Gastric cancer in India

HCMV detection in Asian gastric cancer RNA-seq data sets and clinical validation in Indian GC patients reveals the HCMV-GC specific gene signatures

Gastric cancer (GC) prevalence is very high in the Asian population. Oncogenic viruses play a crucial role in the progression of different types of cancers. Through reanalysis of clinical RNA-seq data sets derived from Asian GC patients, this study identified the presence of human cytomegalovirus (HCMV) in Asian GC tumors, next to the well-studied association of EBV. Clinical recruitment of the Indian GC cohort and screening for HCMV presence identified a 14.28% occurrence, similar to that observed in the bioinformatics analysis. A combinatorial approach of rank-based meta-analysis and ranking of groups based on an expectation-maximization algorithm identified that the upregulated LINC02864 and MAGEA10 correlated with poor survival of GC patients and downregulated tumor suppressor genes enriching for gastric acid secretion pathway to be associated with HCMV-positive GC patients, revealing the progressive role of HCMV infection in GC. Genes that discriminate between different stages of GC were identified through feature selection implemented in a machine-learning approach. LTF and KLK10 expressions were found to be specifically dysregulated by HCMV and can also indicate the GC stages. The results of this study will guide future studies to identify the functional role of these genes in the HCMV-associated GC.IMPORTANCENearly 75% of gastric cancer (GC) cases reported globally are from the Asian population. Most existing public databases, such as TCGA, comprise only a fractional portion of data derived from Asian ancestry. This study identified EBV and human cytomegalovirus (HCMV)'s higher detection in GC patients. The presence and role of EBV associated with GC are well-known, and the observation of HCMV prompted us to validate the findings in a small cohort of 40 Indian GC patients. We observed a 14.28% occurrence of HCMV in the Indian cohort, similar to that observed from next-generation sequencing. A combinatorial approach of rank-based meta-analysis and ranking of groups based on an expectation-maximization algorithm identified that the upregulated LINC02864 and MAGEA10 correlated with poor survival of GC patients and downregulated tumor suppressor genes enriching for gastric acid secretion pathway to be associated with HCMV-positive GC patients, revealing the progressive role of HCMV infection in GC.

Descriptive Epidemiology of Gastric Cancer: A Population-Based Study From Georgia

Background Gastric cancer (GC) remains a significant public health issue in many countries globally due to its high morbidity and mortality rates. In Georgia, the incidence of GC reflects the prevalence patterns of established risk factors. To develop appropriate prevention and treatment strategies, GC requires a comprehensive approach and research. This study aims to review and describe GC epidemiologic characteristics in the country. Methodology We conducted a descriptive analysis utilizing data from the national population-based cancer registry. All patients diagnosed with invasive GC between 2015 and 2022 were eligible for inclusion in the analysis. To calculate age-standardized incidence (ASIR) and mortality (ASMR) rates we used a direct method, standardized to the World (WHO 2000-2025) standard population. Trends in Incidence and mortality were assessed using standardized rate ratios (SRRs). The mortality-to-incidence ratio (MIR) was defined as the ratio of the ASMR to the ASIR for the corresponding year. The Kaplan-Meier method was utilized to construct survival curves with survival comparisons performed using the log-rank test. Results A total of 2,707 GC cases with 62% (n = 1,668) of patients being male were enrolled in this descriptive study. The median age at diagnosis was 65 years, and about 70% (n = 1,893) of cases were detected at advanced (III and IV) stages. Over the study period, the ASIR per 100,000 population for both sexes decreased from 8.4 to 7.3. The SRR and 95% confidence interval indicated no significant change in ASIR for males but it decreased for females in 2022 compared to 2015. In 2022, the ASMR decreased compared to 2015 for males (from 10.5 to 7.3/100,00) and for females (from 5.8 to 3.0/100,000) as well. However, the MIR ​​indicated an unstable reduction in mortality, fluctuating over the observation period. The five-year survival rate was around 22.0%. Conclusions This study provides a comprehensive overview of GC epidemiology in Georgia between 2015 and 2022. GC remains a significant public health challenge, characterized by the high proportion of late-stage diagnoses and high mortality rates. The implementation of prevention and early diagnosis strategies is crucial to reduce the burden of GC in the country.

