Surgical care quality and oncologic outcome after D2 gastrectomy for gastric cancer

1657 Resected Gastric Adenocarcinomas at a Single Institution: Outcomes and Trends over 17 Years

BACKGROUND

Outside of clinical trials, real-world data of advanced gastric cancers (AGCs) managed with perioperative or adjuvant chemotherapy with a backbone of D2 lymphadenectomy is limited.

PATIENTS AND METHODS

Curative resections for gastric adenocarcinoma between January 2003 and January 2020 at the Tata Memorial Centre were analyzed, comparing three time periods marking major increments in annual gastric resections (GRs).

RESULTS

1657 radical gastric resections were performed with a morbidity and mortality rate of 34.9% and 1.4%, respectively. Over three consecutive periods, the number of annual GRs increased from 56/year to 97/year to 156/year (P < 0.001) with a significant escalation in surgical magnitude and complexity. Improvement in surgical quality indicators (median lymph node yield from 15 to 25, P < 0.001 and margin negativity from 8.2 to 5.5%, P = 0.002) was observed with no corresponding increase in severe complications (6.9%) or mortality (1.4%). The proportion of distal and signet ring cancers was found to decrease over time, with an increase in proximal cancers and younger age at presentation. Overall, 90% of GRs were for AGCs with a median overall survival (OS) of 4.4 years (± 6 months), and 5-year OS rate of 47.6% (± 1.9%).

CONCLUSIONS

Change in pattern of tumor characteristics was observed. Aggressive treatment options for AGC were employed progressively with excellent survival. With increase in volumes, improvements in surgical quality indicators, and a relative improvement in postoperative mortality was observed. These results provide a roadmap for developing dedicated gastric cancer centers.

Impact of a board certification system and adherence to the clinical practice guidelines for gastric cancer on risk-adjusted surgical mortality after distal and total gastrectomy in Japan: a questionnaire survey of departments registered in the National Clinical Database

PURPOSE

The relationship between board certification, clinical guideline implementation, and quality of gastric cancer surgery remains unclear.

METHODS

A web-based questionnaire survey was administered to departments registered in the National Clinical Database (NCD) of Japan between October 2014 and January 2015. Quality indicators (QIs) based on the Donabedian model were evaluated. Structural QIs (e.g., affiliations with academic societies and board certifications) and process QIs (adherence to clinical practice guidelines for gastric cancer) were assessed using risk-adjusted odds ratios (AORs) for surgical mortality. Multivariable logistic regression models with a generalized estimating equation were used.

RESULTS

A total of 835 departments performing 40,992 distal gastrectomies and 806 departments performing 19,618 total gastrectomies responded. Some certified institutions and physicians showed significant associations, with lower AORs for surgical mortality. Important process QIs included pre- and postoperative abdominal CT scanning, endoscopic resection based on progression, curative resection with D2 dissection for advanced gastric cancer, laparoscopic surgery, and HER2 testing for patients with unresectable recurrent gastric cancer.

CONCLUSIONS

Multiple structural and process QIs are associated with surgical mortality after gastrectomy in Japan. Measuring and visualizing QIs may enhance healthcare improvements.

Implementation of Multimodality Therapy and Minimally Invasive Surgery: Short- and Long-term Outcomes of Gastric Cancer Surgery in Medium-Volume Center

BACKGROUND

Multimodal treatment of gastric cancer includes careful preoperative staging, perioperative oncological treatment, and selective minimally invasive approach. The aim was to evaluate whether this approach improves short- and long-term outcomes in operable gastric cancer.

METHODS

This study included 181 gastric cancer patients who underwent curative intent surgery in Central Finland Central Hospital between years 2005 and 2021 for gastric or esophagogastric junction adenocarcinoma. Those 65 patients in group 1 operated between years 2005-2010 had open surgery with possible adjuvant therapy. During the second period including 58 patients (2011-2015), perioperative chemotherapy and minimally invasive surgery were implemented. The period, when these treatments were standard practise, was years 2016-2021 including 58 patients (group 3). Outcomes were lymph node yield, major complications and 1- and 3-year survival rates.

RESULTS

Median lymph node yield increased from 17 in group 1 and 20 in group 2 to 23 in group 3 (p < 0.001). Major complication rates in groups 1-3 were 12.3%, 32.8%, and 15.5% (group 1 vs. group 2, p = 0.007; group 2 vs. group 3, p = 0.018), respectively. Overall 1-year survival rates between study groups 1-3 were 78.5% vs. 69.0% vs. 90.2% (p = 0.018) and 3-year rates 44.6% vs. 44.8% vs. 68.1% (p = 0.016), respectively. For overall 3-year mortality, adjusted hazard ratio (HR) was 1.02 (95%CI 0.63-1.66) in group 2 and HR 0.37 (95%CI 0.20-0.68) in group 3 compared to group 1.

CONCLUSIONS

In medium-volume center, modern multimodal therapy in operable gastric cancer combined with minimally invasive surgery increased lymph node yield and improved long-term survival without increasing postoperative morbidity.

