Adjuvant radiochemotherapy for gastric cancer: Should we use prognostic factors to select patients?

Chemoradiotherapy or chemotherapy as adjuvant treatment for resected gastric cancer: should we use selection criteria?

Background

The management of gastric adenocarcinoma is essentially based on surgery followed by adjuvant treatment. Adjuvant chemotherapy (CT) as well as chemoradiotherapy (CTRT) have proven their effectiveness in survival outcomes compared to surgery alone. However, there is little data comparing the two adjuvant approaches. This study aimed to compare the prognosis and survival outcomes of patients with gastric adenocarcinoma operated and treated by adjuvant radio-chemotherapy or chemotherapy.

Materials and methods

We retrospectively evaluated 80 patients with locally advanced gastric cancer (LGC) who received adjuvant treatment. We compared survival outcomes and patterns of recurrence of 53 patients treated by CTRT and those of 27 patients treated by CT.

Results

After a median follow-up of 38.48 months, CTRT resulted in a significant improvement of the 5-year PFS (60.9% vs. 36%, p = 0.03) and the 5-year OS (55.9% vs. 33%, p = 0.015) compared to adjuvant CT. The 5-year OS was significantly increased by adjuvant CTRT (p = 0.046) in patients with lymph node metastasis, and particularly those with advanced pN stage (p = 0.0078) and high lymph node ratio (LNR) exceeding 25% (p = 0.012). Also, there was a significant improvement of the PFS of patients classified pN2-N3 (p = 0.022) with a high LNR (p = 0.018). CTRT was also associated with improved OS and PFS in patients with lymphovascular and perineural invasion (LVI and PNI) compared to chemotherapy.

Conclusion

There is a particular survival benefit of adding radiotherapy to chemotherapy in patients with selected criteria such as lymph node involvement, high LNR LVI, and PNI.

Adjuvant Radiochemotherapy versus Chemotherapy Alone for Gastric Cancer: Implications for Target Definition

The INT0116 trial was a milestone study and laid the foundation for the adjuvant radiotherapy (RT) associated to concurrent chemotherapy (CT) for the treatment of gastric cancer (GC) after gastrectomy. However, it is still controversial whether adding RT to CT could further benefit D2-dissected GC patients. The ARTIST trial indicated that the addition of RT to CT did not have a positive impact on disease-free survival (DFS). Nevertheless, in a subgroup of 396 patients with positive pathological lymph nodes, combined treatment with RT was superior to CT alone. A similar randomized Chinese trial confirmed the superiority of adding RT to CT in terms of DFS for patients with D2 lymphadenectomy. However, several previous randomized studies provided inconsistent results with the benefits of combined treatment of RT and CT. The inconsistent results of several studies may be due to the differences between tumor epidemiology, treatment policies, and treatment outcomes. During the past decade, major progress in accurate target delineation utilizing RT technology has been observed. However, even though the use of adjuvant RT doubled after the INT-0116 trial results became public, the fraction of patients receiving adjuvant RT was still low according to the SEER database. The low rate of adjuvant RT can partially be explained by concern over toxicity while undergoing RT. Several studies have also defined the specific location of locoregional recurrence for postoperative RT in GC, but these studies are still limited. A number of retrospective studies demonstrated that the most prevalent nodal recurrence was outside the D2 dissection field. In order to overcome the restricted nature of a retrospective study and provide more individual radiation field determination, additional large-scale prospective multicenter studies are required to evaluate the optimal RT target.

SEPROGADIC - serum protein-based gastric cancer prediction model for prognosis and selection of proper adjuvant therapy

Gastric cancer (GC) patients usually receive surgical treatment. Postoperative therapeutic options such as anticancer adjuvant therapies (AT) based on prognostic prediction models would provide patient-specific treatment to decrease postsurgical morbidity and mortality rates. Relevant prognostic factors in resected GC patient’s serum may improve therapeutic measures in a non-invasive manner. In order to develop a GC prognostic model, we designed a retrospective study. In this study, serum samples were collected from 227 patients at a 4-week recovery period after D2 lymph node dissection, and 103 cancer-related serum proteins were analyzed by multiple reaction monitoring mass spectrometry. Using the quantitative values of the serum proteins, we developed SEPROGADIC (SErum PROtein-based GAstric cancer preDICtor) prognostic model consisting of 6 to 14 serum proteins depending on detailed purposes of the model, prognosis prediction and proper AT selection. SEPROGADIC could clearly classify patients with good or bad prognosis at each TNM stage (1b, 2, 3 and 4) and identify a patient subgroup who would benefit from CCRT (combined chemoradiation therapy) rather than CTX (chemotherapy), or vice versa. Our study demonstrated that serum proteins could serve as prognostic factors along with clinical stage information in patients with resected gastric cancer, thus allowing patient-tailored postsurgical treatment.