Clinicopathological Significance and Prognostic Role of Her2neu Protein Expression in Patients with Carcinoma Stomach: A Prospective Study from Northern India

Manas Kumar BeheraBackground and Aims  Gastric cancer is the third most common cause of cancer-related mortality worldwide after lungs and colorectum. Although controversial, Her2neu overexpression by immunohistochemistry is usually associated with poor prognosis in patients with carcinoma stomach. We conducted a prospective study to evaluate the prognostic role of Her2neu and its correlation with clinical, pathologic type, and stage of the disease. Methods  A prospective study was performed on paraffin blocks of 111 gastric cancer specimens (88 patients were biopsy specimens and 23 were gastrectomy specimens). The paraffin blocks were processed for Her2neu receptor immunohistochemical staining and fluorescence in situ hybridization, and scoring was done. Results  Her2neu overexpression was detected in 30 out of 111 (27%) patients. The mean age was 57.68 ± 12.82 years, with males constituting two-thirds of total patients. Tobacco addiction was found in 44% of the patients and smoking in 33% of the patients. Her2neu expression was similar in Lauren's intestinal and diffuse histologic type; however, proximal gastric tumors overexpressed Her2neu as compared with distal tumors. Her2neu 2+ or 3 + (odds ratio: 2.52, 95% CI: 1.61-3.95, p  = 0.001) was the only independent predictor of survival in gastric cancer patients. Kaplan-Meir survival analysis showed that the survival of gastric cancer patients with Her2neu overexpression (Her2neu 2+ or 3 + ) was significantly lower than that of those with Her2neu nonexpression ( p  = 0.001). Conclusion  Her2neu positivity was a significant predictor of mortality in patients with carcinoma stomach, and Her2neu overexpression was associated with a lower overall survival rate compared with Her2neu nonexpression.

VD. Surgical and Survival Outcomes of Operable Gastric Cancer-Experience from a Tertiary Care Center in South India

Gastric cancer is one of the leading cancers in Southern India. Data regarding the gastric cancers among the Indian population is sparse. Most patients in our country have locally advanced gastric cancers due to delayed presentation. In this article, we present our data regarding the presentation patterns, epidemiological demographics, surgical outcomes, and survival patterns from a tertiary care center in South India. This is a retrospective analysis of gastric cancer patients who underwent gastrectomy in our institution between January 2015 and November 2021 (n = 102). The data regarding patient characteristics, histopathology, and perioperative outcomes were analysed from medical records. The adjuvant treatment received and survival details were collected from the follow-up records and by telephonic interviews. A total of 128 patients were assessable, 102 patients underwent gastrectomy in a period of 6 years. The median age of presentation was 60 years and males were more commonly affected (70.6%). Most common presentation was pain abdomen followed by gastric outlet obstruction. Adenocarcinoma NOS (93%) was the most common histological type. Most of the Patients had antropyloric growths (79.4%) and subtotal gastrectomy with D2 lymphadenectomy was the most common surgery performed. Majority of the tumors were T4 tumors (55.9%) and nodal metastases were detected in 74% of the specimens. Predominant morbidity was wound infection (6.1%) followed by anastomotic leak (5.9%) with a combined overall morbidity of 16.7% and 30-day mortality of 2.9%. Seventy five (80.5%) patients were able to complete all planned 6 cycles of adjuvant chemotherapy. The median time of survival calculated by Kaplan-Meier method was 23 months with 2-year and 3-year overall survival rates of 31% and 22%, respectively. Lymphovascular invasion (LVSI) and lymph nodal burden were the risk factors associated with recurrences and deaths. The patient characteristics, histological factors, and perioperative outcomes revealed most of our patients presented in locally advanced stages with poor risk histological types and increased nodal burden contributing to the lower survival in our population. Inferior survival outcomes suggest the need to explore perioperative and neoadjuvant chemotherapy options in our population.

S, Prasad H. L. K. Utility of serum interleukin-18 (IL-18) as a tumour marker in gastric cancer

Introduction: Gastric cancer (GC) is the fourth most prevailing cancer globally, attributing to more than 70% of cases in developing countries. Protein cancer biomarkers, such as CEA, CA- 125, AFP and PSA, are clinically helpful diagnostic tools, but they have low sensitivity and specificity for GC. Hence, it is essential to discover better markers for GC diagnosis. Interleukin-18 (IL-18) is the member of Interleukin-1 family. It is hypothesized to be a potent inhibitor of gastric acid secretion, leading to gastric atrophy and causing an increased risk of GC. This study was to evaluate the association between the serum IL-18 in GC.   Methodology: We included cases who underwent UGI Scopy and were proven to have GC histopathologically. The patients who presented to the out-patient who underwent UGI scopy and was found to have no growth were selected as controls. Twenty-eight cases and 84 control sample sizes were derived from nMaster V2. Blood samples from patients and controls were collected, and serum IL-18 levels were estimated using a solid-phase sandwich ELISA method.   Results: We found that the cut-off value of serum IL-18 was 85.59 pg/ml, had a sensitivity of 63.1% and specificity of 57.1%, with a positive predictive value of 81.5% and a negative predictive value of 34% in diagnosing GC. The study plotted the receiver operating characteristic curve against IL-18 for sensitivity and specificity. Statistically, we found through the Area Under the Curve (AUC) that the rise in serum IL-18 levels was a poor indicator of GC with a p-value of 0.078.   Conclusion: Statistically, a cut-off of 85.59pg/ml showed good sensitivity and specificity; however, the probability was insignificant, suggesting that IL-18 may not be of diagnostic importance. Studies with a larger sample size are required to further probe into the usefulness of estimating IL-18 in GC.

