Identification of maximal tumor size associated with negligible lymph node metastasis for endoscopic submucosal dissection of undifferentiated-type early gastric cancer

BACKGROUND AND AIMS

When treating undifferentiated-type early gastric cancer (UD-EGC) that is limited to the mucosa (clinically T1a), endoscopic submucosal dissection (ESD) can be considered if the tumor is 2 cm or less and is not ulcerated. However, there is insufficient evidence to determine the relationships between tumor size and oncological safety of ESD in UD-EGC.

METHODS

The pathology reports of Korean patients who were diagnosed with UD-EGC (n = 5286) were retrospectively reviewed. The cumulative incidence of lymph node metastasis (LNM) according to tumor size was evaluated in subgroups. The tumor-size cut-off was identified as the upper limit of the 95% confidence interval (CI) of cumulative LNM incidence that did not exceed 1.0%.

RESULTS

We identified 1516 patients with non-ulcerated T1a tumors ≤2 cm in size. Among patients without lymphatic invasion, 1.5% (95% CI 0.91-2.16%) had LNM. In patients with poorly differentiated tubular adenocarcinoma (PD), LNM increased from 0 to 0.74% based on a tumor size of 1.0 cm. Regardless of tumor size, smaller percentages of undifferentiated-type (UD) and poorly cohesive carcinoma (PCC) patients experienced LNM than did those with PD. In non-ulcerated mucosal cancer without lymphatic invasion and tumor size ≤0.9 cm, no LNM was observed in patients with UD (95% CI 0-0.53%), PCC (95% CI 0-0.59%), or PD (95% CI 0-0.86%) histologic type.

CONCLUSION

In patients diagnosed with non-ulcerated T1a UD-EGC, ESD can be performed if the tumor size is 0.9 cm or less, regardless of histologic type.

Prognostic Significance of Esophagogastric Junction Invasion in Patients with Adenocarcinoma of the Cardia or Subcardia

BACKGROUND

There has been no comparison of the prognoses of Korean patients who underwent curative surgery for cancer located at the cardia or subcardia of the stomach. We performed this comparison and further investigated the prognostic significance of esophagogastric junction (EGJ) invasion in patients.

METHODS

The medical records of patients (n = 511) who were diagnosed with cardia or subcardia cancer and underwent surgery between January 2010 and May 2019 were retrospectively reviewed. Patients were further categorized into four groups for analysis: subcardia gastric cancer (sGC; subcardia cancer without EGJ invasion; n = 97), AEG (adenocarcinoma of the esophagogastric junction) type III (subcardia cancer with EGJ invasion, n = 54), AEG type II without EGJ invasion (n = 158), and AEG type II with EGJ invasion (n = 202). We compared the overall survival of the four groups using a gastric cancer staging system and evaluated the prognostic significance of EGJ invasion with multivariate analysis.

RESULTS

The median follow-up of patients was 46.0 months (range: 0-124 months). There was significant difference in overall survival curves among the four groups (p < 0.001). Subgroup analysis showed a significant difference in overall survival between the groups with and without EGJ invasion (p < 0.001). Cancers with EGJ invasion were more frequently in the cardia (p < 0.001), had a larger size (p < 0.001), and showed a more advanced pathologic stage (stages II and III; 67.6% versus 33.7%, p < 0.001) than those without EGJ invasion. EGJ invasion and the pathologic stage were significant independent prognostic factors of overall survival in cardia and subcardia cancer patients (hazard ratio 2.24, 95% confidence interval 1.32-3.81, p = 0.003).

CONCLUSION

The overall survival between patients with cardia or subcardia cancer was significantly different according to EGJ invasion. EGJ invasion was an independent prognostic factor and should be considered for staging. Additional research is needed to apply this feature to gastric and esophageal cancer classification.

Trends in vitamin D level and risk of vitamin D deficiency after gastrectomy for gastric cancer: A retrospective study of a single high-volume center experience

BACKGROUND & AIMS

Post-gastrectomy vitamin D deficiency can result in osteoporosis and fractures, which can decrease patient quality of life and increase their socioeconomic burden. However, because there is no consensus around preoperative measurement and regular postoperative monitoring of serum vitamin D [25(OH)vitD] level for gastric cancer patients, we performed a retrospective study with a single high-volume center experience.

METHODS

We reviewed a database of 614 gastric cancer patients who underwent curative gastrectomy between December 2015 and December 2019. Multivariate analyses were performed to identify risk factors for 25(OH)vitD deficiency after one year postoperative (n = 546). A linear mixed model was used to evaluate changes between preoperative (n = 585) and postoperative (6 [n = 504] and 12 months [n = 572]) 25(OH)vitD values.

RESULTS

Preoperative 25(OH)vitD deficiency occurred in 67.7% of patients with gastric cancer. Patients who underwent postoperative chemotherapy for advanced pathologic disease were more likely to be 25(OH)vitD deficient at postoperative year one than those who did not receive chemotherapy (P = 0.005). Postoperative chemotherapy was an independent risk factor along with preoperative 25(OH)vitD level for one year postoperative 25(OH)vitD deficiency (P = 0.002). Meanwhile, there was significant change in 25(OH)vitD level after surgery according to reconstruction (increased in Billroth I group compared to gastrojejunostomy group, P = 0.016), pathologic stage (increased in stage I group, decreased in stage II and III group, P = 0.005), postoperative chemotherapy (increased in non-chemotherapy group, decreased in chemotherapy group, P = 0.001), and season of surgery (increased when the blood tests were performed at summer, decreased when tested in non-summer season, P = 0.009).

CONCLUSION

More than half of gastric cancer patients had preoperative 25(OH)vitD deficiency, and those who had postoperative chemotherapy were at risk for 25(OH)vitD deficiency one year after surgery. There was a significant change in 25(OH)vitD level after surgery according to reconstruction method and postoperative chemotherapy. Preoperative measurement and regular postoperative monitoring should be considered for high-risk patients.

Meso-jejunal lymph node dissection has a survival benefit in patients with remnant gastric cancer

BACKGROUND

Clinical benefits of the meso-jejunal lymph node (MJLN) dissection in remnant gastric cancer (RGC) patients have not been fully established. Hence, in this retrospective study, we evaluated the survival benefit of MJLN dissection and prognostic significance of MJLN metastasis in RGC patients who underwent gastrojejunostomy reconstruction after their initial gastrectomy.

METHODS

We retrospectively reviewed 391 patients who underwent surgery for RGC at our institution between 1996 and 2019. Among them, 60 patients had MJLN dissection. The index value of the survival benefit gained by dissection of the MJLN was calculated by multiplying the frequency of metastasis at the MJLN station and the 5-year overall survival rate (5YOS) of patients with metastasis at that station. When the metastatic rate or 5YOS exceeded 10%, dissection was recommended. An index value of dissection greater than 1.0 was considered significant.

RESULTS

Total metastatic rate of MJLN was 35% (n = 21/60). Patients with MJLN metastasis had advanced pathologic stage compared to patients in the no-metastasis group (p < 0.001). In T2-T4 RGC patients, the metastatic rate of MJLN was 48.6% (n = 17/35), and their 5YOS was 28.4%. The calculated index value was 13.8. Also, patients with MJLN metastasis had a poorer overall survival than those without metastasis. MJLN metastasis was an independent prognostic factor of overall survival in multivariate analysis (HR 6.77, 95%CI 2.21-20.79, p = 0.001).

CONCLUSION

MJLN dissection should be considered for advanced RGC patients who underwent gastrojejunostomy after distal gastrectomy during their initial surgery according to the index value.

Clinical Significance of Preoperative Hematological Parameters in Patients with D2-Resected, Node-Positive Stomach Cancer

The purpose of the present study was to investigate the clinical significance of preoperative hematological parameters in patients with advanced stomach cancer, and to explore who might benefit from adjuvant concurrent chemoradiotherapy (CCRT) compared to chemotherapy alone. Among 1032 patients with node-positive stomach cancer who had a confirmed diagnosis after complete D2 resection, and who received adjuvant chemotherapy alone or CCRT, a total of 692 patients was selected using propensity score matching. Among absolute neutrophil count, absolute lymphocyte count (ALC), absolute monocyte count (AMC), platelet count, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio, AMC was the most relevant prognostic factor for overall survival and recurrence-free survival (hazard ratio (HR) 1.674, 95% confidence interval (CI) 1.180–2.376; HR 1.908, 95% CI 1.650–2.695, respectively). In a subgroup with a high ALC, patients treated with adjuvant CCRT had a favorable recurrence-free survival (HR 0.620, 95% CI 0.393–0.980) compared to those treated with chemotherapy alone. Further study is needed to confirm our findings and to develop tailored adjuvant treatment.

Feasibility of Gastric Tumor Xenograft (GTX)-derived Cell Lines for Individualized Anti-cancer Drug Screening

BACKGROUND/AIM

Because there are ongoing efforts to identify and develop novel drugs in the treatment of refractory gastric cancer, it is necessary to develop effective preclinical studies. Here, the preclinical efficacy of gastric tumor xenograft (GTX)-derived cell line models for the personalized treatment of gastric cancer was investigated.

