray was achievable. Radiotherapy portal so delineated need to be validated in future clinical studies.

Surveillance and outcomes after curative resection for gastroesophageal adenocarcinoma

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.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 1): AN UPDATE ON DIAGNOSIS, STAGING, ENDOSCOPIC TREATMENT AND FOLLOW-UP

BACKGROUND

The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented.

AIM

To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients.

METHODS

To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation.

RESULTS

Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3.

CONCLUSION

The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

Timing and site-specific trends of recurrence in patients with pathological stage II or III gastric cancer after curative gastrectomy followed by adjuvant S-1 monotherapy

BACKGROUND

Adjuvant S-1 monotherapy prolongs the survival of patients with pathological stage II or III gastric cancer undergoing D2 gastrectomy. This therapeutic regimen is standard in Japan. Unfortunately, some patients who undergo this treatment suffer from recurrent disease. However, information regarding the timing and site-specific trends of recurrence is insufficient.

METHODS

Among 396 patients who underwent D2 gastrectomy followed by adjuvant S-1 monotherapy between 2008 and 2012, 122 experienced a recurrence. We retrospectively determined the timing and sites of recurrence.

RESULTS

The median RFS of the 122 patients was 19.5 months, and their 1-, 3- and 5-year RFS rates were 67.2%, 23.0% and 5.7%, respectively. There were no significant differences in RFS among disease substages. Local recurrence, lymph node involvement and peritoneal and hematogenous metastases were found in 6, 25, 63 and 42 patients, respectively. Approximately 10% of patients presented with contemporaneous sites of recurrence. Local recurrence and lymph node metastasis plateaued 3 years after gastrectomy. Peritoneal and hematogenous metastasis increased within 5 years after surgery. In patients with hematogenous metastasis, the number of liver metastases plateaued but increased in others.

CONCLUSIONS

In patients with recurrent disease who underwent D2 gastrectomy followed by adjuvant S-1 monotherapy, 80% of recurrences occur within 3 years after gastrectomy. The timing of recurrence is not significantly different among substages. Although the rates of local recurrence and lymph node and liver metastasis plateau after 3 years, peritoneal and the other hematogenous metastases increase within 5 years.

More Frequent Follow-up CT Scans in Postsurgical Resection Patients Than in Postendoscopic Resection Patients of Early Gastric Cancers: Impracticality of CTs for Mucosal Cancer

RATIONALE AND OBJECTIVES

The aim of this study was to compare the utility and timing of computed tomography (CT) in the detection of recurrent tumors between patients after surgical and endoscopic resections for early gastric cancer (EGC).

MATERIALS AND METHODS

A total of 670 patients after surgical (n = 535) and endoscopic (n = 135) resections for EGC between 2007 and 2009 were enrolled. The mean numbers of CT and endoscopy between both treatment groups were compared. The mean and cumulative dose length products of CT examinations were calculated. The modality that detected recurrence was compared between the two groups using the Pearson chi-square test.

RESULTS

The mean interval of CT was significantly shorter and the mean number of CTs was significantly larger in the surgical resection group than in the endoscopic resection group. All 34 gastric recurrences were diagnosed by endoscopy. All seven extragastric recurrences occurred in patients treated for EGC with submucosal invasion. Six extragastric recurrences were detected by CT out of a total of 5417 CT scans. The average cumulative dose length product was significantly higher in the surgical group than in the endoscopic resection group (P = 0.004).

CONCLUSION

Follow-up CTs were performed more frequently in patients after surgical resection than in patients after endoscopic resection of EGCs. However, CT scans were not effective in detecting recurrent tumors after either treatment methods, especially for patients treated for mucosal gastric cancer.

Lauren Histologic Type Is the Most Important Factor Associated With Pattern of Recurrence Following Resection of Gastric Adenocarcinoma

OBJECTIVE

To examine sites of initial recurrence in patients after resection of gastric and gastroesophageal junction Siewert II/III adenocarcinoma (GA).

BACKGROUND

There are few recent studies on recurrence for Western patients following potentially curative resection of GA.

METHODS

A review of a prospectively maintained, single institution database was performed. Clinicopathologic factors, site(s) of initial recurrence, disease-free survival, and overall survival were examined.