Histomorphological analysis of gastric polyps

Introduction

Incidence of gastric carcinoma and gastric polyps is on rise all over the world. Chronic atrophic gastritis to intestinal metaplasia progressing to adenocarcinoma has been documented pathway for gastric carcinogenesis. Another pathway for gastric carcinoma is adenoma carcinoma sequence similar to colon cancer.

Aim

To study prevalence, endoscopic, and histomorphological features of gastric polyps.

Methods and Material

This was retrospective analysis of gastric polyps from 2012 to 2019 in consecutive 10,800 upper gastrointestinal endoscopies. Demographic, endoscopic, and histopathological data were obtained from hospital records. All gastric polyps were classified as per standard histologic criteria. Additional histological features noted were presence of dysplasia, focus of adenoma, or malignancy.

Results

The prevalence of gastric polyps was 434 (4%) of 10,800 upper gastrointestinal endoscopies. Majority of polyps were found in the last 4 years (277: 63.8%). Mean age was 55.4 years with male to female ratio 1:1.2. Most of the polyps (94.9%) were less than 1 cm, located in gastric antrum. Multiple polyps were seen in 20.9% cases. On histopathology, fundic gland polyps were most common (147: 33.8%), followed by hyperplastic (128: 29.4%) polyps. Adenomatous polyps were nine (2%); of these, two cases of hyperplastic polyps and one each of fundic gland polyp and benign epithelial polyp showed adenomatous foci.

Conclusion

Fundic gland polyps were the most common polyps. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression to carcinogenesis.

Metastatic Gastric cancer: Real world scenario from a developing country

Aim:

Data on epidemiology and outcome in metastatic stomach carcinoma patients from India are scarce. We aimed to evaluate clinical features and treatment outcome in patients treated at our center.

Materials and Methods:

This is a single institutional review of metastatic gastric carcinoma patients treated between May 2011 and October 2016. Patients who received at least one cycle of chemotherapy were included for modified intent-to-treat survival analysis.

Results:

total of 143 patients were diagnosed with metastatic stomach carcinoma with a median age of 56 years (range: 29–86). The most common symptoms were abdominal pain in 112 (78%) patients. The most common site was body in 81 (57%) patients. Common site of metastasis was peritoneum in 86 (60%) and liver in (62%). Seventy-one (50%) patients were eligible for survival analysis. Common chemotherapy regimens were capecitabine-cisplatin in 27 (38%) and EOX in 22 (31%) patients. Survival status could not be assessed in 29 (41%) patients who lost to follow-up. After a median follow-up 9.7 months (range: 0.5–37.7), median progression-free survival (PFS) was 7.9 months (range: 0.5–23.9) and median overall survival (OS) was 12.2 months (range: 0.5–37.7). The Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2 and the presence of linitis plastica showed a trend toward inferior PFS (P = 0.052 and 0.053, respectively) only in univariate analysis. Female sex and ECOG PS ≥2 predicted inferior OS in both univariate and multivariate analysis (P = 0.012, 0.02 and 0.03 and 0.05, respectively).

Conclusions:

Platinum-based doublet chemotherapy was used in the majority of patients. The overall outcome was comparable to that of the available literature. Female sex and ECOG PS ≥2 predicted the inferior outcome.

Retrospective study of oxaliplatin, leucovarin and 5 fluoruracil regimen in patients with advanced gastric cancer with poor performance status: A study at a tertiary center of South India

Background

Gastric carcinoma is the leading cause of cancer in south India. Gastric cancer is frequently diagnosed in locally advanced or metastatic setting in Indian scenario and has a poor survival. There is no standard chemotherapy regimen which can be used in advanced gastric cancer (AGC) patients.

Objective

The aim of this study was to assess the clinical activity and toxicity of oxaliplatin with infusional 5-fluorouracil and leucovorin administered every 3 weeks in patients with locally advanced and inoperable gastric cancer.

Patients and Methods

In this retrospective study, the case records of 25 patients who have received OLF regimen were analyzed.

Results

The median number of cycles for patients was 6 (range: 4-12 cycles). Overall response rate was 36%, with all patients having stable disease. Median survival of patients was 6 months (7 months in locally advanced). Compared to other regimens, there was less toxicity (less hematologic toxicity, less nausea and vomiting, no hair loss, no renal toxicity, no hand foot syndrome, and lesser admissions).

Conclusions

OLF regimen is an acceptable regimen in poor performance status AGC patients with adequate response and an acceptable toxicity profile.