Between evidence and new perspectives on the current state of the multimodal approach to gastric cancer: Is there still a role for radiation therapy?

In patients affected by gastric cancer (GC), especially those in advanced stage, the multidisciplinary approach of treatment is fundamental to obtain a good disease control and quality of life. Although many chemotherapeutics in combination to radiotherapy are adopted in the peri- or postoperative setting, the most optimal timing, regimens and doses remains controversial. In the era of radical surgery performed with D2-lymphadenectomy, the role of radiation therapy remains to be better defined. Categories of patients, who could benefit more from an intensified local treatment rather than more toxic systemic therapy, are still under investigation. Evidence and recent updates of the randomized trials, meta-analysis and prospective trials show that the postoperative radiotherapy plays a fundamental role in reducing the loco-regional recurrence and in turn the disease-free survival in operable advanced GC patients, also after a well performed D2 surgery. Therapeutic decisions should be taken considering the individual patients, but the multimodal approach is necessary to guarantee a longer survival and a good quality of life. Ongoing randomized trials could better define the timing and the combination of radiotherapy and systemic therapy.

Parameters for Predicting Surgical Outcomes for Gastric Cancer Patients: Simple Is Better Than Complex

BACKGROUND

Various parameters are used to predict perioperative surgical outcomes. However, no comprehensive studies in gastrectomy have been conducted. This study aimed to compare the performance of each parameter in patients with gastric cancer.

METHODS

The medical records of 1032 gastric cancer patients who underwent curative gastrectomy between 2009 and 2015 were reviewed. Laboratory values and associated parameters (neutrophil count, lymphocyte count, platelet count, albumin level, Prognostic Nutritional Index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and Systemic Immune-Inflammation Index) as well as body weight-related data and associated parameters [body mass index (BMI), percentage of weight loss, Nutritional Risk Screening 2002 assessment, the Malnutrition Universal Screening Tool, and the Nutritional Risk Index] were measured and calculated. The study end points were major complications, operative mortality, prolonged hospital stay, overall survival (OS), and recurrence-free survival (RFS).

RESULTS

Multivariable logistic regression analysis showed that male gender, total gastrectomy, advanced-stage gastric cancer, and low albumin level were risk factors for major complications. Old age, total gastrectomy, advanced-stage cancer, and high BMI were risk factors for operative mortality. Old age, open approach, and total gastrectomy were risk factors for prolonged hospital stay. Multivariable Cox proportional hazards models showed that old age, total gastrectomy, advanced-stage cancer, and high neutrophil count were unfavorable risk factors for OS. Old age, advanced-stage cancer, high neutrophil count, and high BMI were unfavorable risk factors for RFS.

CONCLUSIONS

Albumin level, BMI, and neutrophil count are the most useful parameters for predicting short- and long-term surgical outcomes. Compared with complex parameters, simple-to-measure parameters are better for predicting surgical outcomes for gastric cancer patients.

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

BACKGROUND

The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer.

METHODS

Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated.

RESULTS

Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10, >0.10-0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (>0.25: hazard ratio 2.3; all P < .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P < .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio >0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P < .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P > .05).

CONCLUSION

Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio >0.25).

Five-year Survival Rate for Gastric Cancer in Yazd Province, Central Iran, from 2001 to 2008

BACKGROUND

The number of patients with gastric cancer is growing worldwide. In Iran (in 2009) of 74067 new cases of cancer, 6886 were diagnosed as having gastric cancer. This study was conducted to investigate 5-year survival rate for gastric cancer in Yazd province, central Iran.

METHODS

In this descriptive study, the medical records of patients with gastric cancer were collected from the archives of Yazd hospitals from 2001 to 2008. The data gathered included age, sex, type of histopathology, site of involvement, cancer staging, and mode of treatment, which were analyzed using SPSS software version 11.5. To investigate the survival and the factors influencing the survival time of patients, which are the main objectives of this study, Kaplan-Meier method was used and Cox proportional hazards model was fitted to the data. To compare survival function in different subgroups, the log rank test or generalized Wilcoxon test was used.

RESULTS

295 cases of gastric cancer were enrolled in the study. The mean age of the subjects was 59.3 ± 9 years. 5-year survival rate of the patients was calculated as 18% where the highest rate was 39% for the age group of 50-60 years and the lowest was 3% for the age group of above 80 years. 5-year survival rates in different groups were as follows: 32% in women, 13% in men; 16% in adenocarcinoma, 46% in other pathologies; 16% in gastric cardia involvement, 17% in antrum; 59% in stage 1, 31% in stage 2, 13% in stage 3, and 3% in stage 4.

CONCLUSION

The results of this study showed that age, stage of the cancer, mode of therapy, and type of histopathology affected the survival rate of gastric cancer. No significant association was found between the site of involvement and survival rate. In general, the survival rate for gastric cancer was low, which might be due to slow but steady progress of the disease and delayed referral of the patients.