MATERIALS AND METHODS

Anti-cancer drugs were scanned with high-throughput screening (HTS) using pre-established GTX-derived cell lines. The efficacy of a selected drug (afatinib) was re-confirmed in vivo and intracellular signaling pathways were investigated in xenograft tumor cell lysates using western blotting. Validation studies, such as cell proliferation and caspase activity assays, were also conducted in vitro with GTX-derived cell lines.

RESULTS

HTS indicated that afatinib was effective in one of the five GTX-derived cell lines (GTX-087). A xenograft mouse model was established from GTX-087, and administration of afatinib at 1 mg/20 g body weight/day per oral resulted in tumor-suppressive activity in vivo. The RAS-ERK pathway was inactivated by an increase in Bax and cleaved caspase-3 in this xenograft model. In vitro cell proliferation assay also revealed that afatinib was able to suppress the growth of the GTX-087 cell line. Caspase activity assay confirmed that afatinib had an apoptotic role on GTX-087 and showed that caspase-3/7 activity increased in a time dependent manner.

CONCLUSION

The GTX-derived cell line model might be useful for estimating novel drug responses and could be an alternative to patient-derived xenograft animal models.

Prospective multicentre randomised clinical trial comparing survival rates, quality of life and nutritional status between advanced gastric cancer patients with different follow-up intensities: study protocol for the STOFOLUP trial

INTRODUCTION

Patients who underwent curative gastrectomy for gastric cancer are regularly followed-up for the early detection of recurrence and postoperative symptom management. However, there is a lack of evidence with regard to proper surveillance intervals and diagnostic tools. This study aims to evaluate whether frequent surveillance tests have a survival benefit or improve the quality of life in patients who underwent curative resection for advanced gastric cancer.

METHODS AND ANALYSIS

The STOFOLUP trial is an investigator-initiated, parallel-assigned, multicentre randomised controlled trial involving 16 hospitals in the Republic of Korea. Patients (n=886) diagnosed with pathological stage II or III gastric adenocarcinoma will be randomised to either the 3-month or the 6-month group at a 1:1 ratio, stratified by trial site and tumour stage. Patients allocated to the 3-month group will undergo an abdominal CT scan every 3 months postoperatively and those allocated to the 6-month group will undergo CT every 6 months. The primary endpoint is 3-year overall survival and the secondary endpoints are quality of life, as assessed using KOrean QUality of life in Stomach cancer patients Study group-40, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the stomach cancer-specific module (STO22), and nutritional outcomes. Other survival data including data concerning 3-year disease-free survival, recurrence-free survival, gastric cancer-specific survival and postrecurrence survival will also be estimated. The first patient was enrolled on July 2021 and active patient enrolment is currently underway.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of eight of the participating hospitals (NCC 2021-0085, KBSMC2021-01-059, SMC 2021-01-140, KC21OEDE0082, 4-2021-0281, AJIRB-MED-INT-20-608, 2021-0515 and H-2102-093-1198). This study will be disseminated through peer-reviewed publications, national or international conferences.

TRIAL REGISTRATION NUMBER

NCT04740346.

Prognostic significance of splenectomy during completion total gastrectomy in patients with remnant gastric cancer: propensity score matching analysis

Purpose

Splenectomy for patients with remnant gastric cancer has been controversial. The purpose of this study is to identify the impact of splenectomy in the treatment of remnant gastric cancer.

Methods

We retrospectively analyzed 285 patients with remnant gastric cancer who underwent completion total gastrectomy with or without splenectomy in Samsung Medical Center, between September 1996 and December 2017. We used a 1:1 propensity score matching method for the analysis. The matching factors were age, sex, and pathologic stage. After the matching process, we compared the 5-year overall survival (OS) and the disease-free survival (DFS) between patients with and without splenectomy during completion total gastrectomy.

Results

The median duration of follow-up was 58.0 months (range, 0-132 months). After propensity score matching, there were no statistically significant differences between the splenectomy group (n=77) and no splenectomy group (n=77) in terms of clinicopathological features. The 5-year OS rate between the no splenectomy and splenectomy group were not significantly different. There was no significant difference between 5-year DFS of the matched groups. Multivariate analysis revealed that splenectomy is not a significant prognostic factor in terms of 5-year OS (no splenectomy vs. splenectomy; 61.5% vs. 60.2%, P=0.884) or DFS (74.9% vs. 69.8%, P=0.880).

Conclusion

Splenectomy has no impact on the OS and DFS in patients with remnant gastric cancer. Splenectomy during completion total gastrectomy may not be necessary.

International Retrospective Cohort Study of Conversion Therapy for Stage IV Gastric Cancer 1 (CONVO‐GC‐1)

Aim

Much attention has been paid to conversion therapy for stage IV gastric cancer, however, its operative comorbidities and survival benefit have not yet been clarified. CONVO‐GC‐1, an international retrospective cohort study, was designed to investigate the role of conversion surgery in Japan, Korea, and China.

Methods

The rate of operative complications was the primary endpoint and the overall survival (OS), according to the four‐category criteria previously published (Gastric Cancer:19; 2016), was analyzed as the secondary endpoint.

Results

A total of 1206 patients underwent surgery after chemotherapy with curative intent. Operative complications were observed in 290 (24.0%) patients in all grades, including pancreatic fistula and surgical site infection. The median survival time (MST) of all resected patients was 36.7 mo (M) and those of R0, R1, and R2 resection were 56.6 M, 25.8 M, and 21.7 M, respectively. Moreover, the MST of R0 patients were 47.8 M, 116.7 M, 44.8 M in categories 1, 2, and 3, respectively, and not reached in category 4. Interestingly, the MST of P1 patients was as favorable as that of P0CY1 patients if R0 resection was achieved. The MST of patients with liver metastasis was also favorable regardless of the number of lesions, and the MST of patients with para‐aortic lymph node (LN) No 16a1/b2 metastasis was not inferior to that of patients with para‐aortic LN No 16a2/b1 metastasis.

Conclusion

Conversion therapy for stage IV gastric cancer is safe and could be a new therapeutic strategy to improve the survival of patients, especially those with R0 resection.

Prognostic Value of Highly Expressed Type VII Collagen (COL7A1) in Patients With Gastric Cancer

Collagen is a major component in the tumor microenvironment. This study reveals a novel biomarker candidate, type VII collagen (COL7A1), in patients with gastric cancer. To identify genes differentially expressed in gastric cancer tissue, we analyzed cancerous (n = 20) and noncancerous tissues (n = 13) using a DNA microarray. To perform immunohistochemistry and validate the upregulation of COL7A1 expression, we collected 200 more gastric cancer tissues and 100 normal gastric tissues from 200 randomly selected patients who underwent gastrectomy for gastric cancer between January 2010 and December 2013. The correlations between COL7A1 expression and clinicopathological parameters and patients’ overall survival (OS) were analyzed. In the microarray, COL7A1 was upregulated in gastric cancer tissue compared with normal tissue. In the immunohistochemistry study, COL7A1 was more highly expressed in cancer tissue than in normal tissue (p = 0.001). Patients with intracellular COL7A1 expression had significantly poorer five-year OS than those with only extracellular expression (41.5 versus 69.7%, p = 0.001), and the site of expression was an independent prognostic factor of OS (hazard ratio 2.00, 95% CI 1.26–3.16, p = 0.003). Also, we found a significant association between the COL7A1 immunohistochemistry score and distant metastasis (high versus low, odds ratio 4.45, 95% CI 1.40–14.16, p = 0.011). The site and total immunohistochemistry score of COL7A1 expression in gastric cancer showed prognostic significance for OS and distant metastasis, respectively. COL7A1 could be a novel biomarker with diagnostic and therapeutic value.

Comparison of transabdominal and transthoracic surgical approaches in the treatment of Siewert type II esophagogastric junction cancers: A propensity score-matching analysis

BACKGROUND

The appropriate surgical approach for Siewert type II esophagogastric junction (EGJ) cancer remains under discussion. We compared surgical outcomes between transabdominal (TA) and transthoracic (TT) approaches for treating type II EGJ cancers.

MATERIALS AND METHODS

This retrospective study reviewed 397 type II EGJ cancer patients who underwent surgery from January 2001 to May 2019. We used a 1:3 propensity score-matching method for the analysis. The matching factors were age, sex, American Society of Anesthesiologists score, period of operation, and pathologic stage. Matching was performed using the MatchIt package of R 4.0.2.

RESULTS

A total of 46 patients in the TT group was matched to 126 patients in the TA group. R0 resection was achieved in both groups and was not statistically different between groups (p = 0.455). In the TA group, the operation time and in-hospital stay length were significantly shorter (p < 0.001) and the intraoperative estimated blood loss (EBL) was significantly lower than in the TT group (p = 0.011). The postoperative complication rate between the two groups was significantly different (p = 0.003). There was marginal difference in the five-year OS rate (p = 0.049) and significant difference in the five-year DFS (p = 0.039). However, surgical approach was not a significant prognostic factor in multivariate analysis of OS or DFS.