Does Neoadjuvant Chemotherapy Increase the Survival in Patients with Locally Advanced Gastric Cancer Patients? – A Real‑World Evidence

Background: In locally advanced gastric cancer (LAGC), perioperative chemotherapy has shown to improve the survival to a larger extent compared to surgery alone. In India, the treatment followed for gastric carcinoma widely varies based on the type of health-care provider and treatment access. There is a paucity of data on the role of neoadjuvant chemotherapy on survival among LAGC patients in the Indian context. Aim: The aim of this study was to compare the disease-free survival (DFS) and overall survival (OS) between neoadjuvant and adjuvant chemotherapies among LAGC patients. Subjects and Methods: This was a retrospective cohort study involving clinical record review of LAGC patients enrolled between 2015 and 2017 from four tertiary cancer centers in South India. The date for the following events, namely diagnosis, recurrence, death, and last day of visit, was extracted in a mobile-based open-access tool. The median duration of OS and DFS between the neoadjuvant and adjuvant groups was compared using Kaplan–Meier survival curves. Results: Of the 137 patients, 70 (51%) had received neoadjuvant chemotherapy followed by surgery and 67 (49%) had adjuvant chemotherapy following the surgery. The mean (standard deviation) age of participants was 55.4 (11.4) years. Seventy-eight percent of the patients were diagnosed at Stage 3 or 4. Regional lymph nodes were involved in 83.9%. The median duration of follow-up was 15 months. The OS in the neoadjuvant and adjuvant groups was 18.6 months and 8.3 months, respectively. Nonregional lymph node involvement and adjacent organ involvement had independently increased the risk of death. Conclusion: Among LAGC patients, the neoadjuvant chemotherapy indicated a better median and DFS compared to the adjuvant group. However, these findings were statistically not significant. The current study has contributed an important finding to the existing evidences of clinical practice in an Indian setting. Further large-scale studies are required to validate the promising trend of using neoadjuvant chemotherapy in LAGC.

Patterns of Cancer Incidence and Mortality in North- Eastern India: The First Report from the Population Based Cancer Registry of Tripura

BACKGROUND

There is, till date no population-based data regarding cancer patterns in North- Eastern India, dictating the need to understand the epidemiology of cancer in this population for its effective management.

METHODS

This is the first report of the Population Based Cancer Registry (PBCR) in Tripura (2010-2014). The protocol involves active collection of data on all cancer cases from Tripura through staff visit in more than 150 sources of incident and mortality registration, government and private hospitals, municipal corporation, etc. and scrutiny, corroboration with existing records. Data was analyzed statistically to understand cancer trends in terms of incidence and mortality across different sites, age groups affected and gender.

RESULTS

A total of 10,251 cases were registered during the period, with overall age-adjusted incidence rates of 75.7 and 54.9 per 100,000 males and females respectively. Crude Incidence Rate (CR) and Age- Adjusted Rate (AAR) was among the lowest reported in India, probably due to associated socio-economic factors. The most prevalent cancers were lung (18.1%), esophageal (8.3%) for men and cervix uteri (17.6%), breast (13.8%) for females. Gall bladder cancer in females was one of the highest in the country. Rate of cancer mortality in the population was quite high and significantly increased with time, probably accounting for dearth in early detection and feasible treatment alternatives.

CONCLUSION

The data suggests that high cancer incidence and mortality are prevalent in the population of Tripura, dictating the need of active tobacco control measures, early detection and awareness drives for effective cancer control.

Radical Gastrectomy: Still the Gold Standard Treatment for Gastric Cancer-Our Experience from a Tertiary Care Center from Northeast India

Gastric cancer (GC) is common in the northeast and southern parts of India. Radical surgery is the cornerstone of treatment and offers the only chance for cure. This study was conducted to assess the outcomes of all resectable gastric cancers that presented to our tertiary cancer center in Northeast India. All patients undergoing upfront surgery for gastric cancer with curative intention between 2012 and 2017 were included in the study. A total of 116 patients who underwent upfront radical gastrectomy were included in the study. Males (58.6%) were more common than females (41.4%). Mean age at presentation was 56.12 years (range 26-89). The most common mode of presentation was pain abdomen (53.8%). The most common location of tumor was the distal part (81%) followed by the proximal part (10.3%). The most commonly done procedure was distal radical gastrectomy (56.9%) followed by subtotal gastrectomy (32.8%). Median number of lymph nodes isolated was 14. Fifty-four patients received adjuvant chemotherapy while 32 patients received adjuvant chemoradiation (CTRT). At a median follow-up of 14 months (range, 2-78 months), overall 5-year survival was 23.75% (mean survival 33.77 months, median survival 24 months). The 5-year survival for stages I-III was 100%, 26.25%, and 11.25%, respectively (P < 0.001). Though perioperative chemotherapy has a role in gastric cancer, it is not the substitute for radical D2 gastrectomy which is still the gold standard treatment especially in high-volume centers.

