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Lilley EJ, Lu P, Robinson K, Griffith H, Mansfield P, Ikoma N, Badgwell BD. High symptom burden in patients undergoing gastrectomy for cancer. J Surg Oncol 2024; 129:228-232. [PMID: 37849370 DOI: 10.1002/jso.27492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/13/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND There is little data describing symptom burden before or after gastrectomy for patients with cancer. We aimed to examine the perioperative patterns of symptom severity in patients undergoing gastrectomy. METHODS In this single-institution prospective cohort study, patients scheduled to undergo gastrectomy for cancer completed serial symptom measurement questionnaires preoperatively, at postoperative day (POD) 1-3, and POD 4-7. The percent of patients with moderate to severe scores was calculated at each time point. RESULTS Thirty-nine patients completed 94 surveys. Preoperatively, 46% reported at least one moderate/severe symptom. This increased to 88% during POD 1-3 and 79% during POD 4-7. During the preoperative period, 25% of patients reported moderate to severe interference in at least one aspect of daily life. This increased to 73% of patients at both POD 1-3 and POD 4-7. CONCLUSIONS Patients undergoing gastrectomy for cancer frequently experience symptoms that interfere with daily life. A better understanding of these symptoms may improve patients' experiences with, and recovery from, gastrectomy.
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Affiliation(s)
- Elizabeth J Lilley
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pamela Lu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristen Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heather Griffith
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Mitchell KG, Bayley EM, Ikoma N, Antonoff MB, Mehran RJ, Rajaram R, Rice DC, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Maru DM, Erasmus JJ, Weston BR, Ajani JA, Badgwell BD, Hofstetter WL. Gastric Extent of Tumor Predicts Peritoneal Metastasis in Siewert II Adenocarcinoma. Ann Thorac Surg 2024; 117:320-326. [PMID: 37080372 DOI: 10.1016/j.athoracsur.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/14/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Whereas current guidelines recommend staging laparoscopy for most patients with potentially resectable gastric cancer, such a recommendation for patients with adenocarcinoma of the gastroesophageal junction (AEG) is lacking. This study sought to identify baseline clinicopathologic characteristics associated with peritoneal metastasis (PM) among patients with Siewert II AEG. METHODS Trimodality therapy-eligible patients with Siewert II AEG (2000-2015, single institution) were retrospectively identified. A composite PM outcome was defined as follows: (1) PM at staging laparoscopy; (2) PM diagnosed during neoadjuvant chemoradiation; or (3) PM ≤6 months postoperatively. Logistic regression was used to identify features associated with PM; bootstrapped analysis (Youden J) identified the distal tumor extension that best discriminated the composite outcome. RESULTS Of 188 patients, a composite PM outcome was observed in 26 of 188 (13.8%); 12 of 26 had positive staging laparoscopy, 10 of 26 experienced PM during chemoradiation, and 4 of 26 had PM ≤6 months postoperatively. Tumor extension below the GEJ was greater in patients with PM (median, 4.0 cm [interquartile range, 3.0-5.0] vs 3.0 cm [interquartile range, 2.0-3.0]; P < .001). All patients with PM had cT3 to cT4 tumors. Among patients with cT3 to cT4 tumors (n = 168 of 188; 89.4%), distal tumor extent (odds ratio, 1.67/cm; 95% CI, 1.23-2.28; P = .001) was independently associated with increased odds of PM. Gastric tumor extension ≥4 cm remained independently associated with PM (OR, 5.14; 95% CI, 2.11-12.53; P < .001) after adjustment for signet ring cell status. CONCLUSIONS Distal tumor extent beyond the GEJ is independently associated with increased odds of PM in patients with Siewert II AEG. Patients with extensive gastric involvement should therefore be considered for staging laparoscopy before trimodality therapy.
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Affiliation(s)
- Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erin M Bayley
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dipen M Maru
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeremy J Erasmus
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian R Weston
- Department of Gastroenterology Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Daniel SK, Badgwell BD, McKinley SK, Strong VE, Poultsides GA. Great Debate: Chemoradiation Should be Added to Chemotherapy as a Neoadjuvant Treatment Strategy for Resectable Gastric Adenocarcinoma. Ann Surg Oncol 2024; 31:405-412. [PMID: 37865940 DOI: 10.1245/s10434-023-14378-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/17/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Most patients with resectable gastric cancer present with locally advanced disease and warrant neoadjuvant chemotherapy based on level 1 evidence. However, the incremental benefit of adding radiation to chemotherapy as a neoadjuvant treatment strategy for these patients is less clear. METHODS While awaiting the results of two ongoing randomized clinical trials attempting to specifically address this question (TOPGEAR and CRITICS-II), this article presents the debate between two gastric cancer surgery experts supporting each side of the argument on the use or omission of neoadjuvant radiation in this setting. RESULTS On the one hand, neoadjuvant radiation may be better tolerated compared with modern triplet chemotherapy and may be associated with higher rates of major pathologic response. Additionally, there is evidence to suggest that radiation may offer a survival benefit when the tumor is located at the gastroesophageal junction or there is concern for a margin-positive resection. However, in the setting of adequate surgery, no survival benefit has been demonstrated by adding radiation to modern chemotherapy, likely reflecting the fact that death from gastric cancer is a result of distant recurrence, which is not addressed by local treatment such as radiotherapy. CONCLUSION While awaiting the results of the TOPGEAR and CRITICS-II trials, this discussion of current evidence can facilitate the refinement of an optimal neoadjuvant therapy strategy in patients with resectable gastric cancer.
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Affiliation(s)
- Sara K Daniel
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sophia K McKinley
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Hirata Y, Gottumukkala V, Ajith J, Schmeisser JA, Ninan EP, Maxwell JE, Snyder RA, Kim MP, Tran Cao HS, Tzeng CWD, Badgwell BD, Katz MHG, Ikoma N. Laparoscopic transverse abdominis plane block: how I do it and a cost efficiency analysis. Langenbecks Arch Surg 2023; 409:16. [PMID: 38147123 DOI: 10.1007/s00423-023-03210-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE To determine the efficacy and efficiency of laparoscopic transverse abdominis plane block (Lap-TAP) in patients undergoing pancreatoduodenectomy and gastrectomy compared to those of ultrasound-guided TAP (US-TAP). METHODS We retrospectively analyzed the records of patients who underwent open or minimally invasive (MIS) pancreatoduodenectomy and major gastrectomy with the use of Lap-TAP or US-TAP at our institution between November 1, 2018, and September 30, 2021. We compared the estimated time and cost associated with Lap-TAP and US-TAP. We also compared postoperative opioid use and pain scores between patients who underwent open laparotomy with these TAPs. RESULTS A total of 194 patients were included. Overall, 114 patients (59%) underwent pancreatectomy, and 80 patients (41%) underwent gastrectomy. Additionally, 138 patients (71%) underwent an open procedure, and 56 patients (29%) underwent MIS. A total of 102 patients (53%) underwent US-TAP, and 92 (47%) underwent Lap-TAP. The median time to skin incision was significantly shorter in the Lap-TAP group (US-TAP, 59 min vs. Lap-TAP, 45 min; P < 0.001), resulting in an estimated reduction in operation cost by $602. Pain scores and postoperative opioid use were similar between Lap-TAP and US-TAP among open surgery patients, indicating equivalent pain control between Lap-TAP and US-TAP. CONCLUSION Lap-TAP was equally effective in pain control as US-TAP after pancreatectomy and gastrectomy, and Lap-TAP can reduce operation time and cost. Lap-TAP is considered the preferred approach for MIS pancreatectomy and gastrectomy, which occasionally needs conversion to laparotomy.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeeva Ajith
- Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason A Schmeisser
- Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth P Ninan
- Division of Procedures and Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Badgwell BD. Multidisciplinary Care: How to Win Friends and Influence Your Colleagues to Provide Quality Goals-of-Care Discussions. Ann Surg Oncol 2023; 30:7913-7914. [PMID: 37723357 DOI: 10.1245/s10434-023-14291-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 09/20/2023]
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Blumenthaler AN, Robinson KA, Hodge C, Xiao L, Lilley EJ, Griffin JF, White MG, Day R, Tanco K, Bruera E, Badgwell BD. Communication Frameworks for Palliative Surgical Consultations: A Randomized Study of Advanced Cancer Patients. Ann Surg 2023; 278:e1110-e1117. [PMID: 36806227 PMCID: PMC10440363 DOI: 10.1097/sla.0000000000005823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
OBJECTIVE To evaluate whether patients with advanced cancer prefer surgeons to use the best case/worst case (BC/WC) communication framework over the traditional risk/benefit (R/B) framework in the context of palliative surgical scenarios. BACKGROUND Identifying the patient's preferred communication frameworks may improve satisfaction and outcome measures during difficult clinical decision-making. METHODS In a video-vignette-based randomized, double-blinded study from November 2020 to May 2021, patients with advanced cancer viewed 2 videos depicting a physician-patient encounter in a palliative surgical scenario, in which the surgeon uses either the BC/WC or the R/B framework to discuss treatment options. The primary outcome was the patients' preferred video surgeon. RESULTS One hundred fifty-five patients were approached to participate; 66 were randomized and 58 completed the study (mean age 55.8 ± 13.8 years, 60.3% males). 22 patients (37.9%, 95% CI: 25.4%-50.4%) preferred the surgeon using the BC/WC framework, 21 (36.2%, 95% CI: 23.8%-48.6%) preferred the surgeon using the R/B framework, and 15 (25.9%, 95% CI: 14.6%-37.2%) indicated no preference. High trust in the medical profession was inversely associated with a preference for the surgeon using BC/WC framework (odds ratio: 0.83, 95% CI: 0.70-0.98, P = 0.03). The BC/WC framework rated higher for perceived surgeon's listening (4.6 ± 0.7 vs 4.3±0.9, P = 0.03) and confidence in the surgeon's trustworthiness (4.3 ± 0.8 vs 4.0 ± 0.9, P = 0.04). CONCLUSIONS Surgeon use of the BC/WC communication framework was not universally preferred but was as acceptable to patients as the traditional R/B framework and rated higher in certain aspects of communication. A preference for a surgeon using BC/WC was associated with lower trust in the medical profession. Surgeons should consider the BC/WC framework to individualize their approach to challenging clinical discussions.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - Caitlin Hodge
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Lianchun Xiao
- Department of Biostatistic; University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth J Lilley
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - James F Griffin
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Surgical Oncology, Piedmont Healthcare, Athens, GA
| | - Michael G White
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan Day
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Hirata Y, Chiang YJ, Estrella JS, Das P, Minsky BD, Blum Murphy M, Ajani JA, Mansfield P, Badgwell BD, Ikoma N. Independent Stage Classification for Gastroesophageal Junction Adenocarcinoma. Cancers (Basel) 2023; 15:5137. [PMID: 37958312 PMCID: PMC10650394 DOI: 10.3390/cancers15215137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023] Open
Abstract
In gastroesophageal junction (GEJ) adenocarcinoma cases, a prognosis based on ypTNM staging could be affected by preoperative therapy. Patients with esophageal adenocarcinoma and gastric adenocarcinoma who underwent preoperative therapy followed by surgical resection from 2006 through 2017 were identified in the National Cancer Database. To enable stage-by-stage OS comparisons, tumors were classified into four gross ypTNM groups: ypT1/2, N-negative; ypT1/2, N-positive; ypT3/4, N-negative; and ypT3/4, N-positive. Prognostic factors were examined, and an OS prediction nomogram was developed for patients with abdominal/lower esophageal and gastric cardia adenocarcinoma, representing GEJ cancers. We examined 25,463 patient records. When compared by gross ypTNM group, the abdominal/lower esophageal and gastric cardia adenocarcinoma groups had similar OS rates, differing from those of other esophageal or gastric cancers. Cox regression analysis of patients with GEJ cancers showed that preoperative chemoradiotherapy was associated with shorter OS than preoperative chemotherapy after adjustment for the ypTNM group (hazard ratio 1.31, 95% CI 1.24-1.39, p < 0.001), likely owing to downstaging effects. The nomogram had a concordance index of 0.833 and a time-dependent area under the curve of 0.669. OS prediction in GEJ adenocarcinoma cases should include preoperative therapy regimens. Our OS prediction nomogram provided reasonable OS prediction for patients with GEJ adenocarcinoma, and future validation is needed.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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8
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Jain AJ, Badgwell BD. Current Evidence for the Use of HIPEC and Cytoreductive Surgery in Gastric Cancer Metastatic to the Peritoneum. J Clin Med 2023; 12:6527. [PMID: 37892663 PMCID: PMC10607605 DOI: 10.3390/jcm12206527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Gastric cancer (GCa) is an aggressive malignancy, representing the third leading cause of cancer mortality worldwide. The poor prognosis of GCa can be associated with the prevalence of peritoneal metastasis (PM). Current international and national GCa treatment guidelines only recommend palliative treatment options for patients with PM. Since the 1980s there have been multiple single arm trials, randomized controlled trials, and metanalysis investigating the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced GCa, with or without PM. Results from these studies have been encouraging, with some large-volume centers even incorporating HIPEC into their treatment algorithms for patients with advanced GCa. Additionally, there are several ongoing trials that, when completed, will increase our understanding of the efficacy of CRS & HIPEC in patients with GCa metastatic to the peritoneum. Herein we review the current evidence, ongoing trials, consensus guidelines, and future considerations regarding the use of CRS & HIPEC in patients suffering from GCa with PM.
