The impact of contour maps on estimating the risk of gastrointestinal stromal tumor recurrence: indications for adjuvant therapy: an analysis of the Kinki GIST registry

INTRODUCTION

Contour maps enable risk classification of GIST recurrence in individual patients within 10 postoperative years. Although contour maps have been referred to in Japanese guidelines, their usefulness and role in determining indications for adjuvant therapy is still unclear in Japanese patients. The aims of this study are to investigate the validity of contour maps in Japanese patients with GIST and explore the new strategy for adjuvant therapy.

MATERIALS AND METHODS

A total of 1426 Japanese GIST patients who were registered to the registry by the Kinki GIST Study Group between 2003 and 2012 were analyzed. Patients who had R0 surgery without perioperative therapy were included in this study. The accuracy of contour maps was validated.

RESULTS

Overall, 994 patients have concluded this study. Using contour maps, we validated the patients. The 5-year recurrence-free survival rates of patients within the GIST classification groups of 0-10%, 10-20%, 20-40%, 40-60%, 60-80%, 80-90%, and 90-100% were 98.1%, 96.6%, 92.3%, 48.0%, 37.3%, 41.0% and 42.4%, respectively. We confirmed that this classification by contour maps was well reflected recurrence prediction. Further, in the high-risk group stratified by the modified National Institutes of Health consensus criteria (m-NIHC), the 10-year RFS rate was remarkably changed at a cutoff of 40% (0-40% group vs. 40-100% group: 88.7% vs. 50.3%, p < 0.001).

CONCLUSION

Contour maps are effective in predicting individual recurrence rates. And it may be useful for the decision of individual strategy for high-risk patients combined with m-NIHC.

Role of reduction gastrectomy in patients with gastric cancer with a single non-curable factor: Supplementary analysis of REGATTA trial

Background

REGATTA trial failed to demonstrate the survival benefit of reduction gastrectomy in patients with advanced gastric cancer with a single non-curable factor. However, a significant interaction was found between the treatment effect and tumor location in the subset analysis. Additionally, the treatment effect appeared to be different between Japan and Korea. This supplementary analysis aimed to elucidate the effect of reduction surgery based on tumor location and country.

Methods

Multivariable Cox regression analyses in each subgroup were performed to estimate the hazard ratio (HRadj), including the following variables as explanatory variables: country, age, sex, incurable factor, cT, cN, primary tumor, performance status, histological type, and macroscopic type.

Results

Patients (95 in Japan and 80 in Korea) were randomized to chemotherapy alone (86 patients) or gastrectomy plus chemotherapy (89 patients). The subgroup analysis according to the country revealed a worse overall survival in gastrectomy plus chemotherapy arm in Japan (hazard ratio: 1.32, 95% confidence interval: 0.85-2.05), but not in Korea (hazard ratio: 0.85.95% confidence interval: 0.52-1.40). Overall survival was better in distal gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 0.69, 95% confidence interval: 0.42-1.13), and worse in total gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 1.34, 95% CI: 0.93-1.94), which was more remarkable in Korea than in Japan.

Conclusions

Primary chemotherapy is a standard of care for advanced gastric cancer; however, the survival benefits from reduction by distal gastrectomy remained controversial.

Effect of the number of cycles of docetaxel + S-1 therapy on long-term survival in adjuvant chemotherapy for stage III gastric cancer. A pooled analysis of the OGSG0604 and OGSG1002 trials

BACKGROUND

S-1 plus docetaxel (DS) therapy followed by S-1 is the standard of care in Japan in postoperative adjuvant chemotherapy for stage III gastric cancer, but long-term survival and the number of DS cycles required are unclear. The purpose of this study was to investigate the impact of the number of cycles of DS therapy on the 5-year survival in stage III gastric cancer in a pooled analysis of two phase II trials (OGSG0604 and OGSG1002).

PATIENTS AND METHODS

Patients with histologically confirmed stage III gastric cancer who underwent gastrectomy with D2 lymphadenectomy were enrolled in this pooled analysis. They received DS therapy for four or eight cycles, followed by S-1 until 1 year postgastrectomy. The 5-year overall survival (OS) and the 5-year disease free survival (DFS) by the landmark analysis was evaluated.

RESULTS

In total, 113 patients from the OGSG0604 and OGSG1002 trials were enrolled in this study. The landmark analysis showed a 5-year OS that was better with four to eight cycles of DS therapy than with one to three cycles of DS therapy, with the best 5-year OS of 77.4% (95% confidence interval, 66.5-90.1%) for eight cycles. The 5-year DFS was approximately 66% when four or eight cycles of DS therapy were given.

CONCLUSION

Although eight cycles of DS therapy may prolong prognosis, the present study did not provide a clear conclusion as to how many DS therapy cycles are needed to improve prognosis after D2 gastrectomy for stage III gastric cancer.

TRIAL REGISTRATION

Registration number: UMIN00000714 and UMIN000004440.

Long-term survival with nivolumab followed by irinotecan after total gastrectomy in alpha-fetoprotein-producing gastric cancer: a case report and review of the literature

BACKGROUND

Alpha-fetoprotein-producing gastric cancer (AFPGC) is a rare type of aggressive gastric cancer (GC) with a dismal prognosis. We present a patient with AFPGC who achieved long-term survival through a multidisciplinary approach.

CASE PRESENTATION

A 67-year-old man with advanced GC was referred to our hospital for systemic chemotherapy. He was diagnosed with cStage IVB AFPGC. During 2nd-line treatment, we could not control bleeding from the GC itself. After complete resection, during chemotherapy, portal venous tumor thrombi (PVTTs) and liver metastases were identified. With nivolumab followed by irinotecan, the PVTTs and liver metastases disappeared. Without immunotherapy and chemotherapy for 23 months, the patient has survived for 48 months so far with no recurrence of GC.

CONCLUSION

Long-term survival with AFPGC can be accomplished by using several different approaches, such as surgery, immunotherapy, and chemotherapy.

TRESBIEN (OGSG 2101): encorafenib, binimetinib and cetuximab for early recurrent stage II/III BRAF V600E-mutated colorectal cancer

The BRAF V600E mutation accounts for approximately 5% of colorectal cancer (CRC) cases and is an extremely poor prognostic factor. However, there are no clear recommendations regarding first-line therapy for patients with early recurrent BRAF V600E-mutated CRC, during or after adjuvant chemotherapy. Recently, a novel combination of encorafenib, binimetinib and cetuximab, showed a higher response rate than standard chemotherapy in patients with BRAF V600E-mutated CRC. Here we describe our plan for the TRESBIEN study (OGSG 2101), which is an open-label, multicenter, single-arm, phase II study designed to evaluate whether encorafenib, binimetinib and cetuximab are effective for patients with early recurrent BRAF V600E-mutated colorectal cancer, during or after adjuvant chemotherapy. The planned number of subjects is 25.

Neoadjuvant docetaxel, oxaliplatin and S-1 therapy for the patients with large type 3 or type 4 gastric cancer (OGSG1902): protocol of a multi-center, phase II study

Background

Large type 3 and type 4 gastric cancers have extremely poor prognoses. To address this, neoadjuvant chemotherapy may be a promising approach. The phase III JCOG0501 study, conducted to confirm the superiority of neoadjuvant S-1 plus cisplatin followed by D2 gastrectomy over upfront surgery, showed no survival benefit for neoadjuvant S-1 plus cisplatin. In Korea, the PRODIGY study, which was a phase III study of neoadjuvant docetaxel plus oxaliplatin plus S-1 (DOS) followed by surgery and adjuvant S-1 versus surgery and adjuvant S-1 for gastric cancer of T2-3N+ or T4Nany, showed that progression-free survival (PFS) was significantly superior in the neoadjuvant DOS arm. Therefore, DOS therapy may be a promising candidate for preoperative chemotherapy for large type 3 or type 4 gastric cancer.