CONCLUSIONS

There was no clear survival benefit of one approach over the other. However, less intraoperative bleeding, lower postoperative complication rate, shorter operation time, and reduced in-hospital stay length were correlated with the TA approach.

A preoperative risk prediction model for high malignancy potential gastrointestinal stromal tumors of the stomach

BACKGROUND

Gastric gastrointestinal stromal tumors (GISTs) exhibit various degrees of aggression and malignant potential. However, no systematic preoperative evaluation strategy to predict the malignancy potential of gastric GISTs has yet been developed. This study aimed to develop a reliable and easy-to-use preoperative risk-scoring model for predicting high malignancy potential (HMP) gastric GISTs.

METHODS

The data of 542 patients with pathologically confirmed gastric GISTs who underwent resection were reviewed. Multivariate logistic regression analysis was used to identify significant predictors of HMP. The risk-scoring system (RSS) was based on the predictive factors for HMP, and its performance was validated using a split-sample approach.

RESULTS

A total of 239 of 542 (44.1%) surgically resected gastric GISTs had HMP. Multivariate analysis demonstrated that tumor size, location, and surface changes were independent risk factors for HMP. Based on the accordant regression coefficients, the presence of surface ulceration was assigned 1 point. Tumor sizes of 4-6 cm and > 6 cm were assigned 2 and 5 points, respectively. Two points were assigned to cardia or fundus locations. A score of 3 points was the optimal cut-off value for HMP prediction. HMP were found in 19.8% and 82.7% of the low and high-risk groups of the RSS, respectively. The area under the receiver-operating characteristic curve for predicting HMP was 0.81 (95% confidence interval (CI) 0.75-0.86). Discrimination was good after validation (0.75, 95% CI 0.69-0.81).

CONCLUSION

This simple RSS could be useful for predicting the malignancy potential of gastric GISTs and may aid preoperative clinical decision making to ensure optimal treatment.

Long-Term Oncological Outcomes of Reduced Three-Port Laparoscopic Gastrectomy for Early-Stage Gastric Carcinoma: a Retrospective Large-Scale Multi-Institutional Study

Purpose

With advances in surgical techniques, reduced-port laparoscopic surgery is increasingly being performed for the treatment of gastric carcinoma. Many studies have reported satisfactory short-term outcomes after reduced 3-port laparoscopic gastrectomy (LG). The aim of this study was to investigate the long-term oncological outcomes of 3-port LG in patients with gastric carcinoma.

Materials and Methods

We reviewed the medical records of 1,117 patients who underwent LG for gastric carcinoma in three major institutions between 2012 and 2015. The data showed that 460 patients underwent 3-port LG without assistance, and 657 underwent conventional 5-port LG. We compared the overall and disease-free survival rates between the 2 groups.

Results

There were 642 male and 475 female patients with a mean age of 56.1 years. Among them, 1,028 (92.0%) underwent distal gastrectomy and 89 (8.0%) underwent total gastrectomy. In the final pathologic examination, 1,027 patients (91.9%) were stage I, 73 (6.5%) were stage II, and 17 (1.5%) were stage III, and there were no significant difference in the pathologic stage between groups. The 3- and 5-port LG groups showed no significant differences in the 5-year overall survival (94.3% vs. 96.7%, P=0.138) or disease-free survival (94.3% vs. 95.9%, P=0.231). Stratified analyses according to pT and pN stages also showed no significant differences in overall or disease-free survival between the two groups.

Conclusions

Long-term survival after 3- and 5-port LG was comparable in patients with early-stage gastric carcinoma. The 3-port technique requiring limited surgical assistance may be an appropriate surgical option for this patient population.

Impact of Radiotherapy on Kidney Function among Patients Who Received Adjuvant Treatment for Gastric Cancer: Logistic and Linear Regression Analyses

Simple Summary

Purpose of the present study was to investigate the incidence of renal function impairment after adjuvant treatment for gastric cancer and the impact of radiotherapy on estimated glomerular filtration rate (eGFR) five years after gastric surgery. Of the 663 patients who were followed up for ≥5 years without disease recurrence and whose baseline kidney function was normal, only 2.0% of patients developed renal function impairment after adjuvant treatment for gastric cancer. While radiotherapy was negatively associated with the five-year eGFR in linear regression analysis, its impact was minimal if the kidneys were properly shielded. This study could serve as a partial basis for further research on radiation-related renal function impairment in patients who received radiotherapy for abdominal malignancy.

Abstract

We investigated the incidence of renal function impairment after adjuvant treatment for gastric cancer and analyzed the impact of radiotherapy on estimated glomerular filtration rate (eGFR) five years after gastric surgery. We reviewed the medical records of 1490 patients with stomach cancer who underwent curative surgery and adjuvant treatment for gastric cancer. Finally, we included 663 patients who were followed up for ≥5 years without disease recurrence and whose baseline eGFR was ≥60 mL/min/1.73 m². Logistic and linear regression analyses were performed to determine independent factors associated with the five-year eGFR. A total of 13 (2.0%) patients developed renal function impairment (five-year eGFR <60 mL/min/1.73 m²). In logistic regression analysis, the baseline eGFR was identified as a prognostic factor for renal function impairment (odds ratio (OR), 0.878; 95% confidence interval (CI), 0.831–0.927; p < 0.001), but radiotherapy was not (OR, 1.130; 95% CI, 0.366–3.491; p = 0.832). In linear regression analysis, age (B = −0.350, p < 0.001), baseline eGFR (B = 0.576, p < 0.001), cisplatin (B = −2.056, p = 0.010), and radiotherapy (B = −2.628, p < 0.001) were predictive variables for the five-year eGFR. Among patients who received adjuvant radiotherapy, age (B = −0.277, p < 0.001), hypertension (B = −4.986, p = 0.004), baseline eGFR (B = 0.665, p < 0.001), and volume of the kidneys receiving ≥20 Gy (B = −0.209, p = 0.012) were predictive variables for the five-year eGFR. Development of renal function impairment after adjuvant treatment for gastric cancer was rare among patients with normal baseline kidney function. While radiotherapy was negatively associated with the five-year eGFR, its impact would have been minimal if the kidneys were properly shielded. Further studies are needed to confirm the impact of radiotherapy in patients with poor kidney function.

Long-term oncological outcomes of laparoscopic gastrectomy for grossly early gastric cancer-mimicking advanced gastric cancer: Propensity score matching analysis

Laparoscopic gastrectomy became an option in the treatment of early gastric cancer (EGC) in clinical practice. However, whether laparoscopic surgery for grossly EGC-mimicking advanced gastric cancer (AGC) patients is oncologically safe long-term is still controversial.We retrospectively analyzed 472 patients with AGC who were diagnosed as clinical EGC. Patients received laparoscopic or open gastrectomy with standard lymph node (LN) dissection from January 2007 to February 2015. We used a 1:3 propensity score matching method for the analysis. The matching factors were age, sex, body mass index, American Society of Anesthesiologists score and pathologic stage. After the matching process, we evaluated the 5-year overall survival and the cumulative incidence curve of recurrence.All of the analyzed patients were pathologically diagnosed with AGC after surgery (grossly EGC-mimicking AGC). The median (range) duration of follow-up was 58.0 (0-132) months. After propensity score matching, 31.5% of patients in the laparoscopy group had D1+ LN dissection and 99.2% of patients in the open group had D2 LN dissection. The 5-year overall survival rate between the laparoscopy (n = 92) and open groups (n = 244) were not significantly different (95.3% versus 91.4%, P = .224). There was no significant difference between the cumulative recurrence incidence curves of the matched groups (P = .319).Laparoscopic surgery for grossly EGC-mimicking AGC might be safe in terms of long-term survival outcome. After confirming grossly EGC-mimicking AGC in the final pathology report, no additional surgery might be required.

A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆

BACKGROUND

Adjuvant chemotherapy and chemoradiotherapy are some of the standards of care for gastric cancer (GC). The Adjuvant chemoRadioTherapy In Stomach Tumors (ARTIST) 2 trial compares two adjuvant chemotherapy regimens and chemoradiotherapy in patients with D2-resected, stage II or III, node-positive GC.

PATIENTS AND METHODS

The ARTIST 2 compared, in a 1:1:1 ratio, three adjuvant regimens: oral S-1 (40-60 mg twice daily 4 weeks on/2 weeks off) for 1 year, S-1 (2 weeks on/1 week off) plus oxaliplatin 130 mg/m² every 3 weeks (SOX) for 6 months, and SOX plus chemoradiotherapy 45 Gy (SOXRT). Randomization was stratified according to surgery type (total or subtotal gastrectomy), pathologic stage (II or III), and Lauren histologic classification (diffuse or intestinal/mixed). The primary endpoint was disease-free survival (DFS) at 3 years; a reduction of 33% in the hazard ratio (HR) for DFS with SOX or SOXRT, when compared with S-1, was considered clinically meaningful. The trial is registered at clinicaltrials.gov (NCT0176146).