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Affiliation(s)
- Anish J. Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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9
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Hirata Y, Chiang YJ, Mansfield P, Badgwell BD, Ikoma N. Trends of Oncological Quality of Robotic Gastrectomy for Gastric Cancer in the United States. World J Oncol 2023; 14:371-381. [PMID: 37869235 PMCID: PMC10588505 DOI: 10.14740/wjon1657] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/09/2023] [Indexed: 10/24/2023] Open
Abstract
Background Robotic gastrectomy (RG) has been increasingly used for treatment of gastric cancer in the United States. However, it is unknown if there has been a nationwide improvement of short-term safety outcomes and oncological quality metrics over time. Methods We used the National Cancer Database to identify patients who underwent major gastrectomy from 2010 through 2018. The short-term safety outcomes and oncological metrics were compared between cases of open gastrectomy (OG), laparoscopic gastrectomy (LG), and RG. We also compared the indications and outcomes of RG between the three periods (2010 - 2012, 2013 - 2015, and 2016 - 2018). Results Of the 22,445 patients included, 1,867 (8%) underwent RG. Number of RG continued to increase from only 37 cases performed in 2010 to 412 cases performed in 2018. The number of lymph nodes (LNs) examined (OG, 16; LG, 17; and RG, 19) and the R0 rate (OG, 88%; LG, 92%; and RG 94%) were better for RG than for OG or LG (P < 0.001). In the RG group, the number of LNs examined (first period, 15; third period, 18; P < 0.001), R0 rate (first period, 88.6%; third period, 91.1%; P < 0.001), length of hospital stay (first period, 9 days; third period, 8 days; P < 0.001), 30-day readmission rate (first period, 10.1%; third period, 7.9%; P < 0.001), and 90-day mortality (first period, 7.3%; third period, 6.0%; P = 0.003) continued to improve cohort over time. The ratio of the robotic cases performed in academic institutions gradually increased (first period, 48.6%; third period, 54.3%; P < 0.001). In multivariable analyses, RG was associated with more than 15 LNs being examined (OR, 1.49; 95% CI, 1.34 - 1.65; P < 0.001). The indications for RG appeared expanding to include more advanced stage, high comorbidity, and patients who underwent preoperative therapy. Conclusions RG has been increasingly performed in the past decade. Although its indication was expanded to include more advanced tumors, we found that the oncological quality metrics and safety outcomes of RG have improved over time and were better than those of OG or LG.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Hirata Y, Agnes A, Prakash LR, Mansfield P, Badgwell BD, Ikoma N. Borrmann Type Predicts Response to Preoperative Therapy in Advanced Gastric Cancer. J Gastrointest Cancer 2023; 54:882-889. [PMID: 36308675 DOI: 10.1007/s12029-022-00880-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The Borrmann classification system is widely used to classify advanced gastric cancer (GC). No studies have focused on the relationship between Borrmann type and response to preoperative therapy. METHODS Patients with advanced GC who received preoperative therapy followed by curative-intent gastrectomy from September 2016 through September 2021 were identified. Clinicopathologic characteristics were compared by Borrmann type. Logistic regression models were fit to analyze the relationship between Borrmann type and pCR rate. RESULTS Of the 227 patients who underwent gastrectomy during the period studied, 73 had pretreatment endoscopic images available for analysis. We classified the tumors as follows: Borrmann type 1, 4 (6%); type 2, 17 (23%); type 3, 33 (45%); and type 4, 19 (26%). Nine patients (12%) achieved pCR; 6 of these (67%) had type 1/2 GC and 3 (33%) had type 3. Multivariable logistic regression showed that Borrmann type 3/4 was the only independent factor associated with pCR (odds ratio 0.12; p = 0.023), but 2-year overall survival rates did not differ by Borrmann type (p = 0.216). CONCLUSION Patients with Borrmann type 3/4 advanced GC have a lower likelihood of achieving pCR after preoperative therapy than those with type 1/2 GC. Determining the Borrmann type preoperatively can guide treatment decision-making.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA
| | - Annamaria Agnes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, USA.
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Ikoma N, Grotz T, Kawakubo H, Kim HI, Matsuda S, Hirata Y, Nakao A, Williams LA, Wang XS, Mendoza T, Wang X, Badgwell BD, Mansfield PF, Hyung WJ, Strong VE, Kitagawa Y. Trans-pacific multicenter collaborative study of minimally invasive proximal versus total gastrectomy for proximal gastric and gastroesophageal junction cancers. BMC Surg 2023; 23:262. [PMID: 37653380 PMCID: PMC10472658 DOI: 10.1186/s12893-023-02163-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The current standard operation for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal extension is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to the loss of gastric functions such as production of ghrelin and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) can mitigate these problems by preserving gastric function. However, PG with direct esophagogastric reconstruction is associated with severe postoperative reflux, delayed gastric emptying, and poor quality of life (QoL). Minimally invasive PG (MIPG) with antireflux techniques has been increasingly performed by experts but is technically demanding owing to its complexity. Moreover, the actual advantages of MIPG over minimally invasive TG (MITG) with regards to postoperative QoL are unknown. Our overall objective of this study is to determine the short-term QoL benefits of MIPG. Our central hypotheses are that MIPG is safe and that patients have improved appetite after MIPG with effective antireflux techniques, which leads to an overall QoL improvement when compared with MITG. METHODS Enrollment of a total of 60 patients in this prospective survey-collection study is expected. Procedures (MITG versus MIPG, antireflux techniques for MIPG [double-tract reconstruction versus the double-flap technique]) will be chosen based on surgeon and/or patient preference. Randomization is not considered feasible because patients often have strong preferences regarding MITG and MIPG. The primary outcome is appetite level (reported on a 0-10 scale) at 3 months after surgery. With an expected 30 patients per cohort (MITG versus MIPG), this study will have 80% power to detect a one-point difference in appetite level. Patient-reported outcomes will be longitudinally collected (including questions about appetite and reflux), and specific QoL items, body weight, body mass index and ghrelin, albumin, and hemoglobin levels will be compared. DISCUSSION Surgeons from the US, Japan, and South Korea formed this collaboration with the agreement that the surgical approach to P/GEJ cancers is an internationally important but controversial topic that requires immediate action. At the completion of the proposed research, our expected outcome is the establishment of the benefit and safety of MIPG. TRIAL REGISTRATION This trial was registered with Clinical Trials Reporting Program Registration under the registration number NCI-2022-00267 on January 11, 2022, as well as with ClinicalTrials.gov under the registration number NCT05205343 on January 11, 2022.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| | | | - Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xin Shelley Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tito Mendoza
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Woo-Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Hirata Y, Agnes A, Estrella JS, Blum M, Das P, Minsky BD, Ajani JA, Badgwell BD, Mansfield P, Ikoma N. ASO Visual Abstract: Clinical Impact of Positive Surgical Margins in Gastric Adenocarcinoma in the Era of Preoperative Therapy. Ann Surg Oncol 2023; 30:4948-4949. [PMID: 37193894 DOI: 10.1245/s10434-023-13601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annamaria Agnes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Hirata Y, Agnes A, Estrella JS, Blum Murphy M, Das P, Minsky BD, Ajani JA, Badgwell BD, Mansfield P, Ikoma N. Clinical Impact of Positive Surgical Margins in Gastric Adenocarcinoma in the Era of Preoperative Therapy. Ann Surg Oncol 2023; 30:4936-4945. [PMID: 37106276 DOI: 10.1245/s10434-023-13495-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Microscopically positive (R1) surgical margins after gastrectomy increase gastric cancer recurrence risk, but optimal management after R1 gastrectomy is controversial. We sought to identify the impact of R1 margins on recurrence patterns and survival in the era of preoperative therapy for gastric cancer. METHODS Patients who underwent gastrectomy for adenocarcinoma during 1998-2017 at a major cancer center were enrolled. Clinicopathologic factors associated with positive margins were examined, and incidence, sites, and timing of recurrence and survival outcomes were compared between patients with positive and negative margins. RESULTS Of 688 patients, 432 (63%) received preoperative therapy. Thirty-four patients (5%) had R1 margins. Compared with patients with negative margins, patients with R1 margins more frequently had aggressive clinicopathologic features, such as linitis plastica (odds ratio [OR] 7.79, p < 0.001) and failure to achieve cT downstaging with preoperative treatment (OR 5.20, p = 0.005). The 5 year overall survival (OS) rate was lower in patients with R1 margins (6% vs 60%; p < 0.001), and R1 margins independently predicted worse OS (hazard ratio 2.37, 95% CI 1.51-3.75, p < 0.001). Most patients with R1 margins (58%) experienced peritoneal recurrence, and locoregional recurrence was relatively rare in this group (14%). Median time to recurrence was 8.5 months for peritoneal dissemination and 15.7 months for locoregional recurrence. CONCLUSION R1 margins after gastrectomy were associated with aggressive tumor biology, high incidence of peritoneal recurrence after a short interval, and poor OS. In patients with R1 margins, re-resection to achieve microscopically negative margins has to be considered with caution.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annamaria Agnes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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14
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Green BL, Blumenthaler AN, Gamble LA, McDonald JD, Robinson K, Connolly M, Epstein M, Hernandez JM, Blakely AM, Badgwell BD, Davis JL. Cytoreduction and HIPEC for Gastric Carcinomatosis: Multi-institutional Analysis of Two Phase II Clinical Trials. Ann Surg Oncol 2023; 30:1852-1860. [PMID: 36348206 PMCID: PMC10683488 DOI: 10.1245/s10434-022-12761-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/24/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION There are no approved locoregional therapies for peritoneal carcinomatosis from gastric adenocarcinoma (GA). Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) represents a potential treatment for advanced GA with isolated peritoneal metastasis. PATIENTS AND METHODS Two separate single-institution phase II, single-arm studies evaluating CRS-HIPEC using cisplatin with mitomycin C (NIH: NCT03092518, MDACC: NCT02891447) in patients with GA and confirmed peritoneal metastasis were analyzed. The primary endpoint of each trial was overall survival (OS). Clinical, pathologic, and treatment variables were analyzed for association with outcomes. RESULTS Over 4 years, 41 patients with peritoneal carcinomatosis from GA underwent CRS-HIPEC. All patients had synchronous peritoneal metastasis and received systemic chemotherapy as front-line therapy. A total of 23 patients also received laparoscopic HIPEC prior to open CRS-HIPEC. The majority (63%, n = 26) were male, and median PCI score at CRS-HIPEC was 2. Median OS was 24.9 months from diagnosis and 14.4 months from CRS-HIPEC. Three-year OS was 25% from diagnosis and 22% from CRS-HIPEC. Median RFS was 7.4 months. The rate of 30-day Clavien-Dindo grade ≥ 3 complications was 32%; specifically, the rate of anastomotic leak was 22%. Multivariable analysis identified the number of pathologically positive lymph nodes as an independent predictor of postoperative OS. CONCLUSIONS In patients with gastric adenocarcinoma and isolated peritoneal metastasis treated with CRS-HIPEC, 3-year OS was 22% from CRS-HIPEC, and complications were common. The number of pathologic lymph node metastases was inversely correlated with overall survival. Further investigation of CRS-HIPEC for GA should include patient selection based on response to systemic chemotherapy or incorporate novel intraperitoneal treatment strategies.