Methods

Preoperative docetaxel 40 mg/m² and oxaliplatin 100 mg/m² will be intravenously administered on day1 every three weeks. S-1 will be orally administered 80 mg/m² on days 1–14 of a 21-day cycle. Patients will receive three courses of treatment and gastrectomy with ≥D2 lymph node dissection. Postoperative S-1 plus docetaxel therapy (DS) will be administered according to the JACCRO GC-07 (START-2) study. The primary endpoint is the 3-year PFS rate. Secondary endpoints include PFS time, overall survival time, pathological response rate, response rate according to RECIST version1.1, proportion of completion of neoadjuvant chemotherapy, R0 resection rate, proportion of completion of surgery, proportion of completion of protocol treatment, proportion of negative conversion of CY, adverse event occurrence rate, and nutritional evaluation. The null hypothesis for the 3-year PFS rate is 45% and the expected value is 60%. The total sample size is 46 considering that the registration period and follow-up period are two and three years, respectively.

Discussion

This is a prospective, multicenter, single-arm, open-label, phase II trial assessing the efficacy and safety of preoperative DOS and postoperative DS for large type 3 or type 4 gastric cancer. The results will inform future phase III trials and are expected to lead to new treatment strategies for large type 3 or type 4 gastric cancer.

Trial registration

Registered with Japan Registry of Clinical Trials on October 11, 2019 (jRCTs051190060).

A phase II study of S-1 therapy for patients with advanced and recurrent esophageal cancer resistant or intolerable to fluorouracil, platinum, and taxane therapy (OGSG 1404)

BACKGROUND

Fluorouracil (FU), platinum (PT), and taxane (TAX) therapy was the standard chemotherapy for esophageal squamous cell carcinoma (ESCC) before the era of anti-programmed death-1 antibodies. The aim of this phase II trial was to evaluate the efficacy and safety of S-1 monotherapy for patients with recurrent or metastatic (R/M) ESCC resistant or intolerable to FU, PT, and TAX therapy.

METHODS

Eligible patients had R/M ESCC; no prior S-1 use; were intolerant or refractory to prior FU, PT, and TAX therapy; aged ≧ 20 years; and Eastern Cooperative Oncology Group performance status 0 or 1. S-1 was administered orally from days 1 to 28, every 6 weeks until disease progression. The primary endpoint was the disease control rate (DCR) for each patient, assessed by Response Evaluation Criteria in Solid Tumors, version 1.1. Secondary endpoints were overall survival, progression-free survival, time to treatment failure, response rate, and toxicity.

RESULTS

Between October 2015 and December 2017, 17 patients were recruited, and the trial was terminated because of slow accrual. The DCR was 46.7%. The response rate was 13.3%. The median progression-free survival was 2.0 months. The median time to treatment failure was 1.9 months. The median overall survival was 8.4 months, and the 1 year overall survival rate was 30.5%.

CONCLUSIONS

Although this trial closed early because of slow accrual, we observed modest clinical activity with S-1 in patients with R/M ESCC who could not tolerate or whose tumors were refractory to FU, PT, and TAX therapy.

The Phase II Study of Panitumumab in Chemotherapy-Naïve Frail or Elderly Patients with RAS Wild-type Colorectal Cancer: OGSG 1602 Final Results

BACKGROUND

We previously reported the response rate of a phase II OGSG1602 study on panitumumab in chemotherapy-naive frail or elderly patients with RAS wild-type unresectable colorectal cancer (CRC) [Terazawa T, Kato T, Goto M, et al. Oncologist. 2021;26(1):17]. Herein, we report a survival analysis.

METHODS

Patients aged ≥65 years and considered unsuitable for intensive chemotherapy or aged ≥76 years were enrolled. Primary tumors located from the cecum to the transverse colon were considered right-sided tumors (RSTs); those located from the splenic flexure to the rectum were considered left-sided tumors (LSTs).

RESULTS

Among the 36 enrolled patients, 34 were included in the efficacy analysis, with 26 and 8 having LSTs and RSTs, respectively. The median progression-free survival (PFS) and overall survival (OS) were 6.0 [95% CI, 5.4-10.0] and 17.5 months (95% CI, 13.8-24.3), respectively. Although no significant differences existed in PFS between patients with LST and RST {6.6 (95% CI, 5.4-11.5) vs. 4.9 months [95% CI, 1.9-not available (NA), P = .120]}, there were significant differences in OS [19.3 (95% CI, 14.2-NA) vs.12.3 months (95% CI, 9.9-NA), P = .043].

CONCLUSION

Panitumumab showed favorable OS in frail or elderly patients with RAS wild-type CRC and no prior exposure to chemotherapy. Panitumumab may be optimal for patients with LSTs (UMIN Clinical Trials Registry Number UMIN000024528).

Effects of an oral elemental nutritional supplement in gastric cancer patients with adjuvant S-1 chemotherapy after gastrectomy: A multicenter, open-label, single-arm, prospective phase II study (OGSG1108)

AIM

Post-surgical weight loss influences chemotherapy compliance and may be a risk factor for survival. Intake of an oral elemental nutritional supplement (OENS) can reduce weight loss after gastric cancer (GC) surgery. We assessed whether therapy completion levels would increase in patients receiving postoperative adjuvant chemotherapy in combination with an OENS.

METHODS

This was a multicenter, open-label, single-arm, phase II study in GC patients who underwent curative total or distal gastrectomy (TG/DG) and received adjuvant S-1 chemotherapy. The primary endpoint was the S-1 completion rate for 1 year with a relative performance (RP) value of ≥70%; secondary endpoints included factors affecting the completion rate of S-1, RP value after eight S-1 courses, S-1 and OENS persistence rates, nutritional index, OENS compliance, and safety.

RESULTS

In 71 efficacy-evaluable patients, the S-1 completion rate was 69.0% (TG, 68.0%; DG, 69.6%) and the RP value was 87.5 (TG, 89.1; DG, 87.5). Over eight treatment courses, median persistence rates were 89.0% for S-1 and 93.8% for the OENS. The mean OENS compliance was 81.8% at the fourth S-1 course and 52.9% at the eighth course. The incidence of Grade 3 or 4 adverse events was 27.2%, most commonly neutropenia (12.3%).

CONCLUSIONS

The completion rate of S-1 for 1 year in patients who could take the OENS exceeded the pre-defined threshold level. Randomized controlled trials are warranted to confirm the role of OENS in adjuvant chemotherapy.

Comparison of S-1-cisplatin every 5 weeks with capecitabine-cisplatin every 3 weeks for HER2-negative gastric cancer (recurrent after S-1 adjuvant therapy or chemotherapy-naïve advanced): pooled analysis of HERBIS-2 (OGSG 1103) and HERBIS-4A (OGSG 1105) trials

BACKGROUND

We previously reported the HERBIS-4A phase II trial comparing S-1 plus cisplatin (SP) with capecitabine plus cisplatin (XP) in chemotherapy-naïve patients with HER2-negative advanced gastric cancer (GC). We performed a pooled analysis of HERBIS-4A and HERBIS-2, the phase II trial comparing SP with XP in HER2-negative recurrent GC patients with a recurrence-free interval after S-1 adjuvant therapy of ≥ 6 months.

