Surgical treatment of gastric cancer: a 10-year experience in a high-volume university hospital

Evaluation of the endoscopic cure criteria in patients undergoing surgery for early gastric cancer

BACKGROUND AND OBJECTIVES

Gastric cancer (GC) prognosis is influenced by the extent of the tumor, lymph node involvement (LNM), and metastasis. Endoscopic resection (ER) or gastrectomy with lymphadenectomy are standard treatments for early GC (EGC). This study evaluated LNM frequency according to eCura categories, clinicopathological characteristics, disease-free (DFS), and overall (OS) survival rates.

METHODS

We included EGC patients who underwent curative gastrectomy between 2009 and 2020 from our single-center database. Anatomopathological and clinical reports were reviewed to analyze eCura categories.

RESULTS

We included 160 EGC patients who underwent gastrectomy with eCura categories A, B, and C, comprising 26.3%, 13.8%, and 60%, respectively. Baseline clinical characteristics showed no intergroup disparities. LNM incidence for A, B, and C was 4.8%, 18.2%, and 19.8%. When evaluating the criteria for ER and its association with eCura categories, we found that 95.2% of eCura A and 100% of eCura B patients had classic or expanded criteria for ER. On the other hand, 97.9% of eCura C patients were referred to surgical resection. Multivariate analysis demonstrated that lymphatic (OR = 5.57, CI95% = 1.45-21.29, p = 0.012) and perineural (OR = 15.8, CI95% = 1.39-179.88, p = 0.026) invasions were associated with a higher risk of LNM. No significant differences in DFS or OS were found among eCura categories.

CONCLUSION

The eCura categories were associated with the occurrence of LNM. In most patients, those with classic and expanded indication criteria for ER were classified as eCura A and B.

THE VALUE OF PREOPERATIVE PROGNOSTIC NUTRITIONAL INDEX IN GASTRIC CANCER AFTER CURATIVE RESECTION

BACKGROUND

Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries.

AIMS

To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients.

METHODS

A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI.

RESULTS

Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival.

CONCLUSIONS

Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.

Robotic versus laparoscopic gastrectomy for gastric cancer: A Western propensity score matched analysis

BACKGROUND

Robot-assisted gastrectomy (RG) has been shown to be safe and feasible in the treatment of gastric cancer (GC). However, it is unclear whether RG is equivalent to laparoscopic gastrectomy (LG), especially in the Western world. Our objective was to compare the outcomes of RG and LG in GC patients.

METHODS

We reviewed all gastric adenocarcinoma patients who underwent curative gastrectomy by minimally invasive approach in our institution from 2009 to 2022. Propensity score matching (PSM) analysis was conducted to reduce selection bias. DaVinci Si platform was used for RG.

RESULTS

A total of 156 patients were eligible for inclusion (48 RG and 108 LG). Total gastrectomy was performed in 21.3% and 25% of cases in LG and RG, respectively. The frequency of stage pTNM II/III was 48.1%, and 54.2% in the LG and RG groups (p = 0.488). After PSM, 48 patients were matched in each group. LG and RG had a similar number of dissected lymph nodes (p = 0.759), operative time (p = 0.421), and hospital stay (p = 0.353). Blood loss was lower in the RG group (p = 0.042). The major postoperative complications rate was 16.7% for LG and 6.2% for RG (p = 0.109). The 30-day mortality rate was 2.1% and 0% for LG and RG, respectively (p = 1.0). There was no significant difference between the LG and RG groups for disease-free survival (79.6% vs. 61.2%, respectively; p = 0.155) and overall survival (75.9% vs. 65.7%, respectively; p = 0.422).

CONCLUSION

RG had similar surgical and long-term outcomes compared to LG, with less blood loss observed in RG.

The therapeutic effects of berberine for gastrointestinal cancers

Cancer is one of the most serious human health issues. Drug therapy is the major common way to treat cancer. There is a growing interest in using natural compounds to overcome drug resistance, adverse reactions, and target specificity of certain types of drugs that may affect several targets with fewer side effects and be beneficial against various types of cancer. In this regard, the use of herbal medicines alone or in combination with the main anticancer drugs is commonly available. Berberine (BBR), a nature-driven phytochemical component, is a well-known nutraceutical due to its wide variety of pharmacological activities, including antioxidant, anti-inflammatory, antibacterial, antifungal, antiparasitic, antidiabetic, antihypertensive, and hypolipidemic. In addition, BBR exerts anticancer activities. In present article, we summarized the information available on the therapeutic effects of BBR and its mechanisms on five types of the most prevalent gastrointestinal cancers, including esophageal, gastric, colorectal, hepatocarcinoma, and pancreatic cancers.

STAGING LAPAROSCOPY IS STILL A VALUABLE TOOL FOR OPTIMAL GASTRIC CANCER MANAGEMENT

BACKGROUND

Complete surgical resection is the main determining factor in the survival of advanced gastric cancer patients, but is not indicated in metastatic disease. The peritoneum is a common site of metastasis and preoperative imaging techniques still fail to detect it.

AIM

The aim of this study was to evaluate the role of staging laparoscopy in the staging of advanced gastric cancer patients in a Western tertiary cancer center.

METHODS

A total of 130 patients with gastric adenocarcinoma who underwent staging laparoscopy from 2009 to 2020 were evaluated from a prospective database. Clinicopathological characteristics were analyzed to identify factors associated with the presence of peritoneal metastasis and were also evaluated the accuracy and strength of agreement between computed tomography and staging laparoscopy in detecting peritoneal metastasis and the change in treatment strategy after the procedure.

