Adjuvant therapy for gastric cancer: What have we learned since INT0116?

Accurate diagnosis and prognosis prediction of gastric cancer using deep learning on digital pathological images: A retrospective multicentre study

Background

To reduce the high incidence and mortality of gastric cancer (GC), we aimed to develop deep learning-based models to assist in predicting the diagnosis and overall survival (OS) of GC patients using pathological images.

Methods

2333 hematoxylin and eosin-stained pathological pictures of 1037 GC patients were collected from two cohorts to develop our algorithms, Renmin Hospital of Wuhan University (RHWU) and the Cancer Genome Atlas (TCGA). Additionally, we gained 175 digital pictures of 91 GC patients from National Human Genetic Resources Sharing Service Platform (NHGRP), served as the independent external validation set. Two models were developed using artificial intelligence (AI), one named GastroMIL for diagnosing GC, and the other named MIL-GC for predicting outcome of GC.

Findings

The discriminatory power of GastroMIL achieved accuracy 0.920 in the external validation set, superior to that of the junior pathologist and comparable to that of expert pathologists. In the prognostic model, C-indices for survival prediction of internal and external validation sets were 0.671 and 0.657, respectively. Moreover, the risk score output by MIL-GC in the external validation set was proved to be a strong predictor of OS both in the univariate (HR = 2.414, P < 0.0001) and multivariable (HR = 1.803, P = 0.043) analyses. The predicting process is available at an online website (https://baigao.github.io/Pathologic-Prognostic-Analysis/).

Interpretation

Our study developed AI models and contributed to predicting precise diagnosis and prognosis of GC patients, which will offer assistance to choose appropriate treatment to improve the survival status of GC patients.

Funding

Not applicable.

Histology-agnostic drug development - considering issues beyond the tissue

With advances in tumour biology and immunology that continue to refine our understanding of cancer, therapies are now being developed to treat cancers on the basis of specific molecular alterations and markers of immune phenotypes that transcend specific tumour histologies. With the landmark approvals of pembrolizumab for the treatment of patients whose tumours have high microsatellite instability and larotrectinib and entrectinib for those harbouring NTRK fusions, a regulatory pathway has been created to facilitate the approval of histology-agnostic indications. Negative results presented in the past few years, however, highlight the intrinsic complexities faced by drug developers pursuing histology-agnostic therapeutic agents. When patient selection and statistical analysis involve multiple potentially heterogeneous histologies, guidance is needed to navigate the challenges posed by trial design. Additionally, as new therapeutic agents are tested and post-approval data become available, the regulatory framework for acting on these data requires further optimization. In this Review, we summarize the development and testing of approved histology-agnostic therapeutic agents and present data on other agents currently under development. Finally, we discuss the challenges intrinsic to histology-agnostic drug development in oncology, including biological, regulatory, design and statistical considerations.

ADJUVANT CHEMORADIOTHERAPY AFTER SUBTOTAL OR TOTAL GASTRECTOMY AND D2 LIMPHADENECTOMY INCREASES SURVIVAL IN ADVANCED GASTRIC CANCER?

BACKGROUND

The treatment of advanced gastric cancer with curative intent is essentially surgical and chemoradiotherapy is indicated as neo or adjuvant to control the disease and prolong survival.

AIM

To assess the survival of patients undergoing subtotal or total gastrectomy with D2 lymphadenectomy followed by adjuvant chemoradiotherapy.

METHODS

Were retrospectively analyzed 87 gastrectomized patients with advanced gastric adenocarcinoma, considered stages IB to IIIC and submitted to adjuvant chemoradiotherapy (protocol INT 0116). Tumors of the esophagogastric junction, with peritoneal implants, distant metastases, and those that had a compromised surgical margin or early death after surgery were excluded. They were separated according to the extention of the gastrectomy and analyzed for tumor site and histopathology, lymph node invasion, staging, morbidity and survival.

RESULTS

The total number of patients who successfully completed the adjuvant treatment was 45 (51.7%). Those who started treatment and discontinued due to toxicity, tumor-related worsening, or loss of follow-up were 10 (11.5%) and reported as incomplete adjuvant. The number of patients who refused or did not start adjuvant treatment was 33 (48.3%). Subtotal gastrectomy was indicated in 60 (68.9%) and total in 27 (31.1%) and this had a shorter survival. The mean resected lymph nodes was 30.8. Staging and number of lymph nodes affected were predictors of worse survival and the more advanced the tumor. Patients undergoing adjuvant therapy with complete chemoradiotherapy showed a longer survival when compared to those who did it incompletely or underwent exclusive surgery. On the other hand, comparing the T4b (IIIB + IIIC) staging patients who had complete adjuvance with those who underwent the exclusive operation or who did not complete the adjuvant, there was a significant difference in survival.