PATIENTS AND METHODS

Patients were randomly assigned to receive either SP [S-1 (40-60 mg twice daily for 21 days) plus cisplatin (60 mg/m² on day 8), every 5 weeks] or XP [capecitabine (1000 mg/m² twice daily for 14 days) plus cisplatin (80 mg/m² on day 1), every 3 weeks].

RESULTS

In the pooled analysis, SP (n = 44-50) showed a longer progression-free survival [6.4 versus 5.1 months; hazard ratio (HR), 0.666; P = 0.062], overall survival (14.8 versus 10.6 months; HR, 0.695; P = 0.099), and time to treatment failure (4.6 versus 3.6 months; HR, 0.668; P = 0.045) as well as a higher disease control rate (86.4% versus 68.1%, P = 0.149) compared with XP (n = 47-51). A significant survival advantage for SP over XP was apparent in patients with a performance status of 0, a differentiated-type tumor histology, or a primary tumor localization to the upper portion of the stomach.

CONCLUSION

Our pooled analysis supports the use of SP in the first-line setting for patients with HER2-negative advanced or recurrent GC with a recurrence-free interval of ≥ 6 months.

CLINICAL TRIAL REGISTRATION

The HERBIS-2 trial was registered with UMIN-CTR as UMIN000006105.

Differences in disease status between patients with progression after first-line chemotherapy versus early relapse after adjuvant chemotherapy who undergo second-line chemotherapy for gastric cancer: Exploratory analysis of the randomized phase III TRICS trial

BACKGROUND

Second-line chemotherapy (SLC) improves survival in advanced gastric cancer (AGC). Patients receiving SLC are categorized into two disease status groups: tumour progression after first-line chemotherapy and early recurrence after adjuvant chemotherapy. Differences between these groups have not yet been clarified.

PATIENTS AND METHODS

A total of 163 eligible patients registered in the randomized phase III TRICS trial evaluating SLC for patients with AGC was classified into the progressive disease (PD) group (n = 55) or the early relapse (ER) group (n = 108). We compared overall survival (OS), progression-free survival (PFS), overall response rate (ORR), and safety. Adjusted OS and adjusted PFS were estimated using inverse probability of treatment weighting (IPTW).

RESULTS

The ER group had a lower median age than the PD group (66 vs. 72 years; P = 0.016), performance status (PS) 0 was more frequently seen in the ER group (87% vs. 71%; P = 0.012). The adjusted median OS was 13.7 months in the ER group and 13.6 months in the PD group (IPTW hazard ratio [HR]: 1.023; P = 0.854). The adjusted median PFS was 4.9 months in the ER group and 4.4 months in the PD group (IPTW HR: 0.707; P = 0.004). ORR was significantly better in the ER group than the PD group (21.3% vs. 4.9%; P = 0.020). No significant differences were observed in the incidence of adverse events.

CONCLUSIONS

ER was associated with improved PFS and better ORR than PD, although no difference in survival was demonstrated. From the viewpoint of treatment outcome, it seems appropriate to treat patients with ER in the same way as patients with PD.

CLINICAL TRIAL REGISTRATION

UMIN 000002571.

[A Successful Management of Thrombocytopenia Due to Multiple Lung Metastasis of Intrahepatic Cholangiocarcinoma Using Laparoscopic Splenectomy-A Case Report]

We report a case of multiple lung metastasis of intrahepatic cholangiocarcinoma treated with chemotherapy, in which laparoscopic splenectomy was effective for thrombocytopenia. A 74-year-old woman was diagnosed with multiple lung metastasis of intrahepatic cholangiocarcinoma 6 years after partial liver resection(S3). She was undergoing treatment for post-transfusion hepatitis C infection since the age of 46 years and developed thrombocytopenia due to splenomegaly. The previous hospital determined that there was no indication for chemotherapy due to thrombocytopenia. Elective laparoscopic splenectomy resulted in an increase in the platelet count and facilitated the initiation of gemcitabine(GEM)and cisplatin (CDDP)combination chemotherapy. The patient has maintained a good treatment course without interruption due to thrombocytopenia during chemotherapy. In advanced cancer patients with thrombocytopenia complication due to splenomegaly, laparoscopic splenectomy may offer an effective auxiliary means for the safe implementation of chemotherapy.

[Analysis of Early Palliative Care for Patients with Gastric Cancer]

BACKGROUND

Palliative care delivered to cancer patients late in the course of disease are inadequate to improve advance care planning and quality of life; thus, early palliative care is recommended. We retrospectively analyzed early palliative care delivered to patients with gastric cancer.

METHOD

Forty-nine gastric cancer patients who underwent surgery and had received interdisciplinary care from the first visit(early palliative care)were assessed for physical and psychosocial symptoms.

RESULTS

All patients were followed up continuously by a nurse certified in palliative care support to provide quality patient-centered care from the beginning(advance care planning). Four patients had experienced relapse, and 3 older patients had decided not to receive chemotherapy following their advance care planning. However, all 4 patients were admitted to a palliative care unit without barriers.

CONCLUSION

Early palliative care might lead patients to have advance care planning, and a better quality of life.

[A Case of Liver Metastasis of Distal Bile Duct Cancer]

A 60-year-old female visited our hospital due to anorexia and jaundice in March 2016. She underwent pancreatoduodenectomy( PD)and was diagnosed with distal bile duct cancer. The histopathological diagnosis was distal bile duct cancer, tub2, pT3aN1M0, pStage ⅡB. Postoperatively, she received S-1 therapy as adjuvant chemotherapy. One year after surgery, abdomi- nal enhanced CT and EOB-MRI revealed a liver metastasis(S3; 20mm). After 4courses of gemcitabine(GEM)/cisplatin(CDDP) combination therapy, there was no new lesion; thus, we performed partial hepatectomy(S3)in July 2017. The histopathology findings revealed well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as a recurrence of bile duct cancer. She remains alive without second recurrence for 2 years since the tumor resection(about 3 years since PD). Surgical intervention might be beneficial in selected patients with recurrent bile duct cancer.

Comparing five-weekly S-1 plus cisplatin with tri-weekly capecitabine plus cisplatin in patients with HER2-negative recurrent gastric cancer after S-1 adjuvant therapy or chemotherapy naïve advanced gastric cancer: A pooled analysis of HERBIS-2 (OGSG 1103) and HERBIS-4A (OGSG 1105) trials