RESULTS

The peritoneal metastasis was identified in 66 (50.76%) patients. The sensitivity, specificity, and accuracy of computed tomography in detecting peritoneal metastasis were 51.5, 87.5, and 69.2%, respectively. According to the Kappa coefficient, the concordance between staging laparoscopy and computed tomography was 38.8%. In multivariate analysis, ascites (p=0.001) and suspected peritoneal metastasis on computed tomography (p=0.007) were statistically correlated with peritoneal metastasis. In 40 (30.8%) patients, staging and treatment plans changed after staging laparoscopy (32 patients avoided unnecessary laparotomy, and 8 patients, who were previously considered stage IVb by computed tomography, were referred to surgical treatment).

CONCLUSION

The staging laparoscopy demonstrated an important role in the diagnosis of peritoneal metastasis, even with current advances in imaging techniques.

Advances in surgical techniques for gastric cancer: Indocyanine green and near-infrared fluorescence imaging. Is it ready for prime time?

Surgery is still the primary curative treatment for gastric cancer, which includes resection of the tumor with adequate margins and extended lymphadenectomy. In order to improve the operative results and the quality of life of patients, several endeavors have been made toward precision medicine through image-guided surgery, allowing access to real-time intraoperative anatomy and accurate tumor staging. The goal of the surgeon is to achieve a more precise, individualized, and less invasive surgery without compromising oncological efficiency and safety. In this perspective, we have demonstrated the role of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging method in gastric cancer surgery. This technique may be used to improve localization of the tumor, detection of sentinel lymph nodes (SLN), real-time lymphatic mapping, and blood flow assessment (anastomosis perfusion).

Short-Term Surgical Outcomes of Robotic Gastrectomy Compared to Open Gastrectomy for Patients with Gastric Cancer: a Randomized Trial

BACKGROUND

Robotic gastrectomy (RG) has been shown to be a safe and feasible method in gastric cancer (GC) treatment. However, most studies are in Eastern cohorts and there is great interest in knowing whether the method can be used routinely, especially in the West.

OBJECTIVES

The aim of this study was to compare the short-term surgical outcomes of D2-gastrectomy by RG versus open gastrectomy (OG).

METHODS

Single-institution, open-label, non-inferiority, randomized clinical trial performed between 2015 and 2020. GC patients were randomized (1:1 allocation) to surgical treatment by RG or OG. Da Vinci Si platform was used.

INCLUSION CRITERIA

gastric adenocarcinoma, stage cT2-4 cN0-1, potentially curative surgery, age 18-80 years, and ECOG performance status 0-1.

EXCLUSION CRITERIA

emergency surgery and previous gastric or major abdominal surgery. Primary endpoint was short-term surgical outcomes. The study is registered at clinicaltrials.gov (NCT02292914).

RESULTS

Of 65 randomized patients, 5 were excluded (3 palliatives, 1 obstruction and emergency surgery, and 1 for material shortage). Consequently, 31 and 29 patients were included for final analysis in the OG and RG groups, respectively. No differences were observed between groups regarding age, sex, BMI, comorbidities, ASA, and frequency of total gastrectomy. RG had similar mean number of harvested lymph nodes (p = 0.805), longer surgical time (p < 0.001), and less bleeding (p < 0.001) compared to OG. Postoperative complications, length of hospital stay, and readmissions in 30 days were equivalent between OG and RG.

CONCLUSIONS

RG reduces operative bleeding by more than 50%. The short-term outcomes were non-inferior to OG, although surgical time was longer in RG.

Gastric adenocarcinoma: 1-year overall survival, disability-adjusted life years, years of life lost, and prognostic factors-a single-institution experience

Objective

To analyze factors affecting 1-year overall survival and burden of gastric adenocarcinoma in a single-institution cohort.

Methods

A prospective cohort study of gastric adenocarcinoma patients from a cancer center in São Paulo, Brazil, was conducted between February 2016 and July 2019. Overall survival was analyzed at 12 months post-diagnosis using the Kaplan-Meier method. A log-rank test was applied to compare curves. Sociodemographic and clinicopathological features were assessed to detect prognostic factors using univariate and multivariable Cox regression analyses to calculate hazard ratio (HR) and its confidence intervals (CIs). Disability-adjusted life years (DALY) constituted the sum of years of life lost (YLL) plus years lived with disability (YLD). YLL represented the sum of years lost before the age of 76.6 years. YLD was calculated as the number of cases multiplied by the duration and burden of the disease. YLL per death was calculated as the mean YLL for each individual.

Results

Overall survival at 1-year follow-up was 80.8%. The multivariable model adjusted for age and sex identified cerebrovascular disease (HR 8.5, 95% CI 3.3-21.8), stage III/IV (HR 5.7, 95% CI 2.3-13.7), diabetes (HR 3.2, 95% CI 1.5-6.6), and<9 years of education (HR 2.9, 95% CI 1.5-5.8) as prognostic factors. Out of the 214 treated cases, there was 700.72 DALY during the first year, of which 90.55% corresponded to YLL and 9.45% to YLD. The average YLL per death was 15.48 and was higher among women (19.24 YLL per death).

Conclusion

At a single cancer center, 1-year overall survival probability was approximately 80% in patients with gastric adenocarcinoma. Patients with a higher risk of death had cerebrovascular disease, advanced clinical staging, diabetes, and/or lower educational level. Approximately 700 years of DALY was documented, with women having the highest YLL per death. Because this study was conducted at a single cancer center, the results might not be representative of a general population. To the best of our knowledge, this study was the first to assess gastric adenocarcinoma DALY, YLL, and YLL per death in the first year of follow-up in a hospital cohort in Brazil.