ARE THERE DIFFERENCES IN LAPAROSCOPIC GASTRECTOMY MORBIDITY AND MORTALITY BETWEEN YOUNG AND OLDER?

Background:

Due to the longer life expectancy and consequently an increase in the elderly population, a higher incidence of gastric cancer is expected in this population in the coming decades.

Aim:

To compare the results of laparoscopic GC surgical treatment between individuals aged<65 years (group I) and ≥ 65 years (group II), according to clinical, surgical, and histopathological characteristics.

Methods:

A observational retrospective study was performed by analyzing medical charts of patients with gastric cancer undergoing total or subtotal laparoscopic gastrectomy for curative purposes by a single oncologic surgery team.

Results:

Thirty-six patients were included in each group. Regarding the ASA classification, 31% of the patients in group I was ASA 1, compared to 3.1% in group II. The mean number of concomitant medications in group II was statistically superior to group I (5±4.21 x 1.42±3.08, p<0.001). Subtotal gastrectomy was the most performed procedure in both groups (69.4% and 63.9% in groups I and II, respectively) due to the high prevalence of distal tumors in both groups, 54.4% group I and 52.9% group II. According to Lauren's classification, group I presented a predominance of diffuse tumors (50%) and group II the intestinal type (61.8%). There was no difference between the two groups regarding the number of resected lymph nodes and lymph node metastases and the days of hospitalization and mortality.

Conclusion:

Laparoscopic gastrectomy showed to be a safe procedure, without a statistical difference in morbidity, mortality, and hospitalization time between both groups.

Transmembrane protein GRINA modulates aerobic glycolysis and promotes tumor progression in gastric cancer

BACKGROUND

Recent observations indicate a decreased cancer risk in patients with Alzheimer's disease (AD). AD is a severe neurodegenerative disorder characterized by progressive cognitive decline. The 8q24 region has been shown to be involved in AD aetiology. We aimed to identify and explore the potential oncogenes or antioncogenes on chromosome 8q24.

METHODS

We compared expression of genes on Chromosome 8q24 in 32 pairs of samples from The Cancer Genome Atlas (TCGA) database. We conducted bioinformatics analysis of the commonly used gastric cancer databases and performed clinical verification of gastric cancer samples, combined with assessment of biological function both in vitro and in vivo to determine the relationship between upregulated expression of GRINA and gastric cancer progression. We also explored the molecular mechanism of GRINA upregulation and its function in gastric cancer development and progression.

RESULTS

The expression of GRINA in cancer tissues was significantly higher than that in normal tissues. GRINA indicated poor prognosis in gastric cancer. GRINA promoted the proliferation, migration and invasion capacity of gastric cancer cells. GRINA was transcriptionally mediated by c-Myc and promotes cell cycle transition. GRINA knockdown decreased PI3K/Akt/mTOR signaling and glycolytic metabolism in gastric cancer cells. The apoptosis rate was significantly increased in gastric cancer cell lines after knockdown of GRINA. The expression of pro-apoptotic protein Bax was significantly upregulated, whereas the anti-apoptotic protein Bcl-2 was significantly downregulated in GRINA silenced cells.

CONCLUSIONS

Human gastric cancers have increased levels of GRINA, which promotes growth of gastric cancer and inhibits tumor cells apoptosis.

Prognostic analysis of stage III gastric cancer after curative surgery according to the newest TNM classification

AIM

To study the prognostic factors of gastric cancer (GC) patients who were classified with stage III disease according to the newest TNM classification.

METHODS

This study retrospectively enrolled 279 patients who underwent radical gastrectomy from January 2012 to December 2014 at our hospital and who were diagnosed with stage III GC according to the new 8th edition of the TNM classification. The patient data that were collected included age, sex, pathological parameters, survival, lymph node ratio, neo-adjuvant chemotherapy with oxaliplatin and S-1, and operation type. The characteristics, survival, and prognostic factors of the patients were analyzed by univariate and multivariate analyses.

RESULTS

The median OS of the patients after curative surgery was 19 months, and the 3-year survival rate (3-YSR) was 25.3%. A univariate analysis showed that tumor location (P = 0.01), neo-adjuvant chemotherapy (P = 0.005), pathological T stage (P = 0.002), pathological N stage (P < 0.001), lymph node ratio (LNR) (P < 0.001), and operation type (P = 0.032) were significantly associated with overall survival. A multivariate analysis revealed that neo-adjuvant chemotherapy (P = 0.009), pathological T stage (P = 0.012), and LNR (P < 0.001) were independent prognostic factors.

CONCLUSIONS

Neo-adjuvant chemotherapy, pathological T stage, and LNR were independent prognostic factors for the overall survival of patients with stage III GC. The neo-adjuvant chemotherapy with oxaliplatin and S-1 can be used for the patients to improve their survival.

Benchmark values for transthoracic esophagectomy are not set as the defined "best possible"-a validation study

Background

Recently, benchmark values for low-comorbidity patients at high-volume centers were set to define "best achievable results" for transthoracic minimally invasive esophagectomy (MIE). We aimed to validate suggested benchmark values by comparing them to outcomes at a medium-volume center in Finland.