RESULTS

A total of 546 patients were recruited between February 2013 and January 2018 with 182, 181, and 183 patients in the S-1, SOX, and SOXRT arms, respectively. Median follow-up period was 47 months, with 178 DFS events observed. Estimated 3-year DFS rates were 64.8%, 74.3%, and 72.8% in the S-1, SOX, and SOXRT arms, respectively. HR for DFS in the control arm (S-1) was shorter than that in the SOX and SOXRT arms: S-1 versus SOX, 0.692 (P = 0.042) and S-1 versus SOXRT, 0.724 (P = 0.074). No difference in DFS was found between SOX and SOXRT (HR 0.971; P = 0.879). Adverse events were as anticipated in each arm, and were generally well-tolerated and manageable.

CONCLUSIONS

In patients with curatively D2-resected, stage II/III, node-positive GC, adjuvant SOX or SOXRT was effective in prolonging DFS, when compared with S-1 monotherapy. The addition of radiotherapy to SOX did not significantly reduce the rate of recurrence after D2 gastrectomy.

Adjuvant Chemotherapy vs. Surgery Alone for pT3N0M0 Gastric Cancer

BACKGROUND

As both the role and clinical application of adjuvant chemotherapy (CTx) for pT3N0M0 gastric cancer after curative gastrectomy have fluctuated chronologically, the oncological benefit of adjuvant CTx in patients should be elucidated.

METHODS

Between 2000 and 2018, 1083 patients underwent radical gastrectomy for pT3N0M0 gastric cancer and were subsequently divided into two groups: the surgery-alone group (n = 471) and the adjuvant CTx group (n = 612). Chronological changes in adjuvant CTx and various chemotherapeutic regimens were evaluated and disease-free survival was compared between the two groups. Risk factors for tumor recurrence were also analyzed.

RESULTS

The proportion of patients in the surgery-alone group was more than 60% until 2001, whereas in the CTx group this increased to over 80%, especially after publication of the American Joint Committee on Cancer (AJCC) 7th edition staging manual. The main chemotherapeutic agents were tegafur-uracil (UFT) and 5-fluorouracil with leucovorin until 2008, whereas tegafur/gimeracil/oteracil (TS-1) has been the main agent since 2009. The 5-year disease-free survival was 89.2% in the surgery-alone group and 89.9% in the CTx group, which was not significantly different (p = 0.694). In multivariate analysis, larger tumor size (≥ 4.5 cm) and venous invasion were significant risk factors for tumor recurrence. In addition, adjuvant CTx did not improve the oncological outcome, even in the large tumor size group (p = 0.760) and the venous invasion group (p = 0.753).

CONCLUSIONS

As adjuvant CTx did not show any oncological benefit in pT3N0M0 gastric cancer in this large-scale study, it might be unnecessary for these patients after curative gastrectomy.

Effect of baseline sarcopenia on adjuvant treatment for D2 dissected gastric cancer: Analysis of the ARTIST phase III trial

BACKGROUND AND PURPOSE

This study evaluated the clinical significance of preoperative sarcopenia according to adjuvant concurrent chemo-radiotherapy (XP-RT) or chemotherapy alone (XP) in the D2 dissected gastric cancer patient cohort of the ARTIST trial.

MATERIALS AND METHODS

Skeletal muscles at the L3 vertebra level from preoperative computed tomography images among the ARTIST trial participants were measured using validated in-house software. Skeletal muscle index (SMI) was defined as the measured skeletal muscle area divided by the square of the height, and sarcopenia was defined according to the Korean-specific cutoff, i.e. L3 SMI ≤ 49 cm²/m² for men and ≤31 cm²/m² for women.

RESULTS

Among the 440 patients in whom we were able to evaluate L3 SMI, 75 (17.0%) met the definition for preoperative sarcopenia. No differences in treatment-related toxicities or treatment compliance were observed according to the presence of preoperative sarcopenia in either treatment arm. In the subgroup of patients without preoperative sarcopenia, recurrence was significantly lower in the XP-RT arm than that in the XP arm (p = 0.02). Recurrence-free survival (RFS) was also significantly higher in the XP-RT arm (p = 0.02, hazard ratio 0.633, 95% confidence interval 0.433-0.926) in this subgroup. In the multivariate analysis, and after adjusting for significant prognostic factors, the superior outcome of XP-RT arm regarding RFS was maintained in the subgroup of the patients without preoperative sarcopenia.

CONCLUSIONS

Superior clinical outcomes of adjuvant XP-RT over XP were only observed in patients without preoperative sarcopenia.

Both cardiovascular and cerebrovascular events are decreased following long-term narrowband ultraviolet B phototherapy in patients with vitiligo: a propensity score matching analysis

BACKGROUND

Systemic effects of long-term narrowband ultraviolet B (NB-UVB) phototherapy have not been well studied in vitiligo patients. An 11-year nationwide population-based retrospective cohort study was conducted using the Korean National Health Insurance claims database (2007-2017).

OBJECTIVES

To investigate the effects of long-term NB-UVB phototherapy on the risk of cardiovascular and cerebrovascular events in vitiligo patients.

METHODS

This study included vitiligo patients with ≥100 phototherapy sessions (phototherapy group, n = 3229) and <3 phototherapy sessions (no phototherapy group, n = 9687), in which covariables with age, sex, insurance type and comorbidities such as diabetes, hypertension and hyperlipidemia were matched by 1 : 3 propensity score matching. The outcomes of interest were cardiovascular (ischaemic heart disease and myocardial infarction) and cerebrovascular events (cerebrovascular infraction and haemorrhage). Cox proportional hazards models were used to assess the associations between NB-UVB phototherapy and each event.

RESULTS

The risk of cardiovascular or cerebrovascular events was significantly decreased in the phototherapy group compared with the no phototherapy group [hazard ratio (HR) 0.637, 95% confidence interval (CI) 0.523-0.776]. Subgroup analysis revealed that the risk of cardiovascular (HR: 0.682, 95% CI: 0.495-0.940) and cerebrovascular events (HR: 0.601, 95% CI: 0.470-0.769) were significantly lower in the phototherapy group than the no phototherapy group, respectively.

CONCLUSIONS

Our findings suggest that long-term NB-UVB phototherapy could decrease the risk of cardiovascular and cerebrovascular events in patients with vitiligo.

Comparison of Postoperative Nutritional Status after Distal Gastrectomy for Gastric Cancer Using Three Reconstructive Methods: a Multicenter Study of over 1300 Patients

PURPOSE

Perioperative nutritional status has been reported to be associated with short- and long-term outcomes after surgery in gastric cancer patients. This study compared changes in nutritional status after distal gastrectomy using the Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY) reconstruction techniques in gastric cancer patients.

MATERIALS AND METHODS

Data from 1305 gastric cancer patients who underwent distal gastrectomy at two tertiary hospitals from January 2011 to December 2016 were reviewed. The patients were divided into three groups according to reconstruction type: BI, BII, and RY. We evaluated changes in nutritional parameters including body mass index (BMI), biochemical data, the prognostic nutritional index (PNI), nutritional risk index (NRI), and geriatric nutritional risk index (GNRI) preoperatively, and 3, 6, and 12 months after surgery.

RESULTS

Total protein, albumin, PNI, and NRI were significantly lower in the BII group than in the BI and RY groups during follow-up (P < 0.001). In multivariate analysis, reconstruction types were independently related to decreases in BMI (> 10%), low serum protein, albumin, and cholesterol 12 months after surgery. Compared with BI, BII was associated with decreased BMI, low protein, and albumin and RY was associated with decreased BMI and low cholesterol.

CONCLUSION

During the first year after gastric cancer surgery, postoperative nutritional status differed according to the reconstruction type; BI resulted in the least weight and nutritional loss, RY yielded results comparable with BI in the nutritional indexes, and BII resulted in the greatest nutritional loss.

Comparisons of remnant primary, residual, and recurrent gastric cancer and applicability of the 8th AJCC TNM classification for remnant gastric cancer staging

BACKGROUND

Because there is no well-established postoperative staging system for patients with remnant gastric cancer (RGC), we compared the overall survival of patients categorized with the 8th AJCC TNM staging system.

METHOD

A total of 391 patients underwent surgery for RGC at our institution between 1996 and 2019. Among them, 201 patients received their first surgery at our institution and 190 received primary surgery elsewhere. We retrospectively reviewed their medical records and classified each according to Kaminishi's classification and the 8th AJCC TNM staging system for comparison and analysis.

RESULTS

All 201 patients who underwent their first operation at our institution for malignancy were classified as primary (n = 41, 20.4%), residual (n = 103, 51.2%), and recurrent (n = 57, 28.4%) RGC. The 5-year overall survival (OS) rates for the primary, residual, and recurrent RGC groups were 78.1%, 73.8% and 56.0%, respectively (p = 0.004). In a multivariate analysis, RGC classification was an independent prognostic factor along with the TNM staging system (p = 0.001). However, there was no significant difference in OS between the three groups of the same TNM stage. In addition, the OS of each stage related to primary cancer was not significantly different from the OS of RGC patients classified in TNM staging.