Surgical and oncological outcomes of distal gastrectomy compared to total gastrectomy for middle‑third gastric cancer: A systematic review and meta‑analysis

Distal gastrectomy (DG) and total gastrectomy (TG) are the most common types of radical surgery for patients with middle-third gastric cancer (MTGC). However, the indications and benefits of the two procedures still remain controversial. The present meta-analysis aimed to compare the surgical and oncological outcomes of DG and TG in the treatment of MTGC. A rigorous literature review was performed in the databases of PubMed, Embase, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature to retrieve studies published up to February 2022. The Newcastle-Ottawa Scale was used to assess the quality of included studies and a meta-analysis was performed using RevMan 5.3 software. A total of 12 retrospective studies performing comparisons of DG and TG were included in the present meta-analysis. For patients who underwent DG, a lower rate of overall post-operative complications, anastomosis leakage and intro-abdominal infection was determined. No significant difference was observed between DG and TG in the 5-year overall survival when the proximal resection margin ranged from 3 to 5 cm. Although DG was associated with a higher 5-year overall survival rate when compared to TG, there was no significant difference in the stratified analyses by TNM stage. In conclusion, the prognosis of MTGC did not depend on the extent of gastrectomy. With lower complications and acceptable oncological outcomes, DG was a safe and feasible surgical procedure for MTGC when a negative proximal margin was confirmed.

Gastric cancer with concurrent pancreatic schwannoma: A case report

BACKGROUND

The differential diagnosis of abdominal masses is somewhat troublesome, especially when there is a malignancy to be evaluated. We report herein a unique case of gastric adenocarcinoma concurrent with a pancreatic schwannoma. Correct assessment of intraoperative findings is essential for adequate tumor staging and to decide the proper management of a concurrent pancreatic lesion.

CASE SUMMARY

Computed tomography scan performed for gastric cancer staging revealed a solid and cystic pancreatic mass that had no signs of local invasiveness. Surgical resection of the pancreas was decided preoperatively since a radical approach of the gastric tumor could be performed. There were no signs of distant metastases, and the large pancreatic mass was in contact with the posterior gastric wall. Histopathological study revealed a pancreatic schwannoma, which is an uncommon neoplasm that arises from Schwann cells around peripheral nerves.

CONCLUSION

Therefore, pancreatic masses deserve special attention regarding the differential diagnosis in patients with gastric cancer. The presence of a large pancreatic mass should not preclude the potentially curative intent of the gastric cancer treatment.

SALVAGE SURGERY IN GASTRIC CANCER

AIM

Salvage surgery (SS) is defined as surgical resection after the failure of the first treatment with curative intent. The aim of this study was to report the experience of a reference center with SS for stomach adenocarcinoma.

METHODS

This is a retrospective study of patients with gastric cancer (GC) operated on between 2009 and 2020.

RESULTS

Notably, 40 patients were recommended for salvage gastrectomy with curative-intent treatment. For analysis purpose, patients were divided into two groups: 23 patients after endoscopic resection and 17 patients after gastrectomy. In the first group, all patients underwent R0 resection, their average hospital length of stay (LOS) was 15.7 days, and 2 (8.6%) patients had major complications. During the average follow-up of 37.2 months, there was only one recurrence. The median overall survival (OS) was 46 months. In the postgastrectomy group, 9 (52.9%) patients were rescued with curative intent, the average hospital LOS was 12.2 days, and 3 (17.6%) had major complications. In a mean follow-up of 22 months, five patients relapsed. Median OS and disease-free survival were 24 and 16.5 months, respectively.

CONCLUSION

SS in GC offers the possibility of long-term disease control and increased survival rate with an acceptable complication rate.

GASTRIC CANCER WITH POSITIVE EXPRESSION OF ESTROGEN RECEPTOR ALPHA: A CASE SERIES FROM A SINGLE WESTERN CENTER

AIM

Despite advances in therapies, the prognosis of patients with advanced gastric cancer (GC) remains poor. Several studies have demonstrated the expression of estrogen receptor alpha (ERa); however, its significance in GC remains controversial. The present study aims to report a case series of GC with ERa-positive expression and describe their clinicopathological characteristics and prognosis.

METHODS

We retrospectively evaluated patients with GC who underwent gastrectomy with curative intent between 2009 and 2019. ERa expression was assessed by immunohistochemistry through tissue microarray construction. Patients with ERa-negative gastric adenocarcinoma served as a comparison group.

RESULTS

During the selected period, 6 (1.8%) ERa-positive GC were identified among the 345 GC patients analyzed. All ERa-positive patients were men, aged 34-78 years, and had Lauren diffuse GC and pN+ status. Compared with ERa-negative patients, ERa-positive patients had larger tumor size (p=0.031), total gastrectomy (p=0.012), diffuse/mixed Lauren type (p=0.012), presence of perineural invasion (p=0.030), and lymph node metastasis (p=0.215). The final stage was IIA in one case, IIIA in three cases, and IIIB in two cases. Among the six ERa-positive patients, three had disease recurrence (peritoneal) and died. There was no significant difference in survival between ERa-positive and ERa-negative groups.

CONCLUSIONS

ERa expression is less common in GC, is associated with diffuse histology and presence of lymph node metastasis, and may be a marker related to tumor progression and worse prognosis. Also, a high rate of peritoneal recurrence was observed in ERa-positive patients.

Cytotoxic T-lymphocyte-associated protein 4 in gastric cancer: Prognosis and association with PD-L1 expression

BACKGROUND

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) is one of the most studied immune checkpoint in gastric cancer (GC). However, the prognostic role of CTLA-4 expression in GC is poorly described. This study aimed to evaluate CTLA-4 expression in GC and its impact on survival, including patients treated with standard platinum-based chemotherapy (CMT), and association with PD-L1 expression.

METHODS

All GC patients who underwent D2-gastrectomy were investigated retrospectively. Tumor samples were examined for CTLA-4 and PD-L1 by immunohistochemistry. Tumor-infiltrating inflammatory cells, including CD4 + and CD8 + , were also examined.