Treatment in resectable non-metastatic adenocarcinoma of stomach: Changing paradigms

Adjuvant treatment in gastric adenocarcinoma has been a challenge for the treating specialists, and despite several trials, a clear consensus is yet to be defined. The higher propensity for lymph nodal involvement and locoregional recurrences led to the hypothesis that locoregional and systemic treatments need to be equally aggressive to achieve better outcomes in the management of gastric adenocarcinoma. Regional, ethnic, and biological differences between the Eastern and Western population are also found to reflect in the tumor behavior and its response to treatment. The MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy), Intergroup 0116, ACTS-GC (Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer), CLASSIC (Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer), ARTIST (Adjuvant Chemoradiation Therapy in Stomach Cancer), and the recently published CRITICS (Chemoradiotherapy after Induction Chemotherapy in Cancer of the Stomach) trials were a few of the randomized controlled trials that tried to give a clearer perspective of this tumor, though it still remains a dilemma. A study incorporating the tumor and demographic factors along with the availability of skilled talent and resources might generate an answer.

PAHs in Indian diet: Assessing the cancer risk

Food products such as bread, biscuits, tea, coffee, oils, chocolates, grapes, pepper and fishes belonging to different categories represent a significant part of everyday diet in India and other countries having variable cooking techniques. In this study, we evaluated cancer risks of long term exposure to polycyclic aromatic hydrocarbons (PAHs) through consumption of these products for eight societal groups in India. Total concentrations of PAHs in these products from India ranged from 0.18 to 61967 μg kg^-1 and the cancer risk values for the eight sections of Indian population ranged between 7.63E-10 to 5.05E+00, indicating product specific distribution of risk from non-significant to significant levels. Cereals, vegetables and decoctions contributed majorly to cancer risk and the most susceptible group identified was children. The spread of risk estimates followed Burr and Exponential distributions. To the best of our knowledge, this is the first study to develop information on the health risk faced by Indian population through dietary PAHs.

Significant Pattern of Promoter Hypermethylation of UNC5C Gene in Colorectal Cancer and Its Implication in Late Stage Disease

Background:The development of Colorectal Cancer (CRC) is a complex multistep process involving an accumulation of multiple genetic and epigenetic alterations. Epigenetic modifications, particularly DNA methylation in selected gene are recognized as common molecular alterations in human tumors. Netrin-1 receptors are aberrantly methylated in primary colorectal cancer. Epigenetic alterations in the netrin-1 receptors have been found to be related with the malignant potential of CRC. Purpose: In the present study, we evaluated the role of promoter hypermethylation of UNC5C gene (one of the netrin-1 receptors) in colorectal cancer patients of Kashmiri population (North India). Hypermethylation in tumour tissue was detected by Methylation- Specific Polymerase Chain Reaction (MS-PCR). Results: UNC5C promoter hypermethylation was significantly found to be associated with colorectal cancer cases where frequency was 62% (31 of 50) and 38% (19 of 50) patients were unmethylated (p<0.0001).UNC5C methylation was significantly higher in CRCs with a frequency of 62% than 10% in corresponding normal mucosa of (p<0.0001). Further, UNC5C hypermethylation was found to be significantly associated with stage-III/IV as compared to stage I/II with a frequency of 75.8% and 42.8% respectively(p>0.05). Conclusion: We conclude that UNC5C hypermethylation is implicated in CRC which plays a role in its tumorigenesis and may predict the late stage disease.

Polymorphisms in ADH1B and ALDH2 genes associated with the increased risk of gastric cancer in West Bengal, India

BACKGROUND

Gastric cancer (GC) is one of the most frequently diagnosed digestive tract cancers and carries a high risk of mortality. Acetaldehyde (AA), a carcinogenic intermediate of ethanol metabolism contributes to the risk of GC. The accumulation of AA largely depends on the activity of the major metabolic enzymes, alcohol dehydrogenase and aldehyde dehydrogenase encoded by the ADH (ADH1 gene cluster: ADH1A, ADH1B and ADH1C) and ALDH2 genes, respectively. This study aimed to evaluate the association between genetic variants in these genes and GC risk in West Bengal, India.

METHODS

We enrolled 105 GC patients (cases), and their corresponding sex, age and ethnicity was matched to 108 normal individuals (controls). Genotyping for ADH1A (rs1230025), ADH1B (rs3811802, rs1229982, rs1229984, rs6413413, rs4147536, rs2066702 and rs17033), ADH1C (rs698) and ALDH2 (rs886205, rs968529, rs16941667 and rs671) was performed using DNA sequencing and RFLP.