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Affiliation(s)
- Benjamin L Green
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren A Gamble
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James D McDonald
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristen Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maureen Connolly
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Monica Epstein
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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15
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Green BL, Blumenthaler AN, Gamble LA, McDonald JD, Robinson K, Connolly M, Epstein M, Hernandez JM, Blakely AM, Badgwell BD, Davis JL. ASO Visual Abstract: Cytoreduction and HIPEC for Gastric Carcinomatosis: Multi-institutional Analysis of Two Phase II Clinical Trials. Ann Surg Oncol 2023; 30:1861-1862. [PMID: 36434483 DOI: 10.1245/s10434-022-12845-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin L Green
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren A Gamble
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James D McDonald
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristen Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maureen Connolly
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Monica Epstein
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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16
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Blumenthaler AN, Bruera E, Badgwell BD. Palliative and Supportive Care Consultation for Patients With Malignant Gastrointestinal Obstruction is Associated With Broad Interdisciplinary Management. Ann Surg 2023; 277:284-290. [PMID: 36745760 PMCID: PMC9902762 DOI: 10.1097/sla.0000000000004974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess rates of palliative care (PC) involvement in the care of patients with malignant gastrointestinal obstruction (GIO) and its influence on interdisciplinary team involvement. BACKGROUND Malignant GIO is an advanced oncologic diagnosis with associated poor prognosis. Data regarding PC and interdisciplinary team involvement in these patients is lacking. METHODS We identified consecutive surgical consultations for GIO in cancer patients at a single institution from August 2017 to July 2019. Clinical characteristics were collected. Rates of PC consultation, ACP discussion, code status change to do not resuscitate, and interdisciplinary service consultation were evaluated. RESULTS We identified 200 patients with consultations for GIO, of whom 114 (57%) had malignant GIO and were included in our study. Of these patients, 95 (83%) had stage IV disease; 68 (60%) had peritoneal metastasis, and 70 (61%) had other intra-abdominal recurrence or metastasis. PC consultation was obtained in 69 patients (61%). PC consultation was associated with higher rates of ACP discussion (64% vs 29%; P < 0.001), code status change to do not resuscitate (30% vs 2%; P < 0.001), nonsurgical procedure (46% vs 11%; P < 0.001), discharge to hospice (30% vs 7%; P < 0.001), and involvement of spiritual care (48% vs 22%; P = 0.01), social work (77% vs 42%, P < 0.001), psychology/psychiatry (42% vs 4%, P < 0.001), nutrition (86% vs 62%, P = 0.006), physical therapy (54% vs 31%, P = 0.02), and occupational therapy (42% vs 16%, P = 0.004). CONCLUSIONS PC consultation benefits patients with malignant GIO by facilitating comprehensive interdisciplinary care, ACP discussions, and transition to hospice care, where appropriate. Diagnosis of malignant GIO should be a trigger for PC consultation or, in facilities with limited PC resources, consideration of deliberately broad interdisciplinary consultation.
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Affiliation(s)
- Alisa N. Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston,
TX
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston,
TX
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17
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Hirata Y, Mansfield P, Badgwell BD, Ikoma N. Evidence-Based Surgical Approach to Gastroesophageal Junction Cancer: How We Do Robotic Transhiatal Lower Mediastinal Dissection and Esophagojejunostomy. Ann Surg Oncol 2023; 30:2956. [PMID: 36658247 DOI: 10.1245/s10434-022-13057-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023]
Abstract
Currently available data suggest that gastroesophageal junction (GEJ) cancers with an esophageal extension less than 2 cm can be removed using gastrectomy with a limited esophagectomy via a transhiatal approach and selective lower mediastinal dissection.1 In this multimedia article, we demonstrate our approach to robotic total gastrectomy with data-driven mediastinal lymph node (LN) dissection and sutured esophagojejunostomy for GEJ cancer.The video shows the case of a 63-year-old man with Siewert type 2 GEJ adenocarcinoma. The size of the tumor was 3 cm, and its esophageal extension was 2 cm. The man underwent preoperative chemoradiotherapy (5-FU/oxaliplatin, 45 Gy) with excellent treatment effect. After dissection of the esophagus from the bilateral diaphragmatic crus, surrounding lymph node (LN) tissue (#110) was identified and dissected. In this case, intraoperative findings showed the posterior lower mediastinal LNs (#112) to be swollen, and they were sampled. Surgeons should take care to avoid penetration of the pleura and thoracic duct injury if pleura penetration is oncologically unnecessary. Because the esophagus often is thickened and prone to ischemia after preoperative chemoradiotherapy,2 the authors perform the anastomosis with hand-suturing techniques regardless whether a robotic or open approach is used. The patient recovered well and was discharged on postoperative day 4 in good condition. Pathology reported a ypT1bN0 tumor with negative margins.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Vassilakopoulou M, Chen HC, Wang X, Harada K, Iwatsuki M, Das P, Blum Murphy M, Matamoros A, Sagebiel T, Devine C, Thomas I, Sanders EM, Shanbhag N, Rogers JE, Lee JH, Weston B, Bhutani MS, Hofstetter W, Nguyen QN, Badgwell BD, Ajani JA. Localized Gastroesophageal Adenocarcinoma in the Elderly: Is Age a Factor Associated with Suboptimal Treatment? Oncology 2022; 101:153-158. [PMID: 36412619 DOI: 10.1159/000525927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/23/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Gastroesophageal adenocarcinoma is relatively common in elderly patients as the incidence increases with age. However, the optimal treatment approach is not well established in this group of patients. The aim of this study is to review our experience for localized gastroesophageal adenocarcinoma in patients aged ≥80 years and to assess association between patient characteristics, clinical factors, and overall survival (OS) in order to optimize the therapeutic approaches for this population. METHODS Patients ≥80 years old treated for localized gastroesophageal adenocarcinoma were retrospectively analyzed. Survival curves were estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards regression models were applied to assess the association between patient characteristics and OS. Factors that were significant in the multivariate model were included in the final reduced model. RESULTS 127 patients ≥80 years old, were included in this study with median age of 83 years. The median follow-up time was 3.2 years, and median OS was 2.5 years (95% CI: 2.0-3.1 years). Independent prognostic factors for OS were Eastern Cooperative Oncology Group (ECOG) performance status (PS) (p = 0.003), baseline clinical stage (p = 0.01), and surgery (p = 0.001). ECOG PS, tumor location, baseline stage, tumor grade, and surgery were included in the final reduced model. CONCLUSION Surgical treatment can improve survival in elderly patients. Therapeutic decisions should be based on the patients' general condition rather that age alone.
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Affiliation(s)
- Maria Vassilakopoulou
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA, .,Department of Medical Oncology, University of Crete, Heraklion, Greece,
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer, Houston, Texas, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer, Houston, Texas, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Aurelio Matamoros
- Department of Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Tara Sagebiel
- Department of Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Catherine Devine
- Department of Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Irene Thomas
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth M Sanders
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jane E Rogers
- Department of Pharmacy Clinical Programs, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Brian Weston
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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19
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Hirata Y, Kim HI, Grotz TE, Matsuda S, Badgwell BD, Ikoma N. The role of proximal gastrectomy in gastric cancer. Chin Clin Oncol 2022; 11:39. [PMID: 36336898 DOI: 10.21037/cco-22-82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
Over the past 30 years, the prevalence of upper third gastric cancer (GC) and gastroesophageal junction (GEJ) cancer has increased. Total gastrectomy with D2 lymph node dissection is the standard surgical treatment for non-early (T2 or higher) upper third and GEJ cancers, but total gastrectomy often results in post-gastrectomy syndrome (5-50%), consisting of weight loss, dumping syndrome, and anemia. Proximal gastrectomy (PG) has the potential to avoid these postoperative problems by preserving stomach function. However, PG has historically been discouraged by surgeons owing to the high incidence of postoperative reflux esophagitis (20-65%), anastomotic stenosis, and decreased quality of life. In recent years, anti-reflux reconstruction techniques, such as the double flap technique and double-tract reconstruction, have been developed to be performed after PG, and evidence has emerged that these techniques not only reduce the incidence of postoperative reflux esophagitis but also decrease postoperative weight loss and prevent anemia. Prospective studies are underway to determine whether PG with anti-reflux techniques improves patient-reported quality of life. In the present work, we reviewed available evidence for the use of PG for GC and GEJ cancer, including oncologically appropriate patient selection for PG, potential functional benefits of PG over TG, and various types of reconstructions that can be performed after PG, as well as future research on the use of PG.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Hirata Y, Witt RG, Prakash LR, Arvide EM, Robinson KA, Gottumukkala V, Tzeng CWD, Mansfield P, Badgwell BD, Ikoma N. ASO Visual Abstract: Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy. Ann Surg Oncol 2022; 29:5873-5874. [PMID: 35771369 DOI: 10.1245/s10434-022-12074-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen A Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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22
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Weng J, Ajani JA, Murphy MB, Badgwell BD, Tchakarov AS, Mamlouk O, Das P. Immunotherapy Recall: Chemoradiation-Induced Reactivation of Immune Checkpoint Inhibitor Nephritis. JCO Precis Oncol 2022; 6:e2200049. [PMID: 35952321 DOI: 10.1200/po.22.00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Julius Weng
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amanda S Tchakarov
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Omar Mamlouk
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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DiPeri TP, Newhook TE, Day RW, Chiang YJ, Dewhurst WL, Arvide EM, Bruno ML, Scally CP, Roland CL, Katz MH, Vauthey JN, Chang GJ, Badgwell BD, Perrier ND, Grubbs EG, Lee JE, Tzeng CWD. A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients. Surg Open Sci 2022; 9:51-57. [PMID: 35663797 PMCID: PMC9161107 DOI: 10.1016/j.sopen.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. Methods Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. Results Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742). Conclusion The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.