CONCLUSION

Adjuvant chemoradiotherapy presents survival gain for T4b patients undergoing surgical treatment with curative intent.

Systemic prognostic score and nomogram based on inflammatory, nutritional and tumor markers predict cancer-specific survival in stage II-III gastric cancer patients with adjuvant chemotherapy

BACKGROUND

To investigate the clinical utility of several established inflammatory, nutritional and tumor markers, and to construct a new scoring system based on preoperative prognostic markers to predict outcomes in gastric cancer (GC).

METHODS

We retrospectively assessed 688 consecutive patients who underwent curative resection followed by adjuvant chemotherapy for stage II-III GC from 2000 to 2012.

RESULTS

On multivariate analysis, C-reactive protein/albumin (CRP/Alb) ratio (>0.2), prognostic nutritional index (PNI) (score 1), preoperative body weight loss (>6%) and carbohydrate antigen 19-9 (CA 19-9) (>27 U/mL) independently predicted unfavorable cancer-specific survival (CSS). These 4 preoperative prognostic markers were allocated 1 point each. Then, a new systemic prognostic score (SPS) was constructed based on the total score. Multivariate analysis revealed that SPS was an independent predictor of CSS (P < 0.001). Patients with a SPS of 0, 1, 2, or 3/4 had a 5-year CSS rates of 67.2%, 45.3%, 29.0%, and 10.6%, respectively (0 vs. 1 [P < 0.001], 1 vs. 2 [P = 0.031] and 2 vs. 3/4 [P = 0.004]). The median survival times for SPS 0, SPS 1, SPS 2 and SPS 3/4 were 68.7, 47.1, 28.3 and 16.3 months, respectively. The area under the receiver operating characteristics (ROC) curve for SPS was higher than other markers (P < 0.001). Furthermore, a nomogram that integrated TNM stage, tumor location and SPS exhibited superior discrimination power compared with the TNM stage alone (C-index, 0.714 vs. 0.630, respectively; P < 0.001).

CONCLUSION

The preoperative SPS combining inflammatory, nutritional and tumor markers independently predicted postoperative survival in stage II-III GC patients treated with adjuvant chemotherapy.

Pathological tumor infiltrative pattern and sites of initial recurrence in stage II/III gastric cancer: Propensity score matching analysis of a multi-institutional dataset

Background

Advanced gastric cancer frequently recurs even after radical resection followed by adjuvant chemotherapy. The aim of this study was to evaluate the relationship between pathological infiltrative pattern (INF) and initial recurrence patterns in patients with stage II/III gastric cancer using a large multicenter database.

Methods

We retrospectively analyzed 1098 eligible patients who underwent curative gastrectomy for stage II/III gastric cancer at nine institutions between 2010 and 2014. Patients were categorized into the INF‐a/b and INF‐c groups and adjusted using propensity score matching.

Results

After propensity score matching, 686 patients (343 for each) were classified in the INF‐a/b and INF‐c groups. There were no significant differences in overall and disease‐free survival between the two groups. In the INF‐a/b group, frequencies of recurrence at the peritoneum, lymph node, and liver were equivalent. In contrast, the peritoneum was the most frequent site and accounted for 60% of the total recurrences in the INF‐c group. The cumulative peritoneal recurrence rate was significantly higher in the INF‐c group than in the INF‐a/b group (hazard ratio 2.47). INF‐c was a significant risk factor for peritoneal recurrences in most subgroups including age, sex, macroscopic type, tumor differentiation, and disease stage, and whether the postoperative treatment was given. Multivariate analysis identified INF‐c as an independent risk factor for peritoneal recurrences. The cumulative liver recurrence rate was significantly higher in the INF‐a/b group than in the INF‐c group (hazard ratio 3.44).

Conclusions

INF may represent an important predictor of recurrence patterns after curative resection of stage II/III gastric cancer.

Clinical significance and biological roles of cyclins in gastric cancer

Background and aim

Cyclins have been reported to be overexpressed with poor prognosis in several human cancers. However, limited numbers of studies evaluated the expressions and prognostic roles of cyclins in gastric cancer (GC). We aim to evaluate the expressions and prognostic roles of cyclins. Also, further efforts were made to explore biological function of the differentially expressed cyclins.

Methods

Cyclins expressions were analyzed by Oncomine and The Cancer Genome Atlas datasets, and the prognostic roles of cyclins in GC patients were investigated by the Kaplan–Meier Plotter database. Then, a comprehensive PubMed literature search was performed to identify expression and prognosis of cyclins in GC. Biological functions of the differentially expressed cyclins were explored through Enrich R platform, and KEGG and transcription factor were analyzed.