RESULTS

Among the 284 GC patients included, 159 (56%) were CTLA-4 positive and the remaining 125 (44%) were classified as negative. CTLA-4 positive GC was associated with increased inflammatory cell infiltration (p < 0.001), high CD8 + T cells (p = 0.016) and PD-L1 expression (p = 0.026). Considering GC referred for treatment, CTLA-4 negative patients who received CMT had a significant improvement in disease-free survival compared to untreated CLTA-4 negative (p = 0.028). In multivariate analysis, GC positive for both CTLA-4 and PD-L1 had a prognostic impact on survival.

CONCLUSION

CTLA-4 positive was associated with PD-L1 expression and a high tumor-infiltrating CD8 + T cells. Accordingly, positivity for both CTLA-4 and PD-L1 was an independent factor associated to better survival in GC patients.

Impact of COVID-19 pandemic on the surgical treatment of gastric cancer

OBJECTIVE

The Coronavirus Disease 2019 (COVID-19) pandemic has been recognized as one of the most serious public health crises. This study aimed to evaluate the short-term impact of the pandemic on the surgical treatment of patients with gastric cancer (GC) in addition to their clinicopathological characteristics. We also verified adherence to the COVID-19 screening protocol adopted in the institution.

METHODS

All patients with GC who underwent surgical treatment between 2015 and 2021 were retrospectively evaluated and divided into two groups according to the time period: control group (2015-2019) and COVID group (2020-2021). The institutional protocol recommends that patients referred for surgery undergo RT-PCR for severe acute respiratory syndrome coronavirus 2 infection.

RESULTS

A total of 83 patients were classified into the COVID group and 535 into the control group. The number of surgical procedures performed in the control group was 107 (SD±23.8) per year. Diagnostic procedures (p=0.005), preoperative chemotherapy (p<0.001), and adenocarcinomas without Lauren's subtype (p=0.009) were more frequent in the COVID group than in the control group. No significant difference was observed in the pathological characteristics and surgical outcomes of curative GC between the two groups. Evaluation of protocol compliance showed that of 83 patients with GC in the COVID group, 19 (22.9%) were not tested for COVID-19 before surgery. Two patients tested positive for COVID-19 (one preoperative and one postoperative).

CONCLUSION

A decrease in the average number of surgeries and a higher frequency of diagnostic procedures occurred during the pandemic than in the previous time period. Tumor/node/metastasis classification, morbidity rates, and mortality rates in patients with GC during the pandemic did not differ from those in the previous time period. Accordingly, GC surgical treatment with acceptable screening protocol compliance could be safely performed during the COVID-19 pandemic.

Jejunostomy in the palliative treatment of gastric cancer: A clinical prognostic score

BACKGROUND

Clinical stage IV gastric cancer (GC) may need palliative procedures in the presence of symptoms such as obstruction. When palliative resection is not possible, jejunostomy is one of the options. However, the limited survival of these patients raises doubts about who benefits from this procedure.

AIM

To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.

METHODS

We performed a retrospective analysis of Stage IV GC who underwent jejunostomy. Eleven preoperative clinical variables were selected to define the score categories, with 90-d mortality as the main outcome. After randomization, patients were divided equally into two groups: Development (J1) and validation (J2). The following variables were used: Age, sex, body mass index (BMI), American Society of Anesthesiologists classification (ASA), Charlson Comorbidity index (CCI), hemoglobin levels, albumin levels, neutrophil-lymphocyte ratio (NLR), tumor size, presence of ascites by computed tomography (CT), and the number of disease sites. The score performance metric was determined by the area under the receiver operating characteristic (ROC) curve (AUC) to define low and high-risk groups.

RESULTS

Of the 363 patients with clinical stage IVCG, 80 (22%) patients underwent jejunostomy. Patients were predominantly male (62.5%) with a mean age of 62.4 years old. After randomization, the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score. The high NLR had the highest value. The ROC curve derived from these pooled parameters had an AUC of 0.712 (95%CI: 0.537-0.887, P = 0.022) to define risk groups. In the validation cohort, the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756, (95%CI: 0.598-0.915, P = 0.006). According to the cutoff, in the validation cohort BMI less than 18.5 kg/m2 (P < 0.001), CCI ≥ 1 (P = 0.001), ASA III/IV (P = 0.002), high NLR (P = 0.012), and the presence of ascites on CT exam (P = 0.004) were significantly associated with the high-risk group. The risk groups showed a significant association with first-line (P = 0.012), second-line chemotherapy (P = 0.009), 30-d (P = 0.013), and 90-d mortality (P < 0.001).

CONCLUSION

The scoring system developed with 11 variables related to patient's performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Laparoscopic gastrectomy for early and advanced gastric cancer in a western center: a propensity score-matched analysis

The employment of laparoscopic gastrectomy (LG) in the management of gastric cancer (GC) is increasing. Despite recent results from randomized trials, its effectiveness and oncological results in different scenarios remain controversial, especially in western centers. The aim of this study was to compare the short-term outcomes and survival of LG with open gastrectomy (OG) for GC. We reviewed all GC patients who underwent curative gastrectomy from a prospective database. Propensity score-matched (PSM) analysis including 10 variables was conducted to reduce patient selection bias using a 1:1 case-control match. A total of 530 GC were eligible for inclusion (438 OG and 92 LG). Older age, lower hemoglobin levels, total gastrectomy, larger tumor size, greater depth of tumor invasion and advanced pTNM stage was more frequent in the OG group. After PMS analysis, 92 patients were matched in each group. All variables assigned in the score were well matched. LG group had a slightly higher number of retrieved lymph nodes (42.3 vs 37.6), however, without reaching statistical significance (p = 0.072). No differences were recorded about the frequency of major postoperative complications (POC) and mortality rates between OG and LG groups (12% vs 15.2%, p = 0.519, respectively). In survival analysis, after matching, there was no difference in survival between the two groups. Multivariate analysis showed that only ASA and pN stage were independent factor associated with survival after PSM. In conclusion, laparoscopic gastrectomy was a safe and effective surgical technique for gastric cancer, with short-term and oncological outcomes comparable to open surgery.