CONCLUSION

The RGC classification system we used may reflect the comprehensive aspects of previous disease states and predict the prognosis of patients with gastric cancer. In addition, the 8th AJCC TNM classification is a practical and applicable staging system for RGC.

Nomogram to predict lymph node metastasis in patients with early gastric cancer: a useful clinical tool to reduce gastrectomy after endoscopic resection

BACKGROUND

The indications for endoscopic dissection have been expanded to improve the quality of life of patients with early gastric cancer (EGC). This study aimed to develop a nomogram to predict the status of lymph node metastasis with the aim of avoiding unnecessary gastrectomies.

METHODS

We reviewed the clinicopathological data of 10 579 patients who underwent curative resection for EGC. The nomogram was developed by multivariate analysis and was evaluated by external validation. Overall, disease-free and recurrence-free survival were compared between the gastrectomy group of 6641 patients and the endoscopic dissection group of 999 patients to show the efficacy of the nomogram.

RESULTS

Multivariate analyses revealed that age, tumor size, lymphatic invasion, depth of invasion, and histologic differentiation were all significant prognostic factors for lymph node metastasis. The nomogram had good discriminatory performance, with a concordance index of 0.846. This was supported by the external validation point of 0.813. For patients with low risk of lymph node metastasis on the nomogram (≤ 3 % of the provisional value in this study), the endoscopic dissection and gastrectomy groups had comparable rates of overall (P = 0.32), disease-free (P = 0.47), and recurrence-free (P = 0.09) survival.

CONCLUSIONS

We developed and validated a nomogram that predicts the risk of lymph node metastasis in EGC based on a large database. This precision nomogram is useful to avoid unnecessary gastrectomy after endoscopic dissection, which may ultimately improve the quality of life of patients with EGC.

Gastric cancer: development and validation of a CT-based model to predict peritoneal metastasis

BACKGROUND

The sensitivity of computed tomography (CT) for the detection of peritoneal metastasis (PM) of advanced gastric cancer (AGC) is relatively low.

PURPOSE

To develop a predictive model to improve the sensitivity of PM detection and to externally validate this model.

MATERIAL AND METHODS

We analyzed data from 78 patients with PM, who had undergone preoperative CT and subsequent surgery between January 2012 and December 2014, and 101 controls to form a derivation set, retrospectively. The following CT findings were evaluated: tumor size; Bormann type 4; enlarged lymph node; indirect findings of PM (peritoneal thickening, fat stranding, plaques or nodules on the peritoneum, and ascites); and definitive findings of PM (omental cake and rectal shelf). A predictive model was created using multivariate logistic regression. Receiver operating characteristic (ROC) analyses were performed to assess the diagnostic performance of the model. The accuracy was externally validated at other hospitals on 31 patients with PM and 48 patients without PM.

RESULTS

Tumor size >5.2 cm, Bormann type 4, enlarged lymph node, peritoneal plaques or nodules, and ascites were independently associated with PM. It was able to predict PM with a higher area under the ROC curve (AUC) and sensitivity than definitive findings of PM (AUC 0.903 vs. 0.647, sensitivity 92.3% vs. 38.3%). External validation confirmed the predictive power with good inter-observer agreement.

CONCLUSION

The CT-driven model shows higher AUC and sensitivity for prediction of PM and may help decision-making with the aim of improving care for patients with AGC.

Long term oncological outcome of patients with grossly early gastric cancer-mimicking advanced gastric cancer

BACKGROUND

The survival of grossly early gastric cancer-mimicking advanced gastric cancer (EGC-mimicking AGC) patients had not been investigated. We evaluated the prognosis of patients who were diagnosed as early gastric cancer before surgery and advanced gastric cancer after surgery.

METHODS

This retrospective study reviewed 3592 gastric cancer patients who had radical surgery from January 2007 to February 2015. We used a 1:2 propensity score matching method for the analysis. The matching factors were age, sex, body mass index and the depth of cancer invasion. The 5-year overall survival (OS) and disease-free survival (DFS) of the two study groups were analyzed.

RESULTS

The 475 grossly EGC-mimicking AGC patients were matched to 910 Borrmann type advanced gastric cancer (AGC) patients. The 5-year OS and DFS of the EGC-mimicking AGC patients were significantly higher than the Borrmann type AGC patients, (89.2% versus 83.4%, p = 0.025; 93.0% versus 85.6%, p < 0.001, respectively). The proportion of patients with lymph node (LN) metastasis was 45.5% in the EGC-mimicking AGC group and 57.1% in the Borrmann type AGC patients (p < 0.001). The ratio of metastatic LNs of N1 and N2 station was 5.2% and 3.1%, respectively, in EGC-mimicking AGC patients; this was lower than in Borrmann type AGC patients (N1: 8.9%, p < 0.001; N2: 3.7%, p = 0.308).

CONCLUSIONS

Patients with grossly EGC-mimicking AGC had better prognosis than patients with the Borrmann type AGC due to fewer LN metastases. This suggests that limited LN dissection of EGC-mimicking AGC patients may be feasible.

Comprehensive pharmacogenomic characterization of gastric cancer

BACKGROUND

Gastric cancer is among the most lethal human malignancies. Previous studies have identified molecular aberrations that constitute dynamic biological networks and genomic complexities of gastric tumors. However, the clinical translation of molecular-guided targeted therapy is hampered by challenges. Notably, solid tumors often harbor multiple genetic alterations, complicating the development of effective treatments.

METHODS

To address such challenges, we established a comprehensive dataset of molecularly annotated patient derivatives coupled with pharmacological profiles for 60 targeted agents to explore dynamic pharmacogenomic interactions in gastric cancers.

RESULTS

We identified lineage-specific drug sensitivities based on histopathological and molecular subclassification, including substantial sensitivities toward VEGFR and EGFR inhibition therapies in diffuse- and signet ring-type gastric tumors, respectively. We identified potential therapeutic opportunities for WNT pathway inhibitors in ALK-mutant tumors, a significant association between PIK3CA-E542K mutation and AZD5363 response, and transcriptome expression of RNF11 as a potential predictor of response to gefitinib.

CONCLUSIONS

Collectively, our results demonstrate the feasibility of drug screening combined with tumor molecular characterization to facilitate personalized therapeutic regimens for gastric tumors.

Ultraviolet photography in vitiligo: image quality, validity and reliability

Background

For clinical care and research in vitiligo, photographs with the use of ultraviolet (UV) light or Wood's lamp are often made. Conventional cameras are insensitive to UV light. The use of a UV camera (UV photography) might improve image quality and ameliorate the assessment of target lesions in vitiligo.

Objectives

To determine image quality and the validity and reliability of UV photography for the assessment of vitiligo target lesions.

Methods

Images of patients with vitiligo were made with UV photography and a conventional camera, and lesions were drawn on graph paper and transparent sheets. Image quality was scored by vitiligo experts and medical interns. The intraclass correlation coefficients (ICCs) of the lesion size determined with UV photography combined with digital surface measurement and the other techniques were hypothesized to be above 0.6. The ICCs between UV images taken by the same physician and between two different physicians were calculated for determining inter‐ and intra‐reliability.

Results

In total, 31 lesions of 17 patients were included. Image quality was assessed as good or very good for 100% and 26% for UV photography and the conventional camera, respectively. ICCs of UV photography and the conventional camera, drawing the lesions on transparent sheets and graph paper, were 0.984, 0.988 and 0.983, respectively, confirming our hypotheses. The ICCs of the intra‐rater and inter‐rater were 0.999 and 0.998, respectively.

Conclusions

The results of this study indicate that the use of UV photography for the assessment of vitiligo lesions improves image quality and is valid and reliable.

Impact of genomic alterations on lapatinib treatment outcome and cell-free genomic landscape during HER2 therapy in HER2+ gastric cancer patients

Background

To identify predictive markers for responders in lapatinib-treated patients and to demonstrate molecular changes during lapatinib treatment via cell-free genomics.

Patients and methods

We prospectively evaluated the efficacy of combining lapatinib with capecitabine and oxaliplatin as first line neoadjuvant therapy in patients with previously untreated, HER2-overexpressing advanced gastric cancer. A parallel biomarker study was conducted by simultaneously performing immunohistochemistry and next-generation sequencing (NGS) with tumor and blood samples.

Results

Complete response was confirmed in 7/32 patients (21.8%), 2 of whom received radical surgery with pathologic-confirmed complete response. Fifteen partial responses (46.8%) were observed, resulting in a 68.6% overall response rate. NGS of the 16 tumor specimens demonstrated that the most common co-occurring copy number alteration was CCNE1 amplification, which was present in 40% of HER2+ tumors. The relationship between CCNE1 amplification and lack of response to HER2-targeted therapy trended toward statistical significance (66.7% of non-responders versus 22.2% of responders harbored CCNE1 amplification; P = 0.08). Patients with high level ERBB2 amplification by NGS were more likely to respond to therapy, compared with patients with low level ERBB2 amplification (P = 0.02). Analysis of cfDNA showed that detectable ERBB2 copy number amplification in plasma was predictive to the response (100%, response rate) and changes in plasma-detected genomic alterations were associated with lapatinib sensitivity and/or resistance. The follow-up cfDNA genomics at disease progression demonstrated that there are emergences of other genomic aberrations such as MYC, EGFR, FGFR2 and MET amplifications.