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Affiliation(s)
- Timothy P. DiPeri
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy E. Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan W. Day
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney L. Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elsa M. Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Morgan L. Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher P. Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina L. Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H.G. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J. Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D. Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G. Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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24
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Hirata Y, Witt RG, Prakash LR, Arvide EM, Robinson KA, Gottumukkala V, Tzeng CWD, Mansfield P, Badgwell BD, Ikoma N. Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy. Ann Surg Oncol 2022; 29:5861-5870. [PMID: 35507230 DOI: 10.1245/s10434-022-11836-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/11/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Minimally invasive, robotic gastrectomy is associated with better short-term outcomes and quicker functional recovery. However, the degree to which the robotic approach influences postoperative pain and opioid use after gastrectomy is unknown. Our primary aim was to determine whether the robotic approach to gastrectomy reduces postoperative opioid use compared with the open approach. METHODS Patients who underwent gastrectomy (November 2018 to September 2021) were identified retrospectively. Clinical characteristics, short-term surgical outcomes, oral morphine equivalent (OME) use, and pain scores were collected. Both groups were managed through an enhanced recovery program in the perioperative period. RESULTS Of 81 patients, 50 underwent open and 31 underwent robotic gastrectomy. Compared with open gastrectomy patients, robotic gastrectomy patients had longer surgery time (360 vs. 288 min), less blood loss (50 vs. 138 mL), and shorter hospital stay (4 vs. 6 days) (all medians, P < 0.001). Robotic gastrectomy patients used lower OMEs on postoperative days 0-4 (all P < 0.05) and in total for days 0-4 (total mean dose 65.0 vs. 169.5 mg; P < 0.001) than did open gastrectomy patients. The robotic gastrectomy patients were prescribed a lower mean OME dose than the open gastrectomy patients (19.0 vs. 29.0 mg, respectively; P = 0.001). Multivariable analysis showed that robotic approach was associated with lower opioid use (odds ratio 3.70; 95% CI 1.01-14.3; P = 0.049). CONCLUSIONS Compared with open gastrectomy, robotic gastrectomy reduces opioid use in the early postoperative period and is associated with fewer OME discharge prescriptions and shorter hospital stay.
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Affiliation(s)
- Yuki Hirata
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen A Robinson
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Departments of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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25
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Hirata Y, Scally C, Badgwell BD, Ikoma N. Robotic excision of gastric and duodenal gastrointestinal stromal tumor. Updates Surg 2022; 74:1483-1484. [PMID: 35247206 DOI: 10.1007/s13304-022-01261-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
Gastrointestinal stromal tumors (GIST) originate from interstitial cells of Cajal and are most often located in the stomach. The mainstay of treatment for GIST is surgical resection. Laparoscopic wedge resection of gastric GIST using linear staplers has been commonly performed and shown to be feasible and safe. However, this technique is not suitable for tumors at particular anatomical locations such as the gastric cardia near the gastroesophageal junction, the lesser curvature of stomach, and the duodenum. The robotic surgery platform with augmented surgical skills has enabled precise dissection and suturing. We consider robotic GIST excision with primary suture closure to be useful for lesions in the above-mentioned locations. In this video, we demonstrate our techniques of robotic excision of gastric and duodenal GIST. At our institution, 13 patients underwent robotic excision of gastric and duodenal GIST between November 2018 and July 2021. Tumor locations included the cardia (n = 2), gastric body (n = 10) [lesser curvature (n = 3) and other (n = 7)], and the duodenum (n = 1). There were no conversions to open laparotomy. The median operation time was 160 min (range 80-270), and median blood loss was 25 mL (range 5-50). The median length of hospital stay was 3 days (range 1-4). There were no complications or readmissions within 90 days. We demonstrated the feasibility and safety of robotic resection of GIST located at the stomach and duodenum. Especially in anatomically challenging locations where the stapling technique is not suitable, robotic approaches are considered useful for performing precise excision.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Christopher Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA.
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26
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Shi C, Badgwell BD, Grabsch HI, Gibson MK, Hong SM, Kumarasinghe P, Lam AK, Lauwers G, O'Donovan M, van der Post RS, Tang L, Ushiku T, Vieth M, Selinger CI, Webster F, Nagtegaal ID. Data Set for Reporting Carcinoma of the Stomach in Gastrectomy. Arch Pathol Lab Med 2021; 146:1072-1083. [DOI: 10.5858/arpa.2021-0225-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
Context.—
A standardized detailed surgical pathology report is the cornerstone of gastric cancer management.
Objective.—
To guide management and prognostication for patients with gastric carcinomas globally, the International Collaboration on Cancer Reporting aimed to produce an evidence-based international pathology reporting data set with a panel of globally recognized expert pathologists and clinicians.
Design.—
Based on published guidelines/data sets for gastric carcinomas, a working draft was developed by the chair of the expert panel of pathologists and clinicians. The draft was then circulated to the panel and discussed in a series of teleconferences and email communications until consensus was achieved. The draft data set was uploaded on the International Collaboration on Cancer Reporting Web site for public comment. The data set was reviewed in consideration of the feedback, and a final version was approved by the panel.
Results.—
This data set was developed for gastrectomy specimens for primary gastric carcinomas, including neuroendocrine carcinomas and mixed neuroendocrine-nonneuroendocrine neoplasms. Well-differentiated neuroendocrine tumors, nonepithelial malignancies, and secondary tumors were excluded from this data set. The final data set contains 15 core (required) elements and 8 noncore (recommended) elements. A commentary is provided for each element.
Conclusions.—
The International Collaboration on Cancer Reporting has published freely available, evidence-based data sets for gastric cancer reporting. Standardized reporting has been shown to improve patient care and facilitates data exchange and analysis for quality assurance, cancer epidemiology, and clinical and basic research.
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Affiliation(s)
- Chanjuan Shi
- From the Department of Pathology, Duke University School of Medicine, Durham, North Carolina (Shi)
| | - Brian D. Badgwell
- The Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston (Badgwell)
| | - Heike I. Grabsch
- The Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands (Grabsch)
- The Division of Pathology & Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom (Grabsch)
| | - Michael K. Gibson
- The Division of Hematology and Oncology, Vanderbilt University Medical Center, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee (Gibson)
| | - Seung-Mo Hong
- The Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (Hong)
| | - Priyanthi Kumarasinghe
- PathWest Laboratory Medicine, PathWest QEII Medical Center, Perth, Australia (Kumarasinghe)
| | - Alfred K. Lam
- Pathology, School of Medicine, Gold Coast Campus, Griffith University, Gold Coast, Australia (Lam)
- Pathology Queensland, Gold Coast University Hospital, Southport, Australia (Lam)
- Faculty of Medicine, The University of Queensland, Herston, Australia (Lam)
| | - Gregory Lauwers
- The Department of Pathology, Moffitt Cancer Center, Tampa, Florida (Lauwers)
| | - Maria O'Donovan
- The Histopathology Department, Cambridge University Hospitals NHS Foundation Trust Addenbrookes Hospital, Cambridge, United Kingdom (O'Donovan)
| | - Rachel S. van der Post
- The Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands (van der Post and Nagtegaal)
| | - Laura Tang
- The Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, (Tang)
| | - Tetsuo Ushiku
- The Department of Pathology and Diagnostic Pathology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (Ushiku)
| | - Michael Vieth
- The Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Germany (Vieth)
| | | | - Fleur Webster
- The International Collaboration on Cancer Reporting, Sydney, Australia (Webster)
| | - Iris D. Nagtegaal
- The Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands (van der Post and Nagtegaal)
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27
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Erstad DJ, Blum M, Estrella JS, Das P, Minsky BD, Ajani JA, Mansfield PF, Ikoma N, Badgwell BD. Navigating Nodal Metrics for Node-Positive Gastric Cancer in the United States: An NCDB-Based Study and Validation of AJCC Guidelines. J Natl Compr Canc Netw 2021; 19:1-12. [PMID: 34678759 DOI: 10.6004/jnccn.2021.7038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/25/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The optimal number of examined lymph nodes (ELNs) and the positive lymph node ratio (LNR) for potentially curable gastric cancer are not established. We sought to determine clinical benchmarks for these values using a large national database. METHODS Demographic, clinicopathologic, and treatment-related data from patients treated using an R0, curative-intent gastrectomy registered in the National Cancer Database during 2004 to 2016 were evaluated. Patients with node-positive (pTxN+M0) disease were considered for analysis. RESULTS A total of 22,018 patients met the inclusion criteria, with a median follow-up of 2.2 years. Mean age at diagnosis was 65.6 years, 66% were male, 68% were White, 33% of tumors were located near the gastroesophageal junction, and 29% of patients had undergone preoperative therapy. Most primary tumors (62%) were category pT3-4, 67% had a poor or anaplastic grade, and 19% had signet features. Clinical nodal staging was inaccurate compared with staging at final pathology. The mean [SD] number of nodes examined was 19 [11]. On multivariable analysis, the pN category, ELNs, and LNR were independently associated with survival (all P<.0001). Using receiver operating characteristic (ROC) analysis, an optimal ELN threshold of ≥30 was established for patients with pN3b disease and was applied to the entire cohort. Node positivity and LNR had minimal change beyond 30 examined nodes. Stage-specific LNR thresholds calculated by ROC analysis were 11% for pN1, 28% for pN2, 58% for pN3a, 64% for pN3b, 30% for total combined. By using an ELN threshold of ≥30, prognostically advantageous stage-specific LNR values could be determined for 96% of evaluated patients. CONCLUSIONS Using a large national cancer registry, we determined that an ELN threshold of ≥30 allowed for prognostically advantageous LNRs to be achieved in 96% of patients. Therefore, ≥30 examined nodes should be considered a clinical benchmark for practice in the United States.