Cancerous and non-neoplastic stem cells in the stomach similarly express CD44 and CD133

CD44 and CD133 have been considered as cancer stem cell (CSC) markers. Stem cell markers are rarely described in healthy stomach tissues. However, the clinicopathological and prognostic value of CD44 and CD133 in gastric cancer remains controversial. This study investigated the expression of CD44 and CD133 in gastric cancer and non-neoplastic gastric mucosa. We used samples of primary gastric adenocarcinomas (n = 69), metastatic lymph nodes (n = 30), intestinal metaplasia (n = 17), and histologically normal gastric tissues of surgical margins (n = 54). The expression of CD44 and CD133 were studied in samples by immunohistochemistry. Fisher's exact test and a logistic regression model were used in this study. CD44 expression was observed in 12% of samples with intestinal metaplasia, 20% with lymph node metastases, 22% with normal mucosa, to 30% of samples with primary tumors. Most of these positive tumors showed immunostaining in less than 4% of cancerous cells, mainly in the diffuse type. CD133 expression was observed in 7% (intestinal metaplasia) to 46% (normal mucosa). In the positive cases of cancer (24%), in most of them, less than 3% of cells were marked. CD44 and CD133 expression in the histologically normal gastric mucosa was restricted to the deeper regions of the gastric crypts at the level where stem cells and progenitor cells are usually found. CD44 and CD133 expression occurs in few gastric cancer cells, mainly in diffuse carcinomas, and are expressed in histologically normal gastric mucosae. None of the markers are specific for cancer and are also present in intestinal metaplasia and the normal mucosa.

Gastric Mixed Neuroendocrine Non-Neuroendocrine Neoplasms: A Western Center Case Series

BACKGROUND

Mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs) represent a rare tumor composed of adenocarcinoma and neuroendocrine carcinoma components. This study reports a case series of gastric MiNEN and discusses issues related to its diagnosis, management, and outcomes.

METHODS

We retrospectively analyzed data from patients with gastric MiNEN who underwent surgical resection at our service from 2009 to 2020. Patients with gastric adenocarcinoma served as a comparison group. Clinical, pathologic, and surgical characteristics were compared.

RESULTS

During the selected period, 5 gastric MiNEN patients and 597 patients with gastric adenocarcinoma were included. Among the clinical variables, age, sex, BMI, and laboratory exams were similar between the two groups. Only ASA classification was different (p = 0.015). Pathological variables such as tumor size, lymphovascular invasion, number of retrieved lymph nodes, and pTNM staging were also similar between both groups. Lastly, early surgical outcomes and long-term survival did not differ between gastric MiNEN and adenocarcinoma patients.

CONCLUSION

A MiNEN is a rare tumor that represents less than 1% of GC patients undergoing curative treatment, and demonstrated clinicopathological characteristics and outcomes similar to gastric adenocarcinoma.

Surgical Management of Gastric Cancer: A Systematic Review

Gastric cancer is the fifth most common cancer worldwide, and it is responsible for 7.7% of all cancer deaths. Despite advances in the field of oncology, where radiotherapy, neo and adjuvant chemotherapy may improve the outcome, the only treatment with curative intent is represented by surgery as part of a multimodal therapy. Two concepts may be adopted in appropriate cases, neoadjuvant treatment before gastrectomy (G) or primary surgical resection followed by chemotherapy. Such an approach, combined with early detection and better screening, has led to a decrease in the overall incidence of gastric cancer. Unfortunately, malignant tumors of the stomach are often diagnosed in locally advanced or metastatic stages when the median overall survival remains poor. Surgical care in these cases must be provided by a multidisciplinary team in a high-volume center. Important surgical aspects such as optimum resection margins, surgical technique, and number of harvested lymph nodes are important factors for patient outcomes. The standardization of surgical treatment of gastric cancer in accordance with the patient’s profile is of decisive importance for a better outcome. This review aims to summarize the current standards in the surgical treatment of gastric cancer.

Epstein-Barr Virus Positive Gastric Cancer: A Distinct Subtype Candidate for Immunotherapy

BACKGROUND

Epstein-Barr virus (EBV) positive gastric cancer (GC) has been described as a distinct molecular subtype of the disease, especially associated with gastric carcinoma with lymphoid stroma (GCLS). The possibility that EBV associated GC (EBVaGC) had better prognosis and may be susceptible to immunotherapy has increased the interest in this subtype. However, immune checkpoint and survival of EBVaGC are still controversial, especially with regard to GCLS and conventional gastric adenocarcinoma (CGA). This study aimed to evaluate the clinicopathological characteristics, immunohistochemical profiles and prognosis of EBVaGC according to the histological type GCLS and CGA.

METHODS

we retrospectively evaluated a series of EBVaGC who underwent gastrectomy with D2-lymphadenectomy. Biomarkers and tumor-infiltrating cells were evaluated by immunohistochemistry. PD-L1 was evaluated using a combined positive score (CPS).

RESULTS

From a total of 30 EBVaGC, 14 (46.7%) were identified as GCLS and 16 (53.3%) as CGA (9 Intestinal, 6 diffuse, 1 undetermined). There were no significant differences in age, sex, and pTNM between GCLS and CGA. CPS-positivity and high-CD8⁺ was significantly higher in GCLS compared with CGA (P = 0.007 and P = 0.005, respectively). Diffuse EBVaGC had worse survival than intestinal type (P = 0.020). There was no difference in survival between GCLS and intestinal CGA (P = 0.260). In multivariate analysis, CPS and pN status were related with survival in EBVaGC.