Methods

All MIEs (n=82) performed at Central Finland Central Hospital between September 2012 and November 2017 including 75 totally MIE and 7 hybrid procedures. The aim of the study was to compare the results to previously suggested benchmark parameters for postoperative morbidity measured with the Clavien-Dindo classification and comprehensive complication index. Target benchmark parameters were ≤55.7% for any complications, ≤30.8% for major complications (Clavien-Dindo ≥3a), ≤40.8% for 30-day and ≤42.8% for 90-day comprehensive complication index, ≤20% for anastomosis leak, ≤31.6% for pulmonary complications, ≤1.0% for 30-day mortality and ≤4.6% for 90-day mortality.

Results

Compared with benchmark patients, our patients were older (median 68 vs. 58 years), with more comorbidities. All parameters measuring complications showed better results in our study than benchmark values. Median intensive care unit stay of 1 (IQR, 1-1) and hospital stay of 9 (IQR, 9-12) days were also shorter. At least 1 complication developed in 45.1%, and 6.1% faced major morbidity. Median (IQR) comprehensive complication index for both 30 and 90 days was 0 (IQR, 0-20.9 days). Anastomosis leak and pulmonary complications were observed in 3.7% and 22.0%, respectively. The 30- and 90-day mortality was 1.2% (1/82).

Conclusions

Benchmark values assessing postoperative morbidity after MIE do not represent the defined "best achievable" results after completed learning curves.

Tryptase mast cell density, protease-activated receptor-2 microvascular density, and classical microvascular density evaluation in gastric cancer patients undergoing surgery: possible translational relevance

BACKGROUND

Mast cells (MCs) can stimulate angiogenesis, releasing several proangiogenic cytokines stored in their cytoplasm. In particular, MCs can release tryptase, a potent in vivo and in vitro proangiogenic factor via protease-activated receptor-2 (PAR-2) activation and mitogen-activated protein kinase (MAPK) phosphorylation. Nevertheless, no data are available concerning the relationship among tryptase MC density (TMCD), endothelial cells (ECs) positive to PAR-2 microvascular density (PAR-2-MVD) and classical MVD (C-MVD) in gastric cancer (GC) angiogenesis.

METHODS

In this study, we analyzed the correlation of TMCD, PAR-2-MVD, C-MVD with each other and with the main clinicopathological features in GC patients who underwent surgery. A series of 77 GC patients with stage T_2-3N_2-3M₀ (classified by the American Joint Committee on Cancer for Gastric Cancer, 7th edition) were selected and then underwent surgery.

RESULTS

Tumour tissue samples were evaluated by mean of immunohistochemistry and image analysis methods in terms of numbers of TMCD, PAR-2-MVD and C-MVD. A significant correlation between the TMCD, PAR-2-MVD and C-MVD groups with each other was found by Pearson t-test analysis (r ranged from 0.64 to 0.76; p value ranged from 0.02 to 0.03). There was no other significant correlation between the above parameters and clinicopathological features.

CONCLUSIONS

Our in vivo preliminary data suggest that TMCD and PAR-2-MVD may play a role in GC angiogenesis and they could be further evaluated as a target of antiangiogenic therapy.

How do surgical stress and low perioperative serum protein and albumin impact upon short term morbidity and mortality in gastric cancer surgery?

Background

Patients undergoing surgery for gastric cancer may be expected to develop a certain range of postoperative complications. This retrospective cohort study determined if gauging the serum value of total proteins and albumins before and especially after surgery can predict an undesired short term outcome in patients with gastric resections for cancer, as we have not found studies debating the link between low postoperative total proteins or albumins and early postoperative morbidity.

Methods

A total of 195 patients with gastric cancer who had been subjected to gastric resection (83 patients) or total gastrectomy (111 patients), were subsequently arranged into study group pairs. In each of these group pairs, one group had a complication, while another was without said complication, or total vs. subtotal gastrectomy, etc. Each of these group pairs were compared between them in order to determine if total serum proteins and/or albumins, before and/or after surgery could predict the onset of certain complications or death. In the end, we performed ROC curves to determine the predictability value of variables for certain complications.

Results

preoperative serum albumin can predict an early onset of anastomotic leakage (p=0.02) as it can predict the occurrence of general complications (p=0.018) and surgical wound infections (p=0.029) as well as a higher risk of reoperation for the management of complications (p=0.028). Total serum protein may be tied to a higher surgical stress, like albumin, as it was significantly lower in patients undergoing total gastrectomy as compared to those subjected to subtotal gastrectomy (p=0.0001 total proteins, p=0.0001 albumins). Postoperative low total serum proteins and albumins translate in a risk of early postoperative death (p=0.031 total proteins, p=0.001 albumins).

Conclusion

We demonstrated the fact that total serum proteins and serum albumins, checked both before and after surgery, are of great value in helping predict a series of postoperative complications in gastric cancer surgery and that they can also be used as surgical stress markers.