RESULTS

From January 2000 to June 2010, 957 patients underwent potentially curative resection for GA, 435 patients (46%) had recurrent disease, and complete data on recurrence site(s) could be obtained in 386 patients. Tumors were Lauren intestinal type in 206 (53%) and diffuse or mixed-type in 180 (47%). Median time to recurrence was 12 months and 75% of recurrences occurred within 2 years. There was a significant difference in pattern of initial recurrence between the intestinal and diffuse/mixed cohorts (P < 0.001). For intestinal tumors, distant metastasis was the most common site (54%), followed by locoregional (20%), peritoneal (15%), and multifocal (11%). For diffuse/mixed tumors, peritoneal recurrence was the most common (37%), followed by distant (32%), locoregional (22%), and multifocal (9%). On multivariate analysis, Lauren histologic type was the only significant factor that was associated with both peritoneal recurrence (diffuse, hazard ratio 2.22, confidence interval 1.38-3.94) and distant recurrence (intestinal, hazard ratio 1.888, confidence interval 1.202-2.966). After recurrence, median overall survival was only 8.4 months.

CONCLUSIONS

In GA patients who recur after resection, patterns of recurrence vary significantly based on Lauren histologic type.

CD44v8-10 as a potential theranostic biomarker for targeting disseminated cancer cells in advanced gastric cancer

Gastric cancer is the third most common cause of cancer mortality, and the survival rate of stage IV advanced gastric cancer (AGC) patients with distant metastasis is very low. Thus, the detection and eradication of disseminated cancer cells by targeting cell surface molecules in AGC would improve patient survival. The hyaluronic acid receptor, CD44, has various isoforms generated by alternative splicing, and some isoforms are known to be correlated to gastric cancer. In this study, to find out the most appropriate CD44v for targeting AGC, we analysed the expression differences of CD44 isoforms at the mRNA level in stomach cancer cell lines as well as in 74 patients with AGC by using exon-specific qRT-PCR. Among the CD44v isoforms, CD44v8-10 was determined as the most promising biomarker for the development of theranostic agents of gastric cancer. Next, we synthesised the conjugate of anti-CD44v9 antibody with near-infrared fluorophore or photosensitiser, and then demonstrated its feasibility for target cell-specific imaging and photoimmunotherapy in gastric cancer. As a result, these conjugates have clearly demarcated the surface of CD44v8-10 expressing cancer cells and showed efficient phototoxic effects. Therefore, this study revealed that CD44v8-10 is the efficient theranostic biomarker to target disseminated cancer cells in AGC.

Surveillance for Gastric Cancer

This article discusses the current National Comprehensive Cancer Network guidelines and other available Western and Eastern guidelines for the surveillance of gastric cancer following surgical resection. It reviews the literature assessing the utility of intensive surveillance strategies for gastric cancer, which fails to show an improvement in survival. The unique issues relating to follow-up of early gastric cancer and after endoscopic resection of early gastric cancer are discussed. This article also reviews the available modalities for follow-up. In addition, it briefly discusses the advancements in treatment of recurrent and metastatic disease and the implications for gastric cancer survival and surveillance strategies.

Does finding early recurrence improve outcomes, and at what cost?

The putative goal of surveillance is the early detection of recurrence while both the cancer and patient are still treatable. To be cost and clinically effective, surveillance requires a tailored approach based on stage, tumor biology, conditional survival, and available treatment options. Although surveillance is the major component of care for cancer patients after potentially curative treatment, current guidelines for surveillance lack the high-level data seen on the treatment side of the patient care continuum. J. Surg. Oncol. 2016;114:329-335. © 2016 Wiley Periodicals, Inc.

Characterising timing and pattern of relapse following surgery for localised oesophagogastric adenocarcinoma: a retrospective study

Background

Oesophagogastric adenocarcinoma (OGA) has a poor prognosis, even for patients with operable disease. However, the optimal surveillance strategy following surgery is unknown.

Methods

We performed a retrospective review of all patients with OGA who had undergone surgery with radical intent at the Royal Marsden between January 2001 and December 2010.

Results

Of the 360 patients with OGA who underwent potentially curative surgery, 100/214 patients (47 %) with oesophageal/gastro-oesophageal junction (GOJ) adenocarcinoma and 47/146 patients (32 %) with gastric adenocarcinoma developed recurrent disease. 51, 79 and 92 % of relapses occurred within 1, 2 and 3 years respectively and the majority of patients relapsed at distant sites. Of the patients who relapsed, 67 % (67/100) with oesophageal/GOJ adenocarcinoma and 72 % of patients with gastric cancer (34/47) were symptomatic at the time of relapse. The majority of asymptomatic relapses were first detected by a rise in tumour markers. There was no difference in disease-free survival between asymptomatic and symptomatic patients, but asymptomatic patients were more likely to receive further treatment and had a longer survival beyond relapse.