CONCLUSIONS

CGLS was associated with a predominance of CD8⁺ cell infiltration and PD-L1 expression. CPS and lymph node metastasis were independent factors associated with prognosis in EBVaGC. These results suggest that specifically EBV-positive GCLS may be prime candidates for PD-1 directed therapy.

Remnant gastric cancer: An ordinary primary adenocarcinoma or a tumor with its own pattern?

BACKGROUND

Remnant gastric cancer (RGC) is defined as a tumor that develops in the stomach after a previous gastrectomy and is generally associated with a worse prognosis. However, there little information available regarding RGCs and their prognostic factors and survival.

AIM

To evaluate the clinicopathological characteristics and prognosis of RGC after previous gastrectomy for benign disease.

METHODS

Patients who underwent curative resection for primary gastric cancer (GC) at our institute between 2009 and 2019 were retrospectively evaluated. All RGC resections with histological diagnosis of gastric adenocarcinoma were enrolled in this study. Primary proximal GC (PGC) who underwent total gastrectomy was selected as the comparison group. Clinical and pathological data were collected from a prospective medical database.

RESULTS

A total of 41 patients with RGC and 120 PGC were included. Older age (P = 0.001), lower body mass index (P = 0.006), hemoglobin level (P < 0.001), and number of resected lymph nodes resected (LN) (P < 0.001) were associated with the RGC group. Lauren type, pathological tumor-node-metastasis, and perioperative morbimortality were similar between RGC and PGC. There was no difference in disease-free survival (P = 0.592) and overall survival (P = 0.930) between groups. LN status was the only independent factor related to survival.

CONCLUSION

RGC had similar clinicopathological characteristics to PGC. Despite the lower number of resected LN, RGC had a similar prognosis.

GASTRECTOMY IN OCTOGENARIANS WITH GASTRIC CANCER: IS IT FEASIBLE?

BACKGROUND

The octogenarian population is expanding worldwide and demand for gastrectomy due to gastric cancer in this population is expected to grow. However, the outcomes of surgery with curative intent in this age group are poorly reported and it is unclear what matters most to survival: age, clinical status, disease´s stage, or the extent of the surgery performed.

AIM

Evaluate the results of gastrectomy in octogenarians with gastric cancer and to verify the factors related to survival.

METHODS

From prospective database, patients aged 80 years or older with histologically confirmed adenocarcinoma who had undergone gastrectomy with curative intent were selected. Factors related to postoperative complications and survival were studied.

RESULTS

Fifty-one patients fulfilled the inclusion criteria. A total of 70.5% received subtotal gastrectomy and in 72.5% D1 lymphadenectomy was performed. Twenty-five (49%) had complications, in eleven major complications occurred (seven of these were clinical complications). Hospital length of stay was longer (8.5 vs. 17.8 days, p=0.002), and overall survival shorter (median of 1.4 vs. 20.5 months, p=0.009) for those with complications. D2 lymphadenectomy and the presence of postoperative complications were independent factors for worse overall survival.

CONCLUSION

Octogenarians undergoing gastrectomy with curative intent have high risk for postoperative clinical complications. D1 lymphadenectomy should be the standard of care in these patients.

Construction of an immune-related gene signature to predict survival and treatment outcome in gastric cancer

Immune cells have emerged as key regulators in the occurrence and development of multiple tumor types. However, it is unclear whether immune-related genes (IRGs) and the tumor immune microenvironment can predict prognosis for patients with gastric cancer (GC). The mRNA expression data in GC tissues (n = 368) were obtained from The Cancer Genome Atlas (TCGA) database. Differentially expressed IRGs in patients with GC were determined using a computational difference algorithm. A prognostic signature was constructed using COX regression and random survival forest (RSF) analyses. In addition, datasets related to "gemcitabine resistance" and "trastuzumab resistance" (GSE58118 and GSE77346) were obtained for GEO database, and DEGs associated with drug-resistance were screened. Then, we analyzed correlations between gene expression and cancer immune infiltrates via Tumor Immune Estimation Resource (TIMER) site. The cBioportal database was used to analyze drug-resistant gene mutation status and survival. One hundred and fifty-five differentially expressed IRGs were screened between GC and normal tissues, and a prognostic signature consisting of four IRGs (NRP1, PPP3R1, IL17RA, and FGF16) was closely related to the overall survival (OS). According to cutoff value of risk score, patients were divided into high-risk and low-risk group. Patients in the high-risk group had shorter OS compared to the low-risk group in both the training (p < 0.0001) and testing sets (p = 0.0021). In addition, we developed a 5-IRGs (LGR6, DKK1, TNFRSF1B, NRP1, and CXCR4) signature which may participate in drug resistance processes in GC. Survival analysis showed that patients with drug-resistant gene mutations had shorter OS (p = 0.0459) and DFS (p < 0.001). We constructed four survival-related IRGs and five IRGs related to drug resistance which may contribute to predict the prognosis of GC.

IMPACT OF AGING IN THE SURGICAL OUTCOMES OF GASTRIC CANCER PATIENTS

BACKGROUND

As age advances, a higher burden of comorbidities and less functional reserve are expected, however, the impact of aging in the surgical outcomes of gastric cancer (GC) patients is unknown.

OBJECTIVE

The aim of this study is to evaluate surgical outcomes of GC patients according to their age group.

METHODS

Patients submitted to gastrectomy with curative intent due to gastric adenocarcinoma were divided in quartiles. Each group had 150 patients and age limits were: ≤54.8, 54.9-63.7, 63.8-72, >72. The outcomes assessed were: postoperative complications (POC), 90-day postoperative mortality, disease-free survival (DFS) and overall survival (OS).