379

Background: HERBIS-2 trial was a phase II trial where S-1 plus cisplatin (SP) and capecitabine plus cisplatin (XP) were compared in recurrent HER2 negative gastric cancer (GC) patients with recurrence free interval (RFI) by S-1containing adjuvant of ≥ 6 months. We performed pooled analyses of HERBIS-2 and HERBIS-4A trial where SP and XP were compared in chemotherapy-naive HER2 negative gastric cancer (GC) patients as these trials being identical. Methods: Both HERBIS-2 and 4A trials, patients were randomly assigned to receive either SP (S-1 at 40–60 mg twice daily for 21 days plus cisplatin at 60 mg/ m2on day 8, every 5 weeks) or XP (capecitabine 1,000 mg/m2twice daily for 14 days plus cisplatin 80 mg/m2on day 1, every 3 weeks). Results: In HERBIS-2 which was s closed early due to poor accrual, SP ( N= 10) tended to confer a better overall survival (OS) compared with XP ( N= 9)[18.7 (95%CI, 2.8 – NR) months vs.13.4 (95% CI, 5.2 – 31.3) months; hazard ratio (HR), 0.443 (95% CI, 0.156 – 1.258); P= .117]. In pooled analyses with HERBIS-2 and 4A, SP ( N= 50) vs. XP ( N = 51) showed longer progression free survival (6.4 vs.5.1 months; HR, 0.666; P= .62), OS (14.8 vs. 10.6 months; HR, 0.695; P= .099), time to treatment failure (4.6 vs. 3.6 months; HR, 0.668; P= .045), and higher disease control rate (86.4% vs. 68.1%, P= .149). Subgroup analysis revealed that OS benefit in SP arm compared to XP arm was significantly larger if the patient having PS of 0 [HR, 0.554 (95% CI, 0.309 to 0.959; interaction P= .035], or the tumor arising from upper area of stomach [HR, 0.266 (95% CI, 0.070 to 0.731); interaction P= .013] or harboring differentiated type cancer [HR, 0.433 (95% CI, 0.228 to 0.822); interaction P= .011], respectively. Conclusions: Our data suggest the use of SP in the 1stline setting in HER2 negative advanced or recurrent GC with RFI by S-1 adjuvant of ≥ 6 months. Pooled analyses further suggest SP as the standard 1st line chemotherapy for HER2 negative AGC irrespective of S-1 adjuvant in Japan. Clinical trial information: UMIN000006755/UMIN000006105.

Meta-analysis of two randomized phase III trials (TCOG GI-0801 and ECRIN TRICS) of biweekly irinotecan plus cisplatin versus irinotecan alone as second-line treatment for advanced gastric cancer

BACKGROUND

Biweekly irinotecan (CPT-11) plus cisplatin (CDDP) combination (BIRIP) and CPT-11 alone are both expectable options for treating advanced gastric cancer (AGC) in a second-line setting. We conducted a meta-analysis to compare the efficacy and safety of these two regimens in patients enrolled two randomized phase III trials.

PATIENTS AND METHODS

Individual patient-level data from two randomized phase III trials were collected for this study. In both trials, patients with AGC refractory to S-1-based chemotherapy were randomly allocated to BIRIP (CPT-11, 60 mg/m²; CDDP, 30 mg/m², q2w) or to CPT-11 (150 mg/m², q2w).

RESULTS

Cumulative data from 290 eligible patients were evaluated. The OS was 12.3 months [95% confidence interval (CI) 10.5-14.1] in the BIRIP group and 11.3 months (95% CI 10.0-13.2) in the CPT-11 group (hazard ratio 0.87; 95% CI 0.68-1.12, P = 0.272), while PFS was significantly longer in the BIRIP group (4.3 months [95% CI 3.5-5.1]) than in the CPT-11 group (3.3 months [2.9-4.1]; HR 0.77; 95% CI 0.61-0.98, P = 0.035). The response rate was 20.5% in the BIRIP group and 16.0% in the CPT-11 group (P = 0.361). However, the disease control rate was significantly better in the BIRIP group (72.1%) than in the CPT-11 group (59.2%) (P = 0.032). The two groups did not differ significantly in the incidences of grade 3 or worse adverse events.

CONCLUSIONS

Both BIRIP and CPT-11 may be good therapeutic options for patients with AGC as second-line treatment.

CLINICAL TRIAL REGISTRATION

UMIN 000025367.

[Long-Term Survival of a Patient with Metastatic Ovarian Cancer and Local Recurrence of Rectal Cancer]

A 60s woman with upper rectal cancer underwent low anterior resection; the patient was diagnosed with pSSN1, Stage Ⅲa cancer. She received adjuvant therapy with UFT. Three years after the primary resection, metastasis to the right ovary and local recurrence were diagnosed. She was treated with CAPOX plus bevacizumab(Bev), capecitabine, FOLFIRI, and irinotecan plus S-1. Because only the ovarian metastasis increased rapidly, we were able to perform surgery and R0 resection. Two years after resection, local recurrence became apparent, and chemotherapy was reinitiated. After treating the patient with chemotherapy and chemo-radiation therapy for 2 years, R0 resection was performed. Twelve years after primary tumor resection and 9 years after primary resection, we observed recurrence-free survival.

[A Case of Superficial-Type Gastric Cancer with Metastatic Ovarian Cancer Diagnosed by Exploratory Laparotomy]

Here, we report a case of superficial-type gastric cancer with metastatic ovarian cancer(Krukenberg tumor)diagnosed by exploratory laparotomy. Chemotherapy was initiated at an early stage in this patient. A 43-year-old woman with superficialtype gastric cancer(0-Ⅱb plusⅡa), an ovarian tumor, and a solitary sclerotic bone lesion underwent exploratory laparotomy and bilateral salpingo-oophorectomy. Pathological findings showed that the resected ovarian tumor specimen contained the same type of signet ring cell carcinoma as the biopsy gastric cancer specimen; hence, the patient was diagnosed with superficial- type gastric cancer with metastatic ovarian cancer. She was treated with first-line chemotherapy(capecitabine plus oxaliplatin)15 days after exploratory laparotomy, followed by second-line chemotherapy(ramucirumab plus paclitaxel), thirdline chemotherapy(nivolumab), and fourth-line chemotherapy(irinotecan). Twenty-two months after the start of first-line chemotherapy, she finally died due to bone metastasis.

Sarcopenia Is Associated With Impaired Overall Survival After Gastrectomy for Elderly Gastric Cancer

BACKGROUND/AIM

The aim of this study was to evaluate the impact of sarcopenia diagnosed by the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm on long-term outcome after gastrectomy.

PATIENTS AND METHODS

A total of 90 elderly gastric cancer patients without distant metastasis aged 65 years or older who underwent gastrectomy at the Osaka National Hospital between July 2012 and January 2015 were included in the current analysis.

RESULTS

The sarcopenic group (n=19) had a poorer overall survival (OS) (p<0.0001) compared to the non-sarcopenic group (n=79). OS after recurrence was also worse in the sarcopenic group. Multivariate analysis indicated that sarcopenia was an independent risk factor for worse OS after gastrectomy (hazard ratio(HR)=2.92; 95% confidence interval(CI)=1.15-7.75; p=0.025), along with N stage ≥2, age ≥75 years, and presence of severe postoperative complications.

CONCLUSION

Sarcopenia is a potential target for preoperative intervention in elderly gastric cancer patients to improve prognosis after gastrectomy. (UMIN-CTR: R000041532).

The Risk Factor of Anastomotic Hypoperfusion in Colorectal Surgery

BACKGROUND

Inadequate blood flow is an important risk factor for anastomotic leakage. Indocyanine green (ICG) fluorescence imaging allows intraoperative assessment of intestinal blood flow. This study determined the risk factor of anastomotic hypoperfusion in colorectal surgery using ICG fluorescence imaging.

METHODS

This study included 74 consecutive patients who underwent colorectal surgery between April 2017 and March 2018. ICG was injected intravenously after dividing the mesentery and central vessels along the planned transection line, but before completing the anastomosis. Intraoperative blood flow was evaluated using ICG fluorescence imaging. With regard to the patient-, tumor-, and surgery-related factors, anastomotic perfusion was evaluated based on the changed transection line and prolonged (more than 60 s) perfusion time.

