A narrative review of the evolving landscape of the management of metastatic gastric cancer: the role of targeted therapies

Background and Objective

Gastric cancer is the fifth most common cancer worldwide and the fourth leading cause of cancer-related death. Unfortunately, patients often present with advanced disease at diagnosis, which is directly related to its high mortality. Numerous trials, as early as the 1980's, have shown that cytotoxic chemotherapy improves survival. This review will focus on targeted therapies and immunotherapies which have emerged as treatment options for metastatic gastric cancer, often used in conjunction with cytotoxic chemotherapy. Here we will review the relevant clinical trials of targeted therapies and immunotherapies in the treatment of metastatic gastric cancer.

Methods

We performed an extensive review of articles in the PubMed database pertaining to targeted therapies and immunotherapies in the treatment of metastatic gastric cancer. Additionally, updated guidelines from the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) were reviewed.

Key Content and Findings

Cytotoxic chemotherapy remains the backbone of treatment of metastatic gastric cancer, but the development of targeted therapies and immunotherapy have revolutionized its treatment with improved survival and outcomes. Therapies have been developed which target human epidermal growth factor receptor 2 (HER2), vascular endothelial growth factor receptor-2 (VEGFR-2), and tyrosine kinase pathways. Novel targeted therapies are currently being investigated with promising results thus far. Immunotherapy, specifically immune checkpoint inhibitors (ICIs), has proven to be a significant advancement in the treatment of gastric cancer.

Conclusions

Targeted therapies and immunotherapies have improved survival and outcomes in metastatic gastric cancer, however more research is needed to make even greater strides.

Multicenter analysis of immunosuppressive medications on the risk of malignancy following adult solid organ transplantation

Objective

This study aimed to assess the risk of maintenance immunosuppression on the post-transplant risk of malignancy across all solid organ transplant types.

Methods

This is a retrospective cohort study from a multicenter hospital system in the United States. The electronic health record was queried from 2000 to 2021 for cases of solid organ transplant, immunosuppressive medications, and post-transplant malignancy.

Results

A total of 5,591 patients, 6,142 transplanted organs, and 517 post-transplant malignancies were identified. Skin cancer was the most common type of malignancy at 52.8%, whereas liver cancer was the first malignancy to present at a median time of 351 days post-transplant. Heart and lung transplant recipients had the highest rate of malignancy, but this finding was not significant upon adjusting for immunosuppressive medications (heart HR 0.96, 95% CI 0.72 - 1.3, p = 0.88; lung HR 1.01, 95% CI 0.77 - 1.33, p = 0.94). Random forest variable importance calculations and time-dependent multivariate cox proportional hazard analysis identified an increased risk of cancer in patients receiving immunosuppressive therapy with sirolimus (HR 1.41, 95% CI 1.05 - 1.9, p = 0.04), azathioprine (HR 2.1, 95% CI 1.58 - 2.79, p < 0.001), and cyclosporine (HR 1.59, 95% CI 1.17 - 2.17, p = 0.007), while tacrolimus (HR 0.59, 95% CI 0.44 - 0.81, p < 0.001) was associated with low rates of post-transplant neoplasia.

Conclusion

Our results show varying risks of immunosuppressive medications associated with the development of post-transplant malignancy, demonstrating the importance of cancer detection and surveillance strategies in solid organ transplant recipients.

Improving otoscopy education and diagnostic accuracy: A prospective interventional study

OBJECTIVE

To assess and improve otoscopy examination skills across various medical specialities who perform otoscopy during their professional practice.

METHODS

A pre-intervention survey was created using www.surveymonkey.com, which included several preliminary questions to clarify the participant's speciality and training level, followed by 25 individual otoscopy images. The participants were given 12 possible diagnoses for each otoscopy image and asked to choose the single best answer. After completing the survey, participants were asked to watch an otoscopy teaching session. This teaching session was created with multidisciplinary feedback, and the content included a demonstration video and a didactic lecture. Finally, a post-intervention survey was circulated four weeks later to the same cohort of doctors to assess improvement.

RESULTS

A total of 79 pre-intervention surveys were collected with an average score of 53% (range 20-100%). The spectrum of medical specialities that completed the pre-intervention survey included paediatrics, ear, nose, and throat (ENT), emergency medicine, and general practice. The largest cohort of surveys came from senior house officers (SHO). In addition, 78.5% of responses were completed by doctors who had not worked in ENT before. After completing the otoscopy teaching session and at least four weeks after the initial survey, 23 post-intervention surveys were completed with an average score of 66% (range 32-100%), a 13% improvement.