RESULTS

Major surgical complications were 2.7% in the younger quartile vs 12% for the others (P=0.007). Major clinical complications raised according to the age quartile: 0.7% vs 4.7% vs 5.3% vs 7.3% (P<0.042). ASA score and age were independent risk factors for major POC. The 90-day mortality progressively increased according to the age quartile: 1.3% vs 6.0% vs 7.3% vs 14% (P<0.001). DFS was equivalent among quartile groups, while OS was significantly worse for those >72-year-old. D2 lymphadenectomy only improved OS in the three younger quartiles. Age >72 was an independent risk factor for worse OS (hazard ratio of 1.72).

CONCLUSION

Patients <55-year-old have less surgical complications. As age progresses, clinical complications and 90-day mortality gradually rise. OS is worse for those above age 72, and D2 lymphadenectomy should be individualized after this age.

Remnant gastric cancer: a neglected group with high potential for immunotherapy

PURPOSE

The importance of targeted therapy and interest in the study of predictive markers in gastric cancer (GC) have increased in recent years with the use of anti-HER2 therapy and immunotherapy with anti-PD1/PD-L1 for microsatellite instability (MSI) and PD-L1 + tumors. However, the behavior of remnant GC (RGC) in this scenario is poorly reported. Thus, this study aims to evaluate the clinicopathological characteristics and prognosis of RGC and its association with the expression of current markers for targeted therapy.

METHODS

All RGC resections performed in a single center from 2009 to 2019 were retrospectively reviewed. As a comparison group, 53 primary proximal GC (PGC) who underwent total D2-gastrectomy were selected. HER2, MSI status and PD-L1 expression were analyzed by immunohistochemistry. Combined Positive Score (CPS) was used to determine PD-L1 positivity.

RESULTS

A total of 40 RGC were included. RGC patients were older (p = 0.001), had lower BMI (p = 0.001) and number of resected lymph nodes (p < 0.001) compared to the PGC. Regarding markers expression, MSI was higher in RGC than PGC (27.5% vs 9.4%, p = 0.022). The frequency of CPS-positive was 32.5% and 26.4% in RGC and PGC, respectively (p = 0.522). HER2 positivity was 17.5% and 22.6% for RGC and PGC, respectively (p = 0.543). In survival analysis, DFS was better for RGC CPS-positive than RGC CPS-negative (p = 0.039) patients. There was no difference in survival considering MSI status.

CONCLUSION

RGC had higher incidence of MSI than PGC, and CPS-positive RGC was associated with better survival. The immunological profile of RGC patients suggests that they would be good candidates for immunotherapy.

Prediction scores for complication and recurrence after multivisceral resection in gastric cancer

BACKGROUND

Multivisceral resection (MVR) is indicated in T4b gastric cancer (GC) when R0 can be achieved. Patient's selection for MVR is imperative, since it carries an increased risk for postoperative complications (POC) and disease recurrence. This study aims to elaborate prediction scores for POC and recurrence after MVR for cT4b GC.

METHODS

Patients who underwent MVR with curative intent due to cT4b gastric adenocarcinoma were selected from our prospective database. Scoring models were based on the variables identified as risk factors for the studied outcome. Through binary regression the model that best predicted the outcome was created.

RESULTS

From 237 MVRs, 58 fulfilled the inclusion criteria. Males were 70.7%, mean age was 61.8 years. A pT4b was confirmed in 34 patients, 29 had 2 or more adjacent organs removed. Major POC occurred in 25.9%, mortality was 8.6%. Overall survival (OS) and disease-free survival (DFS) were similar for pT4b and non-pT4b. DFS was worse for pN+ and when >2 adjacent organs were removed. Scoring models included 5 and 6 parameters for POC and recurrence, respectively, and their accuracy was 80.6% (95%CI = 0.69-0.92) and 78% (95%CI = 0.66-0.90). The POC and recurrence rates in low- and high-score groups were statistically different (p < 0.001 and p = 0.004, respectively). Patients with high-risk for POC had lower OS (p = 0.036) and DFS was worse in the high-recurrence risk group (p = 0.008).

CONCLUSION

The proposed scoring systems accurately predict POC and recurrence in GC patients undergoing MVR. These models are easy to use and can assist in the adoption of an individualized approach.

Lymph node regression after neoadjuvant chemotherapy: A predictor of survival in gastric cancer

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy (nCMT) has been increasingly used in advanced gastric cancer (GC). However, the prognostic impact of tumor response remains unclear. This study aimed to evaluate if tumor response at the primary site and lymph nodes (LN) correlate with survival in GC patients after nCMT.

METHODS

Patients with gastric adenocarcinoma treated with nCMT followed by gastrectomy were evaluated. Residual tumor was graded from 0% to 100%, defining two groups: poor (PR) and major response (MR). LN regression rate (LNRR) was determined based on tumor/fibrosis examination at each LN and a cutoff value established by receiver operating characteristic curve.

RESULTS

Among 62 cases, 20 (32.2%) had MR and 42 (67.7%) PR. Smaller size, diffuse histology, lower ypT status and less advanced stage were associated with the MR group. Based on cutoff value of 57, 45.6% and 54.4% patients were classified as low-LNRR and high-LNRR. High-LNRR correlated with absence of venous, lymphatic and perineural invasion, and less advanced stage. Survival was equivalent between MR and PR (P = .956). High-LNRR had better disease-free survival (DFS) than low-LNRR (P < .001). In multivariate analysis, only LNRR associated with DFS.

CONCLUSION

High-LNRR associates with DFS in GC treated with nCMT. Response at the primary site does not correlate with survival.

Multivisceral resection vs standard gastrectomy for gastric adenocarcinoma

INTRODUCTION

Multivisceral resection (MVR) is potentially curative for selected gastric cancer patients, supposedly at the cost of increased complications. However, current data comparing MVR to standard gastrectomy (SG) is lacking.

OBJECTIVES

Compare complications and survival after MVR and SG.