Conclusions

The present study showed that HER2+ GC patients respond differently according to concomitant genomic aberrations beyond ERBB2, high ERBB2 amplification by NGS or cfDNA can be a positive predictor for patient selection, and tumor genomic alterations change significantly during targeted agent therapy.

Deep Learning-Based Survival Analysis Identified Associations Between Molecular Subtype and Optimal Adjuvant Treatment of Patients With Gastric Cancer

Purpose

Gastric cancer (GC) is the third-leading cause of cancer-related deaths. Several pivotal clinical trials of adjuvant treatments were performed during the previous decade; however, the optimal regimen for adjuvant treatment of GC remains controversial.

Patients and Methods

We developed a novel deep learning–based survival model (survival recurrent network [SRN]) in patients with GC by including all available clinical and pathologic data and treatment regimens. This model uses time-sequential data only in the training step, and upon being trained, it receives the initial data from the first visit and then sequentially predicts the outcome at each time point until it reaches 5 years. In total, 1,190 patients from three cohorts (the Asian Cancer Research Group cohort, n = 300; the fluorouracil, leucovorin, and radiotherapy cohort, n = 432; and the Adjuvant Chemoradiation Therapy in Stomach Cancer cohort, n = 458) were included in the analysis. In addition, we added Asian Cancer Research Group molecular classifications into the prediction model. SRN simulated the sequential learning process of clinicians in the outpatient clinic using a recurrent neural network and time-sequential outcome data.

Results

The mean area under the receiver operating characteristics curve was 0.92 ± 0.049 at the fifth year. The SRN demonstrated that GC with a mesenchymal subtype should elicit a more risk-adapted postoperative treatment strategy as a result of its high recurrence rate. In addition, the SRN found that GCs with microsatellite instability and GCs of the papillary type exhibited significantly more favorable survival outcomes after capecitabine plus cisplatin chemotherapy alone.

Conclusion

Our SRN predicted survival at a high rate, reaching 92% at postoperative year 5. Our findings suggest that SRN-based clinical trials or risk-adapted adjuvant trials could be considered for patients with GC to investigate more individualized adjuvant treatments after curative gastrectomy.

Clinical Outcomes and the Role of Adjuvant Concurrent Chemoradiation Therapy in D2-resected LN-positive Young Patients (≤45 Years) With Gastric Cancer

BACKGROUND/AIM

This study aimed to investigate the clinical outcomes and role of adjuvant concurrent chemo-radiation therapy (CCRT) compared to adjuvant chemotherapy alone in young patients with gastric cancer (GC) defined as those ≤45 years old versus older patients.

PATIENTS AND METHODS

Data were collected from December 2004 to January 2013 on patients with pathologically confirmed, regional lymph node metastasis of GC who had undergone curative D2 resection.

RESULTS

During the study period, a total of 1,633 patients (341 young and 1,292 older GC) was investigated. Female sex and diffuse type were more frequent among the younger group, but, lymphatic and venous invasion were less frequent. During the follow-up, there was no difference in recurrence-free survival (RFS; p=0.81), but RFS was significantly higher in young patients with stage II GC (p=0.02). In the younger group, adjusted RFS did not differ according to adjuvant treatment (p=0.98), but the RFS was significantly higher in the older group treated with CCRT than with chemotherapy alone after adjustment for significant prognostic factors (p=0.008).

CONCLUSION

Although young patients with GC had different characteristics, their clinical outcomes did not differ from those of the older patients. In the present study performed in curatively D2-resected GC, there was no benefit from adjuvant CCRT over chemotherapy alone among young patients, unlike among the older patients.

Prognostic value of mismatch repair deficiency in patients with advanced gastric cancer, treated by surgery and adjuvant 5-fluorouracil and leucovorin chemoradiotherapy

OBJECTIVE

The predictive value of mismatch repair protein deficiency (MMRD) for chemoradiotherapeutic outcome has rarely been reported in gastric cancer. This study investigated the clinical significance of MMRD as a prognostic factor for tumor recurrence, and as a predictor of response to adjuvant chemoradiotherapy in advanced gastric cancer patients.

METHODS

Between 1995 and 2008, tissue specimens of 881 patients who underwent radical gastrectomy for stage II and III gastric cancer were analyzed. MMRD was assessed using immunohistochemical stains for MLH1, PMS2, MSH2, and MSH6. Patients were divided into two groups according to adjuvant treatment: a 5-fluorouracil/leucovorin (FL) adjuvant chemoradiotherapy group and a surgery alone group. Disease-free survival (DFS) was compared between the two groups correlated to MMRD. Risk factors for tumor recurrence were analyzed using multivariate analysis.

RESULTS

Of the 881 gastric cancer patients, 88 (10.0%) exhibited MMRD and 398 (45.2%) patients received adjuvant FL chemoradiotherapy. The multivariate analysis revealed that MMRD was a good independent prognostic factor (hazard ratio, 0.572; 95% confidence interval, 0.370-0.883; P = 0.012). For stage III gastric cancer displaying mismatch repair protein proficiency (MMRP), adjuvant FL chemoradiotherapy after surgery resulted in better DFS than surgery alone (P = 0.001). Among the stage II gastric cancer patients, adjuvant FL chemoradiotherapy did not show survival benefit, regardless of MMRD.

CONCLUSION

MMRD is a good independent prognostic factor in advanced gastric cancer. Adjuvant FL chemoradiotherapy was beneficial in patients with stage III gastric cancer with MMRP but not in those with MMRD.

A comparison of short-term postoperative outcomes including nutritional status between gastrectomy with simultaneous cholecystectomy and gastrectomy only in patients with gastric cancer

Objective

We aimed to evaluate the effect of simultaneous cholecystectomy on the short-term postoperative outcomes and nutritional status in patients with gastric cancer.

Methods

We retrospectively reviewed data from 4,820 patients with gastric cancer who underwent gastrectomy from January 2011 to December 2016. Patients who underwent only gastrectomy (N=4,578) were matched to those who underwent simultaneous cholecystectomy during gastrectomy (N=242) at a 1:1 ratio using propensity score matching analysis. The nutritional status and inflammatory responses preoperatively and postoperatively and postoperative outcomes were compared between the groups.

Results

The simultaneous cholecystectomy group showed more intraoperative blood loss and a longer operative time than the gastrectomy only group [150.0 (100.0, 200.0) mL vs. 100.0 (100.0, 200.0) mL, P=0.006; 176.0 (150.0, 210.0) min vs. 155.0 (128.0, 188.0) min, P<0.001, respectively]. Intraoperative event rate, postoperative complication rate, and postoperative recovery did not differ between the groups. All parameters including body weight, the hemoglobin level, absolute lymphocyte count, total protein level, albumin level, fasting glucose level, and prognostic nutritional index excluding the cholesterol level were not significantly different between the groups, and their changing patterns were similar. Although the cholesterol level was significantly lower in the simultaneous cholecystectomy group than in the gastrectomy only group at all follow-up points, the mean value of the decreased cholesterol level was within normal range.

Conclusions

In gastric cancer patients with gallbladder disease, simultaneous cholecystectomy is safe and not associated with additional nutritional loss.

Tumor Genomic Profiling Guides Patients with Metastatic Gastric Cancer to Targeted Treatment: The VIKTORY Umbrella Trial

The VIKTORY (targeted agent eValuation In gastric cancer basket KORea) trial was designed to classify patients with metastatic gastric cancer based on clinical sequencing and focused on eight different biomarker groups (RAS aberration, TP53 mutation, PIK3CA mutation/amplification, MET amplification, MET overexpression, all negative, TSC2 deficient, or RICTOR amplification) to assign patients to one of the 10 associated clinical trials in second-line (2L) treatment. Capivasertib (AKT inhibitor), savolitinib (MET inhibitor), selumetinib (MEK inhibitor), adavosertib (WEE1 inhibitor), and vistusertib (TORC inhibitor) were tested with or without chemotherapy. Seven hundred seventy-two patients with gastric cancer were enrolled, and sequencing was successfully achieved in 715 patients (92.6%). When molecular screening was linked to seamless immediate access to parallel matched trials, 14.7% of patients received biomarker-assigned drug treatment. The biomarker-assigned treatment cohort had encouraging response rates and survival when compared with conventional 2L chemotherapy. Circulating tumor (ctDNA) analysis demonstrated good correlation between high MET copy number by ctDNA and response to savolitinib. SIGNIFICANCE: Prospective clinical sequencing revealed that baseline heterogeneity between tumor samples from different patients affected response to biomarker-selected therapies. VIKTORY is the first and largest platform study in gastric cancer and supports both the feasibility of tumor profiling and its clinical utility.This article is highlighted in the In This Issue feature, p. 1325.

A prediction model for lymph node metastasis in early-stage gastric cancer: Toward tailored lymphadenectomy

BACKGROUND

The aim of this study was to develop a prediction model for the presence and location of lymph node metastasis (LNM) in early gastric cancer.