RESULTS

Genotype and allele frequency analysis of these SNPs revealed that G allele of rs17033 is a risk allele (A vs G: OR = 3.67, 95% CI = 1.54-8.75, p = 0.002) for GC. Significant association was also observed between rs671 and incidence of GC (p = 0.003). Moreover, smokers having the Lys allele of rs671 had a 7-fold increased risk of acquiring the disease (OR = 7.58, 95% CI = 1.34-42.78, p = 0.009).

CONCLUSION

In conclusion, rs17033 of ADH1B and rs671 of ALDH2 SNPs were associated with GC risk and smoking habit may further modify the effect of rs671. Conversely, rs4147536 of ADH1B might have a protective role in our study population. Additional studies with a larger patient population are needed to confirm our results.

Management of gastric cancer in Indian population

Adenocarcinoma stands the most common malignancies in the gastric carcinomas and holds a significant mortality and morbidity rates annually, due to the early vague symptoms among the population and hence the delayed presentation at advanced stages of cancer. In India the screening programs for gastric cancer has been a setback due to various logistics reasons and the data available from reporting is also not content. Our study is a review article featuring the management of gastric cancer in the Indian population. The lifestyle of India population is varied right from its southern region to its northern counterparts, which is due to its diversified culture within the country. Studies have concluded that the northern population tends to have a higher incidence comparatively and the various risk factors associated with the disease has been discussed. Management of the gastric cancer in India remains the same compared to the outside world, though the availability of endoscopic ultrasound and other technical advancements remain sparse in the field of diagnostics and staging of the disease. D2 gastrectomy remains the mainstay of surgery among the Indian population though significant number of patients are deemed inoperable on table. Neo adjuvant Chemotherapy, Radiotherapy and Targeted therapy is yet to be efficiently used across the country according to our study as there is lack of data in our registries. The incidence is decreasing in developing nations and more proximal cancers are reported. However, in India the major population-based cancer registries report an incidence decline only in Mumbai and Chennai. A shift from distal to proximal as the site of disease has not been reported from India. The contribution of the Indian scientific fraternity to the world medical literature for gastric cancer is sparse and it is clear that a lot more is to be done; the possible reason may be a busy clinical schedule or lack of initiatives. There is an urgent need for research in various aspects of gastric cancer from India including epidemiological and therapeutic areas.

Surgical Outcomes Associated with Operable Gastric Cancer in a Tertiary Care Indian Hospital

Purpose

Data on operable gastric cancer from India is sparse. The purpose of this study was to investigate the clinical details, histopathological demographics, and 5-year overall survival (OS) and disease free survival (DFS) associated with operable, non-metastatic gastric cancer in a dedicated upper gastrointestinal (GI) surgical unit in India.

Materials and Methods

Data for patients diagnosed with operable gastric cancer between January 2006 and December 2014 were retrospectively analyzed. Data were collected from electronic hospital records in addition to mail and telephonic interviews when possible.

Results

A total of 427 patients were included. The tumor was located in the pyloro-antral region in 263 patients (61.7%). Subtotal gastrectomy was performed in 291 patients and total gastrectomy in 136 patients. Tumor stage classification revealed 43 patients (10.0%) with stage I, 40 patients (9.4%) with stage IIA, 59 patients (13.9%) with stage IIB, 76 patients (17.8%) with stage IIIA, 96 patients (22.5%) with stage IIIB, and 113 patients (26.4%) with stage IIIC disease. Follow-up data were available for 71.6% of the patients with a mean duration of 32.4 months. Five-year DFS and OS were 39% and 59%, respectively.

Conclusions

Despite presenting at an advanced stage, the 5-year DFS and OS of patients with operable gastric cancer treated at a dedicated upper GI unit of a tertiary care center in India was good.

Gastric cancer and related epigenetic alterations

Gastric cancer, a malignant and highly proliferative condition, has significantly affected a large population around the globe and is known to be caused by various factors including genetic, epigenetic, and environmental influences. Though the global trend of these cancers is declining, an increase in its frequency is still a threat because of changing lifestyles and dietary habits. However, genetic and epigenetic alterations related to gastric cancers also have an equivalent contribution towards carcinogenic development. DNA methylation is one of the major forms of epigenetic modification which plays a significant role in gastric carcinogenesis. Methylation leads to inactivation of some of the most important genes like DNA repair genes, cell cycle regulators, apoptotic genes, transcriptional regulators, and signalling pathway regulators; which subsequently cause uncontrolled proliferation of cells. Mutations in these genes can be used as suitable prognostic markers for early diagnosis of the disease, since late diagnosis of gastric cancers has a huge negative impact on overall patient survival. In this review, we focus on the important epigenetic mutations that contribute to the development of gastric cancer and the molecular pathogenesis underlying each of them. Methylation, acetylation, and histone modifications play an integral role in the onset of genomic instability, one of the many contributory factors to gastric cancer. This article also covers the constraints of incomplete knowledge of epigenetic factors influencing gastric cancer, thus throwing light on our understanding of the disease.