CONCLUSIONS

The results of the pre-intervention survey show that many doctors have difficulty diagnosing ear conditions. The implementation of a 25-min teaching session achieved a 13% improvement in the otoscopy knowledge of doctors across a variety of specialities.

A Quality Improvement Approach to Reducing the Caesarean section Surgical Site Infection Rate in a Regional Hospital

Surgical site infection (SSI) rates are used extensively by hospitals as a basis for quality improvement. A 30-day post-discharge SSI programme for Caesarean section operations has been implemented in Our Lady of Lourdes Hospital since 2011. It has been shown that skin antisepsis and antibiotic prophylaxis are key factors in the prevention of SSI. Using quality improvement methodology, an infection prevention bundle was introduced to address these two factors. Skin antisepsis was changed from povidone-iodine to chlorhexidine-alcohol. Compliance with choice of antibiotic prophylaxis increased from 89.6% in 2014 to 98.5% in 2015. Compliance with timing also improved. The SSI rate of 7.5% was the lowest recorded to date, with the majority of SSIs (64%) diagnosed after hospital discharge. The level of variation was also reduced. However, the continued presence of variation and possibility of lower infection rates from the literature imply that further improvements are required.

Abandoned, Removed and Moved Object Classification

This paper extends the problem of abandoned/removed object classification in video surveillance to encompass the closely related (but to date ignored) problem of moved object classification. Existing abandoned/removed region classification techniques are shown to arbitrarily classify such localized object movements as either abandonment or removal. Our new approach correctly classifies abandoned and removed objects, and also correctly classified 90% of moved objects.

Twenty four-hour helpline access to expert management advice for food-allergy-triggered anaphylaxis in infants, children and young people: a pragmatic, randomized controlled trial

BACKGROUND

Anaphylaxis is a life-threatening emergency. If promptly administered, adrenaline is potentially life-saving. Many food-allergic-children/carers are unsure when to use their adrenaline autoinjectors, contributing to a low quality of life and worse outcomes in the setting of an acute allergic reaction.

OBJECTIVES

The aim of this study was to assess the effectiveness of 24-hour telephone access to specialist clinical advice on disease-specific quality of life.

METHODS

A pragmatic two-arm, parallel-group randomized control trial was conducted. Children/carers (<16 years) with food allergy, trained in adrenaline auto-injector use, were recruited from a hospital-based paediatric allergy clinic. Baseline disease-specific quality of life was ascertained using the validated Food-Allergy-Related Quality-of-Life Questionnaire (FAQLQ), either Parent Form, Child Form or Teenager Form depending on child's age. Participants were then centrally randomized for a 6-month period to 24-hour telephone specialist support line or to usual care. The primary outcome measure was a change in FAQL scores, at one and 6 months postrandomization, compared with baseline. The minimum clinically important difference (MCID) in score is 0.5.

RESULTS

Fifty two children/carers were recruited. FAQL scores remained static in the control group across the three time points. Scores gradually improved in the intervention group, with a significant difference seen at 6 months (T1-T3 Mean difference = -1.5, (CI 0.87-2.25) P < 0.005] Follow-up questionnaires, 6 months after the intervention was removed, T4, showed sustained significant difference between the groups (control M = 3.0; intervention M = 1.1[t = -4.113, P < 0.05]).

CONCLUSION

The 24-hour helpline improved food-allergy-specific quality of life in children. Six-month intervention support resulted in sustained benefits for at least a further 6 months.

The information-seeking behaviour of paediatricians accessing web-based resources

OBJECTIVES

To establish the information-seeking behaviours of paediatricians in answering every-day clinical queries.

DESIGN

A questionnaire was distributed to every hospital-based paediatrician (paediatric registrar and consultant) working in Ireland.

RESULTS

The study received 156 completed questionnaires, a 66.1% response. 67% of paediatricians utilised the internet as their first "port of call" when looking to answer a medical question. 85% believe that web-based resources have improved medical practice, with 88% reporting web-based resources are essential for medical practice today. 93.5% of paediatricians believe attempting to answer clinical questions as they arise is an important component in practising evidence-based medicine. 54% of all paediatricians have recommended websites to parents or patients. 75.5% of paediatricians report finding it difficult to keep up-to-date with new information relevant to their practice.

CONCLUSIONS

Web-based paediatric resources are of increasing significance in day-to-day clinical practice. Many paediatricians now believe that the quality of patient care depends on it. Information technology resources play a key role in helping physicians to deliver, in a time-efficient manner, solutions to clinical queries at the point of care.