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Affiliation(s)
| | - Mariela Blum
- 2Department of Gastrointestinal Medical Oncology
| | | | - Prajnan Das
- 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Allen CJ, Pointer DT, Blumenthaler AN, Mehta RJ, Hoffe SE, Minsky BD, Smith GL, Blum M, Mansfield PF, Ikoma N, Das P, Ajani J, Dineen SP, Fleming JB, Badgwell BD, Pimiento JM. Chemotherapy Versus Chemotherapy Plus Chemoradiation as Neoadjuvant Therapy for Resectable Gastric Adenocarcinoma: A Multi-institutional Analysis. Ann Surg 2021; 274:544-548. [PMID: 34132693 PMCID: PMC8988446 DOI: 10.1097/sla.0000000000005007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We compare neoadjuvant chemotherapy (CT) to neoadjuvant chemotherapy plus chemoradiation (CRT) for patients with gastric adenocarcinoma (GA). SUMMARY OF BACKGROUND DATA The optimal neoadjuvant therapy regimen for resectable GA is not defined. METHODS Utilizing data from 2 high-volume cancer centers, we analyzed patients who underwent surgery for localized GA from 1/1/2000-12/31/2017. Standard CT regimens were used according to treatment period. We compared propensity matched cohorts based on age, sex, race, histology, and clinical stage. RESULTS Four-hundred five patients (age 62 ± 12 year, 58% male, 56% White) were analyzed. 231 (57%) received CRT and 174 (43%) received CT. Groups differed based on histopathologic characteristics including preoperative stage (p = 0.013). To control for these differences, propensity matched cohorts of 113 CT and 113 CRT patients were compared. CRT had similar frequencies of microscopically negative resections to CT (93% vs 91%, p = 0.81), but higher rates of complete pathologic response (15% vs 4%, p = 0.003) and lower pathologic stage (p = 0.002). Completion of intended perioperative therapy occurred in 63% of CT and 91% of CRT patients (p < 0.001). Median DFS was 45mo (95%CI: 20-70) in the CT group and 113mo (95%CI: 75-151) in the CRT group (p = 0.018). Median OS was 53mo (95%CI: 30-77) versus 120mo (95%CI: 101-138); p = 0.015. CONCLUSIONS In this multi-institutional comparison of neoadjuvant CT and CRT for resectable GA, CRT is associated with higher rates of completed perioperative therapy, higher rates of complete pathologic response, lower pathologic stage, and improved survival.Level of Evidence: Level III.
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Affiliation(s)
- Casey J. Allen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David T. Pointer
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alisa N. Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rutika J. Mehta
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah E. Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F. Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean P. Dineen
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose M. Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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29
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Ikoma N, Kim MP, Tran Cao HS, Prakash LP, Maxwell JE, Tzeng CWD, Mansfield PF, Lee JE, Badgwell BD, Katz MHG. Early Experience of a Robotic Foregut Surgery Program at a Cancer Center: Video of Shared Steps in Robotic Pancreatoduodenectomy and Gastrectomy. Ann Surg Oncol 2021; 29:285. [PMID: 34515886 DOI: 10.1245/s10434-021-10721-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
Over the past few decades, robotic surgery techniques required to resect gastric and pancreatic malignancies have evolved remarkably; however, the safety and generalizability of robotic pancreatoduodenectomy remain unknown. At our cancer center, gastrectomies and pancreatectomies are performed in a combined foregut minimally-invasive surgery program; this effectively increases the composite case volume and shortens the learning curve for any individual surgeon. In this video, we demonstrate the shared steps in pancreatoduodenectomy and gastrectomy and explain how the skills gained through robotic gastrectomy can be used during robotic pancreatoduodenectomy. During the initial 2-year period of our robotic foregut surgery program, we performed 120 pancreatic and gastric operations, including 22 pancreatoduodenectomies and 37 gastrectomies. Our first robotic pancreatoduodenectomy was performed following successful completion of 45 other robotic foregut operations. Of those 22 patients who underwent robotic pancreatoduodenectomy, the median hospital stay was 4 days (range 3-17 days) and the readmission rate was 14% (3/22). The rate of grade B/C pancreatic fistula was 9% (2/22) and there was no 90-day mortality. In conclusion, the presented video showing the shared steps in robotic pancreatoduodenectomy and gastrectomy demonstrates the potential for a combined robotic surgery program to increase composite case volumes and to shorten the learning curve. At our cancer center, implementation of this approach has been helpful in accelerating the development of our new robotic pancreatectomy program, especially in honing the skills necessary to perform robotic pancreatoduodenectomy.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura P Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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30
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Abdelhakeem A, Patnana M, Wang X, Rogers JE, Murphy MB, Sagebiel T, Ikoma N, Badgwell BD, Trail A, Estrella JS, Lu Y, Devine C, Ajani JA. Influence of Baseline Positron Emission Tomography in Metastatic Gastroesophageal Cancer on Survival and Response to Therapy. Oncology 2021; 99:659-664. [PMID: 34352788 DOI: 10.1159/000517842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The value of baseline fluorodeoxyglucose-positron emission tomography-computed tomography (PET-CT) remains uncertain once gastroesophageal cancer is metastatic. We hypothesized that assessment of detailed PET-CT parameters (maximum standardized uptake value [SUVmax] and/or total lesion glycolysis [TLG]), and the extent of metastatic burden could aid prediction of probability of response or prognosticate. METHODS We retrospectively analyzed treatment-naive patients with stage 4 gastroesophageal cancer (December 2002-August 2017) who had initial PET-CT for cancer staging at MD Anderson Cancer Center. SUVmax and TLG were compared with treatment outcomes for the full cohort and subgroups based on metastatic burden (≤2 or >2 metastatic sites). RESULTS We identified 129 patients with metastatic gastroesophageal cancer who underwent PET-CT before first-line therapy. The median follow-up time was 61 months. The median overall survival (OS) was 18.5 months; the first progression-free survival (PFS) was 5.5 months. SUVmax or TLG of the primary tumor or of all metastases combined had no influence on OS or PFS, whether the number of metastases was ≤2 or >2. Overall response rates (ORRs) to first-line therapy were 48% and 45% for patients with ≤2 and >2 metastases, respectively (nonsignificant). ORR did not differ based on low or high values of SUVmax or TLG. CONCLUSIONS This is the first assessment of a unique set of PET-CT data and its association with outcomes in metastatic gastroesophageal cancer. In our large cohort of patients, detailed analyses of PET-CT (by SUVmax and/or TLG) did not discriminate any parameters examined. Thus, baseline PET-CT in untreated metastatic gastroesophageal cancer patients has limited or no utility.
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Affiliation(s)
- Ahmed Abdelhakeem
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA,
| | - Madhavi Patnana
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jane E Rogers
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tara Sagebiel
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Allison Trail
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeannelyn S Estrella
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yang Lu
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Catherine Devine
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Blumenthaler AN, Robinson KA, Kruse BC, Munder K, Ikoma N, Mansfield PF, Gottumukkala V, Kapoor R, Badgwell BD. Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer. J Surg Oncol 2021; 124:780-790. [PMID: 34227691 DOI: 10.1002/jso.26591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 06/23/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer. METHODS We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications. RESULTS One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0]; p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar. CONCLUSIONS Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristen A Robinson
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brittany C Kruse
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn Munder
- Department of Clinical Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vijaya Gottumukkala
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ravish Kapoor
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Song S, Xu Y, Huo L, Zhao S, Wang R, Li Y, Scott AW, Pizzi MP, Wang Y, Fan Y, Harada K, Jin J, Ma L, Yao X, Shanbhag ND, Gan Q, Roy-Chowdhuri S, Badgwell BD, Wang Z, Wang L, Ajani JA. Patient-derived cell lines and orthotopic mouse model of peritoneal carcinomatosis recapitulate molecular and phenotypic features of human gastric adenocarcinoma. J Exp Clin Cancer Res 2021; 40:207. [PMID: 34162421 PMCID: PMC8223395 DOI: 10.1186/s13046-021-02003-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/01/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Gastric adenocarcinoma with peritoneal carcinomatosis (PC) is therapy resistant and leads to poor survival. To study PC in depth, there is an urgent need to develop representative PC-derived cell lines and metastatic models to study molecular mechanisms of PC and for preclinical screening of new therapies. METHODS PC cell lines were developed from patient-derived PC cells. The tumorigenicity and metastatic potential were investigated by subcutaneously (PDXs) and orthotopically. Karyotyping, whole-exome sequencing, RNA-sequencing, and functional studies were performed to molecularly define the cell lines and compare genomic and phenotypic features of PDX and donor PC cells. RESULTS We established three PC cell lines (GA0518, GA0804, and GA0825) and characterized them in vitro. The doubling times were 22, 39, and 37 h for GA0518, GA0804, and GA0825, respectively. Expression of cancer stem cell markers (CD44, ALDH1, CD133 and YAP1) and activation of oncogenes varied among the cell lines. All three PC cell lines formed PDXs. Interestingly, all three PC cell lines formed tumors in the patient derived orthotopic (PDO) model and GA0518 cell line consistently produced PC in mice. Moreover, PDXs recapitulated transcriptomic and phenotypic features of the donor PC cells. Finally, these cell lines were suitable for preclinical testing of chemotherapy and target agents in vitro and in vivo. CONCLUSION We successfully established three patient-derived PC cell lines and an improved PDO model with high incidence of PC associated with malignant ascites. Thus, these cell lines and metastatic PDO model represent excellent resources for exploring metastatic mechanisms of PC in depth and for target drug screening and validation by interrogating GAC for translational studies.