METHOD

We reviewed medical records of 4 929 patients who underwent radical gastrectomy for early gastric cancer. Variables of age, sex, lymphatic invasion, depth of invasion, location, gross type, differentiation, and tumor size were analyzed. Logistic regression analysis was used to determine independent predictors of LNM at each LN station.

RESULT

Overall incidence of LNM was 9.1% (448/4 929 patients). For the presence of LNM, risk factors of age, sex, lymphatic invasion, depth of invasion, anatomical part, gross ulceration, size, and tumor differentiation were significantly associated with LNM. The area under the curve (AUC) for predicting LNM after validation was 0.834 for the test set. For the location of LNM, age, sex, lymphatic invasion, depth of invasion, anatomical part, circumferential portion, gross type, differentiation, and tumor size were significantly associated with LNM. The AUC of each LN station was favorable with the test set.

CONCLUSION

Predicting the location of metastatic LNs appeared to be possible in patients with early gastric cancer.

Prognostic Impact of Increased Perioperative Platelet Count in Gastric Cancer Patients

BACKGROUND

Solid tumors are a common cause of secondary (reactive) thrombocytosis, a paraneoplastic syndrome that is also a prognostic factor for various cancers. However, cutoff values for platelet count specific to gastric cancer and their prognostic roles are unknown.

METHODS

We retrospectively analyzed records of 4643 patients with gastric cancer who underwent radical surgery from 2007 to 2010. The minimum P-value approach was used with the log-rank test to determine the optimal prognosis predicting threshold for preoperative platelet count. Change in perioperative platelet count over time was evaluated with a generalized estimating equation. Clinicopathologic features and prognostic significance were analyzed according to platelet count.

RESULTS

Thrombocytosis prevalence (platelet count ≥40 × 10⁴/μL) was 1.6% (75 of 4643 patients). The platelet count cutoff value with the lowest P-value was ≥25.5 × 10⁴/μL, and patients with higher platelet count had more advanced disease. Multivariate analysis showed that cutoff value was an independent prognostic factor of overall survival (hazard ratio 1.19, 95% confidence interval 1.03-1.37, P = 0.017). Patients who underwent adjuvant chemotherapy (n = 1300) and had a greater than 10% increase in platelet count at postoperative 1 y compared to before surgery had significantly poorer overall survival (hazard ratio 1.65, 95% confidence interval 1.11-2.45, P = 0.013).

CONCLUSIONS

Elevated preoperative platelet count (≥25.5 × 10⁴/μL) and increased platelet count (≥10%) at postoperative 1 y in an adjuvant chemotherapy group were unfavorable prognostic factors. Platelet count could be a cost-effective biomarker for screening and monitoring patients with unfavorable survival outcomes.

Prognostic Impact of Microsatellite Instability in Asian Gastric Cancer Patients Enrolled in the ARTIST Trial

BACKGROUND

Caucasian patients with microsatellite instability (MSI)-high gastric cancer (GC) may have better prognosis but worse outcomes.

OBJECTIVE

Here we explored the prognostic role of MSI in Asian patients.

METHODS

This post hoc analysis comprehended radically resected GC patients randomized to XP (capecitabine/cisplatin) or XPRT. MSI status was assessed by combining immunohistochemistry with multiplex polymerase chain reaction. The MSI prognostic effect on disease-free survival (DFS) and overall survival (OS) was evaluated.

RESULTS

393 tissue samples were analyzed and 35 (9%) were MSI-high. This subgroup was characterized by: older age, Borrmann classification 1-2, antral localization, T3-4 stage, and intestinal type. At univariable analysis, the microsatellite-stable subgroup showed a trend toward a worse prognosis as compared to the MSI-high group: 3-year DFS was 76.3 versus 85.4% (p = 0.122); 3-year OS was 81.7 versus 91.4% (p = 0.046). Multivariable analyses confirmed it in both DFS (hazard ratio, HR = 2.32 [95% CI 0.91, 5.88]; p = 0.077) and OS (HR = 3.17 [95% CI 0.97, 10.43]; p = 0.057).

CONCLUSIONS

MSI-high status was associated with specific clinical-pathological features and a trend toward better outcomes of Asian GC patients.

Short-Term Outcomes of Intracorporeal Delta-Shaped Gastroduodenostomy Versus Extracorporeal Gastroduodenostomy after Laparoscopic Distal Gastrectomy for Gastric Cancer

Background

Billroth I anastomosis is one of the most common reconstruction methods after distal gastrectomy for gastric cancer. Intracorporeal Billroth I (ICBI) anastomosis and extracorporeal Billroth I (ECBI) anastomosis are widely used in laparoscopic surgery. Here we compared ICBI and ECBI outcomes at a major gastric cancer center.

Methods

We retrospectively analyzed data from 2,284 gastric cancer patients who underwent laparoscopic distal gastrectomy between 2009 and 2017. We divided the subjects into ECBI (n=1,681) and ICBI (n=603) groups, compared the patients' clinical characteristics and surgical and short-term outcomes, and performed risk factor analyses of postoperative complication development.

Results

The ICBI group experienced shorter operation times, less blood loss, and shorter hospital stays than the ECBI group. There were no clinically significant intergroup differences in diet initiation. Changes in white blood cell counts and C-reactive protein levels were similar between groups. Grade II-IV surgical complication rates were 2.7% and 4.0% in the ECBI and ICBI groups, respectively, with no significant intergroup differences. Male sex and a body mass index (BMI) ≥30 were independent risk factors for surgical complication development. In the ECBI group, patients with a BMI ≥30 experienced a significantly higher surgical complication rate than those with a lower BMI, while no such difference was observed in the ICBI group.

Conclusion

The surgical safety of ICBI was similar to that of ECBI. Although the chosen anastomotic technique was not a risk factor for surgical complications, ECBI was more vulnerable to surgical complications than ICBI in patients with a high BMI (≥30).

Bridging genomics and phenomics of gastric carcinoma

Genetic alterations are the starting point leading to numerous changes in clinical and pathologic features (phenotypes) of individual cancers; however, their inter-relationships in gastric cancers (GC) are unclear. We performed massive parallel sequencing of 381 cancer-related genes and compared the results with clinical and pathologic findings in 330 GC. High tumor mutation burden (TMB) accounted for 11% of GC (n = 37) and all 19 MSI-H GCs were high TMB. High TMB was significantly more frequent in intestinal-type by Lauren, tumor with higher host cellular immune response, earlier AJCC stage and favorable prognosis. The most significantly mutated genes were TP53 (54%), ARID1A (23%), CDH1 (22%), PIK3CA (12%), RNF43 (10%) and KRAS (9%). For receptor tyrosine kinases, amplifications detected by immunohistochemistry were higher than sequencing (HER2, 9.1% vs. 5.8%; EGFR, 11.2% vs. 6.1%; FGFR2, 4.6% vs. 3.9%, c-MET, 3.4% vs. 0.9%). PTEN protein loss (22%) correlated well with underlying PTEN alterations while ATM loss (27%) was not significantly correlated with genetic alterations of ATM. p53 protein expression predicted alterations of TP53 with high sensitivity (97.8%) and low (15.9%) specificity. The poorly cohesive histology/CDH1-mutant GC subgroup showed the worst survival (p < 0.001). PD-L1 expression was significantly associated with MSI-H, MLH1 loss, ATM loss, MET positivity, higher host immune response, and genetic alterations of ARID1A, BRD3, PIK3CA, KRAS, MAP3K13, CDH2, PTEN and ESR1. The merged clinical, pathology and genomics of GC provide a better understanding of GC and new insights into the treatment of GC.

A Mobile Phone-Based Self-Monitoring Tool for Perioperative Gastric Cancer Patients With Incentive Spirometer: Randomized Controlled Trial

BACKGROUND

An incentive spirometer (IS) is a medical device used to help patients improve the functioning of their lungs. It is provided to patients who have had any surgery that might jeopardize respiratory function. An incentive spirometer plays a key role in the prevention of postoperative complications, and the appropriate use of an IS is especially well known for the prevention of respiratory complications. However, IS utilization depends on the patient's engagement, and information and communication technology (ICT) can help in this area.

OBJECTIVE

This study aimed to determine the effect of mobile ICT on the usage of an IS (Go-breath) app by postoperative patients after general anesthesia.

METHODS

For this study, we recruited patients from April to May 2018, who used the Go-breath app at a single tertiary hospital in South Korea. The patients were randomly classified into either a test or control group. The main function of the Go-breath app was to allow for self-reporting and frequency monitoring of IS use, deep breathing, and active coughing in real time. The Go-breath app was identical for both the test and control groups, except for the presence of the alarm function. The test group heard an alarm every 60 min from 9 am to 9 pm for 2 days. For the test group alone, a dashboard was established in the nurse's station through which a nurse could rapidly assess the performance of multiple patients. To evaluate the number of performances per group, we constructed an incentive spirometer index (ISI).