Conclusion

The majority of relapses occur within the first 3 years and at distant sites. Monitoring of tumour markers should be considered as part of a surveillance program.

Clinicopathological features and outcomes in patients with late recurrence of renal cell carcinoma after radical surgery

OBJECTIVES

To characterize patients experiencing late recurrence after primary radical surgery for renal cell carcinoma and to approach the mechanism of late recurrence.

METHODS

We retrospectively analyzed 657 consecutive patients who underwent radical surgery for pathologically confirmed ≤stage III renal cell carcinoma in a single institution between January 1981 and December 2008. Early or late recurrence was defined as a recurrence occurring before or after 60 months after primary surgery.

RESULTS

Of 657 patients, 96 (14.6%) experienced early recurrence, and 41 (6.2%) developed late recurrence. Patients with late recurrence had smaller diameter of primary tumor (median 5 cm vs 8 cm, P < 0.001), lower pathological stage (P < 0.001) and lower nuclear grade (P = 0.004) at primary surgery than those with early recurrence. On multivariate analysis, vascular invasion (including microscopic and gross invasion) was the predictor of late recurrence (P < 0.01, HR 3.79). Overall survival and disease-specific survival after recurrence were longer in patients with late recurrence (median 64 and 76 months, respectively) than in those with early recurrence (34.5 and 35 months, respectively; P = 0.008 and 0.002).

CONCLUSIONS

These results suggest that micrometastasis at the time of surgery associated with vascular invasion at primary tumor site and their relatively lower malignant potential could lead to late recurrence. Further studies are warranted for better understanding and managing late recurrence of renal cell carcinoma.

External Validation of a Score Predictive of Recurrence after Radical Surgery for Non-Cardia Gastric Cancer: Results of a Follow-Up Study

BACKGROUND

A score predictive of tumor recurrence after radical surgery for non-cardia gastric cancer was previously developed in Italian centers. The aim of this study was to validate the score in a consecutive cohort with prospectively collected follow-up data.

STUDY DESIGN

Of 1,178 patients surgically treated between 1998 and 2006, six hundred and thirty-five patients who fulfilled the selection criteria and completed the follow-up program were available for analysis. The score value for each patient was calculated using the formula obtained from a logistic regression model. Discrimination and calibration of the score in the validation group were evaluated and compared with the data of 438 patients in the study group where the score was developed.

RESULTS

Most patients in both groups had very low or very high score values. In the validation group, the observed recurrence rates ranged from 5% to 92% in different score strata. The area under the receiver operating characteristic curve was 0.889 (95% CI, 0.864-0.914; p < 0.001), indicating a high discrimination value of the score for recurrence. A good calibration was observed by comparing the predicted risk with the actual risk of recurrence. With a score cut-off value of 50, sensitivity, specificity, and overall accuracy were 74%, 86%, and 81%, respectively. An inverse correlation between the time to recurrence and score level was also estimated (R(2) = 0.119; p < 0.001).

CONCLUSIONS

The high predictive value of the score was validated in a consecutive cohort. These results might allow the introduction of the score in clinical practice for Western patients.

Significance of FBX8 in progression of gastric cancer

F-box only protein 8 (FBX8), a novel component of F-box proteins, has recently been observed in several malignancies. However, its clinical implication in the progression of gastric cancer still remains unclear. The aim of this study was to explore the role of FBX8 in gastric cancer (GC) and analyze its correlation with tumor progression and prognosis. The expression of FBX8 in GC cell lines and matched pairs of fresh gastric cancer tissues were detected by real-time RT-PCR and Western blotting. Immunohistochemistry was used to analyze clinicopathological patterns of FBX8 in 136 cases of clinical paraffin-embedded GC tissues. A series of functional assays were conducted to evaluate the effect of FBX8 on proliferation and invasion in vitro and metastasis in vivo. FBX8 was markedly down-regulated in GC tissues compared to adjacent normal tissues. Patients with low FBX8 had shorter overall survival time and poor prognosis. Knocking down FBX8 obviously promoted proliferation and invasion in BGC823 cells, while over-expression of FBX8 in SGC7901 and AGS cells had the opposite effects. Moreover, FBX8 was sufficient to suppress metastasis in nude mice. Down-regulation of FBX8 significantly correlates with invasion, metastasis and poor survival time in GC patients. FBX8 may serve as a promising therapeutic target for inhibition of GC metastasis.