Diagnostic Yield and Clinical Implications of Preoperative Upper Gastrointestinal Endoscopy in Morbidly Obese Patients Undergoing Bariatric Surgery

BACKGROUND AND AIMS

Upper gastrointestinal (UGI) endoscopy in patients undergoing bariatric surgery is controversial. It is recommended routinely by some authors to detect benign or malignant pathology that mostly remains asymptomatic. Others recommend selective use, suggesting not much impact on surgical management of detected pathology, especially in asymptomatic patients. The aim of this study was to evaluate the diagnostic yield and impact of pathological findings on routine UGI endoscopy before bariatric surgery in a cohort of morbidly obese Indian patients.

MATERIALS AND METHODS

We retrospectively reviewed preoperative screening UGI endoscopy reports of 283 patients who underwent bariatric surgery from February 2012 to August 2014. Data were collected on clinical information, UGI endoscopic findings, Helicobacter pylori testing, and management.

RESULTS

Ten patients gave a history of gastroesophageal reflux, and the rest had no specific UGI complaints. Fifty-four had no abnormal findings. One hundred ninety-six had a lax lower esophageal hiatus, hiatal hernias of <5 cm, Grade I-II esophagitis, or mild to moderate gastritis or duodenitis that did not have an impact on surgery. Thirty-one had severe erosive gastritis or duodenitis, or polyposis that delayed surgery for treatment and review of biopsies. A large hiatal hernia >5 cm changed surgical plan to Roux-en-Y gastric bypass from a sleeve gastrectomy in 2 cases. None had varices or malignancy.

CONCLUSIONS

Preoperative UGI endoscopy yielded a high proportion of endoscopic abnormalities even in asymptomatic patients. Surgery was delayed to treat severe mucosal lesions and to investigate polypoidal findings in the majority. A change in surgical approach and surveillance for malignancy was needed in a few cases.

HER 2 Expression in Gastric and Gastro-esophageal Junction (GEJ) Adenocarcinomas

INTRODUCTION

Gastric cancer is one of the leading causes of cancer mortality in the world/India with majority being diagnosed at an advanced stage. Various chemotherapeutic regimens have modestly improved overall survival leading to quest for novel therapeutic agents. Overexpression of HER2 in many gastric cancers has lead to the advent of targeted therapy with anti HER2 antibody like Trastusumab which has improved the overall survival.

MATERIALS AND METHODS

Sixty cases of gastric adenocarcinomas (44 biopsies and 16 gastrectomies) over the past five years ( June 2009 to June 2014),were included in the study. Diagnosis was confirmed by review of slides and IHC with anti HER2 antibodies was performed using Dako Real Envision Detection system and scoring was done by Hoffmann et al., scoring system.

RESULTS

Of the 60 cases, majority were males (60%),with a mean age of 65.65 yrs. Tumours in antrum (76.7%) formed the major bulk. HER2 expression was observed in 26.7% of Tumours, predominantly in males (p=0.006) and intestinal type (p= 0.054). HER2 expression correlated with Tumour grade (moderately differentiated and well differentiated, p= 0.042). Tumours of gastro-esophageal junction (GEJ) showed HER2 expression in 45.5% as opposed to 22.4% in gastric location. Poorly differentiated and diffuse type of adenocarcinomas did not express HER2. Two of three Tumours from patients in the age group 31-40 y expressed HER2.

CONCLUSION

Male gender, intestinal-type and moderately differentiated gastric cancers may be the ones that can be targeted for therapy using Herceptin. Though trastusumab is approved for advanced gastric and GEJ cancers, it's role in adjuvant / neo-adjuvant setting in early stages needs to be evaluated with newer agents like Pertuzumab, Bevacizumab, especially in young patients.

Treatment of patients with advanced gastric cancer: experience from an Indian tertiary cancer center

Majority of patients in developing countries diagnosed with gastric cancer have an advanced stage at presentation with overall poor performance status. The aim of the study was to assess outcomes of first- and second-line chemotherapy and determine prognostic factors among patients with advanced gastric cancer (AGC). Using a prospectively maintained database, we identified 144 patients with AGC treated at Tata Memorial Centre between January 2012 and September 2013. Sixteen patients received best supportive care, and 128 patients received palliative chemotherapy. Cox regression was used for multivariate analysis of survival. Of 128 patients, 42(33%) received Cape-Ox, 22(17.1%) EOX and 47(36.7%) DOX while rest received other regimens. PS was 2 in 36 (28%) patients at presentation, and 97% of patients had ≥3 sites of metastasis. Forty-eight patients (37.5%) had signet ring histology. Median follow-up was 9 months. Median progression-free survival/overall survival (OS) was 6/8 months, respectively. Of 93 patients who progressed 39 (41.9%) patients received second-line chemotherapy. Multivariate analysis for OS showed that PS and use of taxane in first-line setting were significant prognostic factors. Patients who received second-line therapy had longer survival than those who did not (12 vs. 6 months; P=0.002). The overall outcome of our patients is comparable to the Western reported data despite an advanced disease at presentation.