RESULTS

A total of 44 patients were recruited, and 42 of them completed the study protocol. ISI in the test group was 20.2 points higher than that in the control group (113.5 points in the test group and 93.2 points in the control group, P=.22). The system usability scale generally showed almost the same score in the 2 groups (79.3 points in the test group and 79.4 points in the control group, P=.94). We observed that the performance rates of IS count, active coughing, and deep breathing were also higher in the test group but with no statistically significant difference between the groups. For the usefulness "yes or no" question, over 90% (38/42) of patients answered "yes" and wanted more functional options and information.

CONCLUSIONS

The use of the Go-breath app resulted in considerable differences between the test group and control group but with no statistically significant differences.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03569332; https://clinicaltrials.gov/ct2/show/NCT03569332 (Archived by WebCite at http://www.webcitation.org/74ihKmQIX).

Adjuvant Chemotherapy with or without Concurrent Radiotherapy for Patients with Stage IB Gastric Cancer: a Subgroup Analysis of the Adjuvant Chemoradiotherapy in Stomach Tumors (ARTIST) Phase III Trial

Purpose

We aimed to discuss the roles of radiation and chemotherapy as adjuvant treatment in patients with staged IB GC who were enrolled in the adjuvant chemoradiotherapy in stomach tumors (ARTIST) trial.

Materials and Methods

Among the 458 patients who were enrolled in the ARTIST trial, 99 had stage IB disease. The patients were randomly assigned to receive either adjuvant chemoradiotherapy with capecitabine plus cisplatin (XP, n=50) or chemoradiotherapy (XPRT, n=49). Survival analyses were performed in accordance with the AJCC 2010 staging system.

Results

According to the AJCC 2010 system, stage migration from IB to II occurred in 71% of the patients; 98% of the T2 N0 cases were reclassified as T3 N0, and 42% of the T1 N1 cases were reclassified as T1 N2. When comparing survival outcomes between the XPRT and XP arms for stage IB cancer (AJCC 2002), no significant difference in 5-year disease-free survival (DFS) between the 2 arms was found. (median 5-year DFS, not reached, P=0.256). The patients classified as having stage IB cancer (AJCC 2002) and reclassified as having stage II cancer (AJCC 2010) exhibited worse prognoses than those who remained in stage IB, although the difference was not statistically significant (5-year DFS rate, 83% vs. 93%). When we compared 5-year DFS in 70 patients with stage II (AJCC 2010), the addition of radiotherapy to XP chemotherapy did not show better outcome than XP alone (P=0.137).

Conclusions

The role of adjuvant chemoradiotherapy in the treatment of stage IB GC (AJCC 2002) warrants further investigation.

Comparison of the 7th and the 8th AJCC Staging System for Non-metastatic D2-Resected Lymph Node-Positive Gastric Cancer Treated with Different Adjuvant Protocols

PURPOSE

The purpose of this study was to compare prognostic differentiation performances of the 7th and the 8th edition of American Joint Commission on Cancer (AJCC) staging system for gastric cancer (GC) patients.

Materials and Methods

A total of 1,633 GC patients who underwent curative D2 resection followed by adjuvant chemotherapy alone (CA) or concurrent chemo-radiotherapy (CCRT) from 2004 to 2013 were included. Concordance index (c-index) was applied to compare the discriminatory ability.

RESULTS

In the 8th edition, migration of stage was detected in 248 patients (15.2%). Among them, 121 patients were up-staged while 127 patients were down-staged. Overall, there was no statistically significant difference in the discriminatory ability between the 7th and 8th editions. The new edition of staging system, however, showed a trend of better prognostic performance not only in recurrence-free survival (c-index=0.734; 95% confidence interval [CI], 0.706 to 0.762 in the 7th edition vs. c-index=0.740; 95% CI, 0.712 to 0.768 in the 8th edition; p=0.14), but also in overall survival (c-index=0.717; 95% CI, 0.688 to 0.745 in the 7th edition vs. c-index=0.722; 95% CI, 0.694 to 0.751 in the 8th edition; p=0.19), especially in stage III. This finding was repeated in the subgroup analysis regardless of adjuvant CA or CCRT.

CONCLUSION

Generally, the 8th edition of AJCC staging system had failed to show a superior discriminatory ability for curatively D2 resected GC patients than the 7th edition, although there was a trend of better prognostic performance of the new edition, regardless of adjuvant treatment method.

Necessity of adjuvant concurrent chemo-radiotherapy in D2-resected LN-positive gastric cancer

BACKGROUND AND PURPOSE

To investigate the role of adjuvant concurrent chemo-radiotherapy (CCRT) by analyzing the outcomes of adjuvant CCRT versus chemotherapy alone (CA) in patients with D2-resected gastric cancer with lymph node (LN) metastasis.

MATERIALS AND METHODS

Patients with gastric cancer from the institutional registry who underwent curative D2 and R0 resection from December 2004 to January 2013 followed by adjuvant CCRT or CA and demonstrated pathologically confirmed LN metastasis without distant metastasis were included in the study.

RESULTS

A total of 1633 patients were included (909 patients in the adjuvant CCRT group and 724 patients in the CA group), and median follow-up was 65.4 months (range, 3.9-141.7 months). There was a significant difference in age (p < 0.0001), Lauren's classification (p = 0.02), number of LN metastases (p < 0.0001), and pN stage (p < 0.0001) between the CCRT and CA groups. During follow-up, recurrence was detected in 419 (25.7%) of patients overall, 236 (26.0%) in the CCRT group, and 183 (25.3%) in the CA group. Recurrence-free survival (RFS) was not significantly different between the CCRT and CA groups in univariable analysis (p = 0.92). After adjustment, pT/pN stage and perineural invasion showed statistical significance in multivariable Cox regression analysis; however, RFS was significantly higher in the CCRT group (p = 0.03, hazard ratio 0.801, 95% confidence interval 0.658-0.975).

CONCLUSIONS

The adjusted RFS was significantly higher in the CCRT group than the CA group in patients with D2 resected LN metastatic gastric cancer.

Incidence of psoriasiform diseases secondary to tumour necrosis factor antagonists in patients with inflammatory bowel disease: a nationwide population-based cohort study

BACKGROUND

There are increasing reports of paradoxical psoriasiform diseases secondary to anti-tumour necrosis factor (TNF) agents.

AIMS

To determine the risks of paradoxical psoriasiform diseases secondary to anti-TNF agents in patients with inflammatory bowel disease (IBD).

METHODS

A nationwide population study was performed using the Korea National Health Insurance Claim Data. A total of 50 502 patients with IBD were identified between 2007 and 2016. We compared 5428 patients who were treated with any anti-TNF agent for more than 6 months (anti-TNF group) and 10 856 matched controls who had never taken anti-TNF agents (control group).

RESULTS

Incidence of psoriasis was significantly higher in the anti-TNF group (36.8 per 10 000 person-years) compared to the control group (14.5 per 10 000 person-years) (hazard ratio [HR] 2.357, 95% confidence interval [CI] 1.668-3.331). Palmoplantar pustulosis (HR 9.355, 95% CI 2.754-31.780) and psoriatic arthritis (HR 2.926, 95% CI 1.640-5.218) also showed higher risks in the anti-TNF group. In subgroup analyses, HRs for psoriasis by IBD subtype were 2.549 (95% CI 1.658-3.920) in Crohn's disease and 2.105 (95% CI 1.155-3.836) in ulcerative colitis. Interestingly, men and younger (10-39 years) patients have significantly higher risks of palmoplantar pustulosis (HR 19.682 [95% CI 3.867-100.169] and HR 14.318 [95% CI 2.915-70.315], respectively), whereas women and older (≥40 years) patients showed similar rates between the two groups.

CONCLUSIONS

The risks of psoriasiform diseases are increased by anti-TNF agents in patients with IBD. Among psoriasiform diseases, the risk of palmoplantar pustulosis shows the biggest increase particularly in male and younger patients.

Prognostic significance of suprapancreatic lymph nodes and its implication on D2 dissection

There have been few studies on the prognostic significance of suprapancreatic lymph nodes (SPLNs), which are targeted in D2 dissections in patients with gastric cancer. The aim of this study was to investigate the prognostic significance of SPLNs by determining whether treatment outcomes of SPLN-positive gastric cancer are comparable to that of SPLN-negative cancer.This study enrolled patients with node-positive gastric cancer, who underwent curative surgery with D2 dissection, at the Samsung Medical Centre from 2007 to 2009. The survival outcomes of patients with and without metastatic SPLNs were analyzed.The total number of patients was 1086, with 377 patients (34.7%) having metastatic SPLNs. SPLN positivity was associated with a more advanced tumor status and the 5-year survival rate of the SPLN-positive group was significantly lower than that of the SPLN-negative group (59.5% vs 81.2%, P < .001). However, the survival was not significantly different between the 2 groups when comparing SPLN status within a given disease stage. Cox multivariate analysis revealed that SPLN metastasis was not an independent prognostic factor.SPLNs were not different from perigastric lymph nodes in terms of prognostic significance and SPLN metastasis should be regarded as a locoregional disease. Complete removal of SPLNs by D2 dissection is recommended for the locoregional control of gastric cancer.