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Affiliation(s)
- Shumei Song
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Yan Xu
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P. R. China
| | - Longfei Huo
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Shuangtao Zhao
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Ruiping Wang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yuan Li
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P. R. China
| | - Ailing W Scott
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Melissa Pool Pizzi
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Ying Wang
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Yibo Fan
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jiankang Jin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Lang Ma
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Xiaodan Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Namita D Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Qiong Gan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sinchita Roy-Chowdhuri
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P. R. China
| | - Linghua Wang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Ikoma N, Estrella JS, Blum Murphy M, Das P, Minsky BD, Mansfield P, Ajani JA, Badgwell BD. Tumor Regression Grade in Gastric Cancer After Preoperative Therapy. J Gastrointest Surg 2021; 25:1380-1387. [PMID: 32542556 DOI: 10.1007/s11605-020-04688-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Cancer Staging Manual, 8th edition, now includes post-neoadjuvant therapy (ypTNM) staging for gastric cancer patients. Our purpose was to determine whether the tumor regression grade (TRG) of the primary tumor is useful for predicting the survival of these patients. METHODS We performed a retrospective review of an institutional database and identified patients with clinically non-metastatic gastric adenocarcinoma who underwent preoperative chemotherapy or chemoradiation therapy before gastrectomy. Pathology reports were reviewed, and TRG was classified as follows: 0 (complete response), 1 (viable tumor cells ≤ 1-2%), 2 (viable cells ≤ 50%), or 3 (viable cells > 50%). RESULTS Of the 356 patients identified, including 80 (23%) with a gastroesophageal junction tumor, 268 (75%) had undergone preoperative chemoradiation therapy. Fifty-six (16%) had TRG 0, 57 (16%) TRG 1, 128 (36%) TRG 2, and 115 (32%) TRG 3. No association between TRG and pretreatment factors was identified, except for signet-ring cell histologic type and tumor location. A higher TRG was associated with more advanced ypT and ypN categories (both p < 0.001), ypM1 (p = 0.004), and R1 resection (p = 0.052). The median overall survival (OS) duration was 6.6 years, and the 5-year OS rate was 54.1%. TRG 3 was associated with a shorter OS duration than were other TRG scores (p = 0.015), while the OS did not differ significantly among the TRG 0-2 groups (p = 0.803). On multivariable analysis, TRG was not associated with OS after adjustment for ypN status. CONCLUSION In gastric cancer patients who underwent preoperative therapy, TRG 3 was associated with advanced ypStage and R1 resection. Patients with TRG 3 had a shorter OS duration because of associated advanced ypStage, particularly ypN+ status.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ikoma N, Badgwell BD, Mansfield PF. Robotic Proximal Gastrectomy with Double-Tract Reconstruction for Gastroesophageal Junction Cancer. J Gastrointest Surg 2021; 25:1357-1358. [PMID: 33655471 DOI: 10.1007/s11605-021-04958-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/08/2021] [Indexed: 01/31/2023]
Abstract
The current standard surgical procedure for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal involvement is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to decreased levels of ghrelin (a "hunger hormone" secreted by the stomach) and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) with an anti-reflux technique such as double-tract reconstruction (DTR) can improve quality of life (QoL) by preserving gastric function.1 A recent Japanese prospective GEJ adenocarcinoma study reported a low incidence of lymph node metastases at peripyloric stations,2 indicating the oncological safety of PG for GEJ adenocarcinoma regardless of tumor stage. As a result, PG is increasingly performed in South Korea and Japan, although the QoL benefit of PG over TG remains unknown.3, 4 We have performed PG with DTR in select cases with satisfying short-term outcomes. In this video, we introduce our technique for robotic PG with DTR. The presented case is a 75-year-old woman with GEJ adenocarcinoma that showed an excellent response to preoperative chemoradiation therapy. The patient underwent robotic PG with DTR. Fluorescent sentinel lymphatic mapping was performed by injecting indocyanine green solution (total of 2 ml, at four quadrants around the tumor at submucosal space) via endoscopy at the beginning of the operation. It showed absence of sentinel lymphatic flow to peripyloric lymph nodes, which were thus considered safe to preserve. Pathologic examination confirmed a complete response. The patient's recovery was favorable, and she reported satisfaction with her QoL and good appetite, though some intermittent bloating after eating. PG with DTR has theoretical disadvantages including incomplete lymph node removal, which may result in recurrence; therefore, PG should be carefully performed for P/GEJ cancers with low risk of perigastric lymph node metastases, such as cT1 tumors or GEJ tumors with limited gastric involvement.2 In addition, delayed gastric emptying of the remnant stomach can cause upper gastrointestinal symptoms such as reflux and bloating. The QoL benefits of PG with DTR must be demonstrated before encouraging its use in the USA and other countries. International collaboration is warranted to test the benefits and safety of PG, and the effective use of sentinel lymphatic mapping, to standardize the surgical care of patients with P/GEJ cancers.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX, 77030, USA.
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX, 77030, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX, 77030, USA
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Abstract
Gastric cancer is not a top-10 malignancy in the United States but represents one of the most common causes of cancer death worldwide. Biological differences between tumors from Eastern and Western countries add to the complexity of identifying standard-of-care therapy based on international trials. Systemic chemotherapy, radiotherapy, surgery, immunotherapy, and targeted therapy all have proven efficacy in gastric adenocarcinoma; therefore, multidisciplinary treatment is paramount to treatment selection. Triplet chemotherapy for resectable gastric cancer is now accepted and could represent a plateau of standard cytotoxic chemotherapy for localized disease. Classification of gastric cancer based on molecular subtypes is providing an opportunity for personalized therapy. Biomarkers, in particular microsatellite instability (MSI), programmed cell death ligand 1 (PD-L1), human epidermal growth factor receptor 2 (HER2), tumor mutation burden, and Epstein-Barr virus, are increasingly driving systemic therapy approaches and allowing for the identification of populations most likely to benefit from immunotherapy and targeted therapy. Significant research opportunities remain for the less differentiated histologic subtypes of gastric adenocarcinoma and those without markers of immunotherapy activity.
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Affiliation(s)
- Smita S Joshi
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Harada K, Hwang H, Wang X, Abdelhakeem A, Iwatsuki M, Blum Murphy MA, Maru DM, Weston B, Lee JH, Rogers JE, Thomas I, Shanbhag N, Zhao M, Bhutani MS, Nguyen QN, Swisher SG, Ikoma N, Badgwell BD, Hofstetter WL, Ajani JA. Frequency and Implications of Paratracheal Lymph Node Metastases in Resectable Esophageal or Gastroesophageal Junction Adenocarcinoma. Ann Surg 2021; 273:751-757. [PMID: 31188215 DOI: 10.1097/sla.0000000000003383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We aimed to evaluate the frequency of paratracheal lymph nodes (LN) metastases and their prognostic influence. SUMMARY BACKGROUND DATA Paratracheal LNs are considered regional nodes in the esophageal cancer classification, but their metastatic rate and influence on survival remain unclear. METHODS One thousand one hundred ninety-nine patients with resectable esophageal or gastroesophageal junction adenocarcinoma (EAC) (January 2002 and December 2016) in our Gastrointestinal Medical Oncology Database were analyzed. Paratracheal LNs were defined as1R, 1L, 2R, 2L, 4R, and 4L, according to the 8th American Joint Committee on Cancer classification. RESULTS Of 1199 patients, 73 (6.1%) had positive paratracheal LNs at diagnosis. The median overall survival (OS) of 73 patients with initial paratracheal LN involvement was 2.10 years (range 0.01-10.1, 5-yrs OS 24.2%). Of 1071 patients who were eligible for recurrence evaluation, 70 patients (6.5%) developed paratracheal LN metastases as the first recurrence. The median time to recurrence was 1.28 years (range 0.28-5.96 yrs) and the median OS following recurrence was only 0.95 year (range 0.03-7.88). OS in 35 patients who had only paratracheal LN recurrence was significantly longer than in patients who had other recurrences (median OS 2.26 vs 0.51 yrs, 5-yrs OS; 26.8% vs 0%, P < 0.0001). Higher T stage (T3/T4) was an independently risk factor for paratracheal LN recurrence (odds ratio 5.10, 95% confidence interval 1.46-17.89). We segregated patients in 3 groups based on the distance of tumor's proximal edge to esophagogastric junction (low; ≤2 cm, medium; 2.0-7.0 cm, and high; >7.0 cm). Paratracheal LN metastases were more frequent with the proximal tumors (low, 4.2%; medium, 12.0%; high, 30.3%; Cochran-Armitage Trend test, P < 0.001). CONCLUSION Paratracheal LN metastases were associated with a shorter survival in resectable EAC patients. Alternate approaches to prolong survival of this group of patients are warranted.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hyunsoo Hwang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed Abdelhakeem
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Masaaki Iwatsuki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Mariela A Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dipen M Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian Weston
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane E Rogers
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Irene Thomas
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Erstad DJ, Blum M, Estrella JS, Das P, Minsky BD, Ajani JA, Mansfield PF, Badgwell BD, Ikoma N. Determinants of Survival for Patients with Neoadjuvant-Treated Node-Negative Gastric Cancer. Ann Surg Oncol 2021; 28:6638-6648. [PMID: 33754224 DOI: 10.1245/s10434-021-09625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study sought to determine prognostic markers for disease recurrence and survival in a cohort of neoadjuvant-treated, node-negative gastric cancer patients (ypT0-4N0M0). METHODS Clinicopathologic data from patients treated with neoadjuvant therapy followed by curative-intent gastrectomy at the University of Texas MD Anderson Cancer Center from 1995 to 2017 were evaluated. Patients with AJCC TNM stage ypT0-4N0M0 were considered for analysis. RESULTS The inclusion criteria were met by 212 patients with a mean age of 58.3 years. Of these patients, 60 % were male, 53 % were Caucasian, 87 % received chemoradiation, and 13 % received chemotherapy. The findings showed a median overall survival (OS) rate of 11.3 years, a 5-year survival rate of 72 %, and a 10-year survival rate of 57 %. During a median follow-up period of 5.5 years, 38.2 % of the patients died. In the multivariable analysis, ypT4-stage and nodal yield fewer than 16 were significantly associated with reduced OS. Cancer classified as ypT4 had more aggressive biologic traits, including lymphovascular and perineural invasion, and was treated more aggressively with total gastrectomy and additional organ resection despite frequent positive margins. Depth of invasion remained significantly associated with worse outcome after the analysis controlled for nodal yield and possible stage migration. Compared with ypT0-3 tumors, ypT4 cancers were associated with significantly more recurrences (13 % vs. 45 %; p < 0.05), and the primary modes of failure for ypT4 lesions were local recurrence and peritoneal metastases (88 % of recurrences). CONCLUSIONS Depth of primary tumor invasion and nodal yield were significantly associated with OS among the patients with ypT0-4N0M0 gastric cancer. Serosal invasion (ypT4) was associated with a high rate of peritoneal recurrence, and trials of intraperitoneal therapy targeting these patients should be considered.
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Affiliation(s)
- Derek J Erstad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abdelhakeem A, Wang X, Waters RE, Patnana M, Estrella J, Blum-Murphy MA, Trail A, Lu Y, Devine CE, Ikoma N, Badgwell BD, Rogers JE, Ajani JA. Localized diffuse-type gastric adenocarcinoma: Influence of baseline positron emission tomography on survival and therapy response. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
176 Background: Diffuse type of gastric adenocarcinoma (dGAC) confers a poor but variable prognosis compared to intestinal type of GAC. The value of baseline uptake of FDG-PET in localized dGAC is unclear and ~40% are not FDG-PET avid. We analyzed outcomes based on the avidity (high with SUV > 3.5 or low with SUV ≤3.5) of the primary on baseline FDG-PET. Methods: We retrospectively selected 111 localized dGAC cases who had baseline FDG-PET for staging. We compared the FDG-PET avidity with overall survival (OS) and response to preoperative therapy. Standard statistical methods were utilized. Results: The mean age was 59.4 years and with many female patients (47.7%). All patients had dGAC. The high-SUV group (58 [52.3%] patients) and the low-SUV group (53 [47.7%] patients) were equally divided. While the median OS for all patients was 49.5 months (95% CI: 38.5 – 98.8 months), it was 98.0 months for the low-SUV group and 36.0 months for the high-SUV ( p value = 0.003). While the median PFS for all patients was 38.2 months (95%CI: 27.7 – 97.6 months), it was 98.0 months for the low-SUV group was and 27.0 months for the high-SUV group ( p value = 0.005). Clinical responses before surgery were more common in the low-SUV group but there were only 4 patients with pathologic complete response in the entire cohort. Conclusions: Our unique data suggest that localized dGAC patients with low SUV fare better than those with high SUV meaning highly metabolic GACs consuming glucose confer poor prognosis and overall all dGACs seem resistant to therapy.