RESULTS

Intraoperative ICG fluorescence imaging was performed in all patients, and no adverse events were associated with ICG injection. Based on the perfusion assessment, we changed the transection line in six patients (8.1%). The prolonged perfusion time was observed in nine patients (12.2%). The postoperative course was uneventful in 63 (85.1%) patients, but one patient (1.4%) had postoperative anastomotic leakage. The changed transection line was significantly associated with anticoagulation therapy (P = 0.029). Well-known risk factors, including surgical site, sex, smoking, blood loss, operative time, and preoperative chemoradiotherapy, were not related to the changed transection line. Prolonged ICG perfusion time was not associated with any patient-, tumor-, or surgery-related factors.

CONCLUSIONS

The evaluation of intraoperative blood flow using ICG fluorescence imaging may be able to detect anastomotic hypoperfusion, and anticoagulation therapy is a risk factor of anastomotic hypoperfusion in colorectal surgery.

[A Case of Recurrent Gastric Cancer Successfully Treated by S-1 Chemotherapy]

We report a case of recurrent gastric cancer that was successfully treated by S-1 chemotherapy.An 81-year-old woman with advanced gastric cancer[L Less, Type 2, cT4a(SE), cN0H0P0M0, cStageⅡB]underwent distal gastrectomy.Abdominal CT performed 6 months after surgery revealed a low-density area in the liver.She was diagnosed with liver metastasis and started receiving S-1 chemotherapy.The liver metastasis achieved complete response, so S-1 chemotherapy was discontinued 12 months after recurrence.Abdominal CT performed 9 months after the discontinuation of S-1 chemotherapy revealed multiple low-density areas in the liver.She started receiving S-1 chemotherapy again, but S-1 chemotherapy was discontinued because of side effects after 2 courses.The patient died 24 months after receiving S-1 chemotherapy.

Role of volume reduction gastrectomy according to tumor location in patients with gastric cancer with a single noncurable factor: REGATTA trial (JCOG0705/KGCA01) supplementary analysis

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Background: Chemotherapy (CTX) is the standard of care for incurable advanced gastric cancer (AGC). REGATTA trial, which investigated survival benefit of reduction gastrectomy (Gx) in patients (pts) with AGC with a single non-curable factor, failed to demonstrate the superiority of Gx followed by CTX over CTX alone. However, there was a significant interaction between the treatment effect and tumor location in the subset analysis. In addition, treatment effect appeared to be different between Japan and Korea. So, the aim of this supplementary analysis was to explore the subgroups for which volume reduction Gx was beneficial with special reference to the tumor location and country. Methods: REGATTA trial was a randomized phase III trial at 44 institutions in Japan, Korea, and Singapore. Patients with AGC with a single non-curable factor were randomly assigned in each country to CTX alone or Gx plus CTX. The primary endpoint was overall survival (OS). In this analysis, OS was compared according to tumor location, country, and operative procedure. Results: A total of 175 pts (95 in Japan, 80 in Korea) was randomized to CTX alone (86 pts) or Gx followed by CTX (89 pts). MST was 16.6 months in CTX alone and 14.3 months in GX plus CTX (HR 1.09, 95% CI: 0.78–1.52, p = 0.70) (primary analysis). In subgroup analysis according to the country, OS curves were separated between the arms, worse in Gx plus CTX arm in Japan (HR 1.32, 95% CI: 0.85-2.05), whereas, that was not in Korea (HR 0.85. 95% CI: 0.52-1.40). HRs according to tumor location were 2.23 in upper third, 0.95 in middle third, and 0.63 in lower third. OS tended to be better in pts who received distal GX compared with CTX alone (HR = 0.69), and worse in pts who received total GX compared with CTX alone (HR = 1.34). This trend was more remarkable in Korea than in Japan. Multivariate analysis demonstrated that histological type was selected as an independent prognostic factor. Conclusions: Primary CTX is a standard of care for AGC; however, it would be still an open question whether volume reduction Gx have a survival benefit when the tumors located at the distal stomach for which the pts receive distal Gx. Clinical trial information: UMIN000001012.

[A Case of Esophageal Cancer with Aortic Thrombosis That Was Successfully Treated by Aortic Thrombectomy and Video-Assisted Thoracoscopic Esophagectomy]

We report a case of esophageal cancer with aortic thrombosis that occurred during chemotherapy and was successfully treated by aortic thrombectomy and video-assisted thoracoscopic esophagectomy. A 70-year-old man with esophageal cancer( Mt, Type 1c, cT2cN0cM0, cStage Ⅱ)was administered 5-FU plus cisplatin chemotherapy. On day 7 in the first course of the chemotherapy, he experienced abdominal pain. Abdominal CT revealed endo-aortic thrombotic deposits in the aortic arch about 3 cm in diameter. He immediately received heparin at a dose of 20,000 U/day administered intravenously, but the thrombus had not resolved by the next day. He underwent aortic thrombectomy, and warfarin was administered orally after the thrombectomy. He did not experience any difficulties or discomfort related to the thrombus after the thrombectomy. He then underwent video-assisted thoracoscopic esophagectomy and was discharged uneventfully on the 18th postoperative day. Currently, he is under follow-up with no recurrence.

[A Case of Liver Metastasis of Intrahepatic Cholangiocarcinoma That Achieved Clinical Complete Response after Gemcitabine and Cisplatin Combination Chemotherapy]

We report a case of liver metastasis of intrahepatic cholangiocarcinoma that achieved clinical complete response after gemcitabine(GEM)and cisplatin(CDDP)combination chemotherapy. The patient was a 69-year-old man who was diagnosed with intrahepatic cholangiocarcinoma with hilar invasion and intrahepatic metastasis(cT4N0M0, Stage ⅣA)and was initially treated with right trisegmentectomy with left portal vein resection, lymph node dissection, and reconstruction of the left portal vein and biliary tract after transhepatic portal vein embolization(PTPE). S-1 was administered continuously as postoperative adjuvant chemotherapy, and the patient showed no signs of recurrence. Three years after the surgery, a CT scan showed LDA 10mm in diameter in the middle area of the remnant liver. We suspected liver metastasis when both serum CA19-9 and DUPAN-2 levels were elevated with the increasing size of LDA; liver biopsy was then performed, and he was diagnosed with liver metastasis of intrahepatic cholangiocarcinoma. After 3 courses of combination chemotherapy containing GEM and CDDP, a CT scan revealed that the liver metastasis reduced in size, and PR was achieved based on the RECIST standard. After 12 courses, the liver metastasis disappeared, and the patient had achieved CR based on the RECIST standard. The patient has received S-1 following the combination chemotherapy and survived for 6 years since initial treatment without any other metastatic lesions.

[Analysis of Patients Who Received Nutritional Support and the Enhanced Recovery after Surgery(ERAS)Protocol after Esophagectomy]

BACKGROUND

Malnutrition is a frequently observed phenomenon in patients with esophageal cancer after esophagectomy. Nutritional support and the enhanced recovery after surgery(ERAS)protocol may prevent malnutrition.

METHOD

Nine patients who underwent esophagectomy for esophageal cancer received perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®). We retrospectively evaluated the efficacy and safety of our perioperative management.

RESULTS

The median day of first oral intake(water)was the second postoperative day. The median day of first oral intake(food)was the seventh postoperative day. The patients could consume more than one and a half bottle of enteral nutrition for a year after surgery. The prognostic nutritional index(PNI)was higher than 40, and the neutrophil-to-lymphocyte ratio(NLR)was lower than 3 for a year after surgery.

CONCLUSIONS

Perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®)might be feasible and prevent malnutrition in patients after esophagectomy.