Results

The expression levels of CCNA2 (cyclin A2), CCNB1 (cyclin B1), CCNB2 (cyclin B2), and CCNE1 (cyclin E1) mRNAs were identified to be significantly higher in GC tissues than in normal tissues in both Oncomine and The Cancer Genome Atlas datasets. High expressions of CCNA2, CCNB1, and CCNB2 mRNAs were identified to be related with poor overall survival in Kaplan–Meier Plotter dataset. Evidence from clinical studies showed that CCNB1 was related with overall survival in GC patients. Cyclins were associated with several biological pathways, including cell cycle, p53 signaling pathway, FoxO signaling pathway, viral carcinogenesis, and AMPK signaling pathway. Enrichment analysis also showed that cyclins interacted with some certain transcription factors, such as FOXM1, SIN3A, NFYA, and E2F4.

Conclusion

Based on our results, high expressions of cyclins were related with poor prognosis in GC patients. The above information might be useful for better understanding the clinical and biological roles of cyclins mRNA and guiding individualized treatments for GC patients.

Histopathologic Features are more Important Prognostic Factors than Primary Tumour Location in Gastro-oesophageal Adenocarcinoma Treated with Preoperative Chemoradiation and Surgery

The aim of present study was to evaluate the impact of primary tumour location and other factors on the outcome of preoperative chemoradiation followed by surgery in adenocarcinomas of distal oesophagus, gastro-oesophageal junction and stomach. We retrospectively reviewed the institutional patient database. The therapeutic response was re-evaluated as a percentage of residual tumor cells in surgical resection specimens. Overall survival (OS) and disease-free survival (DFS) were assessed. The effect primary tumour location, clinical and pathological TNM stage, and histopathological factors (histological type, grade, angioinvasion, perineural invasion, tumour response) on treatment outcome were evaluated. A total of 108 patients underwent preoperative chemoradiation for adenocarcinoma of distal oesophagus, gastro-oesophageal junction or stomach. The median prescribed dose of radiation was 45 Gy. The concurrent chemotherapy consisted of 5-fluorouracil +/- cisplatin +/- taxanes. R0 resection was achieved in 80 patients (74%). The complete response was observed in 19%. The median follow-up was 50.8 months. Three-year and 5-year OS and DFS were 36.2% and 25.3%; and 28.1% and 23.7%, respectively. Pretreatment T-stage, pathological N-stage, radicality of resection, histological subtype, grade, angioinvasion and perineural invasion, were identified as statistical significant OS predictors in univariate analysis; pathological N-stage, radicality of resection and angioinvasion, in multivariate analysis. The primary tumor location did not influence the prognosis. The pathologic response to chemoradiation had borderline significance. In conclusion, no prognostic impact of primary tumour location, in contrast to other investigated factors, was evident in the present study. The most important predictors of prognosis were angioinvasion status and pN-stage.

Updated evidence on adjuvant treatments for gastric cancer

Gastric cancer is one of the main causes of cancer-related deaths worldwide. Even when diagnosed as a localized disease and resected with the intent to cure, recurrences frequently arise due to undetected or invisible micrometastases. Importantly, several proposed multimodal strategies to eliminate micrometastases have met some clinical success. However, while pivotal Phase III clinical trials comparing adjuvant therapies with surgery alone have confirmed the overall benefit of adjunctive treatments in patients with locally advanced gastric cancer, further improvement in postoperative outcomes is required, particularly in stage III disease. This review presents the current status of multimodal treatment strategies, with a particular focus on unresolved issues, based on updated literature searches and analysis of clinical trial databases.

Effect of vitamin E succinate on the expression of the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) receptor in gastric cancer cells and CD4(+) T cells

Gastric malignancy, which shows poor prognosis, is one of the most frequent causes of cancer-associated deaths. Vitamin E succinate (VES) inhibits cell proliferation and induces apoptosis in a concentration- and time-dependent manner. We explored the effect of VES on the expression of the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) receptor in gastric cancer cells and CD4(+) T cells. On one hand, VES dose-dependently regulated the expression of the TRAIL receptor in gastric cancer cells. Moreover, the activation of the TRAIL receptor, death receptor 4 (DR4), and death receptor 5 (DR5) in gastric cancer cells increased for up to 12 h. On the other hand, the expression of TRAIL protein in human CD4(+) T cells was obviously upregulated in the presence of VES. On the basis of these findings, we combined VES and human CD4(+) T cells to induce apoptosis of MKN28 human gastric cancer cells. The results showed that VES induced higher gastric cancer cell apoptosis when combined with human CD4(+) T cells than when applied alone. We conclude that VES can induce the expression of TRAIL receptor in gastric cancer cells, as well as the expression of TRAIL in CD4(+) T cells. Overall, our results provide a theoretical basis for future immunotherapy studies.