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Affiliation(s)
| | - Xuemei Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca E Waters
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Allison Trail
- The University of Texas-MD Anderson Cancer Center, Department of Gastrointestinal Medical Oncology, Houston, TX
| | - Yang Lu
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Naruhiko Ikoma
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Jane Elizabeth Rogers
- The University of Texas-MD Anderson Cancer Center, Pharmacy Clinical Programs, Houston, TX
| | - Jaffer A. Ajani
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Blumenthaler AN, Newhook TE, Ikoma N, Estrella JS, Blum Murphy M, Das P, Minsky BD, Ajani JA, Mansfield PF, Badgwell BD. Concurrent lymphovascular and perineural invasion after preoperative therapy for gastric adenocarcinoma is associated with decreased survival. J Surg Oncol 2021; 123:911-922. [PMID: 33400838 DOI: 10.1002/jso.26367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES We sought to evaluate the impact of lymphovascular invasion (LVI) and perineural invasion (PNI) on survival outcomes in gastric cancer patients treated with preoperative therapy. METHODS Patients with gastric cancer treated with preoperative therapy and potentially curative resection were stratified according to the presence of LVI, PNI, or both. Kaplan-Meier and Cox regression analyses were used to evaluate the impact on overall survival (OS) and disease-free survival (DFS). RESULTS The study included 281 patients, of whom 93 (33%) had LVI, 69 (25%) had PNI, 51 (18%) had both LVI and PNI, and 170 (61%) had neither. LVI and PNI were each associated with higher ypT and ypN categories and more positive lymph nodes (all p < .001), associations that were emphasized with both factors present. On multivariable analyses, ypN (p < .001) and concurrent LVI/PNI (hazard ratio [HR]: 2.62; 95% confidence interval [CI]: 1.55-4.45; p = .001) were predictive of OS and DFS (ypN: p < .001; both LVI/PNI: HR: 2.27; 95% CI: 1.34-3.82; p = .002). CONCLUSIONS Gastric cancer patients with concurrent LVI and PNI after preoperative therapy have more advanced disease and worse survival outcomes than patients with neither or only one of these factors.
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Affiliation(s)
- Alisa N Blumenthaler
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Timothy E Newhook
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeannelyn S Estrella
- Departments of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum Murphy
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prajnan Das
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruce D Minsky
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaffer A Ajani
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul F Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Ajani JA, Xu Y, Huo L, Wang R, Li Y, Wang Y, Pizzi MP, Scott AW, Harada K, Ma L, Yao X, Jin J, Zhao W, Dong X, Badgwell BD, Shanbhag ND, Tatlonghari G, Estrella JS, Roy Chowdhuri S, Kobayashi M, Vykouka JV, Hanash S, Calin GA, Peng G, Lee JS, Johnson RL, Wang Z, Wang L, Song S. YAP1 mediates gastric adenocarcinoma peritoneal metastases that are attenuated by YAP1 inhibition. Gut 2021; 70:55-66. [PMID: 32345613 PMCID: PMC9832914 DOI: 10.1136/gutjnl-2019-319748] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 03/19/2020] [Accepted: 03/31/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Peritoneal carcinomatosis (PC; malignant ascites or implants) occurs in approximately 45% of advanced gastric adenocarcinoma (GAC) patients and associated with a poor survival. The molecular events leading to PC are unknown. The yes-associated protein 1 (YAP1) oncogene has emerged in many tumour types, but its clinical significance in PC is unclear. Here, we investigated the role of YAP1 in PC and its potential as a therapeutic target. METHODS Patient-derived PC cells, patient-derived xenograft (PDX) and patient-derived orthotopic (PDO) models were used to study the function of YAP1 in vitro and in vivo. Immunofluorescence and immunohistochemical staining, RNA sequencing (RNA-Seq) and single-cell RNA-Seq (sc-RNA-Seq) were used to elucidate the expression of YAP1 and PC cell heterogeneity. LentiCRISPR/Cas9 knockout of YAP1 and a YAP1 inhibitor were used to dissect its role in PC metastases. RESULTS YAP1 was highly upregulated in PC tumour cells, conferred cancer stem cell (CSC) properties and appeared to be a metastatic driver. Dual staining of YAP1/EpCAM and sc-RNA-Seq revealed that PC tumour cells were highly heterogeneous, YAP1high PC cells had CSC-like properties and easily formed PDX/PDO tumours but also formed PC in mice, while genetic knockout YAP1 significantly slowed tumour growth and eliminated PC in PDO model. Additionally, pharmacologic inhibition of YAP1 specifically reduced CSC-like properties and suppressed tumour growth in YAP1high PC cells especially in combination with cytotoxics in vivo PDX model. CONCLUSIONS YAP1 is essential for PC that is attenuated by YAP1 inhibition. Our data provide a strong rationale to target YAP1 in clinic for GAC patients with PC.
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Affiliation(s)
- Jaffer A. Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,To whom correspondence should be addressed: Shumei Song, PhD, tel.: 713-834-6144, ,; Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA. Jaffer A. Ajani, MD, Tel: 713-792-2828, ; Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Yan Xu
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P.R. China
| | - Longfei Huo
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ruiping Wang
- Detartment of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yuan Li
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P.R. China
| | - Ying Wang
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Melissa Pool Pizzi
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ailing W. Scott
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lang Ma
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiaodan Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jiankang Jin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Wei Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiaochuan Dong
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Namita D. Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ghia Tatlonghari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jeannelyn S. Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sinchita Roy Chowdhuri
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Makoto Kobayashi
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jody V. Vykouka
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Samir Hanash
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - George A. Calin
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Guang Peng
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ju-Seog Lee
- Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Randy L. Johnson
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, First Hospital of China Medical University, Shenyang, 110001, P.R. China
| | - Linghua Wang
- Detartment of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shumei Song
- Department of Gastrointestinal Medical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
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Davis CH, Ikoma N, Mansfield PF, Das P, Minsky BD, Blum MA, Ajani JA, Bass BL, Badgwell BD. Comparison of laparoscopy versus mini-laparotomy for jejunostomy placement in patients with gastric adenocarcinoma. Surg Endosc 2020; 35:6577-6582. [PMID: 33170336 DOI: 10.1007/s00464-020-08155-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/04/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement. METHODS A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission. RESULTS A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6 years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6 days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group. CONCLUSION The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement.
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Affiliation(s)
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela A Blum
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara L Bass
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA.
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Stark AP, Blum MM, Chiang YJ, Das P, Minsky BD, Estrella JS, Ajani JA, Badgwell BD, Mansfield P, Ikoma N. Preoperative Therapy Regimen Influences the Incidence and Implication of Nodal Downstaging in Patients with Gastric Cancer. J Gastric Cancer 2020; 20:313-327. [PMID: 33024587 PMCID: PMC7521984 DOI: 10.5230/jgc.2020.20.e29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/08/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose Nodal downstaging after preoperative therapy for gastric cancer has been shown to impart excellent prognosis, but this has not been validated in a national cohort. The role of neoadjuvant chemoradiation (NACR) in nodal downstaging remains unclear when compared with that of neoadjuvant chemotherapy alone (NAC). Furthermore, it is unknown whether the prognostic implications of nodal downstaging differ by preoperative regimen. Materials and Methods Using the National Cancer Database, overall survival (OS) duration was compared among natural N0 (cN0/ypN0), downstaged N0 (cN+/ypN0), and node-positive (ypN+) gastric cancer patients treated with NACR or NAC. Factors associated with nodal downstaging were examined in a propensity score-matched cohort of cN+ patients, matched 1:1 by receipt of NACR or NAC. Results Of 7,426 patients (natural N0 [n=1,858, 25.4%], downstaged N0 [n=1,813, 24.4%], node-positive [n=3,755, 50.4%]), 58.2% received NACR, and 41.9% received NAC. The median OS durations of downstaged N0 (5.1 years) and natural N0 (5.6 years) patients were similar to one another and longer than that of node-positive patients (2.1 years) (P<0.001). In the matched cohort of cN+ patients, more recent diagnosis (2010–2015 vs. 2004–2009) (odds ratio [OR], 2.57; P<0.001) and NACR (OR, 2.02; P<0.001) were independently associated with nodal downstaging. The 5-year OS rate of downstaged N0 patients was significantly lower after NACR (46.4%) than after NAC (57.7%) (P=0.003). Conclusions Downstaged N0 patients have the same prognosis as natural N0 patients. Nodal downstaging occurred more frequently after NACR; however, the survival benefit of nodal downstaging after NACR may be less than that when such is achieved by NAC.
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Affiliation(s)
- Alexander P Stark
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela M Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Blumenthaler AN, Ikoma N, Blum M, Das P, Minsky BD, Mansfield PF, Ajani JA, Badgwell BD. Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer. J Surg Oncol 2020; 122:1373-1382. [PMID: 32810292 DOI: 10.1002/jso.26177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. METHODS The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). RESULTS The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. CONCLUSION In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Blumenthaler AN, Allen CJ, Ikoma N, Blum M, Das P, Minsky BD, Mansfield PF, Ajani JA, Badgwell BD. Laparoscopic HIPEC for Low-Volume Peritoneal Metastasis in Gastric and Gastroesophageal Adenocarcinoma. Ann Surg Oncol 2020; 27:5047-5056. [PMID: 32737700 DOI: 10.1245/s10434-020-08968-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/21/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND We seek to determine whether laparoscopic hyperthermic intraperitoneal chemoperfusion (LS-HIPEC) improves overall survival (OS) in patients with gastric and gastroesophageal adenocarcinoma and low-volume peritoneal metastasis compared with standard of care treatment. PATIENTS AND METHODS We reviewed data from a prospectively maintained database of patients with gastric and gastroesophageal adenocarcinoma to identify patients with radiologically occult carcinomatosis or positive peritoneal cytology, no evidence of distant metastasis, and without disease progression during initial chemotherapy or observation. Univariate and multivariable analyses were performed to evaluate the impact of LS-HIPEC on OS. RESULTS We identified 25 patients who underwent LS-HIPEC and 27 treated with a standard of care approach due to patient (33.3%) or provider (51.9%) preference or financial limitations/lack of insurance coverage (14.8%). Resection was ultimately performed in 28% of LS-HIPEC patients and no standard care patients. At a median follow-up of 18.9 months, median OS was 24.7 (IQR 20.8-34.2) months in LS-HIPEC patients and 21.3 (IQR 12.3-23.1) months in standard care patients (p = 0.08). Three-year OS in the LS-HIPEC group was 19.1%, compared with 9.6% (p = 0.08). Patients who underwent resection had a median OS of 25.3 (IQR 22.6-47.1) months compared with 21.3 months in standard care patients (p = 0.05). CONCLUSIONS Neoadjuvant LS-HIPEC for the treatment of low-volume peritoneal disease in gastric and gastroesophageal cancer patients did not significantly improve OS compared with standard care. Multiinstitutional studies are necessary to further elucidate the benefit of LS-HIPEC for this patient population.