Evaluation of blood flow on the remnant distal bowel during left-sided colectomy

Adequate blood flow in anastomosis is of paramount importance to prevent anastomotic leakage. However, it is sometimes difficult to predict the viability of the intestine during surgery. During left-sided colectomy, blood flow on the remnant distal bowel is supplied only from the middle and inferior rectal arteries. The blood backflow after the root ligation of the inferior mesenteric artery is often said to be kept up to promontorium levels; however, this premise is actually based on experience, without reliable evidence. Here, we introduce the intraoperative evaluation of blood flow on the remnant distal bowel during left-sided colectomy using an indocyanine green fluorescence technique.

Clinicopathological Features and Prognosis of Primary GISTs with Tumor Rupture in the Real World

Background

Patients with ruptured gastrointestinal stromal tumor (GIST) are recommended for imatinib adjuvant therapy; however, their clinicopathological features and prognosis in the era of imatinib are unknown.

Patients and Methods

The study cohort included 665 patients with histologically proven primary GISTs who underwent R0 or R1 surgery between 2003 and 2007; the validation cohort included 182 patients between 2000 and 2014. The definitions of tumor rupture in the study included perforation at tumor site, tumor fracture, piecemeal resection including open biopsy, and macroscopic injuries to the pseudocapsule.

Results

Tumor rupture occurred in 21 (3.2%) of 665 and 5 (2.9%) of 182 patients in the study and validation cohort, respectively. Ruptured GISTs were more symptomatic, were larger in size, and had higher mitotic count than nonruptured GISTs but were not associated with tumor location or laparoscopic surgery. GISTs with intraoperative rupture had clinicopathological features and prognostic outcomes similar to those with preoperative rupture. Recurrence rates were higher and median recurrence-free survival (RFS) and overall survival (OS) were shorter with ruptured than nonruptured GIST. Tumor rupture was one of the independent prognostic factors for RFS, but not OS, according to multivariate analysis.

Conclusions

Ruptured GISTs were symptomatic larger tumors with high mitotic activity, frequent relapse, and shorter RFS. Tumor rupture was an independent prognostic factor for RFS, but not for OS, in the era of imatinib.

Electronic supplementary material

The online version of this article (10.1245/s10434-018-6505-7) contains supplementary material, which is available to authorized users.

[A Case of Effective Palliative Care with CART for Refractory Ascites Associated with Cancerous Peritonitis of Gastric Cancer]

Refractory ascites associated with cancerous peritonitis causes abdominal tension and reduced oral intake. Frequent ascites drainage can cause rapid worsening ofa patient's general condition. Cell-free and concentrated ascites reinfusion therapy (CART)for refractory ascites was first covered in 1981, and the general conditions ofpatients and their symptoms could be improved after undergoing CART. Herein, we report a case of effective palliative care with CART for refractory ascites associated with cancerous peritonitis. A 66-year-old man was admitted to our hospital because ofabdominal distension. Computed tomography revealed the presence ofascites and gastric wall thickness; upper gastrointestinal endoscopy revealed an ulcerated lesion with raised margins on the body ofthe stomach. Biopsy ofthis lesion confirmed the diagnosis ofadenocarcinoma, and he was diagnosed with gastric cancer(M, Type 3, cT4a[SE], cN0, cH0, cP1, cM1, cStage IV). He underwent palliative care for ascites, followed by FLTAX regimen chemotherapy(5-fluorouracil[5-FU]and Leucovorin[LV]combined with weekly paclitaxel[PTX]). He received CART for 8 courses without complications, and his symptoms improved after receiving CART. He survived for about 18 months, and could ingest a normal diet for a long time. CART may be favorable in palliative care for massive ascites associated with cancerous peritonitis.

[A Case of Advanced Esophageal Cancer Successfully Treated with Multidisciplinary Therapy]

We report a case of advanced esophageal cancer that was successfully treated using chemotherapy, operation, and chemoradiotherapy. A 66-year-old man with advanced esophageal cancer(Mt, O-Is, T4[N0.7-stomach], N2, M0, Stage III)was administered chemotherapy(docetaxel[DOC], cisplatin[CDDP], and 5-fluorouracil[5-FU]: DCF). As the esophageal tumor achieved complete clinical response after 2 courses of chemotherapy, lymph node dissection and proximal gastrectomy were performed for the residual tumor. Abdominal CT 3 months after surgery revealed lymph node swelling. He was diagnosed with lymph node metastasis and was administered chemoradiotherapy. After chemoradiotherapy, liver metastasis was revealed, and he underwent immune checkpoint inhibitor immunotherapy. Despite the administration of immune checkpoint inhibitors, the liver metastasis developed, so he was treated with S-1 chemotherapy. S-1 chemotherapy resulted in a favorable response, and almost all metastatic lesions decreased. The patient is alive 12 months after S-1 chemotherapy without any signs of tumor regrowth.

[A Case of Splenic Metastasis from Serous Surface Papillary Carcinoma of the Peritoneum Treated by Laparoscopic Splenectomy]

A 50-year-old woman with abdominal fullness, lower abdominal pain, elevated serum CA125, and ascites, underwent neoadjuvant chemotherapy with 6 courses of PTX/CBDCA followed by total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and intrapelvic peritoneal stripping based on a diagnosis of serous surface papillary carcinoma(SSPC) of the peritoneum. Complete response(CR)was shown after adjuvant chemotherapy with 3 courses of the same regimen. After 6 months, serum CA125 level re-increased and abdominal CT showed small low density areas in the patient's spleen and the perisplenic fat tissue. After the additional chemotherapy with 3 courses of PTX/CBDCA were performed based on a diagnosis of metastatic lesion from SSPC, anaphylactic shock occurred as the severe adverse event. The patient was given 9 more courses of the chemotherapy changed the regimen to PTX/CDDP. The splenic metastatic lesion had grown rapidly in the followed CT and then, laparoscopic splenectomy with peritoneal resection was performed based on a diagnosis of splenic metastasis from SSPC. The pathological examinations showed the tumor to be a splenic metastasis and peritoneal dissemination from SSPC. No recurrent lesion has been detected in the 9 months since removal of the splenic metastasis without adjuvant chemotherapy and the patient has survived for 4 years and 6 months since initial treatment.

[The Surgical Experience for Bulky Serous Cystic Neoplasm of Pancreas]

A 74-year-old femalewas admitted to our hospital dueto thebulky abdominal tumor pointed out by ultrasonography of medical screening. Abdominal CT revealed the tumor, in a diameter 20 cm, replaced the total pancreas and compressed the surrounding organs and portal vein. We diagnosed as a pancreatic serous cystic neoplasm with a possibility of malignancy. The operative findings showed the tumor tightly adhered to stomach, duodenum, liver, transverse colon mesenterium, retroperitoneum and the surrounding main vessels. Total pancreatectomy, cholecystectomy, splenectomy and distal gastrectomy were performed. As a histopathological finding, thetumor surfacewas smooth and theinsidewas sponge-likeappe arancemixe d with microcystic and solid components. No malignant finding was observed. The patient was discharged without major complications on postoperative day 42, and remains alive with no recurrence for 9 months after surgery.