Surgical treatment of gastric cancer in a community hospital in Brazil: who are we treating and how?

PURPOSE

Surgical treatment of gastric cancer has risks, and the current trend in developed countries is to centralize cases in high-volume centers. Many countries, however, particularly the developing ones, have to rely in low-volume centers for the most part of gastric cancer operations. We aimed to verify the characteristics of the patients and tumors as well as the in-hospital outcomes in a community hospital in Brazil treating gastric cancer.

METHODS

This is a retrospective study on patients undergoing surgical treatment of gastric adenocarcinoma at a community hospital in Brazil. The authors reviewed demographic, clinical, pathological, and perioperative data.

RESULTS

A total of 28 patients were operated on during the study period. Mean age was 69.5 years, 53.6% were male, 67.9% had anemia, 78.5% had ASA score ≥ 3, 89.3% were at nutritional risk, intestinal/diffuse ratio was 1.6, 68.5% had tumor ≥ 6 cm, involvement of lower/middle third of the stomach occurred in 96.4%, 73.7% had serosal invasion, 79% had stage III disease, median number of dissected nodes was 23, median operative time was 255 min, 21.4% had urgent procedures, 67.8% had curative surgery, 50% had distal gastrectomy, 43.5% had a Billroth I, median length of stay was 17 days, 53.6% had some admission to the intensive care unit, 21.4% required relaparotomy, 25% had wound infection/dehiscence, and mortality was 66.7/18.2% (urgent/non-urgent surgery).

CONCLUSION

We treat elderly malnourished patients with multiple comorbidities and advanced cancer. Improvement is required in lymph node dissection, non-surgical therapies, and critical care.

Helicobacter pylori and gastric cancer: Indian enigma

Helicobacter pylori (H. pylori) is a gram negative microaerophilic bacterium which resides in the mucous linings of the stomach. It has been implicated in the causation of various gastric disorders including gastric cancer. The geographical distribution and etiology of gastric cancer differ widely in different geographical regions and H. pylori, despite being labeled as a grade I carcinogen, has not been found to be associated with gastric cancer in many areas. Studies in Asian countries such as Thailand, India, Bangladesh, Pakistan, Iran, Saudi Arabian countries, Israel and Malaysia, have reported a high frequency of H. pylori infection co-existing with a low incidence of gastric cancer. In India, a difference in the prevalence of H. pylori infection and gastric cancer has been noted even in different regions of the country leading to a puzzle when attempting to find the causes of these variations. This puzzle of H. pylori distribution and gastric cancer epidemiology is known as the Indian enigma. In this review we have attempted to explain the Indian enigma using evidence from various Indian studies and from around the globe. This review covers aspects of epidemiology, the various biological strains present in different parts of the country and within individuals, the status of different H. pylori-related diseases and the molecular pathogenesis of the bacterium.

Carcinoma of the stomach: A review of epidemiology, pathogenesis, molecular genetics and chemoprevention

Carcinoma of the stomach is still the second most common cause of cancer death worldwide, although the incidence and mortality have fallen dramatically over the last 50 years in many regions. The incidence of gastric cancer varies in different parts of the world and among various ethnic groups. Despite advances in diagnosis and treatment, the 5-year survival rate of stomach cancer is only 20 per cent. Stomach cancer can be classified into intestinal and diffuse types based on epidemiological and clinicopathological features. The etiology of gastric cancer is multifactorial and includes both dietary and nondietary factors. The major diet-related risk factors implicated in stomach cancer development include high content of nitrates and high salt intake. Accumulating evidence has implicated the role of Helicobacter pylori (H. pylori) infection in the pathogenesis of gastric cancer. The development of gastric cancer is a complex, multistep process involving multiple genetic and epigenetic alterations of oncogenes, tumor suppressor genes, DNA repair genes, cell cycle regulators, and signaling molecules. A plausible program for gastric cancer prevention involves intake of a balanced diet containing fruits and vegetables, improved sanitation and hygiene, screening and treatment of H. pylori infection, and follow-up of precancerous lesions. The fact that diet plays an important role in the etiology of gastric cancer offers scope for nutritional chemoprevention. Animal models have been extensively used to analyze the stepwise evolution of gastric carcinogenesis and to test dietary chemopreventive agents. Development of multitargeted preventive and therapeutic strategies for gastric cancer is a major challenge for the future.