Nematodirus infection in lambs on an alternate grazing system of husbandry

The epidemiology of Nematodirus battus infection under a husbandry system based on an annual alternation of sheep and cattle was studied from 1983 to 1985. Pasture larval levels and sheep and cattle worm egg outputs were monitored from April to September each year. The level of N battus contamination on the sheep pasture and the number of clinically affected lambs increased over the three years despite grazing with cattle in the intervening year. Examination of cattle faeces demonstrated that six-month-old calves excreted moderate numbers of N battus eggs in June and July, thus contaminating next season's sheep grazing.

Brain surface exposure to CO2 and NdYag laser application: effect on pulmonary endothelium response in the rat

Pulmonary endothelial cells and the renin-angiotensin-aldosterone (RAA) system respond to different types of injury (direct or indirect) with variations in their functions. These variations influence the regulatory mechanisms of pulmonary and systemic blood pressure, electrolyte balance and fibrinolysis. Concentration changes of some components of the RAA system and lung plasminogen activator were observed following NdYag laser application to the brain surface in rats. These changes were similar to those observed in cutaneous burn and haemorrhagic hypotension. CO2 laser application did not cause the same changes.

Epidemiology of Nematodirus battus infection in eastern Scotland

A field investigation was carried out from 1981 to 1983 on the prevalence of Nematodirus battus under different systems of lowland sheep management. Pasture larval counts, ewe and lamb worm egg counts, and tracer lamb worm counts were carried out. As expected, contamination was generally greater on permanent pasture than on new leys as measured by pasture larval counts and lamb worm egg counts. However significant contamination was also recorded on young grass fields for which alternate grazing with young calves may have been partly responsible. It is suggested that the 1983 hatch was delayed because of a drop in soil temperature in late March which may have increased subsequent scour problems involving N battus seen in May.

Comparative study of gastrointestinal helminthiasis in sheep on 'clean' grazing and permanent pasture under field conditions

An investigation of sources of helminth infection was carried out on three flocks: a traditional permanent pasture flock (A), one operating a 'clean' grazing system (B), and an East of Scotland College flock (C) which had operated a clean grazing system for nine years. Ewe and lamb worm egg output and pasture larval levels were recorded and tracer lambs were grazed during July and August on each farm. Considerable contamination was present on farm B fields compared with farms A and C, which resulted in higher worm burdens in late summer in farm B tracer lambs and lower weight gains. The main source of this infection was thought to be ewe periparturient egg output, as 21 per cent of ewes had positive worm egg counts over the lambing period. Differences in management practices between farms B and C, eg, earlier stocking of farm B fields, were also considered contributory factors.

Control of ovine gastrointestinal helminthiasis by the use of 'clean' grazing and strategic dosing in the field

Despite the widespread adoption of clean grazing systems in lowland sheep flocks, detailed parasitological investigations had not previously been carried out on such flocks. A trial was therefore conducted on two commercial flocks: a traditional permanent pasture flock (A) and one operating a system of clean grazing (B), and on an East of Scotland College flock (C) which had operated a clean grazing system for eight years. Ewe and lamb worm egg output, pasture larval levels and lamb liveweight gains were monitored and tracer lambs were grazed during July and August on each farm. Under clean grazing conditions on farm C all parasitological parameters were lower than on both commercial farms. However, in the commercial flocks comparable contamination was evident from midsummer onwards and tracer lambs grazed during August on farm B had significantly greater worm burdens than on the other two farms. The differences observed between the flocks were thought to be due to greater residual contamination by overwintered larvae in both commercial flocks while the higher worm burdens in August on farm B probably resulted partly from incomplete control of the periparturient rise in ewe faecal egg output and partly to autoinfection of the lamb crop. It was concluded that farm C grazing was the cleanest. Considerable contamination was present on farm A while farm B occupied an intermediate position which resulted in considerable worm burdens in lambs grazing during the latter part of the season.

Pregnancy termination in the control of the tibial hemimelia syndrome in Galloway cattle

A description is given of the symptoms, frequency and mode of inheritance of a lethal genetic defect in Galloway cattle known as the tibial hemimelia syndrome. Plans for the control of the defect are described, and the role of the Galloway test herd identified. Investigations in the test herd demonstrate that it is possible to detect the tibial hemimelia syndrome characteristics in 90-day-old fetuses and that those fetuses can be regularly and readily obtained undamaged by pregnancy termination using prostaglandin F2 alpha. The role of pregnancy termination in the control of the tibial hemimelia problem is discussed and ideas for its development presented.