Well-leg compartment syndrome after laparoscopic low anterior resection for lower rectal cancer in the lithotomy position: A case report

A 64-year-old man underwent laparoscopic low anterior resection for lower rectal cancer. Because he was overweight (BMI, 28.1 kg/m² ) with rich visceral fat and a narrow pelvic cavity, the operation was technically difficult and the operation time was 686 min. Postoperatively, the patient immediately complained of pain and swelling of the left lower limb. Laboratory examination showed that serum creatinine kinase was markedly increased and urine myoglobin was positive on postoperative day 1. He was diagnosed with well-leg compartment syndrome and was transported to the trauma and critical care center for emergency fasciotomy. After initial treatment, he was transferred to our hospital on postoperative day 7. He completely recovered after 2 months. Although well-leg compartment syndrome is rare, it is necessary to consider it as a potential complication when performing a long colorectal cancer surgery with the patient in the lithotomy position, particularly when laparoscopic surgery is planned.

Survival of second-line irinotecan-based chemotherapy in early relapse patients with gastric cancer after adjuvant chemotherapy: Exploratory subgroup analysis of TRICS trial

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Background: Second-line chemotherapy (SLC) was reported to improve the survival of advanced gastric cancer (AGC). The TRICS trial which a randomized phase III study of second-line irinotecan plus cisplatin versus irinotecan alone in patients with AGC refractory to S-1 monotherapy, revealed that both irinotecan based chemotherapies were effective with favorable long-term survivals and generally well tolerated. Eligible patients included patients with recurrence within 6 months after the completion of adjuvant therapy with S-1 (early relapse cases), or patients with tumor progression after first-line S-1 for an advanced cancer (progressive cases), in this trial. However, it is unclear whether survivals in early relapse cases were different from these in progressive cases or not. Methods: A total of 168 patients registered to the TRICS trial were classified as early relapse group (n = 111) or progressive group (n = 57), and 168 (irinotecan plus cisplatin, early relapse 56/83, 67%; irinotecan alone, 55/85, 65%) and 163 (55/81, 68%; 53/82, 65%) patients were analyzed for survival. Adjusted OS and adjusted PFS were constructed adjusted Kaplan-Meier curve with inverse probability weight, and were estimated by inverse probability of treatment weighting method (IPTW). Results: In baseline characteristics, PS 0 were more frequently seen in early relapse group than in progressive group (86% vs 72%, p = 0.0328), and median age of early relapse group was younger than progressive group (66 vs 72, p = 0.0162). The median OS was 13.9 months in early relapse group and 10.0 months in progressive group (HR:0.746, p = 0.1019). The adjusted median OS was 14.0 months in early relapse group and 10.6 months in progressive group (IPTW HR:0.864, p = 0.1019). Early relapse group showed better trends in PFS compared to the progressive group (4.7M vs 3.6M, HR: 0.650, p = 0.0149). The adjusted median PFS was 4.8 months in early relapse group and 3.7 months in progressive group (IPTW HR:0.673, p = 0.0008). Conclusions: Irinotecan based chemotherapies were effective especially in early relapse cases after adjuvant therapy with S-1, in second-line setting of AGC.

[A Case of Advanced Rectal Cancer with Synchronous Pulmonary Metastasis Undergoing Laparoscopic Curative Resection after Chemotherapy]

The patient was a 50-year-old man who complained of bloody stool and proctal discomfort. After hospitalization, he was diagnosed bearing advanced lower rectal cancer with lateral lymph nodes and bilateral pulmonary metastases(cT3N3M1a, Stage IV ). He was treated with irinotecan, Leucovorin and 5-fluorouracil(FOLFIRI)plus cetuximab because of RAS wild type. After 11 courses of the chemotherapy, all pulmonary metastases were disappeared(CR). Six months after the initialtreatment, laparoscopic abdominoperineal resection with lateral lymph node resection was performed with curative intent. After the operation, additional1 2 courses of the same chemotherapy were carried out. One year after operation, there is no sign of recurrence. Though used to be considered non-curative, advanced rectal cancer with distant metastases could be potentially cured by multidisciplinary treatments.

[Analysis of Patients Who Received Enteral Nutrition in the Course of Chemotherapy]

BACKGROUND

Chemotherapy-related adverse events can deteriorate the quality of life, as well as chemotherapy tolerance, for patients with gastric cancer. Nutritional support may prevent chemotherapy-related adverse events.

METHODS

Five patients who received chemotherapy for advanced gastric cancer were prescribed enteral nutrition(Elental®or ENEVO®). We retrospectively evaluated the efficacy and safety of chemotherapy while receiving enteral nutrition.

RESULTS

All patients consumed more than one bottle of enteral nutrition during chemotherapy. Median progression-free survival(PFS)and overall survival(OS)were 166 days(100-349)and 328 days(115-431), respectively. Major Grade 3 or 4 adverse events included neutropenia(0%), anemia(40%), and diarrhea(20%). The prognostic nutritional index(PNI)was higher than 40, and the neutrophil lymphocyte ratio(NLR)was lower than 3 over the course of chemotherapy.

CONCLUSIONS

Nutritional support for gastric cancer patients receiving chemotherapy is feasible. There was a low incidence of chemotherapy-related hematological toxicity, with a relatively longer PFS in patients receiving enteral nutrition.

Clinicopathological features and prognosis of primary GISTs with tumor rupture in the real world

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Background: Ruptured GIST has poor prognosis and patients (pts) with ruptured GISTs are recommended for imatinib adjuvant therapy, however, their clinicopathological features and the prognosis in the era of imatinib are unknown. Using data obtained from two different registry studies in Japan, we examined ruptured GIST patients in clinical practice. Methods: The study cohort registered 665 pts (339 male and 326 female; median age 66 yrs) with histologically-proven primary GISTs who underwent R0 or R1 surgery between 2003 and 2007. The validation cohort included 172 pts (100 and 72; median age 62.5) between 2000 and 2014. Pathological Dx was done with H&E, KIT- and DOG1-IHC. Results: Disease located in the stomach (n = 506), small intestine (n = 119), large intestine (n = 26), or others (n = 14) in the study cohort and it was 120, 37, 14 or 2 in the validation, respectively. Median tumor size was 4.0 and 5.0 cm, median mitosis 2.6 and 5.0 /50HPF, and tumor rupture was seen in 21 pts (3.2%) and 5 pts (2.9%) in the study and validation cohorts, respectively. Rupture occurred preoperatively in 12 pts and intraoperatively in 9 of the study cohort. Ruptured GISTs showed high mitotic activities (median mitosis 13.0 vs 2.5 /50HPF; P < 0.0001), larger tumor (median size 9.6 vs 4.0 cm; P = 0.0008), and were more symptomatic than non-ruptured in the study cohort. Ruptured GIST pts had more frequent relapses (P < 0.0001) and showed shorter RFS (estimated RFS = 2.4 yrs; P < 0.0001) than non-ruptured (8.4 yrs). There were no difference in age, gender, location, surgical approach, cell type, preoperative and postoperative imatinib use between two groups.These results were confirmed in the validation cohort. Ruptured GISTs showed more frequnent relapses in the peritoneum. Multivariate analysis indicated that location (HR = 1.6), size (1.07), mitosis (1.01), and rupture (4.5) were independent prognostic factors of RFS. Rupture was not always prognostic for OS, and age (1.03), gender (2.3), and mitosis (1.01) were independent prognostic factors of OS. Conclusions: Ruptured GISTs were symptomatic larger tumors with high mitotic activity and showed frequent relapses, however, it was not independently prognostic for OS in the era of imatinib.

Serial monitoring of imatinib pharmacokinetics (PK) in perioperative imatinib treatment in patients (pts) with gastrointestinal stromal tumors (GISTs): Results from the multinational phase II trial

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Background: Imatinib plasma levels may be affected by the duration of exposure to imatinib and resection of the stomach. Therefore, we performed PK study to monitor imatinib plasma levels serially in the multinational phase II trial of perioperative imatinib for pts with large ( ≥ 10 cm) gastric GISTs without distant metastasis. Methods: In this trial conducted in Japan and Korea, 53 pts received neoadjuvant imatinib 400 mg daily and 40 pts received adjuvant imatinib after surgery. Blood samples for imatinib trough levels (Cmin) were collected after 1, 3, 6 months of each neoadjuvant and adjuvant imatinib and measured by using liquid chromatography-tandem mass spectrometry. For the comparison of imatinib Cmin between different time points, values were dose-adjusted and log-transformed. Results: During the neoadjuvant treatment, imatinib Cmin (mean ± standard deviation) was 2253.0 ± 1148.0 ng/mL (n = 49), 1623.3 ± 832.4 ng/mL (n = 47), and 1852.0 ± 1572.4 ng/mL (n = 45) after 1, 3, and 6 months of imatinib, respectively. During the postoperative treatment, imatinib Cmin was 1436.1 ± 852.8 ng/mL (n = 31), 1357.8 ± 646.4 ng/mL (n = 33), and 1084.2 ± 360.8 ng/mL (n = 31) after 1, 3, and 6 months of imatinib, respectively. In the neoadjuvant setting, imatinib Cmin was significantly reduced after 3 months (p = 0.0001) and 6 months (p = 0.004) compared to the value at 1 month. In 36 patients that imatinib Cmin was measured at both preoperative and postoperative setting, imatinib Cmin was significantly reduced after surgery (1732.4 ± 997.9 ng/mL vs 1282.8 ± 557.3 ng/mL; p = 0.04). The magnitude of changes in imatinib Cmin after surgery was greatest in patients who underwent total gastrectomy (10.6%, n = 2) followed by proximal gastrectomy (8.4%, n = 3), and wedge resection (3.3%, n = 30). There were no significant relationships between imatinib Cmin and toxicity or objective response. Conclusions: Imatinib exposure was reduced until approximately 3 months after imatinib treatment. It was also significantly reduced after surgery and the magnitude of changes might be affected by the extent of surgical resection of stomach.

Phase II study of adjuvant chemotherapy of S-1 plus oxaliplatin for patients with stage III gastric cancer after D2 gastrectomy

BACKGROUND

The Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer (ACTS-GC) demonstrated a survival benefit by adjuvant S-1 monotherapy in patients who had undergone curative resection of stage II/III gastric cancer, but there is still a need to improve the efficacy of treatment of stage III disease. We investigated the tolerability and safety of S-1 and oxaliplatin as adjuvant chemotherapy for stage III gastric cancer.

METHODS

Japanese patients with stage III gastric cancer who had undergone D2 or more extensive lymphadenectomy were enrolled. In the first cycle, S-1 (40-60 mg/m² twice daily) alone was given orally for 2 weeks of a 3-week cycle. From the second cycle, S-1 was administered as in the first cycle and oxaliplatin (100 mg/m²) was infused intravenously on day 1. Treatment was continued for 8 cycles. The primary end point was the treatment completion rate for eight cycles.

RESULTS

Sixty-three patients were enrolled and 62 patients were included in analysis. The treatment completion rate was 74.2 %, which was higher than the expected completion rate of 72.0 %. The median relative dose intensities were 77.1 % for S-1 and 72.6 % for oxaliplatin, with 41.9 and 61.7 % patients requiring dose reduction of S-1 and oxaliplatin, respectively. Neutropenia was the only grade 3 or higher adverse event with an incidence 10 % or greater (32.3 %). There was no grade 3 or higher peripheral sensory neuropathy or treatment-related death.

CONCLUSIONS

S-1 and oxaliplatin therapy is suggested to be manageable and safe with optimal dose reduction and delay in selected patients for stage III gastric cancer after D2 gastrectomy, and warrants further evaluation in larger studies.

[A Case of Splenic-Hilum Lymph Node Recurrence after Spleen Preserving Total Gastrectomy for Gastric Cancer Following Neoadjuvant Chemotherapy]

A 69-year-old man was diagnosed with a large type 3, cT4bN2M0, cStage III c advanced gastric cancer located at the lesser curvature of the upper stomach. Neoadjuvant chemotherapy with S-1 plus CDDP was administered, and partial response was obtained after 2 courses. Subsequently, spleen preserving total gastrectomy with partial hepatectomy was performed. The final pathological diagnosis was UM, Less, yType 3, por1, ypT4b(SI liver), was ly2, v1, ypN2, M0, pStage III c, R0. Adjuvant chemotherapy with S-1 was administered; however, 5 months after the surgery, splenic-hilum lymph node recurrence was detected. Chemotherapy with CPT-11 plus CDDP was administered and a salvage operation was planned when the response to treatment was nonCR or nonPD. After 6 courses of chemotherapy, the treatment response was PR. Nine months after the first operation, spleno-pancreatic tail resection combined with partial hepatectomy was performed. The patient is currently disease-free without chemotherapy.

[A Case of Laparoscopic Resection of a Lymph Node Recurrence after Surgery for Descending Colon Cancer]

The patient was an 81-year-old woman who underwent laparoscopic anterior resection for her descending colon cancer with final pathology results of tub2, pT3(SS), int, INFb, ly0, v1, EX(-), no lymph metastasis, and fStage II . She was followed up without adjuvant chemotherapy. Six months after the surgery, a CT scan revealed a tumor shadow 8mm in diameter near the clip fixed around the inferior mesenteric vein(IMV). After another 3 months, the tumor size increased to 11mm and it was diagnosed as a recurrence. Chemotherapy with capecitabine and bevacizumab was carried out for 6 months. Since her treatment response was judged as PR and no other recurrence was found, a local resection was planned. In order to identify the exact location of the recurrent lesion, a small laparotomy was performed at first to identify the tumor via palpation. A laparoscopic surgery was then performed to remove the recurrent lesion. Based on a pathological examination, the tumor was diagnosed as a lymph node recurrence and the histological response was judged as Grade 1b. A laparoscopic approach is technically feasible even for resection of recurrent lesions.

[Is Adjuvant Chemotherapy Necessary after R0 Resection for pCR or ypStage I Patients with Gastric Cancer ?]

Neoadjuvant chemotherapy(NAC)followed by surgery and palliative chemotherapy for unresectable advanced gastric cancer followed by conversion surgery are currently under investigation in clinical trials and are attractive therapeutic alternatives. We examined the relationship between ypStage and prognosis among patients with gastric cancer who underwent surgery following preoperative chemotherapy and evaluated the necessity of adjuvant chemotherapy in patients with pCR or ypStage I gastric cancer. Sixty-one patients received chemotherapy followed by surgery from 2006 to 2014 in Osaka National Hospital. For preoperative chemotherapy, 41 patients received NAC, and 20 patients received palliative chemotherapy. Five (8.2%)patients with pCR, ypStage I A, and Stage I B disease(n=2, 1, and 2, respectively), 3 of whom received adjuvant chemotherapy and 2 of whom did not, were all alive without recurrence after a median follow-up of 3 years and 6 months. The overall survival for patients from each ypStage in the preoperative chemotherapy group was comparable with that for each ypStage in the surgery without preoperative chemotherapy group during the same period. Discontinuation of adjuvant chemotherapy and intense follow-up is a treatment option after R0 resection for patients with gastric cancer who achieve pCR or downstaging to ypStage I .