METHODS

In a retrospective cohort of 1015 patients with gastric adenocarcinoma, 58 underwent MVR and 466 SG. Groups were compared concerning their characteristics, complications, and survival.

RESULTS

One hundred seventy-six patients had postoperative complications. Major complications were more frequent after MVR (P = .002). Surgical mortality was 8.6% and 4.9% for MVR and SG (P = .221). Older age, higher morbidities, and MVR were independent risk factors for major complications. The odds ratio for major complications was 5.89 for MVR with one or two organs and 38.01 for MVR with three or more organs. The pancreas was the most commonly removed organ and pT4b disease were confirmed in 34 (58.6%) of the MVR cases. Disease-free survival (DFS) was lower in MVR patients (51% vs 77.8%; P < .001), being worse according to the number of organs resected. In pN+ patients, DFS was worse after MVR. DFS was equivalent to pT4b and non-pT4b in the MVR group.

CONCLUSIONS

Increased morbidity and lower survival are expected for gastric cancer patients undergoing MVR.

Oncological Robot-Assisted Gastrectomy: Technical Aspects and Ongoing Data

Robotic surgery through the da Vinci Surgical System has been widely spread for many procedures across the globe for several years. At the same time, robot-assisted gastrectomy for gastric cancer (GC) remains mostly available only in specialized centers in minimally invasive surgery and stomach neoplasm. The robotic platform has been introduced to overcome possible drawbacks of the laparoscopic approach. The safety and the feasibility of robotic radical gastrectomy have been reported in many retrospective case series and nonrandomized prospective studies. However, the superiority of robotic gastrectomy over the laparoscopic access has not yet been proven. This study aimed to report the technical aspects of robot-assisted gastrectomy for GC as well as the latest evidence on this subject.

Gastric partitioning for the treatment of malignant gastric outlet obstruction

BACKGROUND

Gastric outlet obstruction (GOO) is one of the main complications in stage IV gastric cancer patients. This condition is usually managed by gastrojejunostomy (GJ). However, gastric partitioning (GP) has been described as an alternative to overcoming possible drawbacks of GJ, such as delayed gastric emptying and tumor bleeding.

AIM

To compare the outcomes of patients who underwent GP and GJ for malignant GOO.

METHODS

We retrospectively analyzed 60 patients who underwent palliative gastric bypass for unresectable distal gastric cancer with GOO from 2009 to 2018. Baseline clinicopathological characteristics including age, nutritional status, body mass index, and performance status were evaluated. Obstructive symptoms were graded according to GOO score (GOOS). Surgical outcomes evaluated included duration of the procedure, surgical complications, mortality, and length of hospital stay. Acceptance of oral diet after the procedure, weight gain, and overall survival were the long-term outcomes evaluated.

RESULTS

GP was performed in 30 patients and conventional GJ in the other 30 patients. The mean follow-up was 9.2 mo. Forty-nine (81.6%) patients died during that period. All variables were similar between groups, with the exception of worse performance status in GP patients. The mean operative time was higher in the GP group (161.2 vs 85.2 min, P < 0.001). There were no differences in postoperative complications and surgical mortality between groups. The median overall survival was 7 and 8.4 mo for the GP and GJ groups, respectively (P = 0.610). The oral acceptance of soft solids (GOOS 2) and low residue or full diet (GOOS 3) were reached by 28 (93.3%) GP patients and 22 (75.9%) GJ patients (P = 0.080). Multivariate analysis demonstrated that GOOS 2 and GOOS 3 were the main prognostic factors for survival (hazard ratio: 8.90, 95% confidence interval: 3.38-23.43, P < 0.001).

CONCLUSION

GP is a safe and effective procedure to treat GOO. Compared to GJ, it provides similar surgical outcomes with a trend to better solid diet acceptance by patients.

Expression Profile of Markers for Targeted Therapy in Gastric Cancer Patients: HER-2, Microsatellite Instability and PD-L1

BACKGROUND

The assessment of human epidermal growth factor receptor 2 (HER2), microsatellite instability (MSI) and programmed cell death-ligand 1 (PD-L1) expression is relevant for the selection and effectiveness of targeted therapy in gastric cancer (GC).

OBJECTIVE

We aimed to investigate the clinicopathological characteristics and prognosis of GC patients according to these profiles.

METHODS

GC patients who underwent gastrectomy with D2 lymphadenectomy were eligible. HER2, MSI status and PD-L1 expression were analyzed by immunohistochemistry (IHC). Patients were grouped as follows: HER2+ group, immunotherapy (IT) group (MSI and/or PD-L1+), and non-targeted therapy (NTT) group (stable microsatellite and HER2/PD-L1-).

RESULTS

Among 282 patients, 50 (17.7%) were HER2+ and 79 (28%) MSI/PD-L1+. Fifteen had HER2+ and MSI/PD-L1+, while 168 (59.6%) were in the NTT group. HER2+ GCs were related to male gender (p = 0.007), intestinal type (p = 0.001) and less advanced pTNM stage (p = 0.029). Older age (p = 0.003), subtotal gastrectomy (p = 0.025), intestinal type (p = 0.008), pN0 status (p = 0.002) and less advanced pTNM stage (p = 0.001) were associated with the IT group. IT GC had better disease-free survival (DFS) and overall survival than the NTT group (p = 0.015 and p = 0.027, respectively). Concerning patients eligible for the standard adjuvant therapy, the treatment impacted positively on DFS for HER2+ and NTT groups (p = 0.003 and p = 0.042, respectively). No difference in DFS was seen between IT patients who received perioperative/adjuvant therapy and those treated only with surgery (p = 0.160).

CONCLUSIONS

GC patients who exhibited markers that can serve as an indication for known targeted therapy represent 40.4% of cases. The IT group was associated with a better prognosis. No benefit with standard adjuvant treatment appears to be achieved in MSI/PD-L1+ GCs.