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Affiliation(s)
- Alisa N Blumenthaler
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Casey J Allen
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Allen CJ, Blumenthaler AN, Smith GL, Das P, Minsky BD, Blum M, Ajani J, Mansfield PF, Ikoma N, Badgwell BD. Chemotherapy Versus Chemotherapy Plus Chemoradiation as Preoperative Therapy for Resectable Gastric Adenocarcinoma: A Propensity Score-Matched Analysis of a Large, Single-Institution Experience. Ann Surg Oncol 2020; 28:758-765. [PMID: 32696305 DOI: 10.1245/s10434-020-08864-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We compared oncologic outcomes of patients who received neoadjuvant chemotherapy (CT) with those of patients who received neoadjuvant chemotherapy plus chemoradiation (CRT) for resectable gastric adenocarcinoma. METHODS We compared oncologic and survival outcomes of patients who received CT or CRT for gastric adenocarcinoma at our institution between July 1995 and July 2018. We analyzed propensity score-matched cohorts based on age, sex, race, tumor histologic characteristics, and clinical stage. RESULTS We identified 440 patients (mean age 61 ± 12 years, 62% male, 55% white); 345 (78%) received CRT, and 95 (22%) received CT. The propensity score-matched cohorts included 65 patients who received CT and 65 who received CRT. The CRT group had similar frequencies of R1 resection margins to the CT group (7.7% vs. 6.2%, p = 0.75) but significantly higher frequency of pathologic complete response (27.7% vs. 1.5%, p < 0.001). The CRT group had lower pathologic stages (p = 0.002). Median disease-free survival was 50.9 months (95% confidence interval [CI]: 4.7-97.2) in the CT group and 122.1 months (95% CI: 69.0-175.1) in the CRT group (p = 0.07). Median overall survival was 70.7 months (95% CI: 23.9-117.5) in the CT group and 122.1 months (95% CI: 68.7-175.4) in the CRT group (p = 0.21). CONCLUSIONS Compared with CT, CRT for resectable gastric adenocarcinoma is associated with higher rates of pathologic complete response and subsequent lower final pathologic stage, but survival differences are not significant. Ongoing investigation is necessary to better determine the optimal neoadjuvant therapy and identify patients who receive optimal benefit from CRT. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Casey J Allen
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alisa N Blumenthaler
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Stark AP, Estrella JS, Chiang YJ, Das P, Minsky BD, Blum Murphy MA, Ajani JA, Mansfield P, Badgwell BD, Ikoma N. Impact of tumor regression grade on recurrence after preoperative chemoradiation and gastrectomy for gastric cancer. J Surg Oncol 2020; 122:422-432. [PMID: 32462681 DOI: 10.1002/jso.25984] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES It is unknown whether the degree of response to preoperative therapy correlates with locoregional recurrence (LR) or distant recurrence (DR) after resection of gastric cancer. METHODS Patients who underwent resection of gastric adenocarcinoma following chemotherapy and chemoradiation (1995-2015) were reviewed. The tumor regression grade (TRG) was defined by the percentage of viable tumor cells in the specimen (TRG0 = 0%; TRG1 = 1%-2%; TRG2 = 3%-50%; TRG3 ≥ 50%). The relationships among TRG, recurrence-free survival (RFS), LR, and DR were examined. RESULTS Two hundred forty-seven patients met the inclusion criteria (TRG0, 52 [21%]; TRG1, 49 [20%]; TRG2, 98 [40%]; TRG3, 48 [19%]). LR and DR occurred in 6.1% and 32.0% of patients, respectively. No patient with TRG0 experienced LR. R1 resection (6%-15%) and LR (6%-8%) rates were similar among TRG1-3 patients. R1 resection was associated with LR (hazard ratio [HR], 17.85; P < .001). ypN status (HR, 2.44; P = .004) and linitis plastica (HR, 2.90; P < .001) were associated with DR. TRG was not independently associated with RFS, LR, or DR. CONCLUSIONS TRG0 imparted excellent local control. However, TRG1-3 patients had similar R1 resection rates and therefore similar LR. DR is associated with ypN status and linitis plastica, not TRG.
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Affiliation(s)
- Alexander P Stark
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeannelyn S Estrella
- Departments of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariela A Blum Murphy
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul Mansfield
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Abdelhakeem A, Badgwell BD, Ikoma N, Meyer L, Zhao M, Ta A, Das P, Sagebiel TL, Waters RE, Estrella J, Ajani JA, Blum-Murphy MA. Survival benefit of oophorectomy in stage IV gastric cancer patients with Krukenberg tumors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e16566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16566 Background: The management of Krukenberg tumors from primary gastric cancer remains unclear and it is unknown if oophorectomy improves survival. The purpose of this study was to compare the overall survival (OS) of patients with ovarian metastases from gastric cancer treated with standard chemotherapy to chemotherapy and oophorectomy. Methods: Between January 2008 and August 2019, we retrospectively analyzed the clinicopathological features and treatment data of 97 patients with stage IV gastric cancer patients with ovarian metastases. Patients were categorized into two groups: Oophorectomy plus standard chemotherapy treatment vs. standard chemotherapy only (non-oophorectomy). The primary objective was to assess OS. Results: A total of 97 patients were identified. 37 (38.1%) patients had oophorectomy and 60 (61.9%) patients did not have oophorectomy. OS was better in the oophorectomy group relative to the non-oophorectomy group (37 months vs. 20 months; P= 0.0554). Survival from the time of diagnosis of ovarian metastases was significantly better in oophorectomy group relative to the non-oophorectomy group (26 months vs. 12 months; P= 0.0006). Conclusions: Our results showed that Oophorectomy in addition to systemic chemotherapy in this unique population seems to confer survival advantage in this retrospective analysis. Prospective evaluation is warranted.
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Affiliation(s)
| | | | - Naruhiko Ikoma
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Larissa Meyer
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Meina Zhao
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Anh Ta
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- The University of Texas MD-Anderson Cancer Center, Houston, TX
| | | | - Rebecca E Waters
- The University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Jaffer A. Ajani
- The University of Texas - MD Anderson Cancer Center, Houston, TX
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Harada K, Patnana M, Wang X, Iwatsuki M, Murphy MAB, Zhao M, Das P, Minsky BD, Weston B, Lee JH, Bhutani MS, Estrella JS, Shanbhag N, Ikoma N, Badgwell BD, Ajani JA. Low metabolic activity in primary gastric adenocarcinoma is associated with resistance to chemoradiation and the presence of signet ring cells. Surg Today 2020; 50:1223-1231. [PMID: 32409870 DOI: 10.1007/s00595-020-02018-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/17/2020] [Indexed: 12/14/2022]
Abstract
PURPOSES Preoperative chemoradiation is a potential treatment option for localized gastric adenocarcinoma (GAC). Currently, the response to chemoradiation cannot be predicted. We analyzed the pretreatment maximum standardized uptake value (SUVmax) and total lesion glycolysis (TLG) on positron emission tomography/computed tomography as potential predictors of the response to chemoradiation. METHODS We analyzed the SUVmax and TLG data from 59 GAC patients who received preoperative chemoradiation. We used logistic regression models to predict a pathologic complete response (pCR) and Kaplan-Meier curves to determine overall survival among patients with high and low SUVmax or TLG. RESULTS Twenty-nine patients (49%) had Siewert type III adenocarcinoma and 30 (51%) had tumors located in the lower stomach. Forty-one patients had poorly differentiated GAC, and 26 had signet ring cells. The median SUVmax was 7.3 (0-28.2) and the median TLG was 56.6 (0-1881.5). Patients with signet ring cells had a low pCR rate, as well as a low SUVmax and TLG. In the multivariable logistic regression model, high SUVmax was a predictor of pCR (odds ratio = 11.1, 95% confidence interval = 2.12-50.0, p = 0.004). Overall survival was not associated with the SUVmax (log-rank p = 0.69) or TLG (log-rank p = 0.85) CONCLUSION: A high SUVmax was associated with sensitivity to chemoradiation and pCR in GAC, and signet ring cells seemed to confer resistance.
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Affiliation(s)
- Kazuto Harada
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Madhavi Patnana
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Masaaki Iwatsuki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Mariela A Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Meina Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Weston
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Namita Shanbhag
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Ikoma N, Agnes A, Chen HC, Wang X, Blum MM, Das P, Minsky B, Estrella JS, Mansfield P, Ajani JA, Badgwell BD. Linitis Plastica: a Distinct Type of Gastric Cancer. J Gastrointest Surg 2020; 24:1018-1025. [PMID: 31754987 DOI: 10.1007/s11605-019-04422-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 09/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prognosis of patients with linitis plastica (LP) gastric cancer is reported to be poor. The purpose of our retrospective study was to characterize the clinicopathologic features and survival outcomes of patients with LP, using a univocal definition. METHODS We defined LP as gastric cancer that involves more than 1/3 of the gastric wall macroscopically. We reviewed a prospectively maintained institutional database of gastric cancer patients and summarized and compared clinicopathologic factors of patients with and without LP who had undergone gastrectomy. Patients were matched 1:1 using propensity score matching, and their overall survival (OS) rates and durations were compared. Multivariable Cox regression analyses were conducted, using gastrectomy as a time-varying covariate. RESULTS We identified 740 patients with radiographically non-metastatic gastric cancer, 157 (21.2%) of whom had LP. Most patients with LP had advanced-stage disease (75.8% had stage IV disease, mainly due to peritoneal involvement). Patients with LP had significantly shorter OS durations than did those without LP in the entire cohort (median OS, 14.0 vs. 33.5 months; p value < 0.001) and in the surgical cohort (median OS after gastrectomy, 21.8 vs. 91.0 months; p < 0.001), as well as in the propensity-matched surgical cohort. In the LP cohort, chemotherapy (hazard ratio [HR] = 0.594; p = 0.076), chemoradiation therapy (HR = 0.346; p = 0.001), and gastrectomy (HR = 0.425; p = 0.003) were associated with a longer OS. CONCLUSIONS LP is a phenotype of gastric cancer that often presents at an advanced stage, with a high rate of peritoneal involvement. The survival durations of patients with LP were poor in our study, even in the surgical cohort. The use of preoperative chemotherapy, chemoradiation therapy, and gastrectomy appeared to be important in carefully selected patients with localized LP.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Annamaria Agnes